Rabii Madi

Late failures after laparoscopic pyeloplasty.

OBJECTIVES We present the results of our series of 65 consecutive laparoscopic pyeloplasties, which include some unexpected late failures. METHODS We retrospectively reviewed the perioperative course of 65 consecutive patients who underwent transperitoneal laparoscopic pyeloplasty from August 1996 through July 2005 at our institution. RESULTS Of the obstructions, 47 and 18 were primary and secondary, respectively. Laparoscopic pyeloplasty was successfully performed on 64 patients. Of the patients, 42 (65%) had crossing vessel(s) found intraoperatively. We performed dismembered pyeloplasty for 50 (77%), Y-V plasty for 12 (18%) and Fengerplasty for 3 patients (5%). Mean laparoscopic operative time was 218 minutes, not including a mean of 40 minutes for stent placement and repositioning. The median hospital stay was 2 days. All 9 major complications (14%) pertained to urinary leakage/ureteral obstruction. Of the 60 patients with follow-up, 7 (12%) failed within 1 year of surgery. An additional 3 patients who appeared cured at initial follow-up presented with late recurrences, at 2, 2.5, and 6 years postoperatively. The overall success rate at 1 year was 88%, with a long-term success rate of 83%, and was not related to type of obstruction or repair, or urinary leakage/ureteral obstruction. CONCLUSIONS Contrary to findings in other series, 30% of our failures occurred 2 or more years after pyeloplasty. All failures, however, were symptomatic, such that radiographic follow-up after 1 year in patients with symptoms preoperatively may not be necessary.

Extraperitoneal v Intraperitoneal Robotic Prostatectomy: Analysis of Operative Outcomes

BACKGROUND AND PURPOSE Robotic prostatectomy can be performed either via an extra- or intraperitoneal approach. The extraperitoneal approach has advantages similar to those of an extraperitoneal open radical prostatectomy, but the potential disadvantages of a small working space. We report our experience using both approaches. METHODS From July 2003 to June 2004, 55 patients underwent a robot-assisted laparoscopic prostatectomy. During the first 6 months, 21 prostatectomies were performed using an intraperitoneal approach (group 1); 34 were performed using an extraperitoneal approach (group 2) during the next 6 months. Clinicopathologic parameters and perioperative complications were compared in both groups. All patients were categorized as intent-to-treat analysis. RESULTS Median surgery time was significantly shorter in the extraperitoneal compared with the intraperitoneal approach (3 hours and 34 minutes v 4 hours and 1 minute, respectively, P = 0.017). This was because of the shorter time interval between the skin incision and incision of the endopelvic fascia in the extraperitoneal v the intraperitoneal approach (55 minutes v 74 minutes, respectively, P < 0.0001). There was no significant difference in terms of patient age, clinical and pathologic stage, length of hospital stay, and perioperative complications between the two approaches. CONCLUSION Extraperitoneal robot-assisted laparoscopic prostatectomy offers a similar clinical outcome as the intraperitoneal approach. However, the extraperitoneal approach avoids potential bowel injury or complications related to an intraperitoneal urine leak.

Factors associated with suicide in patients with genitourinary malignancies

Approximately 70% of all suicides in patients aged >60 years are attributed to physical illness, with higher rates noted in patients with cancer. The purpose of the current study was to characterize suicide rates among patients with genitourinary cancers and identify factors associated with suicide in this specific cohort.

Robot-Assisted Anatrophic Nephrolithotomy: Description of Technique and Early Results

PURPOSE To assess the feasibility and report early outcomes of robot-assisted anatrophic nephrolithotomy (RAN) as a treatment modality for patients with complex staghorn calculi. PATIENTS AND METHODS In this single-center prospective study, seven consecutive patients underwent RAN for complex staghorn calculi. After dissection to the renal hilum and clamping of the renal vessels, a nephrotomy was made along the Brodel line and dissection carried through the collecting system to the calculus. The stone was extracted, and the collecting system and parenchyma were closed in layers; no cooling of the kidney was performed. RESULTS The mean patient age was 47±16 years, mean body mass index was 31.9±10.0 kg/m(2), and five of seven patients had complete staghorn calculi. Mean warm ischemia time was 35±7 minutes, mean robotic time was 158±51 minutes, and mean estimated blood loss was 121±39 mL. Mean length of stay was 3.0±1.7 days, and there was one perioperative complication. Five of seven patients had >90% reduction in stone burden, and two (29%) patients were completely stone free. Mean follow-up time was 5.1±4.3 months, and there was no decrease in postoperative estimated glomerular filtration rate compared with preoperative values. CONCLUSIONS Our preliminary experience with RAN demonstrates a safe procedure with encouraging outcomes as a minimally invasive treatment modality for patients with extensive stone burden. Longer follow-up to determine the effect of RAN on renal function is needed.

