How I do it: prostate cryoablation (PCry)

Prostate cryoablation (PCry) is a well-established minimally invasive therapy for the treatment of prostate cancer. Unfortunately, PCry still carries the stigma of a high rate recto-urethral fistula procedure but with the advent of argon/helium gas technology, urethral warmer and high quality transrectal ultrasound imaging, complications decreased and efficacy increased. The Denver Health Medical Center's technique in prostate cryoablation is described as follows.

Highlights of the 34th Annual Ralph E. Hopkins at Jackson Hole Seminars (JHS) on February 7-12, 2014, Jackson Hole, WY, USA

The prestigious Jackson Hole Seminars (JHS) successfully gathered several world leaders in academic urology and urologists in private practice for a unique scientific experience in Wyoming, USA. Unfortunately, this year Dr. Ralph Hopkins' seat was empty but his spirit continue to be the driving force for the meeting's excellence and friendship. The JHS has pioneered the concept of a Critique Panel comprised of previous speakers that would discuss in depth the presentations of the faculty chosen by the scientific board of the JHS. The 2014 JHS featured Dr. Fernando J. Kim, the President of JHS, Dr. Robert Flanigan, the Program Chair, and the Critique Panel that included: Drs. Peter Albertsen, Arthur Burnett, Michael Coburn, Ann Gormley, and Marshal Stoller. The invited speakers were: Drs. Leonard Gomella (1st prize), Olivier Traxer (2nd prize), Jennifer Anger, Anthony Bella, Jim Hu, and Allen Morey. Some of the in depth discussions and topics are highlighted.

Determinants of holmium:yttrium-aluminum-garnet laser time and energy during ureteroscopic laser lithotripsy

OBJECTIVE

To evaluate the association of preoperative noncontrast computed tomography stone characteristics, laser settings, and stone composition with cumulative holmium:yttrium-aluminum-garnet (Ho:YAG) laser time/energy.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent semirigid/flexible ureteroscopy and Ho:YAG laser lithotripsy (200 or 365 μm laser fiber; 0.8-1.0 J energy; and 8-10 Hz rate) at 2 tertiary care centers (April 2010-May 2012). Studied parameters were as follows: patient's characteristics; stone characteristics (location, burden, hardness, and composition); total laser time and energy; and surgical outcomes.

RESULTS

One hundred patients met our inclusion criteria. Mean stone size was 1.01 ± 0.42 cm and volume 0.33 ± 0.04 cm(3). Mean stone radiodensity was 990 ± 296 HU, and Hounsfield units density 13.8 ± 6.0 HU/mm. All patients were considered stone free. Stone size and volume had a significant positive correlation with laser energy (R = 0.516, P <.001; R = 0.621, P <.001) and laser time (R = 0.477, P <.001; R = 0.567, P <.001). When controlling for stone size, only the correlation between HU and laser time was significant (R = 0.262, P = .011). In the multivariate analysis, with exception of stone composition (P = .103), all parameters significantly increased laser energy (R(2) = 0.524). Multivariate analysis revealed a positive significant association of laser time with stone volume (P <.001) and Hounsfield units density (P <.001; R(2) = 0.512). In multivariate analysis for laser energy, only calcium phosphate stones required less energy to fragment compared with uric acid stones. No significant differences were found in the multivariate laser time model.

CONCLUSION

Ho:YAG laser cumulative energy and total time are significantly affected by stone dimensions, hardness location, fiber size, and power. Kidney location, laser fiber size, and laser power have more influence on the final laser energy than on the total laser time. Calcium phosphate stones require less laser energy to fragment.

Laminar and turbulent surgical plume characteristics generated from curved- and straight-blade laparoscopic ultrasonic dissectors

OBJECTIVE

To characterize laparoscopic ultrasonic dissector surgical plume emission (laminar or turbulent) and investigate plume settlement time between curved and straight blades.

MATERIALS AND METHODS

A straight and a curved blade laparoscopic ultrasonic dissector were activated on tissue and in a liquid environment to evaluate plume emission. Plume emission was characterized as either laminar or turbulent and the plume settlement times were compared. Devices were then placed in liquid to observed consistency in the fluid disruption.

RESULTS

Two types of plume emission were identified generating different directions of plume: laminar flow causes minimal visual obstruction by directing the aerosol downwards, while turbulent flow directs plume erratically across the cavity. Laminar plume dissipates immediately while turbulent plume reaches a second maximum obstruction approximately 0.3 s after activation and clears after 2 s. Turbulent plume was observed with the straight blade in 10 % of activations, and from the curved blade in 47 % of activations. The straight blade emitted less obstructive plume.

