Robot-assisted simple prostatectomy: the evolution of a surgical technique

ABSTRACT Purpose: Enucleation of a large prostate is the best surgical choice for patients refractory to clinical treatment (1,2). Since the first robot-assisted simple prostatectomy (RASP) was described (3,4), some technical modifications (5-7) and different approaches to reach the adenoma have been proposed (8,9). The aim of this video is to demonstrate three different techniques of RASP. Materials and Methods: The first procedure begins with a transversal incision over the bladder neck, the second is a transvesical approach and the last one is a Retzius-sparing RASP. All techniques were performed with a vesico-urethral anastomosis. Results: Three patients underwent RASP, each one with a different approach. Patients presented mean age of 66±4.4 years, PSA baseline level of 7.8±3ng/mL, IPSS score of 17.7±4.5, maximum urine flow of 8.3±1.5mL/seg and 122.3±11.2cm3 of prostate volume. The mean operative time was 63±8 minutes, estimated blood loss of 106.7±11.5mL, prostate weight of the surgical specimen of 106.3±8 grams and 1 day of length of stay. No continuous bladder irrigation was required and there was no complication. The mean postoperative PSA and IPSS were 0.7±0.3ng/mL, 4.7±1.5. The maximum urine flow raised to 20±4.4mL/seg. Conclusions: RASP with vesico-urethral anastomosis allowed minimal blood loss, short length of stay and great functional outcomes. All the three approaches allowed to perform this technique in a safe way, while showing different alternatives to reach the adenoma.

Robot - assisted laparoscopic local recurrence resection after radical prostatectomy

ABSTRACT Introduction and objective: Local prostate cancer recurrence is usually treated with salvage radiation (sRDT) with or without adjuvant therapy. However, surgical resection could be an option. We aim to present the surgical technique for robot - assisted laparoscopic resection prostate cancer local recurrence after radical prostatectomy (RP) and sRDT in 2 cases. Patients and method: First case depicts a 70 year - old man who underwent RP in 2001 and sRDT in 2004. Following adjuvant therapy, patient had biochemical recurrence. MRI showed a solid mass in the prostatic fossa close to vesicourethral anastomosis, measuring 2.1 cm and PET / CT revealed hyper caption significant uptake in the prostatic fossa. Second case is a 59 year - old man who underwent RP in 2010 and sRDT in 2011. Again, patient presented with biochemical recurrence. PET / CT showed hyper caption in the prostatic fossa. Biopsy conformed a prostate adenocarcinoma. Both patients underwent robot - assisted extended pelvic lymph nodes dissection and local recurrence resection. A standard 4 robotic arms port placement was utilized. Results: Both procedures were uneventfully performed in less than 3 hours and there were no complications. Pathological examination showed a prostate adenocarcinoma Gleason 7 and 8 in the first and second case, respectively; surgical margins and lymph nodes were negative. After 6 months of follow-up, continence was not affected and both patients presented with PSA < 0.15 ng / mL. Conclusion: Robot - assisted laparoscopic resection of prostate cancer local recurrence after RP and sRDT detected by PSMA PET / CT seems to be safe in experienced hands. It may postpone adjuvant therapy in selected cases.

Predictive factors for prolonged hospital stay after retropubic radical prostatectomy in a high-volume teaching center

