Search

Walter Rayford, Alp Tuna Beksac et al. investigated gene expression alterations in African-American and European-American men who underwent radical prostatectomy for prostate cancer. The observed differences include higher expression of inflammation genes and lower expression of mismatch repair genes in African-American men.

ABSTRACT Objective: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. Materials and Methods: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. Results: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. Conclusion: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

PurposeTo describe our Seldinger technique of percutaneous renal cryoablation that was devised to facilitate renal biopsy, cryoprobe placement, and instillation of adjunctive hemostatics while protecting surrounding tissues from cryoinjury.Patients and MethodsThis approach was used to manage 13 renal masses in 12 adult patients. Under CT-fluoroscopic guidance, an access needle was inserted to abut the surface of the tumor, followed by an Amplatz super-stiff guidewire and a customized coaxial catheter system, which was used as a conduit for needle biopsy, cryoprobe insertion, and FloSeal®instillation. In addition, a porcine model was used to compare the temperature readings adjacent to the sheathed and the unsheathed cryoprobe during percutaneous renal cryoablation.ResultsIn all patients, the use of this access approach was accomplished without incident. Two patients needed blood transfusions. No patient had significant skin, muscle, or nerve debility. At a mean follow-up of 11 months, none had evidence of persistent disease on CT or MRI contrast imaging. In the porcine model, the customized sheath protected the surrounding tissues from reaching temperatures below 5°C while temperatures down to −15°C were obtained when no insulating sheath was used.ConclusionsA modified Seldinger technique enabled us to perform percutaneous renal cryotherapy through a single access channel, which facilitated access for biopsy, cryoprobe placement, and instillation of hemostatic agents. This approach may provide a protective barrier against cryogenic damage to neighboring tissues and could theoretically help minimize the chance of tract seeding. [ABSTRACT FROM AUTHOR]

Background and PurposeThere have been several reports of rhabdomyolysis occurring after prolonged laparoscopic procedures in the flank position. Accordingly, we evaluated interface pressures between the skin and three commonly used operating room table surfaces. The aim of our study was to determine if pressure changes could be related to body mass index (BMI), sex, position, andor the table surface material.Patients and MethodsTen men and 10 women were grouped according to BMI <25 or ≥25, with five participants in each group. Subjects were placed in the left lateral decubitus position with the operating table flat, half flexed, fully flexed, half flexed with the kidney rest elevated, and fully flexed with the kidney rest elevated. Interface pressures were recorded, using an X-Sensor pressure sensing mat, for 5-minute periods in each of the described positions on each surface.ResultsSex and BMI were statistically significant predictors of increased pressures (P 0.0042 and 0.0402, respectively). The parameter estimate for the difference between men and women was 4.63 mm Hg (P 0.0002), and the difference for BMI ≥ 25 compared with <25 was also significant (P< 0.0209). Full table flexion (50-degree) produced significantly higher pressures than both flat (P 0.0001) and the half-flexed (25-degree) position (P< 0.0001). Positions with the kidney rest elevated were associated with significantly higher pressures than without elevation (P< 0.0001). With regard to the surface used, egg crate provided lower pressures than gel pads (P 0.0117).ConclusionWomen have significantly lower interface pressures when compared with men. BMI ≥ 25 also increases interface pressures. The use of the kidney rest is associated with markedly increased pressure; use of a half-flexed position is preferable to a full-flexed position. These data have implications for patient positioning and identification of persons at risk for rhabdomyolysis during laparoscopic renal surgery. [ABSTRACT FROM AUTHOR]

ObjectiveWe developed a simple, inexpensive model to simulate four reconstructive laparoscopic procedures pyeloplasty, vesicourethral anastomosis, bladder injury repair, and partial nephrectomy.Materials and MethodsLiquid silicone was applied in layers to a mold to create the 4-in-1 model. A questionnaire evaluating its face and content validity was distributed to postgraduate urologists participating in a mini-residency program at the University of California–Irvine (UCI), and in the 2006 American Urological Association Hands-On course on reconstructive laparoscopic pyeloplasty.ResultsA total of 56 postgraduate urologists used the model and completed an evaluation questionnaire. Ninety-four percent (5154) and 96 (4850) agreed that the model was helpful for practicing laparoscopic pyeloplasty and urethrovesical anastomosis, respectively. Urologists who were experienced in either performing laparoscopic pyeloplasty (n 6) or robot-assisted andor laparoscopic prostatectomy (n 11) would recommend this model to surgeons in training. Overall, 94 (4851) and 96 (5052) of the respondents would recommend this model for postgraduate surgeons and residents, respectively.ConclusionWe present a versatile model for practicing laparoscopic and robotic suturing and knot-tying skills in four reconstructive urologic procedures. Our results support the face and content validity of this model for performing pyeloplasty and vesicourethral anastomoses. [ABSTRACT FROM AUTHOR]