CONCLUSION

Turbulent flow is disruptive to laparoscopic visibility with greater field obstruction and requires longer settling than laminar plume. Ultrasonic dissectors with straight blades have more consistent oscillations and generate more laminar flow compared with curved blades. Surgeons may avoid laparoscope smearing from maximum plume generation depending on blade geometry.

Histopathologic findings of small renal tumor biopsies performed immediately after cryoablation therapy: a retrospective study of 50 cases

OBJECTIVES

To evaluate the histopathology of small renal tumor biopsies following cryoablation.

METHODS

We retrospectively evaluated small renal tumor biopsy specimens after cryoablation treatment for renal cell carcinoma and determined the ability to differentiate tumor types, effect on nuclear grading, immunohistochemical staining, and if the number of freeze cycles affected interpretation.

RESULTS

Of the biopsy specimens, 66% were diagnostic of tumor and 34% showed normal renal parenchyma. Tumor subtype was determined in 91% of diagnostic cases. Nuclear grading was affected due to freeze effect, complicating the assessment of chromatin pattern and nucleolar details at low magnification. In particular, the distinction between Fuhrman nuclear grades I and II was compromised; these were designated as low nuclear grade. Immunohistochemical staining was retained similar to untreated tumors. Tumor subtyping was not affected after one or two freeze cycles.

CONCLUSIONS

Biopsies performed immediately after cryoablation can be used to render an optimal histologic diagnosis.

Anterior tumors of the prostate: diagnosis and significance

INTRODUCTION

Prostate biopsies are usually taken from the peripheral rather than anterior region of the prostate. Consequently, tumors originating from the anterior apical region and transition zones may be under-sampled. We examined whether addition of transrectal anterior biopsy (TAB) would improve efficacy of prostate biopsies.

MATERIALS AND METHODS

Simulations of TAB and sextant biopsy (SB) were performed using computer models of 86 autopsy prostates (AP) and 40 radical prostatectomy (RP) specimens. TAB was obtained bilaterally from apex, mid, and base regions by advancing the biopsy needle 5 mm-35 mm beyond the prostatic capsule. A phase I clinical trial with 114 patients was conducted to determine the performance of an extended biopsy protocol consisting of TAB, SB, and laterally-directed biopsy (LDB).

RESULTS

The overall cancer detection rates of SB and TAB were 33% and 55% for AP series (p = 0.00003); 60% and 88% for RP series (p = 0.006). Alternatively, SB + bilateral apical TAB and SB + bilateral mid TAB had cancer detection rates of 45% and 42% for AP series; 80% and 78% for RP series. The extended biopsy protocol detected cancer in 33% (38/114) of patients with 29, 25, and 15 diagnosed by SB, LDB, and bilateral apical TAB, respectively. Patients diagnosed by bilateral apical TAB versus SB (p = 0.01) and LDB (p = 0.02) were statistically significant. Without bilateral apical TAB, the overall cancer detection rate decreased to 30% (34/114).

CONCLUSIONS

Inclusion of bilateral TAB from apical region for first time and repeat prostate biopsies may increase diagnosis of prostate cancer. The clinical significance of these findings needs further investigations and clinical follow up.

Extending boundaries in minimally invasive procedures with simultaneous bilateral video endoscopic inguinal lymphadenectomy (veil) for penile cancer: initial Denver health medical center and ABC school of medicine experience and surgical considerations

PURPOSE

To report the surgical technique, procedural outcomes, and feasibility of simultaneous bilateral Video Endoscopic Inguinal Lymphadenectomy (VEIL) in the management of patients with indication for inguinal lymphadenectomy.

SURGICAL TECHNIQUE

VEIL was applied in all patients using the oncological landmarks (the adductor longus muscle medially, the sartorius muscle laterally and the inguinal ligament superiorly). A 1.5 cm incision was made 2 cm distally to the lower vertex of the femoral triangle. A second incision was made 2 cm proximally and 6 cm medially. Two 10 mm Hasson trocars were inserted in these incisions and the working space was insufflated with CO2 at 5-15 mmHg. The final trocar was placed 2 cm proximally and 6 cm laterally from the first port.

RESULTS

A total of 5 VEIL procedures in 3 patients were performed. Two patients underwent simultaneous bilateral VEIL while another underwent simultaneous bilateral surgery with VEIL on the right and open lymphadenectomy on the left side due to an enlarged node. All laparoscopic procedures were successfully performed without conversion and maintained the oncological templates. One lymphocele occurred in the patient who underwent the open procedure. None of the patients presented with skin necrosis after the procedure. Mean number of nodes retrieved was 6 from each side and 2 patients presented with positive inguinal nodes. After one year of follow-up no recurrences were observed.

