Haluk Akpinar

Robot-Assisted Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy: Comparison of Outcomes

PURPOSE We report our initial experience with laparoscopy- and robot-assisted partial nephrectomy (RAPN) operations. MATERIALS AND METHODS Between November 2003 and April 2009, laparoscopic partial nephrectomy (LPN) was performed in 20 patients (hand-assisted procedure in one patient) and RAPN in 11 patients. Transperitoneal approach was used in both groups. RESULTS The patient demographics were similar in both groups. The groups were statistically comparable for body mass index (BMI), gender, and American Society of Auesthesiologists (ASA) scores. The mean tumor size was 32.1 mm (range 20-41 mm) in the RAPN group and 31.45 mm (range 15-70 mm) in the LPN group. The operative time was 226 minutes (range 120-420) in the LPN group and 185 minutes (range 120-270) in the RAPN group; the difference was not statistically significant (p = 0.07). The mean warm ischemia time was significantly shorter in the RAPN group (27.3 minutes for the RAPN group and 35.8 for the LPN group) (p = 0.02). The mean estimated blood loss was 286.4 mL in the RAPN group and 387.5 mL in the LPN group (p = 0.3). One patient (5%) had focal positive margin in the LPN group. No patient had positive surgical margins in the RAPN group. CONCLUSIONS In this pilot study, we found that RAPN and LPN are feasible and safe operations in T1 renal tumors. The advantages for RAPN are excision of the tumor under three-dimensional vision and easy suturing with the articulated instruments of the robotic system. The cost and the need for two experienced laparoscopic surgeons are the disadvantages of robotic surgery. Larger randomized studies are needed to evaluate whether RAPN has any advantages over LPN.

Is Prophylactic Breast Radiotherapy Necessary in All Patients With Prostate Cancer and Gynecomastia and/or Breast Pain?

PURPOSE We investigated the efficacy of prophylactic radiotherapy for gynecomastia/breast pain induced by 150 mg bicalutamide in a prospective, randomized, multi-institutional trial. MATERIALS AND METHODS After definitive treatment for localized prostate cancer 125 patients were randomized to 12 Gy radiotherapy before bicalutamide as prophylactic radiotherapy (53) or bicalutamide only for nonprophylactic radiotherapy (72). The incidence of gynecomastia, breast pain and tenderness, and discomfort perceived by the patients was assessed by physical examination and direct questioning at 3, 6 and 12 months of followup. RESULTS At the end of 12 months the gynecomastia rate was 15.8% in the prophylactic group and 50.8% in the nonprophylactic group (p <0.001). On patient evaluation the breast enlargement rate was 34.4%. The severity of breast pain and tenderness was not different between the groups. The breast pain rate was 36.4% and 49.2% by 12 months in the prophylactic and nonprophylactic groups, and the rate of patients who felt discomfort from gynecomastia was 11.4% and 29.5%, respectively. CONCLUSIONS In this prospective study the incidence of gynecomastia was not as high as previously believed. Although prophylactic breast irradiation seemed to decrease the gynecomastia rate in patients on 150 mg bicalutamide, our study proves that not all patients need prophylaxis since only 52% were significantly bothered by gynecomastia. Thus, individual assessment is needed to select patients who need prophylactic radiation while on 150 mg bicalutamide.

Anterior and posterior reconstruction technique and its impact on early return of continence after robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE Urinary incontinence is a significant cause of morbidity after robot-assisted radical prostatectomy (RARP). Several techniques have been developed to improve continence rates. In this study, we compared the continence rates of patients who underwent RARP with total reconstruction and without reconstruction. PATIENTS AND METHODS Between March 2005 and September 2009, 245 patients underwent RARP at our institution. The initial 120 patients (control group) underwent standard RARP without reconstruction and the last 125 patients (reconstruction group) underwent a total reconstruction technique, which included an anterior and posterior reconstruction. Patients were followed for 1, 4, 12, 24, 36, and 52 weeks after the operation. Continence was defined with strict criteria-no usage of pads and no leakage of urine. RESULTS In the reconstruction group, the continence rates at, 1, 4, 12, 24, 36, and 52 weeks postoperatively were 71%, 72%, 80%, 84%, 86%, and 91%, respectively; in the control group, the continence rates were 23%, 49%, 76%, 80%, 85%, and 88%, respectively. CONCLUSION The overall continence rates were similar in both groups at 52 weeks of follow-up. Patients in the total reconstruction group, however, had higher early continence rates compared with patients in the control group. The total reconstruction procedure is an efficient way to achieve an early return to continence.

