A history of urolithiasis risk in space.

INTRODUCTION: The development of renal stones in space would not only impact the health of an astronaut but could critically affect the success of the mission. MATERIALS AND METHODS: We reviewed the medical literature, texts and multimedia sources regarding the careers of Dr. Abraham Cockett and Dr. Peggy Whitson and their contributions to the study of urolithiasis in space, as well as the studies in between both of their careers that helped to further characterize the risks of stone formation in space. RESULTS: Dr. Abraham T. K. Cockett (1928-2011) was Professor and Chair of the Department of Urology at the University of Rochester and served as AUA President (1994-1995). In 1962, Dr. Cockett was one of the first to raise a concern regarding astronauts potentially forming renal stones in space and suggested multiple prophylactic measures to prevent stone formation. Many of the early studies in this field used immobilized patients as a surrogate to a micro-gravity environment to mimic the bone demineralization that could occur in space in order to measure changes in urinary parameters. Dr. Peggy A. Whitson (1960-), is a biochemistry researcher and former NASA astronaut. She carried out multiple studies examining renal stone risk during short term space shuttle flights and later during long-duration Shuttle-Mir missions. CONCLUSION: From the early vision of Dr. Cockett to the astronaut studies of Dr. Whitson, we have a better understanding of the risks of urolithiasis in space, resulting in preventive measures for urolithiasis in future long duration space exploration.

Validation of a Full-Immersion Simulation Platform for Percutaneous Nephrolithotomy Using Three-Dimensional Printing Technology.

INTRODUCTION AND OBJECTIVES: The restriction of resident hours with an increasing focus on patient safety and a reduced caseload has impacted surgical training. A complex and complication prone procedure such as percutaneous nephrolithotomy (PCNL) with a steep learning curve may create an unsafe environment for hands-on resident training. In this study, we validate a high fidelity, inanimate PCNL model within a full-immersion simulation environment. METHODS: Anatomically correct models of the human pelvicaliceal system, kidney, and relevant adjacent structures were created using polyvinyl alcohol hydrogels and three-dimensional-printed injection molds. All steps of a PCNL were simulated including percutaneous renal access, nephroscopy, and lithotripsy. Five experts (>100 caseload) and 10 novices (<20 caseload) from both urology (full procedure) and interventional radiology (access only) departments completed the simulation. Face and content validity were calculated using model ratings for similarity to the real procedure and usefulness as a training tool. Differences in performance among groups with various levels of experience using clinically relevant procedural metrics were used to calculate construct validity. RESULTS: The model was determined to have an excellent face and content validity with an average score of 4.5/5.0 and 4.6/5.0, respectively. There were significant differences between novice and expert operative metrics including mean fluoroscopy time, the number of percutaneous access attempts, and number of times the needle was repositioned. Experts achieved better stone clearance with fewer procedural complications. CONCLUSIONS: We demonstrated the face, content, and construct validity of an inanimate, full task trainer for PCNL. Construct validity between experts and novices was demonstrated using incorporated procedural metrics, which permitted the accurate assessment of performance. While hands-on training under supervision remains an integral part of any residency, this full-immersion simulation provides a comprehensive tool for surgical skills development and evaluation before hands-on exposure.

Risk Factors for Readmission after Shock Wave Lithotripsy for Urinary Stones.

INTRODUCTION: Cost saving measures have put an increased emphasis on reducing complications and rehospitalization. We analyzed the rate of readmission and presentation to emergency departments within 90 days of shock wave lithotripsy to identify prognostic risk factors for this outcome. METHODS: We retrospectively reviewed patients who underwent shock wave lithotripsy at our institution from January 2011 to May 2013 using the Modulith® SLX-F2 lithotripter for solitary ureteral or renal stones 2.0 cm or smaller. The primary outcome was readmission or presentation to the emergency department within 90 days. Secondary end points included stone-free rates at 30 and 90 days. Univariate and multivariate logistic regression analyses were performed to identify risk factors for primary and secondary outcomes. RESULTS: The study population consisted of 307 patients with renal and 270 with ureteral stones. Mean stone size was 9.2 mm. The 90-day readmission rate was 11.6%. Of analyzed metrics only urgency of procedure predicted readmission. Among patients who were readmitted renal colic was the most common chief complaint (67%), followed by infection (10%) and postoperative hematoma or hematuria (7.5%). Stone-free rates were 57% and 78% at 30 and 90 days, respectively. Stone size and nonurgent shock wave lithotripsy status predicted stone-free status. CONCLUSIONS: The 90-day readmission rate following shock wave lithotripsy was 11.6%. Urgency of shock wave lithotripsy was predictive of this outcome. Stone centers should monitor their readmission rates following shock wave lithotripsy to establish national standards and guide decision making when considering other endourological methods if these outcomes are considered unacceptable.

