Radical prostatectomy for prostatic adenocarcinoma: a matched comparison of open retropubic and robot-assisted techniques.

OBJECTIVE: To assess the perioperative complications and early oncological results in a comparative study matching open radical retropubic (RRP) and robot-assisted radical prostatectomy (RARP) groups. PATIENTS AND METHODS: From August 2002 to December 2005 we identified 294 patients undergoing RARP for clinically localized prostate cancer. A comparison RRP group of 588 patients from the same period was matched 2:1 for surgical year, age, preoperative prostate-specific antigen level, clinical stage and biopsy Gleason grade. Perioperative complications were compared. Patients completed a standardized quality-of-life questionnaire. Pathological features were assessed and Kaplan-Meier estimates of biochemical progression-free survival (PFS) were compared. RESULTS: There was no significant difference in overall perioperative complications between the RARP and RRP groups (8.0% vs 4.8%, P = 0.064). Wound herniation was more common after RARP (1.0% vs none, P = 0.038), and development of bladder neck contracture was more common after RRP (1.2% vs 4.6%; P < 0.018). The hospital stay was less after RARP (29.3% vs 19.4%, P = 0.004, for a stay of 1 day). At the 1-year follow-up there was no significant difference in continence (RARP 91.8%, RRP 93.7%, P = 0.344) or potency (RARP 70.0%, RRP 62.8%, P = 0.081) rates. The biochemical PFS was no different between treatments at 3 years (RARP 92.4%, RRP 92.2%; P = 0.69). CONCLUSION: There was no significant difference in overall early complication, long-term continence or potency rates between the RARP and RRP techniques. Furthermore, early oncological outcomes were similar, with equivalent margin positivity and PFS between the groups.

Radiofrequency ablation of renal tumors in the solitary kidney.

OBJECTIVES: Radiofrequency ablation (RFA) is a minimally invasive therapy aimed at maximal preservation of renal function in the nonsurgical renal mass patient. We evaluate our experience with RFA of renal tumors in the solitary kidney. PATIENTS AND METHODS: A retrospective review of all patients with a solitary kidney treated with RFA for renal mass was performed. Two radiologists reviewed all images. From December 2001 to June 2006, 55 renal tumors were treated with RFA in 30 patients with a solitary kidney. Percutaneous approach was used in 44 tumors (26 patients) and intraoperative open approach in 11 tumors (4 patients). Average mass size was 2.0 cm (1.2-5.4). Biopsy performed prior to ablation in 14 tumors showed renal cell carcinoma in 12 (86%) and was non diagnostic in 2 (14%). RESULTS: There were no major post procedural complications. Initial technical success was noted in 98% of tumors in 97% of patients. Average follow-up with contrast enhanced CT or MRI was 25 months (3-47) in 26 patients (50 tumors) and showed local tumor control in 100%. No difference in preoperative and postoperative calculated creatinine clearance was noted (p = 0.072). There was no difference in systolic (p = 0.102) and diastolic (p = 0.790) blood pressure pre and post ablation. CONCLUSIONS: RFA of renal masses in the solitary kidney appears to be a safe, minimally invasive alternative to open surgical resection in properly selected patients. Local tumor control was achieved with no adverse effects on renal function and blood pressure in this series.

Long-term success of antegrade endopyelotomy compared with pyeloplasty at a single institution.

