Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Studies in other surgical populations have found that scarring is a relatively unimportant preoperative patient consideration when compared with surgical cure and safety, but that younger age was a significant factor influencing preference for ‘scarless’ surgery. The present study corroborates the findings of previous series, among patients who were contemplating kidney surgery.

OBJECTIVE

• ? To evaluate patient attitudes towards cosmesis relative to other considerations, before and after undergoing laparoendoscopic single‐site surgery (LESS) vs laparoscopic/robot‐assisted vs open kidney surgery.

METHODS

• ? Participants were provided with a survey querying demographic information, surgical history and importance of scarring relative to other surgical outcomes and considerations.
• ? The relative importance of each outcome was recorded on a nine‐level ranking scale, ranging from 1 (most important) to 9 (least important).
• ? The median scores for each outcome were compared before and after surgery using the Wilcoxon signed‐rank test, and by surgical approach using the Kruskal–Wallis test.
• ? The importance of scarring was further analysed according to age (≤50 vs >50 years), surgical indication (oncological vs non‐oncological), gender, and proportion of patients who had undergone previous abdominal surgery.

RESULTS

• ? A total of 90 patients completed surveys before surgery, of whom 65 (72.2%) also completed surveys after surgery.
• ? ‘Surgeon reputation’ and ‘no complications’ were the most important considerations before surgery (median scores 2 and 3, respectively) and after surgery (median scores of 2 for both).
• ? ‘Size/number of scars’ was the least important consideration before surgery (median score 8) and the second least important consideration after surgery (median score 7).
• ? The median score for ‘size/number of scars’ was significantly higher for the LESS cohort before surgery (laparoscopic/robot‐assisted vs LESS vs open surgery: 8.5 vs 6 vs 9; P = 0.003), but was nonsignificant after surgery (laparoscopic/robotic vs LESS vs open surgery: 7 vs 6.5 vs 7.5; P = 0.83).
• ? The median score for ‘size/number of scars’ before surgery was significantly higher for younger patients (P = 0.05) and those with non‐oncological surgical indications (P < 0.001), but there was no significant difference in this outcome for these sub‐groups after surgery.

CONCLUSIONS

• ? For most patients contemplating urological surgery, cosmesis is of less concern than surgeon reputation and avoidance of surgical complications.
• ? Cosmesis may be a more important preoperative consideration for younger patients and those with benign conditions, which warrants further investigation.

     

Robotic paediatric urology

What's known on the subject? and What does the study add? Robot assisted laparoscopic surgery (RALS) is slowly gaining acceptance in the field of paediatric urology. Accumulating data on safety and efficacy when performing paediatric robotic urologic procedures has led paediatric urologists to gradually embrace increasingly more complex reconstructive surgeries. Indeed, the unique and delicate movements generated by the robotic system make this technology ideal for children who often require reconstructive procedures. We critically review the current role of RALS in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. We also propose a structured plan to expedite training and the surgical ‘learning curve’.

OBJECTIVES

• ? To critically review the current role of robot‐assisted laparoscopic surgery (RALS) in paediatric urology and to analyse the published data, with a special emphasis on the most common applications.
• ? One of the greatest benefits of RALS has been the ability to truly spread the application of minimally invasive surgery to paediatric surgical patients. The unique attributes of the robotic interface make this technology ideal for children with congenital anomalies, who often require reconstructive procedures.
• ? We also propose a structured plan to expedite training and the surgical ‘learning curve’.

PATIENTS AND METHODS

• ? Currently, almost all urological surgical procedures in children have been performed with the assistance of the robotic interface.
• ? The most commonly performed procedures include pyeloplasty, nephrectomy/hemi‐nephrectomy and surgery for vesico‐ureteric reflux.
• ? Initial series of bladder augmentation and appendicovesicostomy are available.

RESULTS

• ? Initial results with RALS are encouraging and have shown safety similar to open procedures, and outcomes at least equivalent to standard laparoscopy.
• ? Accumulating data have consistently shown that postoperative analgesia requirements and overall hospital stay are decreased.
• ? However, operative durations are significantly longer than their open counterparts, but this is decreasing as experience accumulates.

CONCLUSIONS

• ? RALS is already part of paediatric urological surgery.
• ? Larger single‐institution case series and comparative studies with the open approach and multi‐institutional meta‐analyses will help to identify the benefits of RALS in paediatric urology.

     

Early oncological outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical cystectomy

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To determine oncological outcomes including early survival rates among unselected bladder urothelial carcinoma (BUC) patients treated with robotic‐assisted radical cystectomy (RRC).

