Robotic-assisted laparoscopic partial cystectomy for symptomatic urachal hamartoma.

We report a case of an urachal hamartoma in a 30-year-old African American woman. The urachal lesion was excised with a robotic-assisted laparoscopic partial cystectomy. Pathologic analysis revealed cysts, smooth muscle, and ciliated epithelium consistent with a hamartoma. The patient recovered without complication. This case highlights an unusual pathology that is infrequently reported following urachal remnant excision.

Robotic-Assisted Ureteral Re-implantation: A Case Series.

INTRODUCTION: Minimally invasive surgical techniques are currently used for numerous urologic disorders and generally offer decreased morbidity and equivalent outcomes compared with open surgery. There is a relative paucity of data on robot-assisted ureteral re-implantation (RAUR) in adult patients for benign stricture disease. PATIENTS AND METHODS: We retrospectively reviewed our recent experience with mid-/distal ureteral reconstruction at a single tertiary-care center. From 2010 to 2012, 13 consecutive patients presenting with benign obstruction of mid-/distal ureters were managed with RAUR. RESULTS: In all cases the operative procedure was undertaken with six-port transperitoneal access, and all procedures were completed robotically. All ureters (left, n=5; right, n=7; bilateral, n=1) were re-implanted in a standard Bricker fashion into the dome of the bladder with (n=8) or without (n=6) a psoas hitch. Catheters were removed 4-11 days postoperatively, and all cystograms were negative for leak. Stents were removed 14-48 days after surgery. All were negative for hydronephrosis. Average follow-up was 10 (range, 2-20) months. There were two grade 1, two grade 2, two grade 3, and no grade 4 or 5 complications in 3 patients. CONCLUSIONS: RAUR is a safe and effective procedure. Extensive laparoscopic lysis of adhesions represents the primary challenge to an otherwise straightforward minimally invasive surgery. At our institution, RAUR has replaced open ureteral re-implantation as the preferred treatment for benign mid-/distal ureteral stricture disease.

Nomogram to predict prostate cancer diagnosis on primary transrectal ultrasound-guided prostate biopsy in a contemporary series.

OBJECTIVE: Transrectal ultrasound-guided biopsy (TRUSB) remains the mainstay for prostate cancer (CaP) diagnosis. Numerous variables have shown associations with development of CaP. We present a nomogram that predicts the probability of detecting CaP on TRUSB. METHODS: After obtaining institutional review board approval, all patients undergoing primary TRUSB for CaP detection at a single center at our institution between 2/2000 and 9/2007 were reviewed. Patients undergoing repeat biopsies were excluded, and only the first biopsy was included in the analysis. Variables included age at biopsy, race, clinical stage, prostate specific antigen (PSA), number of cores removed, TRUS prostate volume (TRUSPV), body mass index, family history of CaP, and pathology results. S-PLUS 2000 statistical software was utilized with p < 0.05 considered significant. Cox proportional hazards regression models with restricted cubic splines were utilized to construct the nomogram. Validation utilized bootstrapping, and the concordance index was calculated based on these predictions. RESULTS: A total of 1,542 consecutive patients underwent primary TRUSB with a median age of 64.2 years (range 34.9-89.2 years), PSA of 5.7 ng/ml (range 0.3-3,900 ng/ml), number of cores removed of 8.0 (range 1- 22) and TRUSPV of 36.4 cm(3) (range 9.6-212.0 cm(3)). CaP was diagnosed in 561 (36.4%) patients. A nomogram was constructed incorporating age at biopsy, race, PSA, body mass index, clinical stage, TRUSPV, number of cores removed, and family history of CaP. The concordance index when validated internally was 0.802. CONCLUSIONS: We have developed and internally validated a model predicting cancer detection in men undergoing TRUSB in a contemporary series. This model may assist clinicians in risk-stratifying potential candidates for TRUSB, potentially avoiding unnecessary or low-probability TRUSB.

Comparison of rates and risk factors for development of anaemia and erythropoiesis-stimulating agent utilization after radical or partial nephrectomy.

