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Objective To determine the feasibility of applying a postoperative clinical pathway after robotic nephroureterectomy (RNU) targeting safe omission of a pelvic drain and removal of the bladder catheter on the day after surgery with hospital discharge on postoperative day 1 (POD#1). Methods We reviewed a prospectively collected database of all RNUs performed by a single surgeon (R.A.) since institution of our clinical pathway in 2008 that includes pelvic drain omission, bladder catheter removal the morning after surgery, and discharge on POD#1. Patient demographics, and perioperative and postoperative outcomes were evaluated. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined. Results RNU was performed in 29 patients with mean age and body mass index of 69 years (50-90 years) and 30 kg/m 2 (19-41 kg/m 2 ), respectively. No patient required a pelvic drain, and 2 were discharged with a catheter. All but 2 patients (93%) were discharged on POD#1. Overall, successful pathway application was achieved in 26 of 29 patients (90%) including no drain, catheter removal on the morning after surgery, and discharge on POD#1. No patient developed urine leak or other complications related to early catheter removal. Conclusion Our clinical pathway after RNU allows safe omission of a pelvic drain with early discontinuation of the bladder catheter and discharge on the POD#1 in most patients. To our knowledge, similar pathways have not been previously achieved with nephroureterectomy by any approach, but should be considered by surgeons treating urothelial carcinoma of the upper urinary tract.

Background Sentinel lymph node (SLN) biopsy in patients undergoing prophylactic mastectomy (PM) remains controversial. We sought to determine the incidence of finding occult cancer and the frequency of SLN positivity in patients undergoing contralateral PM. Methods Medical records of patients undergoing bilateral mastectomy at our institution from 2003 to 2008 were reviewed ( n = 115). Eight patients (6.9%) had known bilateral cancer; an additional eight patients (6.9%) underwent BPM for risk reduction. The remaining 99 patients who had ipsilateral breast cancer and underwent contralateral PM formed the cohort of interest for this study. Univariate and multivariate analyses to determine factors correlating with occult malignancy and SLN positivity in the PM specimen were performed using SPSS ver. 17 (SPSS Inc., Chicago, IL). Results The median patient age was 50 y, and median ipsilateral tumor size was 1.7 cm. Occult contralateral malignancy was found in eight (8.1%); of these, six (75.0%) had DCIS only. A positive SLN was found on the prophylactic side in 2 (2.0%) patients. Both had ipsilateral inflammatory cancer, and over 15 positive ipsilateral lymph nodes post-neoadjuvant chemotherapy. Ipsilateral inflammatory breast cancer was correlated with the finding of invasive cancer in the contralateral PM ( P = 0.006), and both the finding of ipsilateral inflammatory breast cancer and number of positive lymph nodes correlated with the finding of a positive contralateral SLN. Conclusion The incidence of occult malignancy in PM is low (2%). However, patients with ipsilateral inflammatory cancer are at high risk of contralateral malignancy; SLN biopsy on the prophylactic side in these patients may be warranted.