Herbert C. Ruckle

Complications of Laparoscopic Pelvic Lymph Node Dissection

Intraoperative and postoperative complications were assessed in the first 372 patients undergoing laparoscopic pelvic lymph node dissection at 8 medical centers. In 16 patients laparoscopic node dissection could not be completed due to patient body habitus or technical difficulties. Of these aborted procedures 14 occurred during the initial 8 dissections at each institution. A total of 55 complications (15%) occurred: 14 were noted in the intraoperative and 41 in the postoperative period. Of these patients 13 required open surgical intervention for the treatment of a complication. Complications included vascular injury (11 patients), viscus injury (8), genitourinary problems (10), functional/mechanical bowel obstruction (7), lower extremity deep venous thrombosis (5), infection/wound problem (5), lymphedema (5), anesthetic complications (2) and obturator nerve palsy (2). Based on our experience, there is a significant learning curve associated with performing laparoscopic pelvic node dissection. However, with experience and adherence to laparoscopic surgical principles, the risk of complications may be minimized.

Laparoscopic Treatment of a Stone-Filled, Caliceal Diverticulum: A Definitive, Minimally Invasive Therapeutic Option

We describe the laparoscopic treatment of a symptomatic, stone-filled caliceal diverticulum in a patient who would have otherwise required open surgical excision of the diverticulum. Laparoscopic management was chosen as an alternative to an open operation in this patient because the anterior location of the diverticulum precluded treatment with percutaneous nephrolithotomy, while the stone burden and stenotic orifice precluded management with extracorporeal shock wave lithotripsy. The patient had no morbidity, returned to the preoperative activity level by 2 weeks and remains asymptomatic. The options for managing caliceal diverticula are discussed.

Fracture of penis : diagnosis and management

Fracture of the penis is a rupture of the rigid corporeal body. Nine consecutive patients with this malady were managed by an operative repair, which included degloving of the penis, evacuation of the hematoma, and closure of the corporeal tear. Postoperatively all patients reported excellent rigidity of a straight penis. We conclude that operative management of a fractured corporeal body is safe and effective.

Salvage focal prostate cryoablation for locally recurrent prostate cancer after radiotherapy: Initial results from the cryo on-line data registry

Several investigators have tried to apply salvage focal prostate cryoablation to small numbers of patients with biopsy‐proven unilateral recurrent prostate cancer (PCa) after radiotherapy with the aim of decreasing complications of salvage cryoablation. We report contemporary outcomes of salvage focal cryoablation for locally recurrent PCa after radiotherapy within the Cryo On‐Line Data (COLD) Registry.

Histopathologic Evaluation of the Canine Prostate Following Electrovaporization

PURPOSE Transurethral electrovaporization of the prostate (TVP) for symptomatic benign prostatic hypertrophy (BPH) has proven to be efficacious with minimal patient morbidity. When compared to transurethral resection of the prostate (TURP), TVP demonstrates comparable postoperative flow rates, American Urologic Association (AUA) symptom score indices, and a potential cost savings. However, in the human studies it has not been possible to correlate these clinical parameters with procedure-related histopathologic changes in the prostate immediately postoperative or during wound healing. The following study was done using a canine model in an effort to evaluate these histopathologic changes. METHODS AND MATERIALS Fifteen hounds (25-35 kg.) underwent antegrade electrovaporization of the prostate, via an open cystotomy, using a Circon ACMI USA series resectoscope and video equipment. The dogs were sacrificed and the prostates harvested at various intervals postoperatively (0-11 weeks). The prostates were evaluated grossly as well as histologically for cavitary defects, depth of necrosis, and cellular response. RESULTS Prostates examined immediately following the procedure demonstrated superficial necrosis (less than 2 mm.) in the region of vaporized tissue. One week postoperatively, the vaporized regions demonstrated an intense acute inflammation amidst superficial necrosis with focal hemorrhage and dystrophic calcification. Transient glandular cystic changes developed, but were resolving by seven weeks postoperatively. Re-epithelialization was underway by the third postoperative week and epithelial stratification underway by the fifth week. There was no extension of the initial two millimeter zone of necrosis at any time point examined. CONCLUSION TVP in the canine model vaporizes prostatic tissue at the site of contact. Only a shallow remnant of necrosis remains at the site of vaporization, indicating the highly localized effect of this technique. Healing at the site of vaporization occurs in a rapid and expected manner. These data provide a histopathologic rationale for the minimal morbidity and the efficacious nature of this technique demonstrated in clinical studies.

Local recurrence of renal cell carcinoma causing duodenal-inferior vena caval fistula: Case report and review of the literature

We report the first case of a duodenal-inferior vena caval (IVC) fistula resulting from locally recurrent renal cell carcinoma (RCC). A 45-year-old man presented with gross hematuria and underwent a right radical nephrectomy to treat a solid renal mass. Histologic evaluation showed RCC, Stage pT3aN0M0. The patient presented 21 months later in hemorrhagic shock, with upper gastrointestinal bleeding. He underwent an exploratory laparotomy and Whipple procedure for a mass in the second portion of the duodenum extending to the inferior vena cava with a secondary duodenal-IVC fistula. We describe this case and review the previously published reports of duodenal-IVC fistulae.

