Manoj B. Patel

Robotic-assisted radical prostatectomy: a review of current outcomes

With the widespread diffusion of the screening for prostate cancer, the disease has been diagnosed more commonly in the organ‐confined stage, and in younger and healthier men. For these patients, radical prostatectomy (RP) is still the standard treatment. In an effort to decrease the morbidity associated with open RP, minimally invasive approaches have been described, including robotic‐assisted RP (RALP). Almost one decade after the introduction of RALP, large and mature series have now been reported. We reviewed the outcomes of the largest series of RALP published recently. We searched Medline for reports published between 2006 and 2009, to identify articles describing intraoperative data, surgical complications, oncological outcomes, continence and potency rates after RALP. Relevant articles were selected and the outcomes evaluated.

Robot-assisted Laparoscopic Dismembered Pyeloplasty for Ureteropelvic Junction Obstruction: A Multi-institutional Experience

OBJECTIVE To report a 6-year multi-institutional experience and outcomes with robot-assisted laparoscopic pyeloplasty (RLP) for the repair of ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS Between June 2002 and October 2008, 168 adult patients from 3 institutions underwent RLP for UPJO. A retrospective analysis of prospectively collected data were performed after institutional review board approval. Diagnosis was by intravenous urogram or computed tomography scan and diuretic renogram. All patients underwent RLP through a 4-port laparoscopic technique. Demographic, preoperative, operative, and postoperative endpoints for primary and secondary repair of UPJO were measured. Success was defined as a T½ of <20 minutes on diuretic renogram and symptom resolution. Pain resolution was assessed by subjective patient reports. RESULTS Of 168 patients, 147 (87.5%) had primary repairs and 21 (12.5%) had secondary repairs. Of the secondary repairs, 57% had a crossing vessel etiology. Mean operative time was 134.9 minutes, estimated blood loss was 49 mL, and length of stay was 1.5 days. Mean follow-up was 39 months. Overall, 97.6% of patients had a successful outcome, with a 6.6% overall complication rate. CONCLUSIONS To our knowledge, this review represents the largest multi-institutional experience of RLP with intermediate-term follow-up. RLP is a safe, efficacious, and viable option for either primary or secondary repair of UPJO with reproducible outcomes, a high success rate, and a low incidence of complications.

Preliminary analysis of the feasibility and safety of salvage robot-assisted radical prostatectomy after radiation failure: Multi-institutional perioperative and short-term functional outcomes

BACKGROUND AND PURPOSE Open radical prostatectomy after radiation treatment failure for prostate cancer is associated with significant morbidity. The purpose of the study is to report multi-institutional experiences while performing salvage robot-assisted radical prostatectomy (sRARP). PATIENTS AND METHODS We retrospectively identified 15 patients with biopsy-proven prostate cancer after definitive radiotherapy who underwent sRARP in three academic institutions over a 20-month period. Continence was defined as the use of 0 pads after surgery. Potency was defined as the ability to achieve erections adequate enough for penetration with or without the use of phosphodiesterase-5 inhibitors. Biochemical recurrence after sRARP was defined as a prostate-specific antigen value of >0.2  ng/mL. RESULTS Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine brachytherapy (BT) in five cases, proton beam therapy in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. The median operative time, the median estimated blood loss, and the median length of hospital stay were 140.5  min (interquartile range [IQR] 97.5-157  min), 75  mL (IQR 50-100  mL), and 1 day (IQR 1-2 d), respectively. There were no rectal injuries. Two (13.3%) patients had a positive surgical margin. A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II), one had wound infection (Clavien grade II), and one patient had an anastomotic leak (Clavien gradeId). An anastomotic stricture (Clavien grade IIIa) later developed in this same patient, which was managed by direct visual internal urethrotomy. Of the patients, 71.4% were continent. At a median follow-up of 4.6 months (IQR 3-9.75 mos), four (28.6%) patients presented with biochemical recurrence after sRARP. CONCLUSIONS The challenge during sRALP is the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. It is a technically challenging but feasible procedure. The early complication rates were low, and early continence rates are encouraging.

Retrograde Endoscopic-Assisted Percutaneous Renal Access: A Novel “Lasso” Technique to Achieve Rapid Secure Access to the Collecting System

Image-guided percutaneous renal access for placement of an access sheath for percutaneous nephrolithotomy can be a challenging procedure, especially in patients with nondilated collecting systems, obstructed infundibula (stones or stricture), or extreme body habitus. We describe our experience using ureteroscopy along with a zero-tip stone basket to facilitate a through-and-through (percutaneous-urethra) access to the collecting system.

Efficacy of Multi-Detector Computed Tomography for the Diagnosis of Medullary Sponge Kidney

Objective: To expand the diagnostic armamentarium for medullary sponge kidney (MSK), we evaluate the use of high-resolution multidetector computed tomography (MDCT) for MSK diagnosis and compare to the standard intravenous urography (IVU). Despite a significant prevalence amongst stone formers, diagnosis of this well described condition has declined. IVU, the gold standard in MSK diagnosis, has largely been replaced by CT, which has previously been shown unable to demonstrate signs of MSK. Methods and Materials: Patients with known history of MSK based on IVU underwent limited MDCT urogram. Control group patients, without MSK, also had MDCT urograms performed for other clinically indicated conditions. Studies were scored by board-certified radiologists on a 0-2 scale based on the likelihood of MSK. IVU studies, when available, were similarly graded. Results: MDCT was diagnostic of MSK in 9 out of the 10 patients with known history of MSK. No false positives were present in our series. The one case of MSK not detected on MDCT was graded as a “1” on its respective IVU. Sensitivity and specificity were 90 and 100%, respectively, when compared with IVU. Conclusion: Concordance with IVU findings, despite a small reduction in sensitivity, indicates MDCT to be a suitable, and more readily available replacement for IVU in the diagnosis of MSK.