Transvaginal bone-anchored sling for the treatment of female stress urinary incontinence: effect of Valsalva leak point pressure and prior pelvic surgery on outcomes.

The effect of lower Valsalva leak point pressure (VLPP) and previous pelvic surgery on outcomes following sling surgery is controversial. We assessed outcomes following bone-anchored sling (BAS) placement in patients with intrinsic sphincteric deficiency (ISD) and previous pelvic surgery. A retrospective review of 149 patients undergoing BAS placement was performed. Patients were stratified by VLPP (> or =60, <60, and <30) and by history of previous anti-incontinence/pelvic floor surgery. Outcomes were assessed using a questionnaire comprising validated urogenital distress inventory (UDI)-6, incontinence impact questionnaire (IIQ)-7 questionnaires and additional items addressing satisfaction. In comparing the three VLPP cohorts, the percentage of patients reporting incontinence episodes of <1/week (64%, 68%, and 63%, respectively) and postoperative UDI/IIQ questionnaire scores were similar (p > 0.2, all comparisons). Lower rates of patients achieving <1 episode of incontinence per week (50%; p = 0.07) and worse UDI/IIQ scores (p = 0.02) were associated with patients with > or =2 prior surgeries. Whereas results are similar following BAS in patients with or without varying degrees of ISD, worse outcomes are associated with prior surgery.

Cadaveric fascial sling with bone anchors: minimum of 24 months of follow-up.

OBJECTIVES: Available published studies to define outcomes using cadaveric fascia for transvaginal urethral sling placement have revealed, in general, disappointing outcomes. However, limited data exist detailing long-term outcomes using this sling type and, more specifically, fascial grafts prepared using solvent-dehydrated techniques. We present our long-term outcomes using non-frozen solvent-dehydrated cadaveric fascia lata for transvaginal urethral sling placement with bone anchors. METHODS: A retrospective review was performed of 354 patients who had undergone non-frozen solvent-dehydrated cadaveric fascia lata for transvaginal urethral sling placement with bone anchors with a minimal follow-up of 24 months. A subjective assessment was performed using validated incontinence and quality-of-life questionnaires performed at 6 and 12 months and annually thereafter. RESULTS: A total of 238 patients (67%) completed follow-up questionnaires with a minimum of 24 months of follow-up. Of the 238 respondents, 71%, 67%, and 65% reported fewer than one episode of stress urinary incontinence per week, and 63%, 58%, and 59% of respondents reported minimal clinical improvement of 70% at a minimal follow-up of 24, 48, and 60 months, respectively. The corresponding rates of dryness were 34%, 27%, and 22% for the same follow-up periods. The Urogenital Distress Inventory, 6-item, and Incontinence Impact Questionnaire, 7-item, scores were not significantly different statistically when compared at each assessed follow-up point. CONCLUSIONS: Our data suggest that non-frozen solvent-dehydrated cadaveric fascia lata for transvaginal urethral sling placement with bone anchors is a safe and efficacious procedure for the treatment of stress urinary incontinence. Mild decreases in subjective satisfaction and improvement were seen during an extended follow-up period, although the validated questionnaire scores remained stable throughout the same period. However, a significant reduction in the dry rate was also observed during extended follow-up.

Minimum 24-month followup of the sling for the treatment of stress urinary incontinence.

PURPOSE: The SPARC procedure is a retropubic approach for the placement of a synthetic polypropylene sling for stress urinary incontinence. Although the approach appears to be efficacious, there still exist limited long-term data. We report our experience with SPARC at a minimum followup of 24 months. MATERIALS AND METHODS: Patients with stress urinary incontinence undergoing a SPARC sling procedure were entered into a prospective, institutional review board approved database. Postoperatively patients were asked to complete quality of life questionnaires at 6 months and annually thereafter. Success was defined by questionnaire response of 1 or fewer stress urinary incontinence episode per week or greater than 70% subjective improvement in those with greater than 1 stress urinary incontinence episodes per week. RESULTS: A total of 307 patients were identified during a 5-year period, of whom 280 were more than 24 months from surgery. Of the patients 154 (55%) had questionnaire followup at 24 months or greater from surgery (mean 36, median 36, range 24 to 49). Mean Valsalva leak point pressure in this subset of patients was 66 cm H(2)O (median 63, range 15 to 175). Of the patients 106 (68.8%) reported 1 or greater stress urinary incontinence episodes per week and 11 (7.1%) reported greater than 70% subjective improvement despite greater than 1 stress urinary incontinence episodes per week. Based on these definitions 75.9% of the cases were considered successful. CONCLUSIONS: The antegrade polypropylene mid urethral sling appears effective and most patients are satisfied with the outcome. The ease and minimally invasive nature of this technique does not preclude significant complications. Nevertheless, results in this series are competitive with those of other available surgical options.