Spontaneous Ureteral Urine Extravasation From Invasion of a High-grade Angiosarcoma.

A 69 year-old male with a past medical history of hypertension, diabetes, and atrial fibrillation presented to the Urology clinic with asymptomatic microscopic hematuria. His work up for hematuria included a negative cystoscopy and a computed tomography (CT) scan, which revealed what appeared to be a fluid collection around the left kidney with a perinephric infiltrative mass and two para-aortic enlarged lymph nodes.

Perineal Pseudoaneurysm from Traumatic Foley Removal Leads to Recurrent Life-Threatening Hematuria.

Hematuria resulting from urethral traumatic catheter insertion and removal is often encountered. Usually, hematuria resolves with conservative measures. We report a case of traumatic Foley removal leading to intermittent life-threatening hematuria resulting in blood loss anemia requiring multiple transfusions and multiple episodes of hypotension requiring pressors. A pelvic angiogram revealed a pseudoaneurysm of the left pudendal artery, which was treated with microcoil embolization leading to resolution of bleeding.

Androgen receptor enhances kidney stone-CaOx crystal formation via modulation of oxalate biosynthesis & oxidative stress.

Males develop kidney stones far more frequently than females with a ratio of 2-3:1, suggesting that androgen receptor (AR) signaling might play a key role in the development of nephrolithiasis. Using the cre-loxP system to selectively knock out AR in glyoxylate-induced calcium oxalate (CaOx) crystal mouse models, we found that the mice lacking hepatic AR had less oxalate biosynthesis, which might lead to lower CaOx crystal formation, and that the mice lacking kidney proximal or distal epithelial AR also had lower CaOx crystal formation. We found that AR could directly up-regulate hepatic glycolate oxidase and kidney epithelial NADPH oxidase subunit p22-PHOX at the transcriptional level. This up-regulation might then increase oxalate biosynthesis and oxidative stress that resulted in induction of kidney tubular injury. Targeting AR with the AR degradation enhancer ASC-J9 led to suppression of CaOx crystal formation via modulation of oxalate biosynthesis and oxidative stress in both in vitro and in vivo studies. Taken together, these results established the roles of AR in CaOx crystal formation.

Near infrared fluorescence imaging after intravenous indocyanine green: initial clinical experience with open partial nephrectomy for renal cortical tumors.

OBJECTIVE: To evaluate the safety of near infrared fluorescence (NIRF) of intravenously injected indocyanine green (ICG) during open partial nephrectomy, and to demonstrate the feasibility of this technology to identify the renal vasculature and distinguish renal cortical tumors from normal parenchyma. METHODS: Patients undergoing open partial nephrectomy provided written informed consent for inclusion in this institutional review board-approved study. Perirenal fat was removed to allow visualization of the renal parenchyma and lesions to be excised. The patients received intravenous injections of ICG, and NIRF imaging was performed using the SPY system. Intraoperative NIRF video images were evaluated for differentiation of tumor from normal parenchyma and for renal vasculature identification. RESULTS: A total of 15 patients underwent 16 open partial nephrectomies. The mean cold ischemia time was 26.6 minutes (range 20-33). All 14 malignant lesions were afluorescent or hypofluorescent compared with the surrounding normal renal parenchyma. NIRF imaging of intravenously injected ICG clearly identified the renal hilar vessels and guided selective arterial clamping in 3 patients. No adverse reactions to ICG were noted, and all surgical margins were negative on final pathologic examination. CONCLUSION: The intravenous use of ICG combined with NIRF is safe during open renal surgery. This technology allows the surgeon to distinguish renal cortical tumors from normal tissue and highlights the renal vasculature, with the potential to maximize oncologic control and nephron sparing during open partial nephrectomy. Additional study is needed to determine whether this imaging technique will help improve the outcomes during open partial nephrectomy.

