Hong Gee Sim

Intravesical prostatic protrusion predicts clinical progression of benign prostatic enlargement in patients receiving medical treatment

Objectives:u2003 To assess intravesical prostatic protrusion (IPP) as a novel predictor of clinical progression in patients with benign prostatic enlargement (BPE).

Is photodynamic diagnosis using hypericin better than white-light cystoscopy for detecting superficial bladder carcinoma?

To review the initial clinical results of photodynamic diagnosis (PDD) using hypericin (a new photosensitizer for PDD that helps to label flat urothelial tumours to facilitate biopsy) for the early detection of superficial bladder carcinoma, as flat noninvasive tumours of the bladder may be missed during conventional white‐light cystoscopy (WLC) if there is bladder overdistension or ongoing cystitis.

Equipment and technology in surgical robotics

Contemporary medical robotic systems used in urologic surgery usually consist of a computer and a mechanical device to carry out the designated task with an image acquisition module. These systems are typically from one of the two categories: offline or online robots. Offline robots, also known as fixed path robots, are completely automated with pre-programmed motion planning based on pre-operative imaging studies where precise movements within set confines are carried out. Online robotic systems rely on continuous input from the surgeons and change their movements and actions according to the input in real time. This class of robots is further divided into endoscopic manipulators and master–slave robotic systems. Current robotic surgical systems have resulted in a paradigm shift in the minimally invasive approach to complex laparoscopic urological procedures. Future developments will focus on refining haptic feedback, system miniaturization and improved augmented reality and telesurgical capabilities.

Team-based approach reduces learning curve in robot-assisted laparoscopic radical prostatectomy.

Aim:u2002 We assessed the team approach in reducing the learning curve during our 2‐year experience transiting from open to robot‐assisted laparoscopic radical prostatectomy (rLRP).

Early Experience with Robot-assisted Laparoscopic Radical Prostatectomy

INTRODUCTIONnWe assessed the feasibility of a robot-assisted laparoscopic radical prostatectomy (rLRP) programme through a review of our early experience.nnnPATIENTS AND METHODSnSeventeen patients underwent rLRP between 1 February 2003 and 31 December 2003 at Singapore General Hospital. All patients had histologically confirmed adenocarcinoma on prostate biopsy and a negative bone scan. The Da Vinci robot was employed. The Montsouris technique was used for our first eight patients, and the Vattikuti Institute Prostatectomy technique was used for all subsequent patients. We studied perioperative parameters and early surgical outcome prospectively.nnnRESULTSnThe mean age at diagnosis was 63.9 +/- 5.6 years. The median Gleason sum was 6 (range, 5-9), and mean pretreatment prostate-specific antigen level was 10.5 +/- 5.4 ng/mL. The mean set-up time was 34 +/- 18 minutes, and mean dissection time was 247 +/- 43 minutes. Perioperative blood loss averaged 494 +/- 330 mL, and three patients required blood transfusion. Normal diet was resumed after 1.7 +/- 0.6 days. The mean duration of bladder catheterization was 9.8 +/- 6.1 days, and mean hospital stay was 2.7 +/- 1.3 days. There was no perioperative mortality or major complications, and no conversion to open radical prostatectomy. From Case 9 onwards, there was significant reduction in operating time (284 vs 215 minutes), blood loss (650 vs 400 mL) and hospital stay (3.8 vs 1.8 days).nnnCONCLUSIONSnrLRP is feasible in a practice with a low volume of radical prostatectomies. Significant improvement in perioperative parameters occurs after the first eight cases. This technique confers the benefits of enhanced precision and dexterity for complex laparoscopic work in the pelvic cavity.

