Long term experience of robotic retroperitoneal partial nephrectomy as the default approach in the management of renal masses: should the paradigm shift?

Although retroperitoneal surgery has demonstrated a better quality of recovery compared to transperitoneal routes, Retroperitoneal Robot Assisted Partial Nephrectomy (RRAPN) remains proportionally infrequent. As the boundaries of what is achievable robotically continue to be pushed, we present our experience at a high-volume tertiary referral centre that specialises in retroperitoneal surgery, exploring its feasibility as standard of care in the management of small renal masses. A prospective database of 784 RAPNs (2009-2020) was reviewed and 721 RRAPNs (92%) were performed at our centre. In our practice, we utilise a four-port approach to RRAPN. Patient, tumour and operative characteristics were assessed and both oncological outcomes and trifecta and pentafecta achievements were determined. Pentafecta was defined as achieving trifecta (negative surgical margin, no post-operative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Multivariate analysis was conducted to predict peri-operative factors which may prevent achieving a trifecta/pentafecta outcome. From 784 cases, 112 RAPNs were performed for imperative reasons, whilst the remainder were elective. Mean BMI ± s.d amongst our cohort was 28.6 ± 5.7. Mean tumour size was 3.1 cm (range 0.8-10.5 cm) and 47% of cases were stratified as intermediate/high risk using R.E.N.A.L nephrometry scoring. Forty-six patients had lesions in a hilar location, and 31% were anterior. Median blood loss was 30mls, with an open conversion rate of 1% and transfusion rate of 1.6%. Median warm ischaemic time (WIT) was 21 min, positive surgical margins were found in 4% and our post-operative Clavien 3/ > complication rate was 2.6%. We had a 1-day median length of stay with a 30 day readmission rate of 2%. Of 631 patients (80%) with a definitive histological diagnosis of cancer, 23% had T1b/ > disease. Over a mean 15 month follow-up period (range 1-125 months), 2% of patients developed recurrences and our cohort demonstrated a 99% 5 year cancer specific survival. Trifecta was achieved in 67% of cases and pentafecta in 47%. Age (p = 0.05), operative time (p = 0.008), pT1b tumours (p = 0.03), R.E.N.A.L score and blood loss (p = 0.001) were found to statistically significantly influence achievement of trifecta. Pentafecta achievement was influenced by R.E.N.A.L score (p = 0.008), operative time (p = 0.001) and blood loss (p = 0.001). We demonstrate the retroperitoneal approach in RAPN is feasible and safe irrespective of lesion location and complexity. In the hands of high-volume centres that are skilled in the retroperitoneal approach the benefits of retroperitoneal surgery can be extended even to challenging cohorts of patients without compromising their oncological or functional outcomes.

The impact of a fellow on a regional robotic-assisted partial nephrectomy service

INTRODUCTION

Training a fellow has a cost in time and effort for the surgeon and their team. Their relative inexperience may also negatively affect the patient. The aim of this study was to determine and quantify the impact of a fellow on a regional robotic-assisted partial nephrectomy service and on perioperative outcomes.

MATERIALS AND METHODS

We reviewed the prospectively collected data for 522 patients who had undergone robotic-assisted partial nephrectomy since 2015 during the tenure of six fellows. Perioperative outcomes for three groups were compared: group A (no fellow participation), group B (some participation) and group C (fellow completed entire operation). We also reviewed progression over 12 months.

RESULTS

Demographics were similar in all groups apart from the percentage of men, which was lower in group C (p < 0.05). Operative time was 27 minutes longer for group B (p < 0.001). Warm ischaemia time was significantly shorter for group A but the difference was only four minutes (p < 0.001). Length of stay was slightly shorter for group C compared with the other groups (p < 0.01). Trifecta achievement was greatest for group A (p < 0.001). There were no perioperative deaths in any group and positive margins, complications and readmissions were low and similar in all groups. Towards the end of their fellowship, fellows performed more operations independently.

CONCLUSION

There is a measurable, but small, negative impact of a fellow on a robotic-assisted partial nephrectomy service, which reduces with experience. With appropriate supervision and patient selection, a fellow can be taught robotic-assisted partial nephrectomy without affecting patient safety or treatment outcome.

