Robert Marcovich

PROSPECTIVE ASSESSMENT OF PATIENT REPORTED URINARY CONTINENCE AFTER RADICAL PROSTATECTOMY

PURPOSE Reported urinary continence rates after radical prostatectomy vary. Although modifications of radical prostatectomy meant to improve outcome, such as nerve sparing or bladder neck preservation, are in widespread use, to our knowledge evidence to support these practices based on patient report is scant. We evaluated the potential effects of nerve sparing and bladder neck preservation on urinary continence after radical prostatectomy, and assessed the impact of various urinary continence definitions on the observed outcome. MATERIALS AND METHODS We prospectively evaluated a cohort of men with prostate cancer who elected surgery with and without nerve sparing, and bladder neck preservation as primary therapy. A total of 482 men completed a brief urinary continence questionnaire preoperatively and postoperatively at a median followup of 18 months. Urinary continence was followed prospectively using the questionnaire and patient reported urinary continence recovery was based on 3 definitions of continence. RESULTS Median time to continence recovery based on patient reporting was significantly shorter in the nerve sparing than in the nonnerve sparing group when continence was defined as no urinary leakage (5.3 versus 10.9 months, p <0.01). A multivariate model controlling for baseline factors revealed that significant predictors of continence outcome were preoperative continence, patient age, nerve sparing and the interaction of nerve sparing with age (p <0.05). The definition of urinary continence also affected outcome. CONCLUSIONS The nerve sparing technique of radical prostatectomy was associated with improved recovery of urinary continence in an age dependent manner, whereas bladder neck preservation was not beneficial. Patient age and the sensitivity of the incontinence definitions, as reflected by the associated variable rates of preoperative baseline incontinence, are significant contexts for interpreting urinary function data after radical prostatectomy. These factors may partially explain the variation in continence rates in the literature.

Survey of neuromuscular injuries to the patient and surgeon during urologic laparoscopic surgery

OBJECTIVES Laparoscopy may be complicated by neuromuscular injuries, both to the patient and to the surgeon. We used a survey to estimate the incidence of these injuries during urologic laparoscopic surgery, to assess risk factors for these injuries, and to determine preventive measures. METHODS A survey of neuromuscular injuries associated with laparoscopy submitted to 18 institutions in the United States was completed by 18 attending urologists from 15 institutions. RESULTS From among a total of 1651 procedures, there were 46 neuromuscular injuries in 45 patients (2.7%), including abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2). Neuromuscular injuries were twice as common with upper retroperitoneal as with pelvic laparoscopy (3. 1% versus 1.5%). Among patients with neuromuscular injuries, those with rhabdomyolysis were heavier (means 91 versus 80 kg) and underwent longer procedures (means 379 versus 300 minutes), and those with motor deficits were older (means 51 versus 42 years of age). Of the surgeons, 28% and 17% reported frequent neck and shoulder pain, respectively. CONCLUSIONS Although not common, neuromuscular injuries during laparoscopy do contribute to morbidity. Abdominal wall neuralgias, injuries to peripheral nerves, and joint or back injuries likely occur no more frequently than during open surgery, but risk of rhabdomyolysis may be increased. Positioning in a partial rather than full flank position may reduce the incidence of some injuries. Measures to reduce neuromuscular strain on the surgeon during laparoscopy should be considered.

Comparison of 2-octyl cyanoacrylate adhesive, fibrin glue, and suturing for wound closure in the porcine urinary tract

OBJECTIVES To evaluate 2-octyl cyanoacrylate glue (OCG) for wound closure in the urinary tract and compare the ability of OCG, fibrin glue (FG), and suture to withstand physiologic and supraphysiologic stress, because the use of tissue adhesives such as OCG or FG might simplify laparoscopic surgery. METHODS Female domestic pigs (n = 22) underwent a 7.5-cm cystotomy. Of these, 8 had closure with OCG and 8 with FG (6 open and 2 laparoscopic in each group). The controls were closed with suture (n = 4) or not at all (n = 2). Postoperative catheter drainage was not used. At 2 days or 4 weeks postoperatively, the bladders were filled with saline to 200 mm Hg pressure and the cystotomy scars inspected for leakage. The excised scars were also examined histologically. RESULTS The 2 OCG and 2 FG pigs tested on postoperative day 2 leaked at less than 200 mm Hg. None of the 6 OCG pigs tested at 4 weeks leaked at less than 200 mm Hg, including the 2 closed laparoscopically. Of the 6 FG pigs intended for study at 4 weeks, 3 (including the 2 closed laparoscopically) died from a massive urine leak, 1 tested at 4 weeks leaked, and 2 did not leak. Thus, 4 of 6 FG pigs leaked by 4 weeks compared with none in the OCG group (P = 0.06). The histologic examination was similar in the two groups. CONCLUSIONS Preliminary results suggest that OCG provides enough strength to hold together a large bladder wound. In the same model, FG did not consistently provide adequate closure.