OBJECTIVE: To examine the incidence of and risk factors for the development of anaemia and erythropoiesis-stimulation agent (ESA) treatment in patients undergoing radical nephrectomy (RN) and partial nephrectomy (PN) because anaemia is a significant cause of morbidity in chronic kidney disease. PATIENTS AND METHODS: The study comprised a retrospective review of 905 patients (610 RN/295 PN; mean age, 57.5 years; mean follow-up, 6.4 years) who underwent surgery for renal tumours at two institutions from July 1987 to June 2007. Demographics, disease characteristics and pre- and postoperative (i.e. renal function, metabolic parameters, anaemia and ESA treatment) were recorded. Data were analyzed within subgroups based on treatment (RN vs PN). Multivariate analysis was conducted to determine the risk factors for developing anaemia after surgery. RESULTS: Tumour size (cm) was significantly larger for RN (RN 7.0 vs PN 3.7; P < 0.001). No significant differences were noted with respect to demographics and preoperative anaemia (RN 16.4% vs PN 18.6%; P = 0.454) and ESA-treatment (RN 0.7% vs PN 1.4%; P = 0.499). After surgery, significantly less de novo anaemia (PN 4.1% vs RN 17.5%; P < 0.001) and ESA utilization (PN 2.7% vs RN 13.4%; P < 0.001) occurred in the PN cohort. Multivariate analysis showed that age ≥60 years (odds ratio, OR, 1.62; P = 0.008), African American ethnicity (OR, 2.30; P < 0.001), smoking (OR, 1.60; P = 0.013), glomerular filtration rate (GFR) <60 mL/min/1.73 m(2) (OR, 4.09; P < 0.001), ≥1+ proteinuria (OR, 2.19; P < 0.03), metabolic acidosis (OR, 4.08; P = 0.007) and RN (OR, 2.58; P < 0.001) were significantly associated with de novo anaemia. CONCLUSIONS: Patients who underwent RN had a significantly higher prevalence of anaemia and ESA-treatment compared to a well-matched cohort that underwent PN. In addition to RN, age ≥60 years, African American ethnicity, history of smoking, GFR < 60 mL/min/1.73 m(2), proteinuria and metabolic acidosis were associated with developing anaemia.

Comparison of rates and risk factors for development of osteoporosis and fractures after radical or partial nephrectomy.

OBJECTIVE: To examine incidence of and risk factors for development of osteoporosis and fractures in patients who underwent radical nephrectomy (RN) and partial nephrectomy (NSS), as osteoporosis is an important cause of morbidity in chronic kidney disease. METHODS: This was a retrospective review of 905 patients (mean age 57.5 years, mean follow-up 6.4 years) who underwent RN or NSS for renal tumors at 2 institutions from July 1987 to June 2007. Demographics, renal function, metabolic parameters, and history of preoperative and postoperative osteoporosis and fractures were recorded. Data were analyzed within subgroups based on treatment (RN vs NSS). Multivariate analysis was conducted to elucidate risk factors for developing osteoporosis following surgery. RESULTS: A total of 610 patients underwent RN and 295 underwent NSS. Tumor size (cm) was significantly larger for RN (RN 7.0 vs NSS 3.7, P<.0001). No significant differences were noted with respect to demographic factors and preoperative osteoporosis (RN 8.7% vs NSS 9.5%, P=.785) and fractures (RN 1.7% vs NSS 0.7%, P=.382). Postoperatively, significantly less osteoporosis (NSS 12.5% vs RN 22.6%, P<.001) and fewer fractures (NSS 4.4% vs RN 9.8%, P=.007) developed in the NSS cohort. MVA demonstrated female (OR 1.85, P=.001), Caucasian (OR 2.33, P<.0001), preoperative eGFR<60 mL/min/1.73 m2, (OR=3.02, P<.0001), preoperative metabolic acidosis (OR=4.22, P=.0006), and RN (OR 2.59, P<.0001) were risk factors for developing osteoporosis. CONCLUSIONS: Patients undergoing RN had a significantly higher incidence of osteoporosis and fractures compared with a well-matched cohort of patients who underwent NSS. In addition to RN, female gender, Caucasian background, preoperative eGFR<60, and preoperative metabolic acidosis were associated with developing osteoporosis.

Second prize: Recurrence rates after percutaneous and laparoscopic renal cryoablation of small renal masses: does the approach make a difference?

BACKGROUND AND PURPOSE: As radiologic detection of small renal masses increases, patients are increasingly offered percutaneous renal cryoablation (PRC) or transperitoneal laparoscopic renal cryoablation (TLRC). This multicenter experience compares these approaches. PATIENTS AND METHODS: Between September 1998 and May 2010, review of our PRC and TLRC experience was performed. Patients with ≥ 12-month follow-up were included for analysis. Post-treatment surveillance consisted of laboratory studies and imaging at regular intervals. Treatment failure was considered if persistent mass enhancement or interval tumor growth was radiographically evident. Repeated biopsy and re-treatment were recommended in the event of recurrence. RESULTS: Sixty-one patients underwent PRC and 84 patients underwent TLRC. No significant differences were noted with respect to demographic factors. Mean tumor size was 2.7 ± 1.1 cm (PRC) and 2.5 ± 0.8 (TLRC) cm (P = 0.090). Mean follow-up was 31.0 ± 15.9 months (PRC) and 42.3 ± 21.2 (TLRC) months (P = 0.008), with local tumor recurrence noted in 10/61 (16.4%) PRC and 5/84 (5.9%) TLRC (P = 0.042). For PRC, disease-free survival (DFS) and overall survival (OS) were 93.7% and 88.9%, respectively, with four patients having evidence of disease at last follow-up. DFS and OS were 91.7% and 89.3% for TLRC, with seven patients having evidence of disease at last follow-up. DFS (P = 0.654) and OS (P = 0.939) were similar. CONCLUSIONS: In this multicenter study of well-matched cohorts, PRC had higher primary treatment failure rates than TLRC. While no differences were noted between DFS and OS, analysis is limited by intermediate follow-up. Further study is necessary to discern reasons for the higher recurrence rates in PRC and to determine what long-term consequences exist.