BACKGROUND AND PURPOSE: The classic standard for surgical repair of ureteropelvic junction (UPJ) obstruction has been open pyeloplasty, with a 95% success rate. Antegrade endopyelotomy is a less-invasive option with a slightly lower success rate. However, recent data call into question the long-term durability of UPJ repair. We present the long-term success of treatment of UPJ obstruction comparing these two modalities. PATIENTS AND METHODS: We reviewed the medical records of patients undergoing percutaneous antegrade endopyelotomy or open and laparoscopic pyeloplasty for UPJ repair in our practice from 1988 to 2004. Success was defined as both radiographic and symptomatic improvement. We evaluated the impact of preoperative factors, including prior surgical repair, crossing vessels, renal function, and calculi, on success. RESULTS: The estimated 3-, 5-, and 10-year recurrence-free survival rates for the endopyelotomy group (N = 182) were 63%, 55%, and 41%, respectively, compared with 85%, 80%, and 75% for the pyeloplasty group (N = 175; P < 0.001). Of the failed endopyelotomies undergoing salvage open repair, 8 of 26 (31%) had crossing vessels. Poor renal function and previous failed pyeloplasty decreased success in the pyeloplasty group. Variation from standard cold-knife incision adversely affected endopyelotomy success. CONCLUSIONS: Long-term success rates after both endopyelotomy and pyeloplasty are worse than previously reported. Although most failures in both groups occurred within 2 years, failures continue to appear after 5 and 10 years, and patients should be followed accordingly. In view of these results of endopyelotomy, laparoscopic pyeloplasty may prove to be the preferred minimally invasive approach to repair UPJ obstruction.

Outcomes of Gleason score 10 prostate carcinoma treated by radical prostatectomy.

OBJECTIVES: To evaluate the outcome of radical prostatectomy for the rarest and most poorly differentiated prostate tumors of all: those with Gleason score 10. Controversy exists as to which form of therapy is most effective for high-grade prostate cancer (PCa). METHODS: We retrospectively reviewed the charts of all patients with pathologic Gleason score 10 PCa treated at our institution with radical prostatectomy from 1977 to 1999. All pathology specimens were reviewed by a urologic pathologist, and 13 cases with true Gleason score 10 PCa were identified. The preoperative covariables (prostate-specific antigen level, biopsy Gleason score, and clinical stage), perioperative covariables (pathologic stage, margin status, and tumor ploidy), and postoperative covariables (prostate-specific antigen level and adjuvant and salvage treatments) were assessed with respect to the oncologic outcomes. RESULTS: The median follow-up was 4.2 years. Preoperatively, only 4 of the 13 cases were correctly identified at biopsy, and the median preoperative prostate-specific antigen level was 4.5 ng/mL (interquartile range 0.3 to 12.5). Pathologic examination showed a small cell component in 7 cases, seminal vesicle invasion in 11, and positive lymph nodes in 3. Six patients developed recurrent PCa: three local, two systemic, and one biochemical recurrence. The biochemical recurrence-free and cancer-specific survival rate at 5 years was 53.8% and 76.9%, respectively. CONCLUSIONS: Gleason score 10 PCa is a highly aggressive disease that is usually lethal if managed conservatively. The results of the present study have provided some evidence that radical prostatectomy may be of benefit to patients with Gleason score 10 PCa.

Time-dependent variations in inflammation and scar formation of six different pubovaginal sling materials in the rabbit model.

OBJECTIVES: To provide pathologic evidence, using six different sling materials, of the findings from rabbit model studies demonstrating loss of tensile strength and stiffness in porcine and cadaveric sling materials. METHODS: Ten rabbits randomized into two survival groups (6 and 12 weeks of age) each had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh, and autologous fascia implanted on their anterior rectus fascia. At harvest, hematoxylin-eosin and immunohistochemical staining for CD3, CD20, and MIB-I were performed. A pathologist unaware of the content of the slides quantified the degree of inflammation and fibrosis of each. RESULTS: Significant differences were found for inflammation (P = 0.016), eosinophil infiltrate (P = 0.035), and inflammatory rind (P = 0.027) at 12 weeks, with polypropylene mesh having the lowest degree. At 12 weeks, differences were found in the presence of fibrosis/scar formation (P = 0.010) and degree of fibrosis/scar (P = 0.009). Although polypropylene mesh, cadaveric fascia, and porcine dermis all demonstrated a high presence of fibrosis/scar, polypropylene mesh had the greatest overall degree of scar formation at 12 weeks. CONCLUSIONS: The inflammation with the cadaveric fascia and porcine materials may cause rapid clinical deterioration compared with autologous fascia and polypropylene mesh. These data provide a possible explanation for prior biomechanical studies demonstrating variations in tensile strength and stiffness of the different materials. The fibrosis and scarring noted with polypropylene mesh may also contribute to a more lasting repair.

