Robot-assisted radical prostatectomy in patients with previous renal transplantation.

PURPOSE: To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) in patients with previous renal transplantation. PATIENTS AND METHODS: We retrospectively identified all patients who had undergone RARP for localized prostate cancer between 2005 and 2008 at a single institution (N=228). Of these, three patients were renal transplant recipients. A four-arm robotic configuration was used in all patients. Port placement was modified in two of the three renal transplant recipients to avoid trauma to the renal allograft. Preoperative demographics, perioperative parameters, and postoperative outcomes were reviewed. RESULTS: RARP was completed successfully in all three renal transplant recipients. As expected, the American Society of Anesthesiologists score (3.3 vs 2.4) and Charlson weighted index of comorbidity (4.7 vs 2.4) were greater in previous transplant patients. There were no major differences in mean age, Gleason score, body mass index, estimated blood loss, operative time, complications, or oncologic outcomes between the two groups. Each of the patients with renal allografts had an undetectable prostate-specific antigen level and was continent (needing no pads) at 13 months of follow-up. CONCLUSIONS: RARP is feasible in patients with a previous renal transplant. Although technically more challenging, RARP can be performed in previous transplant patients with acceptable morbidity and oncologic outcomes similar to those of other prostate cancer patients.

A prospective randomized comparison of traditional laparoendoscopic single-site surgery with needlescopic-assisted laparoscopic nephrectomy in the porcine model.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site (LESS) surgery produces virtually no scar but is technically challenging because of the loss of triangulation. The objective of this study is to compare classic transumbilical LESS nephrectomy with needlescopic-assisted laparoscopy (NAL) surgery. In doing so, we evaluated whether the addition of a single 2-mm subcostal port could restore triangulation while not jeopardizing recovery or cosmetic outcome in the porcine model. MATERIALS AND METHODS: Ten female farm pigs were randomized to laparoscopic nephrectomy with either LESS or NAL. In LESS, a TriPort was placed through a single 2.5-cm umbilical incision. In NAL, 5- and 10-mm ports were placed in the umbilicus and a 2-mm port was placed in the midclavicular line. Preoperative, perioperative, and postoperative parameters were compared. Variables were analyzed with the Wilcoxon signed-rank test and two-tailed Fisher exact test. Cosmesis was evaluated objectively using the Vancouver Scar Scale and subjectively by a blinded dermatologist. A cost analysis was performed. RESULTS: Estimated blood loss was minimal in both groups (28.8 mL in LESS and 9.4 mL in NAL). Operative time was significantly shorter in NAL (103 vs 150 min; P<0.001). There was no difference in complications (2 vs 1; P=0.500), objective cosmesis (3.9 vs 3.8; P>0.2), or subjective cosmesis (2 vs 3; P=0.500). The NAL protocol had significantly lower disposable equipment costs ($363 vs $1696). CONCLUSIONS: The addition of a 2-mm subcostal port and the restoration of triangulation in the NAL protocol enable shorter operative times, increased surgeon comfort, improved technical ease, and lower costs while maintaining the scarless cosmesis of the traditional LESS protocol.

Comparison of a reduced radiation fluoroscopy protocol to conventional fluoroscopy during uncomplicated ureteroscopy.

OBJECTIVES: Although the long-term effects of radiation exposure are not completely predictable, the principle of keeping radiation exposure "as low as reasonably achievable" should be used. The purpose of this study was to compare fluoroscopy times before and after the implementation of a protocol designed to reduce fluoroscopy usage during ureteroscopy. METHODS: A retrospective review was conducted of 300 consecutive ureteroscopy patients at a single institution. Patients undergoing simple ureteroscopy without ancillary procedures or balloon dilation were further evaluated to determine the effect of a reduced fluoroscopy protocol. The protocol included several measures, including use of a laser-guided C-arm, use of a designated fluoroscopy technician and substitution of visual for fluoroscopic cues during ureteroscopy. Fluoroscopy times were compared between groups using a paired t test with P < .05 considered significant. RESULTS: Ureteroscopy cases before protocol implementation (n = 30) were compared with procedures after implementation (n = 30). Stone size and location were similar between groups. Protocol implementation significantly reduced the mean fluoroscopy exposure from 86.1 seconds (range 30-300) to 15.5 seconds (range 0-54; P < .001). There was no difference in mean operative time (74.2 vs 65.1 minutes; P = .14), or complications (2 patients vs 2 patients; P = 1) between groups. No complication in either group could be ascribed to the fluoroscopic technique. CONCLUSIONS: The reduced fluoroscopy protocol resulted in an 82% reduction in fluoroscopy time without altering patient outcomes. These simple radiation-reducing techniques add no technical difficulty and improve safety for the patient, surgeon, and operating room staff by lowering radiation exposure.