Faculty Bibliography

BACKGROUND AND PURPOSE: Specimen 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 METHODS: We 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. RESULTS: Laparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T(1)N(0)M(0). 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 T(3b). 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. CONCLUSIONS: Intracorporeal, 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.

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 renal/adrenal 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 (96/195, 49%) had postoperative CXR, and abnormalities were noted in 75 (75/96, 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.

OBJECTIVE:We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized. MATERIALS AND METHODS/METHODS:The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California). RESULTS:Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7% and 9.7% of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3%. Our overall positive surgical margin rate was 3.3%. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8% and 16.7%, respectively. CONCLUSIONS:Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.

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 (17/36, 47%) or infection (13/36, 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% v 78%, 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.

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 > or =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 v 319 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 > or =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.

Reactivation of latent human cytomegalovirus is of significant concern in immunocompromised transplant patients and is likely to occur through transcriptional activation of immediate early (ie) gene expression through mechanisms that are not well understood. TNF-mediated activation of NF-kappaB has been proposed to be one pathway leading to transcriptional activation of CMV ie gene expression. Using transgenic mice carrying a lacZ reporter gene under the control of the HCMV major ie promoter/enhancer (MIEP-lacZ mice) and MIEP-lacZ mice deficient in TNF receptor 1 and TNF receptor 2 (MIEP-lac Z TNFR DKO mice), we demonstrate that renal ischemia/reperfusion (I/R) injury activates the HCMV enhancer independently of TNF. Induction of MIEP-lacZ expression was preceded by TNFR-independent formation of reactive oxygen species (ROS), weak and transient activation of NF-kappaB and strong and sustained activation of AP-1. Our studies show that, in addition to TNF-mediated signaling, TNF-independent signaling induced by I/R injury can contribute to the activation of the HCMV enhancer. This likely occurs through ROS-mediated activation of AP-1. Targeting MAP kinase signaling pathways as well as NF-kappaB may be of therapeutic value in patients with CMV infection.