Matched pair analysis of laparoscopic versus open radical nephrectomy for the treatment of T3 renal cell carcinoma.

PURPOSE: The perioperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for T1-T2 renal cell carcinoma (RCC) are well established. We aim to determine whether LRN is a comparable alternative to open radical nephrectomy (ORN) in the treatment of T3 RCC using a matched pair analysis study design. METHODS: A review of a prospectively collected database at the Western General Hospital, Edinburgh, between 2000 and 2011 was conducted. Patient pairs were matched based on age at operation, gender, histological subgroup, maximal tumour diameter, TNM stage and grade. Patient demographics, operative and post-operative outcomes were compared. Overall, cancer-specific and progression-free survival [overall survival, cancer-specific survival (CSS) and progression-free survival (PFS)] were estimated using the Kaplan-Meier method. RESULTS: From 252 patients with T3 disease, 25 pairs were matched. Patients were of median age 66.2 years, 64 % male. Tumours were all clear cell RCC, were stage pT3a (32 %) or pT3b and had maximal tumour diameters of 8.7 cm for LRN and 10.0 cm for ORN. Estimated blood loss (100 ml LRN; 650 ml ORN, p < 0.001) and length of post-operative hospital stay (4 days LRN: 9 days ORN, p < 0.001) were lower in the LRN group. Operation time and post-operative complication rates were comparable. CSS and PFS were comparable with a mean CSS of 91.3 months for LRN and 88.7 months for ORN. CONCLUSION: This study reports the longest median follow-up in a T3 LRN cohort. In matched patients, LRN has been shown to have a superior perioperative profile to ORN for the treatment of pT3a/b RCC, with no adverse effect on midterm oncological outcomes.

Analysis of the pentafecta learning curve for laparoscopic radical prostatectomy.

PURPOSE: Laparoscopic radical prostatectomy (LRP) has a long learning curve; however, little is known about the pentafecta learning curve for LRP. We analysed the learning curve for a fellowship trained surgeon with regard to the pentafecta with up to 6-year follow-up. METHODS: A retrospective review was performed in 550 cases, by dividing these cases into 11 groups of 50 patients. Outcomes analysed were the following: (1) the pentafecta (complication rate, positive surgical margin (PSM) rate, continence, potency and biochemical recurrence); (2) operative time and blood loss; and (3) overall pentafecta attainment. RESULTS: The mean complication rate for the entire series was 9 %; this plateaued after 150 cases. The overall PSM rate for the series was 23.5 %, 16.3 % for pT2 and 40.5 % for pT3. PSM plateaued after 200 cases. Excluding the first 100 cases, the overall PSM rate for pT2 was 10.9 % and 37.8 % for pT3. The continence rate stabilised after approximately 250 cases. The rate of male sling/artificial urinary sphincter plateaued after 200 cases. The potency learning curve continues to improve after 250 cases of nerve-sparing (ns) endoscopic extraperitoneal radical prostatectomy (EERPE) as does the pentafecta learning curve which closely follows the pattern of the potency learning curve. The last group of nsEERPE achieved pentafecta in 63 %. CONCLUSION: This study shows multiple learning curves: an initial for peri-operative outcomes, then stabilisation of oncologic outcomes and the final for stabilisation of functional outcomes. In this series over 250 cases were required to achieve the learning curve.

Micro-engineered remote palpation device for assessing tissue compliance.

This paper concerns the operation of the actuator for a prototype micro-engineered mechanical palpation device for deployment via a cystoscope to measure the dynamic mechanical properties of the prostate gland in vivo. The subassembly consists of a 400x200 microm silicon (Si) piston manufactured using deep reactive ion etching (DRIE) housed within an anodically bonded glass-Si-glass sandwiched housing. The micro-channel on the Si layer was formed by powder blasting and contains the micro-piston with one end pointing to the side of the housing and the other facing a via hole leading to a capillary tube. The opening on the side of the housing was sealed by a 5 microm thick silicone membrane which acts to retain the micro-piston and act as a return spring. A 320 microm diameter capillary forms the connection between the micro-channel and a micro-syringe which is operated by a programmable syringe pump to produce a reciprocating action. A pressure sensor is connected along the capillary tube to measure the dynamic pressure within the system. The micro-piston has already been used, separately actuated to measure the dynamic mechanical properties of known viscoelastic materials and prostate tissue. The purpose of the present work is to assess the functionality of the actuator assembly.

In-vitro dynamic micro-probing and the mechanical properties of human prostate tissues.

