The use of robotics is a recent innovation in surgery. In addition to dexterity enhancement and motion scaling, this new technology opens the horizon of remote surgery. This latter advancement has ...potential use during surgery involving a high risk of patient-to-professional or professional-to-patient virus transmission. We investigated the feasibility of robotic assisted kidney transplantation.
A right cadaveric kidney was transplanted into a 26-year-old male patient who has been on hemodialysis for 11 years. Surgery was done with the help of the da Vinci robot (Intuitive Surgical, Inc., Mountain View, California) by a remote surgeon, who completely performed vascular dissection and anastomosis as well as ureterovesical anastomosis. The role of the assistant by the side of the patient was limited to access creation, exposure, hemostasis and maintaining traction on the running sutures performed by the robot.
Operative time was 178 minutes. Robotic assistance made anastomosis possible by its unique ability of stereoscopic magnification and ultra-precise suturing techniques due to the flexibility of the robotic wristed instruments. Renal perfusion was excellent with immediate diuresis. Postoperative acute tubular necrosis started to resolve after 1 week.
This study demonstrates that robotic assisted kidney transplantation is feasible. Currently technical and cost hindrances limit the routine use of robots. However, with ongoing improvement and future availability of this technology the prevention of patient-to-professional and professional-to-patient viral transmission may become a potential field of application.
To evaluate prospectively the diagnostic yield of a 21-sample ultrasound-guided needle biopsy procedure for prostate cancer in patients with elevated serum prostate-specific antigen and/or abnormal ...digital rectal examination findings.
Between December 2000 and May 2002, 303 patients underwent 21-sample needle biopsy under local anesthesia, comprising sextant biopsies at a 45° angle, 3 biopsies in each peripheral zone at an 80° angle, 3 biopsies in each transition zone (TZ), and 3 biopsies in the midline peripheral zone. Morbidity was assessed clinically. A short questionnaire was filled out by 90 consecutive patients.
The cancer detection rate using 6 biopsy samples (sextant biopsies only), 12 samples (sextant plus lateral biopsies), 18 samples (sextant plus lateral plus TZ biopsies), and 21 samples (sextant plus lateral plus TZ, plus midline biopsies) was 22.7%, 28.3%, 30.7%, and 31.3%, respectively. The 21-sample procedure statistically improved the cancer detection rate by 37.9% relative to the 6-sample procedure. The improvement was most marked in patients with a prostate volume of more than 40 cm3 (48.3%), patients with Stage T1c prostate disease (44.9%), patients undergoing repeat biopsy (66.2%), and patients with prostate-specific antigen levels greater than 10 ng/mL (38.5%). Adverse effects were infrequent (3%), consisting of prostatitis in 3 patients, acute urinary retention in 6 patients, and rectal bleeding requiring hospitalization in 1 patient taking aspirin. Using the questionnaire, 84% of patients reported macroscopic hematuria for an average of 3.4 days and hematospermia for 12.8 days, and 45% reported minor rectal bleeding lasting 1.1 days. The mean pain score, with a visual analog scale ranging between 0 (no pain) and 10 (intense pain), was 4.56.
A 21-sample needle biopsy procedure increased the prostate cancer detection rate relative to a 6-sample procedure, without increasing morbidity. Patients with elevated prostate-specific antigen values should undergo sextant biopsies and at least 6 additional biopsies in the peripheral zone and 6 in the TZ.
Purpose
To evaluate the incidence of high-grade prostatic intraepithelial neoplasia (HGPIN) and atypical small acinar proliferation (ASAP) in an initial 21-core extended biopsy scheme and to ...determine the prostate cancer detection rate in the repeated biopsy.
Methods
Between 2002 and 2008, 2,006 patients underwent a first 21-core extended biopsy scheme. Incidences of cancer, ASAP and HGPIN were studied. Cancer detection rate in the repeated 21-core extended biopsy for ASAP and HGPIN was reported and compared with those obtained on repeated biopsy for clinico-biological indications.
Results
Incidences of HGPIN and ASAP were 1.7 and 1.1%, respectively. The 6-core and 12-core biopsy schemes detecting HGPIN would have missed the diagnosis of cancer in 10 and 3.6% of cases, compared to a 21-core biopsy protocol, respectively. The cancer detection rate on repeated biopsy for HGPIN was 19% and not significantly different compared with the detection rate on repeated biopsy for clinico-biological indications (16.8%,
p
= 0.77). Seven prostate cancers were found among the 17 re-biopsies for ASAP revealing a detection rate of 41.2% (
p
= 0.01). All detected cancers were organ confined. No clinico-pathological data were independent predictor of cancer on repeated biopsy.
