Nerve Sparing, Robot-Assisted Radical Cystectomy with Intracorporeal Bladder Substitution in the Male.

PURPOSE: We provide a step-by-step description of our technique of nerve and seminal vesicle sparing robot-assisted radical cystectomy with an orthotopic neobladder. We also present preliminary oncologic and functional outcomes. MATERIALS AND METHODS: Nerve and seminal vesicle sparing robot-assisted radical cystectomy with a modified Y-shaped orthotopic neobladder was performed by the same surgeon in 40 men with clinically localized bladder cancer from January 2011 to September 2014. Operative, perioperative and pathological data as well as continence and erectile function outcomes are presented. RESULTS: Median followup was 26.5 months (range 8 to 52). A soft tissue positive surgical margin was found in a patient with pT3a disease. A global rate of 30% early and 32.5% late complications was observed. However, the grade III or higher complication rate was low in both settings at 2.5% and 5%, respectively. There was 1 cancer related death 23 months after surgery. Of the 40 patients 30 (75%) gained daytime continence (0 pad) within 1 month postoperatively. The 12-month nocturnal continence rate was 72.5% (29 of 40 patients). Mean preoperative IIEF-6 (International Index of Erectile Function-6) score was 24.4. Erectile function returned to normal, defined as an IIEF-6 score greater than 17, in 31 of 40 patients (77.5%) within 3 months while 29 of 40 patients (72.5%) returned to the preoperative IIEF-6 score within 12 months. CONCLUSIONS: In the hands of an experienced surgeon nerve and seminal vesicle sparing robot-assisted radical cystectomy with intracorporeal reconstruction of the neobladder seems feasible and safe. It provides short-term oncologic efficacy and promising functional outcomes. Yet comparative, long-term followup studies with standard open cystectomy are required.

Individualized medicine for renal cell carcinoma: establishment of primary cell line culture from surgical specimens.

BACKGROUND: The lack of effective "in vivo" and "in vitro" models to predict success of pharmacological therapy for patients with renal cell carcinoma, as well as, the variety of cancer cell types demands the development of better experimental models to understand the pathophysiology of the disease and evaluate drug sensitivity in vitro. PURPOSE: To develop primary renal cancer cell culture irrespective of tumor grade and tumor type, harvested from the patient's pathological specimen immediately after the laparoscopic radical nephrectomy to study potential "in vivo" pharmacological sensitivity. MATERIALS AND METHODS: A total of 24 patients (17 males and 7 females). Mean age of 63.1+/-3.1 y.o. The mean size of the renal masses was 7.56+/-3.1 cm. Normal and pathological renal tissue was collected immediately after the specimen was extracted and submitted to enzymatic digestion for 16-24 hours. Clear cell carcinoma cells were selected through multiple passages in DMEM medium supplemented with glucose and antibiotics. RESULTS: Establishment of cell line culture from all the patients' specimens irrespective of tumor grade and tumor type was achieved successfully. In addition to the tumor cell line culture, normal parenchyma tissue yielded primary cell lines to allow testing the response of tumor types to various pharmacological therapeutic agents and toxicity of such treatments to healthy tissue. From the initial collection of the specimens obtained after the removal of the kidney to the development of cell lines took occurred in average 32+6 hrs. The cells in culture showed characteristics of epithelial cells; like expression on cytokeratin and were maintained in culture for more than 20 passages. CONCLUSION: The development of renal cancer cell cultures in vitro is labor intense but may yield a more realistic model to tailor pharmacological therapies and predict therapeutic success prior to "in vivo" application-a step in the direction of individualized medicine for RCC.

Laparoscopic management of intraperitoneal bladder rupture secondary to blunt abdominal trauma using intracorporeal single layer suturing technique.

BACKGROUND: Since Parra reported the first case of laparoscopic repair of bladder rupture caused by nonlaparoscopic injury to the bladder in 1994, several case reports have demonstrated the feasibility of this reconstructive surgical technique. We report the series of six patients that underwent laparoscopic repair of intraperitoneal bladder rupture (LRIB) because of blunt trauma using a single layer suturing technique. To our knowledge, this is the first series of LRIB reported secondary to blunt abdominal trauma. METHODS: From January of 2002 through June of 2006, a total of 139 patients were identified in our trauma registry with bladder ruptures secondary to abdominal blunt trauma. Among them 111 (79.8%) patients had associated pelvic injury. Seventy-one patients underwent surgical exploration and open bladder repair. Six cases were managed with laparoscopic technique. Patients were positioned in supine position and a three port-technique (5 mm, 10 mm, and 12 mm) was performed using the intracorporeal single layer suturing with a 3.0 Vycril (UR-6 needle). A close system Jackson-Pratt drain was placed in the retropubic space to monitor possible urine extravasation. RESULTS: The mean age of the patients was 47.3 years old (18-74 years). There were three female and three male patients. The average operation time was 43 minutes (31-75 minutes), mean length of bladder tear was 6.37 cm (5.3-7.7 cm), mean estimated blood loss was 16.6 cc (10-35 cc) and mean follow-up was 25.5 months (20-28 months). Two patients underwent combined orthopedic procedures. Computerized Tomography (CT) cystogram was performed between 5 days and 7 days after surgery with no signs of leakage in all patients. CONCLUSION: LRIB perforation because of blunt abdominal trauma using single layer intracorporeal suturing technique is a minimally invasive alternative to open surgery in well selected patients with no other intrabdominal injuries or intracranial pressure issues, offering faster recovery and better cosmetic results.

Primary culture and characterization of human renal inner medullary collecting duct epithelial cells.

PURPOSE: Our understanding of physiological and pathophysiological events associated with inner medullary collecting duct epithelium is based on studies in cells isolated from mice and rats. We established primary cultures of hIMCD (human papillary collecting duct epithelial) cells. MATERIALS AND METHODS: Normal papillary tissues were dissected from the surgical waste of consenting patients undergoing renal surgery. Tissues were digested enzymatically. Cells were maintained in Dulbecco's modified Eagle's medium supplemented with glucose and antibiotics. Cultures were treated with ethylenediaminetetraacetic acid and epithelial select medium was also used to obtain a pure epithelial culture. RESULTS: The hIMCD cells grew in a monolayer. Cells showed the expression of epithelial specific markers, including cytokeratin, the tight junction marker zonula occludens 1 and the cytoskeletal protein vimentin. They lacked expression of factor VIII, which is a glycoprotein synthesized by endothelial cells. To our knowledge we also noted for the first time uroplakin expression in collecting duct epithelial cells. This expression was maintained in primary culture. The hIMCD cells in culture were highly resistant to hypertonic solutions and they responded to hypertonicity by cyclooxygenase-2 over expression. Moreover, these cells also survived prolonged periods of hypoxia. CONCLUSIONS: To our knowledge this is the first report of successful culture and characterization of primary cultures of collecting duct epithelial cells from human renal papillae. These cells will serve as essential tools in helping us fill the gaps in our understanding of the events associated with the physiology and pathophysiology of human renal inner medullary collecting duct epithelium.