Hani Rashid

Near infrared fluorescence imaging with robotic assisted laparoscopic partial nephrectomy: initial clinical experience for renal cortical tumors.

PURPOSE We evaluated the utility of near infrared fluorescence of intravenously injected indocyanine green in performing robotic assisted laparoscopic partial nephrectomy. In addition, we evaluated the initial performance of a novel near infrared fluorescence imaging system integrated into the da Vinci® Si Surgical System during robotic assisted laparoscopic nephrectomy. MATERIALS AND METHODS Fluorescence imaging for the da Vinci Si Surgical System was used for all cases. Indocyanine green was injected before near infrared imaging. Immediate imaging assessed the renal vasculature while delayed imaging differentiated renal cortical tumors from normal parenchyma. The intraoperative performance of near infrared fluorescence of intravenous indocyanine green was evaluated for tumor appearance relative to surrounding renal parenchyma as well as identification of the renal vasculature. RESULTS A total of 11 patients underwent robotic assisted laparoscopic nephrectomy with 2 converted to robotic assisted laparoscopic radical nephrectomy. Indocyanine green injections were repeated up to a total of 5 times depending on the goal of visualization. Of the 11 patients 10 demonstrated malignancy on final pathology. Of the malignant tumors 7 were hypofluorescent and 3 were isofluorescent compared to the surrounding renal parenchyma. Near infrared fluorescence imaging delineated the vascular anatomy in all cases. All surgical margins were negative on final pathology. CONCLUSIONS Intraoperative imaging of indocyanine green with near infrared fluorescence is a safe and effective method to accurately identify the renal vasculature and to differentiate renal tumors from surrounding normal parenchyma. The capacity for multimodal imaging within the surgical console further facilitates this imaging. Further study is needed to determine if this technique will help improve outcomes of robotic assisted laparoscopic nephrectomy.

Testicular microlithiasis: a review and its association with testicular cancer

Testicular microlithiasis (TM) is an entity of unknown etiology that results in the formation of intratubular calcifications. It is of concern to the urologist because of its possible association with intratubular germ cell neoplasia and testicular germ cell cancer. Although commonly present in patients with germ cell tumors, there appears to be no definitive association with TM and cancer. Therefore, follow-up at this time should be dictated based on risk factors for developing testis cancer more than on the presence of TM.

Near Infrared Fluorescence Imaging After Intravenous Indocyanine Green: Initial Clinical Experience With Open Partial Nephrectomy for Renal Cortical Tumors

OBJECTIVE To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. METHODS Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. RESULTS A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. CONCLUSION The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy.

Robot-Assisted and Laparoscopic Partial Nephrectomy with Near Infrared Fluorescence Imaging

BACKGROUND AND PURPOSE Recent literature has focused on the importance of maximal nephron preservation during partial nephrectomy to avoid complications associated with chronic renal insufficiency. Accurate differentiation of tumor from normal surrounding parenchyma is critical to ensure excessive normal renal tissue is not made ischemic or excised along with the tumor. The feasibility of a novel intraoperative imaging technique to differentiate tumor from surrounding parenchyma during laparoscopic and robot-assisted partial nephrectomy was evaluated. PATIENTS AND METHODS Patients who were scheduled to undergo laparoscopic or robot-assisted partial nephrectomy were recruited from April 2009 to July 2010. The Endoscopic SPY Imaging System was used as an adjunct to intraoperative imaging in all cases. Patients received intravenous injections of indocyanine green (ICG), which was visualized intraoperatively with the near infrared fluorescence (NIRF) imaging capability of the SPY scope. The degree of tumor fluorescence compared with surrounding renal parenchyma was qualitatively assessed before tumor resection, and partial nephrectomy was then performed with standard techniques while intermittently using NIRF imaging. RESULTS Nineteen patients underwent intravenous administration of ICG followed by NIRF during partial nephrectomy. Average tumor size was 3.0 cm (range 0.8-5.9 cm). Thirteen masses were malignant on final pathology results, and all of these were seen to be hypofluorescent compared with surrounding renal parenchyma during intraoperative imaging. The imaging behavior of benign tumors ranged from isofluorescent to hyperfluorescent compared with normal parenchyma. No complications were associated with ICG injection. CONCLUSION NIRF imaging after intravenous ICG administration may be a useful intraoperative imaging tool to differentiate malignant tumors from normal renal parenchyma during laparoscopic and robot-assisted partial nephrectomy. Advanced intraoperative imaging techniques such as this one may become increasingly helpful as more complicated tumors are resected with minimally invasive approaches.

Statin use and the risk of biochemical recurrence of prostate cancer after definitive local therapy: a meta‐analysis of eight cohort studies

Whats known on the subject? and What does the study add?

Interstitial cystitis antiproliferative factor (APF) as a cell-cycle modulator

BackgroundInterstitial cystitis (IC) is a chronic bladder disorder of unknown etiology. Antiproliferative factor (APF), a peptide found in the urine of IC patients, has previously been shown to decrease incorporation of thymidine by normal bladder epithelial cells. This study was performed to determine the effect of APF on the cell cycle of bladder epithelial cells so as to better understand its antiproliferative activity.MethodsExplant cultures from normal bladder biopsy specimens were exposed to APF or mock control. DNA cytometry was performed using an automated image analysis system. Cell cycle phase fractions were calculated from the DNA frequency distributions and compared by two-way analysis of variance (ANOVA).ResultsAPF exposure produced statistically significant increases in the proportion of tetraploid and hypertetraploid cells compared to mock control preparations, suggesting a G2 and/or M phase cell cycle block and the production of polyploidy.ConclusionsAPF has a specific effect on cell cycle distributions. The presence of a peptide with this activity may contribute to the pathogenesis of interstitial cystitis through disruption of normal urothelial proliferation and repair processes.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery

