Jason D. Engel

Hand-Assisted Laparoscopic Radical Nephrectomy: The Experience of the Inexperienced

PURPOSE We retrospectively examined the experience of novice laparoscopic surgeons performing hand-assisted laparoscopic radical nephrectomy. The purpose was to determine if urologists with minimal laparoscopic training could perform hand-assisted laparoscopic nephrectomies in a safe and efficient manner. MATERIALS AND METHODS The first six hand-assisted laparoscopic radical nephrectomies performed by four different urology residents at the Chicago Lakeside VA hospital were reviewed. The residents included three chief urology residents and one postgraduate year 3 urology resident. None of the residents had taken any laparoscopic course, and all had limited exposure to the hand-assisted technique. In all cases, the residents performed the entire operation. The patients were evaluated for operative time, tumor size, body mass index, and ASA score. RESULTS All six procedures were completed without conversion to the open technique. The average operating time was 215.8 minutes, and the time from incision to organ removal averaged 140.8 minutes. The average estimated blood loss was 166 mL. Complications included an intraoperative diaphragmatic injury (recognized and repaired laparoscopically) and one postoperative ileus. CONCLUSION Hand-assisted laparoscopic radical nephrectomy can be performed safely and efficiently by urologists with minimal laparoscopic experience.

Surgical Versus Endoscopic Correction of Vesicoureteral Reflux in Children with Neurogenic Bladder Dysfunction

PURPOSE We attempted to compare the efficacy of subureteral polytetrafluoroethylene injection and ureteral reimplantation for treating vesicoureteral reflux in children with neurogenic bladder dysfunction. MATERIALS AND METHODS We retrospectively studied the records of all children with neurogenic bladder dysfunction and reflux into single collecting systems treated with cross-trigonal ureteroneocystostomy or subureteral polytetrafluoroethylene injection. Followup cystography was performed 2 months postoperatively and ultrasound was done twice yearly thereafter. Urodynamic data were evaluated when available. Success was defined as complete eradication of reflux. Data were stratified by procedure, patient sex, grade and laterality of reflux, and the presence of unilateral or bilateral reflux, and then compared using chi-square analysis. RESULTS Of 85 patients (118 ureters) identified followup data were available in 95%. Subureteral polytetrafluoroethylene injection and ureteroneocystostomy were done on 60 and 47 ureters, respectively. Both groups were similar in mean patient age, followup and preoperative degree of reflux. Success rates after ureteroneocystostomy and a single injection were 84.3 versus 56.7%. The cumulative success rate of subureteral polytetrafluoroethylene injection was 61% after a second injection. The success rate of ureteroneocystostomy was significantly greater than that of injection (p = 0.02). Reflux resolved in all patients in whom injection failed and who underwent secondary reimplantation. Successful ureteroneocystostomy was unrelated to patient sex, reflux grade or laterality, or bilateral versus unilateral reflux. Subureteral polytetrafluoroethylene injection was more likely to fail in higher grades of reflux (p = 0.03) but success was otherwise unrelated to other parameters. Failure to correct reflux was unrelated to urodynamic findings. CONCLUSIONS Primary open ureteral reimplantation is more effective than subureteral polytetrafluoroethylene injection for correcting reflux in children with neurogenic bladder dysfunction. Despite controversy related to the appropriate injectable substance, the relative technical simplicity, outpatient nature, rapid recovery and potential for successful secondary reimplantation support a role for subureteral polytetrafluoroethylene injection in managing reflux in these difficult cases.

Angiosarcoma of the bladder: a review.

OBJECTIVES To present a new case of angiosarcoma of the bladder, review 9 other previously reported cases, and discuss the unique features of our case with regard to presentation, treatment, and clinical course of patients with this exceedingly rare tumor. The utility of multimodality therapy is emphasized. METHODS We report the latest case of angiosarcoma of the bladder. We also reviewed the world literature (MEDLINE) and discovered 9 previously reported cases of angiosarcoma of the bladder. Presentation, treatment, and clinical course were analyzed. RESULTS Of the 10 cases, 2 were considered to have arisen from a preexisting bladder hemangioma. Two patients had a history of prior gynecologic malignancies treated with external beam radiotherapy, with subsequent sarcoma formation within the past treatment field. Two other patients presented with skin lesions that predated the discovery of bladder lesions. Only 4 patients presented with primary bladder lesions and no preexisting disease or previous carcinogenic exposure (except for tobacco use). Hematuria was a universal presentation, and treatment was widely variant. Of the 10 patients, 8 died during a period of follow-up of 23 months. Five patients died of tumor-related causes. Mean survival of these 5 was 10.6 months. The 2 most recent patients (including ours) were alive and tumor free at 8 and 32 months, respectively. Both of these patients underwent multimodality oncologic approaches as part of their treatment regimen. CONCLUSIONS Angiosarcoma of the bladder is exceedingly rare and usually fatal. Prognosis is poorer than that of angiosarcomas in more traditional sites. Regional lymph nodes are typically spared, but local recurrence with eventual distant metastasis is the rule. Optimal therapy has not been determined, but it most likely should involve a multimodal approach combining radical surgery with chemotherapy and radiotherapy.

