Microbiological evaluation of infected pelvic lymphocele after robotic prostatectomy: potential predictors for culture positivity and selection of the best empirical antimicrobial therapy.

OBJECTIVES: To examine symptomatology and microbiology of infected lymphocele (LC) post-robotic-assisted radical prostatectomy and pelvic lymph node dissection (PLND) and to assess for potential predictors for LC fluid culture positivity. Secondly, to provide general recommendations about use of select antimicrobial therapy. METHODS: This was a single-center, IRB-approved, retrospective, case series review conducted between October 2008 and October 2014. Data included symptomatology, microbiology of symptomatic LC in men post-robotic prostatectomy and PLND. Those with infected LC were compared to those men with symptomatic LC in the absence of infection. RESULTS: Symptomatic LC was seen in 7% of men, and among those, infected LC was seen in 42%. Infected LC cultures showed predominance of G+ cocci such as S. aureus, coagulase-negative Staphylococcus species, S. pyogenes, S. fecalis and S. viridans. Monomicrobial infection was seen in 85%. Multivariate logistic regression showed leukocytosis [Odds: 12.3, p = 0.03, 95% CI (1.2-125)] was significant predictor for culture positivity, whereas trend toward significance for factors such CT findings of thickened walls around the LC +/- air. CONCLUSIONS: LC infection following PLND for prostate cancer is usually monomicrobial and caused by Gram+ cocci. GI tract and skin flora are the main habitat. High index of suspicion of infected LC is undertaken in the presence of leukocytosis, fever and abnormal CT findings. Based upon our local hospital antibiogram, combination of IV ampicillin/sulbactam and vancomycin is suggested as the best initial empiric therapy in treating these patients.

Safer Surgery by Learning from Complications: A Focus on Robotic Prostate Surgery.

BACKGROUND: The uptake of robotic surgery has led to changes in potential operative complications, as many surgeons learn minimally invasive surgery, and has allowed the documentation of such complications through the routine collection of intraoperative video. OBJECTIVE: We documented intraoperative complications from robot-assisted radical prostatectomy (RARP) with the aim of reporting the mechanisms, etiology, and necessary steps to avoid them. Our goal was to facilitate learning from these complications to improve patient care. DESIGN, SETTING, AND PARTICIPANTS: Contributors delivered videos of complications that occurred during laparoscopic and robotic prostatectomy between 2010 and 2015. SURGICAL PROCEDURE: Surgical footage was available for a variety of complications during RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Based on these videos, a literature search was performed using relevant terms (prostatectomy, robotic, complications), and the intraoperative steps of the procedures and methods of preventing complications were outlined. RESULTS AND LIMITATIONS: As a major surgical procedure, RARP has much potential for intra- and postoperative complications related to patient positioning, access, and the procedure itself. However, with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, we suggest that the majority of such complications are preventable. CONCLUSIONS: Considering the complexity of the procedure, RARP is safe and reproducible for the surgical management of prostate cancer. Insight from experienced surgeons may allow surgeons to avoid complications during the learning curve. PATIENT SUMMARY: Robot-assisted radical prostatectomy has potential for intra- and postoperative complications, but with a dedicated approach, increasing experience, a low index of suspicion, and strict adherence to safety measures, most complications are preventable.

Infiltration of liposome bupivacaine into the transversus abdominis plane for postsurgical analgesia in robotic laparoscopic prostatectomy: a pilot study.

