Abstract We present a propensity-matched analysis of patients undergoing placement of dehydrated human amnion/chorion membrane (dHACM) around the neurovascular bundle (NVB) during nerve-sparing (NS) ...robot-assisted laparoscopic prostatectomy (RARP). From March 2013 to July 2014, 58 patients who were preoperatively potent (Sexual Health Inventory for Men SHIM score >19) and continent (no pads) underwent full NS RARP. Postoperative outcomes were analyzed between propensity-matched graft and no-graft groups, including time to return to continence, potency, and biochemical recurrence. dHACM use was not associated with increased operative time or blood loss or negative oncologic outcomes ( p > 0.500). Continence at 8 wk returned in 81.0% of the dHACM group and 74.1% of the no-dHACM group ( p = 0.373). Mean time to continence was enhanced in group 1 patients (1.21 mo) versus (1.83 mo; p = 0.033). Potency at 8 wk returned in 65.5% of the dHACM patients and 51.7% of the no-dHACM group ( p = 0.132). Mean time to potency was enhanced in group 1, (1.34 mo), compared to group 2 (3.39 mo; p = 0.007). Graft placement enhanced mean time to continence and potency. Postoperative SHIM scores were higher in the dHACM group at maximal follow-up (mean score 16.2 vs 9.1). dHACM allograft use appears to hasten the early return of continence and potency in patients following RARP.
We report the overall rate, locations and predictive factors of positive surgical margins （PSMs） in 271 patients with high-risk prostate cancer. Between April 2008 and October 2011, we prospectively ...collected data from patients classified as D＇Amico high-risk who underwent robot-assisted laparoscopic radical prostatectomy. Overall rate and location of PSMs were reported. Stepwise logistic regression models were fitted to assess predictive factors of PSM. The overall rate of PSMs was 25.1% （68 of 271 patients）. Of these PSM, 38.2% （26 of 68） were posterolateral （PL）, 26.5% （18 of 68） multifocal, 16.2% （11 of 68） in the apex, 14.7% （10 of 68） in the bladder neck, and 4.4% （3/68） in other locations. The PSM rate of patients with pathological stage pT2 was 8.6% （12 of 140）, 26.6% （17 of 64） of pT3a, 53.3% （32/60） of pT3b, and 100% （7 of 7） of pT4. In a logistic regression model including pre-, intra-, and post-operative parameters, body mass index （odds ratio OR. 1.09; 95% confidence interval CI： 1.01-1.19, P = 0.029）, pathological stage （pT3b or higher vs pT2; OR： 5.14; 95% Ch 1.92-13.78; P = 0.001） and percentage of the tumor （OR： 46.71; 95% CI： 6.37-342.57; P 〈 0.001） were independent predictive factors for PSMs. The most common location of PSMs in patients at high-risk was the PL aspect, which reflects the reported tumor aggressiveness. The only significant predictive factors of PSMs were pathological outcomes, such as percentage of the tumor in the specimen and pathological stage.
Objective To better use virtual reality robotic simulators and offer surgeons more practical exercises, we developed the Tube 3 module for practicing vesicourethral anastomosis (VUA), one of the most ...complex steps in the robot-assisted radical prostatectomy procedure. Herein, we describe the principle of the Tube 3 module and evaluate its face, content, and construct validity. Materials and Methods Residents and attending surgeons participated in a prospective study approved by the institutional review board. We divided subjects into 2 groups, those with experience and novices. Each subject performed a simulated VUA using the Tube 3 module. A built-in scoring algorithm recorded the data from each performance. After completing the Tube 3 module exercise, each subject answered a questionnaire to provide data to be used for face and content validation. Results The novice group consisted of 10 residents. The experienced subjects (n = 10) had each previously performed at least 10 robotic surgeries. The experienced group outperformed the novice group in most variables, including task time, total score, total economy of motion, and number of instrument collisions ( P <.05). Additionally, 80% of the experienced surgeons agreed that the module reflects the technical skills required to perform VUA and would be a useful training tool. Conclusion We describe the Tube 3 module for practicing VUA, which showed excellent face, content, and construct validity. The task needs to be refined in the future to reflect VUA under real operating conditions, and concurrent and predictive validity studies are currently underway.
Background
The impact of parathyroidectomy on allograft function in kidney transplant patients is unclear.
Methods
We conducted a retrospective, observational study of all kidney transplant ...recipients from 1988 to 2008 who underwent parathyroidectomy for uncontrolled hyperparathyroidism (n = 32). Post‐parathyroidectomy, changes in estimated glomerular filtration rate (eGFR) and graft loss were recorded. Cross‐sectional associations at baseline between eGFR and serum calcium, phosphate, and parathyroid hormone (PTH), and associations between their changes within subjects during the first two months post‐parathyroidectomy were assessed.
