Faculty Bibliography

BACKGROUND AND PURPOSE: Robot-assisted laparoscopic radical prostatectomy (RALRP) is the most expensive, yet most common, surgical treatment for patients with prostate cancer. Furthermore, its popularity continues to grow despite the lack of evidence for functional and oncologic superiority over other treatments. As a result, we modified operating room (OR) processes to determine if the times and costs that are associated with RALRP in an academic setting could be reduced. PATIENTS AND METHODS: Four modifications in OR processes were implemented: Trainee adherence to time-oriented surgical goals; use of a dedicated anesthesia team; simultaneous processing by nursing and urology house staff during case turnover; and identification and elimination of unused disposable instruments. Total surgical, anesthesia, and OR turnover times were measured. Payroll, surgical supply, OR time, and anesthesia costs were also measured. One hundred RALRP cases before and after the modifications were implemented were compared. RESULTS: Patients undergoing RALRP were similar both before and after the modifications were implemented. Total surgical, anesthesia, and turnover times were reduced by 17.4 (6.8%, P=0.041), 4.5 (19.1%, P=0.006), and 12.1 (28.1%, P=0.005) minutes, respectively. Payroll, surgical supply, and OR costs were reduced by $330 (25%), $609 (15.7%), and $1638 (27.7%), respectively. There was no fiscally significant change in anesthesia costs. CONCLUSIONS: Using simple modifications, it is possible that RALRP efficiency can be improved by decreasing its associated times and costs. These modifications were implemented in an academic setting but may be used in any institution. These modifications represent an initial attempt to improve RALRP cost-competitiveness with other treatment modalities.

Nanotechnology is poised to have a substantial influence on biomedicine. A unique example of a nanotechnology that has progressed from proof-of-concept to human clinical trials is the use of ultrasmall superparamagnetic iron oxide nanoparticles as a cell-specific contrast agent for MRI. When injected systemically, these particles are taken up by macrophages of the reticuloendothelial system and accumulate in lymph nodes. This passive, cell-specific targeting of the iron oxide nanoparticles to lymph nodes, and the differential cellular content of benign versus malignantly infiltrated nodes make this method suitable for cancer staging. By using lymphotropic nanoparticle enhanced MRI, differences in benign versus malignant infiltration of lymph nodes can be visualized, which adds accuracy to standard MRI beyond criteria based solely upon the size and shape of lymph nodes. This technology has been used to assess lymph node metastases in a large number of human cancer types. In this Review, we focus on lymphotropic nanoparticle enhanced MRI and its application for the staging of genitourinary malignancies.

OBJECTIVES: 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.

INTRODUCTION 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.

BACKGROUND AND PURPOSE: Most series on ureteroscopy for urolithiasis use postoperative plain radiography of the kidneys, ureters, and bladder (KUB) or intravenous urography (IVU) to determine outcomes. These imaging modalities, however, are not very sensitive and may overestimate stone-free rates (SFRs). The aim of our study was to assess SFRs after ureteroscopy for urolithiasis using CT follow-up. PATIENTS AND METHODS: A total of 92 patients underwent 113 ureteroscopic procedures for either renal or ureteral stones. Success of ureteroscopy was then determined by the absence of any stone fragments (stone-free). Stone-clearance rates (SCRs) were also calculated for < or = 2 mm and < or = 4 mm residual stone fragments. RESULTS: Each renal unit contained a mean of 1.87 stones with a mean stone diameter of 8 +/- 6 mm. The overall SFR was 50.4%. SFRs were significantly higher for ureteral stones (80%) than renal stones (34.8%) (P = 0.0001). Renal units with multiple stones were less likely to be stone free than those with single stones (P = 0.011). No difference in SFRs was found between lower pole and non-lower-pole stones. CONCLUSIONS: Overall SFRs by CT were lower than SFRs reported by radiography of the KUB or IVU criteria. Further studies to identify the clinical significance and natural history of residual stone fragments on CT scan after ureteroscopy are needed.