Routine vascular control using the Hem-o-Lok clip in laparoscopic nephrectomy: Animal study and clinical application

BACKGROUND AND PURPOSEnDuring laparoscopic nephrectomy (LPN), a stapling device is often used for vascular control, especially of the renal vein. Herein, we report our experience using a polymer clip (Hem-o-lok) for routine control of the vessels during LPN in the animal and clinical setting.nnnPATIENTS AND METHODSnFifty ablative and fifteen live-donor nephrectomies were performed in domestic pigs. Hem-o-lok clips (10 mm; Weck Closure System, Research Triangle Park, NC) were routinely used for vascular control. In addition, from January 2001 to July 2002, 46 patients underwent hand-assisted laparoscopic (HAL) (N=40) or laparoscopic (N=6) nephrectomy for renal disease or donor nephrectomy. Venous control was achieved solely by the Hem-o-lok clips where at least two clips were applied on the patient side. Arterial control was obtained by the Hem-o-lok clips either alone or in combination with the metal clips. The technical difficulty in obtaining vascular control, transfusion requirement, and clinical outcome were evaluated.nnnRESULTSnIn the animal study (total 65 nephrectomies), individual vascular control was obtained by the Hem-o-lok clip in all cases except two, where vascular injury during dissection necessitated endoscopic stapling of renal hilum or open conversion. The warm ischemic time for animal donor kidney harvest was uniformly <2 minutes. In the clinical study, arterial control was obtained mostly by a combination of Hem-o-lok and metal clips. Venous control using the Hem-o-lok was successful in all 46 cases without any slipping of clips or uncontrolled bleeding. The mean operating time was 148 minutes. No open conversion was required. The transfusion rate was 6.5% (N=3), with none of the transfusions being related to inadequacy of vascular control using the Hem-o-lok. Major complications included deep vein thrombosis and postoperative retroperitoneal hemorrhage (same patient) and acute respiratory distress syndrome (N = 1). The mean postoperative stay was 5.2 days (range 1-20 days).nnnCONCLUSIONnThe Hem-o-lok is a reliable and economical device for vascular control in laparoscopic renal surgery.

Robotic radical prostatectomy in east Asia: development, surgical results and challenges.

Purpose of review The shift toward robot-assisted laparoscopic radical prostatectomy has reshaped the surgical approach for localized prostate cancer in America and many parts of Europe. Its impact on Asia, however, has been somewhat delayed and less widespread compared with western countries. We reviewed and surveyed the evolving trends in robotic prostatectomy in east Asia and describe how the influence of cancer demography, financial reimbursement models, refinements in robotic technology and robotic surgical training will alter the future direction of the procedure in this region. Recent findings There are about 50 systems installed in east Asia. Numerous centers have reported successful implementation of robotic prostatectomy program, with transfusion rate of 7–26.4%. Margin positivity for T2 disease ranges from 9.8 to 24%, whereas continence rates range from 75 to 94% over 3–6 months. Significant increase in number of prostatectomy has been observed in some centers. Summary The outlook for robotic prostatectomy in east Asia remains rosy despite the obstacles in financial reimbursement, patient volume and surgical skill development. Future robotic systems with smaller footprint, leaner instrument arms and lower costs will help to accelerate its integration into more Asian hospitals.

Predictors of androgen independence in metastatic prostate cancer

To assess the factors that influence the onset of androgen independence (AI, which heralds a dismal outcome) in patients with metastatic prostate carcinoma.

Laparoscopic Nephrectomy: New Standard of Care?

OBJECTIVEnThe pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period.nnnMETHODSnFrom January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery.nnnRESULTSnMost operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was 4,943 dollars compared with 4,479 dollars for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (7,500 dollars versus 7,907 dollars).nnnCONCLUSIONnThe laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.

What is the optimum PSA screening interval after an initial negative test

DESIGN AND INTERVENTION This study included men from a center in Gothenburg, Sweden (enrolled from November 1993), and a center in Rotterdam, The Netherlands (enrolled from January 1995), who participated in the European Randomized Study of Screening for Prostate Cancer (ERSPC). Participants were randomly assigned to a PSA screening group or a control group. The screening intervals in the screening groups of the Rotterdam center and Gothenburg center were 2 years and 4 years, respectively. Participants in the screening groups generally received a prostate biopsy if they had a serum PSA level ≥3.0 ng/ml. Prostate cancers were classified by pathologists blinded to the patients’ study group. The study period was until December 2005, and participants aged 50–65 years were included in the analysis.