Modifications to facilitate extraperitoneal robot-assisted radical prostatectomy post kidney transplant.

INTRODUCTION: Renal transplantation is the treatment of choice for patients with end-stage renal failure. With advances in immunosuppression, the short-term and long-term outcome has improved significantly. Subsequently, urologists are encountering more transplant recipients with genitourinary malignancies, and therefore urologists are becoming increasingly compelled to offer curative treatment options. MATERIALS AND METHODS: We present modifications to facilitate E-RARP in these patients that include modified trocar arrangement, delayed bladder neck transection, utilizing the robotic Hem-o-lok applier, and posterior reconstruction of the anastomosis using a barbed V-loc suture. A 68-year-old male with a history of polycystic kidney disease, end-stage renal failure, and an allograft renal transplantation in the right iliac fossa, presented with T1c, Gleason 3+4 prostate cancer. He had a preoperative PSA of 6.93ng/mL, ASA score of 3, and a BMI of 26kg/m2. Follow-up for metastasis (MRI and bone scan) was negative. E-RARP was performed via the extraperitoneal approach using a 5-port 2-arm approach at an insufflation pressure of 10 mm Hg. RESULTS: The radical prostatectomy was successfully performed. Ureterovesical anastomosis was completed, and total console time was 130 minutes, with an estimated blood loss of 125mL. Final pathology was T2bNx, Gleason 3+4 with negative surgical margins. The patient was discharged with no change in serum creatinine or GFR. The catheter was removed on POD 10 with no intraoperative or immediate postoperative complications. CONCLUSION: E-RARP in the carefully selected renal allograft recipient is feasible and accomplished safely with technical modifications to avoid injuring the renal allograft, transplanted ureter, and ureteroneocystostomy.

Robot-assisted partial nephrectomy: analysis of the first 100 cases from a single institution.

Robot-assisted partial nephrectomy (RAPN) is an alternative to open and laparoscopic partial nephrectomy for small renal tumors. Our objectives were to report our experience and short-term outcomes from the first 100 cases of robot-assisted partial nephrectomy (RAPN) performed at a single institution, as well as to evaluate the effect of the learning curve and identify any factors associated with adverse perioperative outcomes. Patient records of the first 100 RAPN cases performed by three surgeons between October 2007 and March 2010 were retrospectively reviewed. The cases were divided into two groups to analyze a possible learning curve effect. Group 1 consisted of the first half (chronologically) of the cases performed by each surgeon, and Group 2 consisted of the second half. For the entire series, the median warm ischemia time was 24 min (range 11-49), mean length of follow-up was 13.4 months, and the median postoperative change in glomerular filtration rate (GFR) was -6.6 mL/min/1.73 m(2). Three patients had microscopically positive margins on final pathology, three intraoperative complications occurred, and 13 postoperative complications were recorded (10 Clavien grade IIIa or less). Median operative time was significantly longer in Group 1 (193 min) than in Group 2 (165 min, P = 0.003). Multivariate analysis identified male gender and cases done in Group 1 to be associated with increased operative time, while male gender and higher nephrometry scores were associated with increased blood loss. Tumor characteristics associated with greater reductions in GFR included higher nephrometry scores, endophytic tumors, and hilar tumors. In conclusion, RAPN appears to be safe and the major effect of the learning curve appears to be on operative time. Warm ischemia times are sufficiently low to prevent significant renal impairment, while male gender and higher nephrometry scores may be predictors of longer operative times and more intraoperative blood loss. Overall operative time decreased with increasing case volume, although this was not uniform among the three surgeons in the study. Further longitudinal study is necessary to establish oncologic outcomes.

Role of frozen section analysis of testicular/paratesticular fibrous pseudotumours: a five-case experience.

BACKGROUND: Fibrous pseudotumours of the testicular and paratesticular tissues are fibroinflammatory reactive lesions that can clinically mimic neoplasms. Very little is known about the role of frozen section analysis (FSA) for these lesions in terms of intraoperative surgical management. METHODS: We recently experienced 5 patients with testicular/paratesticular fibrous pseudotumours in whom frozen sections were used to demonstrate its non-neoplastic nature prior to the decision for radical surgery. RESULTS: In 2 cases, FSA resulted in testicular-sparing surgery. In contrast, the remaining 3 cases ultimately underwent radical orchiectomy, due to questionable viability of the testicle involved by inflammatory/infiltrative lesions and in 1 case a slight possibility of lymphoproliferative malignancy. CONCLUSION: Urologists should be aware of this entity and its gross features, such as firm masses and diffuse fibrous proliferation encasing the testicle to help determine intraoperative management. In select cases, intraoperative FSA is helpful in obviating radical orchiectomy.

