Mark H. Katz

Robotic Radical Prostatectomy in Overweight and Obese Patients: Oncological and Validated-Functional Outcomes

OBJECTIVES To determine the impact of body mass index (BMI) on perioperative functional and oncological outcomes in patients undergoing robotic laparoscopic radical prostatectomy (RLRP) when stratified by BMI. METHODS Data were collected prospectively for 945 consecutive patients undergoing RLRP. Patients were evaluated with the UCLA-PCI-SF36v2 validated-quality-of-life questionnaire preoperatively and postoperatively to 24 months. Patients were stratified by BMI as normal weight (BMI < 25 kg/m(2)), overweight (BMI = 25 to < 30 kg/m(2)) and obese (BMI > or = 30 kg/m(2)) for outcomes analysis. RESULTS Preoperatively, obese men had a significantly greater percentage of medical comorbidities (P < .01) as well as a baseline erectile dysfunction (lower mean baseline Sexual Health Inventory for Men score [P = .01] and UCLA-PCI-SF36v2 sexual function domain scores [P = .01]). Mean operative time was significantly longer in obese patients when compared with normal and overweight men (234 minutes vs 217 minutes vs 214 minutes; P = .0003). Although overall complication rates were comparable between groups, a greater incidence of case abortion caused by pneumoperitoneal pressure with excessive airway pressures was noted in obese men. Urinary continence and potency outcomes were significantly lower for obese men at both 12 and 24 months (all P < .05). CONCLUSIONS In this series, obese men experienced a longer operative time, particularly during the initial robotic experience. As such, surgeons early in their RLRP learning curve should proceed cautiously with surgery in these technically more difficult patients or reserve such cases until the learning curve has been surmounted. These details, including inferior urinary and sexual outcomes, should be discussed with obese patients during preoperative counseling.

Pelvic Lymphadenectomy During Robot-assisted Radical Prostatectomy: Assessing Nodal Yield, Perioperative Outcomes, and Complications

OBJECTIVES To describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. METHODS PLND was routinely performed on men with higher risk preoperative prostate cancer parameters (ie, prostrate-specific antigen >10 ng/mL, primary Gleason score > or =4, or clinical Stage T2b or greater). The outcomes of robot-assisted radical prostatectomy with bilateral, standard template PLND (group 1; n = 296 [26%]) were compared with those of a cohort of 859 robot-assisted radical prostatectomy patients (74%) without PLND (group 2). We also compared these data with those from a single-surgeon experience of open, standard-template PLND for retropubic radical prostatectomy. RESULTS The mean number of lymph nodes removed was 12.5 (interquartile range 7-16). The mean operative time (224 vs 216 minutes; P = .09), estimated blood loss (206 vs 229 mL; P = .14), and hospital stay (1.32 vs 1.24 days; P = .46) were comparable between the 2 groups. The rate of intraoperative complications (1% vs 1.5%; P = .2), overall postoperative complications (9% vs 7%; P = .8), and lymphocele formation (2% vs 0%; P = .9) were not significantly different. The review of our open series and the historically published open standard-template PLND series revealed a mean yield of 15 and a range of 6.7-15 lymph nodes removed, respectively. CONCLUSIONS Our data support the feasibility and low complication rate of robotic standard-template PLND with lymph node yields comparable to those with open PLND. Considering the low morbidity of PLND in experienced hands, coupled with the potential of preoperative undergrading and understaging and the therapeutic benefit to patients with micrometastatic disease, an increase in overall standard-template PLND use should be considered.

Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins Characteristics

OBJECTIVES To evaluate the pathologic and functional outcomes of patients with bilateral interfascial (IF) or extrafascial nerve-sparing (EF-NSP) techniques. It is believed that the IF-NSP technique used during robotic-assisted radical prostatectomy (RARP) spares more nerve fibers, while EF dissection may lower the risk for positive surgical margins (PSM). METHODS A prospective database was analyzed for RARP patients with bilateral IF- or EF-NSP technique. Collected parameters included age, body mass index, prostate-specific antigen, clinical and pathologic Gleason score and stage, estimated blood loss, operative time, and PSM characteristics. Functional outcomes were evaluated with the use of the University of California Los Angeles Prostate Cancer Index questionnaire. Men receiving postoperative hormonal or radiation therapy were excluded from sexual function analysis. RESULTS A total of 110 and 703 cases with bilateral EF- and IF-NSP, respectively, were analyzed. EF-NSP patients had higher prostate-specific antigen, clinical, pathologic stage, and pathologic Gleason score. PSM rate did not achieve statistically significant difference between groups. There was a trend toward lower pT3-PSM in the EF group (51% vs 28%; P = .08). Mid- and posterolateral PSM location were lower in the EF-NSP group, 11% vs 37% and 11% vs 29%, respectively (P < .001). The IF-NSP group patients achieved statistically significant better sexual function (P = .02) and potency rates (P = .03) at 12 months after RARP. CONCLUSIONS In lower risk patients, bilateral IF-NSP technique does not result in significantly higher PSM rates. EF-NSP appears to reduce posterolateral and mid-prostate PSM. Men with bilateral IF-NSP demonstrate significantly better sexual function outcomes.

