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.

The impact of robotics on treatment of localized prostate cancer and resident education in Rochester, New York.

BACKGROUND AND PURPOSE: Robot-assisted radical prostatectomy (RARP) has been performed in Rochester, NY, since 2003. Currently, 10 area urologists perform RARP, and robotic training has become an important component of the residency. We present data describing the timeline for adoption, both in clinical practice and in the residency program. MATERIALS AND METHODS: We reviewed the operating logs for all surgeons who were performing prostatectomies in all hospitals in Rochester, NY, from 2003 to 2007. We examined the influence RARP had on other treatments, including brachytherapy and cryotherapy. Surgical logs of graduating chief residents were also reviewed. RESULTS: Eleven surgeons in Rochester regularly perform radical prostatectomy (10 perform primarily RARP, one performs only open prostatectomy). Three of the city's four hospitals have robotic systems. In 2003-2004, there were 30 open prostatectomies performed monthly and fewer than 10 performed robotically. By 2006, the trend was reversed, with 50 robot-assisted prostatectomies performed each month and fewer than 10 open prostatectomies (P<0.05). The rate of brachytherapy fluctuated, increasing in centers without a robot. The number of open prostatectomies in centers without a robot dropped significantly to fewer than 10 cases per year. There was also a significant decrease in the number of open prostatectomies performed by chief residents. CONCLUSIONS: Since the introduction of surgical robotics, significant changes have been seen. The volume of radical prostatectomies performed by surgeons at institutions with robotics has increased; the volume at robot-free institutions has become nominal. There is a trend toward increased radiation therapy at robot-free institutions. While radical prostatectomies logged by graduating chief residents have increased, open prostatectomy experience is now minimal.

Long-term outcome of patients with a negative work-up for asymptomatic microhematuria.

OBJECTIVES: To assess the validity of the American Urological Association guidelines, we investigated 14-year outcomes of men aged > or = 50 years who had hematuria detected in a bladder cancer (BC) screening trial, were thoroughly evaluated, and were not found to have urological cancers. The American Urological Association guidelines for follow-up of adults with asymptomatic microhematuria (MH) who have negative evaluations include repeat urinary cytologies, urinalyses, and office visits for several years, primarily to detect BC (Cohen and Brown, N Engl J Med 348: 2330-2338, 2003; and Grossfeld et al, Urology 57:604-610, 2001). METHODS: Of 1575 screening participants, 258 had MH detected by daily home testing with the Ames hemastix during two 14-day periods. This test has been shown to accurately reflect MH on microscopic urinalysis when each is correctly performed. Any man with at least 1 positive test (> or = "trace") underwent a complete evaluation including microscopic urinalysis, culture, cytology, complete blood count, serum creatinine, coagulation profile, intravenous urography or computed tomography scan, and cystoscopy. BC or other urological tumors was not detected in 234 participants. Using Wisconsin state tumor registry and death certificate data, the outcomes of these men were tracked for 14 years since their last testing. RESULTS: Two of the 234 men (0.85%) developed BC during the 14-year follow-up, at 6.7 and 11.4 years after their negative evaluations; one died of BC 7.6 years after his last screening. During this follow-up, 0.93% of the screenees who tested negatively for hematuria had BC diagnosed, none within a year of their last testing date. CONCLUSIONS: Patients who have negative complete evaluations for asymptomatic MH have little chance of subsequently developing BC. The recommended "appropriate" follow-up for these patients may require reconsideration in light of these data.

Treatment of nonmuscle invading bladder cancer: do physicians in the United States practice evidence based medicine? The use and economic implications of intravesical chemotherapy after transurethral resection of bladder tumors.