Quality of life after open or robotic prostatectomy, cryoablation or brachytherapy for localized prostate cancer.

PURPOSE: Health related quality of life concerns factor prominently in prostate cancer management. We describe health related quality of life impact and recovery profiles of 4 commonly used operative treatments for localized prostate cancer. MATERIALS AND METHODS: Beginning in February 2000 all patients treated with open radical prostatectomy, robot assisted laparoscopic prostatectomy, brachytherapy or cryotherapy were asked to complete the UCLA-PCI questionnaire before treatment, and at 3, 6, 12, 18, 24, 30 and 36 months after treatment. Outcomes were compared across treatment types with statistical analysis using univariate and multivariate models. RESULTS: A total of 785 patients treated between February 2000 and December 2008 were included in the analysis with a mean followup of 24 months. All health related quality of life domains were adversely affected by all treatments and recovery profiles varied significantly by treatment type. Overall urinary function and bother outcomes scored significantly higher after brachytherapy and cryotherapy compared to open radical prostatectomy and robotic assisted laparoscopic radical prostatectomy. Brachytherapy and cryotherapy had a 3-fold higher rate of return to baseline urinary function compared to open radical prostatectomy and robotic assisted laparoscopic radical prostatectomy. Sexual function and bother scores were highest after brachytherapy, with a 5-fold higher rate of return to baseline function compared to cryotherapy, open radical prostatectomy and robotic assisted laparoscopic radical prostatectomy. All 4 treatments were associated with relatively transient and less pronounced impact on bowel function and bother. CONCLUSIONS: In a study of sequential health related quality of life assessments brachytherapy and cryotherapy were associated with higher urinary function and bother scores compared to open radical prostatectomy and da Vinci prostatectomy. Brachytherapy was associated with higher sexual function and bother scores compared to open radical prostatectomy, robotic assisted laparoscopic radical prostatectomy and cryotherapy.

Peyronie's disease compromises the durability and component-malfunction rates in patients implanted with an inflatable penile prosthesis.

OBJECTIVE: To compare the durability and complication rates of surgery to implant an inflatable penile prosthesis (IPP) between patients with and without Peyronie's disease (PD). PATIENTS AND METHODS: We retrospectively reviewed all patients undergoing IPP surgery at one centre (Memphis) between July 1997 and May 2007. Variables included age at surgery, race, body mass index, presence of PD, brand/type of IPP (two vs three pieces), presence of diabetes mellitus (DM), active tobacco use, and complications. The result were assessed using t-tests, chi-square and regression analysis, with P < 0.05 considered to indicate significant differences. RESULTS: In all, 79 men were analysed (mean age 59.8 years, range 38.1-81.5). Nine (11%) patients had PD and had a IPP implanted, with penile modelling. Overall, 43 (54%) patients had pre-existing DM and 51 (65%) actively used tobacco. At a mean (range) follow-up of 19.6 (0.1-115.3) months, six (8%) patients had component malfunctions. Of these, three had DM and four actively smoked. Of the nine patients with PD, three developed component malfunctions, vs three (4%) who did not have PD (P= 0.002). Both groups had similar infection rates (P= 0.98). The mean (range) time to component malfunction was 4.3 (0.1-9.6) months, which was longer (but not significantly) in the PD group, with a mean (median, range) of 10.9 (6.3, 1.1-9.6) months, than the 3.0 (1.0, 0.2-7.9) months in the group without PD (P= 0.4). Groups were matched for rates of DM (P= 0.1) and tobacco use (P= 0.2). PD was a significant predictor of component malfunction on both univariate (P= 0.001) and multivariate analysis (P= 0.002) when adjusting for age (P= 0.2), body mass index (P= 0.7), DM (P= 0.3) and tobacco use (P= 0.8). CONCLUSION: Patients with PD implanted with a IPP, with penile modelling, had significantly higher component malfunction rates. Further, PD independently predicted component malfunction. These findings might be related to stress on the device at the time of surgery, during use, or both. Further study into this relationship is required.

Variation in the incidence of and risk factors for the development of nephrolithiasis after radical or partial nephrectomy.

