Nocturia in women.

PURPOSE OF REVIEW: Nocturia in women is a notable health concern, associated with significant morbidity and decreases in health-related quality of life. It is implicated in daytime somnolence and poor sleep quality, and has been found to negatively impact household activities, work, exercise, and sexual activity. This review is intended to relay new information regarding the prevalence, cause, risk factors, ramifications, and treatment options for nocturia in women as it gains traction as a clinical entity in and of itself. RECENT FINDINGS: New literature exposes the prevalence and burden of nocturia among young, healthy nulliparous women; reveals its presence in women without daytime symptoms; suggests its relationship with abnormal bowel function; and supports its association with obesity, cardiac burden and poor sleep. The link between nocturia and menopause has been challenged, and recent nomenclature describing the genitourinary symptoms of menopause excludes it from the list. Desmopressin and tamsulosin trials in women have demonstrated safety and efficacy in limiting nocturia frequency and severity, as well as in improving sleep parameters. SUMMARY: Nocturia is an impactful health issue at risk of being missed, especially in younger female patients. Open dialogue, purposeful questioning, and screening surveys can help elicit this symptom in women who are embarrassed or who accredit it to normal aging and therefore do not seek medical attention. In light of a growing geriatric population, nocturia is a clinical entity of increasing importance as it can be a clue to underlying systemic disorder or it can be an isolated symptom with significant clinical implications if left unaddressed.

The da vinci robot system eliminates multispecialty surgical trainees' hand dominance in open and robotic surgical settings.

BACKGROUND AND OBJECTIVES: Handedness, or the inherent dominance of one hand's dexterity over the other's, is a factor in open surgery but has an unknown importance in robot-assisted surgery. We sought to examine whether the robotic surgery platform could eliminate the effect of inherent hand preference. METHODS: Residents from the Urology and Obstetrics/Gynecology departments were enrolled. Ambidextrous and left-handed subjects were excluded. After completing a questionnaire, subjects performed three tasks modified from the Fundamentals of Laparoscopic Surgery curriculum. Tasks were performed by hand and then with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, California). Participants were randomized to begin with using either the left or the right hand, and then switch. Left:right ratios were calculated from scores based on time to task completion. Linear regression analysis was used to determine the significance of the impact of surgical technique on hand dominance. RESULTS: Ten subjects were enrolled. The mean difference in raw score performance between the right and left hands was 12.5 seconds for open tasks and 8 seconds for robotic tasks (P<.05). Overall left-right ratios were found to be 1.45 versus 1.12 for the open and robot tasks, respectively (P<.05). Handedness significantly differed between robotic and open approaches for raw time scores (P<.0001) and left-right ratio (P=.03) when controlling for the prior tasks completed, starting hand, prior robotic experience, and comfort level. These findings remain to be validated in larger cohorts. CONCLUSION: The robotic technique reduces hand dominance in surgical trainees across all task domains. This finding contributes to the known advantages of robotic surgery.

Robot-assisted nephroureterectomy and bladder cuff excision without patient or robot repositioning: description of modified port placement and technique.

INTRODUCTION: Nephroureterectomy (NUx) with full bladder cuff excision is the gold-standard treatment for upper urinary tract urothelial cancer. Although minimally invasive techniques for NUx have demonstrated comparable outcomes to those of the open technique, the robotic technique is limited by the need for intraoperative patient repositioning and robot redocking to manage the distal ureter and bladder cuff. We describe our novel technique of robotic NUx that allows for complete access to the kidney and full bladder cuff excision. PATIENTS AND METHODS: This modified technique was performed on a consecutive series of patients undergoing robotic NUx for upper urinary tract urothelial cancer from August 2012 to January 2014. Operative parameters and pathologic data were recorded, and patients were followed up for surveillance. After insufflation, the robotic trocars are placed in a standardized fashion, allowing for a one-time switch of instruments to facilitate distal ureteral dissection and a wide bladder cuff excision without patient repositioning or robot redocking. RESULTS: Twenty-six patients have undergone NUx using our modified technique. Mean blood loss and operative time were 66 mL and 230 minutes, respectively. There were no intraoperative complications or open conversions, and there were no positive surgical margins. The average follow-up time was 7.8 months (range, 2-17 months), and 4 cases of cancer recurrence in the bladder were identified. CONCLUSIONS: This novel technique for robotic NUx offers a standardized and easy-to-implement approach for NUx that requires a minimal learning curve for an experienced robotic surgeon, while affording a comparable oncologic control without the need for patient repositioning or additional port placement.

