Mehrdad Alemozaffar

Randomized Controlled Trial of Barbed Polyglyconate Versus Polyglactin Suture for Robot-Assisted Laparoscopic Prostatectomy Anastomosis: Technique and Outcomes

BACKGROUND Transperitoneal robot-assisted laparoscopic prostatectomy (RALP) urethrovesical anastomosis is a critical step. Although the prevalence of urine leaks ranges from 4.5% to 7.5% at high-volume RALP centers, urine leaks prolong catheterization and may lead to ileus, peritonitis, and require intervention. Barbed polyglyconate sutures maintain running suture line tension and may be advantageous in RALP anastomosis for reducing this complication. OBJECTIVE To compare barbed polyglyconate and polyglactin 910 (Vicryl, Ethicon, Somerville, NJ, USA) running sutures for RALP anastomosis. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, randomized, controlled, single-surgeon study comparing RALP anastomosis using either barbed polyglyconate (n = 45) or polyglactin 910 (n = 36) sutures. SURGICAL PROCEDURE RALP anastomosis using either barbed polyglyconate or polyglactin 910 sutures was studied. MEASUREMENTS Operative time, cost differential, perioperative complications, and cystogram contrast extravasation by anastomosis suture type were measured. RESULTS AND LIMITATIONS Although baseline characteristics and overall operative times were similar, barbed polyglyconate sutures were associated with shorter mean anastomosis times of 9.7 min versus 9.8 min (p = 0.014). In addition, anastomosis with barbed polyglyconate rather than polyglactin 910 sutures was associated with more frequent cystogram extravasation 8 d postoperatively (20.0% vs 2.8%; p = 0.019), longer mean catheterization times (11.1 d vs 8.3 d; p = 0.048), and greater suture costs per case (

Athermal Division and Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes

51.52 vs

Technical Refinement and Learning Curve for Attenuating Neurapraxia During Robotic-Assisted Radical Prostatectomy to Improve Sexual Function

8.44; p < 0.001). After 8 of 29 (27.6%) barbed polyglyconate anastomosis sites demonstrated postoperative day 8 cystogram extravasation, we modified our technique to avoid overtightening, reducing cystogram extravasation to 1 (6.3%) of 16 subsequent barbed polyglyconate anastomosis sites. Potential limitations include small sample size and the single-surgeon study design. CONCLUSIONS Compared to traditional sutures, barbed polyglyconate is more costly and requires technical modification to avoid overtightening, delayed healing, and longer catheterization time following RALP.

Comparing costs of robotic, laparoscopic, and open partial nephrectomy.

BACKGROUND Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP). OBJECTIVE To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC). DESIGN, SETTINGS, AND PARTICIPANTS Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures. SURGICAL PROCEDURE RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection. MEASUREMENTS Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day. RESULTS AND LIMITATIONS Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p<0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p<0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p<0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p=0.033), and one DVC-SSL versus zero SL-DVC were transfused (p=0.442). Overall (12.2% vs 12.0%, p=1.0) and apical (1.3% vs 2.7%, p=0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p<0.001) and continence (61.4% vs 39.6%, p<0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE]±standard error [SE]: 16.84±2.56, p<0.001), and better 5-mo urinary function (PE±SE: 19.93±3.09, p<0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07-5.57, p<0.001). CONCLUSIONS DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.

Stepwise Description and Outcomes of Bladder Neck Sparing During Robot-Assisted Laparoscopic Radical Prostatectomy

BACKGROUND While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes. OBJECTIVE Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP). DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction. SURGICAL PROCEDURE Our approach to RARP has been described previously. A single-console robotic system was used for all cases. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function. RESULTS AND LIMITATIONS Greater surgeon experience was associated with better 5-mo sexual function (p = 0.007) and a trend for better 12-mo sexual function (p = 0.061), with improvement plateauing after 250-300 cases. Additionally, younger patient age (both p<0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p=0.021), while unilateral nerve sparing/non-nerve sparing was associated with worse 5-mo sexual function (p = 0.009). Limitations include the retrospective single-surgeon design. CONCLUSIONS With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement.

Patient Frailty and Discharge Disposition following Radical Cystectomy

UNLABELLED Abstract Background and Purpose: Laparoscopic and robot-assisted partial nephrectomy (LPN and RPN) are common minimally invasive alternatives to open partial nephrectomy (OPN) for management of renal tumors. Cost discrepancies of these approaches warrants evaluation. We compared hospital costs associated with RPN, LPN, and OPN. PATIENTS AND METHODS Costs were captured for 25 patients in each group who underwent RPN, LPN, or OPN at our institution between November 2008 and September 2010. Variable costs included operating room (OR) time, supplies, anesthesia, and inpatient care costs. Fixed costs included equipment purchase and maintenance. Impact of variable and fixed costs were estimated using sensitivity analysis. RESULTS Overall variable costs were similar for RPN, LPN, and OPN (

The role of adjuvant radiotherapy in pathologically lymph node positive prostate cancer

6375 vs

Onodera's Prognostic Nutritional Index as an Independent Prognostic Factor in Clear Cell Renal Cell Carcinoma

6075 vs

Partial Clamping of the Renal Artery During Robot-Assisted Laparoscopic Partial Nephrectomy: Technique and Initial Outcomes

5774, P=0.117, respectively). OR supplies contributed a greater cost for RPN and LPN than OPN (

Urologist Use of Cystoscopy for Patients Presenting With Hematuria in the United States

2179 vs