Robotic management of benign mid and distal ureteral strictures and comparison with laparoscopic approaches at a single institution.

OBJECTIVE: To present our experience and outcomes with robotic mid and distal ureteral reconstruction and to compare these results with our previous laparoscopic series. METHODS: In an institutional review board-approved retrospective study, 16 patients underwent robotic mid and distal ureteral repair (13 ureteral reimplantations and 3 ureteroureterostomies) at our institution from August 2008 to September 2011. Proximal ureteral stricture, extrinsic obstruction, and ureteropelvic junction obstruction cases were excluded. The demographic, perioperative, and postoperative data were reviewed in the reimplantation and ureteroureterostomy robotic groups. These data were compared with the outcomes from our previously published series on laparoscopic ureteral reimplantation. RESULTS: The data from 16 robotic procedures were included in the present study, including 2 open conversions because of excessive scar tissue. A symptomatic bowel injury (Clavien grade IIIb) occurred in 1 case. In our previous series, 5 of the 6 laparoscopic procedures were performed completely laparoscopically with 1 open conversion for anastomosis completion. No major complications occurred. The mean robotic surgery time was 258.6 minutes (range 146-450) compared with 276.5 minutes (range 180-360) for the laparoscopic group. The mean robotic hospital stay was 2.5 days (range 1-8) compared with 2.7 days (range 2-5) for the laparoscopic group. The mean robotic estimated blood loss was 171 mL (range 30-500) compared with 150 mL (range 50-250) for the laparoscopic group. All cases were clinically and radiographically successful at the last follow-up examination. CONCLUSION: Although early in our experience, the robotic repair of mid and distal ureteral strictures appears to be an efficacious approach comparable to laparoscopy for such conditions.

Report of aggressive renal cell carcinoma in two patients with von Hippel-Lindau disease.

Renal cell carcinoma is relatively common in patients with von Hippel-Lindau disease, yet characteristically follows a less aggressive course compared with sporadic renal cell carcinoma. We report on 2 patients with von Hippel-Lindau disease and atypically aggressive renal tumors. In these patients, more rigorous screening guidelines may help to identify the more aggressive variants.

The fate of the medically castrated testis: expectation versus reality.

PURPOSE: Cosmetic expectation has a major role in influencing patient choice between medical and surgical castration, and yet to our knowledge the fate of the medically castrated testis has never been accurately tested and documented in the literature. We determined the weight of testes in patients receiving medical castration and compared it to that in a control group receiving primary surgical castration. MATERIALS AND METHODS: We performed a retrospective analysis of 88 patients with prostate cancer who underwent bilateral simple orchiectomy with epididymal sparing. The study was done at Veterans Administration Medical Center, Atlanta, Georgia. All procedures were performed using local anesthesia in an outpatient clinical setting. Patients were divided into 2 groups, namely 52 receiving luteinizing hormone releasing hormone (LH-RH) agonist therapy prior to the procedure and 36 controls who were not. The weight of the testes was compared between the 2 groups. RESULTS: Median testicular weight significantly decreased following treatment with LH-RH agonist compared to the control group. Median weight of the testis was 7.0 gm (range 0.5 to 22.0) in the LH-RH agonist group compared to 15 gm (range 4.0 to 44.0) in the control group (p = 0.0049 x 10). CONCLUSIONS: Medical castration with LH-RH agonist therapy significantly decreases the weight of testes and compromises the cosmetic outcome. Since cosmetic expectation has a major role in influencing patient choice between medical and surgical castration, patients should be fully informed about the significant testicular atrophy associated with medical castration before making their decision.

Donor nephrectomy: A comparison of techniques and results of open, hand assisted and full laparoscopic nephrectomy.

PURPOSE: Laparoscopic donor nephrectomy (LAP) has been gaining more popularity among kidney donors and transplant surgeons. There have been some concerns about the function of kidney grafts harvested by laparoscopic procedures. We report our results of LAP. MATERIALS AND METHODS: Prospective data were collected for our donor nephrectomy operations. A telephone survey was done by an independent investigator on the impact of surgery on quality of life. Graft function was also evaluated by serial serum creatinine and mercaptoacetyltriglycine renal nuclear scans. RESULTS: A total of 100 patients were included in the study; of whom 55 underwent open donor nephrectomy (OD), 28 underwent LAP and 17 underwent hand assisted donor nephrectomy (HAL). Mean patient age was 39 +/- 12 years and it was similar in all groups. Mean operative time was 306 +/- 40 minutes for LAP, 294 +/- 42 minutes for HAL and 163 +/- 24 minutes for OD (p = 0.001). Laparoscopic operative time was decreased to 180 +/- 56 minutes for LAP and 155 +/- 40 minutes for HAL in the last 10 patients. Mean estimated blood loss was 200 +/- 107 cc for LAP, 167 +/- 70 cc for HAL and 320 +/- 99 cc for OD (p = 0.0001). Mean warm ischemia time was 3 +/- 2 minutes for LAP, 2 +/- 2 minutes for HAL and 2 +/- 1 minutes for OD (p = 0.002). Postoperative hospitalization was 2 +/- 2 days for LAP and 3 +/- 2 days for OD (p = 0.01). LAP required 30% less narcotic medicine than OD postoperatively (p = 0.04). There were no major complications in LAP cases and no complete or partial graft loss was noted. Mean followup was 7 months. Recipient creatinine was not significantly different for kidneys harvested by LAP or OD (p = 0.5). Diuretic mercaptoacetyltriglycine renograms were performed in all recipients 1 to 3 days after surgery and mean effective renal plasma flow was similar for the 3 groups (p = 0.9). According to telephone survey results 85% of LAP, 71% of HAL and 43% of OD patients reported a return to normal physical activity within 4 weeks after surgery. Similarly 74% of LAP, 62% of HAL and 26% of OD patients were able to return to work within 4 weeks after surgery. CONCLUSIONS: Our data show no significant difference in graft function between LAP and OD. LAP and HAL were safe and complications were minimal. The main difference was that patients treated with LAP and HAL returned to normal physical activity and work significantly earlier than those who underwent OD.