Dorsal penile nerve block for robot-assisted radical prostatectomy catheter related pain: a randomized, double-blind, placebo-controlled trial.

PURPOSE: Following Robotic-Assisted Radical Prostatectomy (RARP) patients routinely have penile pain and urethral discomfort secondary to an indwelling urethral catheter. Our objective was to assess the effect of dorsal penile nerve block with bupivacaine on urethral catheter-related pain after RARP. METHODS: From 2012-2013, 140 patients with organ-confined prostate cancer were enrolled in an IRB approved double-blinded, randomized control trial comparing a dorsal penile nerve block of bupivacaine versus placebo after RARP performed by a single-surgeon. Patients were asked to complete questionnaires using the Wong-Bakers FACES Pain Rating scale while hospitalized and for 9 days post-operatively, until the catheter was removed. The primary end-points were: catheter-related discomfort, abdominal (incisional) pain, and bladder spasm-related discomfort. Secondary end-points included narcotic and other analgesic usage. RESULTS: 120 patients were randomized to placebo vs. bupivacaine dorsal penile nerve bock. The two arms (n = 56 bupivacaine and n = 60 placebo) did not differ in preoperative, perioperative, or pathological results. There was no difference in narcotic utilization between the two cohorts. Abdominal pain was slightly lower in the bupivacaine arm at 6 hours compared to the placebo arm, but there was no difference in abdominal pain at other time points, and there were no differences in reported catheter-related discomfort or bladder spasm-associated discomfort at any of the measured time points. CONCLUSIONS: The data does not support the routine use of a dorsal penile nerve block with bupivacaine following RARP.

Baseline serum 25-hydroxyvitamin d levels in men undergoing radical prostatectomy: is there an association with adverse pathologic features?

INTRODUCTION/BACKGROUND: The purpose of this study was to evaluate the prevalence of vitamin D (VitD) deficiency in men undergoing radical prostatectomy and determine whether an association exists between preoperative VitD levels and adverse pathologic features. PATIENTS AND METHODS: Patients scheduled to undergo radical prostatectomy for clinically localized disease from January to August 2012 were prospectively followed and those with available preoperative serum 25-hydroxyvitamin D levels were included. Men with a known diagnosis of VitD deficiency or taking VitD supplementation were excluded. Cox regression analysis was performed to determine whether preoperative VitD level is predictive of adverse pathologic outcomes. RESULTS: One hundred consecutive men were included. Mean age was 62 (range, 42-79) years and mean VitD level was 26 (range, 6-57) ng/mL. Overall, 65 men (65%) had suboptimal levels of VitD (< 30 ng/mL), and 32 (32%) had deficiency (< 20 ng/mL). There was no significant correlation between VitD and age (P = .5). In logistic regression analysis, VitD level was not predictive of pathologic Gleason (P = .11), pathologic stage (P = .7), or positive margin status (P = .8). CONCLUSION: The association between VitD and prostate cancer has been controversial and data suggesting an increased risk of aggressive cancer in men with low levels of VitD have been inconsistent. We found that baseline preoperative VitD level was not associated with any adverse pathologic features. However, VitD deficiency is a common finding in this population, although unrelated to patient age. These results represent the first time the correlation between VitD and prostate cancer has been evaluated in a cohort of men undergoing radical prostatectomy.

The natural history of clinically complete responders to neoadjuvant chemotherapy for urothelial carcinoma of the bladder.

PURPOSE: We describe the clinical course of patients who achieved cT0 status after neoadjuvant chemotherapy for muscle invasive bladder cancer. There is no established treatment paradigm for these patients. MATERIALS AND METHODS: We retrospectively reviewed the records of 109 patients with muscle invasive bladder cancer (T2 or greater urothelial carcinoma of the bladder) who underwent platinum based neoadjuvant chemotherapy at our institution from 1988 to 2012. Post-chemotherapy assessment of the response included cytology, cystoscopy with biopsy and cross-sectional imaging. RESULTS: Of 109 patients 32 (29.4%) achieved cT0 status after neoadjuvant chemotherapy. Mean ± SD age of the cohort was 68.3 ± 9.6 years. Of the patients 21 received MVAC, 8 received gemcitabine and cisplatin, and 3 received another regimen. Seven complete responders elected immediate radical cystectomy after the completion of neoadjuvant chemotherapy. Of 25 patients who refused radical cystectomy after achieving cT0 status 7 experienced relapse after the completion of neoadjuvant chemotherapy and proceeded to radical cystectomy. The remaining 18 patients (72%) retained the bladder, including 6 (18.8% of the cohort) in whom nonmuscle invasive relapses were managed conservatively and 12 (37.5%) with no recurrence. In the 25 patients who elected bladder preservation after achieving cT0 status following neoadjuvant chemotherapy 5-year cancer specific survival was 88%. CONCLUSIONS: With proper counseling and identification of treatment goals patients with cT0 after neoadjuvant chemotherapy for muscle invasive bladder cancer may have the option to retain the bladder with durable survival. Larger studies are needed to identify possible predictors of response on the clinical, pathological and molecular levels.