Results
Post‐parathyroidectomy, the mean eGFR declined from 51.19 mL/min/1.73 m2 at parathyroidectomy to 44.78 mL/min/1.73 m2 at two months (p < 0.0001). Subsequently, graft function improved, and by 12 months, mean eGFR recovered to 49.76 mL/min/1.73 m2 (p = 0.035). Decrease in serum PTH was accompanied by a decrease in eGFR (p = 0.0127) in the first two months post‐parathyroidectomy. Patients whose eGFR declined by ≥20% (group 1) in the first two months post‐parathyroidectomy were distinguished from the patients whose eGFR declined by <20% (group 2). The two groups were similar except that group 1 had a higher baseline mean serum PTH compared with group 2, although not significant (1046.7 ± 1034.2 vs. 476.6 ± 444.9, p = 0.14). In group 1, eGFR declined at an average rate of 32% (p < 0.0001) during the first month post‐parathyroidectomy compared with 7% (p = 0.1399) in group 2, and the difference between these two groups was significant (p = 0.0003). The graft function recovered in both groups by one yr. During median follow‐up of 66.00 ± 49.45 months, 6 (18%) patients lost their graft with a mean time to graft loss from parathyroidectomy of 37.2 ± 21.6 months. The causes of graft loss were rejection (n = 2), pyelonephritis (n = 1) and chronic allograft nephropathy (n = 3). No graft loss occurred during the first‐year post‐surgery.
Conclusion
Parathyroidectomy may lead to transient kidney allograft dysfunction with eventual recovery of graft function by 12 months post‐parathyroidectomy. Higher level of serum PTH pre‐parathyoidectomy is associated with a more profound decrease in eGFR post‐parathyroidectomy.
Multiparametric magnetic resonance imaging (MP-MRI) helps to identify lesion of prostate with reasonable accuracy. We aim to describe the various uses of MP-MRI for prostate biopsy comparing ...different techniques of MP-MRI guided biopsy.
A literature search was performed for “multiparametric MRI”, “MRI fusion biopsy”, “MRI guided biopsy”, “prostate biopsy”, “MRI cognitive biopsy”, “MRI fusion biopsy systems”, “prostate biopsy” and “cost analysis”. The search operation was performed using the operator “OR” and “AND” with the above key words. All relevant systematic reviews, original articles, case series, and case reports were selected for this review.
The sensitivity of MRI targeted biopsy (MRI-TB) is between 91%–93%, and the specificity is between 36%–41% in various studies. It also has a high negative predictive value (NPV) of 89%–92% and a positive predictive value (PPV) of 51%–52%. The yield of MRI fusion biopsy (MRI-FB) is similar, if not superior to MR cognitive biopsy. In-bore MRI-TB had better detection rates compared to MR cognitive biopsy, but were similar to MR fusion biopsy.
The use of MRI guidance in prostate biopsy is inevitable, subject to availability, cost, and experience. Any one of the three modalities (i.e. MRI cognitive, MRI fusion and MRI in-bore approach) can be used. MRI-FB has a fine balance with regards to accuracy, practicality and affordability.
Purpose We reviewed outcomes and features in patients with bladder cancer who underwent cystectomy and had a history of radiation for prostate cancer. Materials and Methods We performed a ...retrospective analysis of the University of Miami cystectomy database and identified 34 patients with a history of radiotherapy for prostate cancer. An age and stage matched control group was used to compare survival. Our entire male cystectomy population was used to compare clinicopathological features. Results Mean age in the 34 patients with cystectomy was 75 years with a mean latency of 5 years from prostate cancer radiation. Radiotherapy was the primary treatment modality for prostate cancer in 32 of 34 patients and 2 received adjuvant radiation. Of the patients 86% received external beam radiation. Hematuria was the initial symptom in 86% of the cases. In 53% of the patients the initial diagnosis was muscle invasive bladder cancer. An ileal conduit was the method of urinary diversion in 33 cases. Major perioperative complications developed in 9% of the patients. There was 1 perioperative death, resulting in a mortality rate of 2.9%. Of the patients 54% presented with a locally advanced (pT3-4) tumor. Patients with a history of radiation therapy for prostate cancer had significantly poorer overall and bladder cancer specific survival than the matched control group. Conclusions Most bladder cancers in patients with a history of radiation for prostate cancer present as locally advanced tumors and patients have poorer survival than age and stage matched controls.