OBJECTIVE: to examine incidence of and risk factors for the development of nephrolithiasis in patients treated with radical nephrectomy (RN) or partial nephrectomy (nephron-sparing surgery, NSS). PATIENTS AND METHODS: the study comprised a single-centre review of 749 patients treated with RN or NSS from August 1987 to June 2006. Demographics, medical and stone history, metabolic variables and postoperative stone events were recorded. Data were analysed within subgroups based on treatment (RN vs NSS). Multivariate analysis was used to identify risk factors for postoperative stone formation. RESULTS: in all, 499 patients had RN and 250 had NSS (mean age 57.9 years; mean follow-up 6.3 years). There were no significant differences in their demographic factors, but tumours were significantly larger in RN (P < 0.001). There was no significant difference in preoperative urinary pH < 6.0 or stone history. Significantly fewer patients after NSS than RN formed calculi (NSS 1.6% vs RN 8.4%, P < 0.001), developed hypobicarbonataemia (NSS 7.2% vs RN 12.8%, P= 0.020), and a urinary pH of <6.0 (NSS 11.2% vs RN 19.4%, P= 0.004). Multivariate analysis showed that RN (odds ratio 18.18), postoperative urinary pH < 6 (15.63), previous stone disease (13.7), age <60 years (7.33, all P < 0.001), body mass index ≥ 30 kg/m(2) (3.26, P= 0.033), male gender (2.67, P= 0.039), and hypobicarbonataemia (2.46, P= 0.034) were significantly associated with the development of postoperative calculi. CONCLUSIONS: patients undergoing RN have a significantly higher incidence of postoperative nephrolithiasis than a well-matched cohort undergoing NSS. In addition to RN, male sex, urinary pH < 6.0, hypobicarbonataemia, history of stone disease, obesity, and age <60 years were significantly associated with postoperative stone formation.

Renal functional outcomes after cryoablation of small renal masses.

BACKGROUND AND PURPOSE: Renal function outcomes after renal cryosurgery have not been widely scrutinized. We report 2-year renal function outcomes from a single-center cohort of patients who were treated with cryoablation for small renal masses. METHODS: We performed a retrospective review of our laparoscopic and percutaneous renal cryoablation experience between January 2003 and April 2007. Global renal function was assessed using measured serum creatinine and estimated glomerular filtration rate (eGFR) (MDRD equation). Chronic kidney disease (CKD) was defined as a serum creatinine level >2.0 mg/dL or eGFR <60 mL/min/1.73 m(2). RESULTS: Sixty-two patients were included in the analysis. Mean follow-up was 30 months (range 13-63 mos). Mean tumor size was 2.33 cm (range 1-4.6 cm). Comorbid conditions were prevalent: 77% hypertension, 35% hyperlipidemia, 31% diabetes mellitus, 39% tobacco use, and 32% heart disease (coronary artery disease/congestive heart failure). Based on eGFR calculations, preoperative CKD was noted in 17 of 62 (27%) patients. De novo CKD was noted in 5 of 45 (11%) patients. Patients in whom de novo CKD developed had lower pretreatment eGFR (71.0 vs 98.4 60 mL/min/1.73 m(2), P = 0.03) and larger tumor size (2.94 vs 2.19 cm, P = 0.04) compared with patients who were maintaining normal renal function. When CKD was defined as creatinine level >2.0 mg/dL, only one and six patients were identified with preoperative and de novo CKD, respectively. CONCLUSIONS: In a cohort of renal cryosurgery patients who were characterized by highly prevalent medical comorbidities, renal function was generally well maintained, with a low rate of de novo CKD based on eGFR calculations. A serum creatinine level >2.0 mg/dL was a less sensitive measure of CKD.

Single center experience with percutaneous and laparoscopic cryoablation of small renal masses.

BACKGROUND AND PURPOSE: While partial nephrectomy remains the gold standard for the management of most small renal masses, increasing experience with renal cryoablation has suggested a viable alternative with a favorable morbidity profile and good efficacy. We report intermediate-term oncologic outcomes from a single-center experience with laparoscopic and percutaneous renal cryoablation. PATIENTS AND METHODS: We performed a retrospective review of our laparoscopic renal cryoablation (LRC) and percutaneous renal cryoablation (PRC) experience between January 2003 and April 2007. Patients with at least 12 months of follow-up were included in the analysis. Follow-up consisted of imaging and laboratory studies at regular intervals. Persistent mass enhancement or interval tumor growth was considered a treatment failure. RESULTS: Sixty-six patients (44% women/56% men; 42% African-American/58% Caucasian/other; mean body mass index, 29.7) with 72 tumors underwent either LRC (n = 52) or PRC (n = 20) with a mean follow-up of 30 months (median 25.1 mos; range 13-63 mos). Average patient age was 66.5 years (range 34-82 yrs). Mean tumor size was 2.33 cm (range 1-4.6 cm). Comorbid conditions were prevalent: 76% hypertension, 36% hyperlipidemia, 24% chronic kidney disease, 29% diabetes mellitus, 36% tobacco use, and 32% heart disease. RESULTS of pretreatment biopsy were 62% renal-cell carcinoma and 38% benign or nondiagnostic. Overall cancer-specific and cancer-free survival were 100% and 97%, respectively. There were two treatment failures (3.8%) in the LRC group and five primary failures in the PRC group (25%) (P = 0.015), four of which were salvaged with repeated PRC with no evidence of recurrence at 6 to 36 months of follow-up. There has been no significant local or metastatic progression. CONCLUSIONS: LRC and PRC achieved good oncologic control with minimal morbidity at a mean follow-up of 30 months in a patient cohort characterized by numerous comorbid conditions. PRC had a significantly higher primary treatment failure rate than LRC, but re-treatment offered salvage oncologic control with no significant complications.