Hemostatic Agents and Instruments in Laparoscopic Renal Surgery

Control of bleeding is one of the most technically challenging steps in laparoscopic renal surgery, especially partial nephrectomy. Although there is no consensus on how best to approach hemostasis, the options continue to expand. The original method of sutured renorrhaphy is, perhaps, the most effective; however, great skill is needed to avoid prolonged warm ischemia. Tissue sealants and adhesives serve as a barrier to leakage and as a hemostat. The four classes are fibrin sealants, collagen-based adhesives, hydrogel, and glutaraldehyde-based adhesive. Additionally, oxidized cellulose can be applied to the surface of kidney or used as a bolster. Fibrin sealants are self-activating and work best on a dry field. The gelatin matrix agent consists of human-derived thrombin with a calcium chloride solution and bovine-derived gelatin matrix. The fibrinogen required to form a clot comes from autologous blood. Another product is polyethylene glycol-based hydrogel, which acts as a mechanical sealant. The tissue glue consists of bovine serum albumin and glutaraldehyde, which cross-link to each other, as well as to other tissue proteins. Excessive use or spillage around the renal pelvis and ureter may compromise urinary flow. The methylcellulose products, consisting of oxidized cellulose sheets, usually are positioned within a sutured bolster and act in part by providing direct pressure. A number of energy-based technologies also have been utilized. Monopolar cautery consists of a high-frequency electrical current delivered from a single electrode. Care must be taken to avoid injurious current transfer to surrounding structures. With bipolar cautery, hemostasis occurs only between the electrodes. In the argonbeam coagulator, argon, an inert non-flammable gas that clears from the body rapidly, is coupled with an electrosurgical generator. The gas creates a more even distribution of the energy and better sealing of the tissues. There have been a few reports of serious complications, including gas embolism and tension pneumothorax. The holmium:YAG laser simultaneously dissects and coagulates tissue. However, its use may be limited by smoke and by blood splashing onto the camera lens, and the tissue vaporization and liquid could promote tumor-cell spillage. The potassium-titanyl-phosphate (KTP) and diode lasers have shown promise in animal studies. The saline-coupled radiofrequency tool uses a standard electrosurgical generator to deliver energy through the conductive fluid. The fluid keeps the surface temperature much lower, increases the contact area, and reduces char and eschar formation. One caveat for the use of instruments that coagulate and ablate tissue is that they can damage the collecting system. Furthermore, the char can make it difficult to assess margin status. In practice, a combination of instruments, sealants, or both generally is utilized to obtain hemostasis. These multimodality efforts may be especially useful in the patient with compromised renal function. On the other hand, the cost can rise quickly when multiple agents are employed. Combining suturing and hemostatic technology may be the best strategy.

Orthotopic Neobladder Versus Indiana Pouch in Women: A Comparison of Health Related Quality of Life Outcomes

PURPOSE Little is known about the health related quality of life of women who have undergone continent urinary diversion. We compared health related quality of life outcomes for women who underwent radical cystectomy with an orthotopic neobladder or Indiana pouch. MATERIALS AND METHODS From 1995 to June 2008 a single surgeon (GDS) performed radical cystectomy with an orthotopic neobladder in 47 women and radical cystectomy with an Indiana pouch in 45. A comprehensive database provided clinical, pathological and outcomes data. The validated Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index was mailed to 92 patients. RESULTS Complete data were available for 87% of patients treated with radical cystectomy with an orthotopic neobladder and 93% of those treated with radical cystectomy with an Indiana pouch, with a median followup of 34 and 24 months, respectively (p = 0.8). Median (IQR) age was 65 (58, 71) and 61.5 (51, 67) years for patients with an orthotopic neobladder and Indiana pouch, respectively (p = 0.03). No significant differences were found for pathological stage, nodal status, blood loss, Clavien grade III or greater complications, adjuvant therapy or hospital stay between the 2 treatment groups, or between respondents and nonrespondents. Five-year survival rates for patients with an orthotopic neobladder and Indiana pouch were 65% and 58%, respectively (p = 0.9). There were 21 (75%) living patients with an orthotopic neobladder and 19 (61%) with an Indiana pouch who completed the Functional Assessment of Cancer Therapy-Vanderbilt Cystectomy Index, and physical (p = 0.53), social (p = 0.97), emotional (p = 0.61), functional (p = 0.55) and radical cystectomy specific (p = 0.54) health related quality of life domains were not significantly different between the groups. CONCLUSIONS Women undergoing radical cystectomy with an orthotopic neobladder vs an Indiana pouch have similar health related quality of life outcomes. Larger series with longer followup and multiple surgeons are necessary to confirm these findings.