D’Amico high risk prostate cancer is associated with higher incidence of extra prostatic disease. It is recommended to avoid nerve sparing in high risk patients to avoid residual cancer. We report ...our intermediate term oncologic and functional outcomes in patients with preoperative D’Amico high risk prostate cancer, who underwent selective nerve sparing robot-assisted radical prostatectomy (RARP). Between Jan 2008 till June 2013, 557 patients underwent RARP for D’Amico high risk prostate cancer. The criteria for nerve sparing were as follows—complete: non palpable disease with <3 cores involvement on prostate biopsy; partial: non palpable disease with <4 cores involvement on prostate biopsy; none: clinically palpable disease with ≥4 cores involvement on prostate biopsy and intraoperative visual cues of locally advanced disease (loss of dissection planes, focal bulge of prostatic capsule). Degree of nerve sparing (NS) was graded intraoperatively by the surgeon independently at either side as side specific margins were assessed to predict subjectivity of the intraoperative judgment. Various data were collected and analyzed. Of 557 patients who underwent RARP 140 underwent complete (group 1), 358 patients underwent partial (group 2), and 59 patients underwent non-nerve-sparing procedure (group 3). There were no difference in preoperative characteristic between the groups (
p
= 0.678), but group 3 had higher Gleason score sum (
p
= 0.001), positive cores on biopsy (
p
= 0.001) and higher
t
stage (
p
= 0.001). Postoperatively Extra prostatic extension (
p
= 0.001), seminal vesicle invasion (
p
= 0.001), and tumor volume (
p
< 0.001) were higher in Group 3. Side specific positive surgical margins (PSMs) rates were higher for non-nerve-sparing compared to partial and complete nerve sparing RARP (
p
< 0.001; overall PSMs = 25.2 %). On univariate and multivariate analysis, nerve sparing did not affect PSMs (
p
> 0.05). The overall biochemical recurrence (BCR) rate at mean follow-up of 24.3 months was 19.21 %. The continence rate at 3 month was significantly higher in complete NS group in comparison to non-NS group (
p
= 0.020), however, this difference was not statistically significant at 1 year. Similarly, mean time to continence was significantly lower in complete NS group in comparison to non-NS group (
p
= 0.030). The potency rate was significantly higher and mean time to potency was significantly lower in complete NS group in comparison to non-NS group (
p
= 0.010 and 0.020, respectively). In high risk prostate cancer patients, selective nerve sparing during RARP, using the preoperative clinical variables (clinical stage and positive cores on biopsy) and surgeon’s intraoperative perception, could provide reasonable intermediate term oncologic, functional outcomes (continence and potency) with acceptable perioperative morbidity and positive surgical margins rate. Use of these preoperative factors and surgeon’s intraoperative judgment can appropriately evaluate high risk prostate cancer patients for nerve sparing RARP.
The utility of cardiac stress testing as a risk-stratification tool before kidney transplantation remains debatable owing to discordance with coronary angiography and outcome yields at different ...centers.
We conducted a retrospective study of 273 diabetic kidney transplant recipients from 2006 to 2010. By protocol, all diabetic patients underwent pharmacological radionucleotide stress test or dobutamine stress echocardiography before transplant. We compared the 1-year cardiac outcomes between those with negative stress test results and those with positive stress test results.
Patients with a positive stress test result (n=67) underwent coronary angiogram, and significant coronary artery disease (≥70% coronary stenosis) was found in 35 (52.2%) patients. Of the latter, 32 (91.4%) underwent cardiac revascularization (24 underwent cardiac stenting and 8 underwent coronary artery bypass grafting). The rest (n=35) were treated medically. Within 1 year after transplant, the group with positive stress test results experienced more cardiac events (34.3% vs. 3.9%, P<0.001) including acute myocardial infarction (22.4% vs. 3.4%, P<0.001) and ventricular arrhythmias (8.9% vs. 0.05%, P=0.001), higher all-cause mortality (19.4% vs. 4.8%, P<0.001), and cardiac mortality (17.9% vs. 0.9%, P<0.001) compared with the group with negative stress test results.
In this diabetic population, stress testing showed positive and negative predictive values of 34.3% and 96.1%, respectively. Pharmacological cardiac stress testing provided excellent risk stratification in diabetic kidney transplant recipients.
Vesico-urethral anastomosis (VUA) is a technically challenging step in robotic-assisted laparoscopic prostatectomy (RALP) in obese individuals. We describe technical modifications to facilitate VUA ...encountered in obese individuals and in patients with a narrow pelvis. A Pubmed literature search was performed between 2000 and 2012 to review all articles related to RALP, obesity and VUA for evaluation of technique, complications and outcomes of VUA in obese individuals. In addition to the technical modifications described in the literature, we describe our own experience to encounter the technical challenges induced by obesity and narrow pelvis. In obese patients, technical modifications like use of air seal trocar technology, steep Trendlenburg positioning, bariatric trocars, alterations in trocar placement, barbed suture and use of modified posterior reconstruction facilitate VUA in robotic-assisted radical prostatectomy. The dexterity of the robot and the technical modifications help to perform the VUA in challenging patients with lesser difficulty. The experience of the surgeon is a critical factor in outcomes in these technically challenging patients, and obese individuals are best avoided during the initial phase of the learning curve.
:
Renal fusion anomalies are detected incidentally on imaging, with horseshoe kidney being the most common followed by crossed renal ectopia. We report a rare congenital anomaly of renal pyelic ...fusion with a solitary ureter. Both the renal units were in the normal position and location. This rare anomaly was associated with lumbar vertebral defects, neurogenic bladder, vesico‐ureteric reflux, upper tract dilatation and recurrent urinary tract infections.
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