James Ulchaker

Laparoscopic radical cystoprostatectomy with ileal conduit performed completely intracorporeally: the initial 2 cases

OBJECTIVES To present the initial 2 patients who underwent laparoscopic radical cystoprostatectomy, bilateral pelvic lymphadenectomy, and ileal conduit urinary diversion, with the entire procedure performed exclusively by intracorporeal laparoscopic techniques. METHODS Two male patients, 78 and 70 years old, with muscle-invasive, organ-confined, transitional cell carcinoma of the urinary bladder underwent the procedure. The entire procedure, including radical cystoprostatectomy, pelvic node dissection, isolation of the ileal loop, restoration of bowel continuity with stapled side-to-side ileoileal anastomosis, retroperitoneal transfer of the left ureter to the right side, and bilateral stented ileoureteral anastomoses were all performed exclusively by intracorporeal laparoscopic techniques. Free-hand laparoscopic suturing and in situ knot-tying techniques were used exclusively. RESULTS The surgical time was 11.5 hours in the first patient and 10 hours in the second. The respective blood loss was 1200 mL and 1000 mL. In both patients, ambulation resumed on postoperative day 2, bowel sounds on day 3, and oral intake on day 4; the hospital stay was 6 days. Narcotic analgesia comprised 108.3 mg and 16.5 mg of morphine sulfate equivalent, respectively. Pathologic examination revealed pT4N0M0 (prostate) and pT2bN0M0 transitional cell carcinoma of the bladder with the surgical margins negative for cancer in both patients. No intraoperative or postoperative complications occurred in either patient. CONCLUSIONS To our knowledge, this is the initial report of laparoscopic radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion. We believe that with further experience and refinement in the operative technique, laparoscopic radical cystoprostatectomy with ileal conduit urinary diversion may become an attractive treatment option for selected candidates with localized muscle-invasive bladder cancer.

Laparoscopic Radical Cystectomy and Continent Orthotopic Ileal Neobladder Performed Completely Intracorporeally: The Initial Experience

PURPOSE We introduce the operative technique of laparoscopic radical cystectomy and orthotopic ileal neobladder with a Studer limb performed completely intracorporeally. MATERIALS AND METHODS The procedure was performed in 1 man and 1 woman. Using a 6 port transperitoneal approach, radical cystectomy in the female patient and radical cystoprostatectomy in the male patient were completed laparoscopically with the urethral sphincter preserved. Bilateral pelvic lymphadenectomy was done. A 65 cm. segment of ileum 15 cm. from the ileocecal junction was isolated, and ileo-ileal continuity was restored using Endo-GIA staplers (U.S. Surgical, Norwalk, Connecticut). The distal 45 cm. of the isolated ileal segment were detubularized, maintaining the proximal 10 cm. segment intact as an isoperistaltic Studer limb. A globular shaped ileal neobladder was constructed and anastomosed to the urethra. Bilateral stented ureteroileal anastomoses were individually performed to the Studer limb. All suturing was done exclusively using free-hand laparoscopic techniques and the entire procedure was completed intracorporeally. An additional case is described of Indiana pouch continent diversion in which the pouch was constructed extracorporeally. RESULTS Total operative time for laparoscopic radical cystectomy and orthotopic neobladder was 8.5 and 10.5 hours, respectively, with a blood loss ranging from 200 to 400 cc. Hospital stay was 5 to 12 days and surgical margins of the bladder specimen were negative in each case. Both patients with orthotopic neobladder had complete daytime continence. Postoperative renal function was normal and excretory urography revealed unobstructed upper tracts. During followup ranging from 5 to 19 months 1 patient died of metastatic disease, while the other 2 are doing well without local or systematic progression. CONCLUSIONS Laproscopic radical cystectomy and orthotopic ileal neobladder performed completely intracorporeally are feasible.

Single-port transvesical simple prostatectomy: initial clinical report.

INTRODUCTION To present the initial report of single-port transvesical enucleation of the prostate in 3 patients with large-volume benign prostatic hyperplasia. METHODS Single-port transvesical enucleation of the prostate was performed in 3 patients with large-volume (187, 93, and 92 g) benign prostatic hyperplasia. A novel single-port device (r-Port) was introduced percutaneously into the bladder through a 2.5-cm incision under cystoscopic guidance. After establishing pneumovesicum, the adenoma was enucleated in its entirety transvesically under laparoscopic visualization using standard and articulating laparoscopic instrumentation. The adenoma was extracted through the solitary skin and bladder incision after bivalving the prostate lobes within the bladder. RESULTS Single-port transvesical enucleation of the prostate was technically feasible in all 3 cases. The operative time was 6, 1.5, and 2.5 hours, and the blood loss was 900, 250, and 350 mL. In patient 1, who had previously undergone open suprapubic surgery, a bowel injury occurred during r-Port insertion; the injury was recognized and repaired intraoperatively without sequelae. The urethral Foley catheter was removed on day 4, and all patients were voiding spontaneously with a minimal postvoid residual volume and full continence. CONCLUSIONS Transvesical single-port laparoscopic simple prostatectomy is technically feasible. Additional experience at our and other institutions is necessary to determine its role in the surgical management of large-volume symptomatic benign prostatic hyperplasia.

