Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion.

OBJECTIVE: To develop a technique of nerve-sparing robot-assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer. PATIENTS AND METHODS: Robotic assistance should enhance the ability to preserve the neurovascular bundles during laparoscopic radical cystectomy. Thus we undertook RRCP and urinary diversion using a three-step technique. First, using a six-port approach and the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), one surgeon carried out a complete pelvic lymphadenectomy and cystoprostatectomy using a technique developed specifically for robotic surgery. The neurovascular bundles were easily identified and dissected away, the specimen entrapped in a bag and removed through a 5-6 cm suprapubic incision. Second, a different surgical team exteriorized the bowel through this incision and created a neobladder extracorporeally. Third, the neobladder was internalized, the incision closed and the primary surgeon completed the urethro-neovesical anastomosis with robotic assistance. RESULTS: RRCP was carried out in 14 men and three women by the primary surgeon (M.M.). The form of urinary reconstruction was ileal conduit in three, a W-pouch with a serosal-lined tunnel in 10, a double-chimney or a T-pouch with a serosal-lined tunnel in two each. The mean operative duration for robotic radical cystectomy, ileal conduit and orthotopic neobladder were 140, 120 and 168 min, respectively. The mean blood loss was < 150 mL. The number of lymph nodes removed was 4-27, with one patient having N1 disease. The margins of resection were free of tumour in all patients. CONCLUSIONS: We developed a technique for nerve-sparing RRCP using the da Vinci system which allows precise and rapid removal of the bladder with minimal blood loss. The bowel segment can be exteriorized and the most complex form of orthotopic bladder can be created through the incision used to deliver the cystectomy specimen. Performing this part of the operation extracorporeally reduced the operative duration.

Laparoscopic nephrectomy: prediction of outcome in relation to the preoperative risk factors in two approaches.

PURPOSE: The data on laparoscopic nephrectomy in Mansoura Urology & Nephrology Center were reviewed to identify the preoperative findings that may predict the need for conversion to open surgery. PATIENTS AND METHODS: One hundred sixty-three patients were subjected to transperitoneal laparoscopic nephrectomy, while 82 underwent retroperitoneal laparoscopic nephrectomy for benign renal diseases. The preoperative demographic data and laboratory and radiologic findings of these patients were correlated with failure rate of the laparoscopic procedure. RESULTS: The overall failure rate was 10.4% and 11% for the transperitoneal and retroperitoneal approach, respectively. Positive urine culture, renographic clearance of the removed kidney (>10 ml/min), and learning curve were independently associated with a greater risk of failure in patients undergoing transperitoneal nephrectomy. For the retroperitoneal approach, a positive urine culture, renographic clearance (> or =10 ml/min), and large kidney showed statistical significance. CONCLUSION: Preoperative data could be used as a predictor of laparoscopic nephrectomy outcome in patients with benign renal diseases. A more experienced surgeon should be selected for risky cases, bearing in mind the greater potential for early conversion to open surgery.

Rectosigmoid urinary diversion: the functional significance of creating an intussuscepted colorectal valve.

PURPOSE: We assess the functional importance of a colorectal valve in patients with rectal urinary diversion. MATERIALS AND METHODS: A retrospective evaluation of 87 patients with an anal sphincter controlled bladder substitute was performed. Of these patients 42 had colorectal valves and 45 did not. Evaluation included serum chemistry studies and arterial blood samples to study the impact of the colorectal valve on homeostasis. RESULTS: There was a statistically significant difference between the 2 groups in pH, carbon dioxide partial pressure, bicarbonate, base excess and chloride in favor of patients with a colorectal valve. CONCLUSIONS: The difference between the groups was reduction of the surface area available for reabsorption when a valve is constructed. This finding is of particular importance among patients with a long life expectancy. Prophylactic alkalization is necessary in cases without valve reconstruction.

Expression of bcl-2 and p53 oncoproteins in schistosomiasis-associated transitional and squamous cell carcinoma of urinary bladder.

OBJECTIVES: To analyze the expression of bcl-2 and p53 proteins in schistosomiasis-associated bladder cancer compared to adjacent urothelium showing morphological alteration including hyperplasia, metaplasia and dysplasia. MATERIALS AND METHODS: Twenty-two formalin-fixed and paraffin-embedded samples of histologically confirmed schistosomiasis-associated bladder tumours were assessed for grade, pathological stage (pT category) and the presence of hyperplasia, metaplasia and dysplasia in adjacent mucosa. There were 11 transitional cell carcinomas (TCCs), 10 squamous cell carcinomas (SCCs) and one diffuse infiltrating (signet-ring cell type) adenocarcinoma. Epithelial hyperplasia was observed in seven cases and metaplasia in 18, most of which were squamous except for a single case of glandular metaplasia. Focal dysplastic areas were observed in eight cases. Sections were stained immunohistochemically for the expression of bcl-2 and p53 proteins. RESULTS: Immunoreactivity for bcl-2 was present in seven of 22 cases (four SCCs and three TCCs) of which three cases (two SCCs and one TCC) were strongly positive, but in contrast to previous studies, there was no increase in the poorly differentiated tumours, bcl-2 was absent in metaplastic and dysplastic epithelium (except in a single case of glandular metaplasia) but it was present at low levels in basal cells of morphologically normal or hyperplastic transitional epithelium in 15 of 22 cases. Nine of 11 TCCs and seven of 10 SCCs showed p53 nuclear immunoreactivity. Heterogenous weak to moderate immunoreactivity for p53 was seen in 13 of 18 cases of metaplasia and in seven of eight cases of dysplasia in the mucosa adjacent to tumours, p53 was absent in normal and hyperplastic urothelium. Co-expression of p53 and bcl-2 was only seen in well differentiated areas of three tumours (two SCCs and one TCC). CONCLUSION: This study detected the expression of bcl-2 in a subset of bladder cancers (32%), whereas most (72%) of the tumours expressed immunoreactive p53. Additionally, p53 was also detected in metaplastic and dysplastic epithelium. Over-expression of both p53 and bcl-2 in the same tumour was only evident in a minority of schistosomiasis-associated cancers (13%). There was no inverse relationship of p53 and bcl-2 immunoreactivity.