Retroperitoneal robotic-assisted laparoscopic pyeloplasty: A 10 year experience in a single institution

Introduction Pelvi-ureteric junction (PUJ) obstruction was traditionally treated with open pyeloplasty. In recent decades the development of minimally invasive techniques; including laparoscopic and later robotic surgery, has transformed treatment. The transperitoneal approach has most commonly been undertaken with few institutions reporting outcomes of the retroperitoneal approach. We report our 10 year experience of retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP). Methods A prospective database of 160 patients undergoing RALP between February 2010 and November 2019 was analysed. Data was recorded on demographics, operative details, complications and success rate. Success was determined as symptomatic improvement and/or an unobstructed renogram. Results 152 cases (95.0%) were performed using a retroperitoneal approach and 8 (5.0%) transperitoneal. Mean age was 45.317.4 years. Mean operating time was 139.445.6 minutes. A surgical drain was placed in 57 (71.3%) of the first 80 cases and 15 (18.8%) of the second 80 cases. Median hospital stay was 1 night (range 1-27). One case was converted to open pyeloplasty due to dense inflammatory tissue and one to robotic-assisted nephrectomy due to severe adhesions around the PUJ. There were no blood transfusions. There were 6 major (>grade 2 Clavien-Dindo) post-operative complications in 4 patients (2.5%). Two (1.3%) grade 3a complications: urine leak and pain after stent removal requiring nephrostomy. Three (1.9%) grade 3b complications: migrated stent requiring ureteroscopy, perirenal haematoma requiring open evacuation and stent re-insertion. One (0.6%) grade 4 complication requiring ventilatory support on intensive care. 18 patients received follow-up at an alternative hospital and 13 were lost to follow-up. Of the remaining cases 94.5% were successful. Conclusions R-RALP is a safe and effective treatment for PUJ obstruction allowing predictably rapid discharge from hospital without the need for a routine surgical drain. To our knowledge our study represents the largest single institution experience on RALP using a retroperitoneal approach.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy

OBJECTIVE

To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression.

RESULTS

All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677).

CONCLUSION

This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

Renal Function Loss After Cryoablation of Small Renal Masses in Solitary Kidneys: European Registry for Renal Cryoablation Multi-Institutional Study

Objectives: To estimate and quantify the loss of kidney function in solitary kidneys with small renal masses (SRMs) after laparoscopy-assisted renal cryoablation (LARC), from the European Registry for Renal Cryoablation (EuRECA) database. Patients and Methods: Of the 808 patients from eight European centers in the database, 102 patients had SRMs in solitary kidneys. Patient demographics, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, Charlson comorbidity index, and tumor characteristics including nephrometry (PADUA) score where available were collected. Renal function data in the form of estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD) stratification both preoperatively and at 3 months postoperatively were collected. Results: The median (interquartile range [IQR]) age was 67 (59-81) years, the median (IQR) BMI was 26 (23.9-28.9) kg/m², and the median (IQR) ASA score was 2 (2-3). The median Charlson score was 4 (range: 0-10). The median (IQR) tumor size in cross-sectional imaging was 26 (19-38) mm. The follow-up data were available for 72 patients with a median follow-up for this group of 38 (range: 10-132) months. The mean preoperative eGFR was 55.0 mL/minute/1.73 m² (standard deviation [SD] = 18.1), and the mean postoperative eGFR was 51.8 mL/minute/1.73 m² (SD = 18.8). The change was -3.1 mL/minute/1.73 m² (95% confidence interval -5.2 to -1.0) units, which was statistically significant (p = 0.004). The change in the CKD stages comparing before and after LARC was not significant (paired two-tailed t-test, p = 0.06). Critically, the decrease in the eGFR did not translate to any significant adverse outcome and zero patients required dialysis. Conclusion: To the best of our knowledge, this is the largest study of renal function after LARC in SRMs in solitary kidneys. Cryotherapy in this imperative situation is safe, carries clinically insignificant reduction in renal function, therefore providing an option to minimize the risk of developing renal failure necessitating dialysis.

Is Preputioplasty Effective and Acceptable?

Foreskin complaints in childhood, if not manageable conservatively, are usually treated by circumcision. A less radical surgical option, when balanitis xerotica obliterans is absent, is preputioplasty. We sent questionnaires to the parents of 23 boys who had had this procedure and 22 replied.

Mean interval since operation was 20 months (range 3-36). The main indications for surgery had been irretractable foreskin in 9, recurrent balanoposthitis in 10 and ballooning on voiding in 3 and the operation had dealt successfully with these in 7, 7, and 3, respectively. In all but one case the parents were satisfied with the cosmetic result. However, in 8 cases (36%) the parents said they would have preferred circumcision and 3 of the boys had been listed for further surgery.

Preputioplasty is a satisfactory alternative to circumcision in selected cases.

Oncological outcomes and complication rates after laparoscopic-assisted cryoablation: a European Registry for Renal Cryoablation (EuRECA) multi-institutional study

OBJECTIVE

To assess complication rates and intermediate oncological outcomes of laparoscopic-assisted cryoablation (LCA) in patients with small renal masses (SRMs).

