Gaurav Bandi

Stone measurement by volumetric three-dimensional computed tomography for predicting the outcome after extracorporeal shock wave lithotripsy.

To evaluate the efficacy of stone volume measured using a three‐dimensional (3D) reconstruction of preoperative non‐contrast computed tomography (NCCT) as an independent predictor of success after extracorporeal shock wave lithotripsy (ESWL) of upper urinary tract calculi.

Comparison of Postoperative Pain, Convalescence, and Patient Satisfaction after Laparoscopic and Percutaneous Ablation of Small Renal Masses

PURPOSE To compare the convalescence and patient satisfaction between laparoscopic and percutaneous ablation for management of small renal masses. METHODS We performed a telephone survey comparing convalescence and operative satisfaction of patients who underwent laparoscopic and percutaneous ablation between October 2000 and June 2006 at our institution. A retrospective chart review was performed to compare perioperative and postoperative convalescence parameters. RESULTS A total of 93 patients underwent ablation of 103 small renal masses at our institution. Laparoscopic cryoablation was performed in 58 patients, percutaneous cryoablation in 20, and percutaneous radiofrequency ablation in 15 patients. Mean patient age was 66 years (range 24-86 years), median ASA (American society of Anesthesiologists) score was 3, and mean body mass index (BMI) was 30 kg/mm(2). There was no significant difference in the mean age, BMI, and median ASA scores between the groups. The mean diameter of the treated mass was slightly larger in the laparoscopic ablation group (2.6 cm) compared with masses in the percutaneous cryoablation (2.2 cm, P=0.027) and percutaneous radiofrequency ablation (2.2 cm, P=0.042) groups. All procedures were performed under general anesthesia. Compared with laparoscopic cryoablation, percutaneous cryoablation was associated with fewer probes used per lesion (P<0.04), shorter mean anesthesia time (P=0.001), shorter mean hospital stay (P=0.007), early return to nonstrenuous activity (P=0.007), and shorter time to complete recovery (P = 0.05). Similarly, compared with laparoscopic cryoablation, percutaneous radiofrequency ablation was associated shorter mean anesthesia time (P<0.001), early return to nonstrenuous activity (P=0.009), early return to strenuous activity (P=0.007), early return to strenuous activity (P=0.04), and early return to work (P=0.05). There was no difference in the percent of patients who had a preablation biopsy, the median opioid analgesic requirement, and patient satisfaction measured on a 0 to 5 scale between various groups. CONCLUSION Our study suggests that percutaneous ablation in carefully selected patients is associated with early convalescence compared with laparoscopic ablation.

Current practice patterns in the management of upper urinary tract calculi in the north central United States.

PURPOSE To determine the current practice patterns in the management of upper urinary tract calculi in a large group of urologists in the north central United States. MATERIALS AND METHODS An email survey was sent to 790 practicing members of the North Central Section of the American Urological Association. The survey consisted of questions pertaining to practice and training background, and case scenarios with treatment options for upper urinary tract calculi of different sizes at various locations. The responses were then statistically analyzed to determine practice trends. RESULTS Seven urologists did not fill out the survey, as they did not manage patients with stone disease. The overall response rate was 23% (167/783). Although more than 75% of urologists were trained to perform extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL) during their residency, only 61% and 17% were trained to perform open stone surgery (OSS) and medical expulsive therapy (MET), respectively. Twelve percent of respondents were fellowship trained in endourology. Observation was most commonly recommended for asymptomatic renal calculi <5 mm in size (92%). Although SWL continues to be the most commonly utilized therapy for renal (43%-92%) and proximal ureteral calculi <20 mm in size (29%-51%), and PCNL for renal calculi >20 mm in size (72%-92%), many urologists (48%) favored PCNL for lower pole calculi 10 to 20 mm in size. Use of URS was mostly favored for distal (44%-90%) and proximal ureteral calculi (23%-46%), while MET was recommended for small ureteral calculi <5 mm in size (25%-32%). Fellowship-trained endourologists, academic urologists, and urologists in practice for less than 5 years were more likely to utilize URS, PCNL, and MET, and less likely to utilize SWL for urinary calculi. CONCLUSION The results of this survey suggest that practice patterns for treatment of stone disease match the treatment approach recommended in the published literature. This information can be further utilized for assessment of guidelines for the treatment of stone disease.

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis

BACKGROUND Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. OBJECTIVE To report a large multi-institutional series of minimally invasive SP (MISP). DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. INTERVENTION Laparoscopic or robotic SP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications. RESULTS AND LIMITATIONS Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. CONCLUSIONS This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. PATIENT SUMMARY Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

Robot-assisted simple prostatectomy: multi-institutional outcomes for glands larger than 100 grams.