Ergonomic evaluation and guidelines for use of the daVinci Robot system.

INTRODUCTION: The daVinci Robot system has been widely lauded for its improved ergonomic characteristics when compared with the pure laparoscopic technique. Our goal in this study was to assess for the existence of guidelines to maximize the ergonomic benefits of the daVinci system. We also compared the surgeon's console with the recommendations of similar workstations. METHODS: A literature review of seated ergonomics was performed to identify recommendations for work areas similar to the robotic system, where prolong seating is necessary. An upper body biomechanics and ergonomic expert was consulted to evaluate the daVinci system and aid in the formation of ergonomic positioning guidelines. Link-length proportions were used to evaluate size constraints of potential robot operators. RESULTS: No published guidelines exist for proper positioning using the daVinci surgeon console. There are, however, several Occupational Safety and Health Administration workstation guidelines as well as microscope ergonomic guidelines. The use of link-length proportions showed that the surgeon console allows a comfortable posture for individuals with height between 64 and 73 inches. Review of the microscope ergonomics literature indicates that a neutral vertical seating position has been associated with decreased strain and musculoskeletal disorders. CONCLUSIONS: The body mechanics of the daVinci robot system best mimics that of microscopy. Future surgeon console modifications could emulate those reported in the microscope ergonomic literature, where a neutral vertical position has been recommended. This may help avoid potential musculoskeletal disorders similar to those previously seen with microscopy usage. Guidelines are suggested to optimize the surgeon's console position.

Bowel displacement for CT-guided tumor radiofrequency ablation: techniques and anatomic considerations.

PURPOSE: To describe safety and efficacy of bowel displacement techniques and determine lesion characteristics that are likely to necessitate bowel displacement. PATIENTS AND METHODS: A retrospective review of patients who underwent CT-guided renal tumor radiofrequency ablation (RFA) (January 2006-August 2008) was conducted. Techniques included hydrodissection, additional manual torquing of the RFA probe, and additional angioplasty balloon interposition. The goal was to displace bowel from the probe by at least 10 to 20 mm. Air-filled balloon interposition was intended as a thermal barrier. Pre- and postbowel displacement distances were measured by CT. Saline volumes were recorded. Multivariate stepwise regression analysis was used to determine the influence of laterality, renal location, and morphology of renal lesions on their proximity to the colon and use of bowel displacement techniques. RESULTS: RFA was performed on 57 consecutive patients. Eleven (19%) patients had bowel displacement attempts. Median pre-RFA lesion edge to colon distance for nondisplaced vs displaced was 43 mm (range 10-100 mm) vs 6 mm (range 0-16 mm), respectively (P < 0.05). Two variables were significant for bowel displacement (F-ratio = 4.681, P = 0.006): Tumor position within the kidney in the craniocaudal plane (P = 0.014) and anterior-posterior plane (P = 0.007). Lower pole and posterior lesions tended to be closer to the colon and more likely to necessitate bowel displacement. Orientation in the medial-lateral plane (P = 0.77) and exophytic nature of the lesion (P = 0.83) were not significant features. Hydrostatic bowel displacement was always the first-line technique and was completely and partly successful in 8 (73%) and 1 (9%) attempts, respectively. Partial success was augmented by probe torquing (distance increased from 1 mm to 16 mm and then to 23 mm with torquing). Mean saline injection: 105 mL (range 55-440 mL). There were two complete failures (18%) in which bowel was displaced only by 0 to 2 mm despite injection of 280 to 440 mL. Balloon interposition was attempted in these two cases. Five minor complications occurred in the nondisplaced cohort. No complications occurred in the bowel displacement cohort. CONCLUSION: Lower pole, posterior renal lesions are more likely to necessitate bowel displacement. Bowel displacement techniques are effective and safe in displacing bowel.

Evaluation and management of post-shock wave lithotripsy pain with third-generation lithotriptors using rofecoxib.