CONCLUSION

Simultaneous lymphadenectomy procedures are feasible. Improvement in operative and anesthesia time could decrease the morbidity associated with inguinal lymphadenectomy while maintaining the oncological principles.

Male primary retroperitoneal mucinous cystadenoma

Primary retroperitoneal mucinous cystadenoma of borderline malignancy is a rare disease, especially in male patients. Often these tumors are not incidentally found due to abdominal symptoms. We present the radiologic abdominal computed tomography scan, surgical, and pathologic images of this unique, rare condition in a male patient. Surgical treatment is recommended to establish diagnosis and treatment.

Early scrotal approximation after hemiscrotectomy in patients with Fournier's gangrene prevents scrotal reconstruction with skin graft

OBJECTIVE

We report the outcomes of an early loose closure of the scrotum with a modified U-stitch to minimize use of split thickens skin graft for patients with hemiscrotal tissue loss after surgical debridement.

METHODS

From January 2006 to August 2011, 28 male patients presented with Fournier's gangrene, requiring major urological surgical care and scrotal debridement at Denver Health Medical Center. Surgical outcomes were compared between patients receiving a novel U-Stitch approximation and those treated by traditional management.

RESULTS

The mean age of the patients was 47.1 ± 10.2 years. In total 8 patients (2.2%) developed bacteremia and 3 (0.1%) had methicillin-resistant staphylococcus aureus (MRSA) infection. There was conversion from the U-Stitch approximation patients to traditional management. U-stitch patients required less hospitalization than patients requiring split-thickness skin graft (STSG) due to loss of >50% of the total scrotal tissue (11 vs. 35 days, p = 0.081). The U-stitch demonstrated non-inferiority to traditional treatment.

CONCLUSION

Immediate loose scrotal wound approximation with efficient surgical debridement for Fournier's gangrene may prevent testis exposure facilitating local wound treatment, decreasing the length of hospital stay in patients with Fournier's gangrene involving the scrotum. Future randomized trials may validate these findings.

Laparoscopic ureteroneocystostomy for ureteral injuries after hysterectomy

This report suggests that laparoscopic ureteral reimplantation offers an alternative surgical approach to open surgery after distal ureteral injuries.

Objectives:

To examine the feasibility of early laparoscopic ureteroneocystostomy for ureteral obstruction due to hysterectomy injury.

Methods:

We retrospectively reviewed a 10-y experience from 2 institutions in patients who underwent early (<30 d) or late (>30 d) laparoscopic ureteroneocystostomy for ureteral injury after hysterectomy. Evaluation of the surgery included the cause of the stricture and intraoperative and postoperative outcomes.

Results:

A total of 9 patients with distal ureteral injury after hysterectomy were identified. All injuries were identified and treated as early as 21 d after hysterectomy. Seven of 9 patients underwent open hysterectomy, and the remaining patients had vaginal and laparoscopic radical hysterectomy. All ureteroneocystostomy cases were managed laparoscopically without conversion to open surgery and without any intraoperative complications. The Lich-Gregoir reimplantation technique was applied in all patients, and 2 patients required a psoas hitch. The mean operative time was 206.6 min (range, 120–280 min), the mean estimated blood loss was 122.2 cc (range, 25–350 cc), and the mean admission time was 3.3 d (range, 1–7 d). Cystography showed no urine leak when the ureteral stent was removed at 4 to 6 wk after the procedure. Ureteroneocystostomy patency was followed up with cystography at 6 mo and at least 10 y after ureteroneocystostomy.

Conclusion:

Early laparoscopic ureteral reimplantation may offer an alternative surgical approach to open surgery for the management of distal ureteral injuries, with favorable cosmetic results and recovery time from ureteral obstruction due to hysterectomy injury.

Idiopathic scrotal calcinosis: A rare entity and a review of the literature

Scrotal calcinosis is a rare condition with presentation including intradermal nodules varying in size and number. Differentials include calcification of epidermal or pilar cysts noted by the presence of keratinaceous debris. We present 2 cases of scrotal calcinosis at our institution.