Background and PurposeNatural Orifice Transluminal Endoscopic Surgery (NOTES) using the daVinci robot (Intuitive Surgical, Sunnyvale, CA) has never been applied to urologic surgery. Here we present our initial experience with a combined transvaginal and transcolonic, single-port, robot-assisted NOTES nephrectomy.MethodsAn acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline, and two 12-mm standard laparoscopic ports were placed into the abdomen via the vagina and the colon. The robotic ports were then telescoped into the 12-mm ports, and the daVinci S robot was docked. Dissection was performed using the Hot Shearsand the ProGraspinstruments. The robotic camera was placed via the midline port and held by an assistant. Using the 12-mm transvaginal port, the renal artery and vein were divided separately with a vascular Endo GIA(US Surgical, Norwalk, CT) stapler. The kidney was placed into a 10-mm entrapment sack and removed intact via the vagina.ResultsTotal operative time was 150 minutes. Estimated blood loss was less than 50 mL. No intraoperative complications occurred.ConclusionA robot-assisted NOTES nephrectomy was accomplished in a porcine model using the daVinci S robot. Additional testing on survival animals is necessary to further explore this approach. [ABSTRACT FROM AUTHOR]

Purpose We compared healing after laparoscopic cystotomy using fibrin glue, sutures, or a combination to determine whether fibrin glue can obviate the need for sutures and whether there is any detriment when glue is used in the presence of sutures.Materials and Methods In 24 Yorkshire pigs, a 3.5 cm vertical cystotomy was created laparoscopically and repaired as follows Group 1—no closure; group 2—fibrin glue closure; group 3—suture repair; group 4— combined fibrin glue and suture repair. All animals had a Foley catheter for 1 week. In each group, three animals were harvested at 1 week (acute) and three animals were harvested at 6 weeks (chronic).Results Acute Group 1—all pigs had an unhealed defect that leaked when evaluated by cystography. Groups 2, 3, 4—mean leak pressures were 80, 97, and 60 cm H2O (P 0.36), respectively. Mean bladder capacity was not significantly different between groups. Chronic No leakage seen on a cystogram at 1 week; at 6 weeks, bladders were filled at ≥95 to 100 cm H2O without leakage. Histologically, there was more inflammation in the acute group vchronic group pigs. In the acute group pigs repaired with glue or suture glue, there was more inflammation and less epithelial continuity than in the suture alone group. At 6 weeks, there was no difference between groups.Conclusion Fibrin glue provoked an intense inflammatory response that might have delayed healing acutely, resulting in a lower burst pressure in both scenarios in which it was used (i.e., alone or in combination with sutures). However, by 6 weeks, there did not seem to be any difference between groups either clinically or histopathologically. [ABSTRACT FROM AUTHOR]

Purpose To compare our experience with laparoscopic radical cystectomy (LACIC) and robot-assisted laparoscopic radical cystectomy (RACIC) with ileal conduit urinary diversion.Patients and Methods Prospective data were gathered on 20 consecutive patients undergoing LACIC performed between August 2002 and July 2005, and on 14 consecutive patients undergoing RACIC performed between March 2005 and December 2006. Radical cystectomy with pelvic lymphadenectomy was performed laparoscopically or robotically, and an ileal conduit urinary diversion was performed extracorporeally.Results There was no significant difference in terms of preoperative factors or baseline tumor characteristics and no significant difference in mean operative time (410 min v419 min) between groups. There was less blood loss (212 mL v653 mL; P< 0.0001) and fewer transfusions (42.8 v70; P< 0.0011) in the RACIC group. There was one intraoperative complication (7) and no conversions in the RACIC group. There were three (15) intraoperative complications all leading to conversion in patients undergoing LACIC. Three (21) patients in the RACIC group and 10 (50) patients in the LACIC group had at least 1 post-operative complication. The mean number of days to oral intake was less in the RACIC group (2.3 v6.1; P 0.012). There was no significant difference in the number of lymph nodes excised (P 0.09) between groups. Bilateral extended lymphadenectomy was performed in 10 (71) RACIC patients with a mean of 22.3 lymph nodes harvested and in 16 (80) LACIC patients with a mean of 16.5 lymph nodes harvested. There were no positive margins in patients in the LACIC group and one (7.1) among patients in the RACIC group— a patient with pT4 disease.Conclusion Both laparoscopic and robot-assisted radical cystectomies can be performed safely without compromising oncologic standards for surgical margins and extent of lymphadenectomy. In this early experience, the robot-assisted approach appears to have a shorter learning curve, and it is associated with less blood loss, fewer postoperative complications, and earlier return of bowel function than LACIC. [ABSTRACT FROM AUTHOR]