Conclusion
Our report demonstrates the different risk profiles for HGPIN and ASAP in a 21-core extended biopsy scheme. The presence of HGPIN does not imply a higher risk for cancer detection at immediate re-biopsy compared to other patients for whom repeated biopsies were indicated for increasing or persistently increased PSA levels. Repeated biopsy is warranted when ASAP is diagnosed because of a high risk of prostate cancer.
Abstract Background Urinary prostate cancer gene 3 ( PCA3 ) represents a promising novel marker of prostate cancer detection. Objective To test whether urinary PCA3 assay improves prostate cancer ...(PCa) risk assessment and to construct a decision-making aid in a multi-institutional cohort with pre–prostate biopsy data. Design, setting, and participants PCA3 assay cut-off threshold analyses were followed by logistic regression models which used established predictors to assess PCa-risk at biopsy in a large multi-institutional data set of 809 men at risk of harboring PCa. Measurements Regression coefficients were used to construct four sets of nomograms. Predictive accuracy (PA) estimates of biopsy outcome predictions were quantified using the area under the curve of the receiver operator characteristic analysis in models with and without PCA3 . Bootstrap resamples were used for internal validation and to reduce overfit bias. The extent of overestimation or underestimation of the observed PCa rate at biopsy was explored graphically using nonparametric loss-calibration plots. Differences in PA were tested using the Mantel-Haenszel test. Finally, nomogram-derived probability cut-offs were tested to assess the ability to identify patients with or without PCa. Results and limitations PCA3 was identified as a statistically independent risk factor of PCa at biopsy. Addition of a PCA3 assay improved bootstrap-corrected multivariate PA of the base model between 2% and 5%. The highest increment in PA resulted from a PCA3 assay cut-off threshold of 17, where a 5% gain in PA (from 0.68 to 0.73, p = 0.04) was recorded. Nomogram probability–derived risk cut-off analyses further corroborate the superiority of the PCA3 nomogram over the base model. Conclusions PCA3 fulfills the criteria for a novel marker capable of increasing PA of multivariate biopsy models. This novel PCA3 -based nomogram better identifies men at risk of harboring PCa and assists in deciding whether further evaluation is necessary.
OBJECTIVE
To assess the prognostic significance of microscopic bladder neck invasion (BNI+) after radical prostatectomy (RP).
PATIENTS AND METHODS
From January 1988 to December 2006, 1480 patients ...with clinically localized prostate cancer were surgically treated at one tertiary university hospital. The risk of biochemical progression, defined as a prostate‐specific antigen (PSA) level after RP of >0.2 ng/mL, was assessed with univariate and multivariate analyses for clinical and pathological variables. We compared the biochemical progression‐free survival (bPFS) of patients with BNI+ vs stages pT2, pT3a, pT3b and positive lymph nodes (N+). In a second analysis, we evaluated the bPFS of patients in different stages associated with BNI+ and compared them with those in the same stages with no BNI.
RESULTS
BNI+ was found in 132 (9%) patients; the 5‐year bPFS was 86%, 54%, 26% and 10% for stages pT2, pT3a, pT3b and N+, respectively, while it was 30% for BNI+ (P < 0.001). There was no difference in the 5‐year bPFS between stage pT2 and pT2 + BNI (P = 0.32). Stages pT3a and pT3b had a better 5‐year bPFS than stage pT3a + BNI (P = 0.003) and pT3b + BNI (P = 0.001), respectively. In the univariate analysis all variables were associated with BP. In the multivariate analysis, only BNI+ had no association with BP (odds ratio 1.14, 95% confidence interval 0.70–1.85; P = 0.59).
CONCLUSIONS
Microscopic BNI+ in prostate cancer is not an independent risk factor for biochemical progression and should be regarded as a factor that worsens the prognosis of the underlying tumour stage. A longer follow‐up is necessary to confirm these findings.
Study Type – Therapy (outcomes research) Level of Evidence 2c
What’s known on the subject? and What does the study add?
