The gold standard therapy for muscle invasive urothelial carcinoma of the bladder in women is radical cystectomy with anterior pelvic exenteration which involves removal of the lymph nodes, uterus, ovaries, fallopian tubes, bladder, anterior vaginal wall and urethra. For all women there is much concern about sexual function and quality of life after cystectomy and urinary diversion. In this chapter we will explore the advances made in preservation of the reproductive organs in females and review the current rates of concomitant involvement of each with urothelial carcinoma.

The gold standard therapy for mus- cle invasive urothelial carcinoma of the bladder in women is radical cystectomy with anterior pelvic exenteration which involves removal of the lymph nodes, uterus, ovaries, fallopian tubes, bladder, anterior vaginal wall and urethra. For all women there is much concern about sexual function and quality of life after cystectomy and urinary diversion. In this chapter we will explore the advances made in preservation of the reproductive organs in females and review the cur- rent rates of concomitant involvement of each with urothelial carcinoma.

BACKGROUND AND PURPOSE:Angioembolization is often the first-line treatment for patients with renal angiomyolipoma (AML). Regrowth and repeated hemorrhage after embolization, however, remain a concern. Laparoscopic partial nephrectomy (LPN) is the definitive, minimally invasive treatment alternative. We compared the outcomes of LPN in patients who had a diagnosis of AML with patients with other renal tumors.PATIENTS AND METHODS:From a prospective LPN database, we identified patients with a final pathologic diagnosis of AML (group 1). The ability of preoperative imaging to predict AML final pathology results was studied. Surgical and postoperative outcomes in group 1 were compared with the outcomes of the rest of our LPN cohort (group 2).RESULTS:Of 184 LPNs that were performed between 2002 and 2008, 14 (7.6%) patients and 15 renal units had a diagnosis of AML. Two patients underwent concomitant LPN and radiofrequency ablation (RFA) for multiple AML lesions. In group 1, only 33% of the patients had a preoperative diagnosis of AML. There were no significant differences in tumor size, age, preoperative estimated creatinine clearance, body mass index, and comorbidities between the groups. The mean estimated blood loss in groups 1 and 2 was 214 mL and 178 mL, respectively (P = 0.5). The complication rates were similar between the groups. With a median follow-up of 15 months, no AML recurrences or bleeding was observed in group 1.CONCLUSIONS:The results of LPN or RFA, when appropriate, in AML patients are comparable to the results of LPN for other renal tumors. The preoperative imaging studies were a poor predictor of AML in patients who were undergoing LPN.

Objectives Artery-only occlusion (AO) has been used during nephron-sparing surgery to reduce ischemic damage. However, this has not been demonstrated in laparoscopic partial nephrectomy (LPN). We compared our experience with AO and both artery and vein occlusion (AV) in LPN to optimize the method of ischemia. Methods This retrospective case-control study identified 25 patients who underwent AO during LPN and matched them to a cohort of 53 patients who underwent LPN with AV. The groups were compared for ischemia time, blood loss, transfusion rate, and renal function. Results The 2 cohorts were comparable on demographic data. Blood loss was similar, with AO and AV demonstrating equivalent transfusion rates. The 2 cohorts had similar warm ischemia times. Positive margin rate was not affected by venous backflow in the AO cohort (0% AO vs 1.9% AV, P = .679). No significant postoperative change in creatinine (Cr) or creatinine clearance (CrCl) was seen for AO; however, a significant change in Cr and CrCl was seen in AV. Conclusions AO during LPN does not lead to a greater blood loss or an increased warm ischemia time. The benefit of AO on renal function is significant and requires further investigation.