Robot-Assisted Laparoscopic Bladder Diverticulectomy Combined with Photoselective Vaporization of Prostate: A Case Report and Review of Literature

PURPOSE Open surgery, endoscopic technique, and standard laparoscopic technique are surgical options for the management of bladder diverticuli. In this article, we report robot-assisted bladder diverticulectomy (RABD) and photoselective vaporization of prostate (PVP) in the same patient sequentially. To the best of our knowledge, this is the first case report of RABD combined with PVP. MATERIALS AND METHODS A 63-year-old patient with benign prostatic hyperplasia and a secondary large bladder diverticulum underwent sequential PVP and RABD. Cystoscopic examination revealed obstructing prostate lobes and a large diverticulum at posterior wall of bladder. After completion of PVP procedure, a 16F urethral catheter was inserted into the diverticulum via outer sheath of optic urethrotome and another 16F urethral catheter was left in bladder for urinary drainage. A transperitoneal approach was preferred. The diverticulum was distended with saline infusion via the Foley catheter inside the diverticulum. The distended diverticulum was seen easily and dissected from the surrounding tissue. The bladder was closed in two separate layers. RESULTS Total operative time, including diverticulectomy with PVP procedure, was 230 minutes, and console time was 90 minutes. The length of stay was 7 days. CONCLUSIONS There has been always concern about the high intravesical pressures secondary to irrigant instillation that may disrupt the bladder repair. To avoid this problem we combined robotic diverticulectomy with PVP. Because of hemostatic properties of potassium-titanyl-phosphate laser, we did not encounter with bleeding after prostatectomy procedure. Moreover, we did not use irrigation, and the suture line of the bladder was kept safe. Therefore, we recommend to use greenlight laser in combined prostate and RABD operations. RABD is a feasible and safe procedure. RABD and PVP can be performed safely in the same patient sequentially.

Doppler ultrasonography-guided pelvic plexus block before systematic needle biopsy of the prostate: A prospective randomized study.

OBJECTIVES To report a new method to block pelvic plexus and compare its efficacy with widely used periprostatic nerve block (PPNB) for transrectal ultrasonography-guided prostate biopsy. Pelvic plexuses were localized with the aid of color Doppler ultrasonography to create the pelvic block. METHODS This study was a single-center, prospective randomized trial. A total of 80 patients were recruited in 2 groups, with 40 patients in each. In group 1 (PPNB group), 2 mL of 2% lidocaine was injected between the prostate base and seminal vesicle on each side, using ultrasonic guidance. In group 2 (pelvic plexus block group), 2 mL of 2% lidocaine was injected into the region of the pelvic plexus lateral to the tip of vesicula seminalis on each side, using ultrasonic guidance. Color Doppler ultrasonography was used to identify injection sites. Patients were given an 11-point visual analog scale (VAS) to evaluate the level of pain encountered during probe insertion, injection of local anesthetic, and biopsy procedure. RESULTS In both groups, probe insertion was the least painful stage. With regard to local anesthetic injection, VAS pain score was significantly lower in group 2 (2.05 vs 3.12, P = .0007). Sampling the prostate was the most painful stage in both groups and group 2 had significantly lower biopsy VAS pain scores (2.7 vs 4.97, P < .0001). There were no major complications. CONCLUSIONS Administration of lidocaine in the area of the pelvic plexus under Doppler ultrasonographic guidance provides superior analgesia to PPNB, with limited morbidity during transrectal ultrasonography-guided biopsy of the prostate.

Rapid Communication: Removal of UroLume Endoprosthesis Using Holmium:YAG Laser

A potential complication of UroLume endoprosthesis is migration, which may necessitate removal of the stent. Stent removal may be associated with complications such as urethral injury, bleeding, and external sphincter trauma. We report a patient in whom a holmium:yttrium-aluminium-garnet (Ho:YAG) laser was used to cut the UroLume endoprosthesis into fragments, which led to easy and uneventful stent removal.

Validation of Two Preoperative Kattan Nomograms Predicting Recurrence After Radical Prostatectomy for Localized Prostate Cancer in Turkey: A Multicenter Study of the Uro-oncology Society

OBJECTIVES To examine, in a multicenter validation study designed under the guidance of the Uro-Oncology Society, the predictive accuracies of the 1998 and 2006 Kattan preoperative nomograms in Turkish patients. These 2 preoperative Kattan nomograms use preoperative parameters to estimate disease recurrence after radical prostatectomy. METHODS A total of 1261 men with clinically localized prostate cancer undergoing radical prostatectomy were included. The preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, number of positive and negative prostate biopsy cores, and postoperative recurrence status of all patients were studied. The predicted values using the Kattan nomograms and the observed values were compared. RESULTS The patient characteristics in the cohort were comparable with those of the cohorts used to create the Kattan nomograms. The 5-year probability of freedom from recurrence was 73% using Kaplan-Meier analysis and was similar to that of the 1998 Kattan nomogram cohort. However, the 10-year probability of freedom from recurrence was 67%, slightly lower than the same estimate from the 2006 nomogram cohort. The predicted values of recurrence using Kattan nomogram and the observed rates in our cohort were similar. The estimated concordance index value was 0.698 and 0.705 for 1998 and 2006 nomograms, respectively. CONCLUSIONS The Kattan preoperative nomograms can be used with adequate success in Turkey, because the predicted and observed rates in our cohort were similar. Our results have demonstrated satisfactory concordance index values, suggesting that both the 1998 and the 2006 Kattan preoperative nomograms can safely be used in Turkish patients with similar accuracy. Although the 2006 nomogram had slightly better discrimination, the 1998 nomogram was a little more calibrated.

