Laparoscopic radical prostatectomy monotherapy, a more aggressive yet less invasive option, is oncologically effective in selected men with high-risk prostate cancer having only one D'Amico risk factor: experience from an Asian tertiary referral center

PURPOSE

To present oncologic results of laparoscopic radical prostatectomy (LRP) monotherapy for men with high-risk, localized prostate cancer, and to find factors associated with a good prognosis via surgery alone.

PATIENTS AND METHODS

Between 2002 and 2009, 241 men underwent LRP at an Asian tertiary referral center. Among them, we retrospectively identified 85 (35.3%) men who met the D'Amico's high-risk criteria: Prostate-specific antigen level >20 ng/mL, Gleason score of 8 to 10, or clinical stage ≥T2c. Perioperative parameters were analyzed against biochemical recurrence (BCR)-free survival.

RESULTS

At a median follow-up of 54 months, BCR developed in 28 (34.1%), with an actuarial BCR-free survival rate of 63.3% at 5 years. Pathologically, 37.6% of the men had organ-confined (OC) disease. Positive surgical margins (PSM) were identified in 49.4% of the patients. A favorable pathologic outcome, defined as OC(+)PSM(-), was observed in 24 patients and associated with a 5-year BCR-free survival rate of 87.0%, compared with 100%, 54.0%, and 46.4% in men with OC(+)PSM(+), OC(-)PSM(-) and OC(-)PSM(+) disease (log-rank, P=0.008). The overall positive lymph node rate was 14.1%. Men (65.9%) with only one D'Amico risk factor had a 5-year BCR-free survival rate of 76.9%, compared with 34.6% in men (34.1%) with ≥2 risk factors (log-rank, P<0.001).

CONCLUSIONS

Radical prostatectomy monotherapy performed laparoscopically or robotically appears to be an option for high-risk prostate cancer, especially in men with a single D'Amico risk factor. Men with ≥2 risk factors are more prone for BCR to develop after surgery and may need second-line therapy.

Aristolochic acid-induced upper tract urothelial carcinoma in Taiwan: clinical characteristics and outcomes

Aristolochic acid (AA), a component of all Aristolochia-based herbal medicines, is a potent nephrotoxin and human carcinogen associated with upper urinary tract urothelial carcinoma (UUC). To investigate the clinical and pathological characteristics of AA-induced UUC, this study included 152 UUC patients, 93 of whom had been exposed to AA based on the presence of aristolactam-DNA adducts in the renal cortex. Gene sequencing was used to identify tumors with A:T-to-T:A transversions in TP53, a mutational signature associated with AA. Cases with both aristolactam-DNA adducts and A:T-to-T:A transversions in TP53 were defined as AA-UUC, whereas patients lacking both of these biomarkers were classified as non-AA-UUC. Cases with either biomarker were classified as possible-AA-UUC. Forty (26%), 60 (40%), and 52 (34%) patients were classified as AA-UUC, possible-AA-UUC and non-AA-UUC, respectively. AA-UUC patients were younger (median ages: 64, 68, 68 years, respectively; p=0.189), predominately female (65%, 42%, 35%, respectively; p=0.011), had more end-stage renal disease (28%, 10%, 12%, respectively; p=0.055), and were infrequent smokers (5%, 22%, 33%, respectively; p=0.07) compared to possible-AA-UUC and non-AA-UUC patients. All 14 patients who developed contralateral UUC had aristolactam-DNA adducts; ten of these also had signature mutations. The contralateral UUC-free survival period was shorter in AA-UUC compared to possible- or non-AA-UUC (p=0.019 and 0.002, respectively), whereas no differences among groups were observed for bladder cancer recurrence. In conclusion, AA-UUC patients tend to be younger and female, and have more advanced renal disease. Notably, AA exposure was associated with an increased risk for developing synchronous bilateral and metachronous contralateral UUC.

Ergonomic and geometric tricks of laparoendoscopic single-site surgery (LESS) by using conventional laparoscopic instruments

BACKGROUND

The aim of this study was to explore the feasibility and safety of performing laparoendoscopic single-site surgery (LESS) with conventional laparoscopic instruments.

