Fernando P. Secin

Comprehensive Prospective Comparative Analysis of Outcomes Between Open and Laparoscopic Radical Prostatectomy Conducted in 2003 to 2005

PURPOSE In a nonrandomized prospective fashion we compared the oncological, functional and morbidity outcomes after laparoscopic and retropubic radical prostatectomy. MATERIALS AND METHODS Between January 2003 and December 2005 a total of 1,430 consecutive men with clinically localized prostate cancer underwent radical prostatectomy, laparoscopic in 612 and retropubic in 818. The surgical approach was selected by the patient. Preoperative staging, respective surgical techniques, pathological examination and followup were uniform. Functional outcome was measured by patient completed health related quality of life questionnaire. RESULTS Positive surgical margin rates (11%) and freedom from progression (median followup 18 months) were comparable between laparoscopic and retropubic radical prostatectomy (HR 0.99 for laparoscopic vs retropubic radical prostatectomy, p = 0.9). We found no significant association between operation type and time to postoperative potency (HR 1.04 for laparoscopic vs retropubic radical prostatectomy; 95% CI 0.74, 1.46; p = 0.8). Patients who underwent laparoscopic radical prostatectomy were less likely to become continent than those treated with retropubic radical prostatectomy (HR 0.56 for laparoscopic vs retropubic radical prostatectomy; 95% CI 0.44, 0.70; p <0.0005). Laparoscopic radical prostatectomy was associated with less blood loss (mean ml +/- SD 315 +/- 186 vs 1,267 +/- 660) and lower overall transfusion rate (3% vs 49%). No significant difference was noted in cardiovascular, thromboembolic and urinary complications. Emergency room visits and readmissions were higher after laparoscopic radical prostatectomy (15% vs 11% and 4.6% vs 1.2%, respectively). CONCLUSIONS At our institution and during the study period laparoscopic radical prostatectomy and retropubic radical prostatectomy provided comparable oncological efficacy. Laparoscopic radical prostatectomy was associated with less blood loss and a lower transfusion rate, and higher postoperative hospital visits and readmission rate. While the recovery of potency was equivalent, that of continence was superior after retropubic radical prostatectomy.

The Learning Curve for Laparoscopic Radical Prostatectomy: An International Multicenter Study

PURPOSE It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. MATERIALS AND METHODS We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. RESULTS Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. CONCLUSIONS The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Artery Sparing Radical Prostatectomy—Myth or Reality?

PURPOSE Not all patients in whom the neurovascular bundles are preserved recover erectile function after radical prostatectomy. A significant proportion of these men have vascular abnormalities that can impact erectile function recovery after radical prostatectomy. We describe the available evidence supporting the need to spare not only the nerves, but also the arteries to improve erectile function recovery after radical prostatectomy. MATERIALS AND METHODS A literature review was done to determine the available evidence supporting vascular insufficiency as a contributor to erectile dysfunction after radical prostatectomy. RESULTS There is no question that preservation of the cavernous nerves is key to erectile function recovery after radical prostatectomy. In addition, it is believed that erectile tissue requires oxygenation to maintain its integrity, which can be significantly affected if the arteries irrigating the cavernous bodies are damaged intraoperatively, such as the accessory pudendal arteries. In approximately 1 of every 4 patients undergoing laparoscopic radical prostatectomy accessory pudendal arteries of different calibers are identified. Thus, accumulating evidence supports the concept that the accessory pudendal arteries have a role in erectile function and its recovery after radical prostatectomy and, furthermore, supports the idea that preserving the accessory pudendal arteries may contribute to erectile function recovery. CONCLUSIONS Based on the evidence at hand we believe that it is appropriate to build on the notion of nerve sparing radical prostatectomy by introducing the urological community to the concept of artery sparing radical prostatectomy in an attempt to make the urological community aware of the potential need to spare the accessory pudendal arteries. The crux of the difficulty is in deciding which arteries should be preserved and which may be sacrificed. Thus, defining the role of the accessory pudendal arteries in erectile function recovery requires intraoperative analysis of the functional role of these vessels.

