Robot Assisted Renal Allograft Nephrectomy: Initial Case Series and Description of Technique.

OBJECTIVE: To evaluate the outcomes and perioperative complication rates following robot- assisted transplant nephrectomy ((RATN). METHODS: All patients who underwent RATN at our institution were included. No exclusion criteria were applied. Clinical records were retrospectively reviewed and reported. This included preoperative, intraoperative, and postoperative outcomes. Complications were reported utilizing the Clavien-Dindo classification system. Descriptive statistics were reported using frequencies and percentages for categorical variables, means and standard deviation for continuous variables. RESULTS: Between July 2014 and April 2018, 15 patients underwent RATN. Most patients had the transplant in the right iliac fossa (13/15). Ten patients underwent a concomitant procedure. The total operative time for the entire cohort was 336 (±102) minutes (including cases who had concomitant procedures) and 259 (±46 minutes) when cases with concomitant procedures were excluded. Mean estimated blood loss was 383 (±444) mL. Postoperatively, 3 patients required blood transfusion. Average hospital stay was 4 (±2.7) days. Most patients had finding consistent with graft rejection on final pathology. There were 5 complications; 3 of which were minor (grade 2 = 2 and grade 3 = 1); one patient had a wound infection requiring dressing (3A) and one patient died due to pulmonary embolism following discharge. Limitations include small series and retrospective nature of the study. CONCLUSION: This case series demonstrate that RATN is technically feasible. With continued experience and larger case series, the robotic approach may provide a minimally invasive alternative to open allograft nephrectomy.

Simultaneous liver-kidney transplantation from donation after cardiac death donors: an updated perspective.

Outcomes of both donation after cardiac death (DCD) liver and kidney transplants are improving. Experience in simultaneous liver-kidney transplant (SLK) using DCD donors, however, remains limited. In an updated cohort (2010-2018), outcomes of 30 DCD SLK and 131 donation after brain death (DBD) SLK from Mayo Clinic Arizona and Mayo Clinic Minnesota were reviewed. The Model for End-Stage Liver Disease score was lower in the DCD SLK group (23 vs 29, P = .01). Kidney delayed graft function (DGF) rates were similar between the 2 groups (P = .11), although the duration of DGF was longer for DCD SLK recipients (20 vs 4 days, P = .01). Liver allograft (93.3% vs 93.1%, P = .29), kidney allograft (93.3% vs 93.1%, P = .91), and patient (96.7% vs 95.4%, P = .70) 1-year survival rates were similar. At 1 year, there were no differences in the estimated glomerular filtration rate (57.7 ± 18.2 vs 56.3 ± 17.7, P = .75) or progression of fibrosis (ci) on protocol kidney biopsy (P = .67). A higher incidence of biliary complications was observed in the DCD SLK group, with ischemic cholangiopathy being the most common (10.0% vs 0.0%, P = .03). The majority of biliary complications resolved with endoscopic management. With appropriate selection, DCD SLK recipients can have results equivalent to those of DBD SLK recipients.

Morcellation Efficiency in Holmium Laser Enucleation of the Prostate: Oscillating Morcellator Outperforms Reciprocating Morcellator With no Apparent Learning Curve.

OBJECTIVE: To compare the morcellation efficiency of the Wolf Piranha oscillating morcellator with the Lumenis VersaCut reciprocating morcellator. MATERIALS AND METHODS: After institutional review board approval, we conducted a retrospective analysis of patients undergoing holmium laser enucleation of the prostate (HoLEP) for symptomatic benign prostatic hyperplasia. The first 41 cases of HoLEP with morcellation performed with the oscillating morcellator were matched by weight of resected tissue to 41 control patients from our historic data set who underwent morcellation with the reciprocating system. The primary outcome of interest was morcellation efficiency. We also evaluated surgeon experience level to assess for a learning curve with the oscillating morcellator. RESULTS: The 41 patients from each group were comparable in terms of age, prostate size, continuation of aspirin, and catheter status. The oscillating morcellation efficiency was nearly double that of the reciprocating morcellator (8.6 g/min [range: 3.0-18.3] vs 3.8 g/min [range: 0.9-10.1], P <.0001). Mean resected weights for cases with the oscillating and reciprocating instruments were 69 g (range: 17-224 g) and 69 g (range: 17-213 g), respectively (P = .9). The total operative time and complication rates did not significantly differ. For the oscillating system, morcellation efficiency for cases performed by staff alone was 9.8 g/min compared with 8.1 g/min when trainees were involved (P = .2), and there was no correlation between morcellation efficiency and number of cases performed (R = 0.01). CONCLUSION: The oscillating morcellation system resulted in a morcellation efficiency double that of the reciprocating system for tissue retrieval after HoLEP. Achieving efficiency with the oscillating system was not associated with a significant learning curve and was not impacted by trainee involvement.