Vesicouterine fistula: a review of eight cases.

Eight cases of vesicouterine fistula (VUF) (obstetrical etiology in six cases and inflammatory bowel disease in two) have been treated in the past 14 years. All six obstetrical cases were related to cesarean section. Both cases of colovesicouterine fistula presented acutely with watery vaginal discharge or fecaluria. Presenting complaints were vaginal urinary incontinence (five cases), hematuria (three), and vaginal discharge (two). Diagnosis was made with cystoscopy in seven cases and computed tomography in one. VUF usually was between posterior bladder and anterior uterine walls above the internal os. Of the initial treatments, six were surgical (three hysterectomies) with an abdominal (five) or transvaginal (one) approach. Mean follow up was 9 months (range, 2-24). Urinary incontinence resolved in all surgically treated patients. Two patients reporting cyclic hematuria were initially managed medically (medroxyprogesterone injections), with delayed surgical repair elsewhere. Surgical repair is the primary treatment for VUF. Successful pregnancy and cesarean delivery have been reported after VUF repair, without sequelae.

Ureteroiliac artery fistula: diagnosis and treatment algorithm.

OBJECTIVES: To review the diagnosis and treatment of ureteroarterial fistulas and to develop a management algorithm. Long-term ureteral stenting, along with pelvic surgery and radiotherapy, have led to an increased incidence of ureteroarterial fistulas. Experience diagnosing and treating these fistulas has been limited to case reports. METHODS: A retrospective chart review from 1975 to 2004 revealed eight ureteroarterial fistulas in 7 patients at our institution. The patient demographics, presenting symptoms, and diagnostic studies were reviewed. Also, we analyzed the treatment, hospital course, and long-term outcomes. RESULTS: Ureteroarterial fistulas were more common in women (86%) than in men. All patients presented with gross hematuria, and 57% had lateralizing flank pain. Risk factors included chronic indwelling stents (87%), previous pelvic external beam radiotherapy (71%), pelvic surgery (100%), and vascular disease (87%). Provocative angiography was diagnostic in only 63% of cases. Although not sensitive, cystoscopy revealed lateralized, pulsatile hematuria in all cases when performed. Treatment ranged from endovascular stenting with nephrostomy tube to primary surgical repair with nephrectomy. CONCLUSIONS: On the basis of this review, we propose a systematic diagnostic and treatment approach to a serious disease process. The use of these proposed algorithms will minimize unnecessary testing, increase the speed of diagnosis, and potentially improve overall outcomes of patients with ureteroarterial fistulas.

The extent of lymphadenectomy for pTXNO prostate cancer does not affect prostate cancer outcome in the prostate specific antigen era.

