Robotic Assisted Prostatectomy with Magnetic Retraction.

INTRODUCTION: In prostate surgery retraction of the prostate is essential to ensure appropriate visualization of the surgical field. In the past improvement in exposure would require the dedicated use of a port or an additional incision. Magnetic retraction provides a novel solution by allowing shaftless retraction during robotic assisted prostatectomy that does not require a dedicated port or extra incision. METHODS: We conducted a retrospective review of consecutive patients who underwent robotic assisted prostatectomy using magnetic retraction at a single center (Duke Regional Hospital) between April 2017 and November 2018. RESULTS: The 39 cases were all robotic assisted total prostatectomies for adenocarcinoma. All cases were successfully completed without conversion to open. Mean age was 63 years (range 44-75) and preoperative body mass index was 30.4 kg/m2 (range 20.1-43.9). Mean operative time was 184 minutes (range 129-304). Four patients experienced minor 30-day complications that were not directly attributed to the device and did not require further interventions. One patient suffered a myocardial infarction 5 days after surgery and recovered without major sequelae. There were no 30-day mortalities. Surgeons described subjective overall surgical exposure as adequate and device use as technically simple. CONCLUSIONS: Magnetic assisted retraction is a novel approach that allows a safe and reproducible technique for unconstrained tissue retraction, and manipulation does not require another port. The device successfully permitted optimal prostate retraction during robotic assisted prostate surgery, enhancing surgical exposure while not requiring additional abdominal incisions.

Melanoma of the penis, scrotum and male urethra: a 40-year single institution experience.

PURPOSE: Genitourinary melanoma is rare and classically associated with a poor prognosis. We describe our experience with 10 patients with penile or urethral involvement. In addition, we present what is to our knowledge the largest reported series of melanoma of the scrotum (6 cases). MATERIALS AND METHODS: We reviewed the records of 16 men who presented consecutively to our institution with genitourinary melanoma between 1962 and 2000. Clinical and pathological characteristics were assessed, including Breslow thickness, primary surgical intervention and clinical course. RESULTS: Of 10 patients with penile or urethral melanoma 1997 American Joint Committee on Cancer melanoma pathological stage was T1 (depth less than 0.75 mm) in 4, T2 (0.75 to 1.5 mm) in 3 and T3 (1.51 to 4 mm) in 3. Only 1 of 4 patients with clinically palpable inguinal nodes had inguinal metastases at lymphadenectomy (BILND) and 3 who underwent prophylactic superficial BILND had negative findings. In 7 patients with T1-2N0M0 disease there were no local recurrences after wide local excision (WLE) or partial penectomy at a median followup of 35 months. Six of 7 men were rendered disease-free. One patient died of melanoma that developed at a second primary site. The 3 patients with T3 tumors who underwent partial (2) or radical (1) penectomy with or without BILND died of disease (2) or had progression (1). In all patients with penile melanoma the 5-year actuarial disease specific and recurrence-free survival rates were 80% and 60%, respectively, at a median followup of 39 months (range 20 to 210). Six patients with scrotal melanoma were treated with WLE without local recurrences. Three of the 6 patients had palpable inguinal nodes, of whom 2 died after chemotherapy for unresectable disease and 1 died of other causes 51 months after negative BILND. The 3 men with clinically negative groins who did not undergo prophylactic BILND had distant (1) or regional (2) metastases and died of disease. In patients with scrotal melanoma the 5-year actuarial disease specific and recurrence-free survival rates were 33.3% and 33.3%, respectively, at a median followup of 36 months. CONCLUSIONS: Partial penectomy or WLE provided effective local control for low stage penile or urethral melanomas and all scrotal lesions. Patients showing clinically positive, proven metastasis died despite appropriate surgical procedures and multi-agent chemotherapy. Prophylactic modified inguinal lymphadenectomy should be considered in select patients with penile, scrotal and anterior urethral melanoma.

Total pelvic exenteration: effective palliation of perineal pain in patients with locally recurrent prostate cancer.

PURPOSE: Locally recurrent prostate cancer can be a debilitating disease. Perineal pain associated with rectal involvement by prostate cancer is difficult to palliate by conventional methods. We describe a group of patients who had intractable perineal pain due to locally recurrent prostate cancer and underwent total pelvic exenteration for palliation. MATERIALS AND METHODS: We retrospectively reviewed the data for men who underwent total pelvic exenteration with urinary and colonic diversion at our institution between October 1995 and October 2002 for the relief of perineal pain from prostate cancer. Patients were selected for consideration for surgical extirpation on the basis of the presence of biopsy proven recurrent prostate cancer and evidence of rectal invasion on sonography. All patients received radiation therapy and hormonal therapy and had intractable perineal or pelvic pain resistant to narcotics. RESULTS: A total of 14 men underwent total pelvic exenteration for palliation during the 7-year period evaluated. There were no perioperative deaths. There were 7 postoperative events, including pulmonary embolus in 2 patients, and ileus, wound infection, cholecystitis, stomal stenosis and pelvic abscess in 1 patient each. After exenteration all patients had significant relief of pain and 11 (79%) had complete relief of pain symptoms. For these 11 patients the average symptom-free period was 14.1 months (range 3 to 36). Seven patients eventually died of disease, with the median period from exenteration to death being 24 months. CONCLUSIONS: Total pelvic exenteration is effective therapy for palliation of perineal pain associated with locally recurrent prostate cancer and can also effectively palliate other local symptoms such as hematuria, ureteral obstruction, voiding dysfunction and rectal incontinence. This procedure can be performed with acceptable morbidity in a highly select group of patients.

Inhibition of growth and metastasis of orthotopic human prostate cancer in athymic mice by combination therapy with pegylated interferon-alpha-2b and docetaxel.

We evaluated whether treatment of orthotopic human prostate cancer in nude mice with pegylated IFN-alpha-2b (PEG-IFN-alpha-2b) and docetaxel could represent a two-compartment targeting of primary tumor (tumor cells and tumor-associated endothelial cells) and inhibition of regional lymph node metastasis. The antiangiogenic properties of IFN were combined with the cytotoxic properties of docetaxel, resulting in apoptosis of both tumor cells and endothelium and hence significant inhibition of primary tumor growth. We first determined the optimal biological dose of PEG-IFN-alpha-2b (70,000 IU/week) necessary to down-regulate the expression of basic fibroblast growth factor, matrix metalloprotease-9, and matrix metalloprotease-2. The therapeutic dose of docetaxel (10 mg/kg/week) was determined by efficacy and minimal body weight loss. Therapy beginning 3 days after orthotopic implantation of PC3-MM2 prostate cancer cells reduced tumor weight by 37% in mice treated with PEG-IFN-alpha-2b, by 60% in mice treated with docetaxel, and by 83% in those given both drugs. PEG-IFN-alpha-2b also induced apoptosis of tumor-associated endothelial cells and hence a significant decrease in microvessel density. Our data indicate that the combination of PEG-IFN-alpha and docetaxel inhibits neoplastic angiogenesis by inducing a decrease in the local production of proangiogenic molecules by tumor cells, resulting in increased apoptosis of tumor-associated endothelial cells.