Single-Setting Bilateral Hand-Assisted Laparoscopic Partial Nephrectomy

PURPOSE To assess the feasibility and safety of single-setting bilateral hand-assisted laparoscopic partial nephrectomy. MATERIALS AND METHODS Between August 2003 and June 2004, we performed single-setting bilateral laparoscopic partial nephrectomies on three patients. A hand-assisted approach was used, employing the same hand-assistance incision for both sides. Renal hilar clamping was not required, as the depth of penetration of all six tumors was only 0 to 4 mm (mean, 1.8 mm). The tumor diameters ranged from 1.8 to 3.8 cm (mean, 2.4 cm). RESULTS All operations were performed successfully, with no conversion to open surgery. Excision was performed with bipolar forceps, and final hemostasis was obtained with an argon beam coagulator (Valleylab, Boulder, CO) and Floseal (Baxter, Deerfield, IL), without suturing. The mean estimated blood loss was 208 mL. The mean operative time was 246 minutes, which included repositioning. There were no intraoperative complications, and the postoperative course was uneventful in all patients except for a hospital stay of 5 days in one patient owing to transient ileus. Pathology revealed a benign lesion on one side and renal cell carcinoma on the other side in two patients, and bilateral leiomyomas in one patient. All margins of resection were negative, and neither of the two patients with cancer has had recurrence at a mean follow-up of 51 months. Among all three patients, the mean preoperative serum creatinine was 0.9 mg/dL, and the average level at a mean of 35 months postoperatively was 1.0 mg/dL. CONCLUSION Single-setting bilateral hand-assisted laparoscopic partial nephrectomies can be safely and effectively performed on patients with bilateral small exophytic kidney tumors. We do not recommend this technique if both kidneys require temporary hilar occlusion, but it can be considered if only one kidney requires hilar occlusion.

Concurrent Robotic Renal and Prostatic Surgery: Initial Case Series and Safety Data of a New Surgical Technique

INTRODUCTION In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience. PURPOSE To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme. PATIENTS AND METHODS From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5 cm, respectively. RESULTS Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100 mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy. CONCLUSION Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies.

Decreasing suicide risk among patients with prostate cancer: Implications for depression, erectile dysfunction, and suicidal ideation screening

OBJECTIVE Prostate cancer is the most common malignancy among males, accounting for 19% of cancers, and the third most common cancer-related cause of death. Suicide rates in the United States have increased among males over the last decade. Further, suicide rates are higher in oncology patients, including patients with prostate cancer, compared to the general population. The objective of this article is to review the current literature and address the relationship between prostate cancer, depression, erectile dysfunction, and suicidal ideation. MATERIALS AND METHODS We reviewed the current literature pertaining to prostate cancer and depression, and prostate cancer and suicide. Furthermore, associations were made between erectile dysfunction and depression. RESULTS Men with prostate cancer at increased risk for suicidal death are White, unmarried, elderly, and men with distant disease. Time since diagnosis is also an important factor, since men are at risk of suicide>15 years after diagnosis. Approximately 60% of men with prostate cancer experience mental health distress, with 10%-40% having clinically significant depression. Additionally, patients that received androgen deprivation therapy (ADT) are 23% more likely to develop depression compared to those without ADT. Longitudinal studies of prostate cancer patients suggest that erectile dysfunction after curative treatment may have a significant psychological effect leading to depression. Herein, a newly proposed screening algorithm suggests for an evaluation with the expanded prostate cancer index composite-clinical practice, patient health questionnaire-9, and an 8-question suicidal ideation questionnaire to assess for health-related quality of life, depression, and suicidal ideation. CONCLUSION The burden of screening for erectile dysfunction, depression and suicidal ideation lies with the entire health care team, as there appears to be an association between these diagnoses, that is, compounded in patients with prostate cancer. The screening algorithm should assist with guiding timely and appropriate psychiatric referral to optimize outcomes in these high-risk patients.