In vitro macro- and micro-indentation test systems have been designed to measure the dynamic micro-mechanical properties of human prostate tissues at actuation frequencies between 5 Hz and 30 Hz, and 0.5 Hz and 20 Hz, respectively. The development of in vitro test systems was aimed at assessing the capacity of such an in vivo medical probe to provide information useful for the diagnosis of various prostate diseases. The macro-indentation test system is an established one, which we have used to determine structure-property relationships in human and canine prostate tissues and here we use it to validate a newly-developed micro-indentation test system using a tissue phantom. Mechanical testing was also carried out on sections of prostate tissue harvested from cystectomy and radical prostatectomy, diagnosed with bladder cancer and benign prostatic hyperplasia. Dynamic probing under displacement control was carried at pre-strains between 5% and 8% for macro-probing and at 5% pre-strain for micro-probing, and the general effect of pre-strain on the dynamic mechanical properties (described by the amplitude ratio between stress and strain, and the phase lag between strain and stress) of phantom and prostate tissues is presented. Specific point probing on epithelial and stromal histological components was also carried out showing a significant difference between the amplitude ratios of epithelial and stromal components for actuation frequencies exceeding 5 Hz. However, no significant difference was found between phase lags for epithelial and stromal tissues.

Measurement of tissue mechanical characteristics to distinguish between benign and malignant prostatic disease.

OBJECTIVES: To investigate the relationship between the morphology and mechanical properties of benign and malignant prostatic tissues measured in vitro. METHODS: Fresh tissue specimens were collected from patients undergoing transurethral resection of the prostate (TURP) for benign or malignant prostatic enlargement. Individual TURP chippings underwent immediate mechanical testing by applying a dynamic compressive strain to the samples. The amplitude ratio (E*) and phase difference (tan delta), measures of tissue elastic and viscous components respectively, were derived. Individual sections from the processed specimens underwent immunohistochemical staining and computerized image analysis was used to measure the morphologic characteristics of each TURP chipping. Linear regression analysis was used to assess correlations between morphologic and mechanical measurements, and the unpaired t test, assuming equal variances, was used to compare the mechanical and morphologic characteristics of benign and malignant prostates. RESULTS: Significant differences were noted between the morphology of the benign and malignant prostates. Tan delta was significantly smaller within the malignant prostates (P = 001). No difference was found between the benign and malignant prostates with respect to E*. Within the malignant prostates, a strong negative correlation was found between the epithelial tissue content and tan delta (R2 = 0.50, P = 0.031). CONCLUSIONS: The results of this study showed that measurable differences exist between the mechanical characteristics of benign and malignant prostatic tissue and provide further evidence that significant correlations exist between prostatic tissue morphology and mechanical characteristics. We believe that the ability to quantify prostatic tissue mechanical characteristics in vivo may be of clinical benefit in the future assessment of prostatic diseases, both benign and malignant.

Measurement of the mechanical characteristics of benign prostatic tissue: a novel method for assessing benign prostatic disease.

OBJECTIVES: To investigate the relationship between the morphology and the mechanical properties of benign prostatic tissues measured in vitro. METHODS: Fresh tissue specimens were collected from 17 patients undergoing transurethral resection of the prostate for benign prostatic obstruction. Individual tissue specimens underwent immediate mechanical testing, by applying a dynamic compressive strain to the samples. The amplitude ratio (E*) and phase difference (tan delta), measures of tissue elastic and viscous components, were derived. Individual sections from the processed specimens underwent immunohistochemical staining and computerized image analysis to measure the morphologic characteristics of each transurethral resection of the prostate chipping. Correlations between the morphologic and mechanical measurements were assessed. RESULTS: A strong positive correlation was found between prostatic smooth muscle content and (E*) (R2 = 0.58, P = 0.009). CONCLUSIONS: The results of this study have demonstrated that strong correlations exist between prostatic tissue morphology and mechanical characteristics. We believe that the ability to quantify prostatic tissue mechanical characteristics in vivo may be of clinical benefit in the future assessment and treatment of benign prostatic disease.

Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study.