The first objective of radical prostatectomy (RP) is cancer control. However, ...the success of RP should also be measured by the most unforgiving long‐term morbidity outcomes and by the maintenance of quality‐of‐life. Incontinence and erectile dysfunction have clearly negative repercussions on a patient’s quality‐of‐life although most men are usually satisfied with treatment and accept these subsequent disorders. Outcomes of continence, erectile function and cancer control after RP are well described in isolation. However, combined oncological and functional results are lacking, especially in laparoscopic procedures.
Separate presentation of cancer control and functional results does not provide sufficient patient information, and the report of combined outcomes is a necessary point of discussion between the urologist and his patient. Thus, we reported the combined oncological and functional outcomes 2 years after extraperitoneal laparoscopic radical prostatectomy.
OBJECTIVE
To determine the proportion of patients who are continent, potent and cancer‐free (trifecta rate) 2 years after extraperitoneal laparoscopic radical prostatectomy (ELRP).
PATIENTS AND METHODS
We included patients who underwent an ELRP at our department and who were followed for at least 2 years. Those who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 911 men were included. All patients prospectively completed objective, self‐administered questionnaires before the medical visit, concerning their voiding and sexual disorders, before surgery and 12 and 24 months after ELRP. Biochemical recurrence was defined as any detectable serum PSA (≥0.2 ng/mL). Potency was defined as the ability to achieve an erection sufficient for penetration with or without the use of phosphodiesterase‐5 enzyme inhibitor. Urinary continence was defined as absence, or occasional use, of a pad for anticipated vigorous activity. The primary study endpoint was the trifecta rate (cancer control, continence and potency) at 2 years after the surgery. Factors associated with the trifecta outcome were assessed in univariate analysis.
RESULTS
Median age and PSA level were 62.2 years and 9.9 ng/mL, respectively. A trifecta outcome was achieved in 29.7 and 54.4% of patients at 12 and 24 months, respectively. The 2‐year trifecta rate reached 63.5% in patients undergoing bilateral nerve‐sparing surgery and 73.5% in men aged <60 years. Age <60 years, PSA level <10 ng/mL, organ‐confined disease and bilateral nerve‐sparing procedure were significantly associated with the 2‐year trifecta outcome. A total of 84.8% of patients were both cancer‐free and continent at 24 months, regardless of erectile function.
CONCLUSIONS
Two years after ELRP, the trifecta outcome is achieved in 54.4% of patients who remained potent and continent. This rate reaches 63.5% in patients undergoing a bilateral nerve‐sparing procedure. Combined results of good cancer control and continence recovery are reported in 84.8% of patients, regardless of erectile function.
Purpose We evaluated urinary collecting system invasion as a prognostic parameter of renal cell carcinoma. Materials and Methods A total of 1,124 patients who underwent nephrectomy for a renal tumor ...at 5 European centers were included in this retrospective study. Several variables were analyzed including urinary collecting system invasion, age, sex, TNM stage, Fuhrman grade, histological subtype, Eastern Cooperative Oncology Group performance status and cancer specific survival. Results There were 771 males (68.6%) and 353 females (31.4%) in this study, and median age was 61 years (range 14 to 88). Median tumor size was 6 cm (range 1 to 24). Tumors were organ confined and Fuhrman grade was recorded as 1 or 2 in 67.1% and 62.3% of cases, respectively. Symptoms were present at diagnosis, and Eastern Cooperative Oncology Group performance status was 1 or more in 50.3% and 16.1% of the cases, respectively. Median followup was 43 months (range 1 to 299). At the end of followup 246 patients (21.9%) died of cancer. In 132 cases (11.7%) urinary collecting system invasion was noted. Urinary collecting system invasion was associated with symptoms, TNM stage, Fuhrman grade, tumor size (p <0.001) and Eastern Cooperative Oncology Group performance status (p = 0.003), but not with histological subtype (p = 0.7). On univariate analysis TNM stage, Fuhrman grade, symptoms, Eastern Cooperative Oncology Group performance status, tumor size and urinary collecting system invasion (p = 0.0001) were significant predictors of cancer specific survival. Urinary collecting system invasion was an independent prognostic parameter only in the setting of pT1–T2 tumors. When the urinary collecting system was invaded the 5 and 10-year probabilities of survival were 43% and 41%, respectively. Conclusions Urinary collecting system invasion appears to be an independent prognostic parameter of organ confined renal cell carcinoma. Our data support the need to integrate this parameter in further TNM revisions.