Survival outcomes in men receiving androgen-deprivation therapy as primary or salvage treatment for localized or advanced prostate cancer: 20-year single-centre experience.

OBJECTIVES: To evaluate the overall survival (OS) and disease-specific survival (DSS) in men receiving primary androgen-deprivation therapy (PADT) or salvage medical ADT (SADT) for prostate cancer. PATIENTS AND METHODS: After Institutional Review Board approval, we retrospectively reviewed patients receiving ADT for prostate cancer between July 1987 and June 2007. Variables included age at diagnosis and ADT induction, race, PSA level before ADT, ADT schedule (continuous/intermittent), clinical/pathological stage, hormone-refractory prostate cancer (HRCP) status, PADT or SADT, and deaths. RESULTS: In all, 548 men were analysed. The mean age at diagnosis and ADT induction were 70.1 and 72.3 years, respectively, and 321 (58.6%) were African-American. The median PSA level before ADT was 16.3 ng/mL. ADT was administered continuously in 497 (90.7%) patients; 342 (62.4%) received PADT while 206 (37.6%) received SADT. At mean (range) follow-up of 81.8 (2.1-445) months, 98 (17.9%) deaths occurred; 31 (31.6%) were cancer-specific. The OS and DSS in the PADT and SADT groups were not significantly different (P = 0.36 and P = 0.81, respectively). Mortality rates/distributions were similar between groups (P = 0.68). Multivariate predictors of OS and DSS included age at diagnosis (P = 0.03) and ADT induction (P = 0.009), tumour stage (P < 0.001), and PSA level at ADT induction (P = 0.01). Progression to HRPC worsened OS and DSS (both P < 0.001). CONCLUSION: PADT and SADT prolong survival in men with prostate cancer. HRPC portends a poor DSS. Age at diagnosis and ADT induction, PSA level before ADT, and disease stage predict both OS and DSS in this population. However, most men died from causes unrelated to prostate cancer, thus questioning the true value of ADT in prolonging patient survival.

Comparison of rates and risk factors for developing chronic renal insufficiency, proteinuria and metabolic acidosis after radical or partial nephrectomy.

OBJECTIVE: To investigate the incidence of and risk factors for developing chronic renal insufficiency (CRI), proteinuria and metabolic acidosis (MA) in patients treated with radical nephrectomy (RN) or nephron-sparing surgery (NSS). PATIENTS AND METHODS: We retrospectively reviewed 749 patients (mean age 57.7 years; mean follow-up 6.4 years) who had RN or NSS for renal tumours between July 1987 and June 2006 at our institution. The demographics and outcomes were analysed and recorded. The primary outcome variable was the development of an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2), with secondary outcomes being the development of a serum creatinine level of > or =2.0 mg/dL, MA (serum bicarbonate <22 mmol/L), and proteinuria (> or =1+ on dipstick testing). Multivariate logistic regression (MV) was used to identify risk factors for developing an eGFR of <60 mL/min/1.73 m(2), a creatinine level of > or =2.0 mg/dL and MA. RESULTS: Of the 749 patients, 499 had RN and 250 NSS; there were no significant demographic differences between the groups. After surgery a significantly greater proportion of the RN than the NSS group had a low eGFR (44.7% vs 16.0%, P < 0.001), MA (12.8% vs 7.2%, P = 0.02), proteinuria (22.2% vs 13.2%, P = 0.003) and elevated creatinine (14.2% vs 8.4%, P = 0.022). MV showed that diabetes mellitus (odds ratio 8.96, P = 0.002), RN (5.32, P < 0.001), hypertension (4.55, P = 0.003), a body mass index (BMI) of > or =30 kg/m(2) (3.51, P = 0.017), age > or =60 years (2.91, P = 0.015) and smoking (2.44, P = 0.014) were risk factors for developing a low eGFR; and that age > or =60 years (2.00, P = 0.019), diabetes mellitus (10, P < 0.001), hypertension (7.41, P = 0.002), smoking (5.29, P < 0.001) and RN (3.08, P < 0.001) were risk factors for developing an elevated creatinine level; and that being male (2.50, P = 0.019), age > or =60 years (3.13, P = 0.002), a BMI > or =30 (3.52, P < 0.001), RN (9.82, P < 0.001), preoperative eGFR <60 (9.71, P < 0.001) and elevated creatinine (5.9, P = 0.008) were risk factors for developing MA. CONCLUSIONS: Patients undergoing RN had significantly greater CRI, MA and proteinuria rates than a well-matched group undergoing NSS. In addition to RN, age > or =60 years, diabetes mellitus, hypertension and smoking were associated with progression to CRI after surgery.