PATIENTS AND METHODS

A retrospective review of 808 patients treated with LCA for T1a SRMs from 2005 to 2015 at eight European institutions. Complications were analysed according to the Clavien-Dindo classification. Kaplan-Meier analyses were used to estimate 5- and 10-year disease-free survival (DFS) and overall survival (OS).

RESULTS

The median [interquartile (IQR)] age was 67 (58-74) years. The median (IQR) tumour size was 25 (19-30) mm. The transperitoneal approach was used in 77.7% of the patients. The median postoperative hospital stay was 2 days. In all, 514 patients with a biopsy-confirmed renal cell carcinoma (RCC) were available for survival analyses. The median (IQR) follow-up for the RCC-cohort was 36 (14-56) months. A total of 32 patients (6.2%) were diagnosed with treatment failure. The 5-/10-year DFS was 90.4%/80.0% and 5-/10-year OS was 83.2%/64.4%, respectively. A total of 134 postoperative complications (16.6%) were reported, with severe complications (grade ≥III) in 26 patients (3.2%). An American Society of Anesthesiologists score of 3 was associated with an increased risk of overall complications (odds ratio 2.85, 95% confidence interval 1.32-6.20; P = 0.005).

CONCLUSIONS

This large series of LCA demonstrates satisfactory long-term oncological outcomes for SRMs. However, although LCA is considered a minimally invasive procedure, risk of complications should be considered when counselling patients.

Determination of optimal drug dose and light dose index to achieve minimally invasive focal ablation of localised prostate cancer using WST11-vascular-targeted photodynamic (VTP) therapy

OBJECTIVE

To determine the optimal drug and light dose for prostate ablation using WST11 (TOOKAD Soluble) for vascular-targeted photodynamic (VTP) therapy in men with low-risk prostate cancer.

PATIENTS AND METHODS

In all, 42 men with low-risk prostate cancer were enrolled in the study but two who underwent anaesthesia for the procedure did not receive the drug or light dose. Thus, 40 men received a single dose of 2, 4 or 6 mg/kg WST11 activated by 200 J/cm light at 753 nm. WST11 was given as a 10-min intravenous infusion. The light dose was delivered using cylindrical diffusing fibres within hollow plastic needles positioned in the prostate using transrectal ultrasonography (TRUS) guidance and a brachytherapy template. Magnetic resonance imaging (MRI) was used to assess treatment effect at 7 days, with assessment of urinary function (International Prostate Symptom Score [IPSS]), sexual function (International Index of Erectile Function [IIEF]) and adverse events at 7 days, 1, 3 and 6 months after VTP. TRUS-guided biopsies were taken at 6 months.

RESULTS

In all, 39 of the 40 treated men completed the follow-up. The Day-7 MRI showed maximal treatment effect (95% of the planned treatment volume) in men who had a WST11 dose of 4 mg/kg, light dose of 200 J/cm and light density index (LDI) of >1. In the 12 men treated with these parameters, the negative biopsy rate was 10/12 (83%) at 6 months, compared with 10/26 (45%) for the men who had either a different drug dose (10 men) or an LDI of <1 (16). Transient urinary symptoms were seen in most of the men, with no significant difference in IPSS score between baseline and 6 months after VTP. IIEF scores were not significantly different between baseline and 6 months after VTP.

CONCLUSION

Treatment with 4 mg/kg TOOKAD Soluble activated by 753 nm light at a dose of 200 J/cm and an LDI of >1 resulted in treatment effect in 95% of the planned treatment volume and a negative biopsy rate at 6 months of 10/12 men (83%).

Photoselective Vaporization of the Prostate for Benign Prostatic Hyperplasia Using the 180 Watt System: Multicenter Study of the Impact of Prostate Size on Safety and Outcomes

PURPOSE

We evaluated photoselective vaporization of the prostate using the GreenLight™ XPS™ 180 W system for benign prostatic hyperplasia treatment in a large multi-institutional cohort at 2 years. We particularly examined safety, outcomes and the re-treatment rate in larger prostates, defined as a prostate volume of 80 cc or greater, to assess the potential of photoselective vaporization of the prostate as a size independent procedure.

MATERIALS AND METHODS

A total of 1,196 patients were treated at 6 international centers in Canada, the United States, France and England. All parameters were collected retrospectively, including complications, I-PSS, maximum urinary flow rate, post-void residual urine, prostate volume, prostate specific antigen and the endoscopic re-intervention rate. Subgroup stratified comparative analysis was performed according to preoperative prostate volume less than 80 vs 80 cc or greater on transrectal ultrasound.

