A new score for airway assessment using clinical and ultrasound parameters.

Background: Over the last few years, ultrasonography has been introduced as the fifth pillar to patient's bedside physical examination. Clinical assessments aim to screen and look for airway difficulties to predict difficult intubations, but none have demonstrated a significant predictive capacity. Recent systematic reviews have established a correlation between ultrasound imaging and difficult direct laryngoscopy. The primary objective of this study was to determine whether the utilization of ultrasonography to examine the upper airway could accurately predict difficult direct laryngoscopy. Methods: This is a prospective observational study including 102 adult patients that required general anesthesia for elective surgery. Preoperatively, clinical airway assessments were performed. Data such as Mallampati-Samsoon grade (MS), upper lip bite test (ULBT), thyromental (TMD) and sternomental distance (SMD), cervical circumference (CC) and the Arné risk index were collected. Ultrasound evaluation was taken at five different levels in two planes, parasagittal and transverse. Therefore, the following measurements were registered: distance from skin to hyoid bone (DSHB), distance from skin to thyrohyoid membrane (DSTHM), distance from skin to epiglottis (DSE), distance from skin to thyroid cartilage (DSTC) and distance from hyoid bone and thyroid cartilage (DHBTC). Patients were divided into two groups based on the difficulty to perform direct laryngoscopy, according to Cormack-Lehane (C-L) classification. Grades I and II were classified as easy laryngoscopy and grades III or IV as difficult. Logistic regression models and the Receiver Operating Characteristic (ROC) curve was employed to determine the diagnostic precision of ultrasound measurements to distinguish difficult laryngoscopy (DL). Results: The following risk score for DL was obtained, DSTHM ≥ 1.60 cm (2 points), DSTC ≥ 0.78 cm (3 points) and gender (2 points for males). The score can range from 0 to 7 points, and showed and AUC (95% CI) of 0.84 (0.74-0.95). A score of 5 points or higher indicates a 34-fold increase in the risk of finding DL (p = 0.0010), sensitivity of 91.67, specificity of 75.56, positive predictive value of 33.33, and negative predictive value of 98.55. Conclusion: The use of ultrasonography combined with classic clinical screening tests are useful tools to predict difficult direct laryngoscopy.

Selective Adsorption of Aqueous Diclofenac Sodium, Naproxen Sodium, and Ibuprofen Using a Stable Fe3O4-FeBTC Metal-Organic Frameworka.

The FeBTC metal-organic framework (MOF) incorporated with magnetite is proposed as a novel material to solve water contamination with last generation pollutants. The material was synthesized by in situ solvothermal methods, and Fe3O4 nanoparticles were added during FeBTC MOF synthesis and used in drug adsorption. X-ray diffraction (XRD), Fourier-transform infrared spectroscopy (FTIR), and Raman spectroscopy characterized the materials, with N2-physisorption at 77 K. Pseudo-second-order kinetic and Freundlich models were used to describe the adsorption process. The thermodynamic study revealed that the adsorption of three drugs was a feasible, spontaneous exothermic process. The incorporation of magnetite nanoparticles in the FeBTC increased the adsorption capacity of pristine FeBTC. The Fe3O4-FeBTC material showed a maximum adsorption capacity for diclofenac sodium (DCF), then by ibuprofen (IB), and to a lesser extent by naproxen sodium (NS). Additionally, hybridization of the FeBTC with magnetite nanoparticles reinforced the most vulnerable part of the MOF, increasing the stability of its thermal and aqueous media. The electrostatic interaction, H-bonding, and interactions in the open-metal sites played vital roles in the drug adsorption. The sites' competition in the multicomponent mixture's adsorption showed selective adsorption (DCF) and (NS). This work shows how superficial modification with a low-surface-area MOF can achieve significant adsorption results in water pollutants.

Atomic-Scale Investigation on the Evolution of Tio2-Anatase Prepared by a Sonochemical Route and Treated with NaOH.

