Sterile Water Versus Glycine in Transurethral Resection of Bladder Tumors-Immunogenic and Clinical Implications.

BACKGROUND AND OBJECTIVE: We compared the oncologic outcomes of patients with non-muscle invasive bladder cancer (NMIBC) who underwent transurethral resection of bladder tumor (TUBRT) using sterile water vs glycine irrigation. The tumoricidal and immunogenic effects of these solutions on urothelial cancer cell lines were investigated. METHODS: The medical records of 530 consecutive patients who underwent TURBT using sterile water or glycine irrigation for NMIBC were reviewed. Recurrence and progression rates were evaluated using time dependent analyses.Bladder cancer cell lines (RT4, T24 and 5637) were treated with glycine and sterile water. Cell viability was evaluated with the XTT assay. Cell membrane calreticulin levels were evaluated with flow cytometry. Extracellular high mobility group box 1 (HMGB1) and heat shock 70 (HSP70) protein levels were evaluated using western blots. KEY FINDINGS AND LIMITATIONS: After propensity score matching each study arm comprised 161 patients. Median follow-up was 13.6 months (IQR 6.2, 24.5). The 2-year recurrence free survival was significantly lower in the sterile water vs glycine group (43% vs 71%, respectively, p<0.0001). Similarly, the 2-years progression free survival was significantly lower in the sterile water vs glycine group (85% vs 94%, respectively, p<0.014). Sterile water treatment resulted in the lowest number of viable cells. Early and late immunogenic cell death markers were markedly elevated in cells treated with glycine. CONCLUSIONS AND CLINICAL IMPLICATIONS: Sterile water compared to glycine irrigation during TURBT for NMIBC was associated with higher recurrence and progression rates. Possible explanation for these findings is the diminished immune response associated with sterile water reflected in a comparatively lesser expression of immune response inducers. PATIENT SUMMARY: We compared two irrigation fluids in non-muscle-invasive bladder cancer surgery: glycine and sterile water. Glycine outperformed sterile water in cancer recurrence, possibly boosting immunogenicity over sterile water.

Complete Blood Count Markers and C-Reactive Protein as Predictors of Testicular Viability in the Event of Testicular Torsion in Adults.

INTRODUCTION: The association between blood markers and testicular viability after testicular torsion (TT) is not well known. We evaluated the role of complete blood count markers and C-reactive protein (CRP) in predicting testicular viability after TT. METHODS: Fifty men, ≥18 years of age, operated for TT between the years 2015-2020 were enrolled. Blood markers including neutrophil-, lymphocyte-, and platelet count, and CRP were obtained. Neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) were calculated. The study outcome was testicular salvage. RESULTS: Median age was 23 years (interquartile range [IQR]: 21, 31). Median duration of torsion was 10 h (IQR: 6, 42). Sonographic texture of the testis was homogenous in 27 (56%) patients and heterogenous in 21 (44%). During scrotal exploration, 36 patients (72%) underwent orchiopexy and 14 (28%) underwent orchiectomy. Patients who underwent orchiopexy were younger (22 years vs. 31 years, p = 0.009), had a shorter duration of torsion (median 8 h vs. 48 h, p < 0.001), and a homogenous texture on scrotal ultrasound (76.5 vs. 7.1%, p < 0.001). Median NLR, PLR, and CRP were higher among patients who underwent orchiectomy; however, these differences did not reach statistical significance. Patients with heterogenous echotexture were significantly more likely to undergo orchiectomy (odds ratio = 42, 95% confidence interval: 7, 831, adjusted p value = 0.009). CONCLUSIONS: We found no association between blood-based biomarkers and testicular viability after TT; however, testicular echotexture significantly predicted outcome.

Assessment of Intra-Abdominal Pressure with a Novel Continuous Bladder Pressure Monitor-A Clinical Validation Study.

