David E. McGinnis

The Minimally Invasive Treatment of Ureteropelvic Junction Obstruction: A Review of Our Experience During the Last Decade

PURPOSE The minimally invasive treatment of ureteropelvic junction obstruction has evolved during the last decade from endoscopic to laparoscopic and robotic. We review our 10-year experience with ureteropelvic junction obstruction, and report on our experience and followup. MATERIALS AND METHODS We reviewed all patients treated during the last 10 years. There were 294 procedures performed with complete records on 273 patients including 128 retrograde endopyelotomies, 116 laparoscopic pyeloplasties and 29 robotic pyeloplasties. Technique for each procedure is reviewed. Statistical analysis was performed on all results. Variables evaluated were gender, age (younger than 41 vs 41 years or older), side (right or left), presence of crossing vessels, presence of a high insertion, primary or secondary procedure and whether prior endopyelotomy or pyeloplasty had been performed. RESULTS Mean followup for endopyelotomy, laparoscopic pyeloplasty and robotic pyeloplasty was 20, 20 and 19 months, respectively, with success rates of 60.2%, 88.8% and 100%, respectively. On univariable analysis only the presence of crossing vessels or a high insertion was significant for laparoscopic pyeloplasty. On multivariable analysis age was significant for endopyelotomy and the presence of crossing vessels was significant for pyeloplasty. On Kaplan-Meier analysis failures were noted to occur after 5 years in both groups. CONCLUSIONS Laparoscopic pyeloplasty and robotic pyeloplasty are superior minimally invasive treatments for ureteropelvic junction obstruction. However, endopyelotomy can be used for select patients. Because of late failures patients who undergo either of these procedures should receive long-term followup.

Pathologic comparison of laparoscopic versus open radical retropubic prostatectomy specimens

OBJECTIVES To compare the pathologic evaluation of 60 sequential laparoscopic radical prostatectomy (LRP) specimens with 60 sequential and 60 stage and grade-matched open radical retropubic prostatectomy (RRP) cohort specimens. METHODS Of 68 patients undergoing LRP, 3 requiring open conversion and 5 receiving neoadjuvant hormonal therapy were excluded, leaving 60 for analysis. Among 72 sequential open RRP specimens, 60 from patients not receiving neoadjuvant hormonal therapy and without nodal metastases were analyzed. A third cohort of 60 RRP specimens matched with the LRP specimens for clinical stage and biopsy grade was also evaluated. RESULTS The specimen weight and preoperative serum prostate-specific antigen level were similar for each cohort, and approximately 75% of patients from each cohort were clinical Stage T1c. Forty-six LRP and matched open RRP (76.7%) and 39 sequential open RRP (65%) specimens were biopsy Gleason sum 6, and the remainder were primarily Gleason sum 7. The pathologic grade and stage distribution were similar for each cohort. Ten LRP (16.9%) and 12 open RRP (20%) specimens from each cohort had positive inked margins (P > 0.10). Positive apex margins were noted in 3, 7, and 7 and multiple positive margin sites in 0, 5, and 6 of the LRP, matched open RRP, and sequential open RRP specimens (P < 0.05), respectively. CONCLUSIONS Pathologic evaluation of the LRP and open RRP specimens from patients not receiving neoadjuvant hormonal therapy demonstrated similar overall positive margin rates, but LRP had a lower rate of apex and multiple-site positive margins.

Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy

The objective of the study was to compare the perioperative complication rates of our initial 60 laparoscopic radical prostatectomy (LRP) patients and our most recent 60 sequential open radical retropubic prostatectomy (RRP) patients. Sixty sequential LRP and 60 sequential RRP patients treated between March 2000 and March 2002 were retrospectively evaluated. Patients who received neo-adjuvant hormonal therapy or had metastatic disease and 3 LRP patients converted to open RRP were excluded. Estimated blood loss (EBL), transfusion rates, hemoglobin level, serum and drain fluid creatinine levels, hospital stay and complication rates were analyzed. There were 15 (25%) and 11 (18.3%) complications in the LRP and RRP cohorts, respectively. There were 3 (ulnar neuropathy, ureteral stricture, anastomotic leak with ureteral obstruction requiring reoperation), and 4 [2 bladder neck contractures (BNC) and 2 deep venous thromboses (DVT)] major complications, respectively. Minor complications included rectus hematoma, superficial wound infections, ileus and anastomotic urine leaks. A higher incidence of the latter (10 patients) was noted in the LRP cohort. One (1.7%) LRP and 31 (52%) RRP cohort patients received intraoperative or postoperative transfusions. The mean (median) EBL was 317 (250) and 1355 (1100) for the LRP and RRP cohorts, respectively. A transient, insignificant increase in serum creatinine from a median of 1.0 to 1.2 mg/dL was observed only in the LRP cohort. We concluded that our initial 60 LRP patients had a similar, but not improved, rate of perioperative complications when compared with 60 sequential open RRP patients of nearly identical age, preoperative PSA and prostate size. The types of complications differed between the LRP and RRP cohorts.