Single center comparison of laparoscopic cryoablation and CT-guided percutaneous cryoablation for renal tumors.

BACKGROUND AND PURPOSE: Cryoablation has demonstrated therapeutic effectiveness for selected renal tumors. We compared our perioperative and short-term outcomes of laparoscopic (LAP) v percutaneous (PERC) renal cryoablation. PATIENTS AND METHODS: Thirty-four patients (18 men/16 women) underwent a LAP and 26 patients (19 men/7 women) underwent a PERC procedure between September1998 and January 2007. LAP cryoablation was performed transperitoneally with ultrasonographic monitoring. PERC cryoablation was performed with CT guidance. Follow-up imaging was obtained at regular intervals. RESULTS: Mean follow-up was 25 months. Average age (years) was 67.0 for the LAP and 69.7 for the PERC procedure (P = 0.307). Mean body mass index (kg/m(2)) was 29.8 for those undergoing LAP and 28.7 for those undergoing PERC procedures (P = 0.543). Mean tumor size (cm) was 2.9 for LAP patients and 3.1 for PERC patients (P = 0.432). Anterior tumors comprised 61.7% of LAP and 15.4% of PERC procedures (P < 0.001). Posterior tumors comprised 32.4% of LAP and 65.4% of PERC procedures (P = 0.01). Mean procedure time (minutes) was 165.7 for LAP and 106.6 for PERC procedures (P < 0.001). Hospital stay (days) was 2.6 for those undergoing LAP and 1.8 for those undergoing PERC procedures (P < 0.001). Both LAP patients (82.4%) and PERC patients (19.2%) needed postoperative narcotics (P < 0.001). Atelectasis developed in 70.6% of LAP patients and 34.6% of PERC patients (P = 0.005). Residual enhancement was seen in 11.5% of PERC patients and 2.9% of LAP patients (P = 0.192). Complications developed in 14.7% of LAP patients and 26.9% of PERC patients (P = 0.248). 1-year, 2-year, and 3-year disease-specific survival for the two groups was 100%. Tumor size > 4 cm and endophytic location were significantly associated with residual enhancement. CONCLUSIONS: LAP and PERC renal cryoablation have similar short-term outcomes. Significantly more anterior tumors were approached laparoscopically and significantly more posterior tumors were approached percutaneously. The PERC approach may offer advantages regarding hospital stay, narcotic need, and development of atelectasis. Longer-term data are needed to establish success of this approach.

Nonoperative management of blunt renal trauma: is routine early follow-up imaging necessary?

BACKGROUND: There is no consensus on the role of routine follow-up imaging during nonoperative management of blunt renal trauma. We reviewed our experience with nonoperative management of blunt renal injuries in order to evaluate the utility of routine early follow-up imaging. METHODS: We reviewed all cases of blunt renal injury admitted for nonoperative management at our institution between 1/2002 and 1/2006. Data were compiled from chart review, and clinical outcomes were correlated with CT imaging results. RESULTS: 207 patients were identified (210 renal units). American Association for the Surgery of Trauma (AAST) grades I, II, III, IV, and V were assigned to 35 (16%), 66 (31%), 81 (39%), 26 (13%), and 2 (1%) renal units, respectively. 177 (84%) renal units underwent routine follow-up imaging 24-48 hours after admission. In three cases of grade IV renal injury, a ureteral stent was placed after serial imaging demonstrated persistent extravasation. In no other cases did follow-up imaging independently alter clinical management. There were no urologic complications among cases for which follow-up imaging was not obtained. CONCLUSION: Routine follow-up imaging is unnecessary for blunt renal injuries of grades I-III. Grade IV renovascular injuries can be followed clinically without routine early follow-up imaging, but urine extravasation necessitates serial imaging to guide management decisions. The volume of grade V renal injuries in this study is not sufficient to support or contest the need for routine follow-up imaging.

Sutureless laparoscopic heminephrectomy: safety and efficacy in physiologic and chronically obstructed porcine kidney.

