Are complications of transrectal ultrasound-guided biopsies of the prostate gland increasing?

Although transrectal ultrasound-guided biopsies (TRUSB) of the prostate gland are generally considered to be low-risk procedures, a study from Canada reported that there had been a significant increase in the percentage of hospital admissions following TRUSBs between 1996 and 2005 (1.0% to 4.1%). The authors speculated that the increase may be secondary to the emergence of antibiotic-resistant enteric bacteria or the result of an increasing number of cores taken with each TRUSB. In a chart review, we retrospectively evaluated complications from 2,080 consecutive TRUSBs performed by one urology group in Connecticut between January 2003 and August 2010. We identified seven patients (0.34%) who were admitted to an acute-care hospital for infectious complications and three patients (0.14%) who were admitted for bleeding. The risk of serious infections and bleeding did not significantly rise during the study period despite a significant increase in the mean number of biopsy cores taken.

Laparoscopic vascular control techniques in donor nephrectomy: Effects on vessel length.

BACKGROUND: Various techniques for vascular control have been used during urologic laparoscopic procedures. The importance of optimizing the vessel length and securing reliable vascular control are critical for procedures like laparoscopic donor nephrectomy. We aimed to determine the length of vessel lost by using 4 common techniques of vascular control in a fresh human cadaveric vascular model. METHODS: The techniques include application of 2 non-absorbable polymer-ligating clips (10-mm Hem-o-Lok MLX Weck Closure Systems, Research Triangle Park, NC), Endo-GIA II stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT), Endopath ETS35 stapler (35 mm length, 2.5mm staples, Ethicon Endo-Surgery), and the Endo Ta-30 stapler (30-mm length, 2.5-mm staples, Auto Suture, US Surgical, Norwalk, CT). RESULTS: The Endo-TA-30 stapler and the polymer clips resulted in significantly less compromise of the vessel length, when compared with the other methods of vascular control. CONCLUSIONS: The Endo-TA-30 stapler and the polymer clips can be applied during laparoscopic procedures where optimizing vascular length is important.

Methods of vascular control during laparoscopic donor nephrectomy.

Vascular control during laparoscopic donor nephrectomy (LDN) requires expeditious control of the renal artery and vein while preserving maximum graft vascular length. The vascular stapler with three rows of staples on either side of the division has been widely used, but it loses more vascular length than other methods. In the accompanying video, we illustrate vascular control with the different staplers and locking polymer clips. The techniques include two nonabsorbable polymer ligating clips (10-mm Hem-o-Lok; MLX Weck Closure Systems), the Endo-GIA Universal stapler (35-mm length, 2.5-mm staples; Autosuture), and the Endo-TA 30 stapler (30-mm length, 2.5-mm staples; Autosuture). In an in-vitro study, we previously determined that the Endo-TA 30 stapler and the polymer clips resulted in significantly less compromise of the vessel length compared with the other methods of vascular control. LDN has been recently included by the clip manufacturer as a contraindication for the use of the polymer locking clips. The Endo TA stapler can be used when preservation of maximum graft vascular length is important.

Evaluation of hydrogel tissue sealant in porcine laparoscopic partial-nephrectomy model.

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) is technically challenging with a steep learning curve, primarily because techniques used to control bleeding on the cut surface of the kidney can be ineffective, inconsistent, or challenging. Hemostatic techniques can include intracorporeal suturing, vascular coagulation (argon-beam coagulator, bipolar cautery, laser), and application of various tissue sealants. There is no uniformity of opinion regarding which hemostatic technique is optimal for this application. CoSeal, a hydrogel (Baxter Healthcare Corp, Deerfield, IL), has been effective following vascular surgery but has not been applied to a partial-nephrectomy model. We evaluated the effectiveness of this hydrogel in controlling bleeding and sealing the collecting system by comparing it with intracorporeal suturing and fibrin sealant (Tisseel; Baxter) in a porcine laparoscopic partial-nephrectomy model. MATERIALS AND METHODS: Bilateral synchronous upper-pole partial nephrectomies were performed in two groups of 18 farm pigs, and the three hemostatic techniques (suturing, Tisseel, CoSeal) were applied. In the first group, partial nephrectomies were performed and the pigs sacrificed 3 days postoperatively (acute group). In the second group, the pigs were euthanized 6 weeks postoperatively (chronic group). In both groups, weight, blood pressure, estimated blood loss, weight of the partial and completion nephrectomy specimen, presence/ absence of urinary leak on retrograde study, histopathologic findings, and complications were recorded. RESULTS: The mean weight, blood pressure, estimated blood loss, histopathology findings, and weight of the partial and completion nephrectomy specimens were similar in the three groups. CoSeal did not adhere well to the renal parenchyma compared with Tisseel. All three animals in the acute CoSeal group and three of the six pigs in the sutured group had small urinary leaks during retrograde ureteral study, whereas none of the pigs in the fibrin-glue cohort had urinary leaks. There was one complication (urinary leak) in the CoSeal group, necessitating sacrifice of the animal on postoperative day 8 because of sepsis. CONCLUSIONS: CoSeal is not as effective as fibrin glue in adhering to the cut renal surface and sealing the collecting system during laparoscopic partial nephrectomy.