The Economic Implications of a Reusable Flexible Digital Ureteroscope: A Cost-Benefit Analysis.

PURPOSE: Questions remain regarding the durability and longevity of flexible ureteroscopes. The objective of this study was to estimate the potential economic benefits of single use, flexible digital ureteroscopes compared to our recent experience with reusable flexible digital ureteroscopes using cost-benefit analysis. MATERIALS AND METHODS: Ureteroscopic procedures were prospectively recorded over the 12-month period of February 2014 to February 2015. All flexible ureteroscopies were performed using Flex XC digital ureteroscopes (Karl Storz Endoscopy-America, El Segundo, California). Cost assessment was based on the original purchasing cost and repair-exchange fees divided by the number of cases. An algorithm was created to include per case reprocessing costs and calculate the benefit-to-cost ratio. This cost was compared to potential costs of the LithoVue™, a single use digital ureteroscope. RESULTS: In 160 cases a flexible reusable ureteroscope was used. There was damage to 11 ureteroscopes during this time with an average of 12.5 cases to failure. Excluding original purchasing costs, the cost analysis revealed an amortized cost of $848.10 per use. After 99 ureteroscope cases the cost-benefit analysis favored reusable ureteroscopes compared to disposable ureteroscopes. CONCLUSIONS: Digital ureteroscopes are the latest trend in the evolution of endourology. It appears that a disposable ureteroscope may be cost beneficial at centers with a lower case volume per year. However, institutions with a high volume of cases may find reusable ureteroscopes cost beneficial.

A Study of Combination Bicalutamide and Raloxifene for Patients With Castration-Resistant Prostate Cancer.

BACKGROUND: Prostate tissue expresses 2 estrogen receptor (ER) isoforms, ER-α and ER-ß, and estrogen-based therapies have shown activity in preclinical studies. Raloxifene, a selective ER modulator, has inhibited the growth of prostate cancer xenograft models and was tested in a phase II trial of castration-resistant prostate cancer (CRPC), with some patients achieving stable disease. However, no studies have examined the safety of the combination of bicalutamide plus raloxifene for CRPC. Therefore, we investigated the safety of treatment with bicalutamide plus raloxifene in patients with CRPC in an initial study. MATERIALS AND METHODS: We conducted a study to evaluate the toxicity (primary endpoint) of the combination of bicalutamide (50 mg) and raloxifene (60 mg) in 28-day cycles (maximum, 6 cycles) in men with progressive CRPC. The secondary endpoint, quality of life (QOL), was assessed by patients using a 6-item linear analog self-assessment or hormonal domain scale of the Expanded Prostate Cancer Index Composite. RESULTS: We enrolled 18 patients with CRPC in the study to evaluate the safety of, and patient assessment of QOL (mental, physical, social, emotional, and spiritual) with, bicalutamide plus raloxifene therapy. No grade 3 or 4 adverse events occurred. None of the 18 patients required dose reductions. The patient assessment of QOL showed no statistically significant changes after 2 treatment cycles. The median progression-free survival with bicalutamide plus raloxifene was 1.9 months (95% confidence interval, 1.8-2.8 months). CONCLUSION: The results of the present study have shown that bicalutamide/raloxifene treatment is well tolerated. However, limited clinical activity occurred in men with CRPC who had previously undergone secondary hormonal therapy or chemotherapy.

