Faculty Bibliography

PURPOSE: Laparoscopic urinary diversion remains difficult and time consuming even when performed by experienced laparoscopists. Here we describe a novel procedure that quickly creates an ileal orthotopic neobladder with an afferent tubular segment using a laparoscopic stapling device. MATERIALS AND METHODS: Laparoscopic cystectomy and stapled ileal neobladder were performed in five domestic juvenile pigs. Following cystectomy, 30 to 40 cm of terminal ileum was harvested, and ileal continuity restored. The harvested ileum was made into a J configuration, and three to seven laparoscopic staple firings were used to create a spherical pouch with an afferent limb modeled after the Studer-type neobladder. An aperture was created in the dependent portion of the neobladder, and urethral anastomosis was performed using six interrupted absorbable sutures. Ureterointestinal anastomosis was performed using a Wallace technique. Postoperative cystography and intravenous pyelography were performed. A 1-month survival study was completed in one pig. RESULTS: All five procedures were completed successfully without conversion to open surgery. The majority of the steps of the procedures were performed by second- and third-year urology residents (PGY 3-4). Neobladder stapling, ureterointestinal anastomosis, and the first three urethral sutures were performed by an endourology fellow. Average time for neobladder creation and entire procedure was 78 and 355 minutes, respectively. Postoperative cystography revealed spherical orthotopic neobladder with minimal or no leakage in all animals. Average neobladder capacity was 100 mL, and no obstruction was visualized on intravenous pyelography immediately after the procedures. One pig successfully survived the 1-month study period. There was excellent neobladder storage, no clinically apparent renal obstruction, and no postoperative complications. CONCLUSIONS: Total laparoscopic urinary diversion and specifically orthotopic neobladder remains one of the frontiers of minimally invasive urologic surgery. Our technique for stapled ileal neobladder provides substantial advantages in terms of the operative time required for orthotopic neobladder reconstruction. This may offer an avenue to foster the development of more feasible techniques for laparoscopic urinary tract reconstructive surgery

BACKGROUND: Nuclear morphometric signatures can be calculated using nuclear size, shape, DNA content, and chromatin texture descriptors [nuclear morphometric descriptor (NMD)]. We evaluated the use of a patient-specific quantitative nuclear grade (QNG) alone and in combination with routine pathologic features to predict biochemical [prostate-specific antigen (PSA)] recurrence-free survival in patients with prostate cancer. METHODS: The National Cancer Institute Cooperative Prostate Cancer Tissue Resource (NCI-CPCTR) tissue microarray was prepared from radical prostatectomy cases treated in 1991 to 1992. We assessed 112 cases (72 nonrecurrences and 40 PSA recurrences) with long-term follow-up. Images of Feulgen DNA-stained nuclei were captured and the NMDs were calculated using the AutoCyte system. Multivariate logistic regression was used to calculate QNG and pathology-based solutions for prediction of PSA recurrence. Kaplan-Meier survival curves and predictive probability graphs were generated. RESULTS: A QNG signature using the variance of 14 NMDs yielded an area under the receiver operator characteristic curve (AUC-ROC) of 80% with a sensitivity, specificity, and accuracy of 75% at a predictive probability threshold of > or =0.39. A pathology model using the pathologic stage and Gleason score yielded an AUC-ROC of 67% with a sensitivity, specificity, and accuracy of 70%, 50%, and 57%, respectively, at a predictive probability threshold of > or =0.35. Combining QNG, pathologic stage, and Gleason score yielded a model with an AUC-ROC of 81% with a sensitivity, specificity, and accuracy of 75%, 78%, and 77%, respectively, at a predictive probability threshold of > or =0.34. CONCLUSIONS: PSA recurrence is more accurately predicted using the QNG signature compared with routine pathology information alone. Inclusion of a morphometry signature, routine pathology, and new biomarkers should improve the prognostic value of information collected at surgery

PURPOSE: We report on the natural history and factors influencing the prognosis of a cohort of hormone naive, prostate specific antigen era patients in whom metastatic prostate cancer developed after radical prostatectomy who were followed closely and treated with deferred androgen deprivation therapy at the time of metastasis. MATERIALS AND METHODS: A total of 3,096 men underwent radical prostatectomy performed by a single surgeon at Johns Hopkins Hospital between 1987 and 2005. Of these men 422 had prostate specific antigen failure. Distant metastasis developed in 123 patients, of whom 91 with complete data formed the study cohort initially treated during the prostate specific antigen era (1987 to 2005) and receiving androgen deprivation therapy after documented metastasis. A total of 41 men died of prostate cancer. Median survival times were estimated by Kaplan-Meier analysis. Prognostic impact was estimated as the hazard ratio derived from the Cox proportional hazards model. RESULTS: Median followup from radical prostatectomy was 120 months (range 24 to 216). Kaplan-Meier median (range) times to failure were 24 months (12 to 144) from radical prostatectomy to prostate specific antigen failure, 36 months (0 to 132) from prostate specific antigen failure to metastasis, 84 months (12 to 180) from metastasis to death and 168 months (24 to 216) from radical prostatectomy to death. Statistically significant univariate risk factors for prostate cancer specific mortality at the time of metastasis were pain at diagnosis of metastases (p = 0.002), time from radical prostatectomy to metastasis (p = 0.024) and prostate specific antigen doubling time less than 3 months during the 24 months before metastasis (p = 0.016). Multivariable analysis demonstrated independent predictors of prostate cancer specific mortality at the time of metastasis, namely pain (HR 3.5, p = 0.003) and prostate specific antigen doubling time less than 3 months (HR 3.4, p = 0.017). CONCLUSIONS: Men treated with deferred androgen deprivation therapy for the development of metastasis after radical prostatectomy may have a long life span, 169 months after radical prostatectomy (range 24 to 216). The presence of pain and short prostate specific antigen doubling time predicted an unfavorable outcome

