Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the "Trifecta and Pentafecta".

Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if "Trifecta" and "Pentafecta" outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008-2019) was analysed. "Pentafecta" was defined as achievement of "Trifecta" (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres' outcomes.

Surgical anatomy of the pudendal nerve and its branches in South Africans.

Dissection of the pudendal nerve (PN) and its branches in 71 cadavers revealed anatomic variations not previously described. Knowledge of this variation is necessary to prevent nerve injury resulting in sexual of sensory dysfunction. Because descriptions vary, this study re-evaluated the anatomy of the PN as implicated in perineal procedures in South Africans. The course of the PN from the gluteal region into the perineum was dissected in an adult sample of both sexes and of African and European ancestry. Distances between PN and branches to applicable landmarks were measured. Basic descriptive statistics and comparisons were carried out between groups. In 5/13 African females, the inferior rectal nerve (IRN) entered the gluteal region separately and in 12/13 cases it passed medial to the ischial spine with the PN. The dorsal nerve of the clitoris or penis (DNC/DNP) was closer to the bony frame in those of European ancestry. The IRN branches were more superficial in females, but deeper in males of European ancestry. In African females, a PN block and Richter stitch should be placed more medial. Outside-in transobturator tape procedures might endanger the DNC/DNP in obese individuals. In females of European ancestry the IRN branches are compromised during ischioanal abscess drainage. In males of European ancestry, the dorsal penile nerve block might be less effective. Predictions should be verified clinically.

Robotic laparoscopic surgery: cost and training.

The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.

Trans-obturator tape: a single centre experience.

AIM: To assess the clinical outcome of TOT tape for stress and mixed urinary incontinence in a single centre. METHODS: From March 2002 to October 2006, 82 patients completed the study, all were evaluated at 3 and 12 months by physical examination and validated questionnaires. Seventy nine patients had the procedure under epidural anaesthesia and all women received antibiotics starting before surgery. RESULTS: TOT was mostly performed as a day case surgery with short operative time of 22 minute (range 15-38 minute). A total of 62 (70.4%) patients were discharged from the hospital within a few hours (4.3 +/- 1.7 hours). CONCLUSION: The TOT tape can safely be performed as a day-case procedure, which has a continence cure rate of approximately 80%. This figure is comparable with the more established TVT, however the TOT tape has a significantly lower morbidity in our experience.

Ureterocystoplasty is safe and effective in patients awaiting renal transplantation.

OBJECTIVES: Surgical outcomes and bladder function were assessed in a group of patients who had undergone ureterocystoplasty while awaiting renal transplantation. METHODS: An observational cohort study was performed. A chart review was performed of 16 patients who had undergone ureterocystoplasty between 1997 and 2006. The postoperative assessment included measurement of bladder capacity and voiding cystourethrography findings. RESULTS: The median patient age at operation was 17 years (range, 3 to 44 years). The median follow-up was 38 months (range, 3 to 60 months). All patients achieved continence. The median increase in bladder capacity was 162 mL (range, 65 to 265 mL), representing a median proportional increase of 226% (range, 167% to 340%) of the original bladder capacity. None of the patients developed vesicoureteral reflux. Only 4 patients required subsequent intermittent catheterization to fully empty their bladders. Seven patients underwent renal transplantation within 3 to 7 months of ureterocystoplasty. CONCLUSIONS: Ureterocystoplasty in patients awaiting renal transplantation is safe and effective. Good results can be achieved when care is taken to preserve the blood supply of the ureter. The results of this study have confirmed the desirability of preserving the ureters in patients awaiting transplantation who might require bladder augmentation.

Trans-obturator tape for incontinence: a 3-year follow-up.