Comparison of laparoscopic pyeloplasty with and without robotic assistance.

OBJECTIVES: The benefits of laparoscopic surgery with robotic assistance (da Vinci Robotic Surgical System, Intuitive Surgical, Sunnyvale, CA) includes elimination of tremor, motion scaling, 3D laparoscopic vision, and instruments with 7 degrees of freedom. The benefit of robotic assistance could be most pronounced with reconstructive procedures, such as pyeloplasty. We aimed to compare laparoscopic pyeloplasty, with and without robotic assistance, during a surgeon's initial experience to determine whether robotic assistance has distinct advantages over the pure laparoscopic technique. METHODS: We retrospectively compared the first 7 laparoscopic pyeloplasties with the first 7 robotic pyeloplasties performed by a single surgeon. All patients were preoperatively evaluated with computed tomographic angiography with 3D reconstruction to image crossing vessels at the ureteropelvic junction. All patients were followed up by lasix renograms and routine clinic visits. RESULTS: Patients were similar with respect to mean age (34 in laparoscopic pyeloplasty group vs 32 in the robotic pyeloplasty group), operative time (5.2 hours vs 5.4 hours), estimated blood loss (40 mL vs 60 mL), and hospital stay (3 days vs 2.5 days). Two patients in the laparoscopic pyeloplasty group had small anastomotic leaks managed conservatively, and one patient in the robotic pyeloplasty group had a febrile urinary tract infection necessitating treatment with intravenous antibiotics. Another patient in the robotic pyeloplasty group was readmitted with hematuria that was treated conservatively without transfusion. No recurrences were detected in either group. CONCLUSIONS: Operating times and outcomes during the learning curve for laparoscopic pyeloplasty were similar to those for robotic pyeloplasty. Long-term data with greater experience is needed to make definitive conclusions about the superiority of either technique and to justify the expense of robotic pyeloplasty.

Absorbable laparoscopic cigarette sponge.

OBJECTIVES: Minor intraoperative bleeding during laparoscopy poses a significant challenge to the minimally invasive urologist. We report on our improvement of the previously reported laparoscopic cigarette sponge with absorbable materials. METHODS: The sponge was constructed from a strip of absorbable gelatin sponge wrapped in oxidized regenerated cellulose and secured with absorbable suture. This device can be inserted into the laparoscopic field through a standard 12-mm laparoscopic port and similarly removed. It can also remain intracorporeally if left behind following surgery. RESULTS: The sponge has proven to be very effective at controlling minor hemorrhage and aiding with dissection and retraction. CONCLUSION: This device has improved operative safety and provides a useful alternative when laparoscopic bleeding occurs.

Intraoperative mapping of renal lymphatic drainage: technique and application in a porcine model.

BACKGROUND AND PURPOSE: The use of lymphadenectomy in renal-cell carcinoma (RCC) is controversial. Proponents argue that lymphadenectomy improves survival, whereas opponents challenge the procedure on the basis of its morbidity and the variable lymphatic drainage of the kidney. Intraoperative gamma probes have been used to guide resection of radiolabeled sentinel nodes in cancers of the breast, penis, and head and neck and in melanoma. Our goal in applying this technique to RCC is to improve detection and to limit sampling of lymph nodes during lymphadenectomy. This preliminary study in a porcine model evaluated the feasibility and transit time of radiolabeled tracer injected into the kidney. MATERIALS AND METHODS: Data were collected on four 40-kg Yorkshire pigs. The right kidney was exposed through a flank incision. Using both blue dye and technetium-99m, mapping and resection of the sentinel lymph nodes was performed with the assistance of an intraoperative gamma probe (Neoprobe). Remote cervical lymph nodes were utilized as controls. Vascular counts along the carotid vessels were obtained to confirm that the radioisotope was not being dispersed systemically. RESULTS: Within 10 minutes of renal injection of the tracer, excised sentinel lymph nodes demonstrated significant radioactive counts compared with controls. Vascular counts confirmed that radioisotope tracer did not enter the venous circulation. CONCLUSIONS: Sentinel lymph node sampling using a gamma probe and blue dye appears to be feasible in the porcine kidney. Further studies using this technique in humans will evaluate the impact of selective lymphadenectomy on survival in RCC.