PURPOSE: Recent data suggest that extended lymph node dissection in prostate cancer may be necessary for accurate staging. With limited lymph node dissection apparently node negative cases might be under staged. We determined the impact that the number of lymph nodes removed at radical retropubic prostatectomy (RRP) has on cancer progression and cause specific survival in pTXNO cases. MATERIALS AND METHODS: We reviewed the RRP prostate cancer database on 7,036 patients with clinical T1 to T3 disease, no adjuvant therapy and node negative disease in the prostate specific antigen (PSA) era from 1987 to 2000. Factors evaluated were the number of lymph nodes obtained at RRP, preoperative PSA, clinical and pathological stage and grade, margin status, year of surgery and specific surgeon for 5 surgeons who operated throughout the period and performed more than 500 RRPs. Cox analysis was done to determine the RR of progression (PSA or systemic) and prostate cancer death for the number of lymph nodes excised. RESULTS: Median patient age was 65 years and median preoperative PSA was 6.6 ng/ml. At pathological evaluation 5,379 tumors (77%) were organ confined, 4,491 (65%) were Gleason score 5 to 6 and 2,027 (29%) were Gleason score 7 to 10. The median number of nodes obtained significantly decreased from 14 in 1987 to 1989 to 5 in 1999 to 2000 (p <0.001). Ten years after RRP Kaplan-Meier estimates were 63% of cases free of PSA progression, 95% free of systemic progression and 98% free of prostate cancer related death. Median followup was 5.9 years. After adjusting for pathological factors (PSA, grade, stage, margin status and surgical date) the number of lymph nodes obtained at lymphadenectomy was not significantly associated with PSA progression (for each additional node (RR 0.99, 95% CI 0.98 to 1.02, p = 0.90), systemic progression (RR 0.99, 95% CI 0.96 to 1.03, p = 0.68) or cause specific survival (RR 1.01, 95% CI 0.96 to 1.06, p = 0.75). CONCLUSIONS: The extent of lymphadenectomy does not appear to affect prostate cancer outcome in lymph node negative cases. This includes patients with high preoperative PSA, high pathological grade and extracapsular disease. These results suggest that under staging is not present in apparently node negative cases with limited lymphadenectomy and, even if present, its impact on outcome is likely to be negligible.

Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse.

Transabdominal sacrocolpopexy is an excellent treatment option for patients with high-grade vaginal vault prolapse, with long-term success rates ranging from 93% to 99%. However, it is associated with increased morbidity compared with vaginal repairs. In this article, we describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of 4 laparoscopic ports, 3 for the surgical robot and 1 for the assistant. A prolene mesh is then attached to the sacral promontory and to the vaginal apex using nonabsorbable expanded polytetrafluoroethylene sutures. At the end of the case, the mesh material is covered by the peritoneum. A total of 20 patients underwent a robot-assisted laparoscopic sacrocolpopexy at our institution in the past 18 months for severe symptomatic vaginal vault prolapse; 8 of the 20 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5.1 (range, 1-12) months and mean age was 66 (range, 47-82) years. The mean total operative time was 3.2 (range, 2.25-4.75) hours. Of these patients, 1 was converted to an open procedure secondary to unfavorable anatomy. All but 1 patient, who left on postoperative day 2, were discharged from the hospital after an overnight stay. Complications were limited to mild port-site infections in 2 patients, which resolved with oral antibiotic therapy. Recurrent grade 3 rectocele developed in 1 patient, but there was no evidence of cystocele or enterocele. Significant incontinence (>1 pad/day) was present in 2 patients. All 18 patients reported being satisfied with the outcome of their surgery and all 10 would recommend it to a friend. This novel technique for vaginal vault prolapse repair combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high rates of patient satisfaction. Although our early experience is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.

Surgical treatment for local control of female urethral carcinoma.

We reviewed 53 patients (mean age 63 years) who underwent partial urethrectomy (n = 26) or radical extirpation (n = 27) for primary female urethral cancer from 1948 through 1999. Clinical stage, histology, high pathologic stage (3 or 4) and grade, tumor location, nodal status, surgery type, adjuvant therapy, and treatment decade were candidate outcome predictors. The predominant carcinomas were squamous cell (n = 21), transitional cell (TCC) (n = 15), and adenocarcinoma (n = 14). For adjuvant therapy, 20 patients had radiation (8 preoperatively), 2 had radiation + chemotherapy, and 1 had chemotherapy alone. During mean follow-up of 12.8 years, 27 patients had recurrence; 15 local only, 2 distant only and 10 local + distant. Of patients undergoing partial urethrectomy for pT1-3 tumors, 6/27 (22%) had urethral recurrence. Overall, there were no bladder recurrences. Recurrence-free survival +/- standard error (SE) at 10 years was 45 + 8%. Those who recurred had a cancer mortality rate of 71% at 5 years postrecurrence. The estimated 10-year cancer-specific survival (CSS) and crude survival (CS) rates were 60 +/- 8% and 42 +/- 7%, respectively. Pathologic stage was predictive for local recurrence (P = 0.02) and CSS (P = 0.01). Positive nodes on pathology were related to local and distant recurrence and CSS (P = 0.01). Upon review, partial urethrectomy resulted in a high urethral recurrence rate (22%) with no bladder recurrences. These patients may be better served with radical urethrectomy and creation of continent catheterizable stoma.