The impact of training on the perioperative and intermediate functional outcomes after holmium laser enucleation of the prostate.

INTRODUCTION: To systemically measure the impact of trainees' participation on the perioperative and functional outcomes after holmium laser enucleation of the prostate (HoLEP). MATERIALS AND METHODS: Benign prostatic hyperplasia patients who underwent HoLEP at our department between January 2007 and January 2013 were classified based on trainee's level. Perioperative outcomes and complications were collected. Functional outcomes were assessed using the Sexual Health Inventory for Men (SHIM), International Prostate Symptom Score (IPSS), and International Continence Society-Short Form (ICSmaleSF) questionnaires. Voiding and incontinence domains of ICSmaleSF were assessed separately. Patients were divided into group 1 if no trainee participated in the operation, group 2 if a senior trainee performed the operation, and group 3 if a junior trainee participated in the operation. The patient's baseline characteristics, complications, and perioperative outcomes were compared. RESULTS: There were no differences in the baseline characteristics. There were significant differences in overall operative and enucleation time (p = 0.0186, p = 0.0047, respectively) with shorter times noticed with more experienced operators. There were no differences in resected tissue weight, hemoglobin change, and transfusion rates. Postoperatively, all patients had a similar length of stay and catheterization. Complications (graded by Clavien grading system) were not different. All patients were followed up at regular intervals starting at 6 weeks, 3 months , 6 months, 1 year, and every year after that and there were no differences in flow rates or post void residual volumes at any time point. There were no differences in SHIM, IPSS, and ICSmale voiding scale among the groups. However, ICSmale continence scale was significantly different where the highest score seen in group 2. CONCLUSION: Trainee participation in HoLEP in a controlled training environment does not compromise the safety of the procedure.

The impact of ischemia on long-term renal function after partial nephrectomy in the two kidney model.

PURPOSE: To determine whether on-clamp partial nephrectomy (ON-PN) has any significant impact on long-term renal function in a two kidney model. PATIENTS AND METHODS: From November 1999 to July 2013, 607 patients underwent PN at our institution. After excluding patients with solitary kidneys, multiple renal masses, and follow-up less than 90 days, 331 remained. Patient demographics were assessed, as was renal function based on pre- and postoperative mercaptoacetyltriglycine (MAG-3) renal scans and change in estimated glomerular filtration rate (eGFR) using the preoperative and most recent recorded creatinine levels. RESULTS: There were a total of 236 patients who underwent ON-PN and 95 who underwent off-clamp PN (OFF-PN) during the study period. The longest follow-up was 12.6 years with mean follow-up of 3 years. Mean ischemia time of patients undergoing ON-PN was 25 minutes (range 8-63 min). No differences were noted between the ON-PN and OFF-PN cohorts with respect to estimated change in eGFR (ON-PN: -6.07 mL/min/1.73 m(2) vs OFF-PN: -6.00 mL/min/1.73 m(2), P=0.69). No differences were noted in the % change in the MAG-3 renal scans (ON-PN: -0.77% vs OFF-PN: -1.1%, P=0.94). A post hoc sensitivity analysis of the same two variables stratified by age revealed no differences in change in estimated GFR or % change in differential function on renal scan. CONCLUSIONS: In the two kidney model, ischemia does not appear to affect long-term renal function outcomes after PN. These data provide evidence that ON-PN is perfectly acceptable in the appropriately selected patient with two kidneys.

Patient-reported sexual outcomes after holmium laser enucleation of the prostate: a 3-year follow-up study.