Major urological oncological surgeries can be performed using minimally invasive robotic or laparoscopic methods with similar early perioperative outcomes compared to conventional open methods.

Robotic and laparoscopic surgical methods (RLM) are increasingly being used for urological oncological procedures. We compared the outcomes in a cohort of patients undergoing procedures by either RLM or open methods (OM) at a single institution. The data on 279 consecutive patients undergoing major urological oncological procedures from September 2000 to June 2005 was entered into a Microsoft Access database and queried. Continuous variables were compared using the Wilcoxon rank sum test and categorical variables were compared using Fisher's exact test. P values were compared to a significance level of 0.05. Of the 279 patients who underwent urological oncological surgeries, OM and RLM were used in 139 (49.8%) and 140 (50.2%) of patients, respectively. Numbers of perioperative mortalities and morbidities were not statistically different in the OM group versus the RLM group. Primary urological oncological surgeries can be performed without significantly increased perioperative complications by RLM compared to OM.

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion.

INTRODUCTION: Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials. MATERIALS AND METHODS: We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented. RESULTS: Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized. CONCLUSIONS: The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

Comparative analysis of early perioperative outcomes following radical cystectomy by either the robotic or open method.

OBJECTIVE: We analyzed early perioperative outcomes following radical cystectomy by the robotic method compared with the conventional open method. METHODS: All relevant clinical information was entered in a Microsoft Access Database and queried. P < 0.05 were considered statistically significant. RESULTS: The study cohort comprised 37 consecutive patients undergoing radical cystectomy; 24 (64.9%) cases were performed by the conventional open method and 13 (29.7%) by the robotic method. Body mass index, age, sex, blood transfusion rate, and median decrease in hemoglobin were comparable between the 2 groups. The robotic method resulted in significantly lower median estimated blood loss, shorter hospital stay, and longer operating time compared with the open group (P < 0.05). Four (16.7%) perioperative complications occurred in the open group compared with 2 (15.4%) in the robotic group (P = 1.0). The incidence of organ-confined (< or =T2N0Mx) disease was 9 (37.5%) and 7 (53.8%) in the open and robotic groups, respectively (P = 0.49). CONCLUSIONS: Radical cystectomy by the robotic method produces early perioperative results comparable to those of the open method. Although intraoperative estimated blood loss and hospital stay were significantly lower in the robotic group, operative time was longer which likely reflects our early operative experience with radical cystectomy by the robotic method.

Robotic urological surgery in patients with prior abdominal operations is not associated with increased complications.

BACKGROUND: The da Vinci Surgical Robotic System is being increasingly used to perform complex urological operations by minimally invasive techniques. Prior abdominal surgery associated with intra-abdominal adhesions may complicate robotic surgery. METHODS: We used a cohort of consecutive 49 patients undergoing a variety of robotic urological procedures at our institution to study the impact of prior abdominal operations on early perioperative complications. RESULTS: A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%; Group B) had undergone prior abdominal surgery. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P=0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6-8% of complications occurring in each of the two groups (P=1.0). Comparative subset analysis of 28 patients in Group B, 15 (54%) and 13 (46%) with or without intra-abdominal adhesions did not reveal a significant difference in perioperative complication rates either. However, operative time was longer in patients with intra-abdominal adhesions compared to patients without, median of 590 (281-922) and 434 (153-723) min respectively, although not statistically significant (P=0.059). CONCLUSION: Our study demonstrates that robotic urological surgery can be performed in patients with prior abdominal surgery without increased perioperative complications.

Radical nephrectomy performed by open, laparoscopy with or without hand-assistance or robotic methods by the same surgeon produces comparable perioperative results.

