Michael B. Rothberg

Intrarenal pressures generated during deployment of various antiretropulsion devices in an ex vivo porcine model.

INTRODUCTION Pressurized saline irrigation is commonly used during ureteroscopy, which can cause an increase in intrarenal pressure leading to postoperative pain, sepsis, and renal injury due to pyelovenous and pyelolymphatic backflow. To prevent retrograde stone migration during ureteroscopic lithotripsy, antiretropulsion devices can be deployed, which may or may not protect the kidney against high intrarenal pressures. This study compares the intrarenal pressures generated during the use of two antiretropulsion devices in an ex vivo porcine model. MATERIALS AND METHODS Using an ex vivo porcine model of the urinary system, flexible ureteroscopy was performed at the proximal, mid, and distal ureter. Intrarenal pressures were measured in the absence and presence of a coil-based antiretropulsion device and a multifold film-based device. Intrarenal pressure measurements were obtained while using saline irrigation at a gravity of 84 cm H(2)O and pressures of 150 and 300 mm Hg. RESULTS The deployment of a coil device resulted in a significant increase in intrarenal pressures during ureteroscopy with pressurized irrigation when compared with intrarenal pressures without a device. The use of a multifold film device that occluded the ureter during ureteroscopy resulted in a decrease in intrarenal pressures at an irrigation pressure of 300 mm Hg when compared with pressures without a device. In the remaining configurations, the intrarenal pressures were only minimally elevated. When comparing the two devices to each other, the multifold film device had significantly lower intrarenal pressures at each configuration. This has potential implications in preventing renal injury and/or sepsis during ureteroscopy. CONCLUSION The use of a multifold film antiretropulsion device during ureteroscopy with high-pressure irrigation can potentially protect the kidney from elevated intrarenal pressures.

Contemporary Experience with Laparoscopic Radical Nephrectomy

INTRODUCTION We present our single-center contemporary experience with laparoscopic radical nephrectomy (LRN). LRN is an established minimally invasive approach comparable to open radical nephrectomy for the treatment of renal cortical neoplasms. Technical advancements and surgical experience with LRN mandate a re-evaluation of contemporary outcomes. METHODS Between June 2005 and July 2009, 74 patients underwent LRN for an enhancing renal mass. Six of these patients underwent a cytoreductive nephrectomy for metastatic renal cell carcinoma. Patient demographics, perioperative data, tumor characteristics, complication rates, and outcomes were retrospectively collected and analyzed from our prospectively established renal database. RESULTS The mean follow-up for patients undergoing nephrectomy without metastasis was 17.4 months (1-52 months). The mean estimated blood loss was 93 mL (0-600 mL) and the overall complication rate was 5.9%. Two patients developed metastatic disease after surgery, both of whom had high-stage (pT3a) tumors. No death was caused by renal cell carcinoma. In the cytoreductive cohort, the mean estimated blood loss was 592 mL (200-1200 mL). Four were high stage (pT3a/pT3b). The mean follow-up was 4.7 months (1-15 months), with an overall survival of 50%. CONCLUSIONS With contemporary technology and increased laparoscopic surgical experience, LRN and, in selected cases, cytoreductive LRN can be performed safely and effectively for the majority of renal tumors. Experience has resulted in a reduction in operative time and blood loss complication rates. LRN remains the approach of choice for the management of renal cortical neoplasms not amenable to nephron-sparing surgery.

Comparison of Renal Parenchymal Volume Preservation Between Partial Nephrectomy, Cryoablation, and Radiofrequency Ablation Using 3D Volume Measurements.

PURPOSE Small renal masses (SRM) can be managed via a variety of nephron-sparing procedures (NSPs), but the association between choice of NSP and renal parenchymal volume (RPV) preservation is not well understood. We sought to examine RPV preservation after partial nephrectomy (PN) performed via open, robotic, or laparoscopic approaches and thermal ablation (TA) performed via cryoablation (CA) or radiofrequency ablation (RFA). PATIENTS AND METHODS The study was a retrospective review of three institutional databases of patients with a SRM <4 cm treated via one of the five NSPs (open PN, laparoscopic PN, robotic PN, percutaneous CA, or percutaneous RFA). The 30 most recent consecutive cases treated via each NSP were selected to obtain a total of 150 cases for analysis. Patient characteristics were obtained via manual chart review, and tumor characteristics were assessed via the R.E.N.A.L. nephrometry score. Using three-dimensional rendering software, preoperative and postoperative RPV was calculated for the tumor-bearing kidney, excluding the tumor itself (for preoperative images) or the postsurgical/ablative defect (for postoperative images). The percent change in RPV was compared between the procedure types. RESULTS One hundred fifty cases were included in the final analysis, with 30 cases from each NSP category. While preoperative tumors were larger in the PN group, there was no difference in the mean nephrometry score between groups. The TA group was found to have a lower mean RPV loss (-8.1% vs -16.5%, p<0.005). There was no difference in the RPV loss between modalities of TA (CA vs RFA) or between approaches to PN (open, laparoscopic, robotic). Matched-pair analysis based on the tumor size and multivariate analysis indicated TA vs PN was independently associated with less RPV loss. CONCLUSIONS TA is associated with less RPV loss than PN in the management of SRM, but there is no difference between modalities of TA (CA vs RFA) or between approaches to PN.