Comparing Taguchi and Lich-Gregoir Ureterovesical Reimplantation Techniques for Kidney Transplants

PURPOSE We compared the incidence of urological and anastomotic complications, and the duration of ureteral reimplantation for the Taguchi and Lich-Gregoir techniques. MATERIALS AND METHODS We recorded all urological and anastomotic complications that developed from the date of transplantation through December 31, 2001. The cutoff date for transplantation was August 30, 2000. The urological complications evaluated included complicated hematuria, urinary fistula, ureteral stenosis, symptomatic vesicoureteral reflux and operative time. The chi-square test was done to compare the proportion of complications in the groups and the Mann Whitney test was used to compare the duration of ureteral reimplantation. RESULTS Of the 575 transplants evaluated 416 and 159 were performed via the Lich-Gregoir and Taguchi techniques, respectively. The incidence of anastomotic complications was 10.7%. Complications in the Lich-Gregoir group included fistula in 4.7% of cases, stenosis in 4.1%, symptomatic vesicoureteral reflux in 1.9% and complicated hematuria in 0.5%. Complications in the Taguchi group included urinary fistula in 6.3% of cases, stenosis in 2.5% and complicated hematuria in 2.5%. Symptomatic reflux was not observed in this group. There was a higher proportion of hematuria at the limit of statistical significance in the Taguchi group (p = 0.05). There were a higher number of urological complications in transplants from live donors in the Lich-Gregoir group (p = 0.01), mostly involving fistula (p = 0.05). There were no significant differences in the groups in overall complications. Average operative time for the Taguchi and Lich-Gregoir techniques was 14.2 and 29 minutes, respectively. This difference was significant (p = 0.02). CONCLUSIONS In the sample studied Taguchi ureterocystoneostomy proved to be a more rapid method without increasing the incidence of urological or anastomotic complications. There were no cases of symptomatic reflux in the Taguchi group and select fistula cases could be managed conservatively. The Lich-Gregoir cohort was at greater risk for the urological complications of live donor transplantation. The Taguchi method has become the ureterovesical reimplantation technique of choice in our setting.

Renal Cell Carcinoma in Young and Old Patients—Is There a Difference?

PURPOSE Renal cell carcinoma is rare in patients younger than 40 years and conflicting data regarding presentation and outcome are present in the literature. We reviewed our experience with young patients with renal cell carcinoma and compared them to their older counterparts. MATERIALS AND METHODS We identified 1,720 patients 18 to 79 years old who were treated with partial or radical nephrectomy for renal cell carcinoma between 1989 and 2005. Patients were grouped according to age and outcome analysis was performed. RESULTS Of the 1,720 patients with renal cell carcinoma 89 (5%), 672 (39%) and 959 (56%) were younger than 40, 40 to 59 and 60 to 79 years old, respectively. There were no significant differences in sex, tumor size, TNM stage or multifocality by age group. However, patients younger than 40 years were significantly more likely to present with symptomatic tumors (p = 0.028). Additionally, there were significant differences in histology by age (p <0.001), that is chromophobe histology decreased while papillary histology increased with age. Despite similar tumor sizes in each age group the percent of patients treated with partial nephrectomy decreased with age. Of patients younger than 40 years 49% were treated with partial nephrectomy compared with 35% and 30% of those 40 to 59 and 60 to 79 years old, respectively (p <0.001). At a median followup of 2.6 years (range 0 to 14.5) we did not observe a significant difference in cancer specific survival according to age (p = 0.17). CONCLUSIONS Younger patients with renal cell carcinoma are more likely to have symptomatic tumors with chromophobe histology, although the prognosis appears similar across age groups. Older patients are more likely to be treated with radical nephrectomy, which requires careful scrutiny for current clinical practice.

Evaluation of regional lymph node dissection in patients with upper urinary tract urothelial cancer.

Objective:  The role of the lymph node dissection (LND) in conjunction with nephroureterectomy (NU) in upper tract urothelial cell carcinoma (UT‐UCC) remains undefined. We evaluated the manner in which the LND was applied at NU, the patterns of lymph node (LN) involvement and the preoperative variables that could identify patients at high risk for lymph node metastasis (LNM).

Cancer-specific survival and predictors of prostate-specific antigen recurrence and survival in patients with seminal vesicle invasion after radical prostatectomy†‡

The objectives of the current study were to determine the long‐term biochemical recurrence (BCR) and cancer‐specific survival (CSS) rates for men with seminal vesicle invasion (SVI) and to identify risk factors for freedom from BCR and CSS in patients who received treatment in the prostate‐specific antigen era and who had SVI identified at the time of radical prostatectomy (RP).