We sought to develop and examine the feasibility and efficacy of a streamlined sutureless system of repairing parenchymal and collecting system defects using BioGlue (bovine albumin-glutaraldehyde adhesive) and ProPatch (bovine pericardial patch) in swine under physiological conditions and mechanical stress imposed by chronic ureteral obstruction caused by complete ureteral transaction. Five pigs (10 kidneys) underwent left-side transperitoneal laparoscopic heminephrectomy, followed 2 weeks later by right-sided heminephrectomy with complete ureteral transaction (between clips) to provide a mechanical stressor on the repair, followed 2 weeks later by euthanasia. In each case, after hilar clamping, the lower pole was removed with a bipolar dissector. Hemostasis was obtained with argon beam coagulator and FloSeal (thrombin-gelatin matrix), followed by sutureless repair (ProPatch-BioGlue "sandwich"). At euthanasia, harvested kidneys underwent ex vivo retrograde-pyelography and pathological examination to rule out urinoma/perinephric fluid collection and determine collecting system/parenchymal healing. Mean operative time was 77.8 minutes. Mean warm ischemia time was 12.3+/-5.6 minutes. Estimated blood loss was 49.5+/-39.0 mL. All animals demonstrated immediate hemostasis on hilar clamp release. Pyelography failed to demonstrate any collecting system leakage, and closure and healing was confirmed in all. Four of 5 pigs had intact renal function at euthanasia. Two pigs were euthanized for causes unrelated to procedures 4 days prior to study end. This study provides proof of principle that sutureless laparoscopic heminephrectomy is effective in physiological and chronic obstruction conditions in the porcine model. The procedure is reproducible, and resection/renorrhaphy was completed on average with approximately 12 minutes warm ischemia time.

Contemporary analysis of erectile, voiding, and oncologic outcomes following primary targeted cryoablation of the prostate for clinically localized prostate cancer.

PURPOSE: To evaluate erectile function (EF) and voiding function following primary targeted cryoablation of the prostate (TCAP) for clinically localized prostate cancer (CaP) in a contemporary cohort. MATERIALS AND METHODS: We retrospectively reviewed all patients treated between 2/2000-5/2006 with primary TCAP. Variables included age, Gleason sum, pre-TCAP prostate specific antigen (PSA), prostate volume, clinical stage, pre-TCAP hormonal ablation, pre-TCAP EF and American Urologic Association Symptom Score (AUASS). EF was recorded as follows: 1 = potent; 2 = sufficient for intercourse; 3 = partial/insufficient; 4 = minimal/insufficient; 5 = none. Voiding function was analyzed by comparing pre/post-TCAP AUASS. Statistical analysis utilized SAS software with p < 0.05 considered significant. RESULTS: After exclusions, 78 consecutive patients were analyzed with a mean age of 69.2 years and follow-up 39.8 months. Thirty-five (44.9%) men reported pre-TCAP EF level of 1-2. Post-TCAP, 9 of 35 (25.7%) regained EF of level 1-2 while 1 (2.9%) achieved level 3 EF. Median pre-TCAP AUASS was 8.75 versus 7.50 postoperatively (p = 0.39). Six patients (7.7%) experienced post-TCAP urinary incontinence. Lower pre-TCAP PSA (p = 0.008) and higher Gleason sum (p = 0.002) were associated with higher post-TCAP AUASS while prostate volume demonstrated a trend (p = 0.07). Post-TCAP EF and stable AUASS were not associated with increased disease-recurrence (p = 0.24 and p = 0.67, respectively). CONCLUSIONS: Stable voiding function was observed post-TCAP, with an overall incontinence rate of 7.7%. Further, though erectile dysfunction is common following TCAP, 25.7% of previously potent patients demonstrated erections suitable for intercourse. While long-term data is requisite, consideration should be made for prospective evaluation of penile rehabilitation following primary TCAP.

Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer.

OBJECTIVE: Androgen deprivation therapy (ADT) remains a widely utilized modality for treatment of localized and advanced prostate cancer. While ADT-induced alterations in testosterone have demonstrated impacts on quality of life, the effects on mental health remain ill-defined. We investigated the prevalence of de novo psychiatric illness and predictive factors following ADT induction for prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between 1/1989-7/2005, excluding men receiving only neoadjuvant ADT. Variables included age, race, body mass index, prostate-specific antigen (PSA), Gleason sum, clinical stage, ADT type (medical/surgical) and schedule (continuous/intermittent), and presence of pre-ADT and newly diagnosed psychiatric illness. The cohort was divided into three groups for analysis: pre-ADT psychiatric illness, de novo psychiatric illness, and no psychiatric illness. Data analysis utilized statistical software with p < 0.05 considered significant. RESULTS: Three-hundred and ninety-five patients with a mean age of 71.7 years at ADT initiation were analyzed. Thirty-four men (8.6%) were diagnosed with pre-ADT psychiatric illness. At mean follow-up of 87.4 months, 101 (27.9%) men were diagnosed with de novo psychiatric illness, most commonly including: depression (n = 57; 56.4%), dementia (n = 14; 13.9%), and anxiety (n = 9; 8.9%). On multivariate analysis, increasing pre-ADT PSA was predictive of post-ADT anxiety (p = 0.01). Overall and disease-specific survival outcomes were similar between groups. CONCLUSIONS: De novo psychiatric illness was identified in 27.9% of men. While no predictive factors were identified for de novo psychiatric illness, increasing PSA was associated with de novo anxiety. Prospective investigation using validated instruments is requisite to further delineate the relationship between ADT and psychiatric health.