ABSTRACT Objective: To evaluate the length hospital stay and predictors of prolonged hospitalization after RRP performed in a high-surgical volume teaching institution, and analyze the rate of unplanned visits to the office, emergency care, hospital readmissions and perioperative complications rates. Materials and Methods: Retrospective analysis of prospectively collected data in a standardized database for patients with localized prostate cancer undergoing RRP in our institution between January/2010 - January/2012. A logistic regression model including preoperative variables was initially built in order to determine the factors that predict prolonged hospital stay before the surgical procedure; subsequently, a second model including both pre and intraoperative variables was analyzed. Results: 1011 patients underwent RRP at our institution were evaluated. The median hospital stay was 2 days, and 217 (21.5%) patients had prolonged hospitalization. Predictors of prolonged hospital stay among the preoperative variables were ICC (OR. 1.40 p=0.003), age (OR 1.050 p<0.001), ASA score of 3 (OR. 3.260 p<0.001), prostate volume on USG-TR (OR, 1.005 p=0.038) and African-American race (OR 2.235 p=0.004); among intra and postoperative factors, operative time (OR 1.007 p=0.022) and the presence of any complications (OR 2.013 p=0.009) or major complications (OR 2.357 p=0.01) were also correlated independently with prolonged hospital stay. The complication rate was 14.5%. Conclusions: The independent predictors of prolonged hospitalization among preoperative variables were CCI, age, ASA score of 3, prostate volume on USG-TR and African-American race; amongst intra and postoperative factors, operative time, presence of any complications and major complications were correlated independently with prolonged hospital stay.

Ureteroileal bypass: a new technic to treat ureteroenteric strictures in urinary diversion

ABSTRACT Objective: To present our technique of ureteroileal bypass to treat uretero-enteric stric- tures in urinary diversion. Materials and Methods: One hundred and forty-one medical records were reviewed from patients submitted to radical cystectomy to treat muscle-invasive bladder cancer between 2013 and 2015. Twelve (8.5%) patients developed uretero-enteric anastomotic stricture during follow-up. Five patients were treated with endoscopic dilatation and double J placement. Four were treated surgically with standard terminal-lateral im- plantation. Three patients with uretero-enteric anastomotic stricture were treated at our institution by "ureteroileal bypass", one of them was treated with robotic surgery. Results: All patients had the diagnosis of uretero-enteric anastomotic stricture via computerized tomography and DTPA renal scan. Time between cystectomy and diag- nosis of uretero-enteric anastomotic stricture varied from five months to three years. Mean operative time was 120±17.9 minutes (98 to 142 min) and hospital stay was 3.3±0.62 days (3 to 4 days). Mean follow-up was 24±39.5 months (6 to 72 months). During follow-up, all patients were asymptomatic and presented improvement in ure-terohydronephrosis. Serum creatinine of all patients had been stable. Conclusions: Latero-lateral ureter re-implantation is feasible by open or even robotic surgery with positive results, reasonable operation time, and without complications.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy

ABSTRACT Introduction: This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP. Patients and Methods: 110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used. Results: The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad). Conclusions: The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

Low serum testosterone is a predictor of high-grade disease in patients with prostate cancer / Baixa testosterona sérica é prognóstica de doença de alto grau em pacientes com câncer de próstata

Summary Objective: To evaluate the relation between serum total testosterone (TT) and prostate cancer (PCa) grade and the effect of race and demographic characteristics on such association. Method: We analyzed 695 patients undergoing radical prostatectomy (RP), of whom 423 had serum TT collected. Patients were classified as having hypogonadism or eugonadism based on two thresholds of testosterone: threshold 1 (300 ng/dL) and threshold 2 (250 ng/dL). We evaluated the relation between TT levels and a Gleason score (GS) ≥ 7 in RP specimens. Outcomes were evaluated using univariate and multivariate analyses, accounting for race and other demographic predictors. Results: Out of 423 patients, 37.8% had hypogonadism based on the threshold 1 and 23.9% based on the threshold 2. Patients with hypogonadism, in both thresholds, had a higher chance of GS ≥ 7 (OR 1.79, p=0.02 and OR 2.08, p=0.012, respectively). In the multivariate analysis, adjusted for age, TT, body mass index (BMI) and race, low TT (p=0.023) and age (p=0.002) were found to be independent risk factors for GS ≥ 7. Among Black individuals, low serum TT was a stronger predictor of high-grade disease compared to White men (p=0.02). Conclusion: Hypogonadism is independently associated to higher GS in localized PCa. The effect of this association is significantly more pronounced among Black men and could partly explain aggressive characteristics of PCa found in this race.

