Adoption of a Urologic Oncology Perioperative Surgical Home is Associated with Decreased Total Length of Stay: A Pilot Study.

INTRODUCTION: Urologists partnered with anesthesiologists to implement a model of perioperative and postoperative care known as the multidisciplinary perioperative surgical home in order to improve the quality and efficiency of care. We describe early outcomes associated with implementation of the perioperative surgical home. METHODS: Retrospective chart review was performed of patients at a single institution undergoing radical prostatectomy, radical cystectomy, partial nephrectomy and radical nephrectomy from January 2014 to March 2016. Outcomes measured were length of stay and 30-day reoperation, readmission, unexpected intensive care unit admission and mortality rates. Statistical analysis was performed using the independent samples Mann-Whitney U test and Fisher exact test with p <0.05 considered significant. Univariate and multivariate analyses were performed to determine whether implementation of the perioperative surgical home was associated with improved outcomes. RESULTS: Length of hospital stay decreased from 4.79 to 3.19 days and 30-day complication rate decreased from 15.3% to 5.7% after implementation of the perioperative surgical home (p <0.01 for both). There was no change in the 30-day readmission rate. On multivariate analysis surgery occurring after perioperative surgical home implementation was associated with decreased length of stay (p = 0.008). The direct cost savings resulting from this length of stay reduction totaled $1,245,585 for the study period. CONCLUSIONS: The adoption of a perioperative surgical home is associated with a significantly decreased postoperative hospital stay and 30-day complication rate for urologic oncology cases.

Impact of NADiA ProsVue PSA slope on secondary treatment decisions after radical prostatectomy.

BACKGROUND: Selecting appropriate candidates for postprostatectomy radiotherapy is challenging, because adverse pathological features cannot accurately predict clinical recurrence. Biomarkers that identify residual disease activity may assist clinicians when counseling patients on the risks, benefits and costs of secondary treatment. NADiA ProsVue PSA slope results ≤2.0 pg ml(-1) month(-1) are predictive of a reduced risk of clinical recurrence; however, its clinical utility has not yet been studied. METHODS: We prospectively enrolled men treated by radical prostatectomy in a multicenter, institutional review board-approved clinical trial. At postsurgical follow-up, investigators (N=17) stratified men into low-, intermediate- or high-risk groups for prostate cancer recurrence based on clinicopathological findings and other factors. Investigators documented their initial treatment plan for each subject and serially collected three serum samples for ProsVue testing. After the ProsVue result was reported, investigators recorded whether or not the initial treatment plan was changed. The proportion of cases referred for secondary treatment before and after ProsVue was reported, and the significance of the difference determined. RESULTS: Complete assessments were reported for 225 men, 128 (56.9%) of whom were stratified into intermediate- and high-risk groups. Investigators reported that they would have referred 41/128 (32.0%) at-risk men for secondary treatment. However, after results were known, they referred only 15/128 (11.7%) men. The difference in proportions (-20.3%, 95% confidence interval (CI) -29.9 to -10.3%) is significant (P<0.0001). Odds of a referral was significantly reduced after results were reported (odds ratio 0.28, 95% CI 0.15-0.54, P<0.0001). CONCLUSIONS: Knowledge of a ProsVue result had significant impact on the final treatment plan. A ProsVue result ⩽2.0 pg ml(-1) month(-1) significantly reduced the proportion of men at risk of recurrence who otherwise would have been referred for secondary treatment.

Robotic-assisted surgery and the evolution of the radical prostatectomy.

The surgical treatment of prostate cancer has evolved considerably since it was first described in 1905. With the introduction of a robotic, surgical-assist device, minimally invasive techniques for prostate removal have been increasingly utilized throughout the world. Currently, there is a large body of literature suggesting that robotic-assisted laparoscopic prostatectomy is associated with certain improved perioperative and postoperative outcomes and similar cancer control rates compared to open radical prostatectomy. The goal of this review is to objectively evaluate and describe the current state-of-the-art in surgical technique, perioperative and long-term outcomes, complications and the future of robotic-assisted laparoscopic radical prostatectomy.

Conservative treatment of renal angiomyolipomas in patients with tuberous sclerosis.

