S. Duke Herrell

Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: comparison of short-term biochemical recurrence-free survival.

PURPOSE We compared biochemical recurrence-free survival of patients who underwent radical retropubic prostatectomy vs robot assisted laparoscopic prostatectomy in concurrent series at a single institution. MATERIALS AND METHODS A total of 2,132 patients were treated between June 2003 and January 2008. We excluded from study patients with prior treatment (115), missing data (83) and lymph node involvement (30). The remaining cohort (1,904) was compared based on clinical, surgical and pathological factors. Kaplan-Meier analysis was performed comparing biochemical recurrence after robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy. A Cox proportional hazards model was generated to determine whether surgical approach is an independent predictor of biochemical recurrence. RESULTS There were 491 radical retropubic prostatectomies (25.9%) and 1,413 robot assisted laparoscopic prostatectomies (74.1%) performed, and median followup was 10 months (IQR 2 to 23). On univariate analysis the robot assisted laparoscopic prostatectomy group was slightly lower risk with lower median prostate specific antigen (5.4 vs 5.8, p <0.01), a lower proportion of pathological grade 7-10 (48.5% vs 54.7%, p <0.01) and lower pathological stage (80.5% pT2 vs 69.6% pT2, p <0.01). The 3-year biochemical recurrence-free survival rate was similar between the robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy groups on the whole as well as when stratified by pathological stage, grade and margin status. On multivariate analysis extracapsular extension (p <0.01), pathological grade 7 or greater (p <0.01) and positive surgical margin (p <0.01) were independent predictors of biochemical recurrence while surgical approach was not. CONCLUSIONS The likelihood of biochemical recurrence was similar between groups when stratified by known risk factors of recurrence. Surgical approach was not a significant predictor of biochemical recurrence in the multivariate model. Our analysis is suggestive of comparable effectiveness for robot assisted laparoscopic prostatectomy, although longer term studies are needed.

Robotic-Assisted Laparoscopic Prostatectomy: Do Minimally Invasive Approaches Offer Significant Advantages?

Radical prostatectomy has maintained a cardinal role in the treatment of localized prostate cancer. Robotic-assisted laparoscopic prostatectomy (RALP) has been introduced as a less invasive surgical approach. Available data on RALP versus open approaches were reviewed for surgical and cancer related outcomes. RALP is consistently associated with decreased blood loss and limited postoperative pain and hospital stay. Surgical margins seem similar between most reported series of RALP or open radical prostatectomy. Most intrainstitutional comparisons demonstrate better postoperative continence and potency with RALP, but there is still debate about whether results are superior to radical retropubic prostatectomy in the hands of a highly experienced surgeon. RALP provides outcomes at least comparable, and, in some measures, superior to open surgery. Refinements of instrumentation may provide even better results in the future.

National Trends in the Use of Partial Nephrectomy: A Rising Tide That Has Not Lifted All Boats

PURPOSE Treatment of organ confined renal masses with partial nephrectomy has durable oncologic outcomes comparable to radical nephrectomy. Partial nephrectomy is associated with lower risk of chronic kidney disease and in some series with better overall survival. We report a contemporary analysis on national trends of partial nephrectomy use to determine partial nephrectomy use over time, and whether nontumor related factors such as structural attributes of the treating institution or patient characteristics are associated with the underuse of partial nephrectomy. MATERIALS AND METHODS We performed an analysis of the NIS (National Inpatient Sample), which contains 20% of all United States inpatient hospitalizations. We included patients who underwent radical or partial nephrectomy for a renal mass between 2002 and 2008. Survey weights were applied to obtain national estimates of nephrectomy use and to evaluate nonclinical predictors of partial nephrectomy. RESULTS A total of 46,396 patients were included in the study for a weighted sample of 226,493. There was an increase in partial nephrectomy use from 15.3% in 2002 to 24.7% in 2008 (p <0.001). On multivariate analysis hospital attributes (urban teaching status, nephrectomy volume, geographic region) and patient socioeconomic status (higher income ZIP code and private/HMO payer) were independent predictors of partial nephrectomy use. CONCLUSIONS Since 2002 the national use of partial nephrectomy for the management of renal masses has increased. However, the adoption of partial nephrectomy at smaller, rural and nonacademic hospitals lags behind that of larger hospitals, urban/teaching hospitals and higher volume centers. A lower rate of partial nephrectomy use among patients without private insurance and those living in lower income ZIP code areas highlights the underuse of partial nephrectomy as a quality of care concern.

Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma

BACKGROUND The role of malnutrition has not been well studied in patients undergoing surgery for renal cell carcinoma (RCC). OBJECTIVE Our aim was to evaluate whether nutritional deficiency (ND) is an important determinant of survival following surgery for RCC. DESIGN, SETTING, AND PARTICIPANTS A total of 369 consecutive patients underwent surgery for locoregional RCC from 2003 to 2008. ND was defined as meeting one of the following criteria: body mass index <18.5 kg/m(2), albumin <3.5 g/dl, or preoperative weight loss ≥ 5% of body weight. INTERVENTION All patients underwent radical or partial nephrectomy. MEASUREMENTS Primary outcomes were overall and disease-specific mortality. Covariates included age, Charlson comorbidity index (CCI), preoperative anemia, tumor stage, Fuhrman grade, and lymph node status. Multivariate analysis was performed using a Cox proportional hazards model. Mortality rates were estimated using the Kaplan-Meier product-limit method. RESULTS AND LIMITATIONS Eighty-five patients (23%) were categorized as ND. Three-year overall and disease-specific survival were 58.5% and 80.4% in the ND cohort compared with 85.4% and 94.7% in controls, respectively (p<0.001). ND remained a significant predictor of overall mortality (hazard ratio [HR]: 2.41, 95% confidence interval [CI], 1.40-4.18) and disease-specific mortality (HR: 2.76; 95% CI, 1.17-6.50) after correcting for age, CCI, preoperative anemia, stage, grade, and nodal status. This study is limited by its retrospective nature. CONCLUSIONS ND is associated with higher mortality in patients undergoing surgery for locoregional RCC, independent of key clinical and pathologic factors. Given this mortality risk, it may be important to address nutritional status preoperatively and counsel patients appropriately.