The Impact of Local Anesthetic Volume and Concentration on Pain During Prostate Biopsy: A Prospective Randomized Trial

PURPOSE To evaluate the effect of equivalent doses of local anesthetic administered at different concentrations and volumes on pain scores in patients undergoing prostate biopsy. PATIENTS AND METHODS This study was a single-center, randomized trial. A total of 120 patients were randomized into two groups with 60 patients in each group. In group 1, 2.5 mL of 2% lidocaine (low volume-high concentration) and in group 2, 5 mL of 1% lidocaine (high volume-low concentration) was injected just lateral to the junction between the prostate base and seminal vesicle on each side under ultrasonographic guidance. Patients were given an 11 point visual analog scale (VAS) to evaluate the level of pain encountered during transrectal ultrasonographic (TRUS) probe insertion, injection of the local anesthetic, and the biopsy procedure. RESULTS In both groups, TRUS probe insertion was the most painful stage of the procedure. With regard to local anesthetic injection, the VAS pain score was significantly lower in group 1 (1.56 vs. 2.41, P=0.001). Concerning sampling of the prostate, group 1 had a significantly lower VAS pain score compared with group 2 (1.71 vs. 2.48, P=0.008). Neither major complications nor side effects related to local anesthetic absorption occurred in both groups. CONCLUSION Low volume-high concentration lidocaine administration provides superior analgesia compared with high volume-low concentration lidocaine during transrectal biopsy of the prostate.

Robot-Assisted Bladder Diverticulectomy with Concurrent Management of Bladder Outlet Obstruction

Introduction: Robot-assisted bladder diverticulectomy (RABD) through a technique for easier identification of diverticulum along with concomitant management of bladder outlet obstruction (BOO) utilizing a combination of transurethral prostatectomy (TUR-P) and photoselective vaporization of prostate (PVP) is presented. Materials and Methods: Between 2008 and 2015, 9 patients underwent RABD with concurrent treatment of BOO. Diverticula were identified by a technique of catheterizing the diverticulum and the bladder simultaneously and individually. Results: Mean patient age was 62 ± 9.8 and prostate volume was 70 ± 26 ml. Mean time for endourological procedure was 77 ± 35, mean console and total operative times were 108 ± 38 and 186 ± 56 min, respectively. Mean estimated blood loss was 71 ± 37 ml. All diverticula were excised and BOO treated successfully. Bladder irrigation was not necessary in any patient. Mean hospitalization and catheter removal time was 5 ± 3 and 8 ± 3 days, respectively. No complications were observed. Conclusions: BOO is the main cause of acquired bladder diverticula and is largely due to benign prostatic hyperplasia. Concomitant performance of TUR-P and PVP along with RABD is feasible and safe. Individual catheterization of the diverticulum and bladder facilitates the identification of diverticulum even in the presence of multiple diverticula.

Conversion to Hand Assistance May Prevent Conversion to an Open Procedure in Standard Laparoscopic Nephrectomy

BACKGROUND AND PURPOSE Laparoscopic surgery has received wide acceptance within the urologic community. Conversion from standard laparoscopy to the open technique may sometimes be necessary. Conversion to an open procedure may have negative implications for both the surgeon and the patient. Conversion to hand-assisted laparoscopy under these circumstances, however, may obviate open surgery. We intended to review our results and emphasize the efficacy and safety of conversion to hand assistance during standard laparoscopy when necessary. PATIENTS AND METHODS We retrospectively reviewed the results of laparoscopic nephrectomies performed by one surgeon. Demographic and perioperative data were noted. Conversions from standard laparoscopy were analyzed in detail. RESULTS A total of 161 laparoscopic nephrectomies were performed. Conversion was deemed appropriate in 6 of 150 standard laparoscopies. Surgery was successfully completed in five with hand assistance. The reason to convert was failure to progress in three patients and control of hemostasis in two patients. Open surgery was performed in a patient who could not tolerate pneumoperitoneum. CONCLUSION Conversion to hand-assisted laparoscopy is safe and effective when the surgeon decides to convert from standard laparoscopy. Conversion to hand assistance may prevent conversion to an open procedure in these situations.