PURPOSE To present our experience with robot-assisted simple prostatectomy in patients with large gland adenoma (>100 g) that would not be amenable to transurethral treatments. PATIENTS AND METHODS From August 2009 to May 2011, 13 robot-assisted simple suprapubic prostatectomies were performed in patients with symptomatic large gland (>100 g) prostatomegaly on transrectal ultrasonography (mean 163 cc). Essential aspects of our technique include a transverse cystotomy just proximal to the prostatovesical junction and use of a robotic tenotomy grasper to aid in adenoma dissection. RESULTS Mean operative time was 179 minutes (range 90-270 min), and mean estimated blood loss was 219 mL (range 50-500 mL). Mean hospital stay was 2.7 days (range 1-8 d), and the mean urethral catheterization time was 8.8 days (range 5-14 d). None of the patients needed blood transfusion. One patient had an intraoperative urinary leak after bladder closure that was managed with prolonged urethral catheterization (14 d). Histopathologic analysis confirmed benign prostatic hyperplasia (BPH) in all patients, and mean specimen weight on pathologic examination was 127 g (range 100-165 g). Mean follow-up duration was 7.2 months with all patients having a minimum of a 4-month follow-up. Significant improvements were noted in the International Prostate Symptom Score (preoperative vs postoperative 18.1 vs 5.3, p<0.001) and the maximum urine flow rate (preoperative vs postoperative 4.3 vs 19.1 mL/min, P<0.001). CONCLUSIONS Minimally invasive robot-assisted simple prostatectomy is technically feasible in patients with large volume (>100 g) BPH and is associated with significant improvements in obstructive urinary symptoms. Surgeons with robotic expertise may consider using this approach for treatment of their patients with large volume BPH.

Low incidence of new biochemical and clinical hypogonadism following hypofractionated stereotactic body radiation therapy (SBRT) monotherapy for low- to intermediate-risk prostate cancer

BackgroundThe CyberKnife is an appealing delivery system for hypofractionated stereotactic body radiation therapy (SBRT) because of its ability to deliver highly conformal radiation therapy to moving targets. This conformity is achieved via 100s of non-coplanar radiation beams, which could potentially increase transitory testicular irradiation and result in post-therapy hypogonadism. We report on our early experience with CyberKnife SBRT for low- to intermediate-risk prostate cancer patients and assess the rate of inducing biochemical and clinical hypogonadism.MethodsTwenty-six patients were treated with hypofractionated SBRT to a dose of 36.25 Gy in 5 fractions. All patients had histologically confirmed low- to intermediate-risk prostate adenocarcinoma (clinical stage ≤ T2b, Gleason score ≤ 7, PSA ≤ 20 ng/ml). PSA and total testosterone levels were obtained pre-treatment, 1 month post-treatment and every 3 months thereafter, for 1 year. Biochemical hypogonadism was defined as a total serum testosterone level below 8 nmol/L. Urinary and gastrointestinal toxicity was assessed using Common Toxicity Criteria v3; quality of life was assessed using the American Urological Association Symptom Score, Sexual Health Inventory for Men and Expanded Prostate Cancer Index Composite questionnaires.ResultsAll 26 patients completed the treatment with a median 15 months (range, 13-19 months) follow-up. Median pre-treatment PSA was 5.75 ng/ml (range, 2.3-10.3 ng/ml), and a decrease to a median of 0.7 ng/ml (range, 0.2-1.8 ng/ml) was observed by one year post-treatment. The median pre-treatment total serum testosterone level was 13.81 nmol/L (range, 5.55 - 39.87 nmol/L). Post-treatment testosterone levels slowly decreased with the median value at one year follow-up of 10.53 nmol/L, significantly lower than the pre-treatment value (p < 0.013). The median absolute fall was 3.28 nmol/L and the median percent fall was 23.75%. There was no increase in biochemical hypogonadism at one year post-treatment. Average EPIC sexual and hormonal scores were not significantly changed by one year post-treatment.ConclusionsHypofractionated SBRT offers the radiobiological benefit of a large fraction size and is well-tolerated by men with low- to intermediate-risk prostate cancer. Early results are encouraging with an excellent biochemical response. The rate of new biochemical and clinical hypogonadism was low one year after treatment.

Comparison of blade temperature dynamics after activation of Harmonic Ace scalpel and the Ultracision Harmonic Scalpel LCS-K5.