PATIENTS AND METHODS

• ? Clinicopathologic and survival data were prospectively gathered for 85 consecutive BUC patients treated with RRC.
• ? The decision to undergo a robotic rather than open approach was made without regard to tumor volume or surgical candidacy.
• ? Kaplan–Meier survival rates were determined and stratified by tumor stage and LN positivity, and multivariate analysis was performed to identify independent predictors of survival.

RESULTS

• ? Patients were relatively old (25% >80 years; median 73.5 years), with frequent comorbidities (46% with ASA class ≥3). Of these patients 28% had undergone previous pelvic radiation or pelvic surgery, and 20% had received neoadjuvant chemotherapy.
• ? Extended pelvic lymphadenectomy was performed in 98% of patients, with on average 19.1 LN retrieved.
• ? On final pathology, extravesical disease was common (36.5%).
• ? Positive surgicalmargins were detected in five (6%) patients, all of whom had extravesical tumors with perineural and/or lymphovascular invasion, and most of whom were >80 years old.
• ? At a mean postoperative interval of 18 months, 20 (24%) patients had developed recurrent disease, but only three (4%) patients had recurrence locally. Disease‐free, cancer‐specific and overall survival rates at 2 years were 74%, 85% and 79%, respectively. Patients with low‐stage/LN(?) cancers had significantly better survival than extravesical/LN(?) or any‐stage/LN(+) patients, with stage being the most important predictor on multivariate analysis.

CONCLUSION

• ? RRC can achieve adequately high LN yields with a low positive margin rate among unselected BUC patients.
• ? Early survival outcomes are similar to those reported in contemporary open series, with an encouragingly low incidence of local recurrence, however long‐term follow‐up and head‐to‐head comparison with the open approach are still needed.

     

Long-term follow-up of patients undergoing percutaneous suprapubic tube drainage after robot-assisted radical prostatectomy (RARP)

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add?

• ? Initial reports of percutaneous suprapubic tube (PST) drainage following RARP demonstrated feasibility and short‐term safety, while decreasing patient discomfort and utilization of anti‐cholinergic medication.
• ? This study demonstrates the long‐term safety and efficacy of bladder drainage by PST; splinting the urethrovesical anastomosis is simply not essential if mucosal apposition is ensured.

OBJECTIVES

• ? To evaluate the long‐term safety and functional outcomes of patients undergoing percutaneous suprapubic tube (PST) drainage after robot‐assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

• ? Between January 2008 and October 2009, 339 patients undergoing RARP by one surgeon experienced in RA surgery (M.M.) had postoperative bladder drainage with PST and a minimum of 1‐year follow‐up for urinary function.
• ? Functional outcomes were obtained via patient‐administered questionnaire.
• ? Complications were captured by exhaustive review of multiple datasets, including our prospective prostate cancer database, claims data, as well as electronic medical and institutional morbidity and mortality records.

RESULTS

• ? Urinary function assessed by patient‐administered questionnaire was analysed at a mean (sd ) follow‐up of 11.5 (1.7) months; after RARP with PST placement, 293 patients (86.4%) had total urinary control and only nine (2.7%) required >1 pad/day.
• ? In all, 86 patients (25.4%) never wore a pad; the median time to 0–1 pad/day was 2 weeks (interquartile range [IQR] 0,6); median time to total control was 6 weeks (IQR 1,22).
• ? The mean (sd ) follow‐up for complications was 23.7 (6.1) months. In all, 15 patients (4.4%) had a procedure‐specific complication, of which 13 were minor (Clavien Class I/II 3.8%); one patient had a bladder neck contracture.
• ? In all, 16 patients (4.7%) required Foley placement after RARP for gross haematuria (two patients), urinary retention (three), tube malfunction (four) or need for prolonged Foley catheterization (seven).

CONCLUSIONS

• ? PST placement after RARP is safe and efficacious on long‐term follow‐up.
• ? Splinting of the urethrovesical anastomosis is not a critical step of RP if a watertight anastomosis and excellent mucosal apposition are achieved.

     

Comparison of intraoperative outcomes using the new and old generation da Vinci® robot for robot-assisted laparoscopic prostatectomy

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To review and compare intraoperative outcomes for robotic prostatectomy procedures performed on two generations of the da Vinci robotic surgery platform.

MATERIAL AND METHODS

• ? We reviewed 100 consecutive robotic prostatectomy cases and compared intraoperative outcomes for procedures randomly performed on either the da Vinci S robot or first‐generation standard robot.
• ? Baseline demographic data and intra‐operative variables potentially impacting outcomes were reviewed and compared between the two groups.

