Faculty Bibliography

OBJECTIVES/OBJECTIVE:To present our technique, modifications, and experience of laparoscopic partial nephrectomy (LPN). Nephron-sparing surgery is an increasingly accepted treatment for selected T1a kidney tumors. Because of the more complex surgical technique involved, LPN is evolving more slowly than laparoscopic radical nephrectomy. METHODS:The data of 41 consecutive patients with T1a tumors who had undergone LPN from October 2002 to March 2004 were retrospectively reviewed. Four main considerations in our surgical technique were consistently used: (a) LPN was performed in the transperitoneal approach, (b) a suture traction system was placed on the kidney when tumor visualization was challenging, (c) sutures and bolsters were preloaded on the abdominal wall, and (d) hemostasis and closure of the renal defect was performed using Lapra-Ty clips, eliminating knot-tying. RESULTS:The mean patient age was 63.1 years. The mean warm ischemia time was 29.7 minutes, and the mean surgical time was 226.5 minutes. In 26 of 41 patients, the collecting system was entered and repaired. The median estimated blood loss was 150 mL, with a mean tumor size of 2.2 cm. Three cases were converted to open surgery. Five complications (13.2%) occurred. The median hospital stay was 2 days. Of the 41 specimens, 11 were benign. All surgical margins were negative. The mean follow-up was 7.5 months. CONCLUSIONS:Although technically challenging, LPN is emerging as an alternative to open partial nephrectomy. With several easily applied technical considerations, we have simplified LPN, making the procedure more efficient. We believe that the technical considerations we describe can increase the feasibility and ease of LPN for Stage T1a exophytic renal tumors.

OBJECTIVES/OBJECTIVE:To assess the morbidity associated with radical cystectomy in patients who had previously undergone definitive treatment of prostate cancer. METHODS:A retrospective review was undertaken, identifying 35 patients undergoing radical cystectomy with a previous history of radical prostatectomy and/or radiotherapy for prostate cancer. The clinical and surgical information was analyzed to assess patient outcomes. Specific attention was given to the rate, severity, and time course of the postoperative complications. In addition, outcomes after orthotopic and continent cutaneous diversion in this patient cohort were examined. RESULTS:An overall complication rate of 76% was seen in this patient cohort, with 47% of patients experiencing a complication that presented later than postoperative day 30. Radiotherapy was associated with a slightly greater complication rate compared with radical prostatectomy monotherapy (77% versus 71%). Continent urinary diversion (n = 14) was associated with increased morbidity compared with ileal conduit diversion (n = 21). However, a greater percentage of the complications occurring in patients undergoing ileal conduit diversion were major (80% versus 67%). CONCLUSIONS:Our experience has suggested that radical cystectomy in patients previously treated for prostate cancer with radiotherapy and/or radical prostatectomy may be associated with a greater level of morbidity than previously reported. This finding may be, in part, because a significant portion of complications present in a delayed fashion and, as such, have not been seen in previous reports with limited follow-up. For this reason, careful consideration of these risks is necessary when counseling this patient cohort regarding the decision to undergo radical cystectomy.

OBJECTIVE:To determine the potential surgical and clinical factors that contribute to the development of neobladder-vaginal fistula (NVF) after cystectomy and orthotopic neobladder (ONB) construction in women. PATIENTS AND METHODS/METHODS:Of 37 patients who had vaginal-sparing cystectomy, the records of four who developed a NVF after radical cystectomy and ONB construction were reviewed. Retrospective clinical and surgical information was collected, including patient demographics, tumour pathology, surgical technique, presenting symptoms, and method and efficacy of surgical repair. RESULTS:In two of the four patients who developed a NVF a small injury to the anterior vaginal wall was noted during surgery and closed primarily. All patients presented with severe urinary incontinence. The NVF was diagnosed after cystoscopy and/or speculum examination. Three of the four patients had an attempted surgical repair, including one obturator flap interposition, one rectus flap interposition, and one primary two-layer closure. To date, one patient is fistula-free and two were subsequently converted to an ileal conduit or continent cutaneous diversion because the fistula recurred. The fourth patient developed a NVF in association with local tumour recurrence and underwent conversion to an ileal conduit. CONCLUSION/CONCLUSIONS:The development of a NVF is a significant complication after cystectomy. Inadvertent injury to the vaginal wall is an important predisposing factor to subsequent NVF development. The repair of a NVF is often difficult; upon diagnosis, conversion to a continent cutaneous urinary diversion may be considered.