AIMS: Renal angiomyolipoma (AML) associated with tuberous sclerosis (TS) presents a treatment dilemma due to multifocal tumors with a potential for significant growth and subsequent hemorrhage. We reviewed the literature and our experience with AML and TS patients to determine the long-term behavior of these lesions. MATERIALS AND METHODS: We reviewed 8 patients (16 renal units) with bilateral renal AMLs and comorbid TS. We evaluated their renal function, renal imaging, and clinical course. Patients were followed for a mean of 11.5 years (range 3.5 - 21 years). RESULTS: The records of 8 patients (7 females, 1 male) with a mean age of 33.1 years (range 21 - 54) were evaluated. The mean serum creatinine of these patients at the time of diagnosis was 0.75 mg/dl (range 0.4 - 1.1). Mean serum creatinine at last follow-up was 0.83 mg/dl (range 0.6 - 1.3). The average size of the largest lesion was 13.9 cm (range: 0.5 - 28). Of the 8 patients, 6 received treatment during the course of their disease, including arterial embolization of 7 renal units in 5 symptomatic patients (2 patients needed 2 embolizations). Partial nephrectomy was performed on 2 renal units in 2 patients, and a total nephrectomy was performed in 1971 on another patient. Currently, all 8 patients have stable renal function; 4 patients are asymptomatic with regards to their lesions, while the other 4 patients report transient flank pain adequately controlled with oral analgesics (2 patients with propoxyphene plus acetaminophen 100/650 mg PO t.i.d. p.r.n., the other 2 patients with ibuprofen 600 mg PO p.r.n.). None of the patients experienced life-threatening hemorrhage or required dialysis. CONCLUSIONS: Our study and a review of the literature have not revealed an obvious or quantitative risk of morbidity or mortality from renal hemorrhage directly related to AMLs of any specific size in TS patients. Due to multiple lesions and distortion of anatomy it can be difficult to distinguish individual lesions for preemptive treatment in asymptomatic patients. If size criteria alone are used, multiple treatments will be required over the course of the patient's life. Also, preemptive treatment exposes patients to iatrogenic morbidity. Consideration should be given to medical management of AMLs in TS patients with asymptomatic, slowly enlarging tumors that maintain features of an AML. Embolization, partial nephrectomy, or other ablative treatments (i.e. cryotherapy and RFA) can be reserved for symptomatic patients.

Telomerase activity in prostate sextant needle cores from radical prostatectomy specimens.

Human telomerase acts to maintain functioning telomeres, which are required for cellular immortality and very likely for cancer progression. Telomerase activity is present in about 85% of human cancers tested, but it has not been found in most human somatic cells and tissues. We used the Telomeric Repeat Amplification Protocol to perform telomerase activity assays on sextant needle core samples obtained from 35 freshly excised radical retropubic prostatectomy specimens. Similar assays were done on prostatic tissues obtained by means of other urologic procedures from 8 patients without prostate cancer. Telomerase activity was found in one or more specimens from 32 of 35 prostate cancer patients (91%), but was not detectable in all biopsy specimens from 7 of 8 cancer-free patients (88%). Further analysis showed that cancers more poorly differentiated, with higher Gleason scores, were always associated with a higher rate of telomerase detection and stronger telomerase activity. Moreover, comparison of telomerase activity in needle core samples with the volume of cancer in surrounding tissue as observed on corresponding histologic slides showed that stronger activity was positively correlated with a higher cancer volume. Prognostic indicators of prostate cancer and the expression of telomerase appear to be linked. The presence of telomerase activity in prostate tissue may aid in the detection of prostate cancer and produce additional prognostic information.

Perfusion sphincterometry for objective evaluation of postprostatectomy intrinsic sphincter deficiency.

