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Purpose: To compare the recovery of erections and potency following the transection of accessory pudendal arteries (APAs) in men undergoing robot-assisted radical prostatectomy (RARP) compared with men with normal vascular anatomy. Materials and Methods: A total of 880 consecutive patients who underwent RARP from January 1, 2007 to December 31, 2014 were included with prospectively collected data in cross-sectional analysis. Erectile function (EF) was assessed preoperatively and postoperatively at 3, 6, 12, and 24 months using the International Index of Erectile Function (IIEF)-5, a percent erection fullness compared to preoperative status, and two Expanded Prostate Cancer Index (EPIC) questions: (1) are erections firm enough for penetration and (2) are they satisfactory? Results: Two hundred thirty-one (33.1%) men had APAs transected. There were no significant differences in baseline demographics or clinical characteristics in men with or without APAs transected. Multivariate analyses demonstrated that age (confidence interval [95% CI]: 0.94, 0.99) and baseline IIEF-5 (95% CI: 1.15, 1.26) strongly correlated with recovery of erections and potency. Transection of APAs was not a significant predictor of erectile dysfunction (ED). Conclusion: Good surgical technique dictates the preservation of APAs. However, when preservation is questioned, we found that APA transection had no measurable effect on recovery of erections or potency regardless of age, preoperative ED, or number of APAs transected.

Radical prostatectomy is commonly performed for the treatment of patients with prostate cancer. Several studies have demonstrated a reduction in penile size after open radical retropubic prostatectomy. The objective of this study is to describe changes in penile length after after robot-assisted laparoscopic radical prostatectomy (RALRP).We performed a randomized, open label, multicenter study in men with normal erectile function who underwent bilateral nerve-sparing radical prostatectomy. We evaluated changes in measured stretched penile length (SPL), a secondary end point of the study, in a subset of men from a single site who underwent RALRP by one surgeon. They were randomized to either intraurethral alprostadil 125 to 250 μg daily or oral sildenafil citrate 50 mg daily for 9 months. SPL was measured from pubic bone to coronal sulcus using a semirigid ruler before surgery and at 1, 3, 6, 9, 10, and 11 months.A total of 127 patients were enrolled and 94 completed the 11-month follow-up. The mean patient age was 56.5 years. Baseline mean SPL (cm) before surgery was 11.77 and decreased to 11.13 at 1 month (P0.0001). A trend toward recovery of SPL was seen at 3 and 6 months. Mean SPL was not significantly different from baseline at 9, 10, and 11 months.This report describes changes in SPL over time after RALRP for prostate cancer. The expected decrease in length was observed shortly after surgery, but, by 9 months, penile length had returned to the preoperative measurement.

We present the rapid implementation of a robot-assisted surgery program by one of the largest health maintenance organizations (HMOs) in the United States.A core group of 10 urologists were offered access to a new da Vinci S surgical system. A core group of five ancillary staff was assembled and trained at an Intuitive Surgical-designated training site. An experienced robotic surgeon acted as a proctor. Data regarding patient demographics, preoperative parameters, operative times, pathologic outcomes, and EPIC-26 quality-of-life questionnaires were collected prospectively and reviewed. All procedures were recorded on digital video disc as part of a quality assurance protocol. The core group reviewed complications monthly and received feedback on surgical techniques and pathologic outcomes.A total of 100 robot-assisted laparoscopic radical prostatectomies were performed from August to October 2008. The patient demographics, preoperative parameters, operative times, and pathologic outcomes of these first 100 procedures are outlined.We demonstrate the rapid implementation of an efficient multisurgeon HMO-based robot-assisted prostatectomy program with promising initial outcomes.

We demonstrate a safe and reproducible technique for laparoscopic port-site closure. First, we use hemostatic tonsil forceps to deliver a 0-polyglactin suture into the abdomen via a puncture through the rectus fascia parallel to the fascia defect under visual guidance. Second, we perform a similar puncture with the tonsil forceps on the opposite side of the fascia defect under direct vision to grasp the suture. This cost-effective maneuver is safe and eliminates the need for ancillary port-site closure devices.

Previous studies have demonstrated the feasibility of open radical prostatectomy in the high-risk setting. Management of high-risk disease with robot-assisted laparoscopic radical prostatectomy (RALP) is controversial. We examined biochemical recurrence in a selected cohort of high-risk patients who were undergoing RALP.Men with high-risk prostate cancer who underwent bilateral nerve-sparing, nonsalvage RALP by a single surgeon without adjuvant or neoadjuvant therapy of any kind were identified. High risk was defined by preoperative prostate-specific antigen (PSA) level10 ng/dL, Gleason score ≥8 on final pathologic evaluation, or stage ≥pT(3). Postoperative PSA value ≥0.2 ng/dL defined biochemical recurrence.A total of 73 men were identified. There was no significant difference in surgical margin positivity (38% overall) or prostate size between recurrence and nonrecurrence cohorts. Biochemical failure was significantly associated with higher pathologic Gleason score (P = 0.0085) but not pathologic stage (P = 0.22) or preoperative PSA level (P = 0.18). With follow-up to 85 months (mean 31.8 mos), biochemical recurrence-free survival was 77% with mean time to recurrence of 7.7 months. Recurrence occurred significantly earlier than later (P0.001).Reasonable short- to intermediate-term biochemical outcomes can be achieved in a recurrence-prone group of high-risk men who are undergoing RALP. RALP is feasible in a selected cohort of high-risk men who are undergoing aggressive local therapy.