PURPOSE: Radical nephrectomy can be performed using open or laparoscopic (with or without hand assistance) methods, and most recently using the da Vinci Surgical Robotic System. We evaluated the perioperative outcomes using a contemporary cohort of patients undergoing radical nephrectomy by one of the above 4 methods performed by the same surgeon. MATERIALS AND METHODS: The relevant clinical information on 57 consecutive patients undergoing radical nephrectomy from September 2000 until July 2004 by a single surgeon was entered in a Microsoft Access Database and queried. Following appropriate statistical analysis, p values < 0.05 were considered significant. RESULTS: Of 57 patients, the open, robotic, laparoscopy with or without hand assistance radical nephrectomy were performed in 18, 6, 21, and 12 patients, respectively. The age, sex, body mass index (BMI), incidence of malignancy, specimen and tumor size, tumor stage, Fuhrman grade, hospital stay, change in postoperative creatinine, drop in hemoglobin, and perioperative complications were not significantly different between the methods. While the estimated median blood loss, postoperative narcotic use for pain control, and hospital stay were significantly higher in the open surgery method (p < 0.05), the median operative time was significantly shorter compared to the robotic method (p = 0.02). Operating room costs were significantly higher in the robotic and laparoscopic groups; however, there was no significant difference in total hospital costs between the 4 groups. CONCLUSIONS: The study demonstrates that radical nephrectomy can be safely performed either by open, robotic, or laparoscopic with or without hand assistance methods without significant difference in perioperative complication rates. A larger cohort and longer follow up are needed to validate our findings and establish oncological outcomes.

Radical nephrectomy performed by open, laparoscopy with or without hand-assistance or robotic methods by the same surgeon produces comparable perioperative results

PURPOSE: Radical nephrectomy can be performed using open or laparoscopic (with or without hand assistance) methods, and most recently using the da Vinci Surgical Robotic System. We evaluated the perioperative outcomes using a contemporary cohort of patients undergoing radical nephrectomy by one of the above 4 methods performed by the same surgeon. MATERIALS AND METHODS: The relevant clinical information on 57 consecutive patients undergoing radical nephrectomy from September 2000 until July 2004 by a single surgeon was entered in a Microsoft Access DatabaseTM and queried. Following appropriate statistical analysis, p values < 0.05 were considered significant. RESULTS: Of 57 patients, the open, robotic, laparoscopy with or without hand assistance radical nephrectomy were performed in 18, 6, 21, and 12 patients, respectively. The age, sex, body mass index (BMI), incidence of malignancy, specimen and tumor size, tumor stage, Fuhrman grade, hospital stay, change in postoperative creatinine, drop in hemoglobin, and perioperative complications were not significantly different between the methods. While the estimated median blood loss, postoperative narcotic use for pain control, and hospital stay were significantly higher in the open surgery method (p < 0.05), the median operative time was significantly shorter compared to the robotic method (p = 0.02). Operating room costs were significantly higher in the robotic and laparoscopic groups; however, there was no significant difference in total hospital costs between the 4 groups. CONCLUSIONS: The study demonstrates that radical nephrectomy can be safely performed either by open, robotic, or laparoscopic with or without hand assistance methods without significant difference in perioperative complication rates. A larger cohort and longer follow up are needed to validate our findings and establish oncological outcomes.

N-cadherin switching occurs in high Gleason grade prostate cancer.

BACKGROUND: The inappropriate expression of non-epithelial N-(neural) cadherin by epithelial cells, called cadherin switching, has been suggested to play a role in prostate cancer (PC) progression. We explored the role of N-cadherin as a biomarker in PC by correlating the expression with clinical parameters. METHODS: Two pathologists blinded to patients' history independently reviewed and scored the intensity and extent of staining of N-cadherin expression in 44 randomly selected radical prostatectomy specimens. The expression was correlated with total Gleason grade, individual Gleason patterns, tumor stage, and preoperative serum prostate specific antigen (PSA) levels and P-values < 0.05 were considered statistically significant. RESULTS: Of the 44 PC specimens, 14 (32%), 23 (52%), 7 (16%) consisted of Gleason grade 5-6, 7, and 8-10, respectively and 20/44 (45%) demonstrated N-cadherin expression. N-cadherin was expressed in 1/14 (7%) of Gleason 5-6 compared to 15/23 (65%) of Gleason grade 7, and 4/7 (57%) of Gleason grade 8-10, demonstrating a significant correlation between N-cadherin switching and higher Gleason grade (P = 0.001). While only about a third of primary or secondary Gleason pattern 3 demonstrated N-cadherin expression, a majority of Gleason patterns of > or = 4 expressed N-cadherin (P > 0.05), further suggesting that N-cadherin switching occurs with higher Gleason pattern. However, N-cadherin expression did not significantly correlate with preoperative serum PSA levels or tumor stage in our study cohort. CONCLUSIONS: We have demonstrated for the first time that N-cadherin switching occurs in higher grade PC and correlates significantly with increasing Gleason patterns. N-cadherin may be as a useful biomarker of aggressive PC.