To date, the formation mechanisms of TiO2, as well as its heterostructures, have not been clarified. Moreover, detailed research on the transition from a tetragonal anatase phase to the monoclinic phase of the TiO2(B) phase and their interface structure has been quite limited until now. In the present study, we report on the sonochemical synthesis of TiO2-anatase with a crystallite size of 5.2 ± 1.5 nm under different NaOH concentrations via the hydrothermal method. The use of alkaline solution and the effect of the temperature and reaction time on the formation and structural properties of TiO2-anatase nanopowders were studied. The effects of NaOH concentration on the formation and transformation of titanate structures are subject to thermal effects that stem from the redistribution of energy in the system. These mechanisms could be attributed to three phenomena: (1) the self-assembly of nanofibers and nanosheets, (2) the Ostwald ripening process, and (3) the self-development of hollow TiO2 mesostructures.

Erectile Function Recovery after Radical Prostatectomy in Men with High Risk Features.

PURPOSE: We describe the efficacy of radical prostatectomy to achieve complete primary tumor excision while preserving erectile function in a cohort of patients with high risk features in whom surgical resection was tailored according to clinical staging, biopsy data, preoperative imaging and intraoperative findings. MATERIALS AND METHODS: In a retrospective review we identified 584 patients with high risk features (prostate specific antigen 20 ng/ml or greater, clinical stage T3 or greater, preoperative Gleason grade 8-10) who underwent radical prostatectomy between 2006 and 2012. The probability of neurovascular bundle preservation was estimated based on preoperative characteristics. Positive surgical margin rates and erectile function recovery were determined in patients who had some degree of neurovascular bundle preservation. RESULTS: The neurovascular bundles were resected bilaterally in 69 (12%) and unilaterally in 91 (16%) patients. The remaining patients had some degree of bilateral neurovascular bundle preservation. Preoperative features associated with a lower probability of neurovascular bundle preservation were primary biopsy Gleason grade 5 and clinical stage T3 disease. Among the patients with some degree of neurovascular bundle preservation 125 of 515 (24%) had a positive surgical margin, and 75 of 160 (47%) men with preoperatively functional erections and available erectile function followup had recovered erectile function within 2 years. CONCLUSIONS: High risk features should not be considered an indication for complete bilateral neurovascular bundle resection. Some degree of neurovascular bundle preservation can be done safely by high volume surgeons in the majority of these patients with an acceptable rate of positive surgical margins. Nearly half of high risk patients with functional erections preoperatively recover erectile function after radical prostatectomy.

Predicting length of stay after robotic partial nephrectomy.

INTRODUCTION: To investigate factors predictive of length of stay (LOS) after robotic partial nephrectomy (RPN) in an effort to identify patients suitable for RPN with overnight stay at outpatient surgical facilities. MATERIALS AND METHODS: Retrospective chart review of patients who underwent RPN at Memorial Sloan Kettering Cancer Center from January 2007 to July 2012 was conducted. Univariate and multivariate analyses were performed to identify the main predictors of LOS. The discrimination of the multivariate model was measured using the area under the curve (AUC); tenfold cross-validation was performed to correct for over-fit. RESULTS: One hundred and eighty-six patients were included in the analysis; 84 (45 %) had LOS of ≤1 day (median LOS 2 day; interquartile range 1-2). On univariate analysis, preoperative variables associated with LOS > 1 included larger tumors (P < 0.0001), lower estimated glomerular filtration rate (P = 0.003), older age (P = 0.006), female gender (P = 0.035), and higher comorbidity score (P = 0.015); operative variables associated with LOS > 1 day included greater estimated blood loss (P < 0.0001) and longer operative (P < 0.0001) and ischemia (P < 0.0001) times. The AUC of the preoperative model was 0.61 (95 % CI 0.52-0.69) after tenfold cross-validation. CONCLUSIONS: LOS after RPN is influenced by age, gender, medical comorbidities, and tumor size. However, when analyzed retrospectively, these factors had limited ability to predict LOS after RPN with sufficient accuracy to develop a prediction tool.

Ambulatory Extended Recovery: Safely Transitioning to Overnight Observation for Minimally Invasive Prostatectomy.