OBJECTIVE: To evaluate the long-term patient reported sexual function outcomes of holmium laser enucleation of the prostate (HoLEP) for the treatment of lower urinary tract symptoms secondary to prostate enlargement. METHODS: Three hundred ninety-three patients underwent a HoLEP between August 2007 and July 2013 and were reviewed in this retrospective analysis. Sexual function outcomes were assessed before HoLEP, and again at 3, 6, 12, 24, and 36 months after surgery using the International Index of Erectile Function 5 survey. International Prostate Symptom Scores (IPSS) were included for comparison and contextual functional outcome analysis. RESULTS: At the time of surgery, the mean age was 70.9 years (52.0-89.0 years), mean body mass index was 27.7 kg/m(2) (18.0-48.0 kg/m(2)), and mean prostate volume was 96.7 g (20.1-375.0 g). Mean International Index of Erectile Function 5 scores at 3 (13.3 ± 8.37), 6 (12.1 ± 8.76), 12 (12.1 ± 8.83), 24 (12.6 ± 8.80), and 36 months (12.5 ± 8.45) showed no significant change from baseline. There was, however, a significant improvement from baseline seen in IPSS over the same time period (P = .0001). CONCLUSION: These data confirm HoLEP has a significant impact on IPSS and no adverse impact on long-term patient reported sexual function. We believe this series represents the largest cohort with the longest follow-up to date. It represents an important tool for preoperative patient counseling for those patients considering surgical therapy for benign prostatic hyperplasia.

Androgen receptor-positive triple negative breast cancer: a unique breast cancer subtype.

BACKGROUND: The significance of androgen receptor (AR) expression in triple-negative breast cancer (TNBC) is unclear, and published studies so far have been inconclusive. METHODS: A tissue microarray was constructed using tissue obtained from 119 patients with primary TNBC and stained for AR expression. Other tissue types obtained included recurrent TNBC, normal breast tissue, adjacent ductal carcinoma-in situ (DCIS), lymph node (LN) and distant metastases. Positive AR expression was defined as ≥10% nuclear staining. RESULTS: Epithelial tissue was present and evaluable in 94 TNBC patients with a total of 177 tissue cores. AR expression in TNBC was 22 of 94 (23%). AR expression was higher in normal breast tissue (88%) and adjacent DCIS (73% overall). All LN metastases from AR-positive TNBC patients were also AR positive; in addition, no AR-negative TNBC patient had AR-positive LNs. AR expression was associated with older patient age (63 vs. 57 years, respectively, p = 0.051) and LN metastases (p = 0.033). Locoregional recurrence and overall/disease-specific survival were similar between AR-positive and AR-negative patients, although AR-positive patients had more advanced disease. On multivariate analysis, the presence of LN metastases was associated with poorer recurrence-free survival in AR-positive patients (hazard ratio, 4.34) (p = 0.031). CONCLUSIONS: The AR is expressed in normal breast tissue, and expression decreases with advancement to DCIS and invasive cancer. AR-positive TNBC was more common in older patients and had a higher propensity for LN metastases. AR-positive TNBC may represent a breast cancer subtype with unique features that may be amenable to treatment with alternative targeted therapies.

Predicting response to bacillus Calmette-Guérin (BCG) in patients with carcinoma in situ of the bladder.

PURPOSE: Currently, there is no reliable tool to predict response to intravesical bacillus Calmette-Guérin (BCG). Based on the fact that BCG is a Th1-polarizing immunotherapy, we attempt to correlate the pretreatment immunologic tumor microenvironment (Th1 or Th2) with response to therapy. MATERIALS AND METHODS: Bladder cancer patients with initial diagnosis of carcinoma in situ (Tis) were stratified based on their response to BCG treatment. A total of 38 patients met inclusion criteria (20 patients who responded and 18 patients who did not respond). Immunohistochemical (IHC) methods known to assess the type of immunologic microenvironment (Th1 vs. Th2) were performed on tumor tissue obtained at initial biopsy/resection: the level of tumor eosinophil infiltration and degranulation (Th2 response); the number of tumor-infiltrating GATA-3(+) (Th2-polarized) lymphocytes; and the number of tumor-infiltrating T-bet(+) (Th1-polarized) lymphocytes. Results obtained from these metrics were correlated with response to treatment with BCG immunotherapy. RESULTS: The IHC metrics of the tumor immune microenvironment prior to BCG treatment were each statistically significant predictors of responders (R) vs. nonresponders (NR). Eosinophil infiltration and degranulation was higher for R vs. NR: 1.02 ± 0.17 vs. 0.5 ± 0.12 (P = 0.01) and 1.1 ± 0.15 vs. 0.56 ± 0.15 (P = 0.04), respectively. Ratio of GATA-3(+) (Th2-polarized) lymphocytes to T-bet(+) (Th1-polarized) lymphocytes was higher for R vs. NR: 4.85 ± 0.94 vs. 0.98 ± 0.19 (P<0.001). The 3 markers were combined to create a Th2 signature biomarker, which was a statistically significant (P<0.0001) predictor of R vs. NR. All IHC markers demonstrated that a preexisting Th1 immunologic environment within the tumor was predictive of BCG failure. CONCLUSION: The Th1 vs. Th2 polarization of bladder tumor immune microenvironment prior to treatment with BCG represents a prognostic metric of response to therapy. If a patient has a preexisting Th1 immunologic response within the tumor, there is no value in using a therapy intended to create a Th1 immunologic response. An algorithm integrating 3 IHC methods provided a sensitive and specific technique that may become a useful tool for pathologists and urologists to predict response to BCG in patients with carcinoma in situ of the bladder.