Recent finding and new technologies in nephrolitiasis: a review of the recent literature

This review summarizes recent literature on advances regarding renal and ureteral calculi, with particular focus in areas of recent advances in the overall field of urolithiasis. Clinical management in everyday practice requires a complete understanding of the issues regarding metabolic evaluation and subgrouping of stone-forming patients, diagnostic procedures, effective treatment regime in acute stone colic, medical expulsive therapy, and active stone removal. In this review we focus on new perspectives in managing nephrolitihiasis and discuss recentadvances, including medical expulsive therapy, new technologies, and refinements of classical therapy such as shock wave lithotripsy, give a fundamental modification of nephrolithiasis management. Overall, this field appears to be the most promising, capable of new developments in ureterorenoscopy and percutaneous approaches. Further improvements are expected from robotic-assisted procedures, such as flexible robotics in ureterorenoscopy.

Comparison of surgical plume among laparoscopic ultrasonic dissectors using a real-time digital quantitative technology

BACKGROUND

This study aimed to analyze the effect of surgical plume generation from various ultrasonic dissectors on laparoscopic visibility, including the first cordless ultrasonic dissector, using a novel real-time digital quantification technique.

METHODS

The Covidien Cordless Sonicision, the Harmonic ACE, and the Olympus SonoSurg were applied to bovine liver with industry-specified settings. Consecutive activations were digitally captured from a laparoscope positioned to replicate the clinical setting. Plume was recognized by ImageJ software, and the percentage of pixels containing plume in each video frame was calculated. Analysis of variance statistical multi-analysis and Welch's t test were computed for all p values.

RESULTS

The average maximum plume produced by the Sonicision, ACE, and SonoSurg with the maximum setting were respectively 8.76% (range, 4.32-17.41%), 18.04% (range, 9.07-55.12%), and 9.46% (range, 5.68-22.12%) (p = 0.026). The deviations between the ACE and the other devices were significant (p < 0.05). The average maximum plumes produced with the coagulation setting were 4.80% (range, 0.24-19.83%) for the Sonicision, 26.63% (range, 8.12-73.50%) for the ACE, and 0.21% (range, 0.06-1.05%) for the SonoSurg (p < 0.001). The differences between all the instruments in the coagulation setting were significant.

CONCLUSION

To the authors' knowledge, this is the first report on a real-time digital analysis of surgical plume generation using ImageJ software. In the coagulation setting, the SonoSurg generated minimal plume. The Sonicision obstructed approximately 4%, whereas the ACE generated plume that obstructed 25% of the laparoscopic field. In the cutting setting, the SonoSurg and Sonicision generated the least obstruction, whereas the ACE caused the most obstruction.

Initial brazilian experience in the treatment of localized prostate cancer using a new generation cryotechnology: feasibility study

INTRODUCTION

The objective of our study is to present the first Brazilian cryoablation experience in the treatment of low and intermediate risk localized prostate cancer using 3rd generation cryoablation and real-time biplanar transrectal ultrasonography.

MATERIALS AND METHODS

Ten Brazilian patients underwent primary cryoablation for localized prostate cancer between October 2010 and June 2011. All patients consented for whole gland primary cryotherapy. The procedures were performed by 3rd generation cryoablation with the Cryocare System ® (Endocare, Irvine, California). Preoperative data collection included patient demographics along with prostate gland size, Gleason score, serum prostate specific antigen, and erectile function status. Operative and post--operative assessment involved estimated blood loss, operative time, complications, serum PSA level, erectile function status, urinary incontinence, biochemical disease free survival (BDFS), and follow-up time.

RESULTS

All patients in the study successfully underwent whole gland cryoablation. The mean of: age, prostate size, PSA level, and Gleason score, was 66.2 years old; 40.7 g; 7.8 ng/mL; and 6 respectively. All patients were classified as low or moderate D' Amico risk (5 low and 5 moderate). Erectile dysfunction was present in 50% of patients. The estimated blood loss was minimal, operative time was 46.1 minutes. All patients that developed erectile dysfunction post-treatment responded to oral or intracavernosal medications with early penile rehabilitation. All patients maintained urinary continence by the end of a 10 months evaluation period and none had biochemical relapse within the mean follow-up of 13 months (7-15 months).

CONCLUSION

Our initial experience shows that cryoablation is a minimally invasive option for the treatment of localized prostate cancer. Short term data seems to be promising but longer follow-up is necessary to verify oncological and functional results.