Zero-fragment Nephrolithotomy: A Multi-center Evaluation of Robotic Pyelolithotomy and Nephrolithotomy for Treating Renal Stones

BACKGROUND Robotic pyelolithotomy (RPL) and robotic nephrolithotomy (RNL) may be utilized for treating kidney stones as an alternative to percutaneous nephrolithotomy or flexible ureteroscopy. OBJECTIVE To describe the techniques of RPL and RNL, and present multi-center outcome data for patients undergoing these procedures. DESIGN, SETTING, AND PARTICIPANTS This study was a retrospective analysis of 27 patients undergoing RPL and RNL at five tertiary academic institutions between 2008 and 2014. SURGICAL PROCEDURE RPL and RNL without use of renal ischemia. MEASUREMENTS We assessed stone clearance by visual assessment and postoperative imaging. We also examined other factors, including complications (Clavien grade), estimated blood loss, operative time, and length of stay. RESULTS AND LIMITATIONS Twenty-seven patients underwent 28 procedures for a mean renal stone size of 2.74cm (standard deviation: 1.4, range: 0.8-5.8). The mean stone volume was 10.2cm3. RPL accounted for 26 of these procedures. RNL was performed in one patient, while another underwent combined RPL-RNL. Indications included failed previous endourological management (13), staghorn calculi (five), gas containing stone (one), calyceal diverticulum (one), complex urinary tract reconstruction (two), and patient preference (four). The mean patient age was 35.6 yr and mean body mass index was 25.5kg/m2. Mean operative time/console times were 182min and 128min, respectively. The mean estimated blood loss was 38ml. The mean length of stay was 1.7 d. There was no significant change in preoperative and postoperative serum creatinine levels. The overall complication rate was 18.5% (Clavien 1=3.7%; 2=7.4%; 3b=7.4%). The complete stone-free rate was 96%. CONCLUSIONS RPL and RNL are safe and reasonable options for removing renal stones in select patients. In particular, RPL allows the removal of stones without transgressing the parenchyma, reducing potential bleeding and nephron loss. PATIENT SUMMARY The robotic approach allows for complete removal of the renal stone without fragmentation, thereby maximizing chances for complete stone clearance in one procedure.

The impact of radical cystectomy and urinary diversion on suicidal death in patients with bladder cancer

PURPOSE: Compared to the general population, suicide is more common in the elderly and in patients with cancer. We sought to examine the incidence of suicide in patients with bladder cancer and evaluate the impact of radical cystectomy in this high-risk population. METHODS: Patients diagnosed with urothelial carcinoma from 1988 to 2010 were identified in the Survey, Epidemiology, and End Results (SEER) database. Contingency tables of suicide rates and standardized mortality ratios (SMRs) and 95% confidence intervals were calculated. Multivariable logistic regression models were performed to generate odds ratios (ORs) for the identification of factors associated with suicide in this population. RESULTS: There were 439 suicides among patients with bladder cancer observed for 1,178,000 person-years (Standard Morbidity Ratio [SMR] = 2.71). All demographic variables analyzed had a higher SMR for suicide compared to the general population, in particular age ≥80 years (SMR = 3.12), unmarried status (SMR = 3.41), and white race (SMR = 2.60). The incidence of suicide was higher in the general population for patients who underwent radical cystectomy compared to those who did not (SMR = 3.54 vs SMR = 2.66). On multivariate analysis, the strongest predictors of suicide were male gender (vs female; OR = 6.63) and distant disease (vs localized; OR = 5.43). CONCLUSIONS: Clinicians should be aware of risk factors for suicide in patients diagnosed with bladder cancer, particularly older, white, unmarried patients with distant disease, and/or those who have undergone radical cystectomy. A multidisciplinary team-based approach, including wound ostomy care trained nursing staff and mental health care providers, may be essential to provide care required to decrease suicide rates in this at-risk population.

Retrograde Chemoinfusion of the Upper Tract: Standardizing the Delivery of Topical Adjuvant Therapy

Upper tract urothelial carcinoma has a high recurrence rate after endoscopic treatment. Immediate postoperative topical chemotherapy may reduce recurrences, as in bladder cancer. A reliable delivery method to the upper tract does not exist. We propose a new infusion pump technology for the delivery of topical chemotherapeutic agents to the upper tract. With the patient under general anesthesia, contrast is infused into the upper collecting system using a standard infusion pump. An optimal infusion rate is determined based on fluoroscopic filling of the upper collecting system and transduced intrapelvic pressures. Using this rate, the infusion is repeated postoperatively with the chemotherapeutic agent. We report one case of successful execution to demonstrate proof of concept. We are the first to describe retrograde upper tract chemotherapeutic irrigation with an intravenous pump. This technique may facilitate and standardize the delivery of intracavitary chemotherapy. Further investigation to determine whether it translates into improved safety and/or efficacy is warranted.