BACKGROUND: Transversus abdominis plane (TAP) infiltration has been increasingly used for postsurgical analgesia in abdominal/pelvic procedures; however, duration/extent of analgesia with standard local anesthetics is limited. This pilot study assessed the preliminary efficacy and safety of two volumes of liposome bupivacaine administered via TAP infiltration in patients undergoing robotic laparoscopic prostatectomy. METHODS: In this single-center, open-label, prospective study, patients older than 18 years received TAP infiltration with liposome bupivacaine immediately after surgery. The first 12 patients received a total volume of 20 mL liposome bupivacaine (266 mg); the next 12 received 40 mL liposome bupivacaine (266 mg). The liposome bupivacaine was diluted with 0.9% normal saline. The primary efficacy measure was duration of analgesia, measured by time to first opioid administration. Secondary outcome measures included patient-assessed pain scores, opioid use, and opioid-related adverse events (AEs). RESULTS: Twenty-four patients received liposome bupivacaine (20 mL, n=12; 40 mL, n=12) and were included in the primary analysis. Three refused participation in a 10-day follow-up visit and did not complete the study. Median time to first opioid administration after surgery was 23 and 26 minutes for the 20 and 40 mL groups, respectively. Mean total amount of postsurgical opioids ranged from 25.4 to 27.3 mg; after hospital discharge to day 10, both groups required a mean of 0.7 oxycodone/acetaminophen tablets/day. Mean pain scores of 4.4 and 5.3 were reported at 1 hour and 3.1 and 3.9 at 2 hours postsurgery, with 20 and 40 mL doses, respectively. Neither group had mean scores higher than 3.0 at any further assessments. No opioid-related or treatment-related serious AEs were reported. CONCLUSION: Median time to first opioid administration did not differ between the two groups. No differences in secondary outcomes were observed on the basis of volume administered. These initial findings suggest further study of liposome bupivacaine administered via TAP infiltration as part of a multimodal analgesic regimen in laparoscopic robotic prostatectomy may be warranted.

Chronic low dose-rate radiation down-regulates transcription related to mitosis and chromosomal movement similar to acute high dose in prostate cells.

PURPOSE: Despite concerns over risks from exposure to low-dose ionizing radiations encountered in the environment and workplace, the molecular consequences of these exposures, particularly at representative doses and dose-rates, remains poorly understood. MATERIALS AND METHODS: Using a novel flood source construct, we performed a direct comparison of genome-wide gene expression regulations resulting from exposure of primary human prostate fibroblast cultures to acute (10 cGy and 200 cGy) and longer-term chronic (1.0-2.45 cGy cumulative over 24 h) exposures. RESULTS: Expression profiling showed significant differential regulation of 396 genes with no measureable changes in the acute 10 cGy dose. However, there were 106 genes in common between samples given an acute 200 cGy dose compared to those given chronic doses, most of which were decreased and related to cell cycle or chromosomal movement in M-phase. Biological pathway analysis showed decreases in cell cycle, chromosomal movement, cell survival and DNA replication, recombination and repair as well as a predicted activation of transcriptional regulators TP53, RB1 and CDKN2A. In agreement with these results, prostate epithelial cells given 200 cGy or chronic doses displayed functional decreases in proliferation and mitotic cells. CONCLUSIONS: In summary, we showed a contrast to the common observation of constant or reduced effect per unit dose as the dose (acute) was diminished, that even very low total doses delivered chronically could rival the perturbing effect of acute doses 100 times as intense. Underscored is the importance of the means of dose delivery, shown to be as important as dose size when considering biologic effect.

Robot-assisted radical cystectomy in octogenarians.

BACKGROUND AND PURPOSE: Radical cystectomy is the standard of care for muscle-invasive bladder cancer; however, few patients over age 75 undergo cystectomy. Morbidity and mortality rates in this age group approach 60% and 10%, respectively. We sought to determine if minimally invasive surgery, in the form of robot-assisted radical cystectomy (RARC), may reduce morbidity and mortality associated with this operation in elderly patients. PATIENTS AND METHODS: After Institutional Review Board approval, all RARC performed between 2009 and 2012 from one institution were reviewed, and 23 cases in patients over the age of 80 were identified. Data analyzed included age, indication for cystectomy, American Society of Anesthesiologists score (ASA), Charlson Comorbidity Index, pathologic stage, estimated blood loss, transfusion rate, and 90-day morbidity and mortality rate. RESULTS: Twenty-three patients over the age of 80 years underwent RARC by a single surgeon (IT) between April 2009 and October 2012. Average age was 83.7 years (range 80-88 years) with average Charlson Comorbidity Index score of 4.3 (age-weighted 8.3). Indication for cystectomy was oncologic in all cases (21 bladder malignancy, 2 hemorrhagic cystitis in the setting of prostate cancer). The average blood loss and operative times were 208 mL (range 50-650 mL) and 253 minutes (range 175-365 min). Seven (30.4%) patients needed blood transfusions. The average length of hospital stay was 8.2 days (range 6-24 days). The overall complication rate within 90 days was 34.8% (8 patients) with no mortality. Longest follow-up is 34 months. CONCLUSIONS: RARC should be strongly considered for patients over the age of 80 with clinical indications for cystectomy. The complication rate is acceptable even in complicated patients with multiple comorbidities and those with previous abdominal surgery or pelvic radiation. Hospital stay remains shorter than with open surgery, and complication rates appear to be lower than previously reported for this age group.