Long-term survival of patients with unilateral sporadic multifocal renal cell carcinoma according to histologic subtype compared with patients with solitary tumors after radical nephrectomy.

OBJECTIVES: To determine the pathologic features, including histologic subtype and tumor size, associated with multifocal renal cell carcinoma (RCC) and the impact of multifocality on survival after radical nephrectomy, about which controversy exists. METHODS: We studied 2373 patients who underwent radical nephrectomy for RCC from 1970 to 2000. Histologic subtype, stage (2003 TNM), nuclear grade, tumor size, and multifocality, defined as the presence of more than one ipsilateral RCC tumor of the same histologic subtype, were evaluated. Associations of multifocality with ipsilateral and contralateral recurrence and death from RCC were evaluated using Cox proportional hazards models. RESULTS: The incidence of sporadic histologically concordant multifocality was greater in papillary RCC (29 of 266; 10.9%) compared with clear cell RCC (40 of 1934; 2.0%; P <0.001) and chromophobe RCC (2 of 104; 1.9%; P = 0.005). Patients with solitary clear cell and papillary RCC had larger tumors compared with multifocal clear cell and papillary RCC (P <0.001 and P = 0.024, respectively). Patients with multifocal clear cell RCC were more likely to have a contralateral recurrence than were patients with solitary clear cell RCC (risk ratio 2.91, P = 0.142). Multifocality was not significantly associated with ipsilateral recurrence or death from RCC in patients with clear cell or papillary RCC. CONCLUSIONS: The incidence of multifocality was significantly greater among patients with papillary RCC than among patients with clear cell or chromophobe RCC. Patients with multifocal clear cell RCC were more likely to experience a contralateral recurrence. Multifocality was not significantly associated with ipsilateral recurrence or death from RCC. In addition, multifocality was not associated with larger and higher stage tumors, as previously reported.

Time dependent variations in biomechanical properties of cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia in the rabbit model: implications for sling surgery.

PURPOSE: We investigated time dependent variations in tensile strength, stiffness, shrinkage and distortion in 6 materials commonly used for transvaginal anti-incontinence surgery. MATERIALS AND METHODS: A total of 15 rabbits were randomized into 3 survival groups (2, 6 and 12 weeks, respectively). Each rabbit had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia implanted on the anterior rectus fascia. At harvest tensiometry and image analysis were performed on each sling. Results were compared to baseline for each sling type and the percent decrease from baseline was compared among sling types. RESULTS: Each type of human cadaveric fascia and porcine allografts showed a marked decrease (60% to 89%) in tensile strength and stiffness from baseline. Polypropylene mesh and autologous fascia did not differ in tensile strength from baseline. Polypropylene mesh increased in stiffness from baseline. Autologous fascia and small intestinal submucosa demonstrated a 41% and 50% decrease in surface area, respectively, at 12 weeks. CONCLUSIONS: To our knowledge the relative contribution of biomechanical properties of sling material to the success of anti-incontinence surgery is unknown. However, rapid loss of tensile strength and stiffness in porcine and cadaveric materials may contribute to the early re-emergence of symptoms following successful sling surgery. The results of this study add scientific validity to the increasing use of synthetics in anti-incontinence surgery. Urologists selecting a sling material should be aware of its time dependent biomechanical fate relative to other sling materials.

