Jyoti Upadhyay

Surgical complications of bladder augmentation: comparison between various enterocystoplasties in 133 patients.

OBJECTIVES Ileal and sigmoid augmentation are equally effective at increasing bladder capacity and compliance. Therefore, knowledge of the incidence of major complications, including perforation, small bowel obstruction (SBO), anastomotic complications, calculus formation, and indications for revision may be useful in choosing the ideal segment. We compared the complications of ileocystoplasty and two types of sigmoidocystoplasty that required reoperative surgery. METHODS Between 1981 and 1997, 158 patients with a mean age of 11 years (range 2 to 25) underwent augmentation cystoplasty. Ileum or sigmoid colon was used in 133 patients, who were the subjects of this study. The mean follow-up was 64 months (range 6 to 185). Indications included neurogenic bladder (n = 100), bladder exstrophy (n = 12), cloacal exstrophy (n = 6), posterior urethral valves (n = 3), and miscellaneous (n = 12). Ileum was used in 65 patients and sigmoid colon in 68. Of these, 48 underwent conventional colocystoplasty and 20 seromuscular colocystoplasty lined with urothelium (SCLU). Seventy-nine percent required additional procedures to achieve continence or facilitate catheterization, which included bladder neck procedures in 56% or continent stomas alone in 23%. RESULTS There were no deaths or complications of bowel anastomosis. Overall, continence was achieved in 95%. Spontaneous bladder perforation was highest in patients with neurogenic bladder. Calculi developed more frequently in patients with continent stomas (P = 0.04) and in patients with bladder/cloacal exstrophy (32%) than in patients with neurogenic bladder (P = 0.01). Additional procedures and route of catheterization did not increase the risk of perforation. One patient with SCLU with known hypercalciuria developed bladder calculi. CONCLUSIONS Sigmoid colon showed a trend of a lower rate of SBO with no difference in perforation or stone formation compared with ileum. Primary diagnoses of bladder or cloacal exstrophy and continent stomas are risk factors for the development of calculi. SCLU has a low rate of surgical complications and no incidence of perforation or SBO thus far; therefore, we advocate the use of SCLU when feasible, and sigmoid as the preferred bowel segment for augmentation cystoplasty.

Comparison of costs and complications of radical and partial nephrectomy for treatment of localized renal cell carcinoma.

OBJECTIVES To compare the complications and costs of radical and partial nephrectomy (PN) and to investigate the impact of increasing experience on costs and complications during a 7-year period. Nephron-sparing surgery has found increasing applications in the past decade. PN has achieved similar long-term results in localized renal cell carcinoma with respect to cancer control compared with radical nephrectomy (RN). However, data are limited on the direct comparison of complications and hospital costs between these two modalities. METHODS A retrospective case-matched study was performed comparing 60 RNs and 60 PNs during a 7-year period with respect to complications and hospital costs. A longitudinal comparison was also performed between the various periods to assess the impact of surgical experience on these parameters. RESULTS The mean length of stay was 6.4 +/- 3 days in the RN group and 6.4 +/- 3.3 days in the PN group. The hospital costs were comparable between the two procedures during the observed interval. The mean operative time was 176.6 +/- 51.6 minutes for RN and 220.1 +/- 59.6 minutes for PN (P = 0.0001). This difference was accentuated during the observed period. No differences were found in the blood loss and transfusion rates between the groups. The complication rate was 3.3% and 10% for RN and PN, respectively (P = 0.2). CONCLUSIONS Our data suggest that RN and PN can be performed with a similar rate of complications and comparable hospital costs. This is of practical importance when comparing these modalities as treatment options for localized renal cell carcinoma.

Long-term outcome based on the initial surgical approach to ureterocele.