Effectiveness and safety of extended-duration prophylaxis for venous thromboembolism in major urologic oncology surgery

PURPOSE To examine the association between extended-duration prophylaxis (EDP), low-molecular-weight heparin prophylaxis for 28 days after surgery for urologic cancer in patients at high risk of developing a venous thromboembolism (VTE), the risk of VTE, and the complications resulting from VTE prophylaxis. MATERIALS AND METHODS The cohort included 332 patients at high risk for VTE who were surgically treated for urologic cancer from June 2011 to June 2014. Adherence to VTE prophylaxis protocol, VTEs, and complications within 365 days from surgery were tracked. Patients were grouped as follows: (1) per protocol in-hospital prophylaxis with EDP (n = 107), (2) per protocol in-hospital prophylaxis without EDP (n = 42), (3) not per protocol in-hospital prophylaxis with EDP (n = 83), and (4) not per protocol in-hospital prophylaxis without EDP (n = 100). The risk of VTE was compared between the 4 groups using the Cox model, with adjustment for baseline risk factors. RESULTS The rates of VTEs and median times to VTE were 7% and 58 days in group 1, 17% and 44 days in group 2, 17% and 46 days in group 3, and 21% and 15 days in group 4, respectively. Adjusted hazard ratios (HR) for VTE were HR = 0.27 (95% CI: 0.11-0.70) for groups 1 vs. 4; HR = 0.66 (95% CI: 0.25-1.60) for groups 2 vs. 4; and HR = 0.66 (95% CI: 0.29-1.26) for groups 3 vs. 4 with a trend of P = 0.002. The incidence of complications from VTE prophylaxis was not significantly different between the groups, with a rate of 8% in group 1, 17% in group 2, 6% in group 3, and 12% in group 4 (P = 0.33). CONCLUSIONS In high-risk urologic cancer surgery patients, a clinical protocol, with perioperative and EDP, is safe and effective in reducing VTE events.

Identifying additional lymph nodes in radical cystectomy lymphadenectomy specimens

Lymph node count has prognostic implications in bladder cancer patients who are treated with radical cystectomy. Lymph nodes that are too small to identify grossly can easily be missed, potentially leading to missed nodal metastases and inaccurate nodal counts, resulting in inaccurate prognoses. We investigated whether there is a benefit to submitting the entire lymph node packet for histological examination to identify additional lymph nodes. We prospectively assessed 61 pelvic lymphadenectomy specimens in 14 consecutive patients undergoing radical cystectomy. The specimens were placed in Carnoys solution overnight, then analyzed for lymph nodes. The residual tissue was entirely submitted to assess for additional lymph nodes. In 61 specimens, we identified 391 lymph nodes, ranging from 4–44 nodes per patient. We identified 238 (61%) lymph nodes with standard techniques and 153 (39%) lymph nodes in submitted residual tissue. The number of additional lymph nodes found in the residual tissue ranged from 0 to 26 (0–75%) per patient. These lymph nodes ranged in size from 0.05 to 1 cm. All additional lymph nodes were negative for metastatic disease. Submitting the entire specimen for histological examination allowed for identification of more lymph nodes in radical cystectomy pelvic lymphadenectomy specimens. However, as none of the additional lymph nodes contained metastatic disease, it is unclear if there is a clinical benefit in evaluating lymph nodes that are neither visible nor palpable in lymphadenectomy specimens.

Role of frozen section analysis of surgical margins during robot-assisted laparoscopic radical prostatectomy: a 2608-case experience.

It remains unanswered whether and how intraoperative frozen section analysis contributes to the surgical margin status on radical prostatectomy specimens. We aimed to determine whether frozen section analysis during radical prostatectomy reduces the incidence of positive surgical margins. We retrospectively analyzed a consecutive series of patients undergoing robot-assisted laparoscopic radical prostatectomy performed at our institution between 2004 and 2011. We identified 2608 cases, including 1128 (43.3%) where intraoperative frozen section analysis was performed to assess surgical margins. Of the cases with positive (n = 60; 5.3%)/negative (n = 1029; 91.2%)/atypical or indeterminate (n = 39; 3.5%) frozen section analyses, 22 (36.7%)/83 (8.1%)/4 (10.3%) were found to have positive surgical margins on radical prostatectomy specimens, respectively. Thus, 109 (9.7%) of 1128 cases with frozen section analysis had positive surgical margins, compared with 163 (11.0%) of 1480 cases with no frozen section analysis (P = .264). When the patients were subgrouped by histopathologic characteristics, frozen section analysis led to a considerable reduction in the rate of positive surgical margins in cases with biopsy Gleason score 7 (12.4% → 8.7%; P = .087)/8 (28.6% → 16.3%; P = .048)/≥7 (15.3% → 10.1%; P = .012) tumor or pT3b (36.6% → 23.2%; P = .075)/≥pT3b (38.1% → 25.4%; P = .091) disease. Multivariate analysis further revealed that performing frozen section analysis in biopsy Gleason score 7 or higher tumors was an independent predictor of negative surgical margins (odds ratio, 0.61; P = .018). In addition, frozen section analysis of the distal urethra or apex of the prostate (7.5%, P = .035) as well as multiple negative frozen section analyses (≥2: 6.2%, P = .001; ≥4: 2.2%, P = .007) correlated with significantly lower rates of positive surgical margin, compared with no frozen section analysis. Overall, intraoperative frozen section analysis did not dramatically change surgical margin status of radical prostatectomy. Nonetheless, it could be useful in preventing incomplete tumor resection, especially in men with high-grade (Gleason score ≥7) tumor at the apex.