INTRODUCTION: Newer generation lithotriptors have been modified to induce less pain. We evaluated factors contributing to post-shock wave lithotripsy (SWL) pain and assessed potential benefits of preemptive analgesia using Rofecoxib, a COX-II inhibitor, and potential effects on stone passage rates. MATERIALS AND METHODS: Sixty-nine patients were evaluated. Thirty-eight percent were women and 62% men, with a mean age of 53. Seventy-four patients treated using Dornier lithotriptor-50 were enrolled in a prospective, double-blind, randomized study. The study group received 50 mg of rofecoxib 1 hour before extracorporeal shockwave lithotripsy (ESWL) and 24 hours later. The control group received no pretreatment medications. All patients were discharged with narcotic medications and contacted on postoperative days (POD) 1, 3, and 7. Questionnaires were administered to assess pain control using a numeric pain scale. RESULTS: Seventy-two percent had renal stones, and 28% ureteral, with a mean size of 10 mm. The mean pain score was 4.2 immediately after SWL, 3.4 on POD 1, 1.9 on POD 3, and 0.6 on POD 7. Multivariate analysis revealed a significant decrease in pain with time (p < 0.0001). Patients with severe pain before SWL had more pain after treatment (p = 0.003). Older patients had less pain post-SWL (p = 0.045). Pretreatment with Rofecoxib significantly reduced post-SWL pain from 5.04 to 4.03 (p < 0.0001). Other variables had no effect on posttreatment pain. CONCLUSIONS: Pain after SWL is moderate to severe using third-generation lithotriptors and is significantly reduced by POD 3. Younger patients and those with significant pretreatment pain had more pain after treatment. Preemptive Rofecoxib reduced post-SWL pain, but had no impact on stone passage.

Subcapsular hepatic hematoma with right hepatic vein thrombosis: a complication of shock wave lithotripsy.

Extracorporeal shock wave lithotripsy (ESWL) is a well-established, safe and effective therapeutic modality for surgical treatment of urolithiasis. Hematoma is a rare complication of ESWL and, when it occurs, typically involves the kidney. We report the case of a 71-year-old woman who developed severe, persistent abdominal pain after ESWL for a 9-mm stone at the ureteropelvic junction. Post-treatment CT scan demonstrated a 13 x 6-cm subcapsular hepatic hematoma. A follow-up CT scan showed expansion of the hematoma and development of hepatic vein thrombosis. This finding, along with persistent abdominal pain and rising liver transaminases, led to surgical intervention. The patient's symptoms resolved and liver function returned to baseline following liver decompression.

Sensitivity and specificity of 24-hour urine chemistry levels for detecting elevated calcium oxalate and calcium phosphate supersaturation.

OBJECTIVES: The gold standard for determining likelihood of calcium oxalate (CaOx) and calcium phosphate (CaPhos) stone formation in urine is supersaturation of CaOx and CaPhos. Our objective was to investigate whether traditional measurement of total calcium, oxalate and phosphate in a 24-hour urine collection is sufficiently sensitive and specific for detecting elevated supersaturation to preclude the more expensive supersaturation test. METHODS: We performed a retrospective review of 150 consecutive patients with nephrolithiasis who underwent measurement of CaOx supersaturation (CaOxSS) and CaPhos supersaturation (CaPhosSS), as well as total calcium, oxalate and phosphate in a 24-hour urine collection. We used various cut-off values to determine sensitivity and specificity of 24-hour urine measurements for detecting elevated CaOxSS and CaPhosSS. RESULTS: In men and women, the sensitivity of 24-hour calcium for detecting elevated CaOxSS was 71% and 79%, respectively; for oxalate, sensitivity was 59% and 36%, respectively. In men and women, the sensitivity of 24-hour calcium for detecting elevated CaPhosSS was 74% and 88%, respectively; for phosphate, sensitivity was 57% and 8%, respectively. In men and women, the specificity of 24-hour calcium for detecting elevated CaOxSS was 55% and 48%, respectively; it was 60% for detecting elevated CaPhosSS in both men and women. CONCLUSION: Traditional 24-hour urine analysis is sensitive, but not specific, for detecting elevated CaOxSS and CaPhosSS. Most patients with abnormal 24-hour urine analysis have normal supersaturation, and treatment decisions based on traditional urine analysis would lead to overtreatment in these patients.

Factors associated with ureteral burn injury from an electrified guidewire.