AIM: To assess operative and functional outcomes, including morbidity, after using the trans-obturator tape for stress incontinence. PATIENTS AND METHODS: The first 24 consecutive patients undergoing trans-obturator tape insertion in a single centre were included in this retrospective study. All patients were female with a mean age of 63 (range 40-83) years. Fifteen patients (62.5%) suffered from pure stress incontinence, and 9 patients (37.5%) had mixed incontinence. Of the latter, 2 patients also had nocturnal enuresis. Each patient was followed up for between 3 and 12 months postoperatively and again at 36 months. The patients were assessed by clinical examination, ultrasound for residual urinary volume, and subjective satisfaction which was assessed at 3 and 12 months. At 36 months, all patients completed a validated incontinence questionnaire (International Consultation on Incontinence Questionnaire: ICIQ) which assessed female lower urinary tract symptoms and their impact on the quality of life. RESULTS: All operations were performed under epidural anaesthesia in day surgery, and the mean operative time was 20 (range 15-38) min. Nineteen patients (79.2%) showed significant improvement postoperatively, with 16 of those (66.6%) being completely cured of their incontinence. The remaining 5 patients (20.8%) were considered to have had failed procedures. There were no vascular, bladder, or urethral injuries. One patient had perforation of the vaginal fornix, and 3 patients developed vaginal erosion. CONCLUSIONS: The trans-obturator tape is a safe and effective treatment for stress incontinence and has a low morbidity after a 3-year follow-up period; however, it should only be performed by clinicians with the relevant surgical expertise and experience in treating female incontinence.

Robotic extraperitoneal radical prostatectomy: an alternative approach.

PURPOSE: Laparoscopic radical prostatectomy with or without a robot has been increasingly performed worldwide, primarily using a transperitoneal approach. We report our experience with daVinci(R) robot assisted extraperitoneal laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 325 patients underwent robot assisted extraperitoneal laparoscopic radical prostatectomy for clinically localized prostate cancer at our center during a 2-year period. Perioperative data, and oncological and functional results were prospectively recorded. RESULTS: Perioperative demographics included mean age, PSA and Gleason score, which were 60 years (range 42 to 76), 6.6 ng/ml (range 0.6 to 26) and 6 (range 5 to 9), respectively. Preoperative clinical stage was 81%, 16% and 3% for T1c, T2a and T2b, respectively. Average total operative time was 130 minutes (range 80 to 480). Intraoperative data included a mean blood loss of 196 cc with no open conversions. Bilateral, unilateral and nonnerve sparing prostatectomy was performed in 70%, 24% and 6% of patients, respectively. Of the patients 96% were discharged home within 8 to 23 hours of surgery. Pathological stage was pT2a, pT2b, pT3a and pT3b in 18%, 63%, 14% and 5% of all radical prostatectomy specimens, respectively, with an overall positive surgical margin rate of 13%. Two of 92 patients had positive nodal disease after lymph node dissection. Continence and erectile function were measured. CONCLUSIONS: The extraperitoneal approach offers the advantages of improved dexterity and visualization of the robot, while avoiding the abdominal cavity and potential associated morbidity. As surgeons gain more experience with this new technology, the extraperitoneal approach simulating the standard open retropubic technique is likely to gain popularity.

Penile sensitivity and sexual satisfaction after circumcision: are we informing men correctly?

OBJECTIVES: Currently no consensus exists about the role of the foreskin or the effect circumcision has on penile sensitivity and overall sexual satisfaction. Our study assesses the effect of circumcision on sexually active men and the relative impact this may have on informed consent prior to surgery. MATERIALS AND METHODS: One hundred and fifty men between the ages of 18 and 60 years were identified as being circumcised for benign disease between 1999 and 2002. Patients with erectile dysfunction were excluded from the study. The data was assessed using the abridged, 5-item version of the International Index of Erectile Function (IIEF-5). Questions were also asked about libido, penile sensitivity, premature ejaculation, pain during intercourse and appearance before and after circumcision. IIEF-5 data was analysed using two-tailed paired t test to compare pre-operative and post-operative score changes across the study group. For the rest of the questions, data was analysed using 'Sign Test', calculating two-sided p values and 95% confidence intervals. RESULTS: Fifty-nine percent of patients (88/150) responded. The total mean IIEF-5 score was 22.41 +/- 0.94 and 21.13 +/- 3.17 before and after circumcision, respectively (p = 0.4). Seventy-four percent of patients had no change in their libido levels, 69% noticed less pain during intercourse (p < 0.05), and 44% of the patients (p = 0.04) and 38% of the partners (p = 0.02) thought the penis appearance improved after circumcision. Penile sensation improved after circumcision in 38% (p = 0.01) but got worse in 18%, with the remainder having no change. Overall satisfaction was 61%. CONCLUSIONS: Penile sensitivity had variable outcomes after circumcision. The poor outcome of circumcision considered by overall satisfaction rates suggests that when we circumcise men, these outcome data should be discussed during the informed consent process.