INTRODUCTION: Intra-abdominal hypertension and the resulting abdominal compartment syndrome are serious complications of severely ill patients. Diagnosis requires an intra-abdominal pressure (IAP) measurement, which is currently cumbersome and underused. We aimed to test the accuracy of a novel continuous IAP monitor. METHODS: Adults having laparoscopic surgery and requiring urinary catheter intra-operatively were recruited to this single-arm validation study. IAP measurements using the novel monitor and a gold-standard foley manometer were compared. After anesthesia induction, a pneumoperitoneum was induced through a laparoscopic insufflator, and five randomly pre-defined pressures (between 5 and 25 mmHg) were achieved and simultaneously measured via both methods in each participant. Measurements were compared using Bland-Altman analysis. RESULTS: In total, 29 participants completed the study and provided 144 distinct pairs of pressure measurements that were analyzed. A positive correlation between the two methods was found (R2 = 0.93). There was good agreement between the methods, with a mean bias (95% CI) of -0.4 (-0.6, -0.1) mmHg and a standard deviation of 1.3 mmHg, which was statistically significant but of no clinical importance. The limits of agreement (where 95% of the differences are expected to fall) were -2.9 and 2.2 mmHg. The proportional error was statistically insignificant (p = 0.85), suggesting a constant agreement between the methods across the range of values tested. The percentage error was 10.7%. CONCLUSIONS: Continuous IAP measurements using the novel monitor performed well in the clinical setup of controlled intra-abdominal hypertension across the evaluated range of pressures. Further studies should expand the range to more pathological values.

Improving Prostatic Preoperative Volume Estimation and Planning before Laser Enucleation.

We aimed to validate a formula for improving the estimation of prostatic volume by abdominal ultrasound (AUS) prior to transurethral laser enucleation. A total of 293 patients treated for benign prostate hyperplasia (BPH) by laser enucleation from 2019−2022 were included. The preoperative AUS volume was adjusted by the formula 1.082 × Age + 0.523 × AUS − 53.845, which was based on specimens retrieved by suprapubic prostatectomy. The results were compared to the weight of the tissue removed by laser enucleation as determined by the intraclass correlation coefficient test (ICC). The potential impact of preoperative planning on operating time was calculated. The ICC between the adjusted volumes and the enucleated tissue weights was 0.86 (p < 0.001). The adjusted volume was more accurate than the AUS volume (weight-to-volume ratio of 0.84 vs. 0.7, p < 0.001) and even more precise for prostates weighing >80 g. The median operating time was 90 min. The adjusted volume estimation resulted in an overall shorter expected preoperative operating time by a median of 21 min (24%) and by a median of 40 min in prostates weighing >80 g. The adjustment formula accurately predicts prostate volume before laser enucleation procedures and may significantly improve preoperative planning, the matching of a surgeon's level of expertise, and the management of patients' expectations.

Introducing in clinical practice a new laser suction handpiece for percutaneous nephrolithotomy.

OBJECTIVE: To assess a novel combined laser suction handpiece (LSH) for performing PCNL in a clinical setting. METHODS: The study comprised 40 consecutive PCNLs performed between May 2019 and February 2020. The first 20 procedures (Group A) were performed with conventional ultrasonic or pneumatic devices and the other 20 (Group B) were performed with the use of the new LSH. All patients were treated by tubeless supine PCNL. The groups were compared for demographics, clinical data, operative time, lithotrite effectiveness, stone clearance rate (SCR), and outcome. RESULTS: Groups A and B were similar in age, and in stone size, complexity, and density (Hounsfield units) (p < 0.05). The average operative time was 99 and 78 min, SCR 143 and 200 mm3/min, hospital stay 1.6 and 1.1 days, and stone-free rate 90% and 95%, respectively. Despite a trend toward better results with the new LSH, none of these comparisons reached statistical significance. Ineffective lithotripsy with the initial device (ultrasonic) requiring conversion to another modality (ballistic) occurred in six (30%) procedures in Group A, while all procedures were effectively accomplished with the LSH in Group B (p = 0.02). There were two complications in Group A and none in Group B (p > 0.05). CONCLUSIONS: The LSH is as effective and safe as the traditional lithotrites for performing PCNLs. This new tool completes the capabilities of the holmium laser high-power machines, enabling them to serve as the sole platform for all endourological treatments.

Flexible Cystoscopy in the Setting of Macroscopic Hematuria: Do the Findings Justify Its Use?