RESULTS

• ? Mean total operative time was 191 min using the standard da Vinci robot (range 132–266) versus 169 min with S robot (range 98–230), representing a mean difference of 22 min (P = 0.002).
• ? This difference was statistically significant despite no difference in mean patient BMI of 30.6 (range 19–51) for standard versus 29.3 (range 21–37) for S (P = 0.31), no difference in mean prostate size of 54.6 g (range 26–101) for standard versus 57.3 g (range 32–151) for S (P = 0.55), and no difference in frequency of nerve‐sparing (P = 0.99).
• ? There was also no difference in the portions of procedues performed by residents, which in some cases was none and some the entire procedure, but the standard was more often used for the surgeon’s first case of the day (P = 0.006).
• ? There was no difference in blood loss (P = 0.08), positive margins (P = 0.87), or mean number of lymph nodes removed (10.7 vs 10.6).

CONCLUSIONS

• ? Both generations of da Vinci robotic technology are equally effective for PALP, but the S robot appears to allow shorter procedure times.
• ? Further such evaluations are necessary to guide institutions and public policy decision‐makers on investments in newer generations of robotic technology as incremental advances continue.

     

A prospective, randomized trial comparing the Vienna nomogram to an eight-core prostate biopsy protocol

Study Type – Diagnostic (RCT) Level of Evidence 1b What’s known on the subject? and What does the study add? Several studies have shown that increasing the number of prostate biopsy cores will increase the detection rate of prostate cancer, but also risks overdiagnosing insignificant cancer, particularly in the elderly. Our study suggests that there is no significant advantage in using the Vienna nomogram to determine the number of prostate biopsies to be taken, compared to an eight‐core biopsy protocol.

OBJECTIVE

• ? To compare prostate cancer detection rates using the Vienna nomogram versus an 8‐core prostate biopsy protocol. To compare the complication rates of transrectal prostate biopsy in the two groups.

PATIENTS AND METHODS

• ? In a prospective randomized trial, men with a serum PSA ≥ 2.5 ng/ml were stratified according to serum PSA (I = PSA 2.5–10; II = PSA 10.1–30; III = PSA 30.1–50 ng/mL) and were then randomized to group A (number of cores determined according to the Vienna nomogram) or group B (8‐core prostate biopsy).
• ? Statistical analysis was performed using Student’s t‐test for parametric data, Mann‐Whitney test for nonparametric data and Fisher’s exact test for contingency tables. A two‐tailed p‐value <0.05 was accepted as statistically significant.

RESULTS

• ? In the period July 2006 to July 2009, 303 patients were randomized to group A (n = 152) or group B (n = 151). There were no significant differences in serum PSA, prostate volume, PSA density or post‐biopsy complications between the groups.
• ? The cancer detection rate was lower in group A than in group B for the whole study cohort (35.5% vs 38.4%), for those with PSA < 10 ng/ml (28.1% vs 33%) and for those with prostate volume >50 ml (22% vs 25.8%). These differences were not statistically significant (NSS).

CONCLUSION

• ? These findings suggest that there is no significant advantage in using the Vienna nomogram to determine the number of prostate biopsy cores to be taken, compared to an 8‐core biopsy protocol.

     

Contrast-enhanced ultrasound using a time-intensity curve for the diagnosis of renal cell carcinoma

Study Type – Diagnosis (non‐consecutive series) Level of Evidence 3b What’s known on the subject? and What does the study add? In terms of imaging differentiation, distinguishing complex cystic renal masses that require surgery from those that do not remains a common and difficult diagnostic problem. Magnetic resonance imaging (MRI) is useful for characterizing complex cystic renal masses. But there are some cases that are difficult to diagnose differentially on computed tomography (CT) or MRI. We evaluated the usefulness of contrast‐enhanced ultrasound (CEUS) for the diagnosis of cystic renal cell carcinoma by using a time‐intensity curve (TIC). Assessments of blood flow in the solid component of a cystic tumour by CEUS using a second‐generation US contrast agent and TIC analysis have made it easier to objectively diagnose cystic renal cancer.

OBJECTIVE

• ? To evaluate the usefulness of contrast‐enhanced ultrasound (CEUS) for the diagnosis of renal cell carcinoma by employing a time‐intensity curve (TIC).