Does prostate morphology affect outcomes after holmium laser enucleation?

OBJECTIVE: To determine whether prostate morphology or technique used has any effect on postoperative outcomes after holmium laser enucleation of the prostate. MATERIALS AND METHODS: A retrospective review of prospectively collected data was completed for all patients undergoing a holmium laser enucleation of the prostate at our institution. Prostate morphology was classified as either "bilobar" or "trilobar" according to the cystoscopic appearance. The baseline characteristics, complications, and postoperative outcomes were collected. RESULTS: A total of 304 patients with either "bilobar" (n = 142) or "trilobar" (n = 162) prostate morphology were included. The trilobar group was more likely to have longer operative times (112 vs 100 minutes, P = .04), although this difference was not significant on multivariate analysis. The postoperative outcomes were similar between the 2 groups for American Urological Association symptom score, change in American Urological Association symptom score, bother score, maximal flow rate, change in maximal flow rate, postvoid residual urine volume, and complication rate. However, the trilobar group had a significantly greater decrease in their PVR urine volume (296 vs 176 mL, P = .01), a difference that persisted on multivariate analysis. A subset analysis of the trilobar prostates revealed that performing a 2-lobe technique achieved shorter operative and enucleation times, although the difference was not significant. CONCLUSION: Those patients with trilobar prostate morphology are more likely to achieve a greater decrease in the PVR urine volume after holmium laser enucleation of the prostate. All other outcomes appeared to be similar between the 2 groups. In addition, a 2-lobe technique can be safely used for trilobar prostates when deemed feasible by the surgeon.

A multicenter comparison of the safety and effectiveness of ureteroscopic laser lithotripsy in obese and normal weight patients.

OBJECTIVE: Surgical treatment of kidney stones in an obese patient (body mass index [BMI] >30 kg/m(2)) remains challenging as shockwave lithotripsy may not be an option due to weight limitations. We sought to determine the effectiveness of ureteroscopic laser lithotripsy in obese patients compared to nonobese controls. MATERIALS AND METHODS: Patients from 2004 to 2007 were retrospectively analyzed providing a group of 292 patients (163 obese, 76 overweight, 53 normal) who underwent ureteroscopic procedures for urolithiasis at four centers in the United States and Canada. RESULTS: The percentage of obese patients requiring flexible ureteroscopy (URS) (79%) was higher than in the other groups (P<0.0001). Flexible URS was associated with a lower stone-free rate (SFR) on multivariate analysis (P=0.034). There was no difference in SFRs of patients who required a ureteral access sheath, basket extraction, or received a postoperative stent. Complication rates did not differ between groups. CONCLUSION: SFRs using ureteroscopic lithotripsy in obese and overweight populations are the same as in the normal weight patients. A flexible ureteroscope was associated with a decreased SFR, but this likely due to a more proximal stone location in these patients. Ureteroscopic laser lithotripsy is an effective and safe technique to treat urolithiasis in the overweight/obese patient.