BACKGROUND: Patients hospitalized due to gross hematuria frequently complete evaluation in the outpatient setting. The use of office flexible cystoscopy during hospitalization may lead to prompt diagnosis and treatment but can be limited due to low visualization and artifacts that can hamper diagnostic ability. OBJECTIVE: The objective of this study was to assess flexible cystoscopy findings and yield performed in patients hospitalized due to gross hematuria. METHODS: Medical records of patients who underwent flexible cystoscopy while hospitalized during September 2018-December 2019 were reviewed. Cystoscopic findings were categorized into (1) suspicious mass in the bladder or prostate, (2) nonsuspicious changes in the bladder, and (3) nondiagnostic exam. Descriptive statistics were used to report the clinical characteristics of the study cohort and the findings of cystoscopy. Univariate logistic regression analyses were used to identify predictors of malignant findings. RESULTS: The study cohort consisted of 69 patients (median age of 76 years). Initial cystoscopy findings were suspicious for malignancy in 26/69 patients (38%), nonsuspicious for malignancy in 34/69 patients (49%), and nondiagnostic in 9/69 patients (13%). The median follow-up time was 9 months (range 4-14 months). Twenty patients (29%) were diagnosed with malignancy (sensitivity of 75% and specificity of 78%). The procedure led to either diagnosis or treatment of 39 patients (57%). However, in 30 patients (43%), the initial cystoscopy did not aid in the diagnosis, led to misdiagnoses, or required a follow-up cystoscopy. On univariate analyses, none of the precystoscopy variables were predictive of bladder malignancy. CONCLUSION: Flexible cystoscopy in the setting of acute hematuria requiring hospitalization did not lead to diagnosis or treatment in over 40% of cases. In this setting, consideration should be given to performing an upfront cystoscopy under anesthesia.

Preoperative 68Ga-PSMA PET/CT defines a subgroup of high-risk prostate cancer patients with favorable outcomes after radical prostatectomy and lymph node dissection.

BACKGROUND: High-risk prostate cancer is associated with adverse pathology and unfavorable outcomes after radical prostatectomy. 68Ga-PSMA PET/CT is more accurate than conventional imaging for preoperative staging. We aimed to evaluate whether lymph node involvement on 68Ga-PSMA PET/CT prior to radical prostatectomy in patients with high-risk prostate cancer is associated with worse short-term oncologic outcomes. METHODS: We retrospectively reviewed 149 patients with high-risk localized or locoregional prostate cancer who underwent 68Ga-PSMA PET/CT prior to radical prostatectomy between 2015 and 2020. None of the patients received neoadjuvant or adjuvant treatment. The study endpoints were PSA persistence and biochemical recurrence. Logistic regression models were used to identify preoperative predictors of PSA persistence. Kaplan-Meier analyses were used to estimate biochemical recurrence-free survival. RESULTS: Of 149 identified patients, 19 (13%) were found to have lymph node involvement on preoperative 68Ga-PSMA PET/CT. The sensitivity, specificity, and accuracy of 68Ga-PSMA PET/CT for identifying pathologic lymph node involvement were 68%, 95%, and 92%, respectively. PSA persistence rate was lower among patients with PET-negative lymph nodes than those with PET-positive nodes (15 vs. 84%, p < 0.001). Positive nodes on imaging (OR = 41.03, p < 0.001) and clinical T2c-T3 stage (OR = 6.96, p = 0.002) were associated with PSA persistence on multivariable analysis. Among patients with PET-negative nodes the 1- and 2-year biochemical recurrence-free survival rates were 87% and 76%, respectively. CONCLUSIONS: Preoperative staging with 68Ga-PSMA PET/CT may identify a subgroup of high-risk prostate cancer patients with favorable short-term outcomes after radical prostatectomy without adjuvant treatment. Future studies will evaluate whether these results are sustained during long-term follow-up.

Radical cystectomy and perioperative chemotherapy in octogenarians with bladder cancer.