INTRODUCTION: We evaluated the safety and efficacy of a clinical pathway designed and implemented to transition inpatient minimally invasive radical prostatectomy to a procedure with overnight observation. METHODS: In April 2011 ambulatory extended recovery was implemented at our institution. This was a multidisciplinary program of preoperative teaching and postoperative care for patients undergoing minimally invasive radical prostatectomy. We compared the risk of requiring a more than 1-night hospital stay by patients treated with surgery the year before the program vs those treated after the program was initiated, adjusting for age, ASA® status and surgery type. We also examined the rates of readmission and urgent care visits within 48 hours, and 7 and 30 days before and after the program began. RESULTS: The proportion of patients who stayed longer than 1 night was 53% in the year before initiating the ambulatory extended recovery program vs 8% during the program, representing an adjusted absolute risk decrease of 45% (95% CI 39-50, p <0.0001). There was no important predictor of a greater than 1-night length of stay among ambulatory extended recovery patients. Rates of readmission and urgent care visits were slightly lower during the ambulatory extended recovery phase with no significant difference between the groups. CONCLUSIONS: The ambulatory extended recovery program successfully transitioned most patients to a 1-night hospital stay without resulting in an increased rate of readmission or urgent care visits.

Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial.

BACKGROUND: Open radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk. OBJECTIVE: To compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively. INTERVENTION: Standard ORC or RARC with PLND; all urinary diversions were performed via an open approach. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcomes were overall 90-d grade 2-5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score. RESULTS AND LIMITATIONS: The trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2-5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, -21% to -13%; p=0.7). The similar rates of grade 2-5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings. CONCLUSIONS: This trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique. PATIENT SUMMARY: Of 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.

From open to robotic partial nephrectomy.

The present study does not establish comparisons of the different techniques (open, laparoscopic and robotic surgery); rather, it analyzes the how, when and why of each of them from a historical perspective. This historical analysis begins in the late XIX century and extends up to the present time. The study examines the principles, the uncertainties regarding the feasibility of the techniques, the failures, the complications, the doubts about whether the right thing is being done, and the success of a surgical treatment which is presently beyond question. The historical account is summarized, since it covers a period of over one hundred years. It is the history written by innovating and inspired men and women who changed the course of the treatment of renal neoplastic disease.

De la nefrectomía parcial abierta a la robótica / From open to robotic partial nephrectomy

En este trabajo no realizaremos un estudio comparativo de las distintas técnicas (abierta, laparoscópica y robótica) sino más bien analizaremos el cómo, el cuándo y el porqué de cada una de ellas desde una perspectiva histórica. Este análisis histórico comenzará desde finales del siglo XIX hasta llegar a nuestros días. En él, relataremos los principios; la incertidumbre de si se puede realizar. Los fracasos; las complicaciones y las dudas del saber si se está haciendo lo correcto. Y los éxitos de un tratamiento quirúrgico que hoy en día está fuera de toda duda. Todo ello resumido, ya que supone más de cien años de historia de la medicina. La historia que han escrito hombres y mujeres inconformistas que cambiaron el rumbo del tratamiento de la patología renal neoplásica(AU)

The present study does not establish comparisons of the different techniques (open, laparoscopic and robotic surgery); rather, it analyzes the how, when and why of each of them from a historical perspective. This historical analysis begins in the late XIX century and extends up to the present time. The study examines the principles, the uncertainties regarding the feasibility of the techniques, the failures, the complications, the doubts about whether the right thing is being done, and the success of a surgical treatment which is presently beyond question. The historical account is summarized, since it covers a period of over one hundred years. It is the history written by innovating and inspired men and women who changed the course of the treatment of renal neoplastic disease(AU)

Perineal radical prostatectomy in the minimally invasive era.

Radical prostatectomy is currently the standard of care for localized prostate cancer. In the last decade, the minimally invasive surgery, especially the robotic surgery has been growing and open techniques are less frequent performed. A non-systematic review of the literature is performed, highlighting the current situation of the perineal radical prostatectomy in the minimally invasive era, its indications, and functional and oncological outcomes. Radical perineal prostatectomy, when compared with other surgical approaches, still experience favorable outcomes. Urologist might be abandoning an underused surgical approach.