Resumo Objetivo: Avaliar a relação entre testosterona sérica total (TT) e grau do câncer de próstata (CP) e o efeito da raça e de características demográficas sobre essa associação. Método: Foram analisados 695 pacientes submetidos a prostatectomia radical (PR), dos quais 423 tinham medidas dos níveis séricos de TT. Os pacientes foram classificados como portadores de hipogonadismo ou eugonadismo com base em dois limites de testosterona: limite 1 (300 ng/dL) e limite 2 (250 ng/dL). Avaliou-se a relação entre nível de TT e escore Gleason (GS) ≥ 7 em amostras de PR. Os resultados foram avaliados por análises univariada e multivariada, com ajuste para raça e outros fatores prognósticos demográficos. Resultados: Do total de 423 pacientes, 37,8% apresentavam hipogonadismo com base no limite 1, e 23,9% com base no limite 2. Os pacientes com hipogonadismo, independentemente do limite de referência, tiveram uma chance maior de GS ≥ 7 (OR 1,79, p=0,02 e OR 2,08, p=0,012, respectivamente). Na análise multivariada, após ajuste para idade, TT, índice de massa corporal (IMC) e raça, baixo TT (p=0,023) e idade (p=0,002) foram considerados fatores de risco independentes para GS ≥ 7. Entre os indivíduos negros, baixo TT sérico foi mais preditivo de doença de alto grau em comparação com os brancos (p=0,02). Conclusão: O hipogonadismo é independentemente associado a escores mais altos de GS no CP localizado. O efeito dessa associação é significativamente mais pronunciado entre homens negros, o que poderia explicar, em parte, as características agressivas do CP observadas nessa população.

Predicting calyceal access for percutaneous nephrolithotomy with computed tomography multiplanar reconstruction

OBJECTIVES: Objective parameters in computed tomography (CT) scans that could predict calyceal access during percutaneous nephrolithotomy have not been evaluated. These parameters could improve access planning for percutaneous nephrolithotomy. We aimed to determine which parameters extracted from a preoperative multiplanar reconstructed CT could predict renal calyceal access during a percutaneous nephrolithotomy. METHODS: From January 2009 through April 2011, 230 patients underwent 284 percutaneous nephrolithotomies at our institution. Sixteen patients presented with complete staghorn calculi, and 11 patients (13 renal units) were analyzed. Five parameters were extracted from a preoperative reconstructed CT and compared with the surgical results of percutaneous nephrolithotomy. RESULTS: Fifty-eight calyces were studied, with an average of 4.4 calyces per procedure. A rigid nephroscope was used to access a particular calyx, and a univariate analysis showed that the entrance calyx had a smaller length (2.7 vs. 3.98 cm, p = 0.018). The particular calyx to be accessed should have a smaller length (2.22 vs. 3.19 cm, p = 0.012), larger angles (117.6 vs. 67.96, p<0.001) and larger infundibula (0.86 vs. 0.61 cm, p = 0.002). In the multivariate analysis, the only independent predictive factor for accessing a particular calyx was the angle between the entrance calyx and the calyx to be reached (OR 1.15, 95% confidence interval [CI], 1.053-1.256, p = 0.002). CONCLUSION: The angle between calyces obtained by multiplanar CT reconstruction is the only predictor of calyx access. .

Gene expression profile of renal cell carcinoma clear cell type

PURPOSE: The determination of prognosis in patients with renal cell carcinoma (RCC) is based, classically, on stage and histopathological aspects. The metastatic disease develops in one third of patients after surgery, even in localized tumors. There are few options for treating those patients, and even the new target designed drugs have shown low rates of success in controlling disease progression. Few studies used high throughput genomic analysis in renal cell carcinoma for determination of prognosis. This study is focused on the identification of gene expression signatures in tissues of low-risk, high-risk and metastatic RCC clear cell type (RCC-CCT). MATERIALS AND METHODS: We analyzed the expression of approximately 55,000 distinct transcripts using the Whole Genome microarray platform hybridized with RNA extracted from 19 patients submitted to surgery to treat RCC-CCT with different clinical outcomes. They were divided into three groups (1) low risk, characterized by pT1, Fuhrman grade 1 or 2, no microvascular invasion RCC; (2) high risk, pT2-3, Fuhrman grade 3 or 4 with, necrosis and microvascular invasion present and (3) metastatic RCC-CCT. Normal renal tissue was used as control. RESULTS: After comparison of differentially expressed genes among low-risk, high-risk and metastatic groups, we identified a group of common genes characterizing metastatic disease. Among them Interleukin-8 and Heat shock protein 70 were over-expressed in metastasis and validated by real-time polymerase chain reaction. CONCLUSION: These findings can be used as a starting point to generate molecular markers of RCC-CCT as well as a target for the development of innovative therapies.