BACKGROUND: Phase 3 clinical trials performed primarily outside the US demonstrate that intravesical instillation of chemotherapy immediately after transurethral resection of the bladder (TURB) decreases cancer recurrence rates. The authors sought to determine whether US urologists have adopted this practice, and its potential effect on costs of bladder cancer (BC) care. METHODS: By using 1997-2004 MEDSTAT claims data, the authors identified patients with newly diagnosed BC who underwent cystoscopic biopsy or TURB, and those who received intravesical chemotherapy within 1 day after TURB. Economic consequences of this treatment compared with TURB alone were modeled using published efficacy estimates and Medicare reimbursements. The authors used a time horizon of 3 years and assumed that this treatment was given for all newly diagnosed low-risk BC patients. RESULTS: Between 1997 and 2004, the authors identified 16,748 patients with newly diagnosed BC, of whom 14,677 underwent cystoscopic biopsy or TURB. Of these, only 49 (0.33%) received same-day intravesical instillation of chemotherapy. From 1997 through 2004, there has been little change in the use of this treatment. The authors estimated a 3-year savings of $538 to $690 (10% to 12%) per patient treated with TURB and immediate intravesical chemotherapy compared with TURB alone, reflecting a yearly national savings of $19.8 to $24.8 million. CONCLUSIONS: Instillation of intravesical chemotherapy immediately after TURB has not been embraced in the US. Adopting this policy would significantly lower the cost of BC care.

Grade and stage at presentation do not predict mortality in patients with bladder cancer who survive their disease.

PURPOSE: Our goal was to determine whether presenting grade and stage of bladder cancer (BC), which directly affect disease-specific survival, also influence time to and cause of non-BC deaths. METHODS: Histology slides of all men who lived in Wisconsin age > or = 50 years diagnosed with BC in 1988 were reviewed centrally, and time and cause of death as reported to the state's tumor registry were recorded. Competing risks analyses based on grade, tumor stage, and age at diagnosis were generated to correlate time and causes of death (BC or non-BC) with tumor histology and age at presentation. RESULTS: Grade-stage categories were assigned to 509 patients with BC as follows: LGN = low grade (grade 1 or 2), nonmuscle invading (stage Ta or T1); HGN = high grade (grade 3 or carcinoma in situ), nonmuscle invading (stage Ta, T1, or TIS); and INV = any grade, muscle invasive (> or = stage T2). Three hundred nine patients (60.7%) were LGN, 80 (15.7%) were HGN, and 120 (23.6%) were INV. Grade-stage category predicted overall (P = .0001) and BC-specific (P < .0001) mortality but not non-BC mortality (P = .72), with hazard ratios of 1.095 (95% CI, 0.783 to 1.531) for HGN versus LGN, 1.137 (95% CI, 0.799 to 1.617) for INV versus LGN, and 1.038 (95% CI, 0.670 to 1.607) for INV versus HGN. Age had a highly significant effect on overall and non-BC deaths (P < .0001) but only marginally predicted BC deaths (P = .054). Time to non-BC death did not differ significantly between grade-stage category (P = .12) or cause of death (P = .81). CONCLUSION: Grade-stage category at diagnosis predicts overall and BC mortality but not mortality from other causes. Thus, particularly for INV disease, because BC represents the major threat to life, aggressive therapies that have been shown to be effective are justified.

Long-term outcome of home dipstick testing for hematuria.

The most common symptom of bladder cancer (BC) is hematuria and microhematuria will occur in virtually all patients with BC if one tests for it frequently enough. However, hematuria even when caused by serious disease, often is intermittent, and once above some threshold the degree of microhematuria is unrelated to the seriousness of its underlying cause. Based on these principles a BC screening study was conducted to determine if repetitive hematuria testing can detect BC early and whether this resulted in reduced BC mortality, in long-term follow-up compared with disease related outcomes of a contemporary unscreened population similar to the one taking part in screening. The study and the long-term outcomes are reviewed. At 14 years minimum follow-up, none of the 21 men diagnosed with BC by hematuria screening have died of the disease; 12 were still alive and 9 had died of diseases other than BC, with a median survival of 8.8 years. The lower overall mortality in screenees with BC was primarily because of the reduced mortality from BC in that group. Screening had effected a shift of the high grade tumors to earlier (more superficial) stages at diagnosis.

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.

Current state of screening for bladder cancer.

Bladder cancer is the fourth most commonly diagnosed cancer in men and the eighth most common cancer in women in the USA. Efforts to reduce mortality from bladder cancer must focus on three areas: prevention, development of effective therapies for muscle-invasive and metastatic disease, and early detection of potentially invasive lesions while they are still superficial and amenable to less morbid, but still effective, treatments. As more effective therapies for metastatic transitional cell carcinoma are not on the immediate horizon and preventive measures (except for smoking cessation) have been disappointing, if we are to reduce this disease's morbidity and mortality rates significantly, early detection strategies need to be improved and implemented. The goal of screening for any type of cancer is to detect the disease in its early stages in order to increase the chances for cure or prolongation of life (before micro or gross metastases occur). Since all patients who die of bladder cancer do so from metastases and since almost all patients with metastases have muscle-invading cancers appearing as the first bladder cancer event, diagnosing cancers destined to become muscle invading before they actually are should reduce bladder cancer mortality. This special report reviews the current state of bladder cancer screening in the USA.