Prostatectomía perineal radical en la era de mínima invasión / Perineal radical prostatectomy in the minimally invasive era

OBJETIVO: La prostatectomía radical es en la actualidad el tratamiento estándar para el cáncer de próstata localizado. En la última década, la cirugía mínimamente invasiva ha ido creciendo, especialmente la cirugía robótica y las técnicas abiertas se llevan a cabo con menos frecuencia. Realizamos una revisión no sistemática de la literatura al respecto, destacando la situación actual de la prostatectomía perineal radical en la era mínimamente invasiva, sus indicaciones y los resultados funcionales y oncológicos. La prostatectomía perineal radical continúa teniendo resultados favorables, en comparación con otros métodos quirúrgicos. Los urólogos podrían abandonar un abordaje quirúrgico infrautilizado (AU)

Radical prostatectomy is currently the standard of care for localized prostate cancer. In the last decade, the minimally invasive surgery, especially the robotic surgery has been growing and open techniques are less frequent performed. A non-systematic review of the literature is performed, highlighting the current situation of the perineal radical prostatectomy in the minimally invasive era, its indications, and functional and oncological outcomes. Radical perineal prostatectomy, when compared with other surgical approaches, still experience favorable outcomes. Urologist might be abandoning an underused surgical approach (AU)

Pelvic lymph node dissection for patients with elevated risk of lymph node invasion during radical prostatectomy: comparison of open, laparoscopic and robot-assisted procedures.

BACKGROUND AND PURPOSE: Published outcomes of pelvic lymph node dissection (PLND) during robot-assisted laparoscopic prostatectomy (RALP) demonstrate significant variability. The purpose of the study was to compare PLND outcomes in patients at risk for lymph node involvement (LNI) who were undergoing radical prostatectomy (RP) by different surgeons and surgical approaches. PATIENTS AND METHODS: Institutional policy initiated on January 1, 2010, mandated that all patients undergoing RP receive a standardized PLND with inclusion of the hypogastric region when predicted risk of LNI was ≥ 2%. We analyzed the outcomes of consecutive patients meeting these criteria from January 1 to September 1, 2010 by surgeons and surgical approach. All patients underwent RP; surgical approach (open radical retropubic [ORP], laparoscopic [LRP], RALP) was selected by the consulting surgeon. Differences in lymph node yield (LNY) between surgeons and surgical approaches were compared using multivariable linear regression with adjustment for clinical stage, biopsy Gleason grade, prostate-specific antigen (PSA) level, and age. RESULTS: Of 330 patients (126 ORP, 78 LRP, 126 RALP), 323 (98%) underwent PLND. There were no significant differences in characteristics between approaches, but the nomogram probability of LNI was slightly greater for ORP than RALP (P=0.04). LNY was high (18 nodes) by all approaches; more nodes were removed by ORP and LRP (median 20, 19, respectively) than RALP (16) after adjusting for stage, grade, PSA level, and age (P=0.015). Rates of LNI were high (14%) with no difference between approaches when adjusted for nomogram probability of LNI (P=0.15). Variation in median LNY among individual surgeons was considerable for all three approaches (11-28) (P=0.005) and was much greater than the variability by approach. CONCLUSIONS: PLND, including hypogastric nodal packet, can be performed by any surgical approach, with slightly different yields but similar pathologic outcomes. Individual surgeon commitment to PLND may be more important than approach.

Role of positron emission tomography in urological oncology.

• Positron emission tomography (PET) is a diagnostic tool using radiotracers to show changes in metabolic activities in tissues. We analysed the role of PET and PET/computed tomography (CT) in the diagnosis, staging, and follow-up of urological tumours. • A critical, non-structured review of the literature of the role of PET and PET/CT in urological oncology was conducted. • PET and PET/CT can play a role in the management of urological malignancies. For prostate cancer, the advances in radiotracers seems promising, with novel radiotracers yielding better diagnostic and staging results than 18F-fluorodeoxyglucose (18F-FDG). In kidney cancer, PET and PET/CT allow a proper diagnosis before the pathological examination of the surgical specimen. For testis cancer, PET and PET/CT have been shown to be useful in the management of seminoma tumours. In bladder cancer, these scans allow a better initial diagnosis for invasive cancer, while detecting occult metastases. • PET and its combined modality PET/CT have shown their potential in the diagnosis of urological malignancies. However, further studies are needed to establish the role of PET in the management of these diseases. Future applications of PET may involve fusion techniques such as magnetic resonance imaging with PET.

Oncological outcomes after radical cystectomy for bladder cancer: open versus minimally invasive approaches.

