Jacob Ramon

Radical retropubic prostatectomy: morbidity and quality of life. Experience with 620 consecutive cases

We describe our experience and complications of radical retropubic prostatectomy. From March 1983 through December 1990, 620 consecutive patients have undergone an anatomical radical retropubic prostatectomy for the treatment of prostatic carcinoma. The surgical technique we used is described. In 167 patients the procedure included preservation of the neurovascular bundles. There were no modifications in the surgical technique during this period. There were no operative deaths. Mean operating time was reduced from 3 hours in the first 100 patients to 1.5 hours in the last 220 patients. The average blood loss was reduced remarkably as well. There were only 3 cases of rectal injury, which were closed primarily and healed completely. One patient died of acute myocardial infarction 12 days after an uneventful operation. This patient accounted for the only perioperative death in our experience. Early complications occurred in 43 patients (6.9%), including only 2 cases (0.3%) of anastomotic urinary leakage. The late complication rate, excluding incontinence and impotence, was 1.3%. No patient was totally incontinent. Among the patients who were followed for 1 year or longer 95% achieved complete urinary control and 5% experienced stress urinary incontinence. Preservation of sexual function in patients who underwent a nerve-sparing operation was achieved in 71%. Our results indicate that radical retropubic prostatectomy can be performed with low morbidity and without affecting the quality of life in the majority of patients.

Repair of Pelvic Fracture Posterior Urethral Defects Using an Elaborated Perineal Approach: Experience with 74 Cases

A total of 74 patients with posterior urethral distraction defects (1.5 to 7 cm. long) that followed pelvic fracture was managed by a 1-stage perineal repair. End-to-end anastomosis was performed in all cases but in 66 a variety of surgical maneuvers were necessary to accomplish a tension-free anastomosis. These techniques, which included distal urethral mobilization, corporeal body separation, inferior pubectomy and supracrural urethral rerouting, were resorted to in a sequential manner as needed. Excellent results were achieved in 96% of the cases. These surgical techniques are described and discussed.

Diagnosis of prostate cancer.

The contemporary challenge of prostate cancer diagnosis has been changed in the past decade from the endeavor to increase detection to that of detecting only those tumors that are clinically significant. Better interpretation of the role of prostate-specific antigen (PSA) and its kinetics as a diagnostic tool, the adoption of extended prostate biopsy schemes, and perhaps implementation of new transrectal ultrasound (TRUS) technologies promote the achievement of this clinical mission. This chapter reviews these issues as well as the change in practice of patient preparation for TRUS-biopsy and analgesia during it, the role of repeat and saturation prostate biopsies, and the interpretation of an incidental prostate cancer finding. Currently, the lifetime risk of a diagnosis of prostate cancer for North American men is 16%, compared to the lifetime risk of death from prostate cancer, which is 3% (Carter 2004). The advent of prostate-specific antigen (PSA) screening and transrectal ultrasonography (TRUS) has significantly impacted the detection of prostate cancer over the last 20 years. The mean age at diagnosis has decreased (Hankey et al. 1999; Stamey et al. 2004) and the most common stage at diagnosis is now localized disease (Newcomer et al. 1997; Stamey et al. 2004). The goal of prostate cancer screening is to detect only those men at risk for death from the disease at an early curable phase. The ambiguous natural history of this most common malignancy in men, being latent with questionable life-threatening potential in a large number of cases on the one hand, with only a relatively small number (though not negligible) of highly malignant cases on the other, propels many doubts about whether this is possible. This was famously phrased more than 20 years ago by Whitmore who asked: Is cure possible for those in whom it is necessary; and is it necessary for those in whom it is possible? This is probably even more relevant nowadays. During the past decade two factors influenced significantly the increased detection rate of prostate cancer in general and that of clinically insignificant prostate cancers in particular: the widespread use of serum PSA as a screening tool to a large extent and to a lesser though significant extent the application of extended multiple core biopsy schemes (Master et al. 2005). In fact, 75% of men in the United States aged 50 years and older have been screened with the PSA test (Sirovich et al. 2003). Outside of the screening context, which is dealt with in depth in Chap. 5, clinical suspicion of prostate cancer is raised usually by abnormal digital rectal examination (DRE) and/or by abnormal levels of serum PSA. Final diagnosis is achieved only based on positive prostate biopsies.