Pain and analgesic use after robot-assisted radical prostatectomy.

PURPOSE: While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort. PATIENTS AND METHODS: From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0-10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE). RESULTS: A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasm-related discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved. CONCLUSIONS: After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer.

Comparison of robot-assisted and open retropubic radical prostatectomy for risk of biochemical progression in men with positive surgical margins.

OBJECTIVE: Robot-assisted radical prostatectomy (RARP) is a minimally invasive alternative to open retropubic radical prostatectomy (RP), and is reported to offer equivalent oncologic outcomes while reducing perioperative morbidity. However, the technique of extirpation can differ based on the usage of thermal energy and coagulation during RARP, which may alter the risk of finding a positive surgical margin (PSM) as cautery may destroy residual cancer cells. We sought to evaluate whether the method of surgery (RP vs RARP) affects the rate of biochemical recurrence (BCR) in patients with PSMs. MATERIALS & METHODS: The Columbia University Urologic Oncology Database was reviewed to identify patients who underwent RP and RARP from 2000 to 2010 and had a PSM on final pathology. BCR was defined as a postoperative prostate-specific antigen (PSA) ≥0.2 ng/mL. The Kaplan-Meier analysis was utilized to calculate BCR rates based on the method of surgery. Cox regression analysis was performed to determine if the method of surgery was associated with BCR. RESULTS: We identified 3267 patients who underwent prostatectomy, of which 910 (28%) had a PSM. Of those with a PSM, 337 patients had available follow-up data, including 229 who underwent RP (68%) and 108 who underwent RARP (32%). At a mean follow-up time of 37 months for the RP group, 103 (46%) patients demonstrated BCR; at a mean follow-up time of 44 months for the RARP group, 62 (57%) patients had a BCR (p=0.140). Two-year BCR-free rates for RP vs RARP were 65% and 49%, respectively (log-rank p<0.001). However, after controlling for age, PSA, grade, and year of surgery, the surgical method was not significantly associated with increased risk of BCR (HR 1.25; p=0.29). CONCLUSION: Our results confirm the noninferiority of RARP to RP with regard to patients with PSMs. As such, all patients with a PSM at RP are at high risk for BCR and should be followed in the same manner regardless of the surgical approach.

Outcomes with delayed dorsal vein complex ligation during robotic assisted laparoscopic prostatectomy.

INTRODUCTION: There are many concerns expressed by urologists performed robotic assisted laparoscopic prostatectomy (RALP) regarding management of the dorsal vein complex (DVC). We sought to examine the influence of delayed DVC ligation versus standard DVC ligation on the apical surgical margin status and other key surgical parameters following RALP. MATERIALS AND METHODS: The Columbia University Urologic Oncology Database was retrospectively reviewed to identify patients who underwent RALP between 2008-2011. Operative records were analyzed to determine whether the DVC was ligated in the 'standard' or 'delayed' manner. The standard group had the DVC ligated prior to the apical dissection; in the delayed group, the DVC was initially transected and subsequently oversewn after completion of the apical dissection. Clinical and pathologic data was retrospectively evaluated and stratified by the type of DVC ligation to compare positive apical margin rates based on DVC-control technique. RESULTS: A total of 244 patients were identified, including 118 in the standard group and 126 in the delayed group. Estimated blood loss (112 mL versus 122 mL), operative time (132 min versus 126 min), and postoperative continence rates (81% versus 84% at 3 months) were similar between the standard and delayed DVC groups (p = NS). Apical margin status was also similar in the two groups, with 3.4% having a positive surgical margin in the standard DVC ligation arm, and 1.6% having a positive margin in the delayed DVC ligation arm (p = 0.43). CONCLUSIONS: Delayed DVC ligation after apical dissection is a safe approach with comparable surgical outcomes during RALP. From a technical standpoint, we feel it allows for improved visualization of the apical dissection and therefore has become standard practice at our institution.

Characterization of perioperative leukocytosis in patients undergoing robot-assisted radical prostatectomy: effects of Gleason score and race.