METHODS

We retrospectively reviewed our data from 175 patients who underwent various urological LESS procedures via the same ergonomic and geometric principles between 2008 and 2011. LESS procedures performed included adrenalectomy (N = 23), radical nephrectomy (N = 5), radical nephroureterectomy with bladder cuff resection (N = 5), varicocelectomy (N = 12), nephropexy (N = 4), lumbar sympathectomy (N = 4), orchiectomy for intra-abdominal testis (N = 1), pyeloureterostomy (N = 1), dismembered pyeloplasty (N = 1), and adult inguinal hernia mesh repair (N = 119).

RESULTS

All procedures were completed successfully without the use of ancillary ports or articulating instruments except two cases that required laparoscopic conversion. The mean patient age was 48.9 years. Mean operative time was 99.7 min, mean estimated blood loss was 17.3 ml, and mean hospital stay was 2.1 days. There were no intraoperative complications.

CONCLUSION

According to our ergonomic and geometric principles, use of conventional laparoscopic instruments is feasible and safe in LESS procedures.

Minilaparoscopic herniorrhaphy in pediatric inguinal hernia: a durable alternative treatment tostandard herniotomy

BACKGROUND

The purpose of the article is to report our long-term results of minilaparoscopic inguinal hernia repair in children.

METHODS

Between September 2003 and September 2008, 161 children with inguinal hernia were treated with minilaparoscopic herniorrhaphy. The asymptomatic contralateral internal ring was routinely explored and repaired if a patent processus vaginalis of not less than 2 cm was noted. Patients who were followed for less than 1 year and those who were lost to follow-up were excluded from the study. Intraoperative and postoperative complications and hernia recurrences were documented.

RESULTS

In total, 146 patients were eligible for final analysis. A total of 196 minilaparoscopic herniorrhaphies were performed. The mean follow-up period was 3 years. There were 4 hernia recurrences (2%) in 3 boys. There were no procedure-related complications. None of the patients with a negative contralateral exploration or a contralateral patent processus vaginalis of less than 2 cm had a contralateral metachronous inguinal hernia.

CONCLUSIONS

Our long-term results reveal that minilaparoscopic herniorrhaphy combined with hernia sac transection is a safe and effective alternative treatment to standard open herniotomy.

Laparoendoscopic single-site (LESS) retroperitoneal adrenalectomy using a homemade single-access platform and standard laparoscopic instruments

BACKGROUND

This study aimed to evaluate laparoendoscopic single-site (LESS) adrenalectomy via the retroperitoneal approach using the Alexis wound retractor with standard laparoscopic instrumentation.

METHODS

Since October 2009, seven LESS retroperitoneal adrenalectomies have been completed successfully with a homemade single port created using an Alexis wound retractor as an access platform through a 3-cm incision beneath the tip of the 12th rib.

RESULTS

All the LESS procedures for these seven patients with adrenal tumors (size, 1.3-6.0 cm; 4 right, 1 left) were completed successfully without traditional laparoscopic conversion or complication. The average operative time was 159 min, and the estimated blood loss was 100 ml. The average hospital stay was 2 days (range, 1-3 days).

CONCLUSIONS

The preliminary results show that LESS retroperitoneal adrenalectomy is a safe and feasible procedure for functional adrenal tumors using standard laparoscopic instruments.

Laparoendoscopic single-site (LESS) retroperitoneal nephropexy with standard laparoscopic instruments

A 65-year-old female suffered from recurrent urinary tract infection and intermittent right-flank soreness when active. Serial renal ultrasonography and supine/erect intravenous (i.v.) pyelography work-up revealed a floating right kidney with a descent of two vertebral bodies. A Laparoendoscopic single-site retroperitoneal nephropexy was performed. A homemade single port was created by using a commercially available wound retractor through a 3-cm incision at the tip of the 12th rib. With conventional 5-mm laparoscopy and instruments, a retroperitoneal nephropexy was perfomed. The procedure was completed successfully without any complication and with minimal blood loss. The total operative time was 110 minutes. The postoperative course was uneventful. The follow-up erect i.v. pyelographies revealed a normal right kidney position without descent. Laparoendoscopic single-site retroperitoneal nephropexy was a safe, effective procedure, according to our initial experience.

Urodynamic findings in female diabetic patients with and without overactive bladder symptoms

AIMS

The purpose was to analyze urodynamic findings in female diabetic patients with OAB symptoms.

METHODS

Data from 94 female diabetic patients who underwent urodynamic studies in evaluation of various LUTS were retrospectively reviewed. Urodynamic findings, demographic data, and clinical symptoms were compared between patients with and without OAB.