OBJECTIVESWe sought to evaluate the ability of biopsy core recutting to increase cancer detection in patients with high grade prostatic intraepithelial neoplasia (HGPIN).METHODSThis prospective study encompasses all patients undergoing 12 core TRUS guided prostate biopsy between February 2004 and January 2007. In patients with HGPIN on initial biopsy, the paraffin blocks were resampled for cancer by additional deeper levels per core. Additional analysis was performed in the patients with HGPIN in order to detect whether significant differences in prebiopsy variables were associated with patients subsequently found to have benign versus carcinoma on recutting. Last, the costs associated with this procedure were studied.RESULTSForty of 584 (6.8%) patients undergoing prostate biopsy were found to have HGPIN in the absence of prostatic adenocarcinoma on initial histopathology. Following recutting, 12.5% (5/40) of these patients were found to have prostatic adenocarcinoma not previously detected. Of the remaining 35 patients, 18 underwent repeat biopsy. Of these, five patients were found to have adenocarcinoma and three were found to have persistent HGPIN. The PSA, PSA density (PSAD), and PSA velocity (PSAV) prior to initial biopsy were not statistically different when comparing patients found to have benign tissue versus carcinoma on recutting. In patients with HGPIN, at our institution, recutting the biopsy would yield a cost savings of $436/patient as opposed to universal rebiopsy.CONCLUSIONSOur data suggest that prostate biopsy recutting may increase cancer detection in patients initially found to have HGPIN. Additionally, a significant cost savings is associated with the recutting protocol.

clinically stable and afebrile throughout his course. On hospital day 4, the patient was discharged to complete a 10-day course of intramuscular ceftriaxone daily as an outpatient. The following day his primary care physician noted him to be well appearing, afebrile, and active, but there was left scrotal swelling with mild discomfort on palpation. The scrotum was not discolored and did not transilluminate. An emergent scrotal ultrasound demonstrated areas of heterogeneously increased and decreased echogenicity with a complex hydrocele and enlarged epididymis. Doppler showed increased flow around the left testis, which measured 1.0 cm × 0.8 cm × 0.8 cm. The right testis was normal in appearance. A radiologic diagnosis of chronic left testicular torsion was made, and the patient was scheduled for urologic surgery the following day. At surgery, the left spermatic cord showed no evidence of torsion, but both the epididymis and the cord had significant inflammation. The testis was of normal size and pink, with an inflammatory peel around the entire testis. As the testis was high riding on initial exploration, an orchidopexy was performed. The pathology of the inflammatory peel confirmed the presence of necrosis and inflammatory debris, leading to a final diagnosis of left epididymitis. Postoperatively the patient underwent renal ultrasound (RUS) and voiding cystoureterogram (VCUG). The RUS revealed bilateral grade 1 hydronephrosis without evidence of a duplicated system or ectopic ureter. The VCUG was negative. A repeat RUS was obtained 1 month later with resolution of the hydronephrosis. The patient has been doing well since.

INTRODUCTION: To review the current status of laparoscopic radical prostatectomy (LRP) and robotic assisted radical prostatectomy (RALP) in relation to radical retropubic prostatectomy (RRP) in the management of localized prostate cancer. MATERIALS AND METHODS: Between 1982 and 2007 published literature was reviewed using the National Library of Medicine database and the following key words: retropubic, laparoscopic, robotic, robot-assisted, and radical prostatectomy. Special emphasis was given to the technical and cost considerations as well as operative, functional and oncologic outcomes. In particular, reports with pioneering work that have contributed to the evolution of the technique, presenting comparative outcomes and with large series encompassing intermediate/long term follow-up, were taken into account. RESULTS: After intermediate term follow-up, LRP and RALP achieved similar oncologic and functional results compared to RRP. However, LRP and RALP were associated with decreased blood loss, faster convalescence and better cosmetics when compared to RRP. The RALP technique is undoubtedly more expensive. CONCLUSIONS: The oncologic and functional outcomes for LRP and RALP are similar to RRP after intermediate term follow-up. Long term follow-up and adequately designed studies will determine the inherent advantages and disadvantages of the individual techniques in the management of localized prostate cancer.