Single surgeon's experience with laparoscopic versus robotic partial nephrectomy: perioperative outcomes/complications and influence of tumor characteristics on choice of therapy.

INTRODUCTION: Laparoscopic (LPN) and robotic partial nephrectomy (RPN) may offer similar advantages for nephron-sparing surgery (NSS). We evaluated the perioperative outcomes and complications of LPN versus RPN and sought to evaluate if one technique may have more favorable outcomes over another based on tumor characteristics. MATERIALS AND METHODS: All patients who underwent LPN and RPN by a single surgeon were retrospectively reviewed. The surgeon almost exclusively performed LPN from February 2009 to January 2011 and RPN from January 2011 to January 2012. Patient demographics, tumor characteristics, perioperative outcomes, short term renal functional data, and complications were reviewed. Operative time (OT), warm ischemia time (WIT), and estimated blood loss (EBL) were evaluated for each technique when tumor characteristics were divided by size, location, distance to collecting system, and overall tumor complexity based on nephrometry scoring. RESULTS: Of 39 laparoscopic cases and 30 robotic cases, there were no significant differences in perioperative outcomes, short term renal functional data, or complications between the two groups except for WIT which was shorter in the LPN group (p = 0.006). For medium complexity tumors, OT was less for LPN compared to RPN (p = 0.04); for high complexity tumors, EBL was reduced for RPN compared to LPN cases (p = 0.003). When tumor characteristics were individualized, LPN may be superior to RPN for WIT for small, anterior and exophytic tumors, and tumors located > 5 mm from the collecting system. LPN and RPN appear more equivocal for WIT in posteriorly located tumors. Reduced EBL may be a benefit with RPN for larger tumors. CONCLUSIONS: Although WIT was less in patients undergoing LPN compared to RPN, perioperative outcomes and complications remain similar. RPN may be beneficial for approaching more difficult, posterior tumors, whereas LPN may be a better technique for WIT for simple, accessible renal tumors. Reduced EBL may be a benefit for RPN for highly complex tumors.

Significance of prostate weight on peri and postoperative outcomes of robot assisted laparoscopic extraperitoneal radical prostatectomy.

INTRODUCTION: To determine the significance of prostate weight (PW) on clinical and pathological outcomes in patients undergoing da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP). METHODS: From November 2008 to January 2010, 295 men underwent EP-RARP at our institution. We retrospectively reviewed our database and stratified patients into four groups based on pathologic PW: Group 1, less than 30 g; Group 2, 30 g to less than 50 g; Group 3, 50 g to less than 80 g; and Group 4, 80 g or larger. We prospectively compared these groups with respect to patient age, body mass index, prostate-specific antigen, Gleason score, pathological stage, margin status, operative time, blood loss, transfusion rate and length of stay. Statistical analysis was performed using SYSTAT 13 software. An analysis of variance (ANOVA) model was used to compare the continuous variables among the groups. Chi-square and Fisher's exact tests were used to compare categorical variables. RESULTS: Of the 295 patients, 10, 182, 91, and 12 had a PW of less than 30 g; 30 g to less than 50 g; 50 g to less than 80 g; and 80 g or larger, respectively. A significant difference was found in age, prostate weight and prostate-specific antigen values among the four groups (p < 0.05). Patients in Group 4 had larger prostates, were older (mean age 65 years), had higher pretreatment prostate-specific antigen (median 5.85 ng/mL) and lower Gleason score (mean 6.2). Based on the D'Amico risk stratification, our study showed a trend toward higher risk disease, presence of extra capsular extension, seminal vesicle invasion and positive margin status in Groups 1, 2 and 3 rather than in Group 4. No significant differences in operative time, estimated blood loss, transfusion rate, hospital stay, and postoperative complication rate were observed among the four groups. CONCLUSIONS: Da Vinci robot assisted laparoscopic extraperitoneal radical prostatectomy (EP-RARP) is feasible in patients with larger prostates, offering acceptable operative times, blood loss, hospital stay and complication rates. In our cohort of patients, we found pathologically smaller prostates are generally associated with higher Gleason score, higher risk group stratification and positive surgical margin status. Although technically challenging, increased prostate weight should not be considered a contraindication for EP-RARP if performed by experienced surgeons.