PURPOSE: As nephron sparing surgery is used more frequently for select renal tumors, the incidence of urine leaks will likely increase. To our knowledge the risk factors of and management strategies for urine leaks have not been studied. We report our experience with the risk factors of and management for urine leaks after open and laparoscopic partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the records of 127 consecutive patients who underwent partial nephrectomy between 2001 and 2007, including 70 with open and 57 with laparoscopic partial nephrectomy, as performed by 3 surgeons. Urine leak was defined as drain output consistent with urine greater than 48 hours after laparoscopic partial nephrectomy. RESULTS: Of the patients 21 experienced a urine leak after partial nephrectomy, including 13.3% overall, and 10.5% after laparoscopic and 18.5% after open partial nephrectomy. Patients with a urine leak had significantly greater tumor size (3.2 vs 2.4 cm, p <0.044), endophytic locations (57% vs 19%, p <0.00027) and repair of collecting system defects during partial nephrectomy (95% vs 56%, p <0.00072). There was no association with the number of tumors removed, estimated blood loss, ischemia time, body mass index, age or other surgical complications. The median duration of urine leak was 20 days. While most urine leaks resolved with prolonged drainage, 38% of cases required further intervention. Patient age at surgery was the only factor that correlated with prolonged (greater than 30 days) urine leak. CONCLUSIONS: Urine leak is a complication unique to partial nephrectomy that is more commonly noted when a larger endophytic mass involves the renal collecting system. Most leaks resolve with prolonged drainage or replacement of a ureteral stent.

PURPOSE: We present a single institutional experience over 6 years of intra and postoperative complications following urethral reconstructive surgery, and the impact of these complications on overall results. MATERIALS AND METHODS: From June 2000 through May 2006, 153 consecutive urethral reconstructive procedures were performed on 128 patients by one surgeon (CMG). Complication rates were determined, and subgroups were categorized based on stricture etiology, patient age, length of stricture, location of stricture, type of repair, and presence of various co-morbid conditions. RESULTS: Overall, 23 of 153 cases (15%) had an intra or postoperative complication with a mean follow-up time of 28.3 months (range 3 to 74). The most common complications were related to infection (n = 9). Other complications included repair breakdown (n = 4), bleeding (n = 4), fistulae (n = 3), thromboembolic (n = 2), positioning-related (n = 2), and Foley catheter malfunction (n = 1). Complication rates for anastomotic and substitution urethroplasty were 9.1% (4/44) and 17% (19/109), respectively. The number of patients with at least one year of follow-up who had a complication and eventual stricture recurrence was 20% (4/20), while only 7.4% (7/95) of those who did not have a complication recurred (p = 0.08). CONCLUSIONS: Complications following reconstructive surgery for urethral stricture disease were mostly related to infection or repair breakdown in the immediate postoperative period. It does not appear that an intra or postoperative complication following urethral reconstructive surgery impacts the chance of eventual stricture recurrence at intermediate follow-up.

Iatrogenic occurrences (including radiologically guided renal biopsy, shockwave lithotripsy, and minimally invasive ablative procedures) of subcapsular hematoma that lead to acute renal failure are rare but serious. The advancement of minimally invasive procedures has led to an increase in this complication, especially in patients with a solitary kidney. Fortunately, prompt surgical evacuation of the hematoma in these patients allows decompression of the renal parenchyma and recovery of renal function. We report a case of acute renal failure in a patient with a solitary kidney that resulted from a subcapsular hematoma as a complication of radiofrequency ablation.

PURPOSE: There is limited literature examining urethral reconstruction in patients with neurogenic bladder dysfunction. We describe our experience of urethral reconstruction in men with concurrent neurogenic bladder. MATERIALS AND METHODS: A prospectively maintained database of all urethral reconstruction procedures performed by 1 surgeon was analyzed for patients with neurogenic bladder dysfunction. Patient characteristics including the etiology of neurogenic bladder, urethral pathology, urethral reconstructive technique, complications and recurrences were evaluated. RESULTS: A total of 23 patients were included in the analysis. Urethral pathology included erosions (10), strictures (7), diverticula (3), urethrocutaneous fistulas (2), and a combination of diverticular and stricture disease (1). Median length of the urethral pathology was 5.0 cm (range 2.0 to 10.0). Overall urethral reconstruction was successful in 16 of 23 patients (69.6%) at a mean followup of 24.7 months (range 2 to 79). Success rates differed among the types of pathology with 60% for urethral erosions, 85.7% for urethral strictures, and 66.6% for urethral diverticula and fistulas. Of those cases of recurrence 4 of 7 (57%) were after urethral erosion repair. There was 1 (4.3%) postoperative complication and no patient underwent urinary diversion after recurrence. CONCLUSIONS: When identified at an early stage, urethral reconstruction in patients with neurogenic bladder dysfunction offers acceptable outcomes with limited morbidity. Men undergoing reconstruction for urethral erosion had inferior outcomes compared to those with other urethral pathology.