SUCCESSFUL OUTCOMES IN PHEOCHROMOCYTOMA SURGERY IN THE MODERN ERA

PURPOSE We describe our experience with surgical management, complications and treatment outcome of histologically confirmed pheochromocytoma. MATERIALS AND METHODS The records of 113 patients who underwent surgical excision of pheochromocytoma were reviewed and assessed for preoperative medical treatment, intraoperative findings, postoperative hospitalization and complications. RESULTS There were no surgical mortalities. Average length of stay in the intensive care unit was 1.2 days. There were only 6 major cardiovascular complications all of which occurred in patients who received preoperative medications, including 5 with alpha blockade. Patients receiving no preoperative alpha blockade required an average of 956 cc less in total intraoperative fluids, which approached statistical significance, and 479 cc less fluids on postoperative day 1, which was statistically significant. CONCLUSIONS Preoperative alpha-adrenergic blockade is not essential in pheochromocytoma patients. Calcium channel blockers are just as effective and safer when used as the primary mode of antihypertensive therapy. Surgery for pheochromocytoma is safe in the modern era.

IMPACT OF PROSTATE-SPECIFIC ANTIGEN LEVEL AND PROSTATE VOLUME AS PREDICTORS OF EFFICACY IN PHOTOSELECTIVE VAPORIZATION PROSTATECTOMY: ANALYSIS AND RESULTS OF AN ONGOING PROSPECTIVE MULTICENTRE STUDY AT 3 YEARS

In a multicentre study from the USA, 3‐year results of the high‐power KTP laser prostatectomy are presented. The authors used preoperative PSA level as a marker of prostate volume and assessed its potential predictive value on the level of clinical efficacy for treating symptomatic BPH. They found that the overall results from the technique were positive and durable, and suggested that there was a significant difference in efficacy between patients presenting with a total PSA of <6 or >6 ng/mL.

Single‐port transvesical enucleation of the prostate: a clinical report of 34 cases

Study Type – Therapy (case series)
Level of Evidence 4

Comparison of Biochemical Relapse-Free Survival Between Primary Gleason Score 3 and Primary Gleason Score 4 for Biopsy Gleason Score 7 Prostate Cancer

PURPOSE To determine whether the primary grade (PG) of biopsy Gleason score (GS) 7 prostate cancer (CaP) was predictive for biochemical relapse-free survival (bRFS). Most of the present data regarding the PG of GS7 CaP refer to surgical specimens. Our goal was to determine whether the biopsy GS used at the time of medical decision making predicted for the biochemical outcome. METHODS AND MATERIALS We reviewed the data from 705 patients with biopsy GS7 CaP, from a prospectively maintained database, who had been treated at our institution between September 1996 and March 2005 with radical prostatectomy (n = 310), external beam radiotherapy (n = 268), or prostate radioactive seed implantation (n = 127). The bRFS rates were estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used for univariate and multivariate analyses examining these factors in relation to bRFS: PG of biopsy GS, initial prostate-specific antigen level, clinical T stage, use of androgen deprivation, risk group (high or intermediate), and treatment modality. RESULTS The 5-year bRFS rate was 78% and 71% (p = 0.0108) for biopsy GS7 PG3 CaP and biopsy GS7 PG4 CaP, respectively. Comparing PG3 and PG4 within treatment modalities, only prostate implantation patients had a significant difference in the 5-year bRFS rate, 88% vs. 76%, respectively (p = 0.0231). On multivariate analysis, the PG of biopsy GS remained an independent predictor of bRFS, with PG3 having better bRFS than PG4 (relative risk, 0.655; 95% confidence interval, 0.472-0.909; p = 0.0113). CONCLUSION Biopsy GS7 PG4 CaP carries a worse bRFS than biopsy GS7 PG3 CaP.