The da vinci robot system eliminates multispecialty surgical trainees' hand dominance in open and robotic surgical settings.

Background and Objectives: Handedness, or the inherent dominance of one hands dexterity over the others, is a factor in open surgery but has an unknown importance in robot-assisted surgery. We sought to examine whether the robotic surgery platform could eliminate the effect of inherent hand preference. Methods: Residents from the Urology and Obstetrics/Gynecology departments were enrolled. Ambidextrous and left-handed subjects were excluded. After completing a questionnaire, subjects performed three tasks modified from the Fundamentals of Laparoscopic Surgery curriculum. Tasks were performed by hand and then with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, California). Participants were randomized to begin with using either the left or the right hand, and then switch. Left:right ratios were calculated from scores based on time to task completion. Linear regression analysis was used to determine the significance of the impact of surgical technique on hand dominance. Results: Ten subjects were enrolled. The mean difference in raw score performance between the right and left hands was 12.5 seconds for open tasks and 8 seconds for robotic tasks (P < .05). Overall left-right ratios were found to be 1.45 versus 1.12 for the open and robot tasks, respectively (P < .05). Handedness significantly differed between robotic and open approaches for raw time scores (P < .0001) and left-right ratio (P = .03) when controlling for the prior tasks completed, starting hand, prior robotic experience, and comfort level. These findings remain to be validated in larger cohorts. Conclusion: The robotic technique reduces hand dominance in surgical trainees across all task domains. This finding contributes to the known advantages of robotic surgery.

Predictors of biochemical recurrence in pT3b prostate cancer after radical prostatectomy without adjuvant radiotherapy

Men with pathologic evidence of seminal vesicle invasion (SVI) at radical prostatectomy (RP) have higher rates of biochemical recurrence (BCR) and mortality. Adjuvant radiotherapy (XRT) has been shown to increase freedom from BCR, but its impact on overall survival is controversial and it may represent overtreatment for some. The present study, therefore, sought to identify men with SVI at higher risk for BCR after RP in the absence of adjuvant XRT.

Prospective Correlation between Likelihood of Favorable Pathology on the 17-Gene Genomic Prostate Score and Actual Pathological Outcomes at Radical Prostatectomy

Introduction: We evaluate the Genomic Prostate Score in a prospective clinical setting and determine the cutoff point for likelihood of favorable pathology, below which definitive treatment should be advised. Methods: Pathological data were recorded for men who had the Genomic Prostate Score performed and who ultimately underwent radical prostatectomy. Inclusion criteria were newly diagnosed prostate cancer, and NCCN classification as very low, low and low volume intermediate risk. Adverse pathology was defined as any pT3 stage and primary Gleason grade of 4 or any pattern 5. ROC analysis was used to determine the optimal cutoff point of likelihood of favorable pathology for each NCCN risk group. Results: A total of 95 patients were enrolled and 50 patients (53%) underwent radical prostatectomy. Adverse pathology was found in 21 patients (42%), grouped as very low risk 0%, low risk 32.4% and low volume intermediate risk 71.4%. Among those with low risk disease, ROC analysis determined that a likelihood of favorable pathology cutoff of 76% or greater performed the best, correctly classifying 91.2% of patients with a sensitivity of 95.7%, specificity of 81.8% and AUC 0.95. For intermediate risk patients the optimal likelihood of favorable pathology cutoff was 68% or greater, with 92.3% correct, sensitivity 75%, specificity 100% and AUC 0.95. Conclusions: NCCN low risk patients had the most meaningful information provided by the Genomic Prostate Score. Men with low risk disease with a likelihood of favorable pathology threshold greater than 75% are at very low risk for adverse pathology, whereas those with a likelihood of favorable pathology of 75% or less are at high risk. This likelihood of favorable pathology threshold is greater than 69% for men with low volume intermediate risk disease. These results should help clinicians use Genomic Prostate Score information when making decisions regarding active surveillance or intervention for prostate cancer.