RESULTS

Median prostate size was 50 cc in 387 patients and 108 cc in 741 in the prostate volume groups less than 80 and 80 cc or greater, respectively. The rate of conversion to transurethral prostate resection was significantly higher in the 80 cc or greater group than in the less than 80 cc group (8.4% vs 0.6%, p <0.01). I-PSS, quality of life score, maximum urinary flow rate and post-void residual urine were significantly improved compared to baseline at 6, 12 and 24 months of followup without significant differences between the prostate size groups. The re-treatment rate at 2 years reported in 5 of 411 patients was associated with the delivery of decreased energy density (2.1 vs 4.4 kJ/cc) in the group without re-treatment.

CONCLUSIONS

Photoselective vaporization of the prostate using the XPS 180 W system is safe and efficacious, providing durable improvement in functional outcomes at 2 years independent of prostate size when treated with sufficient energy.

Current Status of Hemostatic Agents and Sealants in Urologic Surgical Practice

There has been a recent and near exponential increase in the use of hemostatic agents and sealants to supplement the rapidly evolving methods in the surgical management of urologic patients. This article reviews the use of hemostatic agents and sealants in current urologic practice.

A framework for managing runoff and pollution in the rural landscape using a Catchment Systems Engineering approach

Intense farming plays a key role in increasing local scale runoff and erosion rates, resulting in water quality issues and flooding problems. There is potential for agricultural management to become a major part of improved strategies for controlling runoff. Here, a Catchment Systems Engineering (CSE) approach has been explored to solve the above problem. CSE is an interventionist approach to altering the catchment scale runoff regime through the manipulation of hydrological flow pathways throughout the catchment. By targeting hydrological flow pathways at source, such as overland flow, field drain and ditch function, a significant component of the runoff generation can be managed in turn reducing soil nutrient losses. The Belford catchment (5.7 km(2)) is a catchment scale study for which a CSE approach has been used to tackle a number of environmental issues. A variety of Runoff Attenuation Features (RAFs) have been implemented throughout the catchment to address diffuse pollution and flooding issues. The RAFs include bunds disconnecting flow pathways, diversion structures in ditches to spill and store high flows, large wood debris structure within the channel, and riparian zone management. Here a framework for applying a CSE approach to the catchment is shown in a step by step guide to implementing mitigation measures in the Belford Burn catchment. The framework is based around engagement with catchment stakeholders and uses evidence arising from field science. Using the framework, the flooding issue has been addressed at the catchment scale by altering the runoff regime. Initial findings suggest that RAFs have functioned as designed to reduce/attenuate runoff locally. However, evidence suggested that some RAFs needed modification and new RAFs be created to address diffuse pollution issues during storm events. Initial findings from these modified RAFs are showing improvements in sediment trapping capacities and reductions in phosphorus, nitrate and suspended sediment losses during storm events.

TOOKAD(®) Soluble vascular-targeted photodynamic (VTP) therapy: determination of optimal treatment conditions and assessment of effects in patients with localised prostate cancer

OBJECTIVES

To evaluate the optimal treatment conditions and effects of TOOKAD(®) Soluble vascular-targeted photodynamic (VTP) therapy in patients with localised prostate cancer. To evaluate the safety and quality of life after TOOKAD(®) Soluble VTP treatment in patients with localised prostate cancer.

PATIENTS AND METHODS

Men (aged >18 years) diagnosed with localised prostate cancer, who were suitable for active surveillance, were invited to take part in the study. Patients who had received prior or current treatment for their cancer were excluded. There were two parts to the study: in part one, patients were assigned to one of two treatment groups based on the size of their prostates (patients with prostate size <60 mL would receive 4 mg/kg TOOKAD(®) Soluble and patients with prostate size ≥60 mL would receive 6 mg/kg TOOKAD(®) Soluble both activated with 200 J/cm light). In part two, patients were assigned to one of two treatment groups based on predefined criteria and received either 4 or 6 mg/kg TOOKAD(®) Soluble and 200 or 300 J/cm light. VTP was conducted under general anaesthesia using TOOKAD(®) Soluble administered intravenously and activated by light-diffusing fibres within the prostate via the perineum. Follow-up was conducted for 6 months. Magnetic resonance imaging (MRI) carried out at 1 week after VTP and transrectal prostate biopsy at 6 months were the key endpoints. Adverse event (AE) recording and patient-reported outcome measures were collected.