Tension-free vaginal tape: avoiding failure.

A prospective, single-centre study to assess the outcome of incontinence surgery in the first 120 consecutive patients who had tension-free vaginal tape (TVT) by a single surgeon. All patients were initially seen at 3 months postsurgery, with a cough provocation test, measurement of residual urine volume and a satisfaction survey. At a mean of 26 months (6-42 months) after surgery, a validated telephone interview was performed. The operation was performed in accordance with the original technique described by Ulmsten et al. [Int Urogynecol J Pelvic Floor Dysfunct 1996; 7: 81-5]. A total of 87 of 120 patients completed the study with the others either not complying or having died. Sixty-three (72.4%) patients were completely dry on cough provocation test. Of these, four (4.5%) had a slow stream and 10 (11.4%) suffered persistent urgency. The remaining 24 patients had varying degrees of leakage (operative failure). Sixteen (18.3%) patients subjectively considered the procedure to have failed at 3 months follow-up, either because leakage occurred once or more a day, and/or the persistence of the preoperative frequency/urgency syndrome. Of these 16 TVT failures, two had previous pelvic radiotherapy, two had double incontinence and eight had TVT for recurrent incontinence. Among the failures, 81.3% had mixed incontinence with predominant urge and nocturia three times per twenty four hours. Our study highlights the need for selection when performing TVT. We recommend that TVT be performed for those who have simple stress incontinence failing conservative measures (pelvic floor exercises and physiotherapy), with no history of incontinence surgery, pelvic radiotherapy, faecal or mixed incontinence.

Bladder neck stenosis after transurethral resection of prostate: does size matter?

AIM: To understand the risk factors associated with the incidence of bladder neck stenosis (BNS) after transurethral prostate surgery. PATIENTS AND METHODS: We retrospectively reviewed 900 patients who underwent transurethral prostate surgery over a 4-year period. The mean age of the men was 72.3 (47-94) years. The specific outcome data assessed related to BNS, including type of operation performed, resected tissue weight and history of previous surgery in the lower urinary tract. RESULTS: 29 (3.4%) patients developed BNS at a mean of 10.3 (3-33) months, with a mean resected prostatic tissue weight of 11+/-3.7 g. Four of the 29 patients with BNS were treated with bladder neck resection and re-stenosed. Fifty-four men underwent bladder neck incision for small prostates with a high bladder neck, measured by digital rectal examination and assessed cystoscopically, with no BNS. All the remaining patients from our series did not have a BNS, with a mean resected weight of 28+/-8.9 g, which is statistically greater than in the BNS group (p<0.05, unpaired t test). CONCLUSIONS: BNS after transurethral prostate surgery is a significant problem. It is clear from our study that resection in small prostates with no sign of a high bladder neck will increase the development of BNS. Thus, small prostates should be managed by an initial bladder neck incision, even if the bladder neck is not high.

Antibiotics on urethral catheter withdrawal: a hit and miss affair.