Lumbar artery branch injury secondary to ureteroscopic manipulation

Iatrogenic vascular injury in ureteroscopy is relatively uncommon and typically presents as a subcapsular hematoma. We report the case of an injury to a branch of the lumbar artery secondary to ureteral trauma during ureteroscopy. In the immediate postoperative period, the patient became hypotensive and tachycardic, prompting a workup that revealed an active hemorrhage. The patient then underwent subsequent angiogram and successful coil embolization.

Baseline Serum 25-Hydroxyvitamin D Levels in Men Undergoing Radical Prostatectomy: Is There An Association With Adverse Pathologic Features?

INTRODUCTION/BACKGROUND The purpose of this study was to evaluate the prevalence of vitamin D (VitD) deficiency in men undergoing radical prostatectomy and determine whether an association exists between preoperative VitD levels and adverse pathologic features. PATIENTS AND METHODS Patients scheduled to undergo radical prostatectomy for clinically localized disease from January to August 2012 were prospectively followed and those with available preoperative serum 25-hydroxyvitamin D levels were included. Men with a known diagnosis of VitD deficiency or taking VitD supplementation were excluded. Cox regression analysis was performed to determine whether preoperative VitD level is predictive of adverse pathologic outcomes. RESULTS One hundred consecutive men were included. Mean age was 62 (range, 42-79) years and mean VitD level was 26 (range, 6-57) ng/mL. Overall, 65 men (65%) had suboptimal levels of VitD (< 30 ng/mL), and 32 (32%) had deficiency (< 20 ng/mL). There was no significant correlation between VitD and age (P = .5). In logistic regression analysis, VitD level was not predictive of pathologic Gleason (P = .11), pathologic stage (P = .7), or positive margin status (P = .8). CONCLUSION The association between VitD and prostate cancer has been controversial and data suggesting an increased risk of aggressive cancer in men with low levels of VitD have been inconsistent. We found that baseline preoperative VitD level was not associated with any adverse pathologic features. However, VitD deficiency is a common finding in this population, although unrelated to patient age. These results represent the first time the correlation between VitD and prostate cancer has been evaluated in a cohort of men undergoing radical prostatectomy.

PD12-08 METFORMIN AND STATINS ACT SYNERGISTICALLY TO REDUCE BIOCHEMICAL RECURRENCE RISK IN DIABETICS FOLLOWING RADICAL PROSTATECTOMY

INTRODUCTION AND OBJECTIVES: The number of robotassisted radical prostatectomy (RARP) in Japan is increasing rapidly due to the application of health insurance to robotic surgery for prostate cancer since April, 2012. To maintain patient safety and high quality of surgery, the implementation of robotic surgeries in our institution were controlled by the minimal invasive surgery center (MISC), which runs robotic surgeries comprehensively. We report our experience of treating patients in MISC together with outcome of RARP. METHODS: The MISC consisted of all the departments related to robotic surgery including anesthesiology, five surgery departments, operation room nurses and medical engineers. From the view of safe implementation of robotic surgery, a certificate for surgery type and the console surgeon were authorized by MISC. Specifically, the MISC has a 0termination order0 authority, which is applied when there is excessive bleeding or surgical time. Robotic surgery must be changed into other types of surgery such as open conversion once the order is given. Each robotic surgery case in five surgery departments is checked and discussed preand post-operatively in the regular meeting held by MISC twice a month. RESULTS: The case number results stratified by robotic surgery types in the MISC over the last 2 years are shown in Table. The Urology, gynecology, respiratory surgery, digestive surgery and otorhinolaryngology departments performed 176, 22, 43, 34 and 2 cases of robotic surgeries, respectively. The number of cases with major complications including Clavien 5, 4 and 3 in all 277 cases were 0, 0 and 6 (2.2 %), respectively with one case of intra-operative open conversion. The core of robotic surgeries in MISC was RARP, and the implementation of this surgery based on the concept of pentafecta was supervised by MISC. At the median follow-up time of 11.9 (range 1.3 27.3) months, the positive surgical margin rate was 15.8 %, 91% of patients had undetectable PSA levels, and 76% of patients were not using pads. CONCLUSIONS: This is the first report of robotic surgery cases that were implemented using the constitutional framework of an academic institution. The MISC is providing immeasurable benefits from the aspects of patient safety and education for the robotic surgical team, and ultimately lead to accomplishment of pentafecta of RARP in urology.