OBJECTIVES: To study the impact of alfuzosin 10 mg once daily (OD) on the outcome of a trial without catheter (TWOC) after a first episode of acute urinary retention (AUR) related to benign prostatic hyperplasia (BPH) and the subsequent management of BPH in these patients. METHODS: A total of 360 patients underwent emergency catheterization and were blindly randomized to alfuzosin 10 mg OD or placebo for 3 days (first phase). All patients with successful TWOC, regardless of treatment, were then again blindly randomized to alfuzosin 10 mg OD or placebo for 6 months (second phase). The need for BPH surgery (primary endpoint) was assessed after 1, 3, and 6 months of treatment. RESULTS: Alfuzosin significantly increased the successful TWOC rate (146 of 236, 61.9%) compared with placebo (58 of 121, 47.9%; P = 0.012). In the second phase, 14 (17.1%) of the 82 alfuzosin-treated patients versus 20 (24.1%) of the 83 placebo-treated patients required BPH surgery, 5 (36%) of 14 versus 13 (65%) of 20 within 1 month, and 8 (57%) of 14 versus 17 (85%) of 20 within 3 months of treatment. Emergency surgery because of AUR relapse was the main cause of failure in both groups (11 [78.6%] of 14 in the alfuzosin group and 16 [80.0%] of 20 in the placebo group). Compared with placebo, alfuzosin improved the Kaplan-Meier survival rates by 9.6% (P = 0.04), 11.4% (P = 0.04), and 8.3% (P = 0.20), with surgical risk reductions of 61%, 52%, and 29% at 1, 3, and 6 months of treatment, respectively. High prostate-specific antigen values and the post-TWOC residual urine volume significantly increased the risk of AUR relapse and BPH surgery. Alfuzosin 10 mg OD was well tolerated. CONCLUSIONS: Alfuzosin 10 mg OD increased the likelihood of successful TWOC in men with a first episode of spontaneous AUR and should be continued beyond the acute phase, as it reduced the need for BPH surgery during a 6-month treatment period.

Alfuzosin once daily facilitates return to voiding in patients in acute urinary retention.

PURPOSE: We confirmed the beneficial effect of the alpha1-blocker alfuzosin for the acute management of acute urinary retention (AUR) related to benign prostate hyperplasia (BPH), and further identified factors influencing the success of a trial without catheter (TWOC). MATERIALS AND METHODS: A total of 360 patients presenting with a first episode of spontaneous AUR related to BPH underwent emergency catheterization and were then randomly and blindly assigned to receive 10 mg alfuzosin once daily or placebo at a ratio of 2:1 for 3 days. The primary efficacy criterion of this large study was the rate of successful TWOC within 24 hours after catheter removal. The influence of factors such as age, urine retention volume, fluid consumption, constipation and urinary tract infection on TWOC outcome was also assessed. RESULTS: Successful TWOC was recorded in 61.9% of the 236 patients treated with alfuzosin vs 47.9% of the 121 receiving placebo (p = 0.012). Elderly patients (65 years or older) and patients with a drained volume of 1000 ml or greater had significantly greater chances of TWOC failure (success vs failure OR 0.309, 95% CI 1.182 to 0.514 and OR 0.361, 95% CI 0.225 to 0.571, respectively). Nevertheless, even in the presence of these 2 factors 10 mg alfuzosin once daily almost doubled the likelihood of successful TWOC (OR 1.98, 95% CI 1,226 to 3,217). Alfuzosin (10 mg) once daily was well tolerated. CONCLUSIONS: Alfuzosin (10 mg) once daily significantly improved the rate of successful TWOC in patients with AUR related to BPH, even in elderly patients and those with a large drained volume who were at increased risk for TWOC failure. This should contribute to decrease the morbidity and mortality associated with emergency surgery and avoid the discomfort and potential morbidity associated with an in situ catheter.

Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.

OBJECTIVE: The standard surgical treatment of upper tract TCC remains nephroureterectomy with excision of a cuff of bladder. However, laparoscopic nephroureterectomy (LNU) has been shown to be associated with reduced perioperative morbidity, a shorter hospital stay, and a reduced requirement for transfusion than open nephroureterectomy (ONU). The objective of this article is to review experience and outcome following laparoscopic nephroureterectomy for upper tract TCC. METHOD: A literature search of PubMed (www.ncbi.nlm.nih.gov/PubMed/) was performed and articles reporting technical aspects and outcome of laparoscopic nephroureterectomy for upper tract TCC were reviewed. RESULTS: The published data show that outcomes reported following LNU in terms of cancer control are comparable to ONU, at least in the short to medium term. Despite concerns about port site recurrences there were no incidences of this in the 125 patients undergoing LNU in the reviewed reports. An interesting observation was that a high percentage of the tumours are Grade 2 or 3 when TCC affects the upper tract, unlike TCC of the bladder where the majority of tumours are of low grade and stage. CONCLUSION: Laparoscopic nephroureterectomy is a safe treatment option for patients with upper tract TCC. The shorter hospital stay and faster overall recovery is obviously of benefit to the patient, but importantly the longer-term tumour control appears to be equivalent to that following open nephroureterectomy.