OBJECTIVES: Male urinary incontinence secondary to intrinsic sphincter deficiency (ISD) is a possible complication of transurethral resection of the prostate (TURP) or radical prostatectomy (RP). For objective assessment of urinary sphincteric competence, we used perfusion sphincterometry (PS) to measure the retrograde urethral perfusion pressure (RUPP). METHODS: A retrospective and prospective analysis of 60 neurologically normal patients of varying continence status was performed. The subjects were divided into three groups: continent patients with no previous prostate surgery (group 1), continent patients after prostatectomy (group 2), and incontinent patients after prostatectomy (group 3). All patients underwent PS with the technique described. All incontinent patients (group 3) had a filling cystometrogram (CMG) to rule out detrusor instability. RESULTS: Continent patients with no prior prostate surgery (group 1) had a mean RUPP of 101 +/- 16 cm H2O; continent postprostatectomy patients (group 2) had a mean RUPP of 77 +/- 14 cm H2O; and incontinent postprostatectomy patients (group 3) had a mean RUPP of 36 +/- 11 cm H2O. The differences were statistically significant (P <0.001). There was no statistically significant difference in RUPP when the patients in groups 2 and 3 were stratified into TURP and RP groups. CONCLUSIONS: PS is a simple and accurate technique for objective evaluation of lower sphincter competence. Patients with stress incontinence after prostatectomy have a statistically significant decrease in RUPP compared with continent controls. In combination with cystourethroscopy and filling CMG, PS can be useful in the evaluation of postprostatectomy incontinence.

Kaposi's sarcoma of the testicle.

The penis and scrotum are the genitourinary tract organs most frequently involved in Kaposi's sarcoma (KS). However, solid organ involvement is rare. A 32-year-old man with AIDS presented with cutaneous KS, which subsequently metastasized to the right testicle.

Ureteroscopic treatment of symptomatic caliceal diverticular calculi.

Renal calculi that reside in caliceal diverticula are difficult to treat. Numerous treatment modalities have been used, including extracorporeal shock wave lithotripsy, laparoscopy, and percutaneous treatment. All therapies directed at fragmenting the stones are limited by the ability of these fragments to pass through the narrow diverticular neck. More recently, the retrograde approach using small-caliber flexible ureteroscopes has been applied successfully in the treatment of diverticular calculi. A description of our retrograde technique is presented. The ultimate success of this technique is dependent upon familiarity with the basic principles of ureteroscopy and successful clearance of stone fragments from the diverticulum.

Endoscopic treatment of continent urinary reservoir calculi.

Formation of calculi is a late complication of continent urinary diversions. The techniques of percutaneous and transstomal treatment of these stones are described. Three patients underwent percutaneous placement of a rigid nephroscope into three different types of continent reservoirs and fragmentation of stones (2-5 cm in size) using ultrasonic lithotripsy. Preoperative CT scan of the abdomen and pelvis with oral and intrareservoir contrast was essential in finding the safest location for percutaneous access. One patient, with small stones, underwent placement of a flexible cystoscope through the continent efferent limb and Holmium laser lithotripsy. There were no instances of reservoir perforation. There was minimal blood loss, with an average operative time of 165 min. Ultrasonic lithotripsy of large stones through a percutaneous approach and Holmium laser lithotripsy for smaller stones via a flexible cystoscope placed through the efferent limb are safe and effective ways to treat calculi within continent urinary diversions.

Renal angiomyolipomas: long-term follow-up of embolization for acute hemorrhage.

OBJECTIVE: To determine if elective, angiographically directed embolization of enlarged renal angiomyolipomas can be used to prevent future hemorrhagic episodes in patients with tuberous sclerosis and thus avoid nephrectomy. PATIENTS AND METHODS: Records were reviewed for all 5 patients who underwent elective, subtotal embolization of large, symptomatic angiomyolipomas at the authors' institution between 1975 and 1996. RESULTS: All 5 patients had tuberous sclerosis and bilateral renal angiomyolipomas. Initial embolization in these patients was performed in 1975, 1981, 1993 (2 patients) and 1994. In 1 patient only a single embolization session was required. In another, initial embolization on the left side was followed by embolization on the right 13 months later. Two patients underwent 2 sessions, and 1 patient had 4 sessions over a 13-year period. Subtotal embolization with particulate material led to a decrease in size of the most severely affected portion of the kidney. One large angiomyolipoma underwent sterile liquefaction after embolization; percutaneous catheter drainage was required. The embolization allowed subsequent partial nephrectomy in this patient. CONCLUSION: Embolization is effective for the long-term management of renal angiomyolipomas in patients with tuberous sclerosis; in this way nephrectomy and loss of renal function can usually be avoided.

Histopathologic evaluation of the canine prostate following electrovaporization.