PURPOSE: The number of centers performing robotic assisted radical cystectomy has recently increased, spurring greater concerns about oncological outcomes. In this review we summarize the most comprehensive articles published on the oncological outcomes of laparoscopic assisted, robotic assisted and open radical cystectomy. MATERIALS AND METHODS: A MEDLINE/PubMed literature search was conducted in March 2009 to review English language articles published from 1998 onward. Of 217 selected articles on the 3 techniques 19 studies were selected for this review. RESULTS: The laparoscopic series reported recurrence-free survival rates in the range of 83% to 85% at 1 to 2 years and 60% to 77% at 2 to 3 years, while the robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years. Large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years. Overall survival in the laparoscopic cohorts was 90% to 100% at 1 to 2 years and 50% to 87% at 2 to 3 years. Publications reporting robotic cases demonstrated a 90% to 96% overall survival in 1 to 2 years of followup. CONCLUSIONS: Despite the surge of centers adopting minimally invasive approaches for radical cystectomy, the long-term effectiveness of these techniques has not yet been proven. This review of recent and landmark articles on open and minimally invasive procedures emphasizes the need for prospective controlled studies and long-term followup data to determine the proper use of laparoscopic and robotic assisted techniques in bladder cancer surgery.

Robotic-assisted laparoscopic partial nephrectomy: initial clinical experience.

OBJECTIVES: To report on our initial experience with robotic-assisted partial nephrectomy. Laparoscopic partial nephrectomy requires experience and a lengthy learning curve to successfully accomplish tumor excision and renal reconstruction, which may adversely prolong the ischemia time. The advent of robotic-assisted laparoscopic surgery has proved successful in prostate cancer surgery, encouraging a growing number of centers to apply this technology to complex renal surgery. METHODS: A total of 20 consecutive patients underwent robotic-assisted partial nephrectomy from September 2007 to April 2008. The surgical technique we used followed the standard 4-port laparoscopic partial nephrectomy technique. Renal hilum clamping was used in 12 cases. The demographic data and perioperative outcomes were retrospectively reviewed. RESULTS: The mean patient age and body mass index was 66 years and 29 kg/m(2), respectively. The mean tumor size was 2.7 cm. The mean operative and warm ischemia time was 142 and 28 minutes, respectively. The mean estimated blood loss was 263 mL, and 3 patients required a blood transfusion. One intraoperative complication required open conversion. Two postoperative complications were observed; 1 patient developed a pulmonary embolism and 1 developed an abscess at the resection site. The average hospital stay was 2.8 days. Pathologic examination of the lesions revealed 14 cases of renal cell carcinoma and 6 of benign lesions. All resection margins were free of tumor. CONCLUSIONS: The results of our study have shown that robotic partial nephrectomy is safe and practical for patients with small renal tumors considered candidates for open partial nephrectomy. In our experience, the procedure can be performed with safe ischemia time and offers all the advantages of a minimally invasive procedure.

Robotic-assisted laparoscopic bladder diverticulectomy and concomitant ureteral re-implantation: initial clinical experience.

We present our initial clinical experience with robotic-assisted laparoscopic bladder diverticulectomy with associated ureteral re-implantation. A 75-year-old man was referred to us for recurrent urinary tract infections and lower urinary tract symptoms. On computed tomography of abdomen and pelvis the patient was found to have a 13 × 14 × 6 cm diverticulum in the left posterior bladder wall. The patient elected to undergo robotic-assisted laparoscopic removal of the diverticulum. The patient's preparation, draping, and trocar placement was performed as per standard fashion of robotic-assisted laparoscopic radical prostatectomy. The bladder was mobilized and diverticulum was identified and removed. The left ureter was transected secondary to its passage through the diverticulum, and required re-implantation. After hemostasis was achieved, the repair was tested and confirmed. The operation was completed in 207 min without any complications. Estimated blood loss was 150 cc. On postoperative day 1, the patient was placed on oral analgesic and discharged home. Our initial report of robotic-assisted laparoscopic bladder diverticulectomy and ureteral re-implantation illustrates that this minimally invasive technique is an effective method of treatment of bladder diverticulum. Proximity of the ureter to the diverticulum should not be a deterrent for this approach of repair.

Endoscopic third ventriculostomy in children: early and late complications and their avoidance.