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.

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 erectile dysfunction (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.

Transition from open to robotic-assisted radical prostatectomy is associated with a reduction of positive surgical margins amongst private-practice-based urologists.

Several recent studies have suggested that thought leaders in radical prostatectomy have decreased their own positive margin rates by switching from open to robot-assisted radical prostatectomy. Theoretically, this improvement is largely attributed to enhanced visualization of the deep pelvis and precision of dissection afforded by the instrumentation. To date, it has not been determined if this phenomenon exists amongst non-fellowship-trained urologists in private practice. Herein, we describe the positive margin rates of two non-fellowship-trained private-practice urologists who converted from open radical retropubic prostatectomy to robot-assisted radical prostatectomy. The margin positivity data from two non-fellowship-trained private-practice urologists (surgeon 1 and surgeon 2) were reviewed retrospectively. The last 50 cases of open radical retropubic prostatectomy from each surgeon were compared with the first 50 robotic prostatectomy cases of surgeons 1 and 2, respectively. A positive surgical margin was defined as tumor present at the inked margin of the prostate. There was a significant decrease in the overall and pT2 positive margin rates for both surgeons. The overall positive margin rate and pT2 positive margin rate for surgeon 1 dropped from 44 to 20% and from 37 to 5.7%, respectively, after changing from open to robotic prostatectomy. For surgeon 2, the overall positive margin rate changed from 26 to 18% and the pT2 positive margin rate changed from 27.5 to 7% after converting. Changing from open to robotic-assisted radical prostatectomy may improve the ability of urologists to obtain negative surgical margins. With proper training this phenomenon does seem to apply to non-fellowship-trained urologists in private practice and can be realized within the first 50 cases performed.

Long-term outcome of hematuria home screening for bladder cancer in men.

BACKGROUND: The objectives of this study were to determine whether bladder cancer (BC) screening in healthy men could lead to earlier detection and reduced BC mortality compared with unscreened men and to determine long-term outcomes of a geographically defined, unscreened population with newly diagnosed BC. METHODS: In 1987 and from 1998 to 1992, 1575 men ages 50 years and older who were solicited from well patient rosters in clinics in and around Madison, Wisconsin, tested their urine repetitively with a chemical reagent strip for hemoglobin. Participants who had positive test results underwent standard urologic evaluation. BC grades and stages and the outcomes of men with BC detected by screening were compared with the grades, stages, and outcomes of 87% of men ages 50 years and older with newly diagnosed BC who were reported to the Wisconsin Tumor Registry in 1988 (n = 509 men). RESULTS: Two hundred fifty-eight screening participants (16.4%) were evaluated for hematuria, and 21 participants (8.1%) were diagnosed with BC. Proportions of low-grade (Grade 1 and 2) superficial (Stage Ta and T1) versus high-grade (Grade 3) superficial or invasive (Stage > or = T2) cancers in screened men (52.4% vs. 47.7%) and in men from the tumor registry (60.3% vs. 39.7%) were similar (P = .50). The proportion of high-grade superficial or invasive BCs that were invasive were lower in screened men (10%) than in unscreened men (60%; P = .002). At 14 years of follow-up, no men with screen-detected BC had died of BC, whereas 20.4% of men with unscreened BC had died of BC (P = .02). CONCLUSIONS: Screening effected the early detection of BC and may reduce mortality from BC compared with BC that is diagnosed at standard clinical presentation.

The use of robotically assisted surgery for treating urachal anomalies.

OBJECTIVE: To report the management of urachal anomalies using a robotically assisted approach. PATIENTS AND METHODS: Between January 2005 and February 2006, five patients (mean age 51 years, range 24-68) were diagnosed with urachal anomalies. Two basic robot-assisted surgical approaches were used for excising the urachal anomalies: excision of the urachal remnant via partial cystectomy, and radical cystectomy for excision of urachal adenocarcinoma. RESULTS: All five cases were successful and the excised specimens were assessed histologically. The short-term oncological outcome in the three patients with histologically confirmed moderately differentiated adenocarcinoma showed no evidence of recurrent disease within a median interval of 8 months. Surveillance follow-up cystoscopy in the patients who had a partial cystectomy showed a well-healed bladder mucosa with no evidence of recurrence. CONCLUSIONS: Radical excision of the urachal tract with partial cystectomy or radical cystectomy using the da Vinci robot is safe, effective and technically feasible.