INTRODUCTION: We aimed to compare the treatment patterns and oncological outcomes, including postoperative morbidity and chemotherapy use, between octogenarians and patients <80 years of age who underwent radical cystectomy for bladder cancer. METHODS: We conducted a retrospective analysis of 119 patients who underwent radical cystectomy for bladder cancer at our center between January 2013 and April 2019. Comorbidities, clinical and pathological data, 30-day postoperative morbidity, and perioperative chemotherapy use were compared between octogenarians (n=31) and younger patients (n=88). Cancer-specific and overall survival rates were estimated with the Kaplan-Meier method and compared between the groups. RESULTS: No significant differences were found between the age groups in the clinical and pathological findings, including Charlson comorbidity index, modified frailty index, albumin level, renal function, and TNM stage. The median followup for survivors was 19 months (interquartile range [IQR] 11-30). Major complications (Clavien-Dindo grade ≥3) and 30-day postoperative mortality rates did not differ between the age groups (p=0.3 and p=0.18, respectively). Despite no difference in baseline glomerular filtration rates, perioperative chemotherapy utilization rate was lower among octogenarians compared to younger patients (13% vs. 34%, p=0.03). Estimated two-year cancer-specific survival rates for octo-generians and younger patients were 40% and 75%, respectively. Similarly, estimated two-year overall survival rates were 30% and 69%, respectively. Both cancer-specific and overall survival rates were significantly lower in octogenarians (p=0.007 and p=0.001, respectively). CONCLUSIONS: Radical cystectomy in octogenarians results in comparable short-term outcomes as in younger patients. However, in the elderly population, perioperative chemotherapy utilization rates are lower and survival is inferior.

Surgical Approach to Abdominal Tumors Involving the Inferior Vena Cava.

BACKGROUND: Abdominal tumors invading the inferior vena cava (IVC) present significant challenges to surgeons and oncologists. OBJECTIVES: To describe a surgical approach and patient outcomes. METHODS: The authors conducted a retrospective analysis of surgically resected tumors with IVC involvement by direct tumor encasement or intravascular tumor growth. Patients were classified according to level of IVC involvement, presence of intravascular tumor thrombus, and presence of hepatic parenchymal involvement. RESULTS: Study patients presented with leiomyosarcomas (n=5), renal cell carcinoma (n=7), hepatocellular carcinoma (n=1), cholangiocarcinoma (n=2), Wilms tumor (n=1), neuroblastoma (n=1), endometrial leiomyomatosis (n=1), adrenocortical carcinoma (n=1), and paraganglioma (n=1). The surgeries were conducted between 2010 and 2019. Extension of tumor thrombus above the hepatic veins required a venovenous bypass (n=3) or a full cardiac bypass (n=1). Hepatic parenchymal involvement required total hepatic vascular isolation with in situ hepatic perfusion and cooling (n=3). Circular resection of IVC was performed in five cases. Six patients had early postoperative complications, and the 90-day mortality rate was 10%. Twelve patients were alive, and six were disease-free after a mean follow-up of 1.6 years. CONCLUSIONS: Surgical resection of abdominal tumors with IVC involvement can be performed in selected patients with acceptable morbidity and mortality. Careful patient selection, and multidisciplinary involvement in preoperative planning are key for optimal outcome.

68Ga-PSMA PET/CT: Does it predict adverse pathology findings at radical prostatectomy?