Vascular pseudoaneurysm is a well-documented complication that results after injury to an arterial wall. We review the urologic literature for all reported postprocedural and post-traumatic cases of pseudoaneurysm.A comprehensive review of the peer-reviewed literature was performed for reported cases of vascular pseudoaneurysm, with emphasis on clinical presentation and treatment options.Vascular pseudoaneurysm is a high-pressure collection of blood that communicates directly with an arterial vessel. The clinical presentation varies, depending on the location and size of the lesion, and can be quite dramatic and potentially life threatening. There may be an increasing incidence of pseudoaneurysms after minimally invasive and laparoscopic techniques. Selective and superselective embolization is the preferred treatment for patients with vascular pseudoaneurysms.Vascular pseudoaneurysm is an important but rare complication that is increasingly reported after minimally invasive urologic surgery. This diagnosis necessitates a high index of suspicion and radiologic acumen. Treatment is individually tailored to each patient, but selective embolization appears to be the standard of care.

We propose an algorithm to help guide surgeons' decisions between laparoscopic partial nephrectomy (LPN) and renal laparoscopic cryoablation (LCA) based on preoperative parameters and outcomes defined in the literature.From July 2004 to December of 2007, we performed 51 LPNs and 22 LCAs. We formulated an algorithm between LPN and LCA based on outcomes from published series. Candidates for LPN are younger than 70 years; have few comorbidities; massesor = 7 cm; and solitary, solid, and or cystic masses with an exophytic or mesophytic location. Candidates for LCA are 70 years old or older, with multiple comorbidities, massesor = 3.5 cm, multiple masses, solid masses only, and include endophytic or hilar tumors. We then applied this decision tree to our series.Our results for LPN are statistically similar to the published series except there was a higher positive margin rate in our series (11.8 v 3.5%). Our LCA series had older patients (71 v 65 y), larger masses (3.2 v 2.5 cm), and a higher rate of bleeding necessitating transfusion (18%). We applied the algorithm to all 73 patients in our series. It estimated that 45 patients should undergo LPN and 28 should undergo LCA. A correlation between the predicted surgery and the surgery performed was seen, but approximately one in five patients would have a change in the surgery performed.This algorithm validates decisions surgeons are already making between LPN and LCA. While not a perfect model, it can be used to help simplify decisions between these two minimally invasive procedures to achieve optimal outcomes.

Various techniques have been described for laparoscopic nephroureterectomy. We reviewed our initial experience of laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff.Nine consecutive patients aged 43 to 83 years underwent laparoscopic nephroureterectomy for transitional cell carcinoma (TCC) between August 2005 and March 2007. The first five patients were repositioned after laparoscopic nephrectomy from flank to lithotomy position to dock the robot for excision of the distal ureter and bladder cuff by a single surgeon. In contrast, the last four patients remained in flank position throughout the entire procedure, with the robot docked in flank position following laparoscopic nephrectomy. A two-layer closure re-approximated the cystotomy and a urethral catheter was left in place for a mean of 5 days.Eight men and one woman with a mean age of 64.2 years and mean body mass index (BMI) of 28.4 kg/m(2) underwent flexible cystoscopy and laparoscopic nephroureterectomy for five right-sided and four left-sided tumors. Mean operative time was 303 minutes (range 210-430 minutes), estimated blood loss was 211 mL (range 50-700 mL), and mean length of hospital stay was 2.3 days. Pathologic staging revealed T(3) for five (55.6%), T(a) for two (22.2%), carcinoma in situ (CIS) for two (22.2%) patients, and high-grade disease for seven (77.8%) patients. With a mean follow-up of 16.2 months (range 4.3-24.3 months), three patients with a history of bladder cancer have experienced recurrence in the bladder, and one of the three has also developed metastatic disease.Laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff appears to be a feasible alternative for patients with TCC of the upper urinary tract.

We describe a modern use of laparoscopic renal descensus during the reconstruction of the upper urinary tract. The patient is a 76-year-old mononephric man with recurrent carcinoma in situ in the distal ureter. Using the described technique, we produced an additional 8 to 10 cm of ureteral length and performed a simple ureteroneocystotomy instead of using a traditional psoas hitch and Boari flap creation, bowel interposition, or autotransplantation. Laparoscopic renal descensus is an uncommonly used but simple procedure that may prevent the need for bladder mobilization or Boari flap creation, particularly in the setting of a hostile pelvis.