Pascal Zehnder

Super Extended Versus Extended Pelvic Lymph Node Dissection in Patients Undergoing Radical Cystectomy for Bladder Cancer: A Comparative Study

PURPOSE There is evidence from retrospective studies that radical cystectomy with extended pelvic lymph node dissection provides better staging and outcomes than limited lymph node dissection. However, the optimal limits of extended lymph node dissection remain unclear. We compared oncological outcomes at 2 cystectomy centers where 2 different extended lymph node dissection templates are practiced to determine whether removing lymphatic tissue up to the inferior mesenteric artery confers an additional survival advantage. MATERIALS AND METHODS Patients undergoing radical cystectomy and extended lymph node dissection with curative intent from 1985 to 2005 were included in analysis if they met certain criteria, including clinically organ confined urothelial bladder carcinoma (cN0M0), pathological stage pT2-pT3, negative surgical margins and no neoadjuvant therapy. Survival and recurrence data were analyzed. RESULTS Demographic data and pathological subgroup distribution (pT2 and pT3) were similar in the 554 University of Southern California and 405 University of Bern patients. University of Southern California patients had higher median number of lymph nodes removed than University of Bern patients (38 vs 22, p <0.0001) and a higher incidence of lymph node metastasis (35% vs 28%, p = 0.02). However, the University of Southern California and University of Bern groups had similar 5-year recurrence-free survival for pT2pN0-2 (57% vs 67%) and pT3pN0-2 (32% vs 34%) disease (p = 0.55 and 0.44, respectively). The overall recurrence rate was equal at the 2 institutions (38%). CONCLUSIONS Meticulous extended lymph node dissection up to the mid-upper third of the common iliac vessels appears to provide survival and recurrence outcomes similar to those of a super extended template up to the inferior mesenteric artery. Complete skeletonization in the extended lymph node dissection template is more important than nodal yield. This does not exclude the possibility that certain patient subgroups with suspicious nodes or after neoadjuvant chemotherapy may benefit from more extensive lymph node dissection.

Face, Content and Construct Validity of a Novel Robotic Surgery Simulator

PURPOSE We evaluated the face, content and construct validity of the novel da Vinci® Skills Simulator™ using the da Vinci Si™ Surgeon Console as the surgeon interface. MATERIALS AND METHODS We evaluated a novel robotic surgical simulator for robotic surgery using the da Vinci Si Surgeon Console and Mimic™ virtual reality. Subjects were categorized as novice-no surgical training, intermediate-surgical training with fewer than 100 robotic cases or expert-100 or more primary surgeon robotic cases. Each participant completed 10 virtual reality exercises with 3 repetitions and a questionnaire with a 1 to 10 visual analog scale to assess simulator realism (face validity) and training usefulness (content validity). The simulator recorded performance based on specific metrics. The performance of experts, intermediates and novices was compared (construct validity) using the Kruskal-Wallis test. RESULTS We studied 16 novices, 32 intermediates with a median surgical experience of 6 years (range 1 to 37) and a median of 0 robotic cases (range 0 to 50), and 15 experts with a median of 315 robotic cases (range 100 to 800). Participants rated the virtual reality and console experience as very realistic (median visual analog scale score 8/10) while expert surgeons rated the simulator as a very useful training tool for residents (10/10) and fellows (9/10). Experts outperformed intermediates and novices in almost all metrics (median overall score 88.3% vs 75.6% and 62.1%, respectively, between group p<0.001). CONCLUSIONS We confirmed the face, content and construct validity of a novel robotic skill simulator that uses the da Vinci Si Surgeon Console. Although it is currently limited to basic skill training, this device is likely to influence robotic surgical training across specialties.

A New Multimodality Technique Accurately Maps the Primary Lymphatic Landing Sites of the Bladder

