Joy Knopf

Near infrared fluorescence imaging with robotic assisted laparoscopic partial nephrectomy: initial clinical experience for renal cortical tumors.

PURPOSE We evaluated the utility of near infrared fluorescence of intravenously injected indocyanine green in performing robotic assisted laparoscopic partial nephrectomy. In addition, we evaluated the initial performance of a novel near infrared fluorescence imaging system integrated into the da Vinci® Si Surgical System during robotic assisted laparoscopic nephrectomy. MATERIALS AND METHODS Fluorescence imaging for the da Vinci Si Surgical System was used for all cases. Indocyanine green was injected before near infrared imaging. Immediate imaging assessed the renal vasculature while delayed imaging differentiated renal cortical tumors from normal parenchyma. The intraoperative performance of near infrared fluorescence of intravenous indocyanine green was evaluated for tumor appearance relative to surrounding renal parenchyma as well as identification of the renal vasculature. RESULTS A total of 11 patients underwent robotic assisted laparoscopic nephrectomy with 2 converted to robotic assisted laparoscopic radical nephrectomy. Indocyanine green injections were repeated up to a total of 5 times depending on the goal of visualization. Of the 11 patients 10 demonstrated malignancy on final pathology. Of the malignant tumors 7 were hypofluorescent and 3 were isofluorescent compared to the surrounding renal parenchyma. Near infrared fluorescence imaging delineated the vascular anatomy in all cases. All surgical margins were negative on final pathology. CONCLUSIONS Intraoperative imaging of indocyanine green with near infrared fluorescence is a safe and effective method to accurately identify the renal vasculature and to differentiate renal tumors from surrounding normal parenchyma. The capacity for multimodal imaging within the surgical console further facilitates this imaging. Further study is needed to determine if this technique will help improve outcomes of robotic assisted laparoscopic nephrectomy.

Treatment of nonmuscle invading bladder cancer: do physicians in the United States practice evidence based medicine? The use and economic implications of intravesical chemotherapy after transurethral resection of bladder tumors.

Phase 3 clinical trials performed primarily outside the US demonstrate that intravesical instillation of chemotherapy immediately after transurethral resection of the bladder (TURB) decreases cancer recurrence rates. The authors sought to determine whether US urologists have adopted this practice, and its potential effect on costs of bladder cancer (BC) care.

Near Infrared Fluorescence Imaging After Intravenous Indocyanine Green: Initial Clinical Experience With Open Partial Nephrectomy for Renal Cortical Tumors

OBJECTIVE To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. METHODS Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. RESULTS A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. CONCLUSION The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy.

Robot-Assisted and Laparoscopic Partial Nephrectomy with Near Infrared Fluorescence Imaging

BACKGROUND AND PURPOSE Recent literature has focused on the importance of maximal nephron preservation during partial nephrectomy to avoid complications associated with chronic renal insufficiency. Accurate differentiation of tumor from normal surrounding parenchyma is critical to ensure excessive normal renal tissue is not made ischemic or excised along with the tumor. The feasibility of a novel intraoperative imaging technique to differentiate tumor from surrounding parenchyma during laparoscopic and robot-assisted partial nephrectomy was evaluated. PATIENTS AND METHODS Patients who were scheduled to undergo laparoscopic or robot-assisted partial nephrectomy were recruited from April 2009 to July 2010. The Endoscopic SPY Imaging System was used as an adjunct to intraoperative imaging in all cases. Patients received intravenous injections of indocyanine green (ICG), which was visualized intraoperatively with the near infrared fluorescence (NIRF) imaging capability of the SPY scope. The degree of tumor fluorescence compared with surrounding renal parenchyma was qualitatively assessed before tumor resection, and partial nephrectomy was then performed with standard techniques while intermittently using NIRF imaging. RESULTS Nineteen patients underwent intravenous administration of ICG followed by NIRF during partial nephrectomy. Average tumor size was 3.0 cm (range 0.8-5.9 cm). Thirteen masses were malignant on final pathology results, and all of these were seen to be hypofluorescent compared with surrounding renal parenchyma during intraoperative imaging. The imaging behavior of benign tumors ranged from isofluorescent to hyperfluorescent compared with normal parenchyma. No complications were associated with ICG injection. CONCLUSION NIRF imaging after intravenous ICG administration may be a useful intraoperative imaging tool to differentiate malignant tumors from normal renal parenchyma during laparoscopic and robot-assisted partial nephrectomy. Advanced intraoperative imaging techniques such as this one may become increasingly helpful as more complicated tumors are resected with minimally invasive approaches.

