A double-blind randomized controlled trial of continuous intravenous Ketorolac vs placebo for adjuvant pain control after renal surgery.

OBJECTIVE: To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS: A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS: The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION: Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.

Posterior reconstruction before anastomosis improves the anastomosis time during robot-assisted radical prostatectomy.

BACKGROUND AND OBJECTIVES: Our goal was to evaluate posterior reconstruction of the rhabdosphincter during robot-assisted radical prostatectomy and determine whether this technique decreased anastomotic time of a surgeon in training to perform vesicourethral reconstruction. METHODS: We reviewed the first 25 robot-assisted prostatectomies performed by 2 urology surgeons in training (surgeon 1 and surgeon 2). The patient populations were matched for age, Gleason score, clinical stage, and PSA. Whereas surgeon 1 performed the vesicourethral anastomosis without posterior reconstruction, surgeon 2 reapproximated Denonvilliers' fascia of the posterior bladder to the rhabdosphincter. Time for each surgeon to complete the anastomosis and clinical factors was compared. RESULTS: Surgeon 1 had a median anastomosis time of 25 minutes (range, 17 to 48), whereas surgeon 2 had a median anastomosis time of 15 minutes (range, 10 to 30) (P<0.001). Biopsy Gleason score, pathological tumor stage, perineural invasion, median age at the time of surgery, PSA, prostate weight, and estimated blood loss were not significantly different between surgeons (P>0.05). Pathological Gleason score (P=0.045) and total console time (surgeon 1-216 minutes, surgeon 2-176 minutes; P=0.002) were significantly different between surgeons. CONCLUSION: Posterior reconstruction prior to anastomosis decreases anastomosis time for robotic surgeons in training.

Laparoscopic radical nephrectomy for very large renal tumors (> or =10 cm): is there a size limit?

BACKGROUND AND PURPOSE: The role of laparoscopic radical nephrectomy (LRN) for very large renal tumors remains to be defined. We review our experience with LRN for very large (> or =10 cm) renal malignancies. PATIENTS AND METHODS: A retrospective analysis of 360 consecutive patients who underwent LRN for renal tumors between October 1999 and May 2007 in a tertiary academic center identified 11 patients with malignancies > or =10 cm. RESULTS: Median age was 67 years (range 48-80 y), operative time was 170 minutes (range 80-240 min), estimated blood loss was 150 mL (range 50-300 mL), and length of stay was 2 days (range 1-6 d). There were two minor postoperative complications (acute renal insufficiency and ileus). Median tumor size was 12 cm (range 10-21 cm). Pathologic stage for patients with renal cell carcinoma was T(2), T(3a), T(3b), and T(4), in five, three, two, and one patient(s), respectively. One patient died after brain metastasis developed. Two patients in whom pulmonary metastases developed were still alive at last follow-up. CONCLUSIONS: LRN was successfully performed in patients with renal tumors up to 21 cm. Important considerations when performing LRN include the individual clinical picture, surgeon experience, tumor location, and patient well-being. LRN for very large tumors is feasible in properly selected patients and can have significant benefits in the palliative setting.