RESULTS

In all, 86 patients were enrolled in the study and 85 patients received treatment. Of the 85 treated patients, one patient discontinued (due to withdrawal of consent). At 6 months, 61/83 (74%) patients who underwent prostate biopsy had histopathology that was negative for prostate cancer (95% confidence interval (CI) 62.7-82.6%). Considering patients who received 4 mg/kg TOOKAD(®) Soluble and 200 J/cm light (unilateral), which are considered optimal treatment parameters, 38/46 (83%) patients had histopathology from the biopsies that was negative for prostate cancer at 6 months (95% CI 68.6-92.2%; P < 0.001). The mean percentage of necrosis of the targeted prostate tissue at 7 days after VTP was 78% overall (83 patients) with extraprostatic necrosis reported in 76% (63/83) of patients. Considering patients who received 4 mg/kg TOOKAD(®) Soluble and 200 J/cm light (unilateral), the mean 7-day necrosis percentage was 88% (46 patients) with extraprostatic necrosis reported in 72% (33/46) of patients. All occurrences of extraprostatic necrosis were considered clinically acceptable and none were associated with any clinical sequelae. The mean percentage prostate necrosis at 7 days was statistically significantly higher (P < 0.001) in patients treated with a therapeutic light density index (LDI) of ≥1 than those treated with a LDI of <1. The percentage of patients with negative biopsies at 6 months was also higher in patients treated with a therapeutic LDI of ≥1 than those treated with a LDI of <1 (78.6% and 63.0%, respectively). In all, 87% (75/86) of patients reported at least one treatment-emergent AE during the study. Most AEs were mild or moderate in intensity and considered related to the technical procedures of the study. No treated patients had hypotension or discontinued due to AEs. Eight patients (9.3%) had serious AEs; none resulted in discontinuation from the study.

CONCLUSIONS

Biopsy data, post-treatment dynamic contrast-enhancement MRI at 1 week after VTP and analysis of the safety data have shown that 4 mg/kg TOOKAD(®) Soluble and 200 J/cm light are the optimal treatment conditions for the VTP procedure resulting in >80% of patients treated with this regimen having a negative biopsy at 6 months. Overall, the treatment was well tolerated and exhibited early signs of efficacy for minimally invasive focal treatment of localised prostate cancer.

Robot-assisted partial nephrectomy: a comparison of the transperitoneal and retroperitoneal approaches

PURPOSE

To present the oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) and analyze retroperitoneal and transperitoneal approaches.

PATIENTS AND METHODS

RAPN was performed on 103 patients; 44 patients underwent a retroperitoneal and 59 a transperitoneal approach. Demographic, operative, and postoperative data was collected and retrospectively analyzed on all patients.

RESULTS

Overall average warm ischemic time was 20.4 (0-48) minutes, total operative time was 175.3 (85-330) minutes, and estimated blood loss was 258.1 (20-3100) mL. When retroperitoneal and transperitoneal approaches were compared, there was no significant difference in warm ischemic time but a significant reduction in both estimated blood loss and total operative time in the retroperitoneal group.

CONCLUSION

Our series would suggest that if performed by a surgeon familiar with a laparoscopic retroperitoneal approach to renal surgery, retroperitoneal RAPN is at least equivalent to the more common transperitoneal approach in the outcomes assessed.

Complete transection of the pelvi-ureteric junction in an adult

We present a unique case report of a 41-year-old man involved in a hit-and-run accident. The patient suffered a complete disruption of the pelvi-ureteric junction along with a fracture of the L3 transverse process. Occasionally seen in children, we believe this to be the first reported adult case. The report details the presentation and symptoms, with subsequent radiology. This case also demonstrates how using an effective multidisciplinary team approach and the ATLS principles, uncommon injuries can be identified and managed successfully. We revisit the classification of ureteric trauma and the accepted best surgical management.

Condyloma acuminatum‐like lesion of the urinary bladder progressing to invasive spindle cell carcinoma

Condyloma acuminata of the urinary bladder is a rare finding, particularly in the absence of similar lesions of the external genitalia. We present a case in which an isolated condyloma acuminatum-like lesion rapidly progressed to a poorly differentiated spindle cell carcinoma, underlying the need for careful endoscopic follow-up of patients with such lesions.

To knot or not to knot? Sutureless haemostasis compared to the surgeon's knot

INTRODUCTION

The aim of this study was to carry out an independent evaluation of the efficacy and security of a number of vessel ligation devices and ligatures.

MATERIALS AND METHODS

A vascular ligation model was devised using fresh, ex vivo porcine internal carotid arteries of varying external diameters. Coloured normal saline was infused via a pressure/monitor device through the artery. The end lumen was occluded by five different techniques: (i) braided suture in a surgeon's knot; (ii) a monofilament suture in a granny knot; (iii) a metallic clip (Ligaclip, Johnson and Johnson); (iv) a bipolar diathermy system (Ligasure, ValleyLab); and (v) an ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson). The vessels were subjected to supraphysiological pressures. Loss of haemostasis was evident by leakage of coloured perfusion fluid.

RESULTS

Secure haemostasis was obtained with all the techniques in all vessels below 5 mm in diameter. In vessels over 5 mm, secure haemostasis was obtained with all modalities except harmonic scalpel. With the harmonic scalpel, leaks occurred in 3/27 (11%) vessels between 5-6 mm and 3/5 (60%) vessels over 6 mm, confirming the manufacturer's instructions.