INTRODUCTION: Data on the accuracy of 68Ga-PSMA positron emission tomography/computed tomography (PET/CT) in patients with intermediate/high-risk prostate cancer are being accumulated. Its role in assessing the extent of local disease has not been fully elaborated. AIM: To determine the performance characteristics of 68Ga-PSMA PET/CT in identifying local disease extension in patients with intermediate/high risk prostate cancer. METHODS: 68Ga-PSMA PET/CT studies of 61 consecutive patients with intermediate/high-risk prostate cancer who underwent radical prostatectomy were reviewed by nuclear medicine specialists. Tumor location, extraprostatic extension (EPE), seminal vesicle invasion (SVI), and lymph nodes involvement (LNI) were compared to pathological findings. The incremental value of 68Ga-PSMA PET/CT to established nomograms was determined. RESULTS: Two patients without pathologic uptake of 68Ga-PSMA were excluded. Seventeen patients were diagnosed with EPE (29%), 12(20%) had SVI and 3(5%) LNI. The concordance between tumor location and 68Ga-PSMA PET/CT findings was 48%, and EPE was not indicated by PET in any of the patients. The sensitivity, specificity, positive, and negative predictive value for SVI were 58%, 96%, 78%, 90%, respectively (area under the receiver operating characteristic curve = 0.77) and for LNI 67%, 98%, 67%, 98%, respectively (area under the receiver operating characteristic curve = 0.82). Incorporating imaging findings into the MSKCC-SVI nomogram enhanced the diagnostic accuracy from 0.84 to 0.95 (Integrated Discrimination Increment 0.24, P = 0.004). CONCLUSION: In patients with intermediate/high-risk prostate cancer, 68Ga-PSMA PET/CT provides information regarding intraprostatic tumor location, SVI and LNI but has no role in assessment for EPE. This information might be useful for pretreatment counseling, decision-making and possibly preoperative planning.

Toward Respiratory-Gated Retrograde Intrarenal Surgery: A Prospective Controlled Randomized Study.

INTRODUCTION: We set out to investigate whether general anesthesia with low ventilation (LV, respiratory rate ≤8/minute and tidal volume <500 mL) could reduce renal mobility and thereby facilitate improved retrograde intrarenal surgery (RIRS) compared with general anesthesia with standard ventilation (SV). MATERIALS AND METHODS: All 60 consecutive patients who presented for RIRS in our department from September 1, 2017 to December 31, 2017 were prospectively randomized 1:1 into one group that was selected to receive SV and another that received LV. Significant factors influencing the study endpoints considered fragmentation rate (FR), removal rate (RR), processing rate (PR), and operating rate (OR), were statistically analyzed for the whole group as well as for comparison by level of surgeon expertise. RESULTS: Univariate analysis revealed that LV was a significant factor in improving all endpoints. Some endpoints were also affected by the stone's volume, number, and density as well as the surgeon expertise. LV remained the single independent factor for FR, RR, and PR in the multivariate analysis. LV significantly improved all four of the fellows' endpoints (p < 0.05 for each) and positively influenced the expert's RR (p = 0.04), PR (p = 0.02) and OR (p = 0.04). The performance gap between the fellows and the experts narrowed under LV. The end-tidal CO2 was significantly higher in the LV group (50 vs 36 mm Hg; p < 0.0001), however, without any clinical significance. The overall stone-free rate (97%) and complication rate (5%) were not significantly different between the two groups. The patient's anesthesia-related safety was not affected by the mode of ventilation as evidenced by no need to convert from LV to SV during the procedures. CONCLUSIONS: LV during RIRS has a significant positive impact on the overall improvement of surgical performance and effectiveness. It does not negatively affect the patient's anesthesia-related safety and may contribute to considerably improving the performance of in-training endourologists.

Do Urology Male Patients Prefer Same-Gender Urologist?

There are several studies on patients' preference for same-gender physicians, especially female preference for same-gender gynecologists. Data regarding the preferences of urology patients, of whom the majority are males, are scarce. The objective of this study is to assess provider gender preference among urology patients. One hundred and nineteen consecutive men (mean age 57.6 years) who attended a urology clinic in one university-affiliated medical center were prospectively enrolled. A self-accomplished 26-item anonymous questionnaire was used to assess patients' preferences in selecting their urologist. Of the 119 patients, 51 (42.8%) preferred a male urologist. Patients exhibited more same-gender preference for physical examination (38.3%), or urological surgery (35.3%), than for consultation (24.4%). Most patients (97%) preferred a same-gender urologist because they felt less embarrassed. Four patient characteristics were identified to be significantly associated with preference for a male urologist: religious status, country of origin, marital status, and a prior management by a male urologist. Of these, religious status was the most predictive parameter for choosing a male urologist. The three most important factors that affected actual selection, however, were professional skills (84.6%), clinical experience (72.4%), and medical knowledge (61%), rather than physician gender per se. Many male patients express gender bias regarding their preference for urologist. However, professional skills of the clinician are considered to be more important factors when it comes to actually making a choice.