Does acute urinary retention respond to alpha-blockers alone?

Studies show that men who undergo prostatectomy after acute urinary retention (AUR) are at increased risk of intraoperative complications, transfusions, postoperative complications and hospital death. Urethral catheterisation for AUR has also been shown to result in bacterial colonization at a rate of 4% per day. Consequently, it is preferable that patients undergo a trial without catheter (TWOC) after an episode of AUR to potentially avoid surgery altogether, or to avoid having a urinary catheter in situ even if they do come to prostatectomy. A number of small studies indicate that alpha(1) blockers may improve the success rate of a TWOC. A placebo-controlled TWOC study of alfuzosin in 81 patients with AUR shows that a successful TWOC was achieved in 55% of alfuzosin-treated patients compared with 29% in the placebo group (p = 0.03). Long-term follow-up suggest that 32% (11/34; 22 treated with alfuzosin and 12 with placebo) of the patients had a further episode of AUR at a mean of 4.1 months following their first episode. This shows that there is a window of opportunity for surgical intervention prior to the occurrence of a second episode of AUR. Patients who had a subsequent episode of AUR or who needed surgery were found to have a higher post-void residual (PVR) urine following their successful TWOC, and thus may be identified as candidates for close follow-up and early intervention. As alfuzosin has been shown to reduce PVR, this factor may help prevent recurrent retention following TWOC.

Postvoid residual urine in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: pooled analysis of eleven controlled studies with alfuzosin.

OBJECTIVES: A pooled analysis was conducted in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia to examine the relationship between the postvoid residual urine (PVR) volume and various clinical characteristics and to assess the effect of alfuzosin, a clinically uroselective alpha(1)-blocker, on PVR volume and any other associated outcome. METHODS: Nine hundred fifty-three patients, 42 to 89 years old, with a baseline PVR volume between 50 and 350 mL (mean 106 mL) were enrolled in 11 double-blind controlled studies and received either alfuzosin (n = 607) or placebo (n = 346) for 1 to 6 months. The relationships between the baseline PVR volume measured by transabdominal ultrasound and age, symptoms, maximum flow rate (Qmax), estimated bladder capacity, and prostate-specific antigen level were assessed. The changes in the PVR volume with treatment were evaluated in all available patients at three endpoints (1, 3, and 6 months). RESULTS: At baseline, a PVR volume of 100 mL or greater was observed in 60%, 47%, and 39% of patients with a Qmax less than 8, 8 to 11, and greater than 11 mL/s, respectively (P = 0.001). The bladder capacity was also significantly related to the Qmax (P = 0.0001). No relationship was found between PVR volume and age, symptoms, or prostate-specific antigen level. The changes in the PVR volume with treatment were related to the baseline PVR volume. However, at all endpoints and whatever the baseline PVR volume, the decreases in the PVR volume were significantly (P <0.01) greater with alfuzosin than with placebo. Acute urinary retention occurred in 7 patients (2 [0.3%] of 607 patients taking alfuzosin and 5 [1.4%] of 346 patients taking placebo); 6 of these 7 patients had a baseline PVR volume greater than 100 mL. CONCLUSIONS: In this population of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia, the PVR olume and bladder capacity were related to the baseline Qmax. Alfuzosin significantly reduced the PVR volume compared with placebo, and this effect was more marked in patients with a high PVR volume at baseline. Acute urinary retention occurred mainly in patients with a PVR volume greater than 100 mL and was less frequent in patients taking alfuzosin than in those taking placebo.

Efficacy of PSA in the detection of carcinoma of the prostate in patients presenting with acute urinary retention.

