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AbstractObjectives:Approximation of the bladder to urethra during robot-assisted laparoscopic prostatectomy (RALP) is a critical step toward achieving long-term continence. To determine the impact on surgical outcomes after RALP, we compare two techniques for constructing the vesicourethral anastomosis.Methods:One hundred fifty-four men underwent RALP by one surgeon between 2005 and 2007. The vesicourethral anastomosis was performed in a standard Van Velthoven fashion for the first 61 patients. The anastomosis in the remaining 93 patients was performed in a running fashion with the sutures under continuous tension applied by the surgical assistant and the third robotic arm. Operative times and surgical outcomes were recorded prospectively.Results:When comparing standard Van Velthoven to continuous tension anastomosis, we demonstrate equivalent oncologic outcomes, continence and time required for the anastomosis. Yet, the frequency of complications related to the anastomotic technique, such as urine leaks, bladder neck contractures and migrated hemo-lock clips, were significantly lower with the continuous tension technique compared to the standard Van Velthoven running anastomosis.Conclusions:Performing the vesicourethral anastomosis under continuous tension demonstrated improved outcomes compared to the Van Velthoven anastomosis by allowing persistent close apposition of the bladder to urethra. Additionally, the learning curve associated with implementation of a new anastomotic technique was negligible. [ABSTRACT FROM AUTHOR]

AbstractBackground and Purpose:Obesity is associated with adverse outcomes with certain urologic procedures and may make patient positioning more difficult. We describe our technique of awake intubation and prone patient self-positioning before percutaneous nephrolithotomy (PCNL), and review the literature regarding prone positioning in obese patients and the impact of obesity on PCNL.Methods:Patient preparation begins with detailed preoperative counseling regarding the procedure. Premedication with a sedative and antisialagogue is followed by airway topicalization to suppress gag reflex and pain. Fiberoptic bronchoscope intubation is then carried out. The patient then positions himself/herself comfortably before induction of general anesthesia.Results:We have successfully performed awake intubation and patient prone self-positioning followed by PCNL, most recently in a 58-year-old (body mass index 51.3 kg/m2) man with a history of gastric bypass, diabetes mellitus, and hypertension, without added morbidity. Adverse effect on patient cardiopulmonary dynamics can be minimized in the prone position.Conclusions:The technique of awake intubation with prone patient self-positioning can be helpful for positioning morbidly obese patients before PCNL and has been safe and effective in properly selected patients. Efficacy of PCNL should not be impacted by obesity or prone positioning and morbidity minimized provided that surgical and anesthesia teams understand and safeguard against potential complications. [ABSTRACT FROM AUTHOR]

AbstractObjectives:Despite nearly equivalent outcomes between open and robot-assisted laparoscopic prostatectomy (RALP) for organ-confined prostate cancer (PCa), the role of primary treatment with RALP in men with locally advanced (T3 or greater) PCa has not been described in detail. We report our experience with RALP for pathologically advanced disease.Patients and Methods:From October 2005 to November 2008, 220 RALPs were performed by a single surgeon (R.B.N.). Outcomes were assessed prospectively in an institutional review board–approved database.Results:Of 220 RALPs, 35 (15.9%) were performed for pT3 PCa; none of them were identified preoperatively. There was no difference in operative time compared with patients with pT2 disease (271 vs. 295 minutes, p= 0.09). The positive surgical margin (PSM) rate was 20% compared with 4.9% for pT2 (p= 0.004). Sural nerve grafts were performed in 20%, and 57% had bilateral nerve sparing. The use of bilateral or unilateral nerve sparing was not associated with increased PSM (p= 0.85). Biochemical recurrence occurred in 28.6% of men with pT3 disease over an average of 13 months of follow-up time, 30% of which occurred in men with a PSM. At 6 months, an 85% continence rate was achieved, and at 1 year continence was 100% for pT3. Compared with pT2, men with advanced disease had similar recovery after RALP based on postsurgery questionnaires.Conclusions:RALP is a feasible approach to patients with pathologically advanced PCa as 71% were without evidence of disease at 13 months postoperatively. PSM rate (20%) is comparable to previously reported open PSM rates (24–66%). [ABSTRACT FROM AUTHOR]