Globally, millions of patients undergo urethral catheterization every year. Our objective was to study the current use of prophylactic antibiotics on urinary catheter withdrawal. A questionnaire (N = 300) was sent to healthcare professionals involved in the management of patients with urinary catheters (consultant microbiologists, infection control nurses, consultant urologists, specialist nurses in urology, continence advisers and consultants in the care of older people). The questionnaire asked about their use of prophylactic antibiotics on the withdrawal of a urethral catheter. Sixty percent of healthcare professionals advocated the use of antibiotics for either all or selected groups of patients. The remainder did not. The use of prophylactic antibiotics varied among different groups. Of the healthcare professionals who used antibiotics, the majority cited more than one reason for their use (prevent bacteraemia, avoid an infection in a prosthesis or urinary tract infection). The course and type of antibiotic used varied. Our study has shown diversity in practice that is of concern. At present, just over one-half of patients with urinary catheters are being given antibiotics, although there is no evidence to suggest that such an intervention confers any benefit. If benefits do not exist, these patients are being exposed to the harm of antibiotics and providers are incurring costs unnecessarily. A formal trial to address this issue is urgently needed.

Current trends in bladder cancer in England and Wales.

PURPOSE: We examined trends in bladder cancer (BC) incidence, mortality and survival in England and Wales during a 30-year period. MATERIALS AND METHODS: Age standardized incidence and mortality rates for BC, cohort incidence ratios, and 1 and 5-year relative survival from BC were calculated, and current trends were assessed. RESULTS: Between 1971 and 1998 the total number of cases of BC increased by 57% from around 7,200 to almost 11,400. Between 1971 and 1998 directly age standardized incidence increased by 16% in males and 37% in females. Directly age standardized mortality decreased by 26% in males and showed little change in females during the same period. Five-year relative survival improved by around 15% points in the 1970s and early 1980s. However, there was less improvement in survival thereafter in that 5-year relative survival for patients diagnosed in 1993 to 1995 was 67% in men and 58% in women. CONCLUSIONS: With an almost 60% increased incidence during the last 3 decades, BC incidence remains much higher in men but has increased more rapidly in women. There have been steady decreases in mortality rates, more marked in men than in women. Unusually, women have a significantly lower survival rate than men. Reasons for these patterns and trends are unclear. The trends in bladder cancer incidence by birth cohort suggest that the relationship with smoking may not be that strong and that other factors may be involved. Further research should focus on reasons for the recent increase in bladder cancer incidence in younger female birth cohorts.

Tissue microarrays: a current medical research tool.

Recent research in molecular biology has identified a significant number of novel markers, which may have diagnostic, prognostic and therapeutic significance. This is particularly pertinent in the field of cancer. Validation of these markers in multiple clinical specimens is currently performed by traditional histopathological techniques, which are disappointingly time consuming, labour intensive and, therefore, economically costly. These limitations have hampered the introduction of many novel markers into everyday clinical practice. The tissue microarray (TMA) is a high throughput technique, which allows the rapid and cost effective validation of novel markers in multiple pathological tissue specimens. Tissue from up to a 1000 histology blocks can be arrayed accurately onto a newly created paraffin block, at designated locations. Subsequently, morphological and molecular investigations can be performed to determine the clinical significance of the novel markers tested. It is now firmly established that the TMA can significantly accelerate the processing of a very large number of tissue specimens with excellent quality, good reliability and preservation of original tissue, with ultimate clinical benefit.

Modified ureterosigmoidostomy (Mainz II): a long-term follow-up.

OBJECTIVE: To assess the long-term results in patients treated using a modified ureterosigmoidostomy (Mainz II). PATIENTS AND METHODS: Between 1994 and 1999, 17 patients had their lower urinary tract reconstructed by a ureterosigmoidostomy, modified by reconfiguring the rectum to make a low-pressure reservoir (Mainz II). All patients were followed on a standard protocol. Data were extracted from the database and from a review of the case-notes. In 12 patients the procedure was with a radical cystectomy for carcinoma. Five had a failed conventional ureterosigmoidostomy for bladder exstrophy and therefore proceeded to a Mainz II. The data on continence and complications were retrieved for a retrospective analysis; the mean (range) follow-up was 6.4 (4-8.6) years. RESULTS: Ten of those with bladder cancer and one in the revision group were continent. Two patients in the revision group had sufficiently severe nocturnal incontinence to require conversion to a colonic conduit. Seven of the 17 patients had hyperchloraemic acidosis, one had pyelonephritis and one had renal stones. There were no anastomotic neoplasms. CONCLUSION: The Mainz II has a good outcome if used as the primary procedure. In patients with an existing ureterosigmoidostomy who are incontinent, detubularization of the rectosigmoid alone is unlikely to restore continence.

