Mohan Verghese

Perioperative Outcomes of Robotic and Laparoscopic Simple Prostatectomy: A European-American Multi-institutional Analysis

BACKGROUND Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. OBJECTIVE To report a large multi-institutional series of minimally invasive SP (MISP). DESIGN, SETTING, AND PARTICIPANTS Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. INTERVENTION Laparoscopic or robotic SP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15ml/s, and no perioperative complications. RESULTS AND LIMITATIONS Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100ml (range: 89-128). Median estimated blood loss was 200ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p=0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p=0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss (p=0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. CONCLUSIONS This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. PATIENT SUMMARY Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

Robotic-assisted prostatectomy and open radical retropubic prostatectomy for locally-advanced prostate cancer: multi-institution comparison of oncologic outcomes

Purpose: Robotic-assisted laparoscopic prostatectomy (RALP) offers reportedly comparable oncologic outcomes for localized disease compared with open radical retropubic prostatectomy (ORRP). However, the oncologic efficacy of RALP in locally-advanced prostate cancer (PCa) is less clear. We report and compare our experience with RALP and ORRP in men with locally advanced PCa. Methods: Patients with locally advanced PCa (stage T3 or greater) were identified in both robotic and open cohorts. Clinicopathologic features including age, clinical stage, prostate-specific antigen, surgical margins, and Gleason score were reviewed. We further examined the incidence of positive surgical margins, the effect of the surgical learning curve on margins, and the need for adjuvant therapy. Results: From 1997 to 2010, 1,011 patients underwent RALP and 415 patients were identified who underwent radical retropubic prostatectomy (RRP) across four institutions. 140 patients in the RALP group and 95 in the RRP group had locally advanced PCa on final pathology. The overall robotic positive margin rate 47.1% compared with 51.4% in the RRP group. A trend towards a lower positive margin rate was seen after 300 cases in the RALP group, with 66.7% positive margin rate in the first 300 cases compared with 41.8% in the latter 700 cases. In addition, a lower incidence of biochemical recurrence was also noted in the latter cases (30.6% vs. 9.5%). Conclusions: Up to 2 out of 3 men undergoing RALP for locally-advanced PCa had positive margins during our initial experience. However, with increasing surgeon experience the overall positive margin rate decreased significantly and was comparable to the positive margin rate for patients with locally advanced disease undergoing ORRP over four academic institutions. We also noted a lower incidence of biochemical recurrence with increasing RALP experience, suggesting better oncologic outcomes with higher volume. Given this data, RALP has comparable oncologic outcomes compared to ORRP, especially with higher volume surgeons.

Management of mucinous urachal neoplasm presenting as pseudomyxoma peritonei.

Background Mucinous neoplasms of the urachus are rare malignancies so that the physicians’ index of suspicion for a timely and accurate diagnosis is low. Also, this disease may present with a wide variety of symptoms and signs. Methods Two patients with pseudomyxoma peritonei as the initial presentation of urachal mucinous adenocarcinoma were treated successfully. The medical literature regarding treatment options for this manifestation of the disease was searched. Results Two patients with large volume of pseudomyxoma peritonei originating in a mucinous urachal neoplasm were treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Our first patient required two reoperations to palliate the accumulation of gross mucinous ascites. She died 11 years after diagnosis with progression of mucinous adenocarcinoma resulting in starvation. The second patient had ostomy closure with second look surgery at one year after definitive treatment; four small tumor nodules were seen and easily resected. The patient is currently without evidence of disease and has a normal quality of life. Seven prior manuscripts that report a single case of pseudomyxoma peritonei were reviewed to explore the full range of treatment options and survival for this rare condition. Conclusion Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy may be a new treatment option for mucinous urachal neoplasms presenting with pseudomyxoma peritonei. Other management strategies such as systemic chemotherapy seemed to hold little promise for this group of patients.

Paratesticular leiomyosarcoma in an elderly man

Soft tissue tumors, both benign and malignant, of the testes are relatively uncommon. Primary leiomyosarcoma of the testis is rare, and its clinical behavior is difficult to predict. We report a case of paratesticular leiomyosarcoma in a 71-year-old man. Routine histologic examination and immunohistochemical staining were performed. The tumor was composed of interlacing fascicles of smooth muscle cells with marked nuclear pleomorphism and three to four mitoses per high power field, with few atypical mitoses. On the basis of the microscopic examination and immunohistochemical studies, the tumor was identified as a paratesticular leiomyosarcoma. The published studies on this entity are reviewed.

Retroperitoneal Ganglioneuroma Encasing the Celiac and Superior Mesenteric Arteries

Ganglioneuroma is a rare neoplasm arising from the sympathoadrenal neuroendocrine system and has anatomic distribution paralleling the sympathetic chain ganglia and the adrenal medulla. In some cases, ganglioneuroma is the end stage maturation of less-differentiated neoplasms such as neuroblastoma or ganglioneuroblastoma, but based on age at diagnosis (over 10 years of age) and anatomic location, many of these tumors appear to arise de novo. It must be included in the differential diagnosis of posterior mediastinal and retroperitoneal mass. We report a case of retroperitoneal ganglioneuroma involving the celiac axis and superior mesenteric arteries in a 40-year-old female.