BACKGROUND Pathoanatomic studies have failed to map accurately the primary lymphatic landing sites of the urinary bladder. OBJECTIVE To use single-photon emission computed tomography (SPECT) combined with computed tomography (CT) plus intraoperative gamma probe verification to map the primary lymphatic landing sites of the bladder. DESIGN, SETTING, AND PARTICIPANTS Clinical trial of 60 consecutive cystectomy patients at a single centre. INTERVENTION Flexible cystoscopy-guided injection of technetium nanocolloid into one of six non-tumour-bearing sites of the bladder for preoperative detection of radioactive lymph nodes (LNs) with SPECT/CT followed by intraoperative verification with a gamma probe. Backup extended pelvic LN dissection (PLND) for ex vivo detection of missed LNs. MEASUREMENTS Three-dimensional projection of each LN site. RESULTS AND LIMITATIONS A median of 4 (range: 1-14) radioactive LNs were detected per site and patient. Ninety-two percent of all LNs were found distal and caudal to where the ureter crosses the common iliac arteries. Eight percent were found proximal to the uretero-iliac crossing, none without simultaneous detection of additional radioactive LNs within the endopelvic region. Extended PLND resected 92% of all primary lymphatic landing sites; limited PLND resected only 52%. A few LNs may have been missed despite preoperative SPECT/CT, intraoperative gamma probe verification, and extended backup PLND. CONCLUSIONS Multimodality SPECT/CT plus intraoperative gamma probe show the template of the bladders primary lymphatic landing sites to be larger than is often thought. PLND limited to the ventral portion of the external iliac vessels and obturator fossa removes only about 50% of all primary lymphatic landing sites, whereas extended PLND along the major pelvic vessels, including the internal iliac, external iliac, obturator, and common iliac region up to the uretero-iliac crossing, removes about 90%.

Concurrent and Predictive Validation of a Novel Robotic Surgery Simulator: A Prospective, Randomized Study

PURPOSE We evaluated the concurrent and predictive validity of a novel robotic surgery simulator in a prospective, randomized study. MATERIALS AND METHODS A total of 24 robotic surgery trainees performed virtual reality exercises on the da Vinci® Skills Simulator using the da Vinci Si™ surgeon console. Baseline simulator performance was captured. Baseline live robotic performance on ex vivo animal tissue exercises was evaluated by 3 expert robotic surgeons using validated laparoscopic assessment metrics. Trainees were then randomized to group 1-simulator training and group 2-no training while matched for baseline tissue scores. Group 1 trainees underwent a 10-week simulator curriculum. Repeat tissue exercises were done at study conclusion to assess performance improvement. Spearmans analysis was used to correlate baseline simulator performance with baseline ex vivo tissue performance (concurrent validity) and final tissue performance (predictive validity). The Kruskal-Wallis test was used to compare group performance. RESULTS Groups 1 and 2 were comparable in pre-study surgical experience and had similar baseline scores on simulator and tissue exercises (p >0.05). Overall baseline simulator performance significantly correlated with baseline and final tissue performance (concurrent and predictive validity each r = 0.7, p <0.0001). Simulator training significantly improved tissue performance on key metrics for group 1 subjects with lower baseline tissue scores (below the 50th percentile) than their group 2 counterparts (p <0.05). Group 1 tended to outperform group 2 on final tissue performance, although the difference was not significant (p >0.05). CONCLUSIONS Our study documents the concurrent and predictive validity of the Skills Simulator. The benefit of simulator training appears to be most substantial for trainees with low baseline robotic skills.

Parenteral Nutrition Does Not Improve Postoperative Recovery from Radical Cystectomy: Results of a Prospective Randomised Trial

BACKGROUND After radical cystectomy, patients are in a catabolic state because of postoperative stress response, extensive wound healing, and ileus. OBJECTIVE To evaluate whether recovery can be improved with total parenteral nutrition (TPN) in patients following extended pelvic lymph node dissection (ePLND), cystectomy, and urinary diversion (UD). DESIGN, SETTING, AND PARTICIPANTS We conducted a prospective, randomised, single-centre study of 157 consecutive cystectomy patients. INTERVENTION Seventy-four patients (group A) received TPN during the first 5 postoperative days, with additional oral intake ad libitum. Eighty-three patients (group B) received oral nutrition alone. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was the occurrence of postoperative complications. Secondary outcomes were time to recovery of bowel function, biochemical nutritional (serum albumin, serum prealbumin, serum total protein) and inflammatory (C-reactive protein) parameters, length of hospital stay, and costs attributed to the TPN. The Pearson χ(2) test was used for dichotomous variables; the Wilcoxon rank sum test was used for continuous variables. RESULTS AND LIMITATIONS Postoperative complications occurred in 51 patients (69%) in group A and in 41 patients (49%) in group B (p=0.013), a difference resulting from group A having more infectious complications than group B (32% vs 11%; p=0.001). Serum prealbumin and serum total protein were significantly lower in group B on postoperative day 7 but not on postoperative day 12. Time to gastrointestinal recovery and length of hospital stay did not differ between the two groups. The costs for TPN were €614 per patient. A potential limitation is the use of a glucose-based parenteral nutrition without lipids. CONCLUSIONS Postoperative TPN is associated with a higher incidence of complications, mainly infections, and higher costs following ePLND, cystectomy, and UD versus oral nutrition alone.

Unaltered oncological outcomes of radical cystectomy with extended lymphadenectomy over three decades

To evaluate oncological outcome trends over the last three decades in patients after radical cystectomy (RC) and extended pelvic lymph node (LN) dissection.

Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management

Bladder urothelial carcinoma is typically a disease of older individuals and rarely occurs below the age of 40 years. There is debate and uncertainty in the literature regarding the clinicopathologic characteristics of bladder urothelial neoplasms in younger patients compared with older patients, although no consistent age criteria have been used to define “younger” age group categories. Use of the World Health Organization 2004/International Society of Urological Pathology 1998 grading nomenclature and recent molecular studies highlight certain unique features of bladder urothelial neoplasms in young patients, particularly in patients below 20 years of age. In this meta-analysis and review, the clinical, pathologic, and molecular features and risk factors of bladder urothelial neoplasms in patients 40 years or less are presented and analyzed according to decades of presentation. Similar to older patients, bladder urothelial neoplasms in patients 40 years or younger occur more common in male patients, present mainly with gross painless hematuria, and are more commonly located at bladder trigone/ureteral orifices, but in contrast have a greater chance for unifocality. Delay in diagnosis of bladder urothelial neoplasms seems not to be uncommon in younger patients probably because of its relative rarity and the predominance of benign causes of hematuria in this age group causing hesitancy for an aggressive work-up. Most tumors in patients younger than 40 years were low grade. The incidence of low-grade tumors was the lowest in the first 2 decades of life, with incremental increase of the percentage of high-grade tumors with increasing age decades. Classification according to the World Health Organization 2004/International Society of Urological Pathology grading system identified papillary urothelial neoplasms of low malignant potential to be relatively frequent among bladder tumors of young patients particularly in the teenage years. Similar to grade, there was marked predominance of low stage tumors in the first 2 decades of life with gradual inclusion of few higher stage and metastatic tumors in the 2 older decades. Bladder urothelial neoplasms occurring in patients <20 years of age lack or have a much lower incidence of aberrations in chromosome 9, FGFR3, p53, and microsatellite instability and have fewer epigenetic alterations. Tumor recurrence and deaths were infrequent in the first 2 decades and increased gradually in each successive decade, likely influenced by the increased proportion of higher grade and higher stage tumors. Our review of the literature shows that urothelial neoplasms of the bladder occurring in young patients exhibit unique pathologic and molecular features that translate to its more indolent behavior; this distinction is most pronounced in patients <20 years. Our overall inferences have potential implications for choosing appropriate noninvasive diagnostic and surveillance modalities, whenever feasible, and for selecting suitable treatment strategies that factor in quality of life issues vital to younger patients.

A Prospective Randomised Trial Comparing the Modified HM3 with the MODULITH® SLX-F2 Lithotripter

BACKGROUND The relative efficacy of first- versus last-generation lithotripters is unknown. OBJECTIVES To compare the clinical effectiveness and complications of the modified Dornier HM3 lithotripter (Dornier MedTech, Wessling, Germany) to the MODULITH(®) SLX-F2 lithotripter (Storz Medical AG, Tägerwilen, Switzerland) for extracorporeal shock wave lithotripsy (ESWL). DESIGN, SETTING AND PARTICIPANTS We conducted a prospective, randomised, single-institution trial that included elective and emergency patients. INTERVENTIONS Shock wave treatments were performed under anaesthesia. MEASUREMENTS Stone disintegration, residual fragments, collecting system dilatation, colic pain, and possible kidney haematoma were evaluated 1 d and 3 mo after ESWL. Complications, ESWL retreatments, and adjuvant procedures were documented. RESULTS AND LIMITATIONS Patients treated with the HM3 lithotripter (n=405) required fewer shock waves and shorter fluoroscopy times than patients treated with the MODULITH(®) SLX-F2 lithotripter (n=415). For solitary kidney stones, the HM3 lithotripter produced a slightly higher stone-free rate (p=0.06) on day 1; stone-free rates were not significantly different at 3 mo (HM3: 74% vs MODULITH(®) SLX-F2: 67%; p=0.36). For solitary ureteral stones, the stone-free rate was higher at 3 mo with the HM3 lithotripter (HM3: 90% vs MODULITH(®) SLX-F2: 81%; p=0.05). For solitary lower calyx stones, stone-free rates were equal at 3 mo (63%). In patients with multiple stones, the HM3 lithotripters stone-free rate was higher at 3 mo (HM3: 64% vs MODULITH(®) SLX-F2: 44%; p=0.003). Overall, HM3 lithotripter led to fewer secondary treatments (HM3: 11% vs MODULITH(®) SLX-F2: 19%; p=0.001) and fewer kidney haematomas (HM3: 1% vs. MODULITH(®) SLX-F2: 3%; p=0.02). CONCLUSIONS The modified HM3 lithotripter required fewer shock waves and shorter fluoroscopy times, showed higher stone-free rates for solitary ureteral stones and multiple stones, and led to fewer kidney haematomas and fewer secondary treatments than the MODULITH(®) SLX-F2 lithotripter. In patients with a solitary kidney and solitary lower calyx stones, results were comparable for both lithotripters.