Ethanol and Polyvinyl Alcohol Mixture for Transcatheter Embolization of Renal Angiomyolipoma

OBJECTIVEnThe purpose of this study was to assess the immediate and midterm effects of embolization of the angiogenic component of renal angiomyolipoma in which a mixture of ethanol and polyvinyl alcohol is used as a permanent obliterator.nnnMATERIALS AND METHODSnSeventeen patients with 18 renal angiomyolipomas (size range, 5.5-20 cm; mean size, 10 cm) were treated with transcatheter embolization over an 8-year period. Embolization was performed with a mixture of 96% ethanol and polyvinyl alcohol particles. Follow-up with CT (mean follow-up period, 22.4 months) and one (mean, 14 months) or two (mean, 27 months) angiographic examinations were conducted to evaluate changes in the size of the tumor and to look for recurrence of the angiogenic component.nnnRESULTSnAll initial angiograms showed the characteristic tortuous, hypervascular, and aneurysm-forming angiogenic component. Immediate complete obliteration was achieved in 17 tumors (94.4% technical success rate). There was one partial technical failure. Mean tumor size was reduced to 7.6 cm (mean size reduction, 24%). Fourteen patients with 15 tumors underwent one angiographic follow-up examination (mean time after treatment, 14 months), and four patients underwent two angiographic follow-up examinations (mean time after treatment, 27 months). Reduction of the angiogenic component occurred in 10 (66.6%) of the tumors and complete obliteration in five (33.3%) of the tumors. No retroperitoneal hemorrhage or tumor growth was seen during the follow-up period. No complications were encountered.nnnCONCLUSIONnWe found a mixture of ethanol and polyvinyl alcohol an efficient embolizing agent with a sustained midterm effect in the management of renal angiomyolipoma. Repeated embolization was needed in tumors with a large angiogenic component. Tumor shrinkage after embolization was minimal.

Salvage Posterior Urethroplasty after Failed Initial Repair of Pelvic Fracture Membranous Urethral Defects

Experience with 20 salvage urethroplasties in patients with pelvic fracture membranous urethral defects who failed previous delayed urethroplasty is presented. A total of 15 patients was successfully managed by 1-stage procedures, 14 by bulboprostatic reanastomosis and 1 by a tubed pedicled island of skin. Substitution urethroplasty with a staged perineoscrotal skin tube inlay was performed in 5 patients in whom an anastomosis could not be achieved either due to an excessively long urethral defect or inelasticity of the anterior urethra precluding its elongation for an anastomosis free of tension. A successful result was achieved in 19 of the 20 patients (95%). The rationale for procedure selection is discussed.

The Outcome of Transvaginal Cystourethropexy in Patients with Anatomical Stress Urinary Incontinence and Outlet Weakness

Preoperative urodynamic and radiographic evaluation identified features of bladder neck and urethral weakness in 62 women undergoing cystourethropexy for the correction of anatomical stress urinary incontinence. Despite the coexistence of anatomical and outlet factors persistent stress incontinence due to intrinsic urethral weakness occurred in only 2 patients (3%), neither of whom was identifiable by preoperative urethral function evaluation. Preoperative coexisting urgency symptoms had no impact on the surgical outcome, resolving in the majority of patients with sensory urgency and responding to alternate postoperative management in those with bladder instability. We conclude that anatomical correction by cystourethropexy is appropriate for women with mixed etiology incontinence in whom urethrovesical hypermobility is present.