PATIENTS AND METHODS

• ? From May 2008 to October 2009, CEUS was performed prior to surgery in 30 patients with renal masses.
• ? In all, 10 of the 30 patients had cystic renal masses. The final diagnoses of all patients were pathologically confirmed. Contrast enhancement as a function of time was measured in two (tumour or solid component of cystic lesions and normal parenchyma) regions of interest (ROI) and TICs were obtained.
• ? The time to the contrast enhancement peak (TTP), intensity change from the baseline to peak (ΔI) and ΔI/TTP of the tumour and the normal parenchyma were measured from the TIC.

RESULTS

• ? Pathological diagnoses were renal cell carcinoma in 30 patients.
• ? The TTP of the cancer was shorter than that of the normal parenchyma in all cases (6.0 ± 2.0 vs 10.4 ± 3.0 s; P < 0.0001).
• ? The ΔI did not differ between the cancer and normal parenchyma [21.3 ± 5.9 vs 20.9 ± 7.0 decibels (db); P= 0.68]; the ΔI/TTP of the cancer was significantly higher than that of the normal parenchyma (3.9 ± 1.4 vs 2.2 ± 0.94 db/s; P < 0.0001).
• ? TIC patterns of solid cancer and cystic cancer were very similar.

CONCLUSIONS

• ? An objective and quantitative diagnosis of renal cell carcinoma by CEUS using a second‐generation ultrasound contrast agent can be made by employing a TIC.
• ? The TIC patterns of solid and cystic cancers were very similar, despite their morphological and vascular differences.
• ? CEUS using TIC is a promising tool in the diagnosis of cystic renal cancer.

     

Contrast-enhanced ultrasonography of the prostate: various imaging findings that indicate prostate cancer

Study Type – Diagnostic (non‐consecutive case series)
Level of Evidence 3b What’s known on the subject? and What does the study add? Contrast‐enhanced ultrasonography (CEUS) can visualize some prostate cancer lesions. Findings suggestive of cancer have been defined as rapid contrast enhancement; increased contrast enhancement. CEUS could be useful for targeted biopsy in patients with a PSA level <10 ng/mL. The CEUS findings suggestive of prostate cancer are more varied than previously reported. Low‐echogenicity areas containing abnormal blood vessels were also found to represent cancer.

OBJECTIVES

• ? To perform transrectal ultrasonography (TRUS) with an ultrasonography (US) contrast agent to visualize prostate cancer.
• ? To explore the possibility of targeted biopsy by studying the findings obtained by different cancerous tissue imaging modalities and evaluating needle biopsies from prostate cancer using contrast‐enhanced ultrasonography (CEUS).

PATIENTS AND METHODS

• ? In all, 41 patients undergoing prostate biopsy and 13 patients undergoing prostatectomy received i.v. injection of the US contrast agent (Sonazoid®).
• ? We evaluated pre‐contrast and contrast‐enhanced US images, and then compared ultrasonographic images and the pathological findings.

RESULTS

• ? Cancer was significantly more frequent at the sites of targeted biopsy where CEUS findings suggested cancer (36.3%) than at sites of systematic biopsy (17.7%, odds ratio = 2.7, P = 0.0026).
• ? In cases with prostate‐specific antigen (PSA) level <10 ng/mL, in particular, prostate cancer was detected at a significantly higher rate by targeted biopsy than by systematic biopsy (27.3 vs 9.5%, odds ratio = 3.4, P = 0.013).
• ? Pathological examination found 26 tumours in prostatectomy specimens. The diameters of the 10 CEUS‐identified tumours were significantly greater than those of the 16 lesions missed by US (mean 18.7 vs 5.9 mm).
• ? CEUS findings suggestive of cancer varied widely: strong contrast enhancement, rapid contrast enhancement, vessels with abnormal perfusion and low contrast enhancement.

CONCLUSIONS

• ? CEUS could be useful for targeted biopsy in patients with a PSA level <10 ng/mL.
• ? The CEUS findings suggestive of prostate cancer are more varied than previously reported.
• ? Detailed examination of CEUS images and application of the data to prostate biopsy could lead to more efficient diagnosis.

     

Incidence and clinical significance of arterial injury in varicocele repair

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

• ? This study was performed to histologically determine the rate of arterial injury in varicocele ligation surgery and to determine the clinical significance of these arterial injuries.

MATERIALS AND METHODS

• ? 41 men who underwent varicocele ligation surgery, and had segments of each ligated vessel examined histologically.
• ? The patients were followed prospectively to determine the effect of arterial injury on surgical results and clinical complications.

RESULTS

• ? Arterial ligation was identified in 6 of 41 patients (12%), and in 7 of 132 specimens (5%), which is higher than previous reports.
• ? Arterial injury was not associated with testicular atrophy and there was no apparent effect of arterial injury on surgical outcome.