Contemporary analysis of erectile, voiding, and oncologic outcomes following primary targeted cryoablation of the prostate for clinically localized prostate cancer

PURPOSE: To evaluate erectile function (EF) and voiding function following primary targeted cryoablation of the prostate (TCAP) for clinically localized prostate cancer (CaP) in a contemporary cohort. MATERIALS AND METHODS: We retrospectively reviewed all patients treated between 2/2000-5/2006 with primary TCAP. Variables included age, Gleason sum, pre-TCAP prostate specific antigen (PSA), prostate volume, clinical stage, pre-TCAP hormonal ablation, pre-TCAP EF and American Urologic Association Symptom Score (AUASS). EF was recorded as follows: 1 = potent; 2 = sufficient for intercourse; 3 = partial/insufficient; 4 = minimal/insufficient; 5 = none. Voiding function was analyzed by comparing pre/post-TCAP AUASS. Statistical analysis utilized SAS software with p < 0.05 considered significant. RESULTS: After exclusions, 78 consecutive patients were analyzed with a mean age of 69.2 years and follow-up 39.8 months. Thirty-five (44.9 percent) men reported pre-TCAP EF level of 1-2. Post-TCAP, 9 of 35 (25.7 percent) regained EF of level 1-2 while 1 (2.9 percent) achieved level 3 EF. Median pre-TCAP AUASS was 8.75 versus 7.50 postoperatively (p = 0.39). Six patients (7.7 percent) experienced post-TCAP urinary incontinence. Lower pre-TCAP PSA (p = 0.008) and higher Gleason sum (p = 0.002) were associated with higher post-TCAP AUASS while prostate volume demonstrated a trend (p = 0.07). Post-TCAP EF and stable AUASS were not associated with increased disease-recurrence (p = 0.24 and p = 0.67, respectively). CONCLUSIONS: Stable voiding function was observed post-TCAP, with an overall incontinence rate of 7.7 percent. Further, though erectile dysfunction is common following TCAP, 25.7 percent of previously potent patients demonstrated erections suitable for intercourse. While long-term data is requisite, consideration should be made for prospective evaluation of penile rehabilitation following primary TCAP.

Tubeless percutaneous nephrolithotomy for complex renal stone disease: single center experience.

OBJECTIVE: Tubeless percutaneous nephrolithotomy (PCNL) has become an option for treatment of renal stone disease, though no clearly defined algorithm exists for selection of patients suitable to tubeless PCNL. We investigated our experience with tubeless PCNL to evaluate its safety and efficacy for cases of complex renal calculi. PATIENTS AND METHODS: Retrospective review of all tubeless PCNLs performed for complex renal calculus disease (bilateral stones, partial/complete staghorn, infundibular stenosis/calyceal diverticulum, pre-existing renal insufficiency) between January 2001 and January 2006. All patients had a ureteral stent placed in an antegrade fashion following stone treatment, and a foley catheter remained in place overnight. No patient received nephrostomy tube (NT). Imaging (CT or KUB) was obtained at the first outpatient follow-up visit. Patient demographics, incidence of complications, clinical outcomes and stone-free rates were noted and analyzed. "Stone free" was defined as negative imaging (CT or KUB). RESULTS: Forty-two patients (47 renal units) were treated with tubeless PCNL for complex renal stone disease (5 bilateral, 25 total/partial staghorn, 12 renal insufficiency, and 10 infundibular stenosis or calyceal diverticulum). Mean age was 58.2+/-9.4 years. Mean length of hospital stay was 2.1 days. Mean preoperative and postoperative hematocrit were 40.5+/-4.5 and 37.2+/-5.8, respectively (p=0.001). Single-procedure stone free rate was 74.5%, and the two-procedure stone free rate was 91.5%. One patient (2.4%) required a blood transfusion and one patient (2.4%) developed urosepsis. CONCLUSIONS: Tubeless PCNL is safe and effective and can be utilized in cases of complex renal stone disease.