PURPOSE: Transurethral electrovaporization of the prostate (TVP) for symptomatic benign prostatic hypertrophy (BPH) has proven to be efficacious with minimal patient morbidity. When compared to transurethral resection of the prostate (TURP), TVP demonstrates comparable postoperative flow rates, American Urologic Association (AUA) symptom score indices, and a potential cost savings. However, in the human studies it has not been possible to correlate these clinical parameters with procedure-related histopathologic changes in the prostate immediately postoperative or during wound healing. The following study was done using a canine model in an effort to evaluate these histopathologic changes. METHODS AND MATERIALS: Fifteen hounds (25-35 kg.) underwent antegrade electrovaporization of the prostate, via an open cystotomy, using a Circon ACMI USA series resectoscope and video equipment. The dogs were sacrificed and the prostates harvested at various intervals postoperatively (0-11 weeks). The prostates were evaluated grossly as well as histologically for cavitary defects, depth of necrosis, and cellular response. RESULTS: Prostates examined immediately following the procedure demonstrated superficial necrosis (less than 2 mm.) in the region of vaporized tissue. One week postoperatively, the vaporized regions demonstrated an intense acute inflammation amidst superficial necrosis with focal hemorrhage and dystrophic calcification. Transient glandular cystic changes developed, but were resolving by seven weeks postoperatively. Re-epithelialization was underway by the third postoperative week and epithelial stratification underway by the fifth week. There was no extension of the initial two millimeter zone of necrosis at any time point examined. CONCLUSION: TVP in the canine model vaporizes prostatic tissue at the site of contact. Only a shallow remnant of necrosis remains at the site of vaporization, indicating the highly localized effect of this technique. Healing at the site of vaporization occurs in a rapid and expected manner. These data provide a histopathologic rationale for the minimal morbidity and the efficacious nature of this technique demonstrated in clinical studies.

Local recurrence of renal cell carcinoma causing duodenal-inferior vena caval fistula: case report and review of the literature.

We report the first case of a duodenal-inferior vena caval (IVC) fistula resulting from locally recurrent renal cell carcinoma (RCC). A 45-year-old man presented with gross hematuria and underwent a right radical nephrectomy to treat a solid renal mass. Histologic evaluation showed RCC, Stage pT3aN0M0. The patient presented 21 months later in hemorrhagic shock, with upper gastrointestinal bleeding. He underwent an exploratory laparotomy and Whipple procedure for a mass in the second portion of the duodenum extending to the inferior vena cava with a secondary duodenal-IVC fistula. We describe this case and review the previously published reports of duodenal-IVC fistulae.

Invasive bladder cancer following cardiac transplantation.

Iatrogenic immunosuppression following renal transplantation has been associated with the development and progression of multiple neoplasms, including transitional cell carcinoma (TCC). We present the first report of invasive TCC of the bladder managed with radical cystectomy in a cardiac transplant recipient. The short survival of this patient, despite organ-confined disease at the time of cystectomy, illustrates the necessity of early diagnosis and aggressive treatment of malignancy following organ transplantation.

Use of exogenous material to bolster closure of the parenchymal defect following partial nephrectomy.

Closure of renal parenchymal defects created by partial nephrectomy can be difficult. We describe a method of using exogenous material to bolster the strength of the parenchymal closure. The horizontal mattress sutures closing the renal parenchyma are less likely to tear through the parenchyma as the result of the application of a more uniform tension across a broad front. This technique is particularly helpful for large and irregular defects. Tying the closure sutures over an exogenous bolster material aids in a rapid, hemostatic, and watertight closure.

Potency-sparing radical retropubic prostatectomy: a simplified anatomical approach.

A simplified method of nerve sparing radical retropubic prostatectomy for clinical stage T2a prostate cancer is described based on primary isolation of both neurovascular bundles and secondary division of the urethra, with the puboprostatic ligaments undivided to provide suspension of the deep venous complex above the urethra. The principles for this approach after division of the deep vein complex are based on early unilateral incision of the prostatic fascia laterally, parallel to the ipsilateral neurovascular bundle and extending from the proximal prostate to the urethra; separation of anterior (prostatic) and posterior (rectal) Denonilliers' fascia, which leaves the neurovascular bundle invested in the latter tissue; perforation and incision of contralateral prostatic fascia at its urethroprostatic angle, with cranial extension of the fascial opening dropping the ipsilateral neurovascular bundle invested in its fascia (Denonvilliers' posterior), and anastomotic division of the urethra at its entrance into the prostate.

