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We evaluated the efficacy of α-blockers to improve ureteral stent related morbidity and quality of life.We performed a search of MEDLINE®, Embase™ and The Cochrane Library plus a hand search of conference proceedings from January 2000 to October 2010 to identify randomized, controlled trials comparing treatment for ureteral stent symptoms with α-blockers. Two reviewers independently screened studies and extracted data. Trial methodological quality was assessed by The Cochrane Collaboration quality assessment tool. Placebo randomized, controlled trials with the ureteral stent symptom questionnaire as the outcome were eligible for meta-analysis. Meta-analysis was done using the mean difference to determine the aggregate effect size.A total of 12 randomized, controlled trials including 2 α-blockers in a total of 946 patients were eligible, including 4 (33%) presented only as an abstract at a urological meeting and 4 (33%) eligible for meta-analysis. Meta-analysis using a random effects model showed that α-blockers were associated with a significant decrease in urinary symptoms (MD -6.76, 95% CI -11.52 to -2.00, p=0.005), a significant decrease in pain (MD -3.55, 95% CI -5.51 to -1.60, p=0.0004) and significant improvement in general health (MD -1.90, 95% CI -3.05 to -0.75, p=0.001). However, they were not associated with a benefit in work (MD 2.41, 95% CI -1.62 to 6.44, p=0.24) or sexual matters (MD 0.20, 95% CI -1.06 to 1.45, p=0.33). Eight studies were not included in the meta-analysis, of which 7 showed a significant clinical decrease in urinary symptoms and pain.Existing evidence from randomized, controlled trials shows that α-blockers are associated with improvement in ureteral stent symptoms and supports their use in routine clinical practice.

Purpose: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. Materials and Methods: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. Results: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. Conclusions: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

To our knowledge the outcomes of laparoscopic renal oncological surgery in patients with major aortic and/or inferior vena caval pathology are unknown. We present our experience spanning an 8-year period.From March 1998 to October 2006, 1,826 laparoscopic renal procedures were performed for tumor. Of these patients 66 (3.6%) had major abdominal aortic or vena caval pathology concomitantly. Demographics, specific entities of the vascular disease, and intraoperative and postoperative data were reviewed.A total of 66 patients had a history of abdominal aortic disease (54), vena caval disease (9) or both (3). Of the patients 85% had 3 or greater comorbidities, 88% had an American Society of Anesthesiologists score of 3 or greater and 88% were on chronic anticoagulation therapy. A total of 27 patients (41%) had undergone prior surgical treatment for vascular pathology. Laparoscopic renal surgery, which was transperitoneal in 25 cases and retroperitoneal in 41, included radical nephrectomy in 20, partial nephrectomy in 17 and cryoablation in 29. Open conversion was performed in 3 patients (5%). There were 3 intraoperative (5%) and 9 postoperative (14%) complications. One patient died of pulmonary sepsis. There was no statistically significant difference in perioperative outcomes between the aortic and vena caval disease groups. The retroperitoneal approach was associated with less blood loss and shorter operative time (p = 0.0003 and 0.004, respectively).Laparoscopic surgery for renal tumor in the presence of aortic or vena caval disease is safe and feasible. Considerable prior laparoscopic experience is necessary when treating these patients at high risk.