Single-Center Comparison of Purely Laparoscopic, Hand-Assisted Laparoscopic, and Open Radical Nephrectomy in Patients at High Anesthetic Risk

BACKGROUND AND PURPOSE The laparoscopic approach for management of high-risk patients with renal-cell carcinoma (RCC) may reduce perioperative and postoperative morbidity. The aim of this study was to compare the outcome of purely laparoscopic radical nephrectomy (LRN), hand-assisted laparoscopic radical nephrectomy (HALRN), and open radical nephrectomy (ORN) for renal tumors in a population of patients at high risk for perioperative complications. PATIENTS AND METHODS All patients undergoing radical nephrectomy for presumed RCC between August 1999 and August 2001 at Vanderbilt University Medical Center and having an American Society of Anesthesiologists (ASA) score of >/=3 were reviewed. Patients with known metastasis, local invasion, caval thrombi, or additional simultaneous surgical procedures were excluded from analysis. Thirteen patients underwent LRN, eight patients underwent HALRN, and 26 underwent ORN. The patient demographics were similar in the three groups. The groups were compared with regard to intraoperative and postoperative parameters. Statistical analysis was done using chi-square testing for categorical variables and analysis of variance (ANOVA) for continuous variables. Differences in outcomes were examined using ANOVA and Dunnetts T for pairwise comparisons. RESULTS The ASA 4 patients had significantly longer hospital stays and total hospital costs than the ASA 3 patients. The mean operative time in the ASA 3 patients was similar in the three groups: 2.8 hours, 2.8 hours, and 2.5 hours for the LRN, HALRN, and ORN patients, respectively. Both the LRN patients (22.9 mg of morphine sulfate equivalent) and the HALRN patients (42.1 mg) required less pain medication than the open surgery patients (97.7 mg). When the total hospital costs were compared, LRN was less costly than HALRN (

Impact of Positive Apical Surgical Margins on Likelihood of Biochemical Recurrence After Radical Prostatectomy

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Salvage Robotic Assisted Laparoscopic Radical Prostatectomy: A Single Institution, 5-Year Experience

7678; P = 0.57) and open surgery (

Selective Renal Parenchymal Clamping in Robotic Partial Nephrectomy: Initial Experience

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Smaller Prostate Size Predicts High Grade Prostate Cancer at Final Pathology

7694; P = 0.04). The complication rate in the LRN, HALRN, and ORN group was 0%, 25%, and 27%, respectively, although the differences were not statistically different (P = 0.12). CONCLUSIONS Both LRN and HALRN can be performed safely in patients with significant comorbid conditions. Careful preoperative preparation, intraoperative monitoring, and awareness of laparoscopy-induced oliguria can preclude inadvertent overhydration, hemodilution, and congestive heart failure. Both LRN and HALRN result in less pain medication requirement and faster return to oral intake than ORN, and LRN results in fewer perioperative complications than HALRN or ORN in patients at high perioperative risk. The LRN technique has a 21% lower total cost than both HALRN and ORN.

Limitations of Ultrasonography in the Evaluation of Urolithiasis: A Correlation With Computed Tomography

PURPOSE We evaluated whether a positive surgical margin at the apex confers a different likelihood of biochemical recurrence than at other sites. MATERIAL AND METHODS A total of 3,087 men underwent radical prostatectomy between January 2000 and June 2008. Patients with prior treatment, positive seminal vesicles, lymph node involvement or less than 6 months of followup were excluded from analysis. The remaining 1,667 men were grouped by margin status, including negative surgical margins, a solitary positive apical margin, a solitary nonapical positive margin and multiple positive margins. Kaplan-Meier analysis was used to compare biochemical recurrence across groups. Cox proportional hazards models were constructed to determine whether a solitary positive apical margin is an independent risk factor for biochemical recurrence. RESULTS Median followup was 21.1 months. Of the cases 1,295 (77.7%) had negative surgical margins, 96 (5.8%) had a solitary positive apical margin, 82 (4.9%) had a solitary positive nonapical margin and 194 (11.6%) had multiple positive margins. The likelihood of biochemical recurrence in solitary positive apical margin cases was between that of negative surgical margins and a solitary positive nonapical margin with multiple positive margins showing the highest likelihood of biochemical recurrence (p <0.001). Three-year likelihood of freedom from biochemical recurrence was 94.7% (95% CI 92.7-96.2), 87.0% (95% CI 74.1-93.7), 81.4% (95% CI 67.2-89.9) and 73.0% (95% CI 63.9-80.2) for negative surgical margins, a solitary positive apical margin, a solitary positive nonapical margin and multiple positive margins, respectively. In the multivariate model a solitary positive nonapical margin (2.17, 95% CI 1.17-4.03, p = 0.01) and multiple positive margins (3.03, 95% CI 1.99-4.61, p <0.001) were independent predictors of biochemical recurrence but a solitary positive apical margin was not (1.34, 95% CI 0.65-2.75, p = 0.43). CONCLUSIONS A solitary positive apical margin was associated with worse biochemical recurrence but on multivariate analysis it was not an independent predictor of recurrence. Models to predict biochemical recurrence after radical prostatectomy should account for differences in the prognostic significance of different positive margin sites.