CONCLUSIONS

In this first, independent, randomised study comparing vessel ligation devices and ligatures, the manufacturer's claims for each of the haemostatic methods were accurate. We find that all the modalities tested perform as well as the traditional surgeon's knot in vessels of 5 mm and below.

Photoselective vaporization of the prostate with the potassium-titanyl-phosphate laser in men with prostates of >100 mL

OBJECTIVES

To assess the efficacy of photoselective vaporization of the prostate (PVP) in men with prostates of >100 mL and causing bladder outlet obstruction (BOO), using the high-power 80 W potassium-titanyl-phosphate laser (GreenLight PV, Laserscope, San Jose, CA, USA), which offers rapid tissue ablation with minimal bleeding.

PATIENTS AND METHODS

We assessed 54 consecutive patients with prostates of >100 mL (mean 135, SD 42, range 100-300) who had PVP between May 2003 and August 2005. Evaluations before PVP included urine flowmetry, the International Prostate Symptom Score (IPSS), a quality-of life (QoL) score, prostate-specific antigen (PSA) level, and prostate volume measured by transrectal ultrasonography (TRUS).

RESULTS

The mean (SD, range) duration of PVP was 81.6 (22.9, 39-150) min, the mean energy used for PVP was 278 (60, 176-443) kJ and the mean duration of catheterization after PVP was 23.0 (17.1, 0-72) h. The mean (sd) maximum urinary flow rate improved from 8.0 (3.1) to 18.2 (8.1), 18.5 (9.2), 17.9 (7.8) and 19.3 (9.8) mL/s at 3, 6, 12 and 24 months, respectively. The IPSS and QoL scores showed similar improvements, and there was a statistically significant reduction in PSA level and prostate volume after PVP. There was no major complication and no patient had transurethral resection syndrome or a blood transfusion.

CONCLUSIONS

The 80 W KTP laser PVP offers rapid tissue ablation in patients with BOO caused by a large prostate. The short- and medium-term outcomes show that this technique can be a viable alternative to open prostatectomy.

Laparoscopic adrenalectomy - a cure for male pattern baldness

A 64-year-old woman presented to a dermatologist with male pattern hair loss and was found to have grossly elevated testosterone levels at 22.3 nmol/l (normal range, 0.0-2.9 nmol/l). The diagnosis of an androgen-secreting adrenal tumour was made and she underwent a laparoscopic retroperitoneal right adrenalectomy with an uneventful speedy recovery, being discharged in less than 48 h, underlining the clear advantage of this approach.

Basic Laparoscopic Surgical Training: Examination of a Low-Cost Alternative

OBJECTIVE

"Dry lab" facilities are integral to laparoscopy training, but access is often limited due to the high costs of video-laparoscopy equipment. We assessed the effectiveness of a cheap and simple training model compared to conventional video-laparoscopy for basic training using a randomised, blinded study.

METHODS

Thirty-six third-year medical students without previous surgical skills were randomised into two groups: group A students were taught basic laparoscopy skills using a conventional video-laparoscopy pelvic trainer and group B students were taught similar techniques using a cardboard box with a cut-out top to allow light and visualisation. Participants in group B had one eye obscured to reduce their stereoscopic vision. After eight sessions of training amounting to 24h, the two groups were assessed by a blinded adjudicator on set tasks using both the video-laparoscopy pelvic trainer and the cardboard box. Accuracy, timing and depth perception were assessed and the results compared.

RESULTS

There was no significant difference in performance scores or times between the two groups in any of the parameters when tested on the cardboard box. However, when assessed on the video trainer, the cardboard box-trained group had significantly faster times with equivalent scores in the majority of tasks.

CONCLUSION

For basic laparoscopic training the cardboard box, costing nothing, is a simple and effective alternative, which can be used in conjunction with sophisticated video-laparoscopy equipment costing thousands of dollars.

Lycopene inhibits DNA synthesis in primary prostate epithelial cells in vitro and its administration is associated with a reduced prostate-specific antigen velocity in a phase II clinical study

Interest in lycopene has focused primarily on its use in the chemoprevention of prostate cancer (CaP); there are few clinical trials involving men with established disease. In addition, most data examining its mechanism of action have been obtained from experiments using immortal cell lines. We report the inhibitory effect(s) of lycopene in primary prostate epithelial cell (PEC) cultures, and the results of a pilot phase II clinical study investigating whole-tomato lycopene supplementation on the behavior of established CaP, demonstrating a significant and maintained effect on prostate-specific antigen velocity over 1 year. These data reinforce the justification for a large, randomized, placebo-controlled study.

