Daniel Park

Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience

BACKGROUND Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands. OBJECTIVE To describe our technique of transvesical robotic simple prostatectomy (RSP). DESIGN, SETTING, AND PARTICIPANTS From May 2011 to April 2013, 25 patients underwent RSP. SURGICAL PROCEDURE We performed RSP using our technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed. RESULTS AND LIMITATIONS Mean patient age was 72.9 yr (range: 54-88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9-35), prostate volume was 149.6 ml (range: 91-260), postvoid residual (PVR) was 208.1 ml (range: 72-800), maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9-56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165-345), estimated blood loss was 143 ml (range: 50-350), and the hospital stay was 4 d (range: 2-8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS (p<0.0001), an 82.2% reduction in mean PVR (p=0.014), and a 77% increase in mean Qmax (p=0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation. CONCLUSIONS Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures. PATIENT SUMMARY We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands.

Robotic salvage retroperitoneal and pelvic lymph node dissection for 'node-only' recurrent prostate cancer: technique and initial series.

To describe the technique of robot‐assisted high‐extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for ‘node‐only’ recurrent prostate cancer.

Robotic Intracorporeal Continent Cutaneous Diversion

Purpose: Robotic intracorporeal urinary diversion has mostly been done for ileal conduit or orthotopic neobladder diversion. We present what is to our knowledge the initial series, detailed technique and outcomes of the robotic intracorporeal Indiana pouch with a minimum 1‐year followup. Materials and Methods: Ten patients underwent robotic radical cystectomy, pelvic lymphadenectomy and intracorporeal Indiana pouch urinary diversion for cancer in 9 and benign disease in 1. Data were collected prospectively. Baseline demographics, pathology data, and 1‐year complication rates and functional outcomes were assessed. Results: All 10 cases were successfully completed intracorporeally without open conversion. Median total operative time was 6 hours, including 3.5 hours for pouch creation. Median blood loss was 200 cc and median hospital stay was 10 days. Four Clavien grade 1‐2 and 3 Clavien 3‐5 complications occurred. None of the patients had a bowel leak. One noncompliant patient requested undiversion to an ileal conduit. The remaining 9 patients successfully catheterized the ileal channel and were completely continent at the last followup at a median of 13.7 months (range 12.3 to 15.2). Study limitations include small sample size and short followup. Conclusions: We present what is to our knowledge the initial series of robotic completely intracorporeal Indiana pouch diversion. Early perioperative data indicate acceptable operative efficiency and complication rates. Longer followup is required to assess the functional outcomes of this less commonly performed diversion.

Contrast-Enhanced Transrectal Ultrasound for Follow-up After Focal HIFU Ablation for Prostate Cancer: Contrast-Enhanced TRUS After Focal Ablation for Prostate Cancer

The optimal strategy for imaging after focal therapy for prostate cancer is evolving. This series is an initial report on the use of contrast‐enhanced transrectal ultrasound (TRUS) in follow‐up of patients after high‐intensity focused ultrasound (HIFU) hemiablation for prostate cancer. In 7 patients who underwent HIFU hemiablation, contrast‐enhanced TRUS findings were as follows: (1) contrast‐enhanced TRUS clearly showed the HIFU ablation defect as a sharply marginated nonenhancing zone in all patients; (2) contrast‐enhanced TRUS identified suspicious foci of recurrent enhancement within the ablation zone in 2 patients, facilitating image‐guided prostate biopsy, which showed prostate cancer; and (3) contrast‐enhanced TRUS findings correlated with multiparametric magnetic resonance imaging and biopsy histologic findings.

Active Surveillance for Small Renal Masses in Young Patients

We certainly agree with active surveillance for small renal masses 9SRMs). However, it must be in appropriate patients, the elderly and the infirm, in whom the comorbidity risks outweigh the oncologic risks. Evidence to support active surveillance for SRMs in the young is lacking.

Contrast-Enhanced Transrectal Ultrasound in Focal Therapy for Prostate Cancer

Purpose of ReviewContrast-enhanced transrectal ultrasound (CeTRUS) is an emerging imaging technique in prostate cancer (PCa) diagnosis and treatment. We review the utility and implications of CeTRUS in PCa focal therapy (FT).Recent FindingsCeTRUS utilizes intravenous injection of ultrasound-enhancing agents followed by high-resolution ultrasound to evaluate tissue microvasculature and differentiate between benign tissue and PCa, with the latter demonstrating increased enhancement. The potential utility of CeTRUS in FT for PCa extends to pre-, intra- and post-operative settings. CeTRUS may detect PCa, facilitate targeted biopsy and aid surgical planning prior to FT. During FT, the treated area can be visualized as a well-demarcated non-enhancing zone and continuous real-time assessment allows immediate re-treatment if necessary. Following FT, the changes on CeTRUS are immediate and consistent, thus facilitating repeat imaging for comparison during follow-up. Areas suspicious for recurrence may be detected and target-biopsied. Enhancement can be quantified using time-intensity curves allowing objective assessment and comparison.SummaryBased on encouraging early outcomes, CeTRUS may become an alternative imaging modality in prostate cancer FT. Further study with larger cohorts and longer follow-up are needed.