AbstractIntroduction and Objective:Specimen morcellation during laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) is controversial. We seek to evaluate the safety and efficacy of specimen morcellation and LRN for treatment of presumed malignant renal lesions.Methods:We retrospectively reviewed all patients who underwent LRN at three academic institutions from 1996 to 2007. One hundred eighty-eight patients underwent specimen morcellation after LRN for enhancing solid or cystic renal masses.Results:LRN was successfully performed on all the patients. Patient age ranged from 36 to 94. One hundred sixty-seven patients were in clinical stage T1, 19 patients T2, and unknown in two. The specimen was manually morcellated within a Cook Lap Sac or Endocatch II bag under laparoscopic or direct observation. On histological review of morcellated specimens, 165 patients were confirmed to have RCC, 17 had an oncocytoma, and 2 had benign cysts. At least 13 patients with RCC were pathologically upgraded to stage T3. Mean operative time was 225 minutes (range 94–650). Mean hospital stay was 2.5 days (range 1–8). In patients with RCC, 11 developed recurrent disease with mean follow-up of 21 months (range 0.3–111). In one patient, a port site recurrence occurred in concert with renal fossa and lymph node metastases.Conclusions:Intracorporeal mechanical morcellation after LRN appears to be safe and effective in clinical stage T1 and T2 RCC. This supports the use of morcellation as an alternative for intact specimen removal in properly selected patients. [ABSTRACT FROM AUTHOR]

Background and PurposeMinimally invasive approaches to manage bladder diverticula have become increasingly popular; however, intracorporeal identification of bladder diverticula may be challenging. We report a novel technique for diverticular illumination using flexible cystoscopy.Patients and MethodsAfter management of bladder neck obstruction, two patients with bladder diverticula and persistent lower urinary tract symptoms underwent robot-assisted bladder diverticulectomy. Cystoscopic illumination was used in both cases to aid diverticular identification and dissection.ResultsOur technique was simple to perform and facilitated identification and dissection of bladder diverticula. Postoperative cystography revealed no evidence of residual diverticula.ConclusionsCystoscope-assisted illumination provides a straightforward method of identifying bladder diverticula during robot-assisted laparoscopic diverticulectomy. [ABSTRACT FROM AUTHOR]

Background and PurposeSpecimen morcellation during laparoscopic radical nephrectomy for renal-cell carcinoma is controversial, and supporting literature remains sparse. We seek to evaluate the safety and efficacy of morcellation for specimen removal after laparoscopic radical nephrectomy for management of renal lesions of malignant potential at a single institution.Materials and MethodsWe retrospectively reviewed the records of all patients who underwent laparoscopic radical nephrectomy at Northwestern Memorial and Evanston Hospital from 2001 to 2006. Twenty-two patients were identified who underwent specimen morcellation for extraction after laparoscopic nephrectomy that was performed for enhancing solid or cystic renal masses.ResultsLaparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T1N0M0. The specimen was mechanically morcellated within Cook Lap Sac under direct and laparoscopic vision. Average tumor size after morcellation was 3.0 cm. On histologic review of the morcellated specimen, 18 patients were confirmed to have renal-cell carcinoma, 2 had an oncocytoma, and 2 had benign cysts. One patient with renal-cell carcinoma had a pathologic upgrade to stage T3b. Average operating time was 268 minutes (range 110 to 389 min). With the exception of the patient who became anephric after nephrectomy, average hospital stay was 2.6 days. A mean clinical and radiographic follow-up of 434 days failed to show any known disease progression or port site recurrence in patients with renal-cell carcinoma.ConclusionsIntracorporeal, mechanical morcellation after laparoscopic radical nephrectomy appears to be safe and effective in clinical stage T1 renal-cell carcinoma. This study adds to current literature that promotes the use of morcellation as an alternative for intact specimen removal in properly selected patients. Further prospective studies are necessary to show long-term oncologic outcomes. [ABSTRACT FROM AUTHOR]

Background and Purpose The usefulness of plain film chest radiography (CXR) in evaluation for thoracic complications after laparoscopic urologic procedures is uncertain. Our objectives were to examine the association between radiographic findings and clinical manifestations of thoracic complications after laparoscopic urologic procedures and to determine the prevalence of postoperative CXR at our institution.Patients and Methods We performed a retrospective review of 195 patients who underwent laparoscopic renaladrenal urologic procedures at our institution from 1998 to 2005. Chi-square analysis was used to compare the rate of radiographic abnormalities and thoracic complications between different types of laparoscopic procedures.Results A total of 96 patients (96195, 49) had postoperative CXR, and abnormalities were noted in 75 (7596, 78). The abnormalities seen on CXR included atelectasis, pleural effusions, pneumomediastinum, pneumothorax, subcutaneous emphysema, and pneumonia. Retroperitoneal laparoscopy had significantly more incidental subclinical pneumothoraces (P 0.000469) and subcutaneous emphysema (P 0.043) identified by CXR than either transperitoneal, hand-assisted, or cryosurgery. Overall, eight patients (8.3) had clinical manifestations of a thoracic complication but only five (5.2) were clinically significant complications detected by CXR. Thus, while 75 CXRs were noted as abnormal, 70 (93) documented incidental findings that did not affect patient care.Conclusions Thoracic complications after laparoscopic urologic procedures are uncommon events. Although the majority of CXRs after such procedures do contain abnormalities, most abnormalities are subclinical and do not affect postoperative management. Patients with significant radiographic findings demonstrated significant clinical symptoms. Thus, routine CXR after urologic laparoscopy does not appear to be necessary to identify thoracic complications and may be overused. [ABSTRACT FROM AUTHOR]