Transforming growth factor-beta type II receptor confers tumor suppressor activity in murine renal carcinoma (renca) cells

OBJECTIVES To demonstrate that the introduction of the transforming growth factor-beta (TGF-beta) type II receptor (TbetaR-II) decreases tumorigenicity in an aggressive murine renal carcinoma line, Renca. These cells do not express TbetaR-II. Because the presence of TbetaR-II in benign epithelial cells is ubiquitous, the ability to restore tumor suppressor activity in the Renca cell line with its introduction would elucidate the role of TbetaR-II as a tumor suppressor gene. METHODS Renca cells were stably transfected with a retrovirus-mediated TbetaR-II expression vector. In vitro sensitivity to growth inhibitory effect of TGF-beta was assessed by the 3H-thymidine incorporation assay. For in vivo testing, xenograft tumors were produced by subcutaneous injection of tumor cells into immunodeficient nude mice. The tumorigenicity of these TbetaR-II transfected cells was tested. Wild-type Renca cells and cells transfected with the control vector were also tested for comparison. RESULTS Expression of TbetaR-II mRNA was evident in Renca cells after transfection with the TbetaR-II construct. In vitro sensitivity to the growth inhibitory effect of TGF-beta was restored. This effect of TGF-beta was reversible with a neutralizing antibody specific for the extracellular domain of TbetaR-II. Xenografts grown from TbetaR-II transfected cells were significantly smaller, weighed less, and developed tumors later than those developed from wild-type Renca cells and those transfected with the control vector. CONCLUSIONS We conclude that TbetaR-II is a central mediator of tumorigenicity in Renca cells. As with other tumor suppressor genes, the loss of TbetaR-II expression allows for the development of an aggressive phenotype.

ABSENCE OF EXPRESSION OF TRANSFORMING GROWTH FACTOR-beta TYPE II RECEPTOR IS ASSOCIATED WITH AN AGGRESSIVE GROWTH PATTERN IN A MURINE RENAL CARCINOMA CELL LINE, RENCA

Transforming growth factor-beta1 (TGF-beta1) inhibits the proliferation of many cancer cells. However, tumor cells frequently become resistant to this inhibitory effect due to the absence of TGF-beta receptor (TbetaR) expression. This study reports the nature of TGF-beta sensitivity in an aggressive murine renal carcinoma cell line, Renca, investigated in a series of experiments. The growth of Renca cells, in tissue culture, was not sensitive to the inhibitory effect of TGF-beta1 with doses ranging from 0.1 to 10 ng./ml., nor was this cell line sensitive to the effect of TGF-beta1 in inducing the expression of plasminogen activator inhibitor-I. Renca cells expressed TGF-beta1 mRNA and protein, as determined by RT-PCR and ELISA, respectively. The level of TGF-beta1 production by Renca cells was moderate, thus eliminating the possibility that endogenous TGF-beta1 production might be masking the effect of TGF-beta sensitivity. Furthermore, Renca cells expressed TbetaR-I mRNA, but did not express TbetaR-II mRNA, suggesting that the absence of this receptor may be the cause of TGF-beta insensitivity. Additionally, a vector containing the TbetaR-II cDNA was transiently transfected into Renca cells. The inhibitory effect of TGF-beta1 was introduced in Renca cells after transfection with this receptor. At the same time, the growth rate of these cells diminished significantly when compared with that of the wild type Renca cells, as judged by the rate of [3H]-thymidine incorporation in the absence of any exogenous TGF-beta1. These observations demonstrated that Renca cells lack the functional TbetaR-II and suggest that their aggressive growth pattern is due, at least in part, to their insensitivity to TGF-beta.