PURPOSE The management of extravesical ureterocele is controversial. Heminephrectomy and recently recommended primary incision or puncture have high reoperation rates. We reviewed and compared the long-term results of these procedures with those of primary lower tract reconstruction for ureterocele. MATERIALS AND METHODS We reviewed the records of 106 children with ureterocele treated between 1979 and 1997. Followup was available in 99 patients, including 72 with extravesical and 27 with intravesical ureterocele. Patients with extravesical ureterocele were divided based on initial management into group 1-13 who underwent transurethral incision or puncture, group 2-41 who underwent an upper tract approach, including partial or complete nephrectomy with partial ureterectomy or ureteroureterostomy and group 3-18 who underwent complete reconstruction, including ureterocelectomy and ureteral reconstruction with or without upper tract surgery. RESULTS Overall the reoperation rate in patients with intravesical ureterocele was 22% and 23% in those treated with initial endoscopic incision or puncture. In patients with extravesical ureterocele the reoperation rate was 100, 41 and 0% in groups 1 to 3, respectively. Differences in followup (overall mean 6 years) and the incidence of preoperative reflux in the 3 groups were not statistically significant. In group 2, the reoperation rate in patients with versus without preoperative reflux was 57 versus 20% (p = 0.08). Of the 25 prenatally diagnosed patients urinary tract infection developed preoperatively in 3 (12%) at ages 2, 3, and 6 months, respectively. Mean age at the time of the initial operation in all prenatally diagnosed patients was 3.1 months (range 5 days to 11 months). CONCLUSIONS Complete reconstruction appears to be safe and highly effective even in infancy for treating extravesical ureterocele. Although the primary upper tract approach is associated with a significantly higher reoperation rate, it is a favorable alternative in patients with no preoperative reflux. However, while transurethral decompression is effective in the majority of patients with intravesical ureterocele, it is not definitive therapy for extravesical ureterocele and it should have a limited role in initial management.

Vesicourethral anastomosis biopsy after radical prostatectomy: predictive value of prostate-specific antigen and pathologic stage.

OBJECTIVES To assess the role of clinical parameters and pathologic stage in predicting a positive vesicourethral anastomosis (VUA) biopsy in patients with a rising prostate-specific antigen (PSA) level after radical prostatectomy. METHODS Forty-five patients were referred for a rising PSA level after radical prostatectomy. Transrectal ultrasound evaluation included visualization of the VUA and VUA quadrant biopsies. The rate of positive biopsies (per core and per patient) was correlated with race, PSA level, and the radical prostatectomy pathologic stage. RESULTS Overall, 53% of patients had a positive biopsy. In multivariate analysis, the dominant independent and synergistic clinical parameters determining positive biopsy rates were a PSA greater than 1 ng/mL at the time of biopsy and the pathologic stage (P = 0.04 and P = 0.02, respectively). Using a PSA cutoff point of 1.0 ng/mL, those patients with organ-confined disease and a PSA of 1.0 ng/mL or less showed no positive cancer cores (low-risk group). Conversely, 89% of patients with extraprostatic extension and a PSA greater than 1.0 ng/mL had a positive biopsy (P <0.01) (high-risk group). Patients with organ-confined disease and a PSA greater than 1.0 ng/mL or extraprostatic extension and a PSA 1.0 ng/mL or less (intermediate-risk group) had a significantly higher chance of having residual cancer than the low-risk group (P <0.025). CONCLUSIONS The PSA level at the time of biopsy and the pathologic stage of the radical prostatectomy specimen were the strongest determinants of a positive biopsy. A combination of PSA and pathologic stage is useful for decisions regarding VUA biopsy. Patients with organ-confined disease and a PSA of 1.0 ng/mL or less do not appear to benefit from a VUA biopsy, and patients with extraprostatic extension and a PSA greater than 1.0 ng/mL have such a high probability (89%) of local recurrence at the VUA that biopsy may be unnecessary. It appears that VUA biopsy can be restricted to those patients with an intermediate risk (organ-confined disease with PSA greater than 1 ng/mL or extraprostatic extension with a PSA less than 1 ng/mL).

Intraoperative, perioperative, and long-term complications of radical prostatectomy

With improved surgical technique and perioperative care, the intraoperative and early postoperative complications of radical prostatectomy have decreased over the last 2 decades. Incontinence and impotence are two of the most significant long-term complications related to this procedure. Although the wide range of incontinence and impotence rates reported has been attributed to multiple factors, including the method of data collection and patient selection, it is apparent that the surgeons experience is a significant factor, and that lower long-term morbidity can be expected from centers with more experience with radical prostatectomies. The impact of long-term complications, including urinary and sexual dysfunction, on the quality of life may be less than previously reported and should be discussed with patients.