RESULTS

Among the 94 subjects analyzed, 34 (36.2%) were diagnosed as OAB. Demographic data were similar between the patients with and without OAB. In the OAB group, patients had significantly higher storage symptom scores and marginally higher voiding symptom scores. On cystometry, the OAB group had a higher percentage of increased bladder sensation (41.2% vs 11.7%, P = 0.001) and detrusor overactivity (29.4% vs 10.0%, P = 0.023). The OAB group had lower peak flow rate (16.2 +/- 5.9 vs 19.3 +/- 6.3 ml/s, P = 0.023), greater PVR volume (60.3 +/- 29.4 vs 45.0 +/- 25.1 ml, P = 0.009), and lower bladder voiding efficiency (BVE, 75.2 +/- 2.8 vs 81.5 +/- 2.9%, P < 0.001). On pressure-flow studies, the OAB group had a higher percentage of BOO (26.5% vs 6.7%, P = 0.008).

CONCLUSIONS

Our study shows that the most frequent urodynamic finding of OAB in female diabetic patients is increased bladder sensation, followed by detrusor overactivity. Compared to those without OAB, female diabetic patients with OAB are more likely to have impaired voiding function, characterized by lower peak flow rate, greater PVR volume, lower BVE, and a higher percentage of BOO. In these patients, BOO not only causes voiding difficulty but may also contribute to the development of OAB.

Metabolic syndrome components worsen lower urinary tract symptoms in women with type 2 diabetes

CONTEXT

Diabetic women are more susceptible to develop lower urinary tract symptoms (LUTS), especially overactive bladder (OAB). However, data regarding the effect of components of metabolic syndrome (MS) on this association are conflicting.

OBJECTIVE

The objective of the study was to examine the potential role of MS in the development of LUTS in diabetic women.

DESIGN

The study was a prevalence study conducted between 2005 and 2007.

SETTING

The study was conducted in a university hospital.

PARTICIPANTS

A total of 518 women with type 2 diabetes aged 50-75 yr were included. They were subgrouped as MS (47.5%) and non-MS (52.5%) groups according to whether they fulfilled the criteria of MS.

MAIN OUTCOME MEASURE

We used American Urological Association Symptom Index (AUA-SI) to evaluate LUTS and Indevus Urgency Severity Scale to evaluate OAB, respectively.

RESULTS

Women in the MS group had significantly higher storage and total AUA-SI scores as well as a higher prevalence of LUTS and OAB. Most intriguingly, the number of MS components was strongly associated with the LUTS severity because the AUA-SI scores increased in parallel to the number of components were present. Similar results were found between MS and OAB. Multivariate analysis revealed that peripheral neuropathy, but not MS, significantly predicted LUTS in diabetic women after age adjustment. However, MS remained significantly predictive for LUTS and OAB after additional adjustment for neuropathy.

CONCLUSIONS

Our results suggest that MS may especially influence LUTS and OAB in diabetic women, probably by compounding the effect of peripheral neuropathy.

Intermediate-term oncological outcomes of hand-assisted laparoscopic versus open bilateral nephroureterectomy for dialysis and kidney transplant patients with upper urinary tract urothelial carcinoma

PURPOSE

To compare the outcomes of hand-assisted laparoscopic bilateral nephroureterectomy (HALBNU) for dialysis and kidney transplant patients with clinically localized upper urinary tract urothelial carcinoma (UUT-UC) with those achieved by open bilateral nephroureterectomy (OBNU).

MATERIALS AND METHODS

Between 1995 and 2006, 49 patients under dialysis or after kidney transplantation underwent simultaneous bilateral nephroureterectomy for clinically presumed localized UUT-UC at our institute. Of those, 33 underwent HALBNU and 16 received conventional open surgery. Perioperative and pathological data and oncological outcomes were collected by chart review. Bladder recurrence, metastasis, and cancer-specific and overall survival were analyzed and compared between both groups.

RESULTS

The median follow-up for HALBNU and OBNU group was 35 and 46 months, respectively. Totally, 40 patients were identified to have pathologically confirmed urothelial carcinoma of upper urinary tract. HALBNU group was associated with less blood loss, earlier bowel recovery, less narcotic use, shorter hospital stay, and earlier convalescence. The operative time and complication rate were comparable between the two groups. There was no open conversion in the HALBNU group. The two groups were similar in regard to bladder recurrence rate. The overall, cancer-specific, and bladder-recurrence-free survival were also equivalent between the HALBNU and OBNU group (all p > 0.05).