BACKGROUND AND PURPOSE:Bladder neck contracture (BNC) after radical prostatectomy has been reported to occur in 5% to 32% of men after open retropubic prostatectomy (RRP) and in 0% to 3% after laparoscopic RRP. Optimal anastomotic closure involves creating a watertight, tension-free anastomosis with well-vascularized, mucosal apposition and correct realignment of the urethra. The cause of BNC is poorly understood; however, it is likely related to multiple factors, including excessive luminal narrowing at the site of reconstruction, local tissue ischemia, failed mucosal apposition, and urinary leakage. In this large series of patients who underwent robot-assisted laparoscopic radical prostatectomy (RLRP), we report the incidence of BNC, evaluate the influence of age, body mass index (BMI), estimated blood loss (EBL), surgical time, and prostate weight on its development and assess follow-up urinary function.METHODS:Between February 2003 and July 2006, 650 consecutive men underwent RLRP at our institution. Patients with aborted or open conversion procedures were excluded from analysis. The mean overall follow-up for the remaining 634 patients was 19.5 months. Patients presenting with symptoms of outlet obstruction were evaluated with cystoscopy to confirm a BNC. Comparisons of age, BMI, EBL, operative time, and prostate weight were performed using the Student t-test and chi-square analysis.RESULTS:BNC was the diagnosis in seven patients (1.1%) with a mean time of presentation of 4.8 (3-12) months postoperatively. The BNC patients had comparable mean age, BMI, prostate weight, and EBL to the non-BNC cohort. Their operative time, however, was significantly longer (283 v 225 min., P = 0.04).CONCLUSIONS:The incidence of BNC after radical prostatectomy is 2.2% in a large series of men undergoing RLRP. The diagnosis was made within 1 year. No significant impact on urinary continence or quality-of-life urinary function was observed after BNC management. A running anastomosis, better visualization, improved instrument maneuverability, and decreased blood loss may account for such a low rate.

OBJECTIVETo describe a modification of the posterior prone retroperitoneoscopic nephrectomy, which allows the entire operation to be performed through a single instrument port.PATIENTS AND METHODSWith the patient prone, a retroperitoneal working space is created using a custom‐made balloon lateral to the sacrospinalis muscle. One instrument port is placed at the tip of the 11th rib under direct vision. The laparoscope and working instrument can both be held by the operating surgeon. Gerota’s fascia is incised and the kidney reflected anteriorly. The vessels are identified and divided. The remaining dissection is completed with a harmonic scalpel and the specimen is placed in an endo‐catch bag. Care must be taken to avoid even minor bleeding, to keep the operating field clear.RESULTSThe technique was successful in 54 children with a mean (range) age of 4.5 (0.25–14) years; the mean operative duration was 52 (35–96) min. Blood loss was minimal and there were no open conversions. Most children (51) were discharged the day after surgery, and the cosmetic outcome has been excellent in all cases.CONCLUSIONSCompared with the traditional approach, the single‐instrument port laparoscopic (SImPL) nephrectomy approach avoids instrument crowding and maximizes the restricted retroperitoneal working space. Avoiding the second port might improve cosmesis and reduce cost. The technique is quickly mastered by both the experienced laparoscopist and trainee, and is feasible and safe.

Large cystic abdominal masses can represent a diagnostic dilemma despite advanced diagnostic and imaging techniques. We report a case of a large cystic mass initially managed as a giant ureteropelvic junction obstruction, but ultimately found to be a congenital splenic cyst. Focus is placed on the diagnostic evaluation of large cystic abdominal masses.