CONCLUSION

• ? The rate of arterial injury during varicocele repair is higher than previously reported, but the clinical significance of these injuries appears to be limited.

     

Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Orgasm has a major influence on patients’ satisfaction with the overall sexual experience, and alternations in orgasm are associated with significant reductions in emotional and physical satisfaction, which in turn may lead to sexual avoidance behaviour, disharmonious relationships and relationship breakdowns. Studies have found a reduction in orgasmic function after retropublic radical prostatectomy. While open radical prostatectomy inevitably damages some pelvic neuronal circuitry, which will thus impact on orgasmic responses, there is a paucity of data investigating the effect on robotic assisted radical prostatectomy on this. To our knowledge this study represents the largest analysis of orgasmic function in the robotic prostatectomy literature, and therefore would be of value to surgeons in counseling candidates for RALP about orgasmic outcomes. In our series, young men (age ≤60 years) and those who underwent bilateral nerve sparing approaches had a better recovery of their premorbid orgasmic function when compared to older men or men with no nerve sparing.

OBJECTIVE

• ? To investigate orgasmic outcomes in patients undergoing robotic‐assisted laparoscopic radical prostatectomy (RALP) and the effects of age and nerve sparing on these outcomes.

PATIENTS AND METHODS

• ? Between January 2005 and June 2007, 708 patients underwent RALP at our institution.
• ? We analysed postoperative potency and orgasmic outcomes in the 408 men, of the 708, who were potent, able to achieve orgasm preoperatively and available for follow‐up.

RESULTS

• ? Of men aged ≤60 years, 88.4% (198/224) were able to achieve orgasm postoperatively in comparison to 82.6% (152/184) of older men (P < 0.001).
• ? Of patients who received bilateral nerve sparing (BNS) during surgery, 273/301 (90.7%) were able to achieve orgasm postoperatively compared with 46/56 (82.1%) patients who received unilateral nerve sparing and 31/51 (60.8%) men who received non‐nerve‐sparing surgery (P < 0.001).
• ? In men ≤60 years who also underwent BNS, decreased sensation of orgasm was present in 3.2% of men, and postoperative orgasmic rates were significantly better than men ≤60 years who underwent unilateral or no nerve sparing (92.9% vs 83.3% vs 65.4%, respectively; P < 0.001).
• ? Potency rates were also significantly higher in men ≤60 years and in those who underwent BNS.

CONCLUSIONS

• ? Age and nerve sparing influence recovery of orgasm and erectile function after RALP.
• ? Men ≤60 years old and those who undergo BNS are most likely to maintain normal sexual function.

     

EXTENDING THE INDICATIONS AND ANATOMICAL LIMITS OF PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: IMPROVED STAGING OR INCREASED MORBIDITY?

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and anatomical limits of pelvic lymph node dissection (PLND).

PATIENTS AND METHODS

• ? In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003–2007.
• ? Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥2% had a PLND limited to the external iliac nodal group (limited PLND group).
• ? After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group).
• ? The risk parameters were PLND‐related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases.

RESULTS

• ? In the subgroup of patients with a LNI ≥2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003).
• ? The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND.
• ? The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001).

CONCLUSIONS

• ? In patients with LNI ≥2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non‐prohibitive complications rate.
• ? The present study found no evidence that the incidence of complications would be reduced by a limited PLND.

     

Erectile dysfunction is predictive of all-cause mortality in patients with prostate cancer treated with permanent interstitial brachytherapy

Study Type – Prognosis (individual cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Cardiovascular disease is a leading cause of death in prostate cancer patients. Pretreatment ED is a surrogate for vascular pathology. Aggressive treatment of medical co‐morbidity in prostate cancer patients may positively impact overall survival.

OBJECTIVE

• ? To evaluate the relationship between pre‐treatment erectile function and all‐cause mortality in patients with prostate cancer treated with brachytherapy.

PATIENTS AND METHODS

• ? In all, 1279 consecutive patients with clinically localized prostate cancer and pre‐implant erectile function assessed by the International Index of Erectile Function‐6 (IIEF‐6) underwent brachytherapy.
• ? Potency was defined as an IIEF‐6 score of ≥13 without pharmacological or mechanical support.
• ? Patients were stratified into IIEF‐6‐score cohorts (≤12, 13–23 and 24–30).
• ? The median follow‐up was 5.0 years.