PurposeAs nephron-sparing surgery becomes more commonly used for the management of renal masses, the incidence of complications unique to this procedure will increase. Urine leak after partial nephrectomy (PN) is a common occurrence that can be difficult to manage if conservative measures fail. We describe our approach for persistent urine leaks after PN.Patients and MethodsTwo patients presented with urine leaks after PN. After an upper-pole heminephrectomy, fever developed in the first patient. CT showed an intra-abdominal fluid collection, and percutaneous drainage confirmed a urine leak with persistently high outputs from an upper-pole calix. Conservative management, including ureteral stent, Foley catheter, and percutaneous nephrostomy (PCN) drainage failed. The calix was then directly accessed percutaneously, dilated to 30F, and a 22F nephrostomy tube was placed through the tract into the renal pelvis. The urine leak quickly resolved. The second patient had a lower pole heminephrectomy, and a urine leak with nephrocutaneous fistula from the posterior aspect of the upper-pole remnant developed. Again, conservative measures failed before percutaneous endoscopy. The PCN tract was dilated to 30F, and 3 weeks later the leaking calix was fulgurated through the tract with a flexible ureteroscope.ResultsBoth patients had complete resolution of urine leaks, stable creatinine levels, and required no further intervention.ConclusionsUrine leak after PN remains a complex problem if conservative measures are unsuccessful. We describe a novel technique to percutaneously manage persistent urine leak after PN through a minimally invasive approach. [ABSTRACT FROM AUTHOR]

Purpose Although the use of stents after ureteroscopy has been studied extensively, relatively little has been published about stent placement before complicated ureteroscopic procedures. In this study, we examined our experience with stent placement before ureteroscopic management of renal and ureteral stone disease.Patients and Methods A total of 90 patients underwent ureteroscopic surgery on 115 renal units by a single surgeon from 2001 to 2006. All patients had documented follow-up with imaging either by CT or intravenous urography (IVU) with tomography. Patients were classified into two groups depending on whether they had a stent placed before ureteroscopy. Baseline characteristics, operative indications for stent placement, stone-free rates, and complications were compared between groups.Results Baseline characteristics were similar between the groups. The majority of patients received stents before stone management because of technical considerations during surgery (1736, 47) or infection (1336, 37). Strict stone-free rates after ureteroscopic treatment were 47 in the 79 procedures without previous stents, compared with 67 in the 36 procedures with prestenting (P< 0.05). Including small fragments (2 mm or smaller), stone-free rates improved to 54 v78, respectively (P< 0.02). Complications were not significantly different in the two groups (P 0.70).Conclusion Although routine stent placement is not necessary before all ureteroscopic procedures, we demonstrate that it is associated with good stone-free rates and few complications. In this retrospective cohort, prestenting was associated with significantly higher stone-free rates. Prestenting should be considered in challenging cases. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the effect of increasing age of urology patients on the outcome of laparoscopic procedures.Patients and Methods We performed a retrospective review of patients undergoing laparoscopic urologic procedures from 1998 to 2005, comparing patients 75 or older with all other patients undergoing the same procedures. Data were available on 175 patients. Length of hospitalization, complications, estimated blood loss (EBL), operative time, ASA class, and the Charlson comorbidity index (CCI) were taken from hospital and outpatient records. Subgroup analysis was performed on older patients, one group aged 65 to 74 years and the other ≥75 years. Statistical analysis was done using a two-tailed t-test and chi-square test.Results Patients aged 75 or older had no statistically significant differences in operative time (318 minutes v319 minutes; P 0.967), EBL (271 mL v 331 mL; P 0.487), or complication rate (14.6 v 12.9; P 0.434). However, there was a significant increase in the length of stay (6.06 days v 3.74 days; P 0.0015). In the subgroup analysis of patients 65 to 74 years v ≥75 years, a significant increase in the length of hospitalization was still present despite controlling for complications.Conclusions Laparoscopic procedures in patients 75 years and older entail a significantly longer hospital stay than in younger patients despite similar medical comorbidities. Overall, there was no significant increase in perioperative complications related to age. [ABSTRACT FROM AUTHOR]