INTRODUCTION: Endoscopic third ventriculostomy (ETV) is considered by many authors the initial surgical procedure of choice for the treatment of non-communicant hydrocephalus. However, this procedure has early and late complications that neurosurgeons must be aware of when performing it. MATERIALS AND RESULTS: A retrospective study of infants and children treated with ETV at Children's Memorial Hospital (Chicago, IL) between 1993 and 2004 is presented. A total of 136 ETVs in 122 patients were performed with 8.8% early complication rate (hemorrhage, CSF leak, infection, diabetes insipidus, and seizures). There were no fatalities but one patient had severe neurological disturbances due to intracranial hemorrhage at the second ETV. We identified several significant factors that influence the late ETV failure rate: age under 12 months (p=0.012), cases performed early in our experience (p=0.009), patients with hydrocephalus without expansive lesions (p=0.026), patients that had an external ventricular drain (EVD) after ETV (p<0.005), and patients who developed early complications (p=0.035). CONCLUSION: A careful patient selection and preoperative planning lead to better results of ETV. A higher early and late complication rate in children younger than 1-year-old were noted in our series. There is definitely a learning curve for this technique, and several technical considerations are helpful to avoid adverse events. Most of the early complications are transient, while potential devastating injuries can occur. Long-term follow-up is needed to identify delayed closure of the fenestration. Ventricular access devise is helpful for diagnostic and therapeutic purposes during the follow-up.

Contemporary appraisal of radical perineal prostatectomy.

PURPOSE: In the age of minimally invasive surgery there has been renewed interest in the perineal approach for the surgical treatment of prostate cancer. We reviewed recent publications regarding radical perineal prostatectomy (RPP) in an effort to define its role in the current management of localized prostate malignancy. At the same time we reviewed the relevant perineal anatomy and surgical approach necessary to perform this operation. MATERIALS AND METHODS: We performed a review of the literature with respect to RPP and included our own extensive experience with this operation, emphasizing patient selection, the current role of pelvic lymph node dissection, surgical anatomy, oncological outcomes and complications. RESULTS: RPP is an effective treatment for localized adenocarcinoma of the prostate with oncological outcomes similar to those of the retropubic technique. In comparison to RRP, patients undergoing RPP have less postoperative discomfort, more rapid return of bowel function, more rapid return to work and a decreased transfusion rate. In addition, RRP is now often performed with cavernous nerve sparing. Prostate specific antigen screening has made the rate of lymph node metastasis low enough to omit lymphadenectomy in many cases. CONCLUSIONS: There is still a role for RPP in the treatment of localized prostate cancer. Erectile dysfunction after nerve sparing and incontinence rates are similar to those of RRP. In addition, it is less morbid then RRP without being as technically challenging as laparoscopic radical prostatectomy.

Orthotopic bladder substitution in women with an ileocolonic pouch: functional and oncological outcome.

OBJECTIVES: In select female patients, bladder reconstruction following cystectomy will provide a better quality of life and self-image. We reviewed our results with ileocolonic orthotopic neobladders in female patients undergoing cystectomy for bladder cancer. Impact of pathologic stage on disease outcome, urinary continence results and surgical technique are described. Because of the relative paucity in the number of female neobladders performed, reporting of our results appear warranted. METHODS: Radical cystectomy with ileocolonic neobladder was performed in 22 consecutive women with bladder cancer over a five year period. Our technique spares the urethral support mechanism and innervation of the rhabdosphincter. Patients were selected based on renal function, ability to perform self-catheterization, organ confined disease and evidence of a disease free urethra, trigone and bladder neck. A retrospective review of the functional and cancer outcome was conducted. RESULTS: Postoperatively total diurnal urinary continence was achieved by 86% of the patients. Seventy-three percent of the patients had diurnal and nocturnal continence. Hypercontinence developed in 13.6% of patients. Only three patients developed advanced metastatic disease. None of the patients had evidence of local pelvic recurrence. The pathologic stage in the three patients that progressed were pT3a, pT3b, and pT2. CONCLUSIONS: Orthotopic neobladder substitution in female patients with bladder cancer is an alternative to a non-continent diversion. We report oncologic outcomes similar to the traditional anterior pelvic exenteration and non-continent urinary diversion. Surgical outcomes and complications are comparable with a significant improvement in the quality of life.