RESULTS

• ? The 8‐year overall survival (OS) of the study population was 85.1%.
• ? The 8‐year OS for IIEF‐6scores ≤12, 13–23 and 24–30 were 78.0%, 92.8% and 91.4%, respectively (P < 0.001).
• ? Cardiovascular events accounted for a significant portion of deaths in each IIEF‐6 group.
• ? When combined with other risk factors for cardiovascular disease, an IIEF‐6 score of ≤12 had an additive effect on all‐cause mortality (IIEF‐6 score of ≤12 and less than two comorbidities vs two or more comorbidities were 18.2% and 32.1%).

CONCLUSIONS

• ? A pre‐implant IIEF‐6score of ≤12 was associated with a higher incidence of all‐cause mortality.
• ? Pre‐treatment erectile dysfunction is a surrogate for underlying vascular pathology, probably explaining the lower OS in this subset of patients.
• ? Aggressive treatment of medical co‐morbidity is warranted to impactOS.

     

Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial

Study Type – Therapy (RCT) Level of Evidence 1b What's known on the subject? and What does the study add? Urinary incontinence is one of the major drawbacks of radical prostatectomy, regardless of the procedure used (i.e. open, laparoscopic or robotic‐assisted). Several technical modifications have been described to improve postoperative continence, highlighting the role of puboprostatic ligaments and posterior reconstruction of the rhabdomyosphincter. The results obtained are inconsistent when applied to robotic surgery. The present multicentre randomized study shows that anterior suspension combined with posterior reconstruction is a safe and easy‐to‐perform technique for improving early continence after robotic‐assisted laparoscopic prostatectomy.

OBJECTIVE

• ? To assess the impact on urinary continence of anterior retropubic suspension with posterior reconstruction during robot‐assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

• ? In total, 72 patients who were due to undergo prostatectomy between July 2009 and July 2010 were prospectively randomized into two groups: group A underwent a standard RALP procedure and group B had anterior suspension and posterior reconstruction during RALP.
• ? The primary outcome measure was urinary continence, assessed using the University of California Los Angeles Prostate Cancer Index questionnaire at 15 days, and at 1, 3 and 6 months, after surgery. Other data recorded were operation duration, blood loss, length of hospital stay, duration of bladder catheterization, complications and positive margin rate.

RESULTS

• ? The continence rates at 15 days, and at 1, 3 and 6 months, after surgery were 3.6%, 7.1%, 15.4% and 57.9%, respectively, in group A, and 5.9%, 26.5%, 45.2% and 65.4%, respectively, in group B. The continence rates differed statistically between groups at 1 and 3 months (P = 0.047 and P = 0.016, respectively).
• ? There was no significant difference between groups regarding complications (P = 0.8) or positive margin rate (P = 0.46).

CONCLUSION

• ? Anterior suspension associated with posterior reconstruction during RALP improved the early return of continence, without increasing complications.

     

Cytoreductive nephrectomy in the elderly: a population-based cohort from the USA

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? While cytoreductive nephrectomy is associated with a survival benefit in the context of metastatic renal cell carcinoma, the rates of morbidity and perioperative mortality remain non‐negligible. For example, perioperative mortality may be as high as 21% in elderly patients. The study shows that perioperative death amongst the elderly was substantially lower than what was previously reported from a single institutional report. Nonetheless, postoperative adverse outcomes were non‐negligible in elderly patients relative to their younger counterparts. In consequence, these rates should be discussed at informed consent and a rigorous patient selection remains essential.

OBJECTIVE

• ? To examine the rate of perioperative mortality (PM), and other adverse outcomes in ‘elderly’ patients treated with cytoreductive nephrectomy (CNT).

MATERIAL AND METHODS

• ? Patients who underwent CNT for metastatic renal cell carcinoma were abstracted from the Nationwide Inpatient Sample (1998–2007). ‘Elderly’ was defined as ≥75 years, according to previous definition.
• ? Endpoints consisted of PM, intraoperative and postoperative complications, blood transfusions and length of stay.
• ? We adjusted for the effect of elderly status within five separate logistic regression models. Covariates consisted of comorbidity, race, gender, year of surgery and hospital region.

RESULTS

• ? Overall, CNT was performed in 504 (15.3%) elderly patients and in 2796 (84.7%) ‘younger’ patients (<75 years).
• ? The rate of PM was 4.8% in elderly patients vs 1.9% in the younger patients (P < 0.001). Similarly, the rates of blood transfusions (29.8 vs 21.5%), postoperative complications (27.8 vs 22.8%), and prolonged length of stay (≥8 days) were higher in the elderly (45.0 vs 32.0%; all P < 0.001).
• ? In multivariable analyses, elderly patients were 2.2‐, 1.5‐, and 1.6fold more likely to experience PM, to receive a blood transfusion and to be hospitalized ≥8 days than the younger patients.