Totally Endoscopic Management of Upper Tract Transitional-Cell Carcinoma

BACKGROUND AND PURPOSE Nephron-sparing therapy arose spurred by efforts to delay dialysis for patients with renal insufficiency or solitary kidneys. As technology has improved, complete endoscopic ablation of tumor via the holmium and Nd:YAG lasers has proven efficacious for cancer control. We have extended ureteroscopic treatment to patients with normal contralateral kidneys given the proper indications. For required extirpative therapy in cases of uncontrolled cancer, laparoscopic nephroureterectomy is rapidly becoming popular and appears to lend the same tumor control as open surgery while significantly lessening morbidity. We reviewed our experience with endourologic treatment and propose an algorithm for the management of upper tract TCC. PATIENTS AND METHODS Over the period from August 1998 to May 2000, 70 patients underwent ureteroscopic evaluation, treatment, or both for TCC. During the same period, 24 patients had a hand-assisted laparoscopic nephroureterectomy (HALNU) performed. A thorough chart review was performed to determine pathologic data and management decision-making. RESULTS Of the 70 patients evaluated ureteroscopically, 46 were examined for the first time, while the remaining 24 patients were already on the surveillance protocol. Of the 46 initially evaluated patients, 18 were referred for HALNU. Fifteen other patients were placed on surveillance. Of the 24 patients already on surveillance, only 1 required HALNU. The most common reasons for nephroureterectomy were bulky tumors that were ureteroscopically unresectable, high-grade disease, and patient preference. CONCLUSIONS The combination of ureteroscopy and laparoscopy has made the management of upper tract TCC totally endoscopic, providing decreased morbidity while maintaining cancer control.

Urinary dysfunction in lyme disease

Lyme disease, which is caused by the spirochete Borrelia burgdorferi, is associated with a variety of neurological sequelae. We describe 7 patients with neuro-borreliosis who also had lower urinary tract dysfunction. Urodynamic evaluation revealed detrusor hyperreflexia in 5 patients and detrusor areflexia in 2. Detrusor external sphincter dyssynergia was not noted on electromyography in any patient. We observed that the urinary tract may be involved in 2 respects in the course of Lyme disease: 1) voiding dysfunction may be part of neuro-borreliosis and 2) the spirochete may directly invade the urinary tract. In 1 patient bladder infection by the Lyme spirochete was documented on biopsy. Neurological and urological symptoms in all patients were slow to resolve and convalescence was protracted. Relapses of active Lyme disease and residual neurological deficits were common. Urologists practicing in areas endemic for Lyme disease need to be aware of B. burgdorferi infection in the differential diagnosis of neurogenic bladder dysfunction. Conservative bladder management including clean intermittent catheterization guided by urodynamic evaluation is recommended.

Hand-Assisted Laparoscopic Cystoprostatectomy and Urinary Diversion

PURPOSE We report the first series of patients who have undergone hand-assisted laparoscopic cystoprostatectomy and diversion (HALCD). PATIENTS AND METHODS Seven patients with muscle-invasive bladder cancer elected to have their surgery by hand-assisted laparoscopy. The bladder was excised using a hand-assisted laparoscopic technique, and the ileal conduit was constructed through the midline incision created for the hand. RESULTS The operative time was relatively short (mean 7.6 hours), blood loss was low (420 mL), and the postoperative stay was short (4.6 days). Long-term follow-up is pending. CONCLUSION Laparoscopic techniques for radical cystectomy are currently being explored at several major medical centers. Hand-assisted laparoscopy offers the distinct advantages of palpation, retraction, speed, and minimal morbidity.

The impact of financial interest in intensity-modulated radiation therapy on the utilization of radiation therapy for treatment of newly diagnosed prostate cancer: a single center experience.

Objective. As recent participants in an integrated prostate cancer (PCa) care center, we sought to evaluate whether financial investment in an intensity-modulated radiation therapy (IMRT) center resulted in an increased utilization of radiation therapy in our patients with newly diagnosed PCa. Materials & Methods. Following institutional review board approval, we retrospectively reviewed the records of all consecutive patients who were diagnosed with prostate cancer in the 12 months prior to and after investment in IMRT. Primary treatment modalities included active surveillance (AS), brachytherapy (BT), radiation therapy (XRT), radical prostatectomy (RP), and androgen deprivation therapy (ADT). Treatment data were available for all patients and were compared between the two groups. Results. A total of 344 patients with newly diagnosed PCa were evaluated over the designated time period. The pre-investment group totaled 198 patients, while 146 patients constituted the post-investment group. Among all patients evaluated, there was a similar rate in the use of XRT (20.71% versus 20.55%, P = 1.000) pre- and post-investment in IMRT. Conclusions. Financial interest in IMRT by urologists does not impact overall utilization rates among patients with newly diagnosed PCa at our center.