PURPOSE/OBJECTIVE:To evaluate the efficacy of permanent metal stent placement in the treatment of ureteroenteric anastomotic strictures following failed balloon dilation or laser endoureterotomy. PATIENTS AND METHODS/METHODS:Metal stents were placed in six ureteroenteric anastomotic strictures in four patients presenting with recurrent obstruction after balloon dilation or laser endoureteromy. Patients were evaluated at 1 week postoperatively with antegrade ureterography and at 3 to 6 months with renal ultrasound or CT scans. Serum creatinine assays and physical examination were performed at serial postoperative clinic visits. RESULTS:At 1-week follow-up, antegrade studies demonstrated a patent anastomosis in all six strictures. With a mean follow-up of 10 months (range 7-12 months), no stricture recurrence has been seen. All patients have been clinically stable, without episodes of pyelonephritis, flank pain, or need for indwelling stents or nephrostomy tube placement. Serum creatinine concentrations have been stable in all patients. CONCLUSIONS:Metal stents offer a useful treatment option in patients who develop ureteroenteric anastomotic strictures after urinary diversion. Further, such stents may be used in patients failing balloon dilation or laser endoureterotomy. Further study to assess the long-term durability of metal stent placement is needed.

PURPOSE/OBJECTIVE:Prior studies have demonstrated that while endoureterotomy offers a reasonable initial treatment option, open anastomotic revision should remain the gold standard for managing ureteroenteric strictures. However, to our knowledge the results of contemporary endoureterotomy series have not been compared with those of open anastomotic revision, and no study has assessed the morbidity or success rate of secondary open anastomotic revision after failed endoureterotomy. MATERIALS AND METHODS/METHODS:Between May 1997 and August 2002 a total of 31 renal units in 22 patients were treated for ureteroenteric strictures after radical cystectomy and urinary diversion. A total of 16 renal units were treated endoscopically, including 9 on the left and 7 on the right side, and open revision was performed in 15 renal units, including 9 on the left and 6 on the right side. Success was defined as radiological improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes. RESULTS:At a median followup of 35 months (range 17 to 62) for endoureterotomy and 34 months (range 5 to 54) for open revision the success rate of endoureterotomy and open revision was 50% (8 of 16 renal units) and 80% (12 of 15), respectively. One of the 3 patients in whom open revision failed underwent prior pelvic external beam radiation and the other 2 underwent prior endoureterotomies. Overall interventions for right strictures were more successful 85% or 11 of 13 cases than those on the left side (50% or 9 of 18) (p = 0.037). Average operative time was longer and average estimated blood loss was higher in patients treated with open repair after failed endoureterotomy (p = 0.009 and 0.016, respectively). No complications developed in patients following endoureterotomy. CONCLUSIONS:Open revision remains the gold standard for the management of ureteroenteric strictures. Left strictures are considerably more resistant to management. Patients with left anastomotic strictures should be cautioned that endoureterotomy might have a lower success rate, and failure may limit the success and increase the morbidity of subsequent open anastomotic revision.

A 56-year-old man presented with a 1-year history of intermittent gross, painless hematuria. Extensive evaluation revealed primary localized amyloidosis of the urinary bladder. Despite several endoscopic resections and fulgurations, the patient continued to have episodes of significant hematuria due to recurrent amyloid deposition. He was then successfully treated with partial cystectomy. At 60 months following surgery, the patient remains free of recurrent or systemic disease.