The use of robotically assisted surgery for treating urachal anomalies

To report the management of urachal anomalies using a robotically assisted approach.

Current state of screening for bladder cancer

Bladder cancer is the fourth most commonly diagnosed cancer in men and the eighth most common cancer in women in the USA. Efforts to reduce mortality from bladder cancer must focus on three areas: prevention, development of effective therapies for muscle-invasive and metastatic disease, and early detection of potentially invasive lesions while they are still superficial and amenable to less morbid, but still effective, treatments. As more effective therapies for metastatic transitional cell carcinoma are not on the immediate horizon and preventive measures (except for smoking cessation) have been disappointing, if we are to reduce this disease’s morbidity and mortality rates significantly, early detection strategies need to be improved and implemented. The goal of screening for any type of cancer is to detect the disease in its early stages in order to increase the chances for cure or prolongation of life (before micro or gross metastases occur). Since all patients who die of bladder cancer do so from metastases and since almost all patients with metastases have muscle-invading cancers appearing as the first bladder cancer event, diagnosing cancers destined to become muscle invading before they actually are should reduce bladder cancer mortality. This special report reviews the current state of bladder cancer screening in the USA.

The Impact of Robotics on Treatment of Localized Prostate Cancer and Resident Education in Rochester, New York

BACKGROUND AND PURPOSE Robot-assisted radical prostatectomy (RARP) has been performed in Rochester, NY, since 2003. Currently, 10 area urologists perform RARP, and robotic training has become an important component of the residency. We present data describing the timeline for adoption, both in clinical practice and in the residency program. MATERIALS AND METHODS We reviewed the operating logs for all surgeons who were performing prostatectomies in all hospitals in Rochester, NY, from 2003 to 2007. We examined the influence RARP had on other treatments, including brachytherapy and cryotherapy. Surgical logs of graduating chief residents were also reviewed. RESULTS Eleven surgeons in Rochester regularly perform radical prostatectomy (10 perform primarily RARP, one performs only open prostatectomy). Three of the citys four hospitals have robotic systems. In 2003-2004, there were 30 open prostatectomies performed monthly and fewer than 10 performed robotically. By 2006, the trend was reversed, with 50 robot-assisted prostatectomies performed each month and fewer than 10 open prostatectomies (P<0.05). The rate of brachytherapy fluctuated, increasing in centers without a robot. The number of open prostatectomies in centers without a robot dropped significantly to fewer than 10 cases per year. There was also a significant decrease in the number of open prostatectomies performed by chief residents. CONCLUSIONS Since the introduction of surgical robotics, significant changes have been seen. The volume of radical prostatectomies performed by surgeons at institutions with robotics has increased; the volume at robot-free institutions has become nominal. There is a trend toward increased radiation therapy at robot-free institutions. While radical prostatectomies logged by graduating chief residents have increased, open prostatectomy experience is now minimal.

Transition from open to robotic-assisted radical prostatectomy is associated with a reduction of positive surgical margins amongst private-practice-based urologists.

Several recent studies have suggested that thought leaders in radical prostatectomy have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined if this phenomenon exists amongst non-fellowship-trained urologists in private practice. Herein, we describe the positive margin rates of two non-fellowship-trained private-practice urologists who converted from open radical retropubic prostatectomy to robot-assisted radical prostatectomy. The margin positivity data from two non-fellowship-trained private-practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as tumor present at the inked margin of the prostate. There was a significant decrease in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44 to 20% and from 37 to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26 to 18% and the pT2 positive margin rate changed from 27.5 to 7% after converting. Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. With proper training this phenomenon does seem to apply to non-fellowship-trained urologists in private practice and can be realized within the first 50 cases performed.