V4-07 CONTRAST-ENHANCED ULTRASOUND (CEUS): EVALUATION OF HIGH INTENSITY FOCUSED ULTRASOUND (HIFU) ABLATION OF THE PROSTATE

INTRODUCTION AND OBJECTIVES: PCNL is the first-line therapy for large and complex renal calculi. To perform PCNL safely and effectively, the most important step is the formation of a nephrostomy tract and tract dilatation. Furthermore, as fine a nephroscope as possible is required for micro PCNL. In this clinical study, renal puncture using 20 G all-seeing needle and 4.8 Fr micro PCNL were performed for large renal stone using a micro-optic disposable scope. METHODS: The f0.65 mm scope with the High Definition Image Guide (HDIG) system reported in previous WCE held in Taiwan (2014) was adopted. The scope consists of an integrated light lead and the micro fiber optic including a f0.5 mm precise object lens and optical glass fiber, where real-time HD images can be seen through the digital image processing device. The scope can be set inside a 20 G puncture needle or 4.8 Fr metal sheath which can simultaneously include the micro-optic scope, 0.018 inch guidewire and 200 mm laser fiber. These devices are developed as part of a collaborative research with Takei Medical & Optical Co. Ltd. (Tokyo, Japan) and Sumita Optical Glass Inc. (Saitama, Japan) funded by Utsukushima Next-Generation Medical Industry Agglomeration Project between 2012 and 2014. After evaluating safety, optical quality and operation performance in an animal study, the clinical study authorized by the ethical committee of Okayama University Hospital was carried out from June 2013. The procedures of micro PCNL are as follows; ultrasound-guided renal puncture using 20 G all-seeing needle, removal of the scope followed by insertion of 0.018 inch guidewire, dilatation by metal introducer, insertion of 4.8 Fr metal sheath into renal calyx, insertion of the HDIG scope into the sheath, complete fragmentation of calculi by Ho-YAG LASER without removal of the fragments. RESULTS: A 68-year old male with renal calculi 21 mm in diameter in left lower calyx once underwent the puncture and the micro PCNL. After the operation, spontaneous discharge of fragmented calculi through lower urinary tract was observed and abdominal X-ray on POD 21 showed no fragment in his left kidney. No adverse event was occurred except slight elevation of serum creatinine during only a week postoperatively. CONCLUSIONS: The micro-optic disposable scope with the HDIG system is extremely useful for safer puncture and finer PCNL. We are now planning to adopt it to percutaneous procedure for urothelial carcinoma in upper urinary tract.

V8-10 ROBOTIC SALVAGE RETROPERITONEAL AND PELVIC LYMPH NODE DISSECTION FOR “NODE-ONLY” RECURRENT PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: Despite primary treatment of prostate cancer with surgery or external radiation therapy, 2040% of patients relapse within 5 years and 25-35% progress to metastatic disease. Salvage lymph node dissection has been proposed in patients with biochemical recurrence from prostate cancer and nodal involvement only, although the optimal template remains a question of debate. Herein we describe the technique of robotic high-extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for “node-only” recurrent prostate cancer. METHODS: Twenty patients underwent robotic sRPLND+PLND for “node-only” recurrent prostate cancer after definitive primary treatment as identified by carbon-11 acetate PET/CT. Our anatomic template extends from bilateral renal artery and vein cranially up to Cloquets node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees. Meticulous node-mapping assessed nodes at 4 prospectively-assigned anatomic zones. RESULTS: Median age at salvage RPLND was 64 (45-76), median BMI was 26.4 kg/m2 (21.4 41.2), previous primary treatment was radical prostatectomy in 17 patients (85%) and external radiation therapy in 4 patients (15%), median time from primary treatment was 32 months (4-160) and median PSA at sRPLND+PLND was 2.1 ng/dl (0.28 38.17). Median operative time was 5 hours (3.5-5.8), blood loss was 100 ml (50-300), and hospital stay was 1 day (1-3). No patient had intra-operative complication, open conversion or blood transfusion. Four patients had Clavien II post-operative complications: flank/scrotal ecchymosis in 1 patient (5%), chylous ascites in 2 patients (10%) and neuropraxia/foot drop in 1 patient (5%). Final histology confirmed positive nodes in 16 patients (20%). Mean and median (range) number of nodes excised per patient was 89 and 80 (41-132) respectively. Mean and median (range) number of positive nodes was 21 and 6 (0-109) respectively. At 2 months post-operatively median (range) PSA was 0.76 ng/mL (<0.01-2 ng/mL). CONCLUSIONS: Herein we describe the detailed technique of robotic high-extended salvage RPLND+PLND for “node-only” recurrent prostate cancer and present the initial experience. Robotic sRPLND+PLND duplicates open surgery, with superior nodal counts and decreased morbidity compared to the published literature. Longer follow-up is necessary to assess oncologic outcomes.