Laparoscopic adrenalectomy for adrenal masses: does size matter?

OBJECTIVES To examine the impact of adrenal tumor size on perioperative morbidity and postoperative outcomes in patients undergoing laparoscopic adrenalectomy. METHODS A total of 227 laparoscopic adrenalectomies were divided in three groups according to size as estimated by pathologic specimen maximum diameter: less than 6 cm (group 1, n = 140), between 6 and 7.9 cm (group 2, n = 47), and equal to or larger than 8 cm (group 3, n = 40). We prospectively recorded and analyzed clinical and pathologic data. RESULTS Average operative time was 60 minutes (range, 50 to 90 minutes) for group 1, 75 minutes (range, 65 to 105 minutes) for group 2, and 80 minutes (range, 65 to 120 minutes) for group 3. Estimated blood loss, median (interquartile range) was 50 mL (range, 20 to 100 mL), 100 mL (range, 48 to 225 mL), and 100 mL (range, 50 to 475 mL) for groups 1, 2, and 3, respectively. We observed a total of 10, 4, and 4 complications in groups 1, 2, and 3, respectively. Average hospital stay was 2 days (range, 2 to 3 days), 2 days (range, 2 to 3 days), and 3 days (range, 2 to 4 days), respectively, for groups 1, 2, and 3. Operative time, average blood loss, and mean hospital stay were significantly higher (P <or=0.05) for group 3 compared with group 1. CONCLUSIONS Laparoscopic adrenalectomy in large adrenal masses (8 cm or greater) is associated with significantly longer operative time, increased blood loss, and longer hospital stay, without affecting perioperative morbidity.

Importance and Limits of Ischemia in Renal Partial Surgery: Experimental and Clinical Research

Introduction. The objective is to determine the clinical and experimental evidences of the renal responses to warm and cold ischemia, kidney tolerability, and available practical techniques of protecting the kidney during nephron-sparing surgery. Materials and methods. Review of the English and non-English literature using MEDLINE, MD Consult, and urology textbooks. Results and discussion. There are three main mechanisms of ischemic renal injury, including persistent vasoconstriction with an abnormal endothelial cell compensatory response, tubular obstruction with backflow of urine, and reperfusion injury. Controversy persists on the maximal kidney tolerability to warm ischemia (WI), which can be influenced by surgical technique, patient age, presence of collateral vascularization, indemnity of the arterial bed, and so forth. Conclusions. When WI time is expected to exceed from 20 to 30 minutes, especially in patients whose baseline medical characteristics put them at potentially higher, though unproven, risks of ischemic damage, local renal hypothermia should be used.

Is it Necessary to Remove the Seminal Vesicles Completely at Radical Prostatectomy? Decision Curve Analysis of European Society of Urologic Oncology Criteria

PURPOSE A publication on behalf of the European Society of Urological Oncology questioned the need for removing the seminal vesicles during radical prostatectomy in patients with prostate specific antigen less than 10 ng/ml except when biopsy Gleason score is greater than 6 or there are greater than 50% positive biopsy cores. We applied the European Society of Urological Oncology algorithm to an independent data set to determine its predictive value. MATERIALS AND METHODS Data on 1,406 men who underwent radical prostatectomy and seminal vesicle removal between 1998 and 2004 were analyzed. Patients with and without seminal vesicle invasion were classified as positive or negative according to the European Society of Urological Oncology algorithm. RESULTS Of 90 cases with seminal vesicle invasion 81 (6.4%) were positive for 90% sensitivity, while 656 of 1,316 without seminal vesicle invasion were negative for 50% specificity. The negative predictive value was 98.6%. In decision analytic terms if the loss in health when seminal vesicles are invaded and not completely removed is considered at least 75 times greater than when removing them unnecessarily, the algorithm proposed by the European Society of Urological Oncology should not be used. CONCLUSIONS Whether to use the European Society of Urological Oncology algorithm depends not only on its accuracy, but also on the relative clinical consequences of false-positive and false-negative results. Our threshold of 75 is an intermediate value that is difficult to interpret, given uncertainties about the benefit of seminal vesicle sparing and harm associated with untreated seminal vesicle invasion. We recommend more formal decision analysis to determine the clinical value of the European Society of Urological Oncology algorithm.