Faculty Bibliography

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

PURPOSE: Prostate specific antigen is the most widely used oncological biomarker in medicine today. Before its implementation as an early diagnostic marker, urologists were limited to prostatic acid phosphatase, digital rectal examination and transrectal ultrasound for the detection of prostate cancer. We review the history of the discovery of prostate specific antigen as a biomarker for the early detection of adenocarcinoma of the prostate. MATERIALS AND METHODS: We performed a structured literature review, searching PubMed for papers on the subject of prostate specific antigen limited to humans between the years 1970 to 2005. We found a total of 8,365 articles. RESULTS: While the use of prostate specific antigen in evaluating newly diagnosed prostate disease, and followup of men after treatment for prostate disease is accepted practice, prostate specific antigen screening for prostate cancer remains controversial. CONCLUSIONS: In the next decade the results of randomized trials of screening may answer some of the questions posed at the beginning of the prostate specific antigen era. To what extent does prostate specific antigen screening affect prostate cancer mortality and at what cost?

CONTEXT: Prostate safety is a primary concern when aging men receive testosterone replacement therapy (TRT), but little information is available regarding the effects of TRT on prostate tissue in men. OBJECTIVE: To determine the effects of TRT on prostate tissue of aging men with low serum testosterone levels. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, placebo-controlled trial of 44 men, aged 44 to 78 years, with screening serum testosterone levels lower than 300 ng/dL (<10.4 nmol/L) and related symptoms, conducted at a US community-based research center between February 2003 and November 2004. INTERVENTION: Participants were randomly assigned to receive 150 mg of testosterone enanthate or matching placebo intramuscularly every 2 weeks for 6 months. MAIN OUTCOME MEASURES: The primary outcome measure was the 6-month change in prostate tissue androgen levels (testosterone and dihydrotestosterone). Secondary outcome measures included 6-month changes in prostate-related clinical features, histology, biomarkers, and epithelial cell gene expression. RESULTS: Of the 44 men randomized, 40 had prostate biopsies performed both at baseline and at 6 months and qualified for per-protocol analysis (TRT, n = 21; placebo, n = 19). Testosterone replacement therapy increased serum testosterone levels to the mid-normal range (median at baseline, 282 ng/dL [9.8 nmol/L]; median at 6 months, 640 ng/dL [22.2 nmol/L]) with no significant change in serum testosterone levels in matched, placebo-treated men. However, median prostate tissue levels of testosterone (0.91 ng/g) and dihydrotestosterone (6.79 ng/g) did not change significantly in the TRT group. No treatment-related change was observed in prostate histology, tissue biomarkers (androgen receptor, Ki-67, CD34), gene expression (including AR, PSA, PAP2A, VEGF, NXK3, CLU [Clusterin]), or cancer incidence or severity. Treatment-related changes in prostate volume, serum prostate-specific antigen, voiding symptoms, and urinary flow were minor. CONCLUSIONS: These preliminary data suggest that in aging men with late-onset hypogonadism, 6 months of TRT normalizes serum androgen levels but appears to have little effect on prostate tissue androgen levels and cellular functions. Establishment of prostate safety for large populations of older men undergoing longer duration of TRT requires further study. Trial Registration clinicaltrials.gov Identifier: NCT00161304