Laparoscopic partial nephrectomy using the potassium titanyl phosphate laser in a porcine model

INTRODUCTION

To evaluate the potential and feasibility of the potassium titanyl phosphate (KTP) Greenlight laser to perform partial nephrectomy in a porcine model.

TECHNICAL CONSIDERATIONS

A total of 15 laparoscopic partial nephrectomies were performed in 4 Danish land-raised pigs under anesthesia. Transperitoneal access was obtained, and using a total of four ports, the 80-W KTP laser was used to perform bilateral upper and lower pole partial nephrectomy. The procedures were done successfully without renal cooling or clamping of the vessels. The estimated blood loss for each procedure was less than 30 mL. Only in one operation, in which a secondary renal vein was transected, was any additional hemostasis required (a single Endoclip). The mean operating time was 42 minutes (range 31 to 59) for each partial nephrectomy. As demonstrated on video, smoke formation was, at times, a problem during the procedure, because it reduced visibility, making only intermittent application of laser energy possible. Histopathologic analysis of the specimens showed a zone of loss of substance (less than 1 mm) at the resection line and narrow adjacent zones on both sides of the resection line with minimal changes.

CONCLUSIONS

We have shown for the first time that normally perfused laparoscopic partial nephrectomy using the KTP laser is feasible and efficacious in the porcine model. This represents a novel application for the KTP laser, which produced excellent renal parenchymal hemostatic ablation. We are currently working on ways to improve the visibility by reducing smoke formation before undertaking a clinical trial in humans.

Use of expired breath ethanol measurements in evaluation of irrigant absorption during high-power potassium titanyl phosphate laser vaporization of prostate

OBJECTIVES

To evaluate formally the risk and levels of irrigant absorption during high-power potassium titanyl phosphate (KTP) laser vaporization of the prostate by the Greenlight PV system using the expired breath ethanol technique.

METHODS

Forty consecutive patients underwent laser vaporization of the prostate. Of these patients, 17 had a preoperative transrectal ultrasound estimation of the prostate volume (mean 97 cm3). All procedures were performed under general anesthesia, by either of two consultants or a trainee. A 1% ethanol solution was used as irrigation fluid. Throughout the operation, the expired breath was analyzed for ethanol using a standard alcometer "plumbed" into the anesthetic circuit. Venous blood samples were taken immediately before and after the procedure for measurements of serum sodium and plasma alcohol levels.

RESULTS

On average, 155,000 J of laser energy was delivered in 47 minutes. In all patients and on all occasions, the expired breath ethanol remained at 0. No statistically significant change was found in the serum sodium concentration during the procedure (P = 0.42), and no patient displayed any clinical evidence of transurethral resection syndrome.

CONCLUSIONS

The results of this study have confirmed, for the first time, the lack of significant absorption of irrigation fluid during high-power KTP vaporization of the prostate using a recognized sensitive technique and the safety of using sterile water as that irrigant. This was the case even in those patients with very large prostates who are usually considered at high risk of experiencing the clinical consequences of fluid absorption during transurethral resection of the prostate and regardless of the experience of the surgeon.

Ease of removal of thermo-expandable prostate stents

OBJECTIVE

To report the ease of removal of the Memokath 028 prostatic stent (Engineers & Doctors A/S, Hornbaek, Denmark), an important attribute of the 'ideal' prostatic stent.

PATIENTS AND METHODS

Data on patients who had had a Memokath 028 stent removed in three different centres in Europe over an 8-year period were collected retrospectively. Standardized forms were used to record relevant information from each physician's patient files.

RESULTS

Ninety-three patients had their stents removed at the three reporting centres; the mean indwelling time of their stent was 12.9 months, and most stents were inserted for symptomatic benign prostate disease. Reasons for removal included recurrent outlet or storage-type urinary symptoms, migration of the stent, stent-related pain, recurrent urosepsis and detrusor failure. The stents were removed on a day-case basis in 32% of patients. Topical anaesthesia or no anaesthesia was used in 48%. Of these patients, only 9% described moderate discomfort or worse. The procedure took a mean of 11 min and was felt to be easy or fairly easy in 90% of patients.

CONCLUSIONS

These data show the ease of removal of the Memokath 028 stent, reinforce its overall success in achieving the requirements of the ideal intraprostatic stent, and further emphasize the advantages of this implant over the epithelializing, permanent intraprostatic stent.

Nephroptosis and Nephropexy—Hung Up on the Past?

The label of 'an ineffective treatment for an imaginary disease' has largely been successfully stuck to the condition of nephroptosis and its surgical management, nephropexy. As a result, younger urologists, especially in the US and UK, have little knowledge of the condition nor why such accusations were made. In this review we explore the historical background to this statement, including descriptions of some of the more exotic surgical procedures employed in the past and visit the diagnosis again in the setting of the modern era, armed with more sophisticated diagnostic tools and less invasive and thus morbid surgical techniques. We aim to demonstrate that with appropriate diagnostic criteria, the diagnosis of symptomatic nephroptosis can be reliably made and that laparoscopic techniques provide an excellent approach in the successful surgical management of this condition.