The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study.

BACKGROUND: We previously reported the learning curve for open radical prostatectomy, reporting large decreases in recurrence rates with increasing surgeon experience. Here we aim to characterise the learning curve for laparoscopic radical prostatectomy. METHODS: We did a retrospective cohort study of 4702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January, 1998, and June, 2007. Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and prostate-cancer recurrence, with adjustment for established predictors. FINDINGS: After adjusting for case mix, greater surgeon experience was associated with a lower risk of recurrence (p=0.0053). The 5-year risk of recurrence decreased from 17% to 16% to 9% for a patient treated by a surgeon with 10, 250, and 750 prior laparoscopic procedures, respectively (risk difference between 10 and 750 procedures 8.0%, 95% CI 4.4-12.0). The learning curve for laparoscopic radical prostatectomy was slower than the previously reported learning curve for open surgery (p<0.001). Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic (risk difference 12.3%, 95% CI 8.8-15.7). INTERPRETATION: Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery. Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy. FUNDING: National Cancer Institute, the Allbritton Fund, and the David J Koch Foundation.

Laparoscopic partial cystectomy for urachal and bladder cancer.

PURPOSE: To report our initial experiences with laparoscopic partial cystectomy for urachal and bladder malignancy. MATERIALS AND METHODS: Between March 2002 and October 2004, laparoscopic partial cystectomy was performed in 6 cases at 3 institutions; 3 cases were urachal adenocarcinomas and the remaining 3 cases were bladder transitional cell carcinomas. All patients were male, with a median age of 55 years (45-72 years). Gross hematuria was the presenting symptom in all patients, and diagnosis was established with trans-urethral resection bladder tumor in 2 patients and by means of cystoscopic biopsy in the remaining 4 patients. Laparoscopic partial cystectomy was performed using the transperitoneal approach under cystoscopic guidance. In each case, the surgical specimen was removed intact entrapped in an impermeable bag. One patient with para-ureteral diverticulum transitional cell carcinoma required concomitant ureteral reimplantation. RESULTS: All six procedures were completed laparoscopically without open conversion. The median operating time was 110 minutes (90-220) with a median estimated blood loss of 70 mL (50-100). Frozen section evaluations of bladder margins were routinely obtained and were negative for cancer in all cases. The median hospital stay was 2.5 days (2-4) and the duration of catheterization was 7 days. There were no intraoperative or postoperative complications. Final histopathology confirmed urachal adenocarcinoma in 3 cases and bladder transitional cell carcinoma in 3 cases. At a median follow-up of 28.5 months (range: 26 to 44 months), there was no evidence of recurrent disease as evidenced by radiologic or cystoscopic evaluation. CONCLUSIONS: Laparoscopic partial cystectomy in carefully selected patients with urachal and bladder cancer is feasible and safe, offering a promising and minimally invasive alternative for these patients.

Pure laparoscopic donor nephrectomy: 3-year experience and analysis of a refined technique to maximize graft function.