Age-stratified outcomes of holmium laser enucleation of the prostate.

OBJECTIVE: To present the first age-stratified assessment of outcomes after holmium laser enucleation of the prostate (HoLEP) for the treatment of lower urinary tract symptoms resulting from prostate enlargement. PATIENTS AND METHODS: We retrospectively analysed and compared the morbidity, and the peri-operative and functional outcomes of patients aged 50-59, 60-69, 70-79 and ≥80 years. Complications at 30 days were stratified using the Clavien system. Functional outcomes were assessed using the International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax ), post-void residual urine volume (PVR) and urinary continence. RESULTS: A total of 311 patients underwent HoLEP for obstructive voiding symptoms from August 2007 to June 2011, of whom 22 patients were aged 50-59 years, 91 were aged 60-69 years, 153 were aged 70-79 years, and 45 were aged ≥80 years. The overall morbidity rates were similar among the age groups (20, 24.4, 21.6 and 22.1% for groups 1, 2, 3 and 4, respectively), as were the incidence of significant complications (Clavien grade ≥ III), change in serum haemoglobin level, and length of hospital stay. Patients ≥80 years did have a longer catheterization time (3.4 days) than patients aged 50-59 years (1.68 days). By 1 year there were no significant differences in urinary continence, IPSS, Qmax , or PVR among the age groups. CONCLUSIONS: Overall morbidity, hospital stay, and 1-year functional outcomes of HoLEP were similar among all age groups. This study shows that HoLEP is a safe and effective treatment for benign prostatic hyperplasia regardless of age.

Oncologic outcomes for lymph node-positive urothelial carcinoma patients treated with robot assisted radical cystectomy: with mean follow-up of 3.5 years.

PURPOSE: Previous studies have shown robot assisted radical cystectomy (RARC) to have comparable perioperative outcomes to open radical cystectomy. There are few reports that have examined the oncologic results of RARC, specifically with respect to lymph node-positive patients. We report the outcomes of pathologic node-positive patients who have undergone RARC with medium-term follow-up. MATERIALS AND METHODS: A total of 275 patients underwent RARC at 2 institutions for invasive bladder cancer between April 2005 and June 2009. We examined the 50 patients with lymph node-positive disease. Oncologic outcomes, overall, and recurrence-free survival were analyzed and compared with the open literature. RESULTS: Mean (median) clinical follow-up in this cohort was 42 (39.5) months (range 16-75 months). The mean (median) number of lymph nodes (LN) removed was 18 (17.5) (range 5-35), and mean (median) number of positive LN was 3 (2) (range 1-12). Mean lymph node density was 18%. Seventeen (34%) patients had ≤ pT2 disease and 33 (66%) pT3/T4 disease. At this follow-up, 29 patients have recurred, and 22 patients have died of disease. Mean (median) time to recurrence was 10 (9) months. The estimated overall survival at 36 and 60 months was 55%, and 45%, respectively. The recurrence-free survival at 36 and 60 months was 43%, and 39%, respectively. Thirty-three (66%) patients had an LN density <20%. The estimated overall survival at 36 months of patients with a lymph node density of <20% was higher than those with a lymph node density >20%, though the difference was not statistically significant. A total of 58% of patients received chemotherapy in this cohort. The use of chemotherapy was associated with a statistically significant (P = 0.033) improvement in overall survival, with an overall survival of 68% at 36 months compared with 36% for the patients who did not receive any chemotherapy. CONCLUSIONS: The oncologic outcomes of patients with lymph node-positive bladder cancer treated with robot assisted radical cystectomy (RARC) compare favorably to previous published studies of open radical cystectomy at medium-term (mean follow-up of 42 months). As our follow-up increases, we expect to continue to accurately define the long-term clinical suitability and oncologic success of this procedure in this high-risk population.

Athermal nerve sparing robot-assisted radical prostatectomy: initial experience with microporous polysaccharide hemospheres as a topical hemostatic agent.