High-power KTP laser prostatectomy: the new challenge to transurethral resection of the prostate

PURPOSE OF REVIEW

The quest for a successful surgical modality that can be used in the day-case setting, with minimal risk of complications and without the need for postoperative catheter drainage, may finally be fulfilled in the form of the new-generation, high-power potassium titanyl phosphate (KTP) lasers. In this review we will trace the development of KTP laser technology and its use by urologists over the years and describe why its physical properties make it so different from the lasers of the past.

RECENT FINDINGS

The most high powered (80 W) incarnation has a relatively short history, particularly in terms of peer-reviewed publications. We will, however, outline the data so far and demonstrate what an exciting tool this represents for the urologist not only in terms of qualitative and quantitative improvements in lower urinary tract symptoms, but also in offering a day case, and in some instances catheterless, procedure with the prospect of a significantly lower impact on sexual function compared with standard surgical options.

SUMMARY

Despite the lack of long-term data it is certainly possible that high-power KTP lasers represent a very significant challenge to the 'gold standard' status of transurethral resection of the prostate. Furthermore, the ability to use this technology to safely and effectively treat very large prostates represents an opportunity to assign the associated morbidity of the open prostatectomy to the annals of history.

Is preputioplasty effective and acceptable?

Foreskin complaints in childhood, if not manageable conservatively, are usually treated by circumcision. A less radical surgical option, when balanitis xerotica obliterans is absent, is preputioplasty. We sent questionnaires to the parents of 23 boys who had had this procedure and 22 replied. Mean interval since operation was 20 months (range 3-36). The main indications for surgery had been irretractable foreskin in 9, recurrent balanoposthitis in 10 and ballooning on voiding in 3 and the operation had dealt successfully with these in 7, 7, and 3, respectively. In all but one case the parents were satisfied with the cosmetic result. However, in 8 cases (36%) the parents said they would have preferred circumcision and 3 of the boys had been listed for further surgery. Preputioplasty is a satisfactory alternative to circumcision in selected cases.

Lycopene and prostate cancer

The role of diet and dietary supplements in the development and progression of prostate cancer represents an increasingly frequent topic of discussion in the urologist's office. As access to information becomes forever easier, patients are more aware and educated about this subject than ever before. The role of antioxidants including carotenoids in all this has been the subject of great interest for some time. Lycopene, the carotenoid that gives tomatoes and other fruits and vegetables their red colour, has been of particular interest recently as regards its role in prostate cancer. The aim of this review is to briefly outline the biology and chemistry of lycopene, the scientific basis for its proposed anticancer properties and evaluate what conclusions the practicing urologist may draw from the data thus far. The media and industry have raced to encourage not only diets high in lycopene but also dietary lycopene supplements but there is probably only sufficient evidence to recommend to patients a diet rich in all vegetables and fruits of which tomatoes and tomato based products should certainly be a part.

Metastases or mesothelioma?

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Characterization of the hydrolytic activity of a polyclonal catalytic antibody preparation by pH-dependence and chemical modification studies: evidence for the involvement of Tyr and Arg side chains as hydrogen-bond donors

The hydrolyses of 4-nitrophenyl 4'-(3-aza-2-oxoheptyl)phenyl carbonate and of a new, more soluble, substrate, 4-nitrophenyl 4'-(3-aza-7-hydroxy-2-oxoheptyl)phenyl carbonate, each catalysed by a polyclonal antibody preparation elicited in a sheep by use of an analogous phosphate immunogen, were shown to adhere closely to the Michaelis-Menten equation, in accordance with the growing awareness that polyclonal catalytic antibodies may be much less heterogeneous than had been supposed. The particular value of studies on polyclonal catalytic antibodies is discussed briefly. Both the kcat and kcat/K(m) values were shown to increase with increase in pH across a pKa of approx. 9. Group-selective chemical modification studies established that the side chains of tyrosine and arginine residues are essential for catalytic activity, and provided no evidence for the involvement of side chains of lysine, histidine or cysteine residues. The combination of evidence from the kinetic and chemical modification studies and from studies on the pH-dependence of binding suggests that catalysis involves assistance to the reaction of the substrate with hydroxide ions by hydrogen-bond donation at the reaction centre by tyrosine and arginine side chains. This combination of hydrogen-bond donors appears to be a feature common to a number of other hydrolytic catalytic antibodies. High-pKa acidic side chains may be essential for the effectiveness of catalytic antibodies that utilize hydroxide ions.