OBJECTIVES/OBJECTIVE:To assess the utility of alpha-methylacyl-coenzyme A racemase (AMACR), also known as P504S, immunohistochemistry in the detection of postradiation prostatic adenocarcinoma in surgical specimens. Pathologic diagnosis of postradiation prostate cancer is difficult because of the radiation-induced cytologic changes in benign and malignant epithelial cells. AMACR/P504S is a recently identified molecular marker for prostatic adenocarcinoma. It has been demonstrated that AMACR is overexpressed in the vast majority of prostatic adenocarcinoma cases by cDNA microarray, RNA analysis, Western blotting, and immunohistochemistry. METHODS:A total of 80 prostate glands, including 40 irradiated prostate specimens (28 with adenocarcinoma and 12 benign prostates) and 40 nonirradiated prostate specimens (20 with adenocarcinoma and 20 benign prostates), were examined. The specimens were obtained after salvage radical prostatectomy (n = 25), transurethral resection (n = 4), or needle biopsy (n = 11). All samples were immunohistochemically analyzed for AMACR. RESULTS:All 48 carcinoma cases (28 of 28 irradiated and 20 of 20 nonirradiated specimens) showed strongly positive AMACR/P504S immunostaining. AMACR immunostaining was negative for all irradiated (n = 12) and nonirradiated (n = 20) benign prostates, as well as the irradiated benign glands adjacent to carcinoma. 34betaE12 confirmed the presence of basal cells in all benign prostates (32 of 32) and the absence of basal cells in carcinoma (0 of 48). CONCLUSIONS:Our results demonstrate that AMACR is a highly specific and sensitive indicator of postradiation prostate cancer. AMACR immunostaining facilitates the challenging differentiation between prostatic adenocarcinoma and radiation-induced atypia in benign prostatic epithelium and may be of exceptional value in limited needle biopsies.

INTRODUCTION/BACKGROUND:To describe a novel partial nephrectomy technique that uses small intestine submucosa (SIS) to ensure a watertight closure of the collecting system and minimize parenchymal bleeding. The indications for nephron-sparing surgery have increased in recent years. The most prevalent complications after partial nephrectomy include urinary leakage/fistula and parenchymal bleeding. Porcine SIS has been used in animal models to reconstruct portions of the urinary tract successfully. TECHNICAL CONSIDERATIONS/METHODS:Twenty-two consecutive patients underwent 24 partial nephrectomies that required entry into the collecting system for presumed renal cell carcinoma. After temporary occlusion of the renal vessels and renal hypothermia, the tumor and a margin of normal parenchyma were excised. The cut surface was cauterized with an argon beam coagulator, and visible vessels were suture ligated. The collecting system was reapproximated with interrupted, absorbable sutures. A multilayer piece of hydrated SIS was sutured in place over the exposed collecting system and parenchymal defect with several figure-of-eight chromic sutures. With a mean follow-up of 18.4 months, none of the 22 patients experienced postoperative urinary leaks/fistulas or postoperative hemorrhage requiring transfusion. The serum creatinine returned to within 0.2 mg/dL of baseline in all patients after surgery. CONCLUSIONS:We describe a novel technique of partial nephrectomy using SIS, which, we believe, aids in closure of the collecting system and decreases parenchymal bleeding.

Extensive ureteral injury can result from renal stone disease, iatrogenic injury, or penetrating trauma. A significant ureteral stricture can be repaired using various techniques, including the psoas hitch, Boari flap, transureteroureterostomy, ileal ureter, or renal autotransplantation. We describe a woman with a 5-cm, ischemic uretero-Indiana pouch stricture that developed after cystectomy and urinary diversion. Severe pelvic fibrosis prevented adequate mobilization of the ureter and Indiana pouch and would not permit any of the above-mentioned procedures. We report the first human use of tubularized small intestine submucosa to successfully replace a 5-cm strictured segment of distal ureter.