PURPOSE: Strategies for vascular control and limiting warm ischemia time (WIT) vary between institutions for laparoscopic live donor nephrectomy (LLDN). We refined our technique and retrospectively determined whether it safely provides an allograft of comparable quality to published series. PATIENTS AND METHODS: Fifty consecutive LLDN between February 2003 and November 2006 were reviewed. Key technical aspects include placing the perfused kidney and transected ureter entirely within an endocatch bag, with the string externalized through an extended lateral port site incision. Vessels are then controlled with clips, or a Satinsky clamp for right sided veins. The extraction incision is completed and the bag immediately withdrawn and placed on ice. WIT ends with perfusion with cold UW solution. RESULTS: The series includes 42 left and 8 right kidneys. 13/50 (26%) demonstrated anatomical complexity (more than one artery, vein and/or ureter). Average operative time was 178 minutes. Average WIT was 128 seconds. Conversion to open surgery occurred in two patients, one to define challenging anatomy, and another for hemorrhage from the renal artery stump. Average blood loss was 76 ml. Average length of stay was 3.6 days. Average recipient creatinine was 1.26 mg/dl at discharge. Delayed graft function occurred in three recipients. ATN/slow normalization of creatinine occurred in four. Graft survival at one year was 96%. CONCLUSIONS: The refined technique of LLDN mimics important principles of open donor nephrectomy. Controllable variables which may impact graft function are optimized. WIT is amongst the lowest reported for pure laparoscopy, without increasing complication rates, blood loss, or operative time.

Complications of laparoscopic retroperitoneal lymph node dissection in testicular cancer.

OBJECTIVES: A proposed benefit of laparoscopic retroperitoneal lymph node dissection (LRPLND) is more favorable morbidity in comparison to open retroperitoneal lymph node dissection (RPLND). The objective of this review is to examine and summarize the literature regarding complications in both primary and post-chemotherapy LRPLND (PC-LRPLND) and, where appropriate, we include the opinions of the senior author regarding management. METHODS: A MEDLINE search was performed using the terms "laparoscopy" or "laparoscopic," "retroperitoneal lymph node dissection" or "RPLND," and "testicular neoplasms." Articles were included on the basis of study design and content. For series updated over time, an effort was made to include only the most recent data to avoid duplicate reporting of patients. RESULTS: In primary LRPLND, vascular injury is the most common complication, occurring in 2.2-20% of reported cases. Bowel injury is rarely reported but potentially catastrophic. Rates of retrograde ejaculation are less than 5%. Chylous ascites and lymphocele are delayed post-operative complications. Rarely reported complications include nerve injury, retroperitoneal hematoma, and ureteral injury requiring internal stent placement. PC-LRPLND is challenging, with high rates of conversion and complications. Hemorrhage is common. Retrograde ejaculation is several-fold more common in PC-LRPLND than in primary LRPLND. No peri-operative mortality has been reported for either LRPLND or PC-LRPLND. CONCLUSIONS: LRPLND and PC-LRPLND are technically demanding. Hemorrhage and vascular injury are the most commonly reported complications. Prospective studies will help clarify the proposed benefits of LRPLND.

Laparoscopic radical prostatectomy: omitting a pelvic drain.

PURPOSE: Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. MATERIALS AND METHODS: A retrospective chart review was performed for all patients undergoing LRP between January 2003 and December 2004. The anastomosis was performed using a modified van Velthoven technique. A drain was placed at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. RESULTS: 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8%. A drain was placed in 51 patients. Of these, 8 (15.6%) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5%). The higher leak rate in the drained vs. undrained cohort was statistically significant (p = 0.002). Twenty-four patients underwent pelvic lymph node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. CONCLUSIONS: Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Comparing the Gleason prostate biopsy and Gleason prostatectomy grading system: the Lahey Clinic Medical Center experience and an international meta-analysis.

BACKGROUND: The accuracy of the prostate biopsy Gleason grade to predict the prostatectomy Gleason grade varies tremendously in the literature. OBJECTIVES: Determine the accuracy and distribution of the prostate biopsy Gleason grade and prostatectomy Gleason grade at LCMC (Lahey Clinic Medical Center) and worldwide. DESIGN, SETTING, AND PARTICIPANTS: Participants included 2890 patients who had not received preoperative hormones, and for whom preoperative and postoperative Gleason sums were available. Participants underwent radical prostatectomy at LCMC, an academic referral center, from 1982-2007. Studies for the meta-analysis were selected from Medline: 1994-2007. Search criteria included keywords "Gleason," "biopsy," and "prostatectomy," >/=200 patients, and whether the biopsy and prostatectomy Gleason scores categorized into the predefined Gleason grades. The meta-analysis included 15 studies and the LCMC database for 14,839 total patients. MEASUREMENTS: Gleason scores 2-6, 7, and 8-10 were converted to low, moderate, and high grade, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated. The kappa statistic and chi-square were used to compare biopsy and prostatectomy grades. RESULTS AND LIMITATIONS: The percentage of patients in whom the prostatectomy grade was accurately predicted, upgraded, and downgraded was 58%, 36%, and 5% at LCMC and 63%, 30%, and 7% in the meta-analysis, respectively. The PPV for low-, moderate-, and high-grade cancer was 54%, 70%, and 60% for LCMC and 62%, 70%, and 50% for the meta-analysis, respectively. The sensitivity decreased with increasing Gleason grade (low, moderate, and high) for LCMC (91%, 38%, 28%) and the meta-analysis (90%, 40%, 33%), respectively. The distribution of low-, moderate-, and high-grade cancer on biopsy (69%, 25%, and 6%) and prostatectomy specimen (47%, 44%, and 9%) demonstrated only "fair" agreement (kappa, 0.37). CONCLUSIONS: Patients and practitioners need to be cognizant of significant upgrading for low-grade disease and the downgrading for high-grade disease.