A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy—Can We Predict Adverse Pathological Outcomes?

PURPOSE Patients with Gleason score 6 microfocal prostate cancer, defined as 5% or less in 1 biopsy core, are often considered to have favorable disease. Few studies have addressed clinical parameters that predict pathological upgrading or up staging at radical prostatectomy. MATERIALS AND METHODS From a prospective database of 1,271 consecutive robot assisted laparoscopic prostatectomies performed from 2003 to 2008 patients with Gleason score 6 microfocal prostate cancer were identified. Adverse pathological outcome was defined as any upgrading and/or up staging on prostatectomy pathological findings. Multivariate logistic regression was used to evaluate the ability of patient age, clinical stage, the total number of biopsy cores, preoperative prostate specific antigen, prostate volume and pathological prostate specific antigen density to predict adverse pathological outcomes. RESULTS A total of 192 patients with a median age of 59 years (range 42 to 73) were identified with Gleason score 6 prostate cancer involving 5% or less of 1 biopsy core, including 177 (92%) with clinical T1c disease. Mean +/- SD preoperative prostate specific antigen was 6.0 +/- 3.9 ng/ml (range 0.8 to 35). Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 (18%) and up staging in 16 (8%). Multivariate logistic regression revealed that age more than 65 years and pathological prostate specific antigen density greater than 0.20 ng/ml/gm were predictive of an increased risk of adverse pathological results (p = 0.0081 and 0.0169, respectively). CONCLUSIONS While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5 risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.

Laparoscopic partial nephrectomy: a single-center evolving experience.

OBJECTIVES To review our laparoscopic partial nephrectomy (LPN) experience, examine the evolution of technique, and compare the outcomes between the early and recent experience. The indications and surgical technique of LPN continuously evolve. METHODS Data for 184 patients who underwent LPN for a tumor between October 2002 and August 2008 was retrieved from a prospective database. Surgical and functional outcomes for the entire cohort were analyzed and the first 50 (group 1) and most recent 50 (group 2) cases were compared. RESULTS The groups were similar in terms of baseline renal function, body mass index, and comorbidities. The mean tumor size and the proportion of central tumors in groups 1 and 2 were 2.4 vs 3 cm and 12% vs 52%, respectively (P <.003). In group 2 we stopped the use of ureteral catheters and bolster renorrhaphy, and routinely clamped the renal hilum. Mean warm ischemia time in groups 1 and 2 (30 and 27 minute, respectively, P = .3) and the complication rate were similar. Overall, patients with tumors >4 cm had more complications (P = .042). In group 2 the estimated blood loss and hospital stay decreased (243 vs 140 mL, P = .01, 1.4 vs 2.5 days, P <.001). Overall 78% of the tumors were malignant and the positive margin rate was 3%. With a median follow-up of 18 months, no local or distant tumor recurrences were observed. CONCLUSIONS With growing experience and technical modifications, LPN is now performed for patients with larger and more central tumors. Longer follow-up is necessary to evaluate oncologic outcomes.

Laparoscopic Partial Nephrectomy for Tumors Larger Than 4 cm: A Comparative Study

PURPOSE To compare the perioperative and functional outcomes of patients with clinical T(1a) and T(1b) renal tumors after laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS Data of 184 patients who underwent LPN were retrieved from a prospective, Institutional Review Board-approved database. The patients were stratified for analysis into groups: 149 (81%) patients with clinical stage T(1a) (group 1) and 35 (19%) patients with clinical stage T(1b) (group 2). Perioperative and postoperative outcomes were compared. RESULTS No significant differences between groups 1 and 2 in warm ischemia time, estimated blood loss, operative time, conversion rate, intraoperative complication rate, and hospital stay were observed. The incidence of postoperative complications in group 2, however, was twice that of group 1 (25.7% vs 12%) (P = 0.04). Clinical staging correlated with the pathologic staging in 96% of the patients in group 1 and in only 71% in group 2 (P < 0.001). Upstaging to pT(2) or pT(3) occurred in 29% of the patients in group 2. High-grade tumors were more prevalent in group 2 (36% vs 12%) (P = 0.001). The number of patients with positive margin was higher in group 2, but the difference was not statistically significant. The mean decline in estimated creatinine clearance (median follow-up 18 months) was significantly higher in group 2. CONCLUSIONS LPN in patients with tumors >4 cm, while safe and feasible in experienced hands, is associated with a higher postoperative complication rate, as well as a higher rate of pathologic upstaging. Such data should be discussed when counseling patients with larger tumors for LPN.