Tubeless percutaneous nephrolithotomy: first 200 cases in Israel.

BACKGROUND: Tubeless percutaneous nephrolithotomy is defined as PCNL without postoperative nephrostomy tubes. It is reported to reduce postoperative pain, hospital stay and recovery time. To date the procedure has been reserved for selected patients. OBJECTIVES: To assess our initial experience in extending the implementation of tubeless PCNL without preoperative patient selection. METHODS: All consecutive PCNLs performed during 2004-2008 were evaluated. Tubeless PCNL was performed when residual stones, bleeding and extravasation were excluded intraoperatively. Staghorn stones, stone burden, supracostal and multiple accesses, anatomic anomalies, solitary kidneys and operative time were not considered contraindications. We analyzed the clinical data and the choice of tubeless PCNL over time. RESULTS: Of 281 PCNLs performed during the study period 200 (71%) were tubeless. The patients' average age was 53 years (range 28-82 years), the stone burden was 924 mm2 (400-3150 mm2), operative time was 99 minutes (45-210 min), complication rate was 14% and immediate stone-free rate 91%. There were 81 conversions to standard PCNL (29%) due to expected second-look (n = 47, 58%), impression of bleeding (n = 21,26%), suspected hydrothorax (n = 7, 9%) and extravasation (n = 6, 7%). The transfusion rate was 1%. The median hospital stay was 1 day (1-15 days) and recovery time 7 days (5-20 days). The rate of implementing the tubeless procedure increased steadily along time from 46% to 83% (P = 0.0001). CONCLUSIONS: Tubeless PCNL can be safely and effectively performed based on intraoperative decisions, without preoperative contraindications. They are easily accommodated by experienced endourologists and provide real advantages.

Partial nephrectomy using renal artery perfusion for cold ischemia: functional and oncologic outcomes.

PURPOSE: We present our series on the safety and long-term oncologic and functional outcomes of laparoscopic partial nephrectomy using renal artery perfusion for cold ischemia. PATIENTS AND METHODS: Of 94 patients who underwent laparoscopic partial nephrectomy at our center between August 2000 and September 2006, 28 procedures were performed using cold ischemia and are included in this review. Mean age was 57.8 years (range 22-80 yrs). Mean tumor size was 2.67 cm (range 1.5-5 cm). Five patients had an imperative indication for partial nephrectomy. Eight tumors were hilar. Cold ischemia was achieved through renal artery catheterization followed by intraoperative artery clamping and perfusion with 4 degrees C lactated Ringer solution with mannitol. RESULTS: Mean ischemia time was 40.8 min (range 25-101 min). Mean estimated blood loss was 241 mL (range 50-1000 mL). Three patients underwent conversion to open surgery, but their procedures were still completed under cold perfusion. Segmental artery penetration and venous penetration took place in one patient each. Two postoperative complications occurred, including pancreatitis and pulmonary embolism; none were related to the cold perfusion. Oncologic outcome revealed 100% disease-specific survival for 45 months median followup. Functional studies showed a mild decrease in renal creatinine clearance with improvement 1 month after surgery. Nuclear scans showed functional kidney moiety in all but one patient. CONCLUSION: Intraoperative cold ischemia for laparoscopic partial nephrectomy using arterial perfusion is safe and feasible. It constitutes a viable alternative for complex tumors when ischemia time is expected to exceed 30 minutes. We provide proof of principle confirming the protective effect of cold perfusion to prevent parenchymal damage.

Laparoscopic partial nephrectomy for hilar tumors: technique and results.

BACKGROUND: Laparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature. OBJECTIVE: To describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors. DESIGN, SETTING, AND PARTICIPANTS: Between April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3 cm (range, 2-4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia. INTERVENTION(S): After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.). MEASUREMENTS: Operative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters. RESULTS AND LIMITATIONS: All surgeries were completed laparoscopically. Mean surgical time was 238 min (range, 150-420). Mean ischemia times were 42.5 min (range, 27-63) and 34.1 min (range, 24-56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165 ml (range, 50-500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1-59), no local recurrence or systemic progression occurred. CONCLUSION: Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.