Laparoscopic radical prostatectomy: omitting a pelvic drain

PURPOSE: Our goal was to assess outcomes of a selective drain placement strategy during laparoscopic radical prostatectomy (LRP) with a running urethrovesical anastomosis (RUVA) using cystographic imaging in all patients. Materials and Methods: A retrospective chart review was performed for all patients undergoing LRP between January 2003 and December 2004. The anastomosis was performed using a modified van Velthoven technique. A drain was placed at the discretion of the senior surgeon when a urinary leak was demonstrated with bladder irrigation, clinical suspicion for a urinary leak was high, or a complex bladder neck reconstruction was performed. Routine postoperative cystograms were obtained. RESULTS: 208 patients underwent LRP with a RUVA. Data including cystogram was available for 206 patients. The overall rate of cystographic urine leak was 5.8 percent. A drain was placed in 51 patients. Of these, 8 (15.6 percent) had a postoperative leak on cystogram. Of the 157 undrained patients, urine leak was radiographically visible in 4 (2.5 percent). The higher leak rate in the drained vs. undrained cohort was statistically significant (p = 0.002). Twenty-four patients underwent pelvic lymph node dissection (8 drained, 16 undrained). Three undrained patients developed lymphoceles, which presented clinically on average 3 weeks postoperatively. There were no urinomas or hematomas in either group. CONCLUSIONS: Routine placement of a pelvic drain after LRP with a RUVA is not necessary, unless the anastomotic integrity is suboptimal intraoperatively. Experienced clinical judgment is essential and accurate in identifying patients at risk for postoperative leakage. When suspicion is low, omitting a drain does not increase morbidity.

Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications. METHODS: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression. RESULTS: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors. CONCLUSIONS: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.

Laparoscopic partial cystectomy for urachal and bladder cancer

PURPOSE: To report our initial experiences with laparoscopic partial cystectomy for urachal and bladder malignancy. MATERIALS AND METHODS: Between March 2002 and October 2004, laparoscopic partial cystectomy was performed in 6 cases at 3 institutions; 3 cases were urachal adenocarcinomas and the remaining 3 cases were bladder transitional cell carcinomas. All patients were male, with a median age of 55 years (45-72 years). Gross hematuria was the presenting symptom in all patients, and diagnosis was established with trans-urethral resection bladder tumor in 2 patients and by means of cystoscopic biopsy in the remaining 4 patients. Laparoscopic partial cystectomy was performed using the transperitoneal approach under cystoscopic guidance. In each case, the surgical specimen was removed intact entrapped in an impermeable bag. One patient with para-ureteral diverticulum transitional cell carcinoma required concomitant ureteral reimplantation. RESULTS: All six procedures were completed laparoscopically without open conversion. The median operating time was 110 minutes (90-220) with a median estimated blood loss of 70 mL (50-100). Frozen section evaluations of bladder margins were routinely obtained and were negative for cancer in all cases. The median hospital stay was 2.5 days (2-4) and the duration of catheterization was 7 days. There were no intraoperative or postoperative complications. Final histopathology confirmed urachal adenocarcinoma in 3 cases and bladder transitional cell carcinoma in 3 cases. At a median follow-up of 28.5 months (range: 26 to 44 months), there was no evidence of recurrent disease as evidenced by radiologic or cystoscopic evaluation. CONCLUSIONS: Laparoscopic partial cystectomy in carefully selected patients with urachal and bladder cancer is feasible and safe, offering a promising and minimally invasive alternative for these patients.

