Douglas E. Sutherland

Robot-Assisted Simple Prostatectomy for Severe Benign Prostatic Hyperplasia

PURPOSE To validate the feasibility of robot-assisted simple retropubic prostatectomy (RSP) for men with severe benign prostatic hyperplasia (>80 g). PATIENTS AND METHODS Institutional Review Board approval was not sought for this series. Men were offered RSP by two surgeons with a combined experience of >350 robot-assisted radical prostatectomies. The RSP replicated previously published robotic and laparoscopic techniques. Postoperative management consisted of continuous bladder irrigation and closed suction pelvic drainage without suprapubic catheterization. RESULTS A total of nine men were treated. Indications for RSP included urinary retention in three patients, failed medical management in eight patients, and refusal of medical management in one. Average age was 68 years, mean prostate-specific antigen level was 17.4 ng/mL, and the average preoperative gland size (height-width-length volume) was 136.5 g (range 86-265 g). No operative or immediate postoperative complications occurred, and no transfusions were needed. Average blood loss, operative time, and console time were 206 mL, 183 minutes, and 147 minutes, respectively. Average pathologic adenoma volume was 112 g (range 53-220 g). Average hospitalization time and catheterization time were 32 hours and 13 days, respectively. The mean preoperative International Prostate Symptom Score was 17.8 compared with 7.77 at 6 months postoperatively (P=0.0096, 95% CI 2.83 - 17.40), with a mean follow-up time of 9.25 months. The mean Sexual Health Inventory for Men score was 12.7 preoperatively compared with 12.5 postoperatively (P=0.74, 95% confidence interval - 6.66-9.16). Persistent, severe urinary incontinence (4-6 pads per day) occurred in one patient. CONCLUSIONS RSP is safe and reproducible when performed by experienced robotic surgeons and provides similar benefits to those associated with robot-assisted radical prostatectomy. In our limited experience, hemostasis was markedly decreased when compared with the open technique. Further investigation is necessary before widespread application of RSP.

Surgical complications after robot-assisted laparoscopic radical prostatectomy: The initial 1000 cases stratified by the clavien classification system

BACKGROUND AND PURPOSE Complications after robot-assisted prostatectomy are widely reported and varied. Our goal was to determine the incidence of surgical complications resulting from robot-assisted laparoscopic radical prostatectomy (RALP) during the initial phase of a new robotics program that was developed by two surgeons without laparoscopic or robotic fellowship training. A secondary goal was to see if experience changed the incidence of complications with this technology. PATIENTS AND METHODS A prospectively maintained database was used to evaluate the first 1000 consecutive patients who were treated with RALP from January 2004 to June 2009. The database was reviewed for evidence of complications in the perioperative period. All patients underwent robot-assisted laparoscopic radical prostatectomy by two surgeons. Complications were confirmed and supplemented by retrospectively reviewing the departmental morbidity and mortality reports, as well as the hospital records. The Clavien classification system, a standardized and validated scale for complication reporting, was applied to all events. The complication rate was determined per 100 patients treated and tested with logistic regression for a relationship with surgeon experience. RESULTS Ninety-seven (9.7%) patients experienced a total of 116 complications; 81 patients experienced a single complication and 16 patients experienced ≥2 complications. The majority of complications (71%) were either grade I or II. The complication rate decreased with experience when the first 500 cases were compared with the latter 500 cases (P=0.007). All the data were reviewed retrospectively. Involvement of residents/fellows increased as primary surgeon experience improved. CONCLUSIONS Complications after RALP are most commonly minor, requiring expectant or medical management only, even during the initiation of a RALP program. The complication rate improved significantly during the study period.

Aetiology, diagnosis and management of urothelial tumours of the renal pelvis and ureter

TCC of the upper urinary tract (UTTCC) is a relatively uncommon tumour, representing 2–6% of all TCC [1] and 10% of all renal tumours in the USA. It is three times more common in men than women and occurs three to four times more commonly in the renal pelvis than the ureter [2]. Of lower ureteric TCC, 70% occur in the distal third with a further 24% occurring in the midureter. The incidence increases with age and is commonest in the fifth to seventh decades (mean age of occurrence 65–67 years, with a peak incidence in the eighth decade).

Bladder Cryoablation in a Porcine Model: Evaluation of Three Surgical Approaches and Cryolesion Predictability

PURPOSE To determine the feasibility of bladder cryoablation (BC) applied laparoscopically, percutaneously, and transurethrally in a porcine survival study. The expected and observed area of cell death after BC was also examined. MATERIALS AND METHODS Nine pigs were divided equally into the three treatment groups. Cryoablation was performed with two freeze-thaw cycles after the bladder had been insufflated with CO2. Each animal was observed for 7 days after the procedure for treatment-related complications. After cystectomy, each specimen was examined pathologically to determine the degree and dimension of cell death achieved. RESULTS BC applied via the laparoscopic and percutaneous approach is feasible and safe. No BC-related complications occurred in these two groups. A complication resulting from BC developed in all three animals that were treated cystoscopically, including two intraperitoneal bladder perforations at the time of BC necessitating immediate sacrifice, and one enterovesical fistula discovered at cystectomy. Transmural necrosis was demonstrated in seven of seven animal specimens that survived to the end of the protocol. The observed diameter of tissue necrosis was highly predictable based on the reported cryoprobe isotherms given by the manufacturer. CONCLUSION All locations within the bladder can be successfully and predictably treated with cryoablation. Of the three approaches, laparoscopically administered BC appears to be the most safe and consistent method. Transurethral BC was not safe with the equipment available without laparoscopic assistance to prevent bowel complications.