Laparoscopic radioisotope-guided sentinel lymph node dissection in staging of prostate cancer.

OBJECTIVES: To present our experience in laparoscopic sentinel lymph node (SLN) dissection in staging of clinically localized prostate cancer. METHODS: From November 2001 to January 2005 laparoscopic SLN dissection was performed in 140 patients with clinically localized prostate cancer preceding radical prostatectomy. Mean preoperative prostate-specific antigen (PSA) level was 8.26 ng/ml (SD 9.46). At 24 h before surgery, 2 ml 99mTc-labeled human albumin (2 ml/200 MBq) colloid was injected into the prostate gland under transrectal ultrasound guidance. Prostatic SLNs were detected by preoperative planar scintigraphy and intraoperative scanning with a specially designed laparoscopic gamma probe. The detected nodes were dissected and evaluated on frozen section. In case of positive frozen section extended lymph node dissection was performed. RESULTS: SLN was identified on both or one pelvic sidewall in 96 (68.1%) and 36 (25.7%) of the patients, respectively. SLNs were undetectable in 8 (5.7%) cases. In 48.2% (135 of 280) of the pelvic sidewalls, SLNs were exclusively outside the obturator fossa. Final histopathologic examination revealed SLN metastases in 19 (13.5%) patients; 71.4% (20 of 28) of the detected metastases were outside the current standard of lymph node dissection limited to the obturator fossa. Mean tumor size was 2.3 mm (SD 1.7). CONCLUSIONS: Our data confirm the reliability of laparoscopic SLN dissection in staging of prostate cancer. Significant numbers of detected metastases were outside of the routinely sampled obturator fossa. Small metastasis size makes them undetectable by currently available preoperative imaging modalities.

Extending the application of tubeless percutaneous nephrolithotomy.

OBJECTIVES: Tubeless percutaneous nephrolithotomy (PCNL) has been successfully performed in selected patients. We assessed its applicability for use without imposing preoperative restrictions. METHODS: The study consisted of a prospective and consecutive series of 126 patients. Tubeless PCNL was performed when perforation, residual stones, and significant bleeding had been intraoperatively excluded by fluoroscopy, nephroscopy, and hemodynamic assessment. Staghorn stones, supracostal and/or multiple access, anatomic anomalies, previously operated kidneys, solitary kidneys, and operative time were not considered contraindications. The demographic, clinical, and intraoperative and postoperative data were statistically analyzed. RESULTS: Using this protocol, we performed 66 (52%) tubeless and 60 (48%) regular PCNLs. The average patient age (54 years versus 52 years), stone burden (924 versus 1044 mm2), operative time (116 versus 130 minutes), complication rate (9% versus 13%), hemoglobin decrease (1.2 versus 1.1 mg/dL), and immediate stone-free rate (92% versus 90%) were similar for the tubeless and regular PCNL groups, respectively (P >0.05). The reasons for performing standard PCNL were an expected second-look procedure (n = 35, 58%), an impression of active bleeding (n = 16, 27%), significant extravasation (n = 5, 8%), and suspected hydrothorax (n = 4, 7%). The overall transfusion rate was 3%. The average analgesia requirement (pethidine HCL) was 0.4 and 1.2 mg/kg (P <0.01), the median hospital stay was 1 and 4 days (P <0.0001), and the median back-to-work time was 7 and 15 days (P <0.001) for the tubeless and regular PCNL groups, respectively. CONCLUSIONS: The results of our study have shown that tubeless PCNL can be safely and effectively performed based on intraoperative factors, without preoperative contraindications. Compared with the standard procedure, tubeless PCNL was associated with reduced postoperative pain, hospital stay, and recovery time.

[Epidemiological characteristics and trends of testicular cancer in Israel 1992-2002].