Optimization of prostate cancer diagnosis by increasing the number of core biopsies based on gland volume

In this prospective, non-randomized phase-I clinical trial, we comparatively studied the performance of six laterally-directed biopsies or the modified fan-shaped biopsies (MFSB), midline sextant biopsies (MB), and transition zone biopsies (TZB) and examine their prostate cancer (PCa) detection rates. A total of 114 patients received combinations of MFSB, MB, and TZB based on prostate gland volume: those ≤15 cc received 8 biopsies; those >15 cc but ≤ 50 cc received 14 biopsies; and those >50 cc received 20 biopsies. The mean prostate-specific antigen (PSA) level, Gleason score, and prostate volume were 8.0 ng/ml, 6.4, and 47 cc, respectively. PCa detection rate of the MB was 25% while the MFSB was 22%. The overall PCa detection rate was 33.3% with all biopsies. PCa and high-grade prostatic intraepithelial neoplasia (HG-PIN) detection rates decrease as the size of the prostate increases. PCa detection rates were 50.0% for volumes ≤19.9 cc and volumes of >50 cc had a detection rate of 25.8%. PSA levels of <3.0 had PCa detection rates of 15% which increased to 58% with PSA levels >9.0. In a multivariate analysis, only TZB was significant for PCa diagnosed by PSA (β=7.4, p<0.01). Our study showed that it is important to perform both the lateral MFSB and the MB to improve overall PCa detections rates. Thus, we recommend performing MB, MFSB, and TZB based on prostate volume, as follows: 8 biopsies for ≤15 cc; 14 for those >15 cc but ≤50 cc, and 14-20 for those >50 cc.

Mini-laparoscopy, laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery-assisted laparoscopy: novice surgeons' performance and perception in a porcine nephrectomy model

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Over the last few years, minimally invasive urological surgery has evolved towards less invasive, 'scarless' procedures. New surgical concepts, such as those of natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been introduced. Mini-laparoscopy has been rediscovered in an attempt to reduce the invasiveness of standard laparoscopy. This study is the first to compare the perception of surgeons when first facing three different scarless options for performing a porcine nephrectomy and when dealing with the constraints of each technique. The study findings suggest that: (i) when first approaching these techniques, surgeons tend to perform equally well under expert guidance in the porcine model; (ii) mini-laparoscopy is perceived as less difficult to perform; (iii) for all the techniques, surgeon's impressions are in line with their expectations.

OBJECTIVE

• To evaluate the perception and performance of urological surgeons when first applying scarless surgical techniques.

METHODS

• The study was conducted during the 2(nd) Minimally Invasive Urological Surgical Week annual course in Braga, Portugal. • Fourteen attendees performed three porcine nephrectomies by using each of the following techniques: mini-laparoscopy, laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES)-assisted laparoscopy. • Peri-operative data were recorded, and operating performance was scored by one experienced surgeon for each working station, using a global rating scale. • The surgeons' subjective perceptions of degree of difficulty were graded and their expectations before the procedures were recorded.

RESULTS

• Forty-two porcine nephrectomies were performed. • There were no differences in overall operating time, or time to dissect and manage the renal vascular hilum, whereas time to gain access was faster for LESS than for mini-laparoscopy or NOTES-assisted laparoscopy (mean [sd] 8 [6] min vs 10.2 [5.3] min vs 9.9 [5.3] min, respectively; P = 0.59). • A better visualization of the surgical field was obtained with mini-laparoscopy and there was a higher degree of difficulty of bimanual dexterity for LESS, but no significant differences were found among the three techniques for any variable (operating field view: P = 0.52; bimanual dexterity: P = 0.49; efficiency: P = 0.77; tissue handling: P = 0.61; autonomy: P = 0.2). • Subjective perception of the degree of difficulty trended in favour of mini-laparoscopy (P= 0.17), but no significant difference was found in terms of surgeons' impression as compared with their expectations (P = 0.34).

CONCLUSIONS

• When first approaching new scarless techniques, surgeons tend to perform equally well under expert guidance in the porcine model. • Mini-laparoscopy is perceived as less difficult to perform and, for all the techniques, surgeons' impressions are in line with their expectations.

Critical review of laparoendoscopic single-site surgery versus multiport laparoscopy in urology

Continued advancement in laparoscopy and a desire for less-invasive surgical approach has led to the development of novel surgical approaches, including laparoendoscopic single-site surgery (LESS). LESS in urology has not reached the pinnacle yet. Objective of this study is to provide an evidence-based analysis of the current status and future directions of minimal access and minimally invasive urological surgery represented by LESS in comparison with classic multiport laparoscopic surgery. Since the initial report of single-port nephrectomy in 2007, the majority of laparoscopic procedures in urology have been described with a single-site approach. Multi-center experience has validated Urological LESS procedures as technically feasible and safe for various urologic diseases. Certainly, several issues must be overcome before LESS can practiced universally in urology. Development of instrumentation and platform, long term follow up and large-scale randomized controlled trials are needed to provide an accurate comparative analysis with other procedures to confirm the significant benefits of LESS.