Control of bleeding is one of the most technically challenging steps in laparoscopic renal surgery, especially partial nephrectomy. Although there is no consensus on how best to approach hemostasis, the options continue to expand. The original method of sutured renorrhaphy is, perhaps, the most effective; however, great skill is needed to avoid prolonged warm ischemia. Tissue sealants and adhesives serve as a barrier to leakage and as a hemostat. The four classes are fibrin sealants, collagen-based adhesives, hydrogel, and glutaraldehyde-based adhesive. Additionally, oxidized cellulose can be applied to the surface of kidney or used as a bolster. Fibrin sealants are self-activating and work best on a dry field. The gelatin matrix agent consists of human-derived thrombin with a calcium chloride solution and bovine-derived gelatin matrix. The fibrinogen required to form a clot comes from autologous blood. Another product is polyethylene glycol-based hydrogel, which acts as a mechanical sealant. The tissue glue consists of bovine serum albumin and glutaraldehyde, which cross-link to each other, as well as to other tissue proteins. Excessive use or spillage around the renal pelvis and ureter may compromise urinary flow. The methylcellulose products, consisting of oxidized cellulose sheets, usually are positioned within a sutured bolster and act in part by providing direct pressure. A number of energy-based technologies also have been utilized. Monopolar cautery consists of a high-frequency electrical current delivered from a single electrode. Care must be taken to avoid injurious current transfer to surrounding structures. With bipolar cautery, hemostasis occurs only between the electrodes. In the argonbeam coagulator, argon, an inert non-flammable gas that clears from the body rapidly, is coupled with an electrosurgical generator. The gas creates a more even distribution of the energy and better sealing of the tissues. There have been a few reports of serious complications, including gas embolism and tension pneumothorax. The holmium:YAG laser simultaneously dissects and coagulates tissue. However, its use may be limited by smoke and by blood splashing onto the camera lens, and the tissue vaporization and liquid could promote tumor-cell spillage. The potassium-titanyl-phosphate (KTP) and diode lasers have shown promise in animal studies. The saline-coupled radiofrequency tool uses a standard electrosurgical generator to deliver energy through the conductive fluid. The fluid keeps the surface temperature much lower, increases the contact area, and reduces char and eschar formation. One caveat for the use of instruments that coagulate and ablate tissue is that they can damage the collecting system. Furthermore, the char can make it difficult to assess margin status. In practice, a combination of instruments, sealants, or both generally is utilized to obtain hemostasis. These multimodality efforts may be especially useful in the patient with compromised renal function. On the other hand, the cost can rise quickly when multiple agents are employed. Combining suturing and hemostatic technology may be the best strategy.

PURPOSE:Open surgery after cystectomy can be a challenge. We report the incidence of postoperative urinary diversion-enteric fistula and ureteral strictures in patients undergoing radical cystectomy, and discuss the diagnosis and management of these complications, including our surgical approach to these patients.MATERIALS AND METHODS:We preformed a retrospective review of 553 patients undergoing radical cystectomy and urinary diversion for bladder cancer between April 1999 and January 2007. Patients in whom a ureteral stricture or fistula developed were identified by serial laboratory and imaging evaluations. A chart review was preformed to identify symptoms, time to stricture or fistula development, radiological findings, type of diversion, estimated blood loss and whether the original anastomosis was stented. Management and outcomes were assessed.RESULTS:Of 553 patients reviewed ureteral stricture developed in 41 (7.4%) with a mean followup of 20.2 months (range 1 to 98). Strictures developed in 11% (31 of 272) of the orthotopic ileal neobladder, 2.5% (6 of 236) of ileal conduit and 8% (4 of 45) of Indiana pouch cases. Open repair led to an overall success rate of 87%. Urinary diversion-enteric fistula developed in 12 (2.2%) of the 553 patients with a mean followup of 28.4 months (range 3 to 94), all of whom had undergone orthotopic neobladder diversion. No patient had recurrence after surgical repair of the fistula.CONCLUSIONS:Open revision remains the gold standard management for ureteral strictures and urinary diversion-enteric fistulas occurring after radical cystectomy. The addition of the chimney modification to the orthotopic neobladder facilitates surgical repair.