PURPOSE: Microporous polysaccharide hemospheres (MPH) are hemostatic beads engineered from plant starch to accelerate the natural clotting cascade. The purpose of this report is to detail our initial experience with MPH as a topical hemostatic agent during robot-assisted radical prostatectomy (RARP). METHODS: We examined a single surgeon series of 30 consecutive RARP's dividing patients into MPH or non-MPH groups. The last ten procedures utilized the MPH, which were matched 1:2 to non-MPH procedures for comparison. Nerve-sparing procedures were performed when clinically indicated and all done athermally. All demographic data, length of operation, margin status, blood loss, change in hemoglobin, and need for blood transfusion were prospectively collected and analyzed. RESULTS: The baseline characteristics were the same. The post-operative decrease in hemoglobin was less in the MPH group (1.8 g/dL MPH group vs. 3.2 g/dL non-MPH). One patient in each group required a blood transfusion. CONCLUSIONS: These preliminary findings support the role for MPH as a potential hemostatic agent during athermal nerve-sparing RARP.

Cost analysis of open radical cystectomy versus robot-assisted radical cystectomy.

Bladder cancer is the fourth and ninth most common malignancy in males and females, respectively, in the U.S. and one of the most costly cancers to manage. With the current economic condition, physicians will need to become more aware of cost-effective therapies for the treatment of various malignancies. Robot-assisted radical cystectomy (RARC) is the latest minimally invasive surgical option for muscle-invasive bladder cancer. Current reports have shown less blood loss, a shorter hospital stay, and a lower morbidity with RARC, as compared with the traditional open radical cystectomy (ORC), although long-term oncologic results of RARC are still maturing. There are few studies that have assessed the cost outcomes of RARC as compared with ORC. Currently, ORC appears to offer a direct cost advantage due to the high purchase and maintenance cost of the robotic platform, although when the indirect costs of complications and extended hospital stay with ORC are considered, RARC may be less expensive than the traditional open procedure. In order to accurately evaluate the cost effectiveness of RARC versus ORC, prospective randomized trials between the two surgical techniques with long-term oncologic efficacy are needed.

Multicenter experience with robot-assisted radical prostatectomy in renal transplant recipients.

OBJECTIVE: To evaluate our multi-institutional outcome with robot-assisted radical prostatectomy (RARP) in renal transplant recipients and describe technical modifications of the procedure. MATERIALS AND METHODS: We retrospectively reviewed 1677 patients, 1422 from Mayo Clinic Arizona and 255 from Loyola University Medical Center, undergoing RARP from March 2004 to October 2010, of which 7 were renal transplant recipients. Baseline demographic features, perioperative data, and oncologic outcomes were reviewed. RESULTS: At diagnosis, mean patient age was 63.3 years and serum prostate specific antigen was 6.17 ng/mL. The mean total operative time was 186 minutes (range, 80-210 minutes). No intraoperative complications were noted. The mean hospital length of stay was 1.8 days (range, 1-3 days). Clavien grade II postoperative complications occurred in 3 of the 7 patients (42.9%), consisting of urosepsis, atrial fibrillation, and gross hematuria, all resolving with appropriate medical management. No significant changes were observed in graft function. Two patients (28.6%) had positive surgical margins. During a mean follow-up of 16 months, 1 patient with pathologic T3a, Gleason 9 cancer experienced a biochemical recurrence, which was treated with salvage external-beam radiation and androgen-deprivation therapy. CONCLUSION: Our series suggests that RARP is a safe and feasible form of therapy for localized prostate cancer in a select group of renal transplant recipients.

Medical expulsive therapy in a tertiary care emergency department.