Role of Transrectal Ultrasonography in the Evaluation of Azoospermic Men With Low-Volume Ejaculate

Objective. The purpose of this prospective study was to evaluate the incidence of distal ejaculatory system defects with transrectal ultrasonography (TRUS) among patients evaluated for azoospermia. Methods. Forty‐two patients with low‐volume ejaculate and azoospermia were evaluated by physical examination, serum follicle‐stimulating hormone and luteinizing hormone level determination, karyotyping, selective screening for cystic fibrosis mutations, and TRUS. Results. On physical examination, in 29 patients (69%), either 1 (12 patients) or both (17 patients) of the vasa deferentia could not be palpated. In the group of 17 patients with bilateral involvement of the vasa deferentia, the ultrasonographic imaging universally showed bilateral absence or hypoplasia of the seminal vesicles with bilateral agenesis of the vasa deferentia and nonvisualization of both ejaculatory ducts. In the patients with a unilateral abnormality on physical examination, the ultrasonographic imaging showed absence of the ipsilateral seminal vesicle in 7 patients and the hypoplastic seminal vesicle in 5. In the group of 13 patients with normal physical examination findings, a variety of obstructive causes were diagnosed by TRUS examination. Conclusions. According to this study, TRUS appears to be a sensitive method for evaluating the anatomy of the distal ejaculatory system. Its safety and low costs make it a good alternative to the other invasive and expensive methods.

The role of indirect radionuclide cystography during the acute phase of pyelonephritis in young women

Authors from Israel have investigated the use of dynamic renal scans in young female patients with acute pyelonephritis, combined with indirect radionuclide cystography. They found that using these techniques may avoid up to half of the delayed voiding cysto‐urethrograms, preventing the related inconvenience and cost.

Percutaneous transhepatic lithotripsy with the holmium: YAG laser for the treatment of refractory biliary lithiasis.

Fourteen patients who failed at least 1 endoscopic retrograde cholangiopancreatograpy attempt underwent Holmium laser biliary lithotripsy between 2003 and 2007. Ten had prior biliary surgeries, 7 harbored multiple stones, and 6 had common bile duct strictures. Mean age at surgery was 63.6 years (50 to 80u2009y), biggest stone burden 30u2009mm, mean operative time 58.4 minutes (24 to 105), and stone free rate 85.7%. One patient had postoperative bleeding from the choledochostomy tube that eventually resolved spontaneously and 3 patients had postoperative cholangitis managed conservatively. Neither conversions to open surgery nor mortality was recorded. Two patients were diagnosed with cholangiocarcinoma missed by previous endoscopic retrograde cholangiopancreatograpy. After a mean follow-up of 18.9 months (2 to 43) no de novo strictures were recorded. Percutaneous choledochoscopy with holmium laser lithotripsy is a safe and effective minimally invasive technique to treat complex biliary stone disease and may preclude high-risk open biliary tract surgery.

Is Postoperative Arteriovenous Fistula Still a Concern After En Bloc Stapling of the Renal Hilum During Laparoscopic Nephrectomy

PURPOSEnTo report our experience with en bloc stapling of the renal hilum during laparoscopic nephrectomy (LN) and nephroureterectomy and to compare it with separate stapling performed during the same period at the same institution.nnnPATIENTS AND METHODSnWe conducted a retrospective review of 125 laparoscopic nephrectomies and nephroureterectomies performed between November 2003 and September 2006 for benign and malignant conditions. The main outcome was assessment of complications, with special emphasis on postoperative arteriovenous fistula. Secondary outcomes included operative blood loss and operative time. Statistical analysis was performed using two-sided parametric, nonparametric, or categorical tests as appropriate. Statistical significance was set at P < or = 0.05.nnnRESULTSnThe transperitoneal approach and 2.5 mM vascular titanium clips were used in all cases. En bloc stapling (group 1) was performed in 65 patients and individual stapling (group 2) in 60. There was a significantly higher proportion of right-side surgeries in group 1 than in group 2 (51 vs 25%, P = 0.05). Overall complications were 31% vs 32%, P = 0.91; mean operative time (confidence interval [CI]) 130 (95% 119, 141) vs 125 min (95% 115, 136), P = 0.3; and mean operative blood loss (CI) 100 (95% 39, 160) vs 135 mL (95% 76, 193), P = 0.33 did not differ for groups 1 and 2, respectively. After a median follow-up (interquartile range) of 25 (24.7) vs 30 (30.0) months, P = 0.14, no cases of arteriovenous fistula were detected.nnnCONCLUSIONSnEn bloc stapling of the renal hilum is as safe and effective as individual stapling. Arteriovenous fistula after LN does not seem to be a concern with the use of modern inorganic titanium staplers.