Diclofenac suppository analgesia for transrectal ultrasound guided biopsies of the prostate: a double-blind, randomized controlled trial.

PURPOSE: A significant proportion of men undergoing transrectal ultrasound (TRUS) and prostate biopsy report pain during the procedure. A number of different methods of pain relief have been suggested in the literature. We prospectively evaluated the effect of diclofenac suppositories on pain experienced by men undergoing TRUS and prostate biopsy. MATERIALS AND METHODS: A prospective, randomized, double-blind, placebo controlled study was performed in 72 patients requiring prostate biopsy. Patients were randomly assigned to receive 100 mg diclofenac or placebo 1 hour prior to the procedure. They were asked to indicate on a 10 cm visual analogue scale the degree of discomfort during the procedure. The patients were then seen 2 weeks later and any morbidity, including infection and bleeding, was assessed. RESULTS: Patients given diclofenac had significantly lower pain scores than those given placebo (2.8 vs 4.9, p <0.001). The 2 groups were similar in regard to age, prostate volume, biopsy number, prostate specific antigen, histological diagnosis and complication rate. CONCLUSIONS: Rectal administration of diclofenac 1 hour prior to TRUS and prostate biopsy is a simple procedure that significantly relieves the pain experienced with no increase in morbidity. With the trend toward more core samples, screening for prostate cancer and the younger age of patients undergoing biopsy we urge urologists to provide analgesia for this painful procedure.

A national survey of transrectal ultrasound-guided prostatic biopsies: time for a national guideline.

The aim of this study was to elicit similarities and differences in transrectal ultrasound guided prostatic biopsy regimens in the UK and the Republic of Ireland. A telephone survey of 60 centres was conducted and information collected on the operator, the anaesthesia used, antibiotic prophylaxis and number of biopsies taken. Most prostatic biopsies were performed by urologists and most procedures involved six cores. There was a marked variation in the use of antibiotic prophylaxis, and anaesthesia was used sparingly. Our survey has shown a diversity in protocols used in transrectal ultrasound guided biopsies in the UK and Ireland. It seems sensible to standardise the technique for optimal patient satisfaction, as well as clinical efficiency. A national co-ordinated, prospective trial is needed.

Intratesticular cysts and malignant potential: conservative management is an option.

Benign intratesticular cysts are rare, but recognition is essential to prevent unnecessary surgical intervention. The diagnostic dilemma is to differentiate these cysts from testicular malignancy. As they are extremely uncommon, experience of their management is limited and controversial. We present a case of a simple intratesticular cyst and discuss the diagnostic and management principles.

Chemokines: key players in cancer.

Chemokines are a family of low molecular weight (8-10 kDa) pro-inflammatory cytokines, which bind to G-protein coupled receptors. Their primary function is chemoattraction and activation of specific leucocytes in various immuno-inflammatory responses. However, new research suggests that they are key players in cancer being involved in the neoplastic transformation of cells, promotion of aberrant angiogenesis, tumour clonal expansion and growth, passage through the extracellular matrix (ECM), intravasation into blood vessels or lymphatics and the non-random homing of tumour metastasis to specific sites. In view of the increasing significance of chemokines and their receptors in cancers of a variety of types, manipulation of this signalling pathway may be important in the development of new anticancer agents. This review provides an overview of recent research advances in this field and examines the potential therapeutic benefits future developments may bring.

Rare case of primary lymphoma of the prostate: giving the patient the benefit of the doubt.

One third of non-Hodgkin lymphomas are extranodal, however it is uncommon for the lower urinary tract to be involved. We present an unusual case of a low-grade primary lymphoma affecting the prostate, which responded well to radical radiotherapy.