Robot-assisted radical prostatectomy in obese patients.

OBJECTIVES: Few centers perform extraperitoneal robot assisted radical prostatectomy. The average patient weight is increasing to the mildly obese. Little is known as to the difficulty-impact, obesity may have on robot-assisted extraperitoneal prostatectomy (RAP). We assess our own experience with obese patients undergoing RAP. MATERIALS AND METHODS: Information on 375 consecutive patients undergoing robot-assisted extraperitoneal prostatectomy by a single surgeon was gathered. Obesity is defined as having a body mass index (BMI) greater than 30 kg/m2. Patients with BMI >/= 30 were compared to those with BMI < 30. Specific comparators between the groups were: age, total operating time, estimated blood loss, total prostate specific antigen (PSA), specimen weight, pathological stage, grade and margin, complications, and functional outcomes. RESULTS: Sixty-seven men were identified as obese. When comparing the two groups, no statistically significant difference (p > .05) was noted in operative time (229 versus 217 min), blood loss (205 versus 175 ml), PSA, clinical and pathologic stages, specimen weight, and complications. 15% of non-obese patients had a positive margin compared to 12% of obese patients (p > .05). The 6-month continence rate in patients with a BMI >/= 30 was 92% versus 97% in patients with a BMI < 30. CONCLUSIONS: The extraperitoneal approach to performing a robot-assisted prostatectomy is not associated with increased morbidity in the obese patient. There were no statistically significant differences noted in oncological or functional outcomes between the two groups.

Inflammatory myofibroblastic tumors.

INTRODUCTION: Inflammatory myofibroblastic tumors (IMT) while uncommon may arise within numerous organs. Historically, the literature regarding IMT has been confined to small one organ case series, with few reviews encompassing multiple anatomic sites, and little data regarding adjuvant treatment. METHODS: A review of patients with IMT treated at two large academic medical centers over a 15-year period was undertaken. Patient demographics, pathologic diagnoses, and pertinent clinical data were obtained. RESULTS: Forty-four cases of pathologically confirmed IMT were identified. Tumor locations included multiple anatomic sites. Therapies included complete resection, incomplete resection, observation, or chemotherapy, and/or radiation. Five patients underwent adjuvant chemotherapy and/or radiation therapy following surgery (14%) for local aggressiveness of the tumor, invasion, positive margins, or location of tumor that was not amenable to surgical resection. A second, concomitant, histologically distinct, neoplasm was identified in five cases. Of the patients who underwent treatment three local recurrences were noted (8%) and occurred in patients with partial resection without adjuvant chemo- or radiotherapy. CONCLUSIONS: Inflammatory myofibroblastic tumors may be a locally aggressive and destructive neoplasm. Tumor recurrence is unusual following complete surgical resection or organ-preserving combined modality therapy.

Povidone-iodine sclerotherapy is ineffective in the treatment of symptomatic renal cysts.

PURPOSE: To evaluate the efficacy of povidone-iodine sclerotherapy after percutaneous drainage of simple renal cysts in the treatment of symptomatic patients. PATIENTS AND METHODS: Sixteen patients with symptomatic renal cysts were treated by percutaneous drainage and injection of povidone-iodine solution. The cysts were drained by a nephrostomy tube catheter, and povidone- iodine injections were repeated every 24 hours for 3 days. All patients were followed up by ultrasound examination during a period ranging from 1 to 4 years (mean 1.8 years). RESULTS: Thirteen patients experienced recurrence of cysts, while complete resolution was observed in only three patients. Of the cysts that recurred, only partial resolution in cyst diameter was observed (from 3-10.5 cm to 2.4-8.6 cm). During the follow-up period, 12 of the 16 patients (75%) continued to have pain that necessitated additional treatments. CONCLUSION: Povidone-iodine sclerotherapy is followed by a high rate of recurrence and is therefore not indicated for the treatment of symptomatic simple renal cysts.