Pelvic anatomy on preoperative magnetic resonance imaging can predict early continence after robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: Postoperative incontinence is multifactorial after radical prostatectomy. Using endorectal coil MRI, we examined features of the male urethra and accompanying muscular sphincter to predict continence after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: 80 patients underwent preoperative 1.5 Tesla endorectal coil MRI. Urethral length was measured in the coronal plane. All patients underwent RARP. Questionnaires were completed by patients at monthly intervals. The primary end point was time to continence defined as necessitating 0 to 1 pad per day (PPD). Statistical analysis was performed using Cox regression models to create both univariate and multivariate survival models. RESULTS: Mean age was 59.7 (standard deviation [SD] 7.1); 98% had bilateral nerve sparing. Mean urethral length was 17.1 mm (SD 4.5 mm). Mean prostate size was 34.7 g (SD 17.8). By 3 months, 60 patients achieved 1 PPD (mean 8.1 weeks, SD 9.4) and 34 patients achieved 0 PPD (mean 10.5 weeks, SD 8.0). Time to social continence was significantly related to prostate size both as a continuous variable (P=0.01), and as a dichotomized variable of ≥ 50 vs<50 g (P=0.02). Increased urethral length was related to decreased time to continence both as a continuous variable (P=0.06), and when dichotomized to ≥ 20 vs<20 mm (P=0.08). In addition to larger prostate size (hazard ratio [HR] 0.97, P<0.04), older age (0.95 P<0.025) was also associated with a longer time to achieve 0 PPD. Multivariate analysis revealed that longer urethral length was associated with a faster recovery of continence (HR 1.11, P<0.01). After controlling for age and urethral length, patients with a prostate size ≥ 50 g had 75% lower likelihood of achieving continence at all time points when compared with patients with prostate size <50 g (HR 0.25; 95% confidence interval: 0.06, 1.06; P=0.06). CONCLUSIONS: Longer urethral length increased the likelihood of achieving continence at all time points postoperatively. Advanced age and larger prostate size were negatively associated with continence outcomes.

Stress incontinence during the learning curve of holmium laser enucleation of the prostate.

BACKGROUND AND PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is an excellent surgical treatment for patients with benign prostatic hyperplasia, but surgical complications are not well described. We set out to determine the predictors of stress incontinence (SUI) after HoLEP during the learning curve. PATIENTS AND METHODS: A retrospective review of our institution's HoLEP database was performed. Patients were divided into two groups: No pads at 3 months (group 1); SUI and/or mixed incontinence necessitating ≥ one pad at 3 months (group 2). RESULTS: Seventy-seven patients underwent HoLEP at our institution. Nine (12%) were excluded for pure urge symptoms and two (3%) were lost to follow-up, leaving 66 total patients. No differences were noted as regards age (P = 0.54), operating room time (P = 0.18), prostate size (P = 0.85), prostate-specific antigen level (P = 0.96), or International Prostate Symptom Score (P = 0.11). The number of days between cases, however, was higher in group 2 (44.5 vs 18.1, P = 0.02) and was associated with SUI in simple logistic regression models (odds ratio [OR] 1.25; 95% confidence interval [CI]: 1.04-1.51; P = 0.019). As the interval time between cases increased from 1, 3, and 5 weeks, the strength of the association increased (1 week: OR 2.75; 95% CI: 0.78-9.66; P = 0.12; 3 weeks: OR 2.86; 95% CI: 0.92-8.91; P = 0.07; 5 weeks: OR 4.69; 95% CI: 1.21-18.26; P = 0.026). SUI resolved in all but two patients by 1 year. CONCLUSIONS: The major associated risk for SUI, a complication presumably related to surgical technique, was prolonged duration between cases. During the learning curve, surgeons should schedule patients frequently to enhance learning and decrease time to mastery of the technique, thereby reducing SUI.

Robot-assisted excision of a retroperitoneal mass between the left renal artery and vein.

BACKGROUND: Extra-adrenal pheochromocytomas are rare. Minimally invasive techniques have been utilized for incidentally discovered masses with successful results. METHODS: We present a case of a 64-year-old female with a 3.5-cm mass located between her left renal artery and vein, treated by a 4-port robot-assisted transperitoneal laparoscopic approach. RESULTS: Careful dissection of the tumor away from the renal hilum was accomplished without major vascular injury. A pedicle to the tumor was identified and ligated. The pathology demonstrated a benign pheochromocytoma. To our knowledge, this is the first report of a peri-hilar excision of a pheochromocytoma using this approach. CONCLUSION: Extra-adrenal pheochromocytomas are rare and can present in difficult locations. While surgical excision may be challenging, the da Vinci Robot may be used effectively and safely for the treatment of these perihilar masses.

Use of renal ultrasound to detect hydronephrosis after ureteroscopy.

INTRODUCTION: Ureteral obstruction is a potentially serious complication after ureteroscopy. Postoperative imaging with intravenous urogram and CT has been described as a means to detect asymptomatic or "silent" obstruction. We sought to evaluate the use of renal ultrasound to diagnose hydronephrosis after ureteroscopy in a large, contemporary series. MATERIALS AND METHODS: Of the 438 ureteroscopies performed by one staff surgeon at our institution from August 2003 to June 2008, 289 underwent a strict follow-up protocol that included renal ultrasound at approximately 1 month from the date of operation in patients without a stent or 1 month from the date of stent removal in patients with a stent. RESULTS: Of the 289 patients with proper follow-up, 27 (9.3%) had sonographic evidence of hydronephrosis. Fourteen patients were asymptomatic, and 13 patients experienced ipsilateral flank pain. A total of 4.8% of the patients (14/289) had silent hydronephrosis. The negative predictive value and positive predictive value of ipsilateral flank pain for hydronephrosis were 94% and 35%, respectively. There was no difference between the symptomatic and asymptomatic groups with respect to need for further surgery (38% vs. 21%, p = 0.42). The number of asymptomatic patients after ureteroscopy needing renal ultrasound to diagnose one case of hydronephrosis was 18. CONCLUSIONS: This study demonstrates that hydronephrosis is present in a small percentage of patients after ureteroscopy. Hydronephrosis can be present in both symptomatic and asymptomatic patients and may warrant further surgery. Renal ultrasonography at 1 month after ureteroscopy permits appropriate detection of hydronephrosis and should be considered as an imaging option.