CONCLUSION

In dialysis and kidney transplant patients with localized UUT-UC, simultaneous bilateral nephroureterectomy with hand-assisted laparoscopic approach offered less perioperative morbidity and, most importantly, comparable intermediate-term oncological and survival results when compared with its open counterpart. A longer follow-up is required to demonstrate the oncological efficacy of this minimally invasive procedure.

Homemade transumbilical port: an alternative access for laparoendoscopic single-site surgery (LESS)

BACKGROUND

Laparoendoscopic single-site surgery (LESS) is a possible advancement for minimally invasive surgical interventions. However, this technique requires a specialized multichannel port for introducing laparoscope and instruments. We present our preliminary experience of using a homemade transumbilical single-port access for performing LESS.

METHOD

An Alexis wound retractor was placed through the umbilical incision, and a pair of sterile surgical gloves was then snapped onto it. Standard laparoscopic trocars were inserted through the gloves after the upper half parts of the gloves were truncated. Using this port and Roticulator articulating instruments, we performed 14 urologic LESS procedures on porcine laboratory and cadaveric cases, and we performed 10 transabdominal pre-peritoneal inguinal hernia repairs (TAPP), and 5 laparoscopic varicocelectomies on human cases, respectively. All procedures were performed with instruments inserted through this port without the need for any extraumbilical incisions or conversion to standard laparoscopic surgery.

RESULTS

All LESS procedures were successfully completed without any complications. The time to achieve the transumbilical port ready for subsequent LESS was short (range, 4-8 (median, 6) minutes). The total operative time was between 60 and 190 minutes. No port-related complications were noted, and the cosmetic results were excellent.

CONCLUSIONS

This homemade transumbilical port offers a safe, reliable, flexible, and cost-effective access for LESS procedures. This technique may be an alternative for current specialized port systems.

Optimal C2 concentration of cyclosporin corrected with good efficacy and safety in Asian kidney transplant recipients

INTRODUCTION

Calcineurin inhibitors (CNI) are known for their renal toxicity. Lower CNI exposure is a reasonable option to mitigate potential CNI-induced renal toxicity. Herein we have presented our long-term results after lower cyclosporine (CsA) exposure in the first year.

MATERIALS AND METHODS

Between 1997 and 2004, 63 renal transplant recipients received CsA-based immunosuppression. CsA dosing was adjusted according to the 2-hour whole blood concentration (C2) level. We retrospectively reviewed acute rejection and graft survivals rates, as well as whole blood C2 levels.

RESULTS

Review of serial mean C2 concentrations at 1, 2, 3, 6, and 12 months after transplantation were 1341, 1241, 1191, 1059, and 927 ng/mL, respectively. These levels were slightly lower than those suggested by the Consensus for C2 levels by Levy et al in 2002, namely, 1600 to 2000 ng/mL (mean, 1700); 1400 to 1600 ng/mL (mean, 1500); 1200 to 1400 ng/mL (mean, 1300); 1000 to 1200 ng/mL (mean, 1100), and 800 to 1000 ng/mL (mean, 900), respectively. Acute rejection rate at 3 months and 1 year are 17.5% and 23.8%. Graft survival at 1 year was 97% and at 5 years, 89%. Two patient were lost to fulminant hepatitis and acute myocardial infarction during the first year, which were not associated with underimmunosuppression.

CONCLUSION

Appropriate CsA C2 levels may be lower among Taiwanese. Our C2 dosing strategy resulted in good outcomes with acceptable side effects in our single-center experience. Appropriate CsA C2 levels for Asians deserve more attention in trials of larger scale; most reference levels are presently concluded from studies of Caucasians.

Acute lobar nephronia in a renal allograft: a case report and literature review

We report a diabetic renal transplant recipient who presented with fever and right lower quadrant abdominal pain. Acute appendicitis was considered initially and she underwent emergent appendectomy. However, persistent symptoms postoperatively made us perform an imaging study to identify the problems. Abdominal and pelvic computed tomography disclosed several focal wedge-shaped lesions of low attenuation in the renal allograft. Acute lobar nephronia was successfully managed with parenteral antibiotics. The patient recovered without any sequela. A renal allograft in the right iliac fossa complicates the diagnosis among acute renal infection, malignancy, acute rejection, and even acute appendicitis. Biopsy of the renal allograft is sometimes needed due to clinically ambiguous imaging results. In this report, we not only detail the clinical course of such a rare case, but also review the previous 3 cases of acute lobar nephronia in renal allografts in the literature.