INTRODUCTION: Our objective was to determine the impact of race and tumor grade on perioperative leukocytosis on patients undergoing robot-assisted radical prostatectomy (RARP). METHODS: A retrospective review of our urologic oncology database for patients undergoing RARP from August 2002 to July 2011 was conducted. A total of 768 patients were identified with complete data. Demographic data, preoperative prostate specific antigen (PSA), biopsy Gleason score, pathology Gleason score, pathology stage, margin status, and node status were collected. White blood cell (WBC) counts were captured preoperatively, 1 hour postoperatively, and on postoperative day 1. We assessed the differences in leukocyte responses according to the race and Gleason score using ANOVA testing. RESULTS: Preoperative WBC was lowest in black men and comparable between white and Hispanic men. At 1 hour, postoperative WBC remained lowest in Black men (p<0.001). Post-RARP leukocytosis varied significantly depending on the race (p<0.001). At 1 hour, patients with Gleason 8-10 tumors had decreased WBC compared to Gleason 6 patients (p<0.05) despite similar preoperative WBC and Charlson comorbidity index values. CONCLUSIONS: We report novel clinical observations that suggest differences in the immune response associated with the race and Gleason grade following RARP. The clinical utility of these findings are yet to be determined.

A Pilot Study of Laparoscopic Doppler Ultrasound Probe to Map Arterial Vascular Flow within the Neurovascular Bundle during Robot-Assisted Radical Prostatectomy.

Purpose. To report on the feasibility of a new Laparoscopic Doppler ultrasound (LDU) technology to aid in identifying and preserving arterial blood flow within the neurovascular bundle (NVB) during robotic prostatectomy (RARP). Materials and Methods. Nine patients with normal preoperative potency and scheduled for a bilateral nerve-sparing procedure were prospectively enrolled. LDU was used to measure arterial flow at 6 anatomic locations alongside the prostate, and signal intensity was evaluated by 4 independent reviewers. Measurements were made before and after NVB dissection. Modifications in nerve-sparing procedure due to LDU use were recorded. Postoperative erectile function was assessed. Fleiss Kappa statistic was used to evaluate inter-rater agreement for each of the 12 measurements. Results. Analysis of Doppler signal intensity showed maintenance of flow in 80% of points assessed, a decrease in 16%, and an increase in 4%. Plane of NVB dissection was altered in 5 patients (56%) on the left and in 4 patients (44%) on the right. There was good inter-rater reliability for the 4 reviewers. Use of the probe did not significantly increase operative time or result in any complications. Seven (78%) patients had recovery of erections at time of the 8-month follow-up visit. Conclusions. LDU is a safe, easy to use, and effective method to identify local vasculature and anatomic landmarks during RARP, and can potentially be used to achieve greater nerve preservation.

A novel solution to reduce the complications of distal shunt catheter displacement associated with obesity.

Despite the varied sources of hydrocephalus, all shunt-treated conditions involve redirection of CSF to the body, commonly the peritoneum. Migration of the distal catheter tip out of the peritoneal space can occur, leading to the need for reoperation. Although uncommon, the authors have recently had 3 such cases in obese patients involving distal tubing retropulsion in otherwise uncomplicated surgeries. In addressing this issue, the authors performed anchoring of the distal catheter tubing through a small abdominal mesh, which is commonly used for hernia repair to increase catheter tube friction without compromising CSF flow. The results suggest this method may mitigate the chance of peritoneal catheter displacement in patients with higher than normal intraabdominal pressure.

Laparoscopic pyelolithotomy with intraperitoneal ultrasonic lithotripsy: report of a novel minimally invasive technique for intracorporeal stone ablation.

We present the case of a 71-year-old Hispanic woman with a 4-cm stone in the renal pelvis of a kidney with thin parenchyma. Retrograde pyelography revealed a normal ureter and normal ureteropelvic junction. A ureteral stent was placed. Six weeks after the stent was placed, a differential renal scan revealed 18% function of the involved kidney. A percutaneous nephrolithotomy was not performed because of the thin parenchyma and intrarenal anatomy, which would have complicated access. The patient underwent an uncomplicated laparoscopic pyelolithotomy. The stone was placed into an Endocatch entrapment sack. The open end of the Endocatch sack was brought through a trocar site, and a nephroscope and ultrasonic lithotripter were deployed. The stone was fragmented and aspirated in the standard manner, thereby avoiding the need to extend the 12-mm trocar incision for stone extraction. The stone fragmentation and extraction time was 14 minutes. The patient was stone-free and discharged home in the morning of the first postoperative day without complications.