Outcome of surgical treatment for primary malignant melanoma of the female urethra.

PURPOSE: We evaluate tumor characteristics, recurrence and survival following surgical treatment for female urethral melanoma. MATERIALS AND METHODS: A review of the records of all female patients with primary localized urethral melanoma (11, mean age 68 years) who underwent partial urethrectomy or radical extirpation from 1950 to 1999 was performed to determine disease specific survival and/or tumor characteristics correlating with survival. Clinical and pathological stage, tumor location, nodal status, adjuvant therapy and tumor pathological components including depth, width, necrosis and vascular/lymphatic invasion, were evaluated. Overall disease recurrence, crude and disease specific survival rates were calculated using the Kaplan-Meier method. RESULTS: Malignant melanoma occurred in the distal urethra in all 11 cases with local extension into the vagina (T3) in 7. Mean depth of invasion was 6.1 mm and mean tumor width was 2.0 cm. No vascular/lymphatic invasion or tumor necrosis was seen pathologically. No patient had received adjuvant therapy at the time of initial surgery. There were 7 recurrences (6 of 7 within 1 year postoperatively). Of the 7 cases of partial urethrectomy, urethral recurrence (1 with concurrent lung metastasis) developed in 5 and none had bladder recurrence. Those who underwent radical surgery had recurrence in the pelvis and lungs and inguinal lymph nodes. Crude and disease specific survival +/- standard error at 3 years was 27 +/- 15% and 38 +/- 19%, respectively. CONCLUSIONS: Primary female urethral melanoma is associated with a rapid and high local recurrence rate (60% at 1 year). Overall and cancer specific survival at 3 years is 27% and 38%, respectively. Local failure may in part be due to inadequate resection.

Multivariate models to predict clinically important outcomes at prostatectomy for patients with organ-confined disease and needle biopsy Gleason scores of 6 or less.

The objective of this study was to determine the clinical and biopsy features associated with outcomes at radical retropubic prostatectomy (RRP) in patients with clinically organ-confined prostate cancers and biopsy Gleason scores (GS) of 6 or less. We reviewed 274 biopsies with GS 6 or less cancers from patients with clinically organ-confined disease between 1995 and 1998 to determine statistically significant predictors for the following outcomes at RRP: tumor volume, small (<0.5 cc), confined (pT2) tumors with RRP GS of 6 or less (potentially "insignificant" tumors), and extraprostatic extension (EPE). Clinical and pathologic features evaluated included age, serum prostate specific antigen (PSA), clinical stage, percent biopsy cores and surface area positive for cancer (tumor extent), perineural invasion, MIB-I proliferation, and DNA ploidy by digital image analysis (DIA). Multivariate analyses showed that biopsy tumor extent (median percent surface area positive 3.3%; P < 0.001 and median biopsy cores positive 28.6%; P = 0.001) and PSA (median 5.5 ng/mL; P = 0.009) predicted tumor volume (median 1.4 cc). Biopsy tumor extent (P = 0.002), PSA (P = 0.002), and percent S-phase nuclei (P = 0.050) predicted potentially "insignificant" tumors at RRP (n = 76, 28%). Percent surface area positive for cancer (P = 0.003) predicted EPE (n = 22, 8%). DNA ploidy (n = 211, 79% diploid) and MIB-I proliferation (median 1.4%) did not add information to predict these RRP outcomes. Biopsy tumor extent and serum PSA were significantly associated with tumor volume. Biopsy tumor extent, serum PSA, and percent S-phase nuclei by DIA were predictive of potentially insignificant tumors. Patients with clinically confined disease, <5% biopsy surface area positive for cancer, <20% biopsy cores positive for cancer, and GS 6 or less, had a 48% chance of having a potentially insignificant tumor at diagnosis if the serum PSA was <10 ng/mL. Percent surface area predicted EPE at RRP. DNA ploidy and MIB-I proliferation by DIA did not provide additional information.