Bladder neck-sparing modification of radical prostatectomy adversely affects surgical margins in pathologic T3a prostate cancer

OBJECTIVES To determine whether the bladder neck-sparing (BNS) modification of radical retropubic prostatectomy (RRP) alters the likelihood of positive surgical margins and postsurgical prostate cancer recurrence. METHODS Surgical outcomes, as measured by pathologic margin status and progression-free survival, were evaluated in 751 consecutive RRP cases, among whom 222 underwent BNS technique. To reduce selection bias, comparison of positive margin rates between BNS and standard RRP was stratified by pathologic stage. Differences in surgical margin rates were assessed using the chi-square test, and effects of bladder neck preservation on prostate-specific antigen (PSA)-free survival were assessed, using multivariable Cox proportional hazards analysis. RESULTS The clinical stage, Gleason score, and preoperative serum PSA profiles were similarly distributed between patients undergoing standard RRP and those undergoing the BNS modification. Surgical margins in the unstratified entire cohort were positive at rates similar to prior reports (28% BNS, 27% standard RRP). However, stratification by pathologic stage revealed that among pT3a cancers, BNS surgery was associated with significantly higher rates of positive surgical margins than was standard RRP (47% versus 20%; chi- square = 6.32, P = 0.01). Differences in positive margin rates were not seen between the two groups at other pathologic stages. The adverse effect of BNS technique on pT3a surgical margins was associated with a trend toward an adverse effect on PSA-free survival (Cox proportional hazards P = 0.016). CONCLUSIONS The BNS modification of RRP can be associated with an increased rate of positive surgical margins specifically in cancers that have focally penetrated through the prostatic capsule (pT3a), with an associated trend toward decreased PSA-free survival in this group. BNS surgery may, therefore, compromise the ability to completely remove a subset of cancers focally penetrating the prostatic capsule.

Laparoscopy for the treatment of positional renal pain

OBJECTIVES The differential diagnosis of renal pain is extensive. When the pain is altered by a change in position, two relatively uncommon etiologies, nephroptosis and ovarian vein syndrome, should be considered. We present an algorithm for the evaluation of positional renal pain and demonstrate the effectiveness of its treatment by laparoscopic surgery. METHODS Laparoscopic technique was used to resect the offending ovarian vein in a case of ovarian vein syndrome and to fix the kidney in position for a case of symptomatic nephroptosis. A review of the evaluation and management of these entities is presented. RESULTS The patient with nephroptosis and the patient with ovarian vein syndrome were both discharged on postoperative day 2, had complete relief of pain, and suffered no long-term complications. CONCLUSIONS Nephroptosis and ovarian vein syndrome should be considered in the differential diagnosis of renal pain altered by change in position. Laparoscopy is an excellent approach for repair of these conditions because it is safe, effective, and causes minimal morbidity.

MP51-20 PROSTATE SPECIFIC COMMUNICATIONS: WHAT THE NEXT GENERATION OF UROLOGY TRAINEES ARE TELLING PATIENTS ABOUT PROSTATE CANCER SCREENING, DIAGNOSIS, AND TREATMENT DURING A VIRTUAL OBJECTIVE STRUCTURED CLINICAL ENCOUNTER.

METHODS: 18 medical students were enrolled in a study on a VR DaVinic surgical skills curriculum. They were randomized into three groups: Group A (n1⁄46, control), no performance feedback; Group B (n1⁄46, standard formative expert feedback), Group C (n1⁄46, summative expert feedback using multicomponent video feedback of the VR task þ webcam feedback of master controls and foot pedal). Each trainee completed each task six times. 4 tasks (Peg Board 2, Camera targeting 2, Ring walk 3 & Suture sponge 3) were chosen. Simulator-measured performance metrics included differences in total score, time and economy of motion over the five trials. Data were analyzed using SPSS version 15. RESULTS: A learning curve was observed across the five trials in all groups. A significant difference was seen between the three groups for change in overall score across the five trials. Ergonomic metric assessment showed that Groups B and C performed better than Group A (P .002 and P .000, respectively) and that the multicomponent feedback was more effective in tasks involving the use of multiple controls (Camera targeting & Ring walk). CONCLUSIONS: Multi-component summative feedback (combination of task, master control, and camera pedal) is effective in significantly shortening the learning curve in the robotic training process, especially in complex tasks.

Selecting and Counseling Patients for Cystectomy or Cystoprostatectomy

Few would argue that radical cystectomy is the most complicated surgical procedure undertaken by the urologist today. Yet performing the operation may not always be as difficult as deciding which bladder cancer patients need cystectomy. The challenge in selecting the proper candidate for cystectomy involves the ability to distinguish the patient who will benefit from surgery from the patient for whom surgery is either unnecessary or futile.