Thomas J. Maatman

Comparison of local anesthesia techniques during transrectal ultrasound-guided biopsies

OBJECTIVES To compare the effectiveness of periprostatic nerve blockade versus intrarectal lidocaine during transrectal ultrasound-guided biopsies. METHODS A prospective randomized study was performed on 150 men requiring biopsy of the prostate. Patients were assigned to three groups: group 1 received no anesthetic, group 2 received 10 mL of 2% lidocaine gel intrarectally, and group 3 received a periprostatic injection of 5 mL of 1% lidocaine solution before undergoing prostate biopsy. Patients were asked to respond to a preprocedural and postprocedural questionnaire that consisted of four questions designed to evaluate pain perception and pain experienced, respectively, during the entire procedure. RESULTS The mean pain scores, comparing responses from groups 2 (topical lidocaine) and 3 (periprostatic) individually with those from group 1 (control), were not statistically different for any of the preprocedural questions. The postprocedural pain scores were significantly lower in groups 2 and 3 compared with those from group 1 (control) for overall procedure impression (3.1 +/- 1.7 and 2.6 +/- 1.8 versus 3.8 +/- 1.8, respectively; P <0.05 for both). The postprocedural scores for probe insertion were significantly lower for the topical group than for the control group (2.2 +/- 1.7 versus 3.7 +/- 2.1, P <0.05) but not for the periprostatic group compared with the control group (3.0 +/- 1.9, P = 0.14). The biopsy postprocedural scores were significantly lower for the periprostatic group than for the control group (2.8 +/- 1.9 versus 4.3 +/- 1.7, P <0.05). CONCLUSIONS Our data confirm that both techniques of local anesthesia are effective in reducing patient discomfort; however, periprostatic nerve blockade using injectable lidocaine appears to be more specific in reducing pain during the biopsy portion of the procedure.

Comparative Analysis of Surgical Margins Between Radical Retropubic Prostatectomy and RALP: Are Patients Sacrificed During Initiation of Robotics Program?

OBJECTIVES To compare the incidence of positive surgical margins obtained with robotic-assisted laparoscopic prostatectomy (RALP), during the initiation of a robotics program, with that from a similarly matched cohort of open radical retropubic prostatectomy (RRP) cases as performed by a single surgeon. METHODS From December 2005 to March 2008, 63 patients underwent RRP and another 50 underwent RALP by a single urologist. The records were retrospectively reviewed, and 50 RRP patients were selected from the RRP group whose records were similar to the records of the 50 patients who had undergone RALP. We compared the incidence of positive surgical margins and the location of positive margins among the 2 groups. Additional variables evaluated included the preoperative prostate-specific antigen level, preoperative Gleason score, clinical stage, postoperative Gleason score, tumor volume, and pathologic stage. RESULTS The positive margin rate for the RRP group was 36% compared with 22% for the RALP group (P = .007). The incidence of positive margins for pathologic Stage pT2c disease in the RALP group was 22.8% compared with 42.8% in the RRP group, a statistically significant difference (P = .006). Fewer positive margins were found in the RALP Gleason score 7 group than in the RRP group, 29% vs 60%, again a statistically significant difference (P = .003). CONCLUSIONS We present our series comparing a single urologists positive margin rates during the learning curve of a robotics program with his experience of a similarly matched cohort of RRP patients. A statistically significant lower positive margin rate can be achieved in RALP patients even during the learning period.

Patient noncompliance after vasectomy

OBJECTIVE To determine the postoperative instruction compliance rate in men undergoing bilateral vasectomy. DESIGN Retrospective chart review. SETTING Private practice urological office. PATIENT(S) The records of all patients undergoing vasectomy were reviewed to determine the rate of compliance with postvasectomy follow-up instructions. It is our policy to have the patient continue to use some form of birth control until he achieves two consecutive negative semen analyses 1 month apart. In addition, we recommend a yearly semen analysis after achieving sterility to screen for the rare patient who recanalizes. Postvasectomy follow-up instructions are given to the patient both verbally and in writing. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The records of 1,892 consecutive patients undergoing vasectomy were reviewed, and the results of semen analyses were noted to determine the rate of compliance with postvasectomy follow-up instructions. RESULT(S) Six hundred forty-four men (34%) never returned after vasectomy and, therefore, no semen analyses were available for examination. Six hundred nineteen men (33%) returned for a single semen analysis. Six hundred twenty-nine men (33%) returned for a second negative semen analysis. Only 60 men (3%) completed postvasectomy follow-up instructions and returned for a yearly semen analysis. CONCLUSION(S) The rate of compliance with postvasectomy follow-up instructions for determining sterility is poor.