OBJECTIVES: A temporary elevation in serum-prostate specific antigen (PSA) levels has been reported in association with acute urinary retention. In spite of this, it is not uncommon for clinicians to assay PSA at the time a patient presents with acute urinary retention. We sought to evaluate whether this practice can be justified. PATIENTS AND METHOD: Fifty-four patients, aged between 55 and 89 years, who presented to a single institution with acute urinary retention were studied. A PSA assay was performed on admission and a record made of the prostatic size as assessed by digital rectal examination. All patients underwent a trial without catheter, those that failed to void underwent prostatic surgery whilst all others were followed up as outpatients. RESULTS: Five patients were found to have prostatic carcinoma, three following transurethral resection of the prostate (TURP) and two following needle biopsy, performed because of persistent elevation of the PSA. A significant elevation in the PSA was associated with acute urinary retention, with only 15 (28%) patients having a PSA of 4.0 ng/ml or less. This elevation reduced the sensitivity of PSA in detecting carcinoma of the prostate; even with a cut-off of 20 ng/ml, the positive predictive value of the test was only 21%. CONCLUSIONS: A PSA assay should not be performed at the time of presentation with acute urinary retention as it may lead to unnecessary investigations and anxiety for the patient. For those in whom a PSA assay is desirable a delay of 2 weeks should be allowed prior to sampling, as the half-life of PSA is known to be 2-3 days.

The long-term outcome after laparoscopic nephroureterectomy: a comparison with open nephroureterectomy.

OBJECTIVES: To assess the long-term outcome of the endourological management of upper tract transitional cell carcinoma (TCC) by laparoscopic nephroureterectomy (LNU) or open nephroureterectomy (ONU). PATIENTS AND METHODS: The records and pathology reports were reviewed retrospectively for 67 nephroureterectomy specimens (42 obtained by ONU and 25 by LNU). The grade, stage, lymph node status and site of the tumour were recorded for each patient. The primary end-point of the follow-up was disease-related death. RESULTS: Overall there was a high proportion of G2 (44%) and G3 (39%) disease, with a significant correlation between increasing grade and stage of TCC (r = 0.74, P < 0.001). Of the 25 patients who underwent LNU, 22 had pelvicalyceal or upper ureteric TCC and conversion to open surgery was required in three (12%). Of the TCCs in this group half were G3 and half were invasive (pT1-3). In the ONU group there were more ureteric tumours because of selection criteria and overall 16 (39%) were G3 and half were invasive. Information on nodal status was available in one LNU and two of the ONU reports. Within a mean follow-up of 32.9 months for LNU and 42.3 months for ONU, nine (21%) of the ONU group and four (16%) of the LNU group had died, with a mean survival of 15.1 and 17 months, respectively, after surgery (not significant). All of these deaths were associated with G3 pT1-3 disease. CONCLUSIONS: In this series the case mix and outcomes were similar for those undergoing LNU and ONU. As laparoscopic renal surgery is associated with less postoperative morbidity it would seem reasonable to offer LNU to all patients with upper tract TCC, where appropriate and when there is no evidence of local invasion or metastasis. Because of the strong correlation between grade and stage, preliminary ureteroscopic assessment and biopsy may influence the surgical approach adopted.

Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled.

OBJECTIVE: To establish whether the administration of sustained-release (SR) alfuzosin improves the outcome of a trial without catheter (TWOC) after an episode of acute urinary retention. PATIENTS AND METHODS: In a prospective, randomized, placebo-controlled trial, 81 patients with acute urinary retention related to benign prostatic obstruction received either SR alfuzosin (n=40), an alpha1-selective blocker, given at a dose of 5 mg twice daily, or placebo (n=41) for 48 h. The catheter was removed after 24 h of treatment. The main outcome measurement was success or failure of the TWOC. At the end of this double-blind phase the patients were followed up on an open basis. RESULTS: After removal of the catheter, 42% of patients voided successfully, 22 of 40 (55%) with SR alfuzosin and 12 of 41 (29%) with placebo (P=0.03). The mean age of patients voiding successfully, regardless of treatment group, was 68. 4 years, whilst the mean age of those who were not successful was 72. 9 years (P=0.015). In an intention-to-treat analysis of outcome adjusted for this age difference, the benefit in favour of those receiving SR alfuzosin was not significant, but at P=0.052 there was a strong suggestion of a positive treatment effect. The observed benefit remained significant in a per-protocol analysis adjusted for age. Taken together, these results indicate that treatment with SR alfuzosin was effective and that the observed benefit was not simply the effect of age difference between the groups. Of the 34 patients who voided successfully 23 (68%) required no further intervention within a mean follow-up of 7 months. CONCLUSIONS: Treatment with SR alfuzosin is effective in improving the success rate of a TWOC after an episode of acute urinary retention, although older patients are less likely to void successfully. By reducing the numbers of men sent home with urinary catheters, such treatment may result in a reduction in the associated perioperative morbidity in those undergoing prostatic surgery, and is clearly desirable for the patients' comfort and convenience.