Does Neoadjuvant Androgen Deprivation Therapy Before Primary Whole Gland Cryoablation of the Prostate Affect the Outcome

OBJECTIVE To evaluate the effect of neoadjuvant androgen deprivation therapy (NADT) on the outcomes for primary whole gland prostate cryoablation (CRYO). NADT before CRYO has sometimes been used for prostate volume reduction, with some theoretical benefit toward improving disease control. NADT has been shown to be beneficial for biochemical disease-free survival (bDFS) with radiotherapy but not in conjunction with radical prostatectomy. METHODS We retrospectively compared risk-stratified cohorts according to whether they had received NADT. bDFS was defined using the Phoenix criteria, and postoperative morbidity and complications were compared. RESULTS A total of 1761 men had undergone NADT before CRYO and 2727 had not. No differences were found in the incidence of postoperative incontinence, pad use, potency, or fistula formation. The rate of urinary retention at 12 months was slightly lower for those who had not undergone NADT (0.8% vs 1.2%, P = .015). No difference was found in bDFS between the NADT and non-NADT men (66.9% vs 66.5% at 5 years). When stratified by risk, however, a statistically significant difference was found between the NADT and non-NADT men only in the intermediate-risk cohort (71.3% vs 65.9%; P < .013). CONCLUSION bDFS was statistically similar between the NADT and non-NADT men, except in the intermediate-risk cohort, with slightly improved survival for those undergoing NADT. No significant difference was found in the complication rates. These data do not support the routine use of NADT for men undergoing primary whole gland cryoablation, although its use could be considered for men with larger prostates or men in the intermediate-risk category.

Intraoperative ultrasound: Determination of the presence and extent of vena caval tumor thrombus

OBJECTIVES To report and discuss five cases of renal cell carcinoma (RCC) in which preoperative imaging studies were equivocal with regard to the presence and extent of vena caval tumor thrombus or in which dynamic intraoperative imaging of the vena cava was advantageous. METHODS We reviewed the cases of five patients who had conflicting preoperative imaging studies and reviewed the literature applying to this clinical situation. RESULTS Two patients whose preoperative magnetic resonance imaging studies suggested inferior vena caval tumor thrombus were shown, on intraoperative color Doppler ultrasound, not to have tumor thrombus but rather turbulent flow within the vena cava mimicking thrombus. In two patients intraoperative ultrasound (IOUS) was used to image the position of the tumor thrombus as it was manipulated to allow for safe vena caval clamp placement. In one patient we used real-time imaging to visualize thrombus extraction from the heart. CONCLUSIONS Intraoperative ultrasound real-time imaging is beneficial in two specific situations: in those cases in which the presence of renal vein or inferior vena cava involvement is equivocal based on preoperative imaging techniques and when there is a need to identify intraoperatively the limits of a known tumor thrombus to allow subsequent safe placement of a caval clamp.

Patients with End-Stage Renal Disease Are Candidates for Robot-Assisted Laparoscopic Radical Prostatectomy

BACKGROUND AND PURPOSE Patients with end-stage renal disease (ESRD) have multiple comorbidities that place them at increased risk for surgical complications. Consequently, patients with both ESRD and prostate cancer (PCa) have rarely been considered candidates for radical prostatectomy. The objective of this study is to compare ESRD patients who are undergoing robot-assisted laparoscopic prostatectomy (RALP) with a cohort of patients with no history of dialysis. PATIENTS AND METHODS A retrospective review was conducted of 430 patients who were undergoing RALP, including 12 receiving dialysis at the time of surgery. Preoperative demographics, perioperative parameters, and postoperative outcomes were compared using a two-tailed Student t test and a chi-square test, with significance at P<0.05. RESULTS Patient demographics including body mass index, Gleason score, and prostate-specific antigen (PSA) value were similar between the two groups. Patients with ESRD had younger age (55.5 vs 62.9 years; P<0.01), higher American Society of Anesthesiologists scores (3.7 vs 2.5; P<0.01), and higher age-adjusted Charlson Comorbidity Index scores (6.2 vs 4.2; P<0.01). Patient outcomes including operative time, estimated blood loss, complication rate, postoperative stay, and positive margins did not differ significantly between groups. No ESRD patients needed pads or had a detectable PSA level using an ultrasensitive assay. CONCLUSIONS This series represents the largest series of patients with ESRD undergoing RALP. These patients experienced similar outcomes compared with patients with no history of dialysis despite greater preoperative comorbidity. RALP produces minimal fluid shifts, low blood loss, and excellent cancer control, making it an ideal treatment option to prepare patients with both ESRD and PCa for renal transplantation.

Phagocytic and Natural Killer Cytotoxic Responses of Murine Transitional Cell Carcinoma to Postsurgical Immunochemotherapy

Postsurgical immunochemotherapy with Corynebacterium parvum (CP) and cis-diamminedichloroplatinum (II) (CDDP) was evaluated in mice with transitional cell carcinoma (MBT-2). C3H/He mice were transplanted subcutaneously in the hind limb with 5 x 10(5) tumor cells. Ten to 14 days later when the tumor reached a diameter of five to seven mm., it was surgically removed. Mice were then randomized into four groups to receive a total of three treatments on days 1, 3 and 5 after surgery: 1) saline (control group); 2) CP, 250 micrograms. into the surgical site; 3) CDDP, 5 micrograms./gm. body weight intraperitoneally; and 4) combined CP and CDDP. Recurrence of tumor occurred in 70%, 52%, 55% and 28% of mice receiving surgery only, CP, CDDP, and combined CP and CDDP respectively. In the second part of the experiment, phagocytic activity using chemiluminescence assay and natural killer (NK) activity using chromium-51 release assay were determined with cells from the peritoneum, spleen and inguinal lymph nodes. CP or CDDP alone enhanced the phagocytic and NK activity. The most significant enhancement was obtained with cells from the inguinal lymph nodes of mice receiving combined CP and CDDP, the group with the lowest tumor recurrence. These results suggest that combination of CP and CDDP may be useful in control of postsurgical recurrence of bladder cancer.