Objectives: UroVysion(TM) (Abbott Molecular Inc., Des Plaines, IL) is a multi-target fluorescent in-situ hybridization (FISH) assay that detects aneuploidy of chromosomes 3, 7, and 17, and loss of the 9p21 locus in exfoliated cells in urine. In this study, we evaluated if UroVysion can predict tumor recurrence in patients with negative cystoscopy and urinary cytology at the time of (FISH) assay.Methods: The study population included patients with history of non-muscle invasive bladder cancer treated by transurethral resection. Follow-up included cystoscopy, barbotage, urinary cytology, and UroVysion testing. Patients were followed for at least 6 months after their initial UroVysion testing.Results: A total of 64 patients (37 males) were enrolled into the study. Mean patient age was 62 years (S.D. 13.2 years). Initial highest tumor stage was Ta in 42 patients (65.6%), T1 in 21 patients (33%), and isolated Tis in a single patient. Abnormal UroVysion results were observed in 40 patients (62.5%). After a median follow-tip of 13.5 months, 21 patients (33%) developed tumor recurrence (Ta in 13 patients, T1 in 5, and Tis in 3). Recurrent tumors developed in 45% of the patients with abnormal UroVysion test compared with 12.5% of the patients with normal assay (P = 0.01). An abnormal UroVysion result preceded the diagnosis of tumor recurrence in 18/21 cases (86%), including all high-grade recurrences.Conclusions: This data suggest that UroVysion may be a useful tool for predicting tumor recurrence. Cystoscopy may be spared and surveillance intervals widened in patients with history of low grade tumors and a normal UroVysion test. (C) 2008 Elsevier Inc. All rights reserved.

You have accessJournal of UrologyPodium 22, Sunday, May 20, 2007, 3:30 - 5:30 pm1 Apr 2007623: Artery only Occlusion is Superior for Renal Preservation During Laparoscopic Partial Nephrectomy Edward M. Gong, Kevin C. Zorn, Alvaro Luciani, Marcelo A. Orvieto, Lambda Msezane, and Arieh L. Shalhav Edward M. GongEdward M. Gong More articles by this author , Kevin C. ZornKevin C. Zorn More articles by this author , Alvaro LucianiAlvaro Luciani More articles by this author , Marcelo A. OrvietoMarcelo A. Orvieto More articles by this author , Lambda MsezaneLambda Msezane More articles by this author , and Arieh L. ShalhavArieh L. Shalhav More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)30863-2AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "623: Artery only Occlusion is Superior for Renal Preservation During Laparoscopic Partial Nephrectomy." The Journal of Urology, 177(4S), p. 209 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 209 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Edward M. Gong More articles by this author Kevin C. Zorn More articles by this author Alvaro Luciani More articles by this author Marcelo A. Orvieto More articles by this author Lambda Msezane More articles by this author Arieh L. Shalhav More articles by this author Expand All Advertisement PDF downloadLoading ...

Objectives Laparoscopic partial nephrectomy (LPN) and radical nephrectomy (LRN) have been shown to be safe and effective treatment options for renal rumors. However, limited data are available regarding the long-term effect on postoperative renal function in patients undergoing LPN and LRN who have a normal preoperative serum creatinine (sCr) less than 1.5 mg/dL and a two-kidney system. We compared the long-term sCr in patients who were treated with LPN and LRN.Methods From October 2002 to April 2006, a total of 93 and 171 patients with a single, unilateral, sporadic renal tumor, a normal contralateral kidney and sCr less than 1.5 mg/dL underwent LPN and LRN, respectively. Perioperative, pathologic data and sCr at least 6 months after surgery were compared between the two groups.Results A total of 42 and 55 patients with at least 6 months of follow-up after LPN and LRN were evaluated. Tumors treated with LPN were significantly smaller (2.4 versus 5.4 cm, P <0.001) than those in the LRN group. The mean age, body mass index, sex, tumor location, and sCr (0.91 and 0.91 mg/dL, P = 0.93) were similar between the two groups. The mean operative time was longer for LPN (222 versus 182 minutes, P = 0.002) with a mean warm ischemia time of 37 minutes (range 13 to 55). The mean 6-month sCr was significantly greater for patients undergoing LRN 0.4 versus 1.0 mg/dL, P <0.001). Similarly, a greater number of LRN patients developed renal insufficiency (sCr 1.5 mg/dL or greater) compared with LPN (36.4% versus 0%, P <0.001).Conclusions Despite the warm ischemia and longer operative times, LPN preserves the kidney function better than LRN. In properly selected patients, LPN should be preferentially performed to prevent chronic renal insufficiency.