Background and Purpose The effects of commonly used reprocessing methods on flexible ureteroscope longevity have never been examined. We prospectively studied the effects of Steris 1™sterilization and Cidex®ortho-phthalaldehyde (OPA) high-level disinfection (HLD) on the image quality, physical structure, and deflective properties of two new flexible ureteroscopes.Materials and Methods Two identical “out-of-the-box” Storz 11278AU1 flexible ureteroscopes (Karl Storz Endoscopy, Tuttlingen, Germany) were sterilized individually using the Steris 1™system (Steris Mentor, Ohio) or disinfected with Cidex®OPA (Advanced Sterilization Products, J&J, Irvine, CA) for 100 trials followed by a crossover to the other method for another 100 trials over a period of 1 year. After every five trials, optical quality, angle of deflection, and fiber damage were analyzed in the laboratory. Throughout the study, neither of these ureteroscopes was used clinically.Results After 100 trials, ureteroscope 1, which was sterilized initially in the Steris system, had a 12-mm tear on its shaft (noted after the 17thtrial), 297 damaged fibers, and a 37 drop in resolution (loss of 3.75 linesmm). There was no change in deflection from baseline. In contrast, after 100 cycles, ureteroscope 2, which was subjected to HLD with Cidex®OPA, had no visible external damage, a 0 change in resolution, 10 damaged fibers, and no change in deflection. After the crossover, ureteroscope 2 developed a semilunar defect that obscured the endoscopic view, whereas there was no further significant damage to ureteroscope 1.Conclusion After 100 cycles, the Steris 1 system rendered the flexible ureteroscope unusable, whereas HLD with Cidex®OPA had minimal adverse impact. [ABSTRACT FROM AUTHOR]

Purpose To characterize the flow of a novel ureteral stent composed of a nickel-cobalt-chromium-molybde-num alloy and compare it with flow in a standard ureteral stent.Materials and Methods Six 6F Resonance stents and six 6F standard Black Beauty ureteral stents were placed in six Yucatan minipigs, with each pig serving as its own control. Flow assessment was performed on all stents via a nephrostomy tube delivering a standard rate of 0.9 saline at 35 cm H2O. Flow studies on the standard stents encompassed extraluminal (i.e., lumen of stent occluded with a guidewire), intraluminal (i.e., ureter secured to stent with a constricting suture), and combined (i.e., open lumen without constricting suture) flow. In the Resonance stent, only combined and intraluminal flow could be addressed, as there is no access to the lumen of this stent.Results With the Resonance stent, intraluminal flow was much greater than combined flow, with mean values of 5.15 mLmin and 2.50 mLmin, respectively (P 0.057; SD 7.73). Intraluminal flow was similar to combined flow in the 6F standard stent, with mean values of 7.34 mLmin and 7.30 mLmin, respectively (P 0.88; SD 1.76). The standard stent had significantly greater combined flow than the Resonance stent (P 0.023) but not intraluminal flow (P 0.247). Of note, whereas it was possible to occlude the 6F standard stent completely with a ureteral ligature (i.e., no guidewire placed in the lumen), it was not possible to occlude the Resonance stent regardless of how tightly the suture was tied.Conclusion The Resonance metal alloy stent provides less overall flow than a standard stent. However, under circumstances of extrinsic ureteral compression sufficient to occlude a standard stent (e.g., extrinsic compression plus an internal guidewire), the metal stent continues to provide satisfactory drainage. [ABSTRACT FROM AUTHOR]

Background and Purpose Natural orifice translumenal endoscopic surgery (NOTES) using purpose-built equipment has never been applied to urologic surgery. Herein, we present our initial experience with a trans-vaginal single-port NOTES nephrectomy.Methods and Results An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline and the TransPort™Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA) was passed transvaginally. This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. Dissection was performed using an endoscopic needle knife and a tissue grasper for retraction. Via the 12-mm port, the renal artery and vein were taken separately with a vascular EndoGIA and standard laparoscopic titanium clips, respectively. The kidney was placed in a 10-mm EndoPouch retriever and removed intact via the vagina. The total operative time was 300 minutes.Conclusion Transvaginal NOTES nephrectomy can be accomplished in a porcine model. Additional testing on survival animals is necessary to validate this approach. [ABSTRACT FROM AUTHOR]

ABSTRACT As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immuno-suppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.