Oncologic efficacy of laparoscopic RPLND in treatment of clinical stage I nonseminomatous germ cell testicular cancer.

OBJECTIVES: To assess the oncologic efficacy of laparoscopic retroperitoneal lymph node dissection (LRPLND) for clinical Stage I nonseminomatous germ cell tumors (NSGCTs) in a large multi-institutional series. LRPLND is emerging as a less-invasive alternative in the adjuvant surgical treatment of patients with testicular cancer. METHODS: The medical records of 120 patients with clinical Stage I NSGCT who underwent LRPLND at one of four institutions in the United States were retrospectively analyzed. All patients had at least 12 months of postoperative follow-up. The modified template dissection was performed at all centers. For the purposes of analysis, the patients were divided into two groups: those with consonant clinical and pathologic Stage I disease (n = 74, 62%) and those upstaged to pathologic Stage II (n = 46, 38%). RESULTS: No patient, including those upstaged to pathologic Stage II disease undergoing surveillance (n = 10), presented with retroperitoneal recurrence after LRPLND. Two patients with consonant pathologic Stage I developed pelvic recurrence that was outside the standard dissection template. The median follow-up for the patients with pathologic Stage I was 28.5 months (range 12 to 144) and was 29 months (range 12 to 108) for those with pathologic Stage II. CONCLUSIONS: In this group of patients with clinical Stage I NSGCT, management at multiple institutions that included LRPLND provided excellent intermediate results, paralleling those historically achieved with open lymph node dissection.

Progression of laparoscopic radical prostatectomy: improved outcomes with the extraperitoneal approach and a running anastomosis.

PURPOSE: To compare the operative and perioperative outcomes of patients undergoing either a transperitoneal or an extraperitoneal laparoscopic radical prostatectomy (TLRP or ELRP) with either an interrupted or a running urethrovesical anastomosis (IUVA or RUVA). PATIENTS AND METHODS: From January 2003 through December 2004, 265 patients underwent LRP by one surgeon at the Lahey Clinic Medical Center. They were divided into three groups according to the operative approach (TLRP or ELRP) and the suture anastomosis (IUVA or RUVA): group 1 = TLRP and IUVA (N = 58; 21.6%), group 2 = TLRP and RUVA (N = 35; 13.1%), and group 3 = ELRP and RUVA (N = 172; 64.2%). RESULTS: Group 3 had statistically better outcomes, as judged by operative time (222, 191, and 170 minutes for groups 1, 2, and 3, respectively; P < 0.0001), postoperative analgesic use (39.6, 30.4, and 18.9 mg of narcotic; P < 0.0001), length of stay (3.76, 2.74 days, and 1.67 days; P < 0.0001), leak on postoperative cystogram (17.9%, 11.4%, and 3.5%; P = 0.001), and complication rate (32.8%, 11.4%, and 9.9%; P < 0.0001). The groups had similar estimated blood loss (168, 145, and 176 mL) and positive surgical-margin rates (15.5%, 14.3%, and 14.5%). CONCLUSIONS: We demonstrate improved surgical outcome for ELRP with RUVA in regard to operative time, analgesic use, length of stay, leak rate, and complication rate. Long-term follow-up will determine whether a difference exists in disease recurrence, continence, and erectile function.

Laparoscopic radical cystectomy with continent urinary diversion.

Laparoscopic radical cystectomy with urinary diversion, although challenging even for the skilled laparoscopist, has evolved rapidly throughout the past decade. These advances are attributable to a series of well-designed animal studies transitioned carefully to humans. Short-term data have shown that this is a feasible technique that respects the basic principles of surgical oncology. However, the possibility of decreased blood loss, improved visualization, shorter hospital stay, and less postoperative pain are balanced against technical difficulty, long operative times, and unproved long-term efficacy compared with the open gold standard. The goal of this review is to reflect the available literature with regard to surgical indications, the current technique in evolution, short-term morbidity, and oncologic outcomes.