PURPOSE: During ureteroscopic procedures, electrocautery is often utilized in the presence of an intra-ureteral guidewire. Inadvertent electrification of the guidewire may occur if the active electrode comes into contact with the guidewire, potentially resulting in a ureteral burn injury. This study investigates under what conditions electrification of a ureteral guidewire would result in ureteral burn injury. MATERIALS AND METHODS: Porcine kidney/ureter units were tested in a saline bath using a guidewire within the ureter. The collecting system was filled with either saline or water and the guidewire was electrified with varying power and mode settings. The contact area between the wire and ureter was adjusted to 1/2 or 1/4 of the total ureteral length. The ureters were then inspected for evidence of burn injury microscopically by a pathologist in a blinded fashion. RESULTS: Ten kidney/ureter units were tested. Four units were filled with saline and none of these demonstrated any burn injury. Six kidney/ureter units were filled with water prior to electrification of the wire. Small amounts of burned tissue were noted in those with the full length of the ureter exposed. Moderate to severe burning was present in those with 1/2 of the ureter exposed. Ureters exposed to 120-W cutting current had more injury than those exposed to 80-W coagulation current. CONCLUSIONS: Inadvertent electrification of a ureteral guidewire does not necessarily result in ureteral burn injury. The presence and extent of ureteral injury depends primarily on the irrigating fluid used, as well as the amount of ureter exposed to the electrified guidewire.

Is there a proper pelvic size for an extraperitoneal robot-assisted radical prostatectomy?

BACKGROUND: A narrow pelvis can potentially complicate an extraperitoneal radical robot-assisted prostatectomy (RAP). We report our experience with RAP and evaluate whether a narrow pelvis can affect treatment outcomes after extraperitoneal RAP. MATERIALS AND METHODS: We prospectively evaluated 50 patients who underwent RAP during a 2-month period using the extraperitoneal approach. To approximate the relative size of the field available for working using the extraperitoneal approach, the arc length between the anterior superior iliac spines was estimated with the umbilicus as the center of the circle. Patients with an arc length measuring <33 cm were compared with those with an arc length > or =33 cm. Additional parameters evaluated included age, total operating time, estimated blood loss, prostate-specific antigen (PSA) level, pathological stage and Gleason grade, intraoperative and perioperative complications, surgical margin status, and continence at 3 months. RESULTS: Twenty-eight (56%) patients had an arc length <33 cm and twenty-two (44%) patients had an arc length > or =33 cm. When comparing the two groups, no statistically significant difference (P > 0.05) was noted in age, PSA level, blood loss (161 v 163 mL), operative time (174 v 176 min), and total positive margin rates (14% v 13.6%). The continence rate at 3 months was 66.6% and equal for both groups. CONCLUSION: In our experience, a narrow pelvis did not significantly affect operative outcome in patients undergoing an extraperitoneal radical RAP. Although this variable should be taken into account, it should not be a primary factor in deciding the route of access.

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate ED, 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.

Impact of prostate size in robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: A large prostate can complicate an extraperitoneal robot-assisted radical prostatectomy (RARP). We report our experience with RARP and evaluate the effects of prostate size on treatment outcomes after extraperitoneal RARP. PATIENTS AND METHODS: Information on 355 consecutive patients undergoing extraperitoneal RARP was gathered, and patients with prostate weight <75 g (N = 319) were compared with those having glands >or=75 g (N = 36). The factors considered were age, body mass index, total operating time, estimated blood loss, serum prostate specific antigen (PSA) concentration, pathologic stage and Gleason grade, intraoperative and peri-operative complications, margin status, and continence. RESULTS: A statistically significant difference (P < 0.05) was noted in age (59 v 64 years), PSA concentration (6.07 v 8.9 ng/dL), and blood loss (175 v 226 mL) between patients with smaller v larger prostates. No difference was seen in Gleason score (6 v 6), clinical T stage, operative time (217 v 225 minutes), or total positive-margin rate (13% v 19%). A higher positive-margin rate was seen in patients with stage T(3) disease and larger prostates. The 6-month continence rate in patients with a prostate volume < 75 g was 97% v 84% in patients with larger prostate volumes ( P < 0.05). CONCLUSION: Although a large prostate volume is associated with a slight increase in short-term urinary complications postoperatively, it should not be considered a contraindication for the experienced surgeon. This higher risk raises the question of a possible need for longer catheterization in this subset of patients.