Application of Ice Cold Irrigation During Vascular Pedicle Control of Robot-Assisted Radical Prostatectomy: EnSeal Instrument Cooling to Reduce Collateral Thermal Tissue Damage

BACKGROUND AND PURPOSE Energy-based hemostasis of the prostatic vascular pedicles (PVP) during robot-assisted radical prostatectomy (RARP) may cause collateral thermal injury to adjacent neural tissue and has been shown to negatively impact sexual function recovery. The unique engineering design of the EnSeal(®) (Ethicon, Cincinnati, OH) has been demonstrated to limit collateral thermal tissue damage to <1.0 mm. Use of tissue and instrument cooling before and during device activation may potentially further reduce thermal spread. As such, we sought to evaluate the collateral tissue effects of EnSeal with or without cold saline irrigation (CSI) during PVP control. PATIENTS AND METHODS The EnSeal Trio device was used for PVP control in 20 consecutive men undergoing bilateral, non-nerve-sparing RARP. Ipsilateral vascular pedicles were randomly selected to EnSeal plus CSI (<4 °C) application to the tissue before and during device activation or EnSeal alone. The primary end point was the distance of thermal injury from the inked margin using both hematoxylin and eosin (H&E) and terminal transferase uridyl nick end-labeling (TUNEL) apoptosis staining. A mean of three measurements was taken for each pedicle. Pathologic analysis was performed by a single, blinded uropathologist. RESULTS Mean distance of thermal injury from the inked margin using H&E staining was 0.31 mm (range 0.15-0.40 mm) and 0.98 mm (range 0.7-1.2 mm) for the EnSeal plus CSI and EnSeal alone, respectively (P < 0.0001). TUNEL staining also demonstrated lateral tissue damage of 0.39 mm (range 0.2-0.5 mm) and 1.12 mm (range 0.9-1.3 mm), respectively (P < 0.001). No complications related to hemostasis or postoperative bleeding were observed in the study. CONCLUSIONS The hemostatic properties of EnSeal work effectively when submerged in CSI. Adjacent thermal tissue damage is significantly minimized with the addition of CSI. This may have a beneficial impact on nerve preservation and sexual function outcomes after RARP.

Laparoscopic Radical Versus Laparoscopic Partial Nephrectomy for Clinical T1bN0M0 Renal Tumors: Comparison of Perioperative, Pathological, and Functional Outcomes

AIM To compare outcomes in patients treated with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for clinical T1bN0M0 renal masses. MATERIALS AND METHODS Between 2002 and 2008, 33 and 52 consecutive patients who underwent LPN and LRN, respectively, for clinical stage T1bN0M0 tumors were retrospectively identified from a prospectively maintained database of 450 patients undergoing laparoscopic renal surgery. Perioperative, pathological, and postoperative outcomes were compared. RESULTS The two groups of patients were similar in age, sex, and body-mass index. Mean radiographic tumor size was smaller (4.8 vs. 5.2 cm, p = 0.04) in the LPN group. Mean operative time (228 vs. 175 minutes, p < 0.0001) and mean estimated blood loss (233 vs. 112 mL, p = 0.003) were higher in the LPN group. Intraoperative complication rates of 15.2% versus 5.7% (p = 0.28) and postoperative complication rates of 24.2% versus 13.5% (p = 0.20) were observed in the LPN and LRN groups, respectively. Overall median follow-up was 15 and 21 months for the LPN and LRN cohorts, respectively. A 12.5% and 29.3% decline in estimated glomerular filtration rate was observed (p = 0.002), and 30.3% compared with 55.7% of patients developed an estimated creatinine clearance (eCrCl) < 60 mL/minutes after treatment (p = 0.04) for LPN and LRN, respectively. There were no differences in pathological stage distribution between the two groups. In the LPN group there were no local or systemic recurrences, and one positive surgical margin was observed. One patient developed metastatic disease in the LRN group. CONCLUSIONS LPN for T1b renal tumors provides superior intermediate-term preservation of renal function compared with LRN. Continued follow-up of these patients is required to evaluate oncological outcomes.