Surgical complications after robot-assisted laparoscopic radical prostatectomy: The initial 1000 cases stratified by the clavien classification system

BACKGROUND AND PURPOSE Complications after robot-assisted prostatectomy are widely reported and varied. Our goal was to determine the incidence of surgical complications resulting from robot-assisted laparoscopic radical prostatectomy (RALP) during the initial phase of a new robotics program that was developed by two surgeons without laparoscopic or robotic fellowship training. A secondary goal was to see if experience changed the incidence of complications with this technology. PATIENTS AND METHODS A prospectively maintained database was used to evaluate the first 1000 consecutive patients who were treated with RALP from January 2004 to June 2009. The database was reviewed for evidence of complications in the perioperative period. All patients underwent robot-assisted laparoscopic radical prostatectomy by two surgeons. Complications were confirmed and supplemented by retrospectively reviewing the departmental morbidity and mortality reports, as well as the hospital records. The Clavien classification system, a standardized and validated scale for complication reporting, was applied to all events. The complication rate was determined per 100 patients treated and tested with logistic regression for a relationship with surgeon experience. RESULTS Ninety-seven (9.7%) patients experienced a total of 116 complications; 81 patients experienced a single complication and 16 patients experienced ≥2 complications. The majority of complications (71%) were either grade I or II. The complication rate decreased with experience when the first 500 cases were compared with the latter 500 cases (P=0.007). All the data were reviewed retrospectively. Involvement of residents/fellows increased as primary surgeon experience improved. CONCLUSIONS Complications after RALP are most commonly minor, requiring expectant or medical management only, even during the initiation of a RALP program. The complication rate improved significantly during the study period.

Bilateral adrenal cortical adenomas in primary hyperaldosteronism.

Bilateral adrenal cortical adenomas in the presence of primary hyperaldosteronism is an extremely rare condition. We present a case of primary hyperaldosteronism in which a unilateral hypersecreting aldosterone-producing adenoma coexisted with a large, contralateral adrenal mass ultimately found to be consistent with cortical adenoma. Management consisted of total adrenalectomy and enucleation of adenoma from the opposite adrenal. The patient is normotensive 3 years after surgery. Enucleation as a successful approach to hyperfunctioning cortical adenomas is proposed.

A PROSPECTIVE CONCURRENT STUDY OF THE LONGITUDINAL EFFECTS ON STRETCHED PENILE LENGTH AFTER ROBOTIC AND OPEN PROSTATECTOMY FROM AN INTRAURETHRAL ALPROSTADIL VS SILDENAFIL PENILE REHABILITATION STUDY

INTRODUCTION AND OBJECTIVE: Observational cross sectional and prospective longitudinal studies have reported the loss of penile size after radical prostatectomy. This observation is supported by histologic studies in animals and humans after cavernous nerve injury demonstrating cavernous smooth muscle fibrosis and apoptosis. As part of a concurrent, multi-center, intraurethral alprostadil (IUA) vs. sildenafil citrate (SC), penile rehabilitation study, with identical inclusion, treatment and outcome measures, we compared the stretched penile length (SL) in men undergoing nerve sparing open radical prostatectomy (ORP) and robotic radical prostatectomy (ROP). METHODS: A multi-center randomized prospective comparative penile rehabilitation study of the effect of 9 months of nightly IUA vs. SC on subjects having ORP and ROP. Medication was started within one month of surgery. SL was measured preoperatively and at catheter removal, 2, 3, 6, 9 and 11months after surgery. SL was measured according to published techniques by 4 observers at the site performing ORP (NYU) and 2 at the site performing ROP (GWU). No inter and intrainstitutional validation of measurements was carried out. RESULTS: A total of 208 patients were enrolled. 51 pts withdrew from the study (25%). Pts were randomized 2/1 to IUA vs. SC. (131/67). Mean age (59.2) and baseline IIEF score (29) were the same at both centers. SL was virtually identical at both centers for visits 1-3. There was a significant difference in SL between ORP and ROP in SL 3-11 month follow up visits, in both treatment arms. These findings all reached a p-value less than .0001 from months six to eleven. CONCLUSIONS: Significant penile shortening occurred immediately after ORP and ROP. There appeared to be a progressive significant difference between RAP and RRP in SL loss that was detected at 3 months and beyond. This difference may be due to surgical technique or represent a combination of site specific measurement techniques or drug compliance variation between medications and institutions. Further study of this phenomenon is needed.