PURPOSE To compare tip temperatures of the vibrating blades of the newer-generation Harmonic Ace device and the older-generation Ultracision Harmonic Scalpel LCS-K5. MATERIALS AND METHODS Comparison of two different harmonic scalpel blades was performed by applying them to 3-mm strips of raw chicken breast at room temperature and measuring the temperature of the tip of the vibrating blade at 0.5-second intervals using a thermocouple. Following activation, the tip was allowed to passively cool to 30 degrees C each time before reactivation. Each device was tested at power settings of 3 and 5 after activation for 1 to 5 seconds. All measurements were performed 5 times. RESULTS Compared to the older-generation Ultracision Harmonic Scalpel LCS-K5, the newer-generation Harmonic Ace was associated with higher tip temperatures at power level 5 at all times of activation (1-5 seconds), and at power level 3 at longer times of activation (3-5 seconds). The Harmonic Ace also takes longer to reach peak temperatures and can maintain blade hyperthermia for a longer period after activation for more than 3 seconds at power levels 3 and 5. CONCLUSION The newer-generation Harmonic Ace may be potentially more effective in tissue dissection, but is associated with greater increases in peak temperatures and longer blade hyperthermia periods compared to the older-generation Ultracision Harmonic Scalpel LCS-K5. The difference is greater after longer periods of activation, and this may have more potential for collateral damage, particularly to nerves and bowel.

Robotic-assisted prostatectomy and open radical retropubic prostatectomy for locally-advanced prostate cancer: multi-institution comparison of oncologic outcomes

Purpose: Robotic-assisted laparoscopic prostatectomy (RALP) offers reportedly comparable oncologic outcomes for localized disease compared with open radical retropubic prostatectomy (ORRP). However, the oncologic efficacy of RALP in locally-advanced prostate cancer (PCa) is less clear. We report and compare our experience with RALP and ORRP in men with locally advanced PCa. Methods: Patients with locally advanced PCa (stage T3 or greater) were identified in both robotic and open cohorts. Clinicopathologic features including age, clinical stage, prostate-specific antigen, surgical margins, and Gleason score were reviewed. We further examined the incidence of positive surgical margins, the effect of the surgical learning curve on margins, and the need for adjuvant therapy. Results: From 1997 to 2010, 1,011 patients underwent RALP and 415 patients were identified who underwent radical retropubic prostatectomy (RRP) across four institutions. 140 patients in the RALP group and 95 in the RRP group had locally advanced PCa on final pathology. The overall robotic positive margin rate 47.1% compared with 51.4% in the RRP group. A trend towards a lower positive margin rate was seen after 300 cases in the RALP group, with 66.7% positive margin rate in the first 300 cases compared with 41.8% in the latter 700 cases. In addition, a lower incidence of biochemical recurrence was also noted in the latter cases (30.6% vs. 9.5%). Conclusions: Up to 2 out of 3 men undergoing RALP for locally-advanced PCa had positive margins during our initial experience. However, with increasing surgeon experience the overall positive margin rate decreased significantly and was comparable to the positive margin rate for patients with locally advanced disease undergoing ORRP over four academic institutions. We also noted a lower incidence of biochemical recurrence with increasing RALP experience, suggesting better oncologic outcomes with higher volume. Given this data, RALP has comparable oncologic outcomes compared to ORRP, especially with higher volume surgeons.

Third prize: Effect of hydrocortisone on porcine ureteral contractility in vitro

BACKGROUND AND PURPOSE Corticosteroids have been commonly used in medical expulsive therapy for obstructing ureteral calculi. The exact mechanism of action responsible for facilitation of stone expulsion is unknown, but it is attributed to the anti-inflammatory properties of corticosteroids. Corticosteroids inhibit the production of phospholipase A2 and cyclooxygenase-2, both of which are involved in prostaglandin synthesis. We sought to determine if hydrocortisone inhibits ureteral contractility directly by assessing its action in an isolated in vitro contractility assay. METHODS Porcine ureters were attached to force displacement transducers and suspended in organ tissue baths containing aerated Krebs buffer. Tissues were equilibrated for 1 hour, and a spontaneous contractility rate was established. After equilibration, tissues were incubated with a 10-fold concentration curve of hydrocortisone (1 nM-10 microM) for 90 minutes, and compared with indomethacin (1 microM) and dimethyl sulfoxide (DMSO) 0.1% as positive and negative controls of contraction, respectively. Contractility rates were recorded on a polygraph and analyzed for changes over exposure time during the course of the experiment. RESULTS Hydrocortisone inhibited ureteral contractility in a concentration dependent trend. After 90 minutes of treatment, 100 nM, 1 microM, and 10 microM all produced a statistically significant decrease in ureteral contractility rates relative to DMSO controls. The average percent decrease was 43.7% by 100 nM, 66.9% by 1 microM, and 66% by 10 microM hydrocortisone. This decrease in ureteral contractility continued to be significant at 120 minutes. In addition, 10 microM and 1 microM hydrocortisone treatment caused a similar reduction in contractility to indomethacin at 120 minutes. CONCLUSION Hydrocortiosone effectively inhibits stretch-induced ureteral contractility of porcine ureter in an isolated in vitro assay.

Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic–robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic–robotic partial nephrectomy—or hybrid procedure—and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system® was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.