Intraoperative ultrasound: determination of the presence and extent of vena caval tumor thrombus.

OBJECTIVES: To report and discuss five cases of renal cell carcinoma (RCC) in which preoperative imaging studies were equivocal with regard to the presence and extent of vena caval tumor thrombus or in which dynamic intraoperative imaging of the vena cava was advantageous. METHODS: We reviewed the cases of five patients who had conflicting preoperative imaging studies and reviewed the literature applying to this clinical situation. RESULTS: Two patients whose preoperative magnetic resonance imaging studies suggested inferior vena caval tumor thrombus were shown, on intraoperative color Doppler ultrasound, not to have tumor thrombus but rather turbulent flow within the vena cava mimicking thrombus. In two patients intraoperative ultrasound (IOUS) was used to image the position of the tumor thrombus as it was manipulated to allow for safe vena caval clamp placement. In one patient we used real-time imaging to visualize thrombus extraction from the heart. CONCLUSIONS: Intraoperative ultrasound real-time imaging is beneficial in two specific situations: in those cases in which the presence of renal vein or inferior vena cava involvement is equivocal based on preoperative imaging techniques and when there is a need to identify intraoperatively the limits of a known tumor thrombus to allow subsequent safe placement of a caval clamp.

One hundred consecutive laparoscopic pelvic lymph node dissections: comparing complications of the first 50 cases to the second 50 cases.

OBJECTIVES: To report the outcome of our first 100 consecutive laparoscopic pelvic lymph node dissections (LPLND) and compare the early complication rate of the first 50 cases (14%) to the second 50 cases (4%). METHODS: We reviewed 100 patients who underwent LPLND: Ninety-six patients had carcinoma of the prostate and underwent LPLND prior to radical prostatectomy or definitive radiation therapy. Four patients had histologically proved penile (2) or bladder carcinoma (2) and underwent LPLND to assess their pelvic lymph nodes. RESULTS: We encountered 7 major and minor complications in our first 50 cases, and 2 minor complications in our second 50 cases. The overall complication rate was 9% (9 of 100). CONCLUSIONS: We believe that modification of our operative technique and changes in patient management resulted in a lower complication rate in the second 50 patients. We conclude that although LPLND has a significant learning curve, it is a viable surgical staging option for patients with urologic pelvic malignancies.

Homologous blood transfusion in patients with prostate cancer: no effect on tumor progression or survival.

OBJECTIVE: To determine the effect of perioperative blood transfusions in patients with prostate cancer who underwent radical prostatectomy, we analyzed 1,785 patients with a follow-up of five years or more who were treated during a twenty-one-year period (1966 to 1987). METHODS: Patients were divided into three groups according to the number of units transfused during the perioperative period: group 1, 0 units (n = 440), group 2, 1 to 2 units (n = 746), and group 3, 3 or more units (n = 599). RESULTS: With univariate analysis, no statistically significant differences were found among the three groups in overall survival rate (71%, 75%, and 71% at ten years; p = 0.48), cause-specific survival rate (89%, 88%, and 86% at ten years; p = 0.36), or progression-free survival rate (61%, 68%, and 68% at ten years; p = 0.83). Adjusting for tumor grade, pathologic stage, and hormonal therapy using the Cox statistical model, we found no significant association between the blood-use group and overall survival rate (p = 0.45), cause-specific survival rate (p = 0.17), or progression-free survival rate (p = 0.34). The estimated relative risk and 95 percent confidence interval associated with blood transfusion (three or more units versus none) were as follows: 1.03 and 0.76 to 1.38 for total mortality, 1.56 and 0.95 to 2.56 for cause-specific death, and 1.20 and 0.91 to 1.57 for disease progression, respectively. CONCLUSIONS: According to these findings, withholding homologous blood transfusion, except for infectious precautions, should not be based on the suspicion that it can accelerate death from cancer in patients who undergo radical prostatectomy for prostate cancer.