Techniques of nerve-sparing and potency outcomes following robot-assisted laparoscopic prostatectomy: [review]

PURPOSE: Nerve sparing radical prostatectomy is the gold standard for the treatment of prostate cancer. Over the past decade, more and more surgeons and patients are opting for a robot-assisted procedure. The purpose of this paper is to briefly review different techniques and outcomes of nerve sparing robot assisted laparoscopic prostatectomy (RALP). MATERIALS AND METHODS: We performed a MEDLINE search from 2001 to 2009 using the keywords “robotic prostatectomy”, “cavernosal nerve”, “pelvic neuroanatomy”, “potency”, “outcomes” and “comparison”. Extended search was also performed using the references from these articles. RESULTS: Several techniques of nerve sparing are available in literature for RALP, which have been described in this manuscript. These include, “the veil of Aphrodite”, “athermal retrograde neurovascular release”, “clipless antegrade nerve sparing” and “clipless cautery free technique”. The comparative and the non comparative series showing outcomes of RALP have been described in the manuscript. CONCLUSIONS: The basic principles for nerve sparing revolve around minimal traction, athermal dissection, and approaching the correct planes. It has not been documented if any one technique is better than the other. Regardless of technique, patient selection, wise clinical judgment and a careful dissection are the keys to achieve optimal oncological outcomes following RALP.

Transurethral resection of the prostate for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia: how much should be resected?

Objective: To assess the impact of the percent of resected tissue on the improvement of urinary symptoms. Materials and methods: The study included a prospective analysis of 88 men with benign prostatic hyperplasia. Patients were divided in three groups according to the percent of resected tissue: Group 1 < 30 percent; Group 2, 30 percent to 50 percent; and Group 3, > 50 percent. Each patient was re-evaluated 3 months after surgery. We assessed the international prostatic symptom score, nocturia and serum prostate specific antigen levels. Results: All patients presented a significant decrease on mean International Prostate System Score (IPSS) (23 to 5.9), Quality of Life (QoL) (4.9 to 1.0) and nocturia (3.2 to 1.9). Variation in the IPSS was 16.7, 16.6 and 18.4 for patients from Group 1, 2 and 3 respectively (P = 0.504). Although the three groups presented a significant decrease in QoL, patients in Group 3 presented a significantly greater decrease when compared to Group 1. Variation in QoL was 3.1, 3.9 and 4.2 for patients from Group 1, 2 and 3 respectively (p = 0.046). There was no significant difference in nocturia variation according to the percent of resected tissue (p = 0.504). Median pre and postoperative PSA value was 3.7 and 1.9 ng/mL respectively. Patients from Group 1 did not show a significant variation (p = 0.694). Blood transfusions were not required in any group. Conclusions:Resection of less than 30 percent of prostatic tissue seems to be sufficient to alleviate lower urinary tract symptoms related to benign prostate hyperplasia. However, these patients may not show a significant decrease in serum PSA level.

Retroperitoneal migration of a self-inflicted ballpoint pen via the urethra

Numerous accounts documenting the introduction of foreign bodies into the urinary bladder have been reported. These foreign bodies are typically self-inserted via urethral but migration from adjacent organs by an ulcerative process and penetrating injuries are also reported. However, "contrary" migration of a self-inflicted vesical foreign body to the retroperitoneum was not previously reported in literature. We report here a case of a ballpoint pen self-inserted via urethral by a female patient, which was identified in retroperitoneal position years later.