SURGICAL COMPLICATIONS RELATED TO ROBOTIC PROSTATECTOMY: PROSPECTIVE ANALYSIS

INTRODUCTION AND OBJECTIVES: Robotic assisted radical prostatectomy (RALP) is now readily available worldwide, but a recent study of Medicare beneficiaries has raised a concern with regard to surgical morbidity related to the procedure. We have performed a critical analysis of our RALP complication profiles, stratified by our learning curve. METHODS: We have reviewed the surgical complications of our first 618 RALP cases performed by a single surgeon since 2003. Surgical data including all complications within 1 year of RALP have been collected prospectively in our ongoing IRB approved prostate cancer database. Multivariate analyses were utilized to identify risk factors for complications. RESULTS: There were 85 (13.8%) patients who experienced perioperative complications, which consisted of 44 major (7.1%) and 41 minor (6.6%) complications. When stratified by our learning curve, there was a significant reduction in overall complications over time. Of major complications, 15 (2.4%) and 12 (1.9%) patients developed a bladder neck contracture and inguinal/incisional hernia at a median follow-up of 3 and 4 months, respectively. There was no mortality or perioperative transfusion in this cohort. No risk factors other than surgeon’s experience were associated with surgical complications. CONCLUSIONS: In our prospective analysis of RALP related complications, the surgeon’s learning curve appears to be the greatest factor in influencing surgical morbidities. Our results reinforce the current wisdom that the surgeon’s experience is the most critical factor in determining surgical outcomes. Careful patient selection and judicious use of the daVinci system are advised during an early learning curve of RALP to minimize surgical complications.

Interstitial pneumonitis secondary to intravesical bacillus calmette-guerin for carcinoma in-situ of the bladder

We report an 81-year-old male who developed severe interstitial pneumonitis on maintenance intravesical Bacillus Calmette-Guerin (BCG) for in-situ carcinoma of the bladder. The patient was treated with steroids and anti-tuberculin therapy with complete response. While there is no established standard of care for the treatment of interstitial pneumonitis, recent reports describe success with combination of corticosteroids and anti-tuberculin medications. We elected to follow this precedent and treated our patient with corticosteroids and antituberculin therapy with good outcome.

Does pure robotic partial nephrectomy provide similar perioperative outcomes when compared to the combined laparoscopic–robotic approach?

Laparoscopic and robotic partial nephrectomy have become the preferred option for surgical management of incidentally discovered small renal tumors. Currently there is no consensus on which aspects of the procedure should be performed laparoscopically versus robotically. We believe that combining a laparoscopic exposure and hilar dissection followed by tumor extirpation and renorrhaphy with robotic assistance provides improved perioperative outcomes compared to a pure robotic approach alone. We performed a comparison of perioperative outcomes between combined laparoscopic–robotic partial nephrectomy—or hybrid procedure—and pure robotic partial nephrectomy (RPN). A multi-center retrospective analysis of patients undergoing RPN and hybrid PN using the da Vinci S system® was performed. Patient data were reviewed for demographic and perioperative variables. Statistical analysis was performed using the Welch t test and linear regression, and nonparametric tests with similar significance results. Thirty-one patients underwent RPN while 77 patients underwent hybrid PN between 2007 and 2011. Preoperative variables were comparable in both groups with the exception of lesion size and nephrometry score which were significantly higher in patients undergoing hybrid PN. Length of surgery, estimated blood loss and morphine used were significantly less in the hybrid group, while warm ischemia time was significantly longer. The difference in WIT was accounted for in this data by adjusting for nephrometry score. In our multi-center series, the hybrid approach was associated with a shorter operative time, reduced blood loss and lower narcotic usage. We believe this approach is a valid alternative to RPN.

A Novel Technique of Exposure During Radical Retropubic Prostatectomy

PURPOSE We describe a novel technique of enhanced exposure during radical retropubic prostatectomy in cases with significant cartilage overgrowth at the junction of the symphysis pubis. MATERIALS AND METHODS At our institution 74 radical retropubic prostatectomies were performed between July 1, 1998 and June 30, 1999. In 9 cases (12%) exposure was limited by overgrowth of cartilage at the posterior aspect of the pubic symphysis. Electrovaporization of this cartilaginous outgrowth was performed using an extended Bovie tip on cut settings of approximately 250 W. using the Bard System 5000, Birtcher 5000 and 6400 series (Valley Lab, Boulder, Colorado). The cartilage was vaporized until flush with the pubic bone. RESULTS This technique provided optimal exposure for direct visualization during the most critical part of the procedure. Added operative time was only 1 to 3 minutes. No intraoperative or postoperative complications were associated with this technique. CONCLUSIONS We recommend this technique of vaporization when surgical exposure is limited by overhanging pubic symphysis cartilage. This technique enables better visualization during apical dissection, control of the dorsal vein complex and division of the urethra without additional operative time or surgical complications.

Specific Surgical Topics: A Multidisciplinary Management of Paratesticular Sarcomas in Adults

Primary paratesticular sarcomas are rare, affecting primarily older men between the ages of 50 and 80 years. They are the most common tumors of the paratesticular region and usually present insidiously as an asymptomatic slow-growing mass. Because of the rarity of these tumors, there is no common consensus regarding the best management, especially in the adjuvant setting. In adults, 75–80% arise from the spermatic cord and the remainder from the epididymis, tunic, or testicular appendages. Among the malignant tumors, the most common histotype is liposarcoma (46.4%), followed by leiomyosarcoma (20%), malignant fibrous histiocytomas (13%), and embryonal rhabdomyosarcoma (9%). Of these, rhabdomyosarcoma, rare after the age of 40, is the most common malignant mesenchymal tumor in children and is considered the most aggressive sarcoma. It has an increased ability to spread via the lymphatic or hematogenous route. The main dissemination pattern of adult paratesticular sarcomas is by local invasion through the contiguous inguinal canal and less commonly via hematogenous or lymphatic channels. Surgery represents the first and the most effective therapeutic approach to most paratesticular sarcomas, and overall, the prognosis after diagnosis has been related to grading, size, depth of invasion, and surgical margin status.