You have accessJournal of UrologyModerated Poster 60, Wednesday, May 23,2007, 1:00 - 3:00 pm1 Apr 20071896: Can Serum Creatinine be used as a Surrugate for Glomerular Filtration Rate in Single Renal-Unit Models? Ofer N. Gofrit, Marcelo A. Orvieto, Kevin C. Zorn, Gregory P. Zagaja, Gary D. Steinberg, and Arieh L. Shalhav Ofer N. GofritOfer N. Gofrit More articles by this author , Marcelo A. OrvietoMarcelo A. Orvieto More articles by this author , Kevin C. ZornKevin C. Zorn More articles by this author , Gregory P. ZagajaGregory P. Zagaja More articles by this author , Gary D. SteinbergGary D. Steinberg More articles by this author , and Arieh L. ShalhavArieh L. Shalhav More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)32069-XAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1896: Can Serum Creatinine be used as a Surrugate for Glomerular Filtration Rate in Single Renal-Unit Models?." The Journal of Urology, 177(4S), p. 630 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 177Issue 4SApril 2007Page: 630 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Ofer N. Gofrit More articles by this author Marcelo A. Orvieto More articles by this author Kevin C. Zorn More articles by this author Gregory P. Zagaja More articles by this author Gary D. Steinberg More articles by this author Arieh L. Shalhav More articles by this author Expand All Advertisement PDF DownloadLoading ...

As indications for laparoscopy surgery continue to grow for management of upper urinary tract pathology, knowledge of the potential complications that may be encountered and their respective management are essential. Pneumothorax during laparoscopic renal surgery is typically related to a diaphragmatic injury that allows pressurized CO(2) to enter the thoracic cavity. The placement of a chest tube is usually required for large defects and symptomatic patients. However, in selected patients, with understanding of the favorable absorptive properties of CO(2), conservative management may be elected. We report a case of an asymptomatic, large pneumothorax that was allowed to resolve spontaneously, thus reinforcing the notion of noninvasive capnothorax management incurred during laparoscopic renal surgery.

PURPOSE:Significant improvement and high patient satisfaction are seen after artificial urinary sphincter implantation for male stress urinary incontinence. However, only a small percent of men are treated with an artificial urinary sphincter nationally. We defined trends in current artificial urinary sphincter use in the United States, specifically focusing on regional differences in use. Current rates of radical prostatectomy and the regional distribution of urologists were analyzed as possible factors to explain these disparities. MATERIALS AND METHODS:Data provided by American Medical Systems, Minnetonka, Minnesota on the number of artificial urinary sphincter units sold were analyzed by state, regional and city distribution. American Urological Association data on the number of urologists were used to estimate urologist use of artificial urinary sphincters. The number of radical prostatectomies reported by the American College of Surgeons National Cancer Database were used to estimate artificial urinary sphincter use per radical prostatectomy. RESULTS:In the most populous states and cities generally the most artificial urinary sphincter units were purchased, the most urologists were reported and the most radical prostatectomies were performed. The proportional use of artificial urinary sphincters per radical prostatectomy by state varied from 1% to 10% (national average approximately 6%). The number of urologists per 100,000 men older than 50 years appeared uniform across states (national average 34). However, artificial urinary sphincter use by urologist appeared localized and concentrated. Nationally 1 artificial urinary sphincter unit was purchased for every 3 urologists in the United States. CONCLUSIONS:Artificial urinary sphincter use demonstrates considerable state and regional variation even when controlled for differences in the frequency of radical prostatectomy and the distribution of urologists. Overall the data suggest that artificial urinary sphincters may be underused in some areas of the country, particularly for post-prostatectomy incontinence.