To describe the surgical technique of robot-assisted sacral colpopexy (RASCP) and to assess its feasibility and safety in a high-volume laparoscopic center.
12 women with symptomatic urogenital ...prolapse with or without concomitant urinary stress incontinence were treated with RASCP by one surgeon at our institution. The preoperative workup involved a detailed urologica and gynecologic history and physical examination to determine the type, the degree of the prolapse and the presence of concomitant stress urinary incontinence.
Mean operative time was 144 minutes (range 120-180 min). No conversion to a laparoscopic or open procedure was necessary. The mean patient age was 57.1 years old (range 44-79). The mean estimated blood loss was 60 mL (range 20-200 mL). The mean catheterization time was 2 days, and the mean hospital stay was 3.4 days (range 3-4 d). At a mean follow-up of 19.1 months (range 8-28 mos), no recurrence of the prolapse occurred.
RASCP for treatment of patients with urogenital prolapse is a feasible alternative to open and laparoscopic procedures. It procures an anatomic repositioning of the pelvic organs. The short-term results and the complication rates are similar with gold standard techniques.
Objectives To compare the morbidity and functional results after laparoscopic radical prostatectomy with and without previous transurethral resection of the prostate (TURP). Methods From May 1998 to ...January 2005, 640 patients underwent laparoscopic radical prostatectomy, of whom 46 (7.2%) had previously undergone TURP. The perioperative and postoperative data were compared between group 1 (with previous TURP) and group 2 (without previous TURP). The functional results were assessed by self-administered questionnaires at 12 and 24 months after surgery. Results In group 1, the operative time, hospital stay, and bladder catheterization duration was increased by 31 minutes, 1.9 days, and 2.9 days, respectively. The positive margin rate was not signficantly different statistically between the two groups ( P = .62). The 5-year actuarial freedom from biochemical recurrence rate was similar between the two groups ( P = .86). Surgical complications occurred in 15.2% of group 1 and 5.7% of group 2 ( P = .02). The risk of anastomotic stricture was 6.5% and 1.2% in groups 1 and 2, respectively ( P = .02). Two years after surgery, the continence rate was 86.9% in group 1 and 95.8% in group 2 ( P = .77), and the potency rate was 63.8% and 70.9%, respectively, after bilateral neurovascular bundle preservation ( P = .61). However, neurovascular bundle preservation was performed after previous TURP in only 56.5% of group 1 vs 78.9% in group 2 ( P = .02). The median follow-up was 50.8 months (range 30–107). Conclusions Laparoscopic radical prostatectomy can be performed after TURP without compromising the oncologic results. However, patients should be informed that the procedure is associated with worse intraoperative and postoperative outcomes. Although the urinary continence rate was not hampered by previous TURP, neurovascular bundle preservation is technically more difficult and compromises postoperative erectile function.
Purpose:
Compare the early oncological results of laparoscopic radical prostatectomy performed by either an extraperitoneal or a transperitoneal approach.
Methods:
330 consecutive men underwent ...laparoscopic radical prostatectomy for localized prostate cancer, the first 165 by transperitoneal approach, and the last 165 by extraperitoneal approach. Clinical stage, serum PSA, Gleason score of biopsy were recorded, as well as operating time, surgical and medical complications, blood loss, length of hospital stay and catheterization time. The weight of the specimen, pathological stage (1997 TNM classification) and status of the surgical margins were noted. The Fisher test as well as the χ
2-test were used for statistical analysis. Differences were considered significant when
p<0.05.
Results:
There were no significant differences between the two groups in terms of preoperative characteristics except for Gleason score of the biopsies which was higher in the extraperitoneal group (
p<0.0001). The operating time was longer with the transperitoneal approach (248.5
min vs. 220.0
min,
p<0.0001). There was no difference in transfusion rate (1.2% vs. 5.4%, transperitoneal vs. extraperitoneal, respectively,
p=0.6). There was no difference in hospital stay, medical and surgical complications. Respectively, in the transperitoneal and extraperitoneal groups, there were 108 and 88 pT2 tumors. There were no differences in terms of positive surgical margins between the two groups, 23% and 29.7% (
p=0.21) overall, 13.0% and 17.0% (
p=0.42) in pT2 tumors and 43.6% and 44.7% (
p=0.99) in pT3 tumors.
Conclusions:
Extraperitoneal approach offers the same early oncological results as transperitoneal approach with a shorter operative time.
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