Simple perineal prostatectomy: lessons learned from a modern series.

PURPOSE: Experience with simple perineal prostatectomy has not been well described in the recent literature. We describe our operative technique and compare objective demographic, preoperative, intraoperative and postoperative parameters in patients undergoing open prostatectomy for benign prostatic hyperplasia via 3 routes, namely perineal, retropubic, and suprapubic. MATERIALS AND METHODS: We retrospectively reviewed all cases of open prostatectomy at Veterans Affairs Medical Center, San Diego between August 2001 and September 2002. A total of 22 patients were identified. Objective parameters were recorded and compared, including patient age, history of urinary retention, ultrasound volume, prostate specific antigen, patient and specimen weight, operative time, estimated blood loss, transfusion requirement, days of hospitalization and postoperative analgesic requirement. RESULTS: In the 22 patients who underwent open prostatectomy the operative approach was perineal in 6, retropubic in 8 and suprapubic in 8. Operative time and hospital stay were significantly less in the perineal prostatectomy group. CONCLUSIONS: Simple perineal prostatectomy is a viable alternative for most patients considered candidates for open prostatectomy and it is our preferred approach for obese patients. With perineal prostatectomy patients may expect shorter hospitalization and less analgesic requirement but likely require a longer period of catheter drainage.

Tubeless Barcat: a patient-friendly hypospadias procedure.

OBJECTIVES: To determine whether the distinct advantages of a catheter-free hypospadias repair can be obtained with a Barcat procedure without an adverse effect on surgical outcome. METHODS: A retrospective review was performed on consecutive patients who had undergone a catheter-free Barcat repair from July 1998 to May 2002. Patient records were examined for information regarding age, meatal location, primary or secondary procedure, operative time, postoperative follow-up, and complications. RESULTS: Thirty-six consecutive catheter-free Barcat hypospadias repairs were performed in the review period. Patient age ranged from 6 months to 9 years (mean 26 months). All patients either had a coronal meatus or a subcoronal meatus. Thirty-three patients (92%) underwent a primary repair. Three patients (8%) underwent the repair as a secondary procedure after a previous failed procedure. The mean follow-up was 25 months. One patient required a single catheterization in the immediate postoperative period for urinary retention. Another patient had glans separation and meatal retrusion requiring a revision procedure. All the other patients achieved a satisfactory cosmetic result with an orthotopic slit-like meatus. CONCLUSIONS: The Barcat hypospadias repair may be performed in patients with distal hypospadias without the use of a postoperative urethral catheter. Foregoing a catheter had no adverse effect on the surgical outcome with reduced patient discomfort.

Sexual dysfunction in combat veterans with post-traumatic stress disorder.

OBJECTIVES: To evaluate the prevalence, clinical correlates, and severity of sexual dysfunction in combat veterans with and without post-traumatic stress disorder (PTSD) using a validated instrument for assessing sexual function. The results of recent studies have suggested that combat veterans with PTSD experience a higher rate of sexual dysfunction than do those without PTSD. METHODS: We administered the International Index of Erectile Function (IIEF) and a demographic and health questionnaire to male combat veterans undergoing treatment for PTSD and to age-comparable male combat veterans without PTSD. RESULTS: The mean total IIEF score was significantly lower in the 44 patients with PTSD than in the 46 controls (26.38 versus 40.86; P = 0.035). With respect to the individual IIEF domains, patients with PTSD had poorer scores on overall satisfaction and orgasmic function and showed trends toward poorer scores on intercourse satisfaction and erectile function. No statistically significant difference was observed for sexual desire. The rate of erectile dysfunction was 85% in patients with PTSD and 22% in controls. Moderate to severe erectile dysfunction was present in 45% of the patients with PTSD and in only 13% of controls. Significantly more patients with PTSD (57%) than controls (17%) were using psychotropic medications. CONCLUSIONS: Combat veterans with PTSD experience a significantly higher rate of sexual dysfunction than do veterans without PTSD and show impairment in some, but not all, specific domains of sexual function. The IIEF may be useful in evaluating the response to treatment of erectile dysfunction. Clinicians should proactively address the sexual concerns of combat veterans with PTSD.