OBJECTIVE: To assess the extent of Medical expulsive therapy (MET) use and practice patterns in our tertiary care emergency department. MET is the first-line intervention for select symptomatic urolithiasis recommended by the American Urological Association and supported by clinical trials investigating its efficacy. Nonetheless, MET is not always prescribed in the emergency department setting for symptomatic patients with ureteral stones. METHODS: Using the "International Classification of Diseases" diagnostic codes, we retrospectively reviewed the medical records of all emergency department patients treated for urolithiasis at our institution from January to December 2008. Abstracted patient data included demographic and medically relevant information; MET use was determined by reviewing the electronic prescriptions at discharge. RESULTS: Of 165 patients identified with a diagnosis of renal colic owing to urolithiasis, 23 were excluded for suspected stone passage or failure to document a stone on cross-sectional imaging. Most (138 [97%] of 142) of the remaining patients met the criteria for outpatient treatment of symptomatic stone episodes and were eligible for MET. Urology consultation was requested in 19 outpatients (13%), and MET was prescribed for most (14 [73.7%] of 19). Of the 119 patients seen by an emergency department physician without urologic input and discharged, 17 (14%) received MET. Overall, tamsulosin was prescribed to 31 (22%) of 138 stone episodes treated with an outpatient trial of passage. CONCLUSION: The underusage of tamsulosin in the emergency department of our institution highlights the need for educational interventions to improve the quality and cost of emergent patient care.

Accuracy of ultrasound in estimation of prostate weight: comparison of urologists and radiologists.

INTRODUCTION: Measurements of prostate size are obtained to contribute in the diagnosis and follow up of patients with a variety of diseases. Since its introduction, transrectal ultrasonography (TRUS) of the prostate has become the most common method for assessment of prostate volumes. Ultrasonography, in general, has been associated with concerns of operator dependent variability. Herein, we analyze the accuracy of urologists and radiologists performing TRUS. MATERIAL AND METHODS: The accuracy of preoperative TRUS prostate volume estimation was evaluated by comparing it to gross specimen prostate weight following robot-assisted radical prostatectomy (RARP) performed from August 2004 to March 2008 in Mayo Clinic Arizona. A total of 800 RARPs were evaluated retrospectively with 302 patients having a prostate volume measurement with TRUS at our institution followed by RARP being performed within 30 days. The TRUS measurements were divided into two groups: those TRUS measurements performed by urologists (group 1), and those performed by radiologists (group 2). The accuracy of the two groups were compared using a Pearson correlation analysis. RESULTS: The estimated weight by TRUS in the total cohort of patients correlated with the pathological specimen weight at 0.802 with a standard error of 0.90. Group 1 performed a total of 114 ultrasounds with a correlation of 0.835 and a standard error of 1.27. Group 2 performed a total of 188 with a correlation of 0.786 and a standard error of 0.88. CONCLUSIONS: Urologists and radiologists are both consistently within 17%-22% of the estimated prostate specimen weight. Urologists appeared to have a slightly higher accuracy in estimation but a higher range of error for the whole group when compared to radiologists. Transrectal ultrasonography is a reliable technique to estimate prostate weight and accuracy to within 20% of the pathological weight. Urologists and radiologists are essentially equally proficient in estimating prostate weight with TRUS. These findings are particularly important with respect to specialty certification and competency/proficiency evaluation, as health care increasingly moves towards outcomes based reimbursement.

Effective use of FibroTest to generate decision trees in hepatitis C.

AIM: To assess the usefulness of FibroTest to forecast scores by constructing decision trees in patients with chronic hepatitis C. METHODS: We used the C4.5 classification algorithm to construct decision trees with data from 261 patients with chronic hepatitis C without a liver biopsy. The FibroTest attributes of age, gender, bilirubin, apolipoprotein, haptoglobin, alpha2 macroglobulin, and gamma-glutamyl transpeptidase were used as predictors, and the FibroTest score as the target. For testing, a 10-fold cross validation was used. RESULTS: The overall classification error was 14.9% (accuracy 85.1%). FibroTest's cases with true scores of F0 and F4 were classified with very high accuracy (18/20 for F0, 9/9 for F0-1 and 92/96 for F4) and the largest confusion centered on F3. The algorithm produced a set of compound rules out of the ten classification trees and was used to classify the 261 patients. The rules for the classification of patients in F0 and F4 were effective in more than 75% of the cases in which they were tested. CONCLUSION: The recognition of clinical subgroups should help to enhance our ability to assess differences in fibrosis scores in clinical studies and improve our understanding of fibrosis progression.