CONCLUSIONS

• ? Although the rate of PM was substantially lower than 21%, elderly patients are significantly more likely to die after this type of surgery, to receive a transfusion, and to experience a prolonged length of stay.
• ? These facts and figures should be discussed at informed consent and a rigorous patient selection is essential.

     

York-Mason procedure for repair of recto-urinary fistulae: a 40-year experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Our previous report, almost 10 years ago, on the York‐Mason procedure was the largest series on this procedure. That report concluded that the York‐Mason posterior, trans‐anal, trans‐rectal correction of iatrogenic recto‐urinary fistula was highly successful, reliable and safe – when employed for small fistulas following prostate surgery. Since then, many other smaller case series have confirmed our success. This study provides a continuing body of evidence of the success, reliability, and safety by the largest York‐Mason series in the literature, and our numbers have now doubled in less than 10 years. Avoiding preliminary fecal diversion after surgical injury, which we proposed on our previous report, has now been observed to be safe and reliable with long‐term follow up. We also tried to push the limits of the surgery into larger, radiated fishtulas, but unfortunately were met with poorer outcomes.

OBJECTIVE

• ? To review the use of the York‐Mason transanal, transrectal procedure, used in properly selected patients over a 40‐year period, for repairing recto‐urinary fistulae.

PATIENTS AND METHODS

• ? We retrospectively reviewed the medical records of all patients who underwent acquired recto‐urethral or rectovesical fistula repair at our institution.
• ? A total of 51 patients have undergone York‐Mason recto‐urinary fistula repair at our institution during this time.

RESULTS

• ? Since our last report in 2003, we have performed this procedure an additional 27 times.
• ? We continue to have good results, with 25 of these patients having resolution of their fistulae after one procedure.
• ? Failures in the updated cohort were radiation‐induced fistulae.
• ? We continue to find no evidence of faecal incontinence or stenosis after this procedure.

CONCLUSIONS

• ? Over a period of 40 years, the York‐Mason posterior, transanal, transrectal correction of iatrogenic recto‐urinary fistula has been highly successful, reliable and safe, when used for fistulae occurring after prostate surgery.
• ? Preliminary faecal diversion can often be avoided in selected patients.

     

Predicting erectile function outcome in men after radical prostatectomy for prostate cancer

What's known on the subject? and What does the study add? Over the last decade, the surgical treatment of prostate cancer has evolved towards minimal access surgery, particularly via a robot‐assisted technique. However, there is still debate regarding the true benefit for patients with respect to a functional outcome such as erectile function. The present prediction model provides a reliable estimation of the likelihood of regaining erectile function after prostatectomy.

OBJECTIVE

• ? To identify the reported rates of potency after prostatectomy in the recent literature for men without preoperative erectile dysfunction (ED) and to develop a statistical model for predicting the expected potency after prostatectomy.

MATERIALS AND METHODS

• ? A Medline search was conducted with the keywords ‘potency’ and ‘prostatectomy’ from 2003 to 2009.
• ? In total, 33 studies in the English language reporting pre‐ and postoperative erectile function were identified.
• ? Data from studies reporting outcome after open, laparoscopic and robot‐assisted prostatectomy were analyzed separately.
• ? Only data obtained from potent men before surgery were included in the analysis.

RESULTS

• ? In potent men before surgery, the main predictors of post‐treatment erectile function are age and time after treatment.
• ? The cumulative range of potency rates at 48 months for all ages (45–75 years) was 49–74% for open, 58–74% for laparoscopic and 60–100% for robotic prostatectomy.
• ? The predicted outcome differs by type of operation and patient age.

CONCLUSIONS

• ? Men aged <60 years have a significant likelihood of regaining erectile function after radical prostatectomy.
• ? The reported statistical model provides a reliable estimation of erectile function outcome after prostatectomy for men with localized prostate cancer and intact erectile function.

     

Maintenance therapy with bacillus Calmette-Guérin Connaught strain clearly prolongs recurrence-free survival following transurethral resection of bladder tumour for non-muscle-invasive bladder cancer

Study Type – Therapy (RCT) Level of Evidence 1b

OBJECTIVE

• ? To confirm the recurrence‐preventing efficacy and safety of 18‐month bacillus Calmette‐Guérin (BCG) maintenance therapy for non‐muscle‐invasive bladder cancer.