Hydro-jet assisted laparoscopic partial nephrectomy: initial experience in a porcine model.

PURPOSE Hemostasis represents a challenge when performing laparoscopic partial nephrectomy. Hydro-Jet cutting is an advanced technology that has been used to create an ultra-coherent water force that functions like a sharp knife. In the surgical field, it has mainly been used for liver surgery and initial clinical experience with laparoscopic cholecystectomies has been favorable. This technique allowed selective parenchymal cutting with preservation of vessels and bile ducts. We describe a novel Hydro-Jet assisted dissection technique for laparoscopic partial nephrectomy in a porcine model. MATERIALS AND METHODS Ten partial nephrectomies were performed in 5 pigs using a Muritz 1000 (Euromed Medizintechnik, A. Pein, Schwerin, Germany) Hydro-Jet generator. A thin stream of ultra coherent fluid is forced at a high velocity through a small nozzle. A modified probe allows both blunt dissection concomitantly with high-pressure water application. Coagulation can be applied via a bipolar thermoapplicator as needed. RESULTS Laparoscopic partial nephrectomy was successful in all animals. Water-jet cutting through the parenchyma was virtually bloodless and preserved the vasculature and the collecting system. The vessels were then ligated or coagulated under direct vision. The continuous water flow established a bloodless operating field and a clear view for the surgeon. The mean dissection time and warm ischemia time were 45+/-9 and 17+/-3 minutes, respectively. CONCLUSIONS This preliminary study supports the suitability of this technique for laparoscopic partial nephrectomy to improve hemostasis. The improved anatomical dissection and hemostasis may further decrease morbidity and operative time. Further studies are underway to compare this technique with laser coagulation for laparoscopic partial nephrectomy.

TESTICULAR POSITION IN THE ANDROGEN INSENSITIVITY SYNDROME: IMPLICATIONS FOR THE ROLE OF ANDROGENS IN TESTICULAR DESCENT

PURPOSE We compared testicular position with genital phenotype in a clinical series and a literature review of androgen receptor mutations to assess the role of androgens in testicular descent. MATERIALS AND METHODS Our clinical reports, the androgen receptor mutations database and selected literature were reviewed. Subjects with a proved androgen receptor mutation were included in our study when a female or ambiguous phenotype was present (Quigley grade 3 to 7) and testicular position was documented. Comparison among groups was done by Fishers exact or chi-square test. RESULTS Of the 7 patients with detailed clinical records 5 had abdominal (bilateral in 4) and 2 had bilateral inguinal testes. Four patients with abdominal testes also had aberrant pelvic ligaments extending medially from the gonads. Including an additional 102 cases identified in the literature, abdominal testes were present in 52% and 3% of those with complete and partial androgen insensitivity, respectively. The incidence of abdominal testes was highest (86%) in patients with a complete female phenotype and no pubic hair (grade 7). It decreased significantly with increasing masculinization and was higher in phenotypic females diagnosed at or after (67%) than in those identified before (22%) puberty. Hernia was associated with inguinal and abdominal testes. CONCLUSIONS Testicular position correlates with genital phenotype in patients with androgen receptor mutations, supporting a major role for androgens in testicular descent. Inguinal hernia and abnormal pelvic ligaments in these individuals may partially determine testicular position but to our knowledge the role of androgen receptors, if any, in their development is unknown.

Salvage radical prostatectomy.

Although technically challenging, salvage prostatectomy for radiorecurrent prostate cancer is an effective option in carefully selected patients and offers the best chance for cure and long-term survival. Alternatively, cystoprostatectomy may be indicated in some patients who have a small capacity fibrotic bladder or intractable voiding symptoms related to radiation cystitis. Good long-term results can be expected in this patient group; however, exenterative surgery in patients with locally advanced disease is associated with comparably inferior results and should not be advocated. If cystectomy is necessary, orthotopic urinary diversion can be performed safely in young motivated patients who wish to maintain a better quality of life with associated morbidity. Although the higher rate of incontinence and impotence after salvage procedures may detract from the quality of life, the impact of these long-term complications on the patients overall well-being is less than previously believed, and most patients are satisfied with their treatment outcome and adjust well to the circumstances, accepting some increased degree of morbidity. This observation emphasizes the value of careful preoperative counseling and the discussion of treatment options and outcomes, which also should incorporate quality of life issues.