Gene Expression Profiling of Renal Cell Carcinoma

Renal cell carcinoma (RCC) is a histologically diverse disease, with variable and often unpredictable clinical behavior. The prognosis worsens dramatically with the onset of clinical metastasis, and current regimens of systemic therapy yield only modest benefits for metastatic RCC. Gene expression profiling is a promising technique for refining the diagnosis and staging of RCC, as well as for highlighting potential therapeutic targets. We review the recent advances in expression profiling of RCC and discuss the clinical and biological insights obtained from these studies.

Validation of a High Fidelity Adult Ureteroscopy and Renoscopy Simulator

PURPOSE Surgical simulation technology may efficiently train and accurately assess the acquisition of many skills. Surgical simulators often lack realism and can be expensive at

The Role of Prostate Specific Antigen as a Tumor Marker in Men with Advanced Adenocarcinoma of the Prostate

3,000 to more than

Simplified management of post-prostate biopsy rectal bleeding.

60,000. We assessed the face, content and construct validity of a newly developed, anatomically accurate, reasonably priced high fidelity ureteroscopy and renoscopy trainer. MATERIALS AND METHODS A total of 46 participants, including attending urologists, urology residents, medical students and industry representatives, assessed the face and content validity of the simulator using a standard questionnaire. Ten experienced ureteroscopists with greater than 30 procedures per year and 10 novice ureteroscopists with 0 were assessed on the ability to perform flexible ureteroscopy, renoscopy and intrarenal basket extraction of a lower pole calculus using the adult ureteroscopy trainer (Ideal Anatomic Modeling, Holt, Michigan). Subject performance was assessed by an experienced ureteroscopist using a checklist, global rating scale and time to task completion. RESULTS Of participants 100% rated the trainer as realistic and easy to use, and thought it was a good training tool, 98% thought that it would serve as a good training format and 96% would recommend it to urology trainees. All participants recommended it for use in residency programs and 96% would or would have used it during residency. Only 37.5% vs 100% of experienced vs novice ureteroscopists would use it to practice. Of participants 9% foresaw a problem with the trainer. On the trainer experienced ureteroscopists scored significantly higher on the global rating scale (mean +/- SD 33.1 +/- 1.3 vs 15.0 +/- 2.7, p <0.0001) and checklist (4.1 +/- 1.0 vs 2.4 +/- 1.1, p = 0.004), and required less time to complete the task (141.2 +/- 40.1 vs 447.2 +/- 301.7 seconds, p = 0.01). CONCLUSIONS Our preliminary study suggests the face, content and construct validity of the adult ureteroscopy trainer as a high fidelity ureteroscopy and renoscopy trainer.

Comparing clinical staging plus transrectal ultrasound with surgical-pathologic staging of prostate cancer

Serial serum prostate specific antigen levels were obtained every 4 hours during a 24-hour interval from 8 men with stage D adenocarcinoma of the prostate. No therapeutic or diagnostic manipulations occurred during sample procurement, so that the amount of fluctuation of serum prostate specific antigen levels that can be expected in these patients could be determined. The coefficient of variation for each man ranged from 1.16 to 10.94 per cent, which was not statistically higher than the expected 4.39 and 11.44 per cent coefficient of variation determined with a control sample. The maximum percentage variations above and below the mean were 19.3 and 17.7 per cent, respectively. The average percentage variation in all patients was within 7.6 per cent greater than and 7.6 per cent less than the mean value of prostate specific antigen. Thus, prostate specific antigen appears to be a reliable tumor marker because there is minimal random fluctuation when serial levels are obtained in men with advanced prostate cancer. Based on these findings certain guidelines are suggested.

Early Oncologic Failure after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

Transrectal ultrasound-guided biopsy of the prostate is a common urologic procedure associated with low morbidity and mortality. On occasion, rectal bleeding occurs and can be effectively managed by temporarily inserting a tampon into the rectum.

Comparative analysis of prognostic factors in men undergoing radical prostatectomy for adenocarcinoma of the prostate, including DNA ploidy, surgical tumor stage, prostatic specific antigen, Gleason grade, and age.

Twenty-five men with histopathologic diagnosis of prostatic adenocarcinoma were staged utilizing traditional staging modalities and transrectal ultrasound of the prostate (TRUSP). A comparison was then done with surgical-pathologic stage. TRUSP accurately predicted the local extent of disease in 84 percent of patients, while digital rectal examination understaged in 64 percent of patients. TRUSP is a valuable adjunct to staging prostate cancer prior to definitive therapy.