Tandem cuff artificial urinary sphincter as a salvage procedure following failed primary sphincter placement for the treatment of post-prostatectomy incontinence.

PURPOSE: Management of post-artificial urinary sphincter (AUS) urethral atrophy can be difficult for the treating physician, yielding unsatisfactory results for the patient. As with many incontinence procedures, initial results are generally encouraging. We determined the durability and success of tandem cuff placement for urethral atrophy following AUS placement. MATERIALS AND METHODS: We reviewed the records of 18 patients with a mean age 74 years who underwent tandem AUS placement from 1994 to 2001. Mean followup was 3.3 years. All patients originally underwent AUS placement for post-prostatectomy stress urinary incontinence and they had subsequent incontinence secondary to urethral atrophy. Adjuvant radiation in 3 cases, hormone therapy in 3, cuff size and pressure, and multiple continence procedures prior to tandem cuff placement in 5 were evaluated as risk factors for cuff erosion. Long-term followup was obtained through office examination and telephone interview using a standardized questionnaire regarding voiding habits and satisfaction. RESULTS: Following tandem cuff placement mean +/- SD pad use daily decreased from 4.3 +/- 0.35 (median 3) to 1.6 +/- 0.42 (median 1) (p <0.0001). Overall 10 of the 18 patients (56%) needed 1 pad or less daily, 16 (88%) would have the tandem cuff placed again and 17 (94%) would recommend the procedure. Median subjective improvement and satisfaction was 4.7 and 4.0, respectively, on a scale of 0 to 5. Reoperation was required for cuff leakage in 1 case and cuff erosion in 2. One patient with erosion had 3 prior AUS revisions, including placement of a 71 to 80 cc balloon reservoir. CONCLUSIONS: Placement of tandem urethral cuff as a salvage procedure for recurrent stress urinary incontinence provides marked sustained improvement in leakage and overall high patient satisfaction in the difficult setting of urethral atrophy.

Subjective and objective comparison of critical care pathways for open donor nephrectomy.

PURPOSE: In the era of minimally invasive techniques and cost containment, care pathways after donor nephrectomy are important. While open donor nephrectomy remains the established procedure, questions regarding the surgical approach, postoperative care and patient morbidity/dissatisfaction have surfaced. We compared results of standard and fast-track care pathways after donor nephrectomy. MATERIALS AND METHODS: Between January 1998 and August 1999, 60 patients underwent open donor nephrectomy. By surgeon preference, patients received either ketorolac only (31), ketorolac plus morphine spinal (17) or patient controlled anesthesia (12). Data related to surgery, hospital course and cost were reviewed. Patients were surveyed regarding return to daily activities and groups were statistically analyzed. RESULTS: The mean dose per patient was 183 (ketorolac only), 180 (ketorolac plus morphine spinal) and 69 (patient controlled analgesia) mg. Median hospital stay was 2 days for the fast-track pathways (ketorolac only, ketorolac plus morphine spinal) compared to 3 days for the patient controlled analgesia group (p <0.001). Delayed oral intake was seen in 6% of patients on ketorolac only and 3% for those on ketorolac plus morphine spinal compared to 83% of the patient controlled analgesia group (p <0.001). Return to exercise (median weeks, p <0.79) was 2 for the ketorolac only group, 3.5 for ketorolac plus morphine spinal and 3.5 for patient controlled analgesia. Mean global cost was $9,394 for the ketorolac only group, $9,238 for ketorolac plus morphine spinal and $11,601 for patient controlled analgesia (p <0.02). CONCLUSIONS: Fast-track pathways significantly shortened hospital stay and quickened oral intake. Cost was significantly contained using new pathways. Resumption of daily activities was comparable among the groups. Comparisons of critical care pathways are required to optimize patient care after kidney donation. Prospective trials are needed to verify our results.