PATIENTS AND METHODS

• ? The enrolled patients had been diagnosed with recurrent or multiple non‐muscle‐invasive bladder cancer (stage Ta or T1) after complete transurethral resection of bladder tumours (TURBT).
• ? The patients were randomized into three treatment groups: a maintenance group (BCG, 81 mg, intravesically instilled once weekly for 6 weeks as induction therapy, followed by three once‐weekly instillations at 3, 6, 12 and 18 months after initiation of the induction therapy), a non‐maintenance group (BCG, 81 mg, intravesically instilled once weekly for 6 weeks) and an epirubicin group (epirubicin, 40 mg, intravesically instilled nine times). The primary endpoint was recurrence‐free survival (RFS).

RESULTS

• ? Efficacy analysis was performed for 115 of the full‐analysis‐set population of 116 eligible patients, including 41 maintenance group patients, 42 non‐maintenance group patients and 32 epirubicin group patients.
• ? At the 2‐year median point of the overall actual follow‐up period, the final cumulative RFS rates in the maintenance, non‐maintenance and epirubicin groups were 84.6%, 65.4% and 27.7%, respectively.
• ? The RFS following TURBT was significantly prolonged in the maintenance group compared with the non‐maintenance group (generalized Wilcoxon test, P= 0.0190).

CONCLUSION

• ? BCG maintenance therapy significantly prolonged the post‐TURBT RFS compared with BCG induction therapy alone or epirubicin intravesical therapy.

     

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoscopic nephron‐sparing procedures have been increasingly utilized. However, in the presence of multiple tumours the procedure choice is usually shifted to radical nephrectomy. In view of favourable perioperative outcomes, the benefits of minimally‐invasive, nephron‐sparing surgery in experienced hands could be safely extended to patients presenting with multiple ipsilateral renal masses.

OBJECTIVE

• ? To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses.

PATIENTS AND METHODS

• ? Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed.
• ? The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12).
• ? The groups were compared with regards to demographic and peri‐operative variables.

RESULTS

• ? Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4–4.0) and 4.0 cm (2.3–5.9) in groups 1 and 2, respectively.
• ? Median secondary tumour size in group 2 was 1.0 cm (1.0–1.8).
• ? Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009).
• ? Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar.

CONCLUSIONS

• ? LPN is a viable option for the treatment of multiple ipsilateral renal tumours.
• ? Peri‐operative outcomes are similar to standard LPN with the exception of longer operative time.
• ? In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

     

Low dose of ketoconazole in patients with prostate adenocarcinoma resistant to pharmacological castration

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Ketoconazole is an inhibitor of adrenal androgen synthesis which carries on the anti‐tumour activity by interfering with different enzymes, cytochrome P450 14‐α‐demethylase, C 17,20 lyase and C 17 α‐hydroxylase. Some studies have shown an anti‐tumour activity of ketoconazole employed at different dose levels following the failure of androgen‐suppressive therapies. Patients refractory to pharmacological castration and/or chemotherapy could have an additional benefit in terms of disease control from the use of low dose of ketoconazole. The safety profile was good.

OBJECTIVE

• ? To assess the efficacy of ketoconazole in patients with castration‐resistant prostate cancer (CRPC).

PATIENTS AND METHODS

• ? From April 2008 to November 2009, 37 patients with CRPC have been treated with ketoconazole. The primary endpoint was the prostate‐specific antigen (PSA) response; the secondary endpoints were progression‐free survival and safety profile.
• ? Ketoconazole was administered by oral route at a dose of 200 mg every 8 h continuous dosing until the onset of serious adverse events or disease progression.
• ? The study was based on a two‐step design with an interim efficacy analysis carried out on the first 12 patients accrued.

RESULTS

• ? Main characteristics of population were: median age 75 years (range 60–88); baseline mean PSA 28.8 ng/mL (4.3–1000); 30 patients previously challenged with at least two lines of hormone therapy; 15 patients previously treated with chemotherapy.
• ? Biochemical responses accounted for: two complete responses (5%), six partial responses (16%), 13 patients with stable disease (35%), and 14 with progressive disease (38%). Of 15 patients resistant to chemotherapy, overall disease control (complete plus partial responses plus stable disease) was recorded in seven of them.
• ? Treatment was feasible without inducing grade 3–4 adverse events. The most common grade 1–2 adverse events were asthenia (27%), vomiting (8%) and abdominal pain (8%).

CONCLUSION

• ? Treatment with low‐dose ketoconazole is feasible and well tolerated. The efficacy was satisfactory in patients previously treated with chemotherapy.