OBJECTIVES: Remote presence is the ability of an individual to project himself from one location to another to see, hear, roam, talk, and interact just as if that individual were actually there. The objective of this study was to evaluate the efficacy and functionality of a novel mobile robotic telementoring system controlled by a portable laptop control station linked via broadband Internet connection. METHODS: RoboConsultant (RemotePresence-7; InTouch Health, Sunnyvale, CA) was employed for the purpose of intraoperative telementoring and consultation during five laparoscopic and endoscopic urologic procedures. Robot functionality including navigation, zoom capability, examination of external and internal endoscopic camera views, and telestration were evaluated. The robot was controlled by a senior surgeon from various locations ranging from an adjacent operating room to an affiliated hospital 5 miles away. RESULTS: The RoboConsultant performed without connection failure or interruption in each case, allowing the consulting surgeon to immerse himself and navigate within the operating room environment and provide effective communication, mentoring, telestration, and consultation. CONCLUSIONS: RoboConsultant provided clear, real-time, and effective telementoring and telestration and allowed the operator to experience remote presence in the operating room environment as a surgical consultant. The portable laptop control station and wireless connectivity allowed the consultant to be mobile and interact with the operating room team from virtually any location. In the future, the remote presence provided by the RoboConsultant may provide useful and effective intraoperative consultation by expert surgeons located in remote sites

OBJECTIVES: To assess the efficacy and safety of helium as an insufflant for transabdominal laparoscopic renal surgery. METHODS: The charts of all patients undergoing laparoscopic renal surgery with helium insufflation by a single physician between May 2003 and April 2006 were reviewed. Ventilatory parameters and postoperative recovery were reviewed. RESULTS: Ten patients underwent laparoscopic renal surgery with helium. These patients had a mean age of 64 years and suffered from a variety of comorbid conditions, including chronic obstructive pulmonary disease (5), congestive heart failure (1), chronic hypoxia from an intrapulmonary shunt (1), malignant hyperthermia (1), and chronic hypoxia from multiple pulmonary infarcts (1). All patients tolerated helium pneumoperitoneum, with mean O2 saturation of 98.6% +/- 0.6%, end-tidal CO2 31.4 +/- 1.7 mm Hg, respiratory rate 9.3 +/- 0.7 breaths per minute, tidal volumes 598.2 +/- 38.0 mL, and peak airway pressures 26.0 +/- 1.2 cm H2O. One patient developed an end-tidal CO2 of greater than 45 mm Hg. Mean operative time was 146.8 +/- 59 minutes, and estimated blood loss was 280.1 +/- 334 mL. Postoperatively 3 patients required continued maintenance of the endotracheal tube, although none required intubation longer than 22 hours. Five patients had critical care monitoring (1.7 +/- 2.9 days on average). CONCLUSIONS: Helium can be used safely as an insufflant during laparoscopic renal surgery. Patients who may benefit are those with potential difficulty in clearing CO2 gas from their bloodstream or those who rely on sensitive monitoring of end-tidal CO2 to manage comorbid pathology

OBJECTIVES: To update the 2001 'Partin tables' with a contemporary patient cohort and revised variable categorization, correcting for the effects of stage migration. METHODS: We analyzed 5730 men treated with prostatectomy (without neoadjuvant therapy) between 2000 and 2005 at the Johns Hopkins Hospital. Average age was 57 years. Multivariable logistic regression was used to estimate the probability of organ-confined disease, extraprostatic extension, seminal vesicle involvement, or lymph node involvement. Predictor variables included preoperative prostate-specific antigen (PSA) level (0 to 2.5, 2.6 to 4.0, 4.1 to 6.0, 6.1 to 10.0, and greater than 10.0 ng/mL), clinical stage (T1c, T2a, and T2b/T2c), and biopsy Gleason score (5 to 6, 3 + 4 = 7, 4 + 3 = 7, or 8 to 10). Bootstrap resampling was used to generate 95% confidence intervals for predicted probabilities. RESULTS: Seventy-seven percent of patients had T1c, 76% had Gleason score 5 to 6, 80% had a PSA level between 2.5 and 10.0 ng/mL, and 73% had organ-confined disease. Nomograms were developed for the predicted probability of pathologically organ-confined disease, extraprostatic extension, seminal vesicle invasion, or lymph node involvement. The risk of non-organ-confined disease increased with increases in any individual prognostic factor. The dramatic decrease in clinical stage T2c compared with the patient series used in the previous models resulted in T2b and T2c being combined as a single predictor in the nomogram. CONCLUSIONS: These updated 'Partin tables' were generated to reflect trends in presentation and pathologic stage for men diagnosed with clinically localized prostate cancer at our institution. Clinicians and patients can use these nomograms to help make important decisions regarding management of prostate cancer