Re: Dipstick Pseudohematuria: Unnecessary Consultation and Evaluation: P. K. Rao, T. Gao, M. Pohl and J. S. Jones J Urol 2010; 183: 560–565

To the Editor: We applaud the authors for their study and totally agree with their attempt to reduce the number of unnecessary, costly and unpleasant/harmful evaluations that urologists perform. However, we have several concerns about the information presented. Any report eliminating more than 72% of patients (229 of 320) from the original series, for whatever reasons, must be regarded with some skepticism. Could not the knowledge of a prior positive dipstick test for hematuria influence the decision to evaluate (and how to evaluate) a patient “referred for a primary reason other than hematuria” or with “significant symptoms or urological history”? Additionally demographic characteristics, such as patient gender, age and smoking history, are not reported. As Drach indicates in the accompanying editorial comment, these factors probably should influence how rigidly one follows American Urological Association (AUA) guidelines, and they clearly influence the likely yield of a hematuria evaluation. What were the ages and genders of the 25 patients with dipstick pseudohematuria and the 22 patients with an appropriate consultation? Furthermore, hematuria is remarkably intermittent, and requiring 2 of 3 tests to be positive before embarking on evaluation in a patient with high risk demographics does not agree with the available data. The AUA guidelines requiring 2 of 3 urinalyses to be positive are based a single reference, which had used this guideline as the hospital standard to evaluate hematuria without providing any data, reference or rationale for selecting this threshold. This policy and the AUA recommendation that quotes it appear to be based on the weakest level of evidence, expert opinion. Finally the chemical reagent strip test (at least the Ames Hemastix®) when properly performed is an extremely accurate reflector of threshold microhematuria found in a properly performed microscopic urinalysis. The authors provide no methodology or references as to which dipstick was used, how and by whom it was read, how and by whom the urinalysis was performed, how specimens were handled before testing and any other quality control measure. Not all tests, or test results, mean the same thing. Again, we heartily concur that urologists should give considerable thought to the evaluation of patients referred to them, and that avoiding unnecessary testing is important. However, given our concerns, we are not convinced that the data presented by the authors support the wisdom of their approach in all circumstances.

Evidence for Alpha Receptors in the Human Ureter

An immunohistochemical and western blot expression analysis of human ureters was performed in order to characterize the alpha‐1‐adrenergic receptor distribution along the length of the human ureteral wall. Mapping the distribution will assist in understanding the potential role alpha ‐1‐adrenergic receptors and their subtype density might have in the pathophysiology of ureteral colic and stone passage. Patients diagnosed with renal cancer or bladder cancer undergoing nephrectomy, nephroureterectomy, or cystectomy had ureteral specimens taken from the proximal, mid, distal and tunneled ureter. Tissues were processed for fresh frozen examination and fixed in formalin. None of the ureteral specimens were involved with cancer. Serial histologic sections and immunohistochemical studies were performed using antibodies specific for alpha‐1‐adrenergic receptor subtypes (alpha 1a, alpha 1b, alpha 1d). The sections were examined under a light microscope and scored as positive or negative. In order to validate and quantify the alpha receptor subtypes along the human ureter. Western blotting techniques were applied. Human ureter stained positively for alpha ‐1‐adrenergic receptors. Immunostaining appeared red, with intense reaction in the smooth muscle of the ureter and endothelium of the neighboring blood vessels. There was differential expression between all the receptors with the highest staining for alpha‐1D subtype. The highest protein expression for all three subtypes was in the renal pelvis and decreased with advancement along the ureter to the distal ureter. At the distal ureter, there was marked increase in expression as one progressed towards the ureteral orifice. The same pattern of protein expression was exhibited for all three alpha ‐1‐adrenergic receptor subtypes. We provide preliminary evidence for the ability to detect and quantify the alpha‐1‐receptor subtypes along the human ureter which to the best of our knowledge has never been done with immunohistochemistry and molecular techniques. These findings may lend support to the preliminary studies of the effectiveness of alpha‐receptor blockade on ureteral colic and stone passage.