Robotic and Laparoscopic High Extended Pelvic Lymph Node Dissection During Radical Cystectomy: Technique and Outcomes

BACKGROUND With the increasing use of laparoscopic and robotic radical cystectomy (RC), there are perceived concerns about the adequacy of lymph node dissection (LND). OBJECTIVE Describe the robotic and laparoscopic technique and the short-term outcomes of high extended pelvic LND (PLND) up to the inferior mesenteric artery (IMA) during RC. DESIGN, SETTING, AND PARTICIPANTS From January 2007 through September 2009, we performed high extended PLND with proximal extent up to the IMA (n=10) or aortic bifurcation (n=5) in 15 patients undergoing robotic RC (n=4) or laparoscopic RC (n=11) at two institutions. SURGICAL PROCEDURE We performed robotic extended PLND with the proximal extent up to the IMA or aortic bifurcation. The LND was performed starting from the right external iliac, obturator, internal iliac, common iliac, preaortic and para-aortic, precaval, and presacral and then proceeding to the left side. The accompanying video highlights our detailed technique. MEASUREMENTS Median age was 69 yr, body mass index was 26, and American Society of Anesthesiologists class ≥ 3 was present in 40% of patients. All urinary diversions, including orthotopic neobladder (n=5) and ileal conduit (n=10), were performed extracorporeally. RESULTS AND LIMITATIONS All 15 procedures were technically successful without need for conversion to open surgery. Median operative time was 6.7h, estimated blood loss was 500 ml, and three patients (21%) required blood transfusion. Median nodal yield in the entire cohort was 31 (range: 15-78). The IMA group had more nodes retrieved (median: 42.5) compared with the aortic bifurcation group (median: 20.5). Histopathology confirmed nodal metastases in four patients (27%), including three patients in the IMA group and one patient in the aortic bifurcation group. Perioperative complications were recorded in six cases (40%). During a median follow-up of 13 mo, no patient developed local or systemic recurrence. Limitations of the study include its retrospective design and small cohort of patients. CONCLUSIONS High extended PLND during laparoscopic or robotic RC is technically feasible. Longer survival data in a larger cohort of patients are necessary to determine the proper place for robotic and laparoscopic surgery in patients undergoing RC for high-risk bladder cancer.

Readaptation of the Peritoneum Following Extended Pelvic Lymphadenectomy and Cystectomy Has a Significant Beneficial Impact on Early Postoperative Recovery and Complications: Results of a Prospective Randomized Trial

BACKGROUND Prolonged postoperative pain and delayed intestinal transit are frequent problems following extended pelvic lymph-node dissection (PLND) and cystectomy. OBJECTIVE To evaluate the impact of bilateral readaptation of the dorsolateral peritoneal layer on postoperative pain, gastrointestinal recovery, and complications following extended PLND and cystectomy. DESIGN, SETTING, AND PARTICIPANTS Randomized, single-blinded, single-center study of 200 consecutive cystectomy patients. INTERVENTION In group A (n=100), lateral peritoneal flaps ventral to the external iliac vessels were bilaterally rotated over the iliac vessels down to the distal obturator fossa and medially fixed to the pararectal peritoneal layer following extended PLND and cystectomy. In group B (n=100), the peritoneal layer was not readapted. MEASUREMENTS Pain according to the visual analog scale (VAS), amount of peridural anesthetics needed, and gastrointestinal activity were assessed on postoperative days 1, 3, and 7. Complications occurring within 30 d following surgery were documented. RESULTS AND LIMITATIONS Readaptation of the dorsolateral peritoneal layer resulted in a significant decrease in pain (p<0.01) with concurrent significantly reduced need for peridural anesthetics (p<0.01). Flatulence and first passage of stool as signs of intestinal transit were noted earlier in group A than in group B. Gastrostomy tube and peridural catheter could be removed 1 d earlier in group A than in group B (postoperative days 7 vs 8 and 6 vs 7, respectively). Group A (30%) had fewer complications than group B (56%; p<0.001). CONCLUSIONS Readaptation of the dorsolateral peritoneal layer after extended PLND and cystectomy resulted in significantly less postoperative pain, earlier recovery of bowel function, and fewer complications in the early postoperative period.