IMPACT OF PRENATAL DIAGNOSIS ON THE MORBIDITY ASSOCIATED WITH URETEROCELE MANAGEMENT

PURPOSE We postulated that prenatal detection of ureteroceles has a positive impact on the natural history and clinical outcome of ureteroceles in duplex system. MATERIALS AND METHODS Between 1992 and 2000, 95 children underwent surgery for a ureterocele in a duplex system. We evaluated the impact of prenatal diagnosis in 40 cases versus postnatal diagnosis in 55 on morbidity, as measured by postoperative urinary tract infection and secondary procedures, while controlling for ureterocele type and the initial surgical approach. RESULTS Mean followup in the 2 groups was 3.9 years. Preoperatively the reflux rate was 51% in the prenatal and 66% in the postnatal groups. Preoperatively urinary tract infections were less common in the prenatal group (12% versus 84%). Mean age at initial intervention in prenatally and postnatally diagnosed patients was 6 and 31 months, respectively. Postoperatively the urinary tract infection rate was double in postnatally diagnosed patients. Overall postoperatively reflux was similar in the 2 groups and grades III to V reflux with urinary tract infection accounted for 14 of the 21 secondary bladder procedures (67%). After initial endoscopic decompression none of the prenatally diagnosed patients with intravesical ureteroceles required reoperation, whereas 6 (50%) with extravesical ureteroceles required reoperation. All 10 prenatally diagnosed extravesical ureteroceles treated with partial nephrectomy were cured. Overall the secondary procedure rate in the postnatal group was higher than in the prenatal group (46% versus 20%, p = 0.02). Also, there was a difference in the reoperation rate in the endoscopic decompression group according to mode of presentation (p = 0.03) and a difference when comparing endoscopic treatment with partial nephrectomy in all patients (p = 0.02). CONCLUSIONS Prenatal diagnosis decreases morbidity and potential adverse outcomes related to infection. Overall prenatal diagnosis is associated with a decreased rate of secondary procedures independent of the type of ureterocele. Prenatally diagnosed intravesical ureteroceles may be cured by endoscopic incision alone but for extravesical ureteroceles partial nephrectomy appears to be more definitive.

Radical Prostatectomy with Bladder Neck Preservation: Impact of a Positive Margin

PURPOSE Bladder neck preservation during radical prostatectomy has been correlated with improved continence. However, the hazard of a positive margin at this specific site has discouraged many urologists. We evaluated if preservation of the bladder neck at the time of radical prostatectomy jeopardizes surgical cancer control with consequent deleterious outcomes. MATERIALS AND METHODS 675 consecutive patients underwent radical prostatectomy (RP) by a single surgeon (J.E.P.) at Wayne State University during the 1990s decade. The bladder neck was preserved. Margin-positivity was categorized by location and number. Preoperative, pathological and disease status data was prospectively collected into the Karmanos Cancer Institute multidisciplinary prostate cancer database. RESULTS Analysis was performed on 555 patients who had RP as monotherapy. Positive margins were found in 178 (32%) of these patients. Correlation between specimen Gleason score, prostatic specific antigen (PSA) and margin status, was encountered (p=0.001). Apical and bladder neck margin-positivity was detected in 104/555 (19%) and 13/555 (2%), respectively. Of those specimens with a positive margin at the bladder neck eight had Gleason score > or =7, three had seminal vesicle invasion and two nodal disease. Only two patients had a positive bladder neck margin as the sole adverse pathological feature. Significant independent predictors of survival included the Gleason score, PSA, pathological stage and presence of positive margins in more than one location. CONCLUSIONS Anatomical preservation of the bladder neck does not increase the percentage of positive margins at this anatomical location and does not compromise disease-free survival.