OBJECTIVES: Numerous publications from Europe and North America show an increase in the incidence of testicular cancer in past years with substantial differences within and among the different countries. This study aimed to evaluate testicular cancer incidence and other epidemiologic characteristics in Israel in recent years. METHODS: Incidence data was retrieved from the Israeli National Cancer Registry database. Patients with primary testicular cancer diagnosed in the years 1992-2002 were evaluated. For the sample of the year 2002, cross reference and deeper epidemiologic characterization using hospital archives was performed. Incidence rates were calculated according to age standardized, world population based standard. Analysis of variables of age, religion, origin, occupation, risk factors and histological subtypes was performed. RESULTS: In the period of 11 years, 983 primary testicular cancer cases were diagnosed in Israeli citizens. Among Jewish men the incidence rate rose from 2.16 to 4.23/100000 while in Arabs it rose from 0.2 to 1.89/100000. Within the Jewish population the incidence rate elevation was notably prominent in immigrants from Asia and Africa. Considering the geographic distribution, in the Northern Negev changes in incidence rate were found to be more noticeable. A statistically significant decrease in the disease presentation age was observed. Germ cell testicular tumors are a leading cause of the process with an elevation of 86.2% in incidence rate from 1992 to 2002. CONCLUSIONS: The incidence of testicular cancer has increased in Israel in recent years. This trend is strongly associated with previously reported data from economically developed countries. It varies between different population groups. No single hypothesis can be put forward to account for the sudden increase in the disease incidence.

Laparoscopic extended pelvic lymph node dissection for prostate cancer: description of the surgical technique and initial results.

OBJECTIVE: In patients with prostate cancer, extended pelvic lymph node dissection (ePLND) yields a higher number of lymph node metastases (LNM) than standard pelvic lymph node dissection (PLND) of the obturator fossa only. We describe our laparoscopic technique of extended lymph node dissection and provide the number and locations of positive lymph nodes from our experience. METHODS: In a total of 35 selected patients with clinically localized prostate cancer, laparoscopic ePLND was performed prior to laparoscopic radical prostatectomy. The template included the genitofemoral nerve up to the bifurcation of the common iliac artery and down to the epigastric artery. In the "split and roll" technique the internal and external iliac arteries including the bifurcation and the external iliac vein were completely mobilized. After freeing the obturator nerve, the entire lymph node package was released from the pelvic side wall. RESULTS: Mean operative time was 90min/patient. The complications were two temporary and reversible neurapraxias (ischiatic nerve and obturator nerve), one deep vein thrombosis, and two lymphoceles. One lymphocele healed conservatively; the second was marsupialized laparoscopically. Eleven (31.4%) patients had lymph node metastases; their mean prostate-specific antigen (PSA) level was 20.3+/-7.0 ng/ml (range: 5.2-39.7 ng/ml) and their median Gleason sum in biopsy was 7 (range: 6-8). Mean size of the LNM was 3.1+/-1.0 mm (range: 0.2-8). In 5 of the 11 patients with LNM these were detected exclusively outside the obturator fossa. LNM were in the obturator fossa only in two (one bilateral), around the external iliac artery only in two, around the internal iliac artery only in two, and around the external iliac artery and internal iliac only in one patient. CONCLUSIONS: Laparoscopic ePLND can be combined with laparoscopic radical prostatectomy. Standardization of the technique facilitates surgery to a great extent. e-PLND detects LNM in a significant number of patients. The majority of LNM are outside the obturator fossa. The transperitoneal approach allows a wide exposure and is the most important factor to enable successful ePLND.

Practical hints for hemostasis in laparoscopic surgery.

With the developments achieved in recent years in laparoscopic surgery, the field has acquired a host of new techniques to achieve haemostasis, allowing the surgeon to tackle complex procedures. These techniques include physical modalities (as simple as compression or suturing and as sophisticated as endovascular staples), thermal modalities (such as bipolar coagulation, laser or ultrasonic dissectors), and topical sealants (e.g. Fibrin glue or gelatine matrix). It is up to the laparoscopic surgeon to be familiar with all these different modalities and their proper use and limitations. It should also be kept in mind that the best approach to haemostasis in laparoscopy is prevention by thorough case preparation and meticulous dissection technique. We herein expose an overview of the available techniques to achieve haemostatic control in laparoscopic surgery in the emergency as well as the elective setting. Representative surgeries are used for illustrative purposes to describe special manoeuvres.