Dosimetric comparison of pre-planned and or-planned prostate seed brachytherapy

PURPOSE To compare the dosimetry of the traditional two step procedure (volume study + treatment planning several weeks later) with that of an OR-based single procedure in which these two steps follow one another immediately. Computer generated treatment plans were used in both procedures. METHODS AND MATERIALS Several dosimetric parameters relating to target coverage were obtained from dose volume histograms of CT-based evaluation plans developed either 1 or 3 days following seed implantation. A total of 113 patients with early stage (T1C, T2A) prostate cancer were used for this retrospective study. RESULTS The fraction of target (prostate) covered by the prescription dose (144 Gy), 90% of the prescription dose (115 Gy), and the dose encompassing 90% of the target in the evaluation plan were all statistically significantly improved for OR-based plans compared to pre-planned cases. CONCLUSION In our hands, there is a small but significant improvement in dose coverage of the prostate when the ultrasound volume study and treatment planning are combined into a single procedure.

Long-term potency after iodine-125 radiotherapy for prostate cancer and role of sildenafil citrate.

OBJECTIVES To assess the long-term sexual potency and attrition in sexual function after iodine-125 ((125)I) seed radiotherapy and the effect of sildenafil on radiation-induced erectile dysfunction (ED). METHODS This prospective study consisted of 86 sexually active patients (mean age 63.5 +/- 7.7 years) who underwent (125)I seed implantation from 1997 to 1999 to treat low-volume prostate cancer (prostate-specific antigen less than 10 ng/mL, Gleason score 6 or less, stage T1-T2). All patients were followed up every 6 to 8 months for 4 years. Patients prescribed sildenafil citrate for ED completed the abridged five-item version of the International Index of Erectile Function (IIEF) and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires. RESULTS The median follow-up was 49.7 months (range 36 to 66). Of 86 patients, 43 (50%) did not initiate drug therapy; and only 36 (83.7%) of the 43 were interviewed at 4 years. Twenty-three (63.8%) of the 36 patients had erections sufficient for vaginal penetration, with a total mean +/- SD IIEF-5 score of 15.76 +/- 1.13. The other 50% (43 of 86) initiated sildenafil citrate for treatment of ED after seed implantation, with a minimal follow-up of 6 months. At 4 years, 32 (74%) of the 43 were responding positively to sildenafil citrate, with a total IIEF-5 score of 18.3 +/- 1.2. The mean EDITS +/- SD score was 76.5 +/- 3.2, and the spousal satisfaction rate was 72% (31 of 43). The dropout rate was 37% (16 of 43); 10 (63%) of the 16 discontinued because of a lack of efficacy, 3 (19%) because of a return of natural erections sufficient for vaginal penetration, and 3 (19%) discontinued because of side effects (headaches). CONCLUSIONS ED is a major long-term issue after (125)I seed radiotherapy, with a long-term potency rate of 29%. Sildenafil citrate improves erections in most patients after (125)I seed implantation.

PSA Bounce and Biochemical Failure After Brachytherapy for Prostate Cancer: A Study of 820 Patients With a Minimum of 3 Years of Follow-Up

PURPOSE To determine clinical or dosimetric factors associated with a prostate-specific antigen (PSA) bounce, as well as an association between a PSA bounce and biochemical relapse-free survival (bRFS), in patients treated with iodine-125 brachytherapy. METHODS AND MATERIALS A variety of clinical and treatment factors were examined in 820 patients who had a minimum of 3 years of PSA follow-up with T1-T2cN0M0 prostate cancer. Four different PSA threshold values were used for defining a PSA bounce: a PSA rise of ≥ 0.2, ≥ 0.4, ≥ 0.6, and ≥ 0.8 ng/mL. RESULTS A PSA bounce of ≥ 0.2, ≥ 0.4, ≥ 0.6, and ≥ 0.8 ng/mL was noted in 247 patients (30.1%), 161 (19.6%), 105 (12.8%), and 78 (9.5%), respectively. The median time to the first PSA rise was 17.4, 16.25, 16.23, and 15.71 months, respectively, vs. 34.35 months for a biochemical failure (p < 0.0001). A PSA rise of ≥ 0.2 ng/mL was the only definition for which there was a significant difference in bRFS between bounce and non-bounce patients. The 5-year bRFS rate of patients having a PSA bounce of ≥0.2 was 97.7% vs. 91% for those who did not have a PSA bounce (p = 0.0011). On univariate analysis for biochemical failure, age, risk group, and PSAs per year had a statistically significant correlation with PSA bounce of ≥ 0.2 ng/mL. On multivariate analysis, age and PSAs per year remained statistically significant (p < 0.0001 and p = 0.0456, respectively). CONCLUSIONS A bounce definition of a rise ≥ 0.2 ng/mL is a reliable definition among several other definitions. The time to first PSA rise is the most valuable factor for distinguishing between a bounce and biochemical failure.