The impact of human ABO blood groups on human xenoreactive antibody-mediated cytotoxicity and the protective effect of human decay-accelerating factors exogene on swine endothelium

Swine tissue can express antigens similar to human A/B blood types. We evaluated whether the variation in human blood type influences the human xenoreactive antibody-mediated cytotoxicity and modifies the protective effect of human decay-accelerating factor (hDAF) exogene, a complement activation regulator, on swine endothelium.

METHODS

Pig aortic endothelial cells were harvested form normal and hDAF transgenic pigs. Cellular viability was evaluated with an MTT assay.

RESULTS

As compared with that of other human blood types, human serum from blood type O donors induced more prominent cytotoxicity on swine endothelial cells both from hDAF transgenic or normal pigs (P < .05). In addition, this difference of xenoreactive antibody-induced cytotoxicity between treatment with O and other human blood type sera was more evident in hDAF transgenic swine endothelial cells than those of normal pigs (P < .05). The hDAF exogene can significantly protect the endothelial cells from human xenoreactive antibody-mediated cytotoxicty when treated with human serum from AB blood type (P < .05). Our data demonstrated that human ABO blood type significantly affected human xenoreactive antibody-induced cytotoxicity, which may modulate the protective effect of hDAF exogene expression on swine endothelial cells.

Perirenal venous aneurysm presenting as retroperitoneal tumor treated successfully by laparoscopic excision

We describe an unusually located venous aneurysm found incidentally in a 46-year-old man that was presumptively diagnosed as a retroperitoneal mass near the left renal hilum. He presented for constipation and weight loss; an abdominal ultrasound scan disclosed an anechoic lesion in the left retroperitoneum. Abdominal CT showed a 3-cm mass with low density located at the junction of the left para-aortic and perirenal hilar regions that was initially suspected of being metastatic lymphadenopathy with an unknown primary origin or a neurogenic tumor. The mass was resected by a laparoscopic approach, which revealed a round mass with a smooth capsule and roots connecting to the paraspinal muscles. On pathologic examination, the mass showed classic features of a venous aneurysm. At 12-month follow-up, no local recurrence or malignancy was documented.

Metastatic hepatocellular carcinoma in the urinary bladder with radiation-induced hemorrhagic cystitis

Metastatic hepatocellular carcinoma (HCC) to the urinary bladder is very rare. We present the case of a 58-year-old female patient who was diagnosed to have both HCC and cervical cancer. She developed hemorrhagic cystitis 2 years after radiation therapy for cervical cancer. During endoscopic electrocauterization for hemorrhagic cystitis, three small reddish tumors measuring less than 1 cm in diameter and with a raspberry-like appearance were found. Transurethral bladder tumor resection was performed. Pathology confirmed metastatic HCC to the bladder. Due to the similar appearance, these tumors are liable to be misinterpreted as engorged vessels secondary to irradiation if biopsies are not taken. Differential diagnosis by pathology is mandatory for such patients.

Laparoscopic partial cystectomy for various bladder pathologies

OBJECTIVE

To present our initial experience with laparoscopic partial cystectomy (LPC) in selected patients with various bladder pathologies.

PATIENTS AND METHODS

Between December 2004 and April 2006, four patients had LPC at our centre (mean age 52 years, range 35-70); the transperitoneal approach was used for three and a pre-peritoneal approach for one. The surgical procedures used sequentially included transurethral incision around the lesion, laparoscopic excision of the lesion (partial cystectomy) and intracorporeal suturing. Laparoscopic pelvic lymphadenectomy was also used for the two patients with malignancy.

RESULTS

All operations proceeded smoothly; the bladder pathologies included one bladder endometriosis, one bladder leiomyoma, one urothelial carcinoma within the bladder diverticulum and one urachal adenocarcinoma. The mean (range) operative duration was 197.5 (120-300) min, the estimated blood loss 70 (50-100) mL, the hospital stay 6.75 (5-9) days, and duration of Foley catheterization 7.25 (6-9) days. No open conversion was required and no patient had peri-operative complications. The surgical margins were free of cancer and the dissected lymph nodes were negative in those two patients with bladder malignancy.

CONCLUSIONS

LPC is safe and feasible in selected patients with various bladder pathologies.