Use of a hyaluronic acid-carboxymethylcellulose adhesion barrier on the neurovascular bundle and prostatic bed to facilitate earlier recovery of erectile function after robot-assisted prostatectomy: an initial experience.

PURPOSE: To investigate the efficacy of hyaluronic acid-carboxymethylcellulose (HACM) in facilitating early recovery of erectile function (EF) after radical prostatectomy, we report our initial experience of HACM use on the neurovascular bundle (NVB) after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Between 2008 and 2010, 459 consecutive patients who underwent RARP with bilateral nerve-sparing technique were included in this study. Patients were classified into two groups: HACM (group 1; n=162) and non-HACM (group 2; n=287). HACM was delivered to the anatomic location of the NVB after prostate removal. We retrospectively analyzed the surgical outcomes including EF, continence, and perioperative complications. RESULTS: At 6 months after surgery, EF recovery rate was 28.5% in group 1 and 17.4% in group 2 (P=0.006). In a subgroup analysis consisting of 225 patients with a preoperative International Index of Erectile Function Short Survey (IIEF)-5 score ≥20, the difference in EF recovery at 6 months was significant with 62.8% in group 1 and 27.0% in group 2 (P=0.002), respectively. HACM use was an independent predictor for EF recovery at 6 months after surgery (odds ratio, 2.735; 95% confidence interval, 1.613-4.638; P<0.001). Age and preoperative IIEF-5 were also independent predictors. No differences in continence at 6 months or perioperative complications were found between the two groups. EF recovery was not different between the two groups after 18 months. CONCLUSIONS: HACM use around the NVBs is safe and facilitates early recovery of EF after nerve-sparing RARP. HACM use is more effective in patients with normal preoperative sexual function.

Oncologic outcomes after laparoscopic partial nephrectomy: mid-term results.

INTRODUCTION: To describe the oncologic outcomes of renal cell carcinoma (RCC) diagnosed in patients and submitted to laparoscopic partial nephrectomy (LPN) in a laparoscopic referral center. PATIENTS AND METHODS: We retrospectively analyzed data of 150 consecutive patients with small renal masses and treated with LPN between 2000 and 2010 at a laparoscopic referral center. Pathologic RCC was diagnosed in 137 patients and were included in the oncologic outcome analysis. Kaplan-Meyer methods were used to estimate the probability of disease recurrence and cancer-specific survival. RESULTS: Median follow-up for patients without recurrence was 38 months (interquartile range [IQR] 19-70). The majority of the patients (88%) were found to have pT1a disease at the final pathology report; eight patients (6%) were classified as pT3a. The median tumor size was 25 mm (IQR 20-32). Clear cell type histology was found in 97 patients (66%); most of the patients had Fuhrman grade 2 (72%) or 3 (21%). The 2- and 5-year recurrence-free survival rates were 98% and 95%, respectively. The positive surgical margin was found in 1.4% of the patients. The 2-year and 5-year CSS rates were 99% and 97%, respectively. Kaplan-Meyer methods showed that patients with pT3a were more likely to experience disease recurrence and patients with Fuhrman grade 3 to die of the disease. CONCLUSIONS: LPN seems to provide excellent cancer control rates and to be an oncologically feasible and safe option for treating patients with small renal masses. Recurrence and death from the disease are extremely uncommon and mostly related to a higher pathologic stage or Fuhrman grade, but not positive surgical margins.

Natural orifice transendoluminal surgery and laparoendoscopic single-site surgery: the future of laparoscopic radical prostatectomy.

Techniques for minimally invasive radical prostatectomy (RP) have been carefully reviewed by surgical teams worldwide in order to identify possible weaknesses and facilitate further improvement in their overall performance. The initial plan of action has been to carefully study the best-practice techniques for open RP in order to reproduce and standardize performance from the laparoscopic perspective. Similar to open surgery, the learning curve of minimally invasive RP has been well documented in terms of objective evaluation of outcomes for cancer control and functional results. Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have recently gained momentum as feasible techniques for minimal access urological surgery. NOTES-LESS drastically limit the surgeon's ability to choose the site of entry for operative instruments; therefore, the advantages of NOTES-LESS are gained with the understanding that the surgical procedure is more technically challenging. There are several key elements in RP techniques (in particular, dorsal vein control, apex exposure and cavernosal nerve sparing) that can have significant implications on oncologic and functional results. These steps are hard to perform in a limited working field. LESS radical prostatectomy can clearly be facilitated by using robotic technology.

Impact of posterior urethral plate repair on continence following robot-assisted laparoscopic radical prostatectomy.

PURPOSE: The objective of this study is to evaluate the continence rate following reconstruction of the posterior urethral plate in robot-assisted laparoscopic radical prostatectomy (RLRP). MATERIALS AND METHODS: A retrospective analysis of 50 men with clinically localized prostate cancer who underwent RLRP was carried out. Twenty-five patients underwent RLRP using the reconstruction of the posterior aspect of the rhabdosphincter (Rocco repair). Results of 25 consecutive patients who underwent RLRP prior to the implementation of the Rocco repair were used as the control. Continence was assessed at 7, 30, 90, and 180 days following foley catheter removal using the EPIC questionnaire as well as a follow-up interview with the surgeon. RESULTS: There was no statistically significant difference between the two groups in any of the patient demographics. At 7 days, the Rocco experimental group had a continence rate of 19% vs. 38.1% in the non-Rocco control group (p = 0.306). At 30 days, the continence rate in the Rocco group was 76.2% vs. 71.4% in the non-Rocco group (p = 1). At 90 days, the values were 88% vs. 80% (p = 0.718), respectively. At 180 days, the pad-free rate was 96% in both groups. CONCLUSION: Rocco repair offers no significant advantage in the time to recovery of continence following RLRP when continence is defined as the use of zero pads per day. On the other hand, Rocco repair was associated with increased incidence of urinary retention requiring prolonged foley catheter placement.

Colorectal cancer pelvic recurrences: determinants of resectability.

PURPOSE: This study was designed to identify preoperative and intraoperative features of locally recurrent colorectal cancer that predict R0 resection in patients scheduled for attempted complete resection followed by intraoperative radiation therapy. METHODS: Review of a prospective data base identified 119 patients brought to the intraoperative radiation therapy suite for planned complete resection of locally recurrent rectal (n = 101) and colon (n = 18) cancer between January 1994 and November 2000. R0 resection was achieved in 61 patients. This group was compared with patients in which an R1 (n = 38), R2 (n = 7), or palliative procedure (n = 13) was performed. Variables evaluated included: tumor location, features of the primary tumor, and preoperative findings on computed tomography, magnetic resonance imaging, and history/physical. Tumor location was established by review of operative/pathologic reports and classified as axial (anastomotic/perineal), anterior (bladder/genitourinary organs), posterior (presacral), or lateral (pelvic sidewall). RESULTS: When recurrence was confined to the axial location only, or axial and anterior locations, R0 resection was achieved significantly more often than when other locations were involved (P < 0.001, P = 0.003, respectively). When a lateral component was present, R0 resection was achieved significantly less often than when there was no lateral component (P = 0.002). For patients with available preoperative computed tomography and/or magnetic resonance imaging results (n = 70), the finding of lateral tumor involvement was associated with R0 resection significantly less often than when lateral disease was not identified (P = 0.004). CONCLUSIONS: Pelvic recurrences confined to the axial location, or axial and anterior locations, are more likely to be completely resectable (R0) than those involving the pelvic sidewall. Efforts to enhance preoperative identification and imaging of these patients are clearly justified.