Gregory Zagaja | University of Chicago (original) (raw)
Papers by Gregory Zagaja
The Journal of Urology, Apr 1, 2006
The Journal of Urology, Apr 1, 2006
Canadian Journal of Urology, Feb 1, 2009
Background and purpose: Single renal unit models are invaluable for studies in renal physiology, ... more Background and purpose: Single renal unit models are invaluable for studies in renal physiology, transplantation and response to ischemic injury. Glomerular filtration rate (GFR) is commonly used for evaluation of renal function. Measuring the GFR involves relatively complicated and expensive systems. In this study we determined whether serum creatinine (Scr) can predict the GFR in this model. Materials and methods: Right laparoscopic nephrectomy was performed in 46 female pigs weighing 25 kg-30 kg. Twelve days later the left kidney was exposed to various periods of warm ischemia (30, 60, 90, and 120 minutes). Scr and GFR (using the iohexol clearance method) were determined preoperatively and at postoperative days 1, 3, 8, 15, 22 and 29. A total of 244 pairs of Scr and GFR values were analyzed to determine a formula for predicting GFR (pGFR) from Scr. Results: Scr range was 1.2 mg/dl -29 mg/dl and GFR range was 1.8 ml/min -180.5 ml/min. The empiric formula deduced from the database for calculating pGFR from Scr was: pGFR = (217 divided by Scr) minus 0.2. pGFR correlated well with the actual GFR (R(2) = 0.85). The graphs for pGFR were almost indistinguishable from the graphs for actual GFR in every single animal. The results and conclusions of the experiments using either actual or predicted GFR were identical. Conclusions: We conclude that in a single renal unit porcine model using ischemia as the insult to the kidney, expensive actual measurements of GFR can be reliably replaced by Scr based calculated GFR.
Urology, Mar 1, 2008
The biomechanical and mental strains placed on the surgeon while performing laparoscopic procedur... more The biomechanical and mental strains placed on the surgeon while performing laparoscopic procedures are significantly higher compared with open surgical techniques. We undertook this study to assess the prevalence of surgeons' deleterious perceptions or injuries related to laparoscopic urologic surgery. METHODS Members of endourological society were mailed a questionnaire evaluating their laparoscopic experience, total number of standard laparoscopic surgeries (SLS), hand-assisted laparoscopic surgeries (HALS), and robotic-assisted laparoscopic surgeries (RALS) they performed. The subjects reported any neuromuscular or arthritic injuries sustained during laparoscopic surgery, and graded the degree of pain, numbness, and fatigue they experienced. RESULTS A total of 73 urologists completed the questionnaires. The average responder was 44 years old, had completed a median of 117 procedures, and was performing 3 laparoscopic surgeries per week. Neuromuscular or arthritic symptoms during surgery were reported by 22 responders (30%), the most common was finger paresthesia (18%). At the conclusion of HALS, 45% of the surgeons suffered from hand and wrist numbness and 37% reported pain in these areas. A significant association was observed between the risk of sustaining injury during surgery and the total number of laparoscopic procedures performed by the responder (P ϭ 0.016). RALS was the procedure least associated with injuries, and HALS the most. CONCLUSIONS The laparoscopic operating theater is a hostile ergonomic environment. Surgeons' awareness of the common injuries associated with laparoscopic surgery and careful equipment adjustments before surgery are mandatory to minimize injury. Future improvements in instrument design according to ergonomic principles are highly warranted. UROLOGY 71: 404-407, 2008.
Journal of Clinical Oncology, Jun 20, 2007
15608 Background: Pre-operative prediction of pathological stage represents the cornerstone of pr... more 15608 Background: Pre-operative prediction of pathological stage represents the cornerstone of prostate cancer management. Patient counseling is routinely based on pre-operative PSA, Gleason score and clinical stage. In this study, we evaluated whether prostate weight (PW) is an independent predictor of extracapsular extension (ECE) and positive surgical margin (PSM). Methods: Between February 2003 and November 2006, 709 men underwent robotic-assisted laparoscopic radical prostatectomy (RLRP). Pre-operative parameters (patient age, pre-operative PSA, biopsy Gleason score, clinical stage) as well as pathological data (prostate weight, pathological stage) were prospectively gathered after IRB approval. Evaluation of the influence of these variables on ECE and PSM outcomes were assessed using both univariate and multivariate logistic regression analysis. Results: Mean overall patient age, pre-operative PSA and PW were 59.6 years, 6.5ng/ml and 52.9g (range 5.5–198.7g), respectively. Of the 393, 209 and 107 men with PW <50g, 50-<70g and >70g, ECE was observed in 20.1%, 15.3% and 9.3%, respectively (p=0.015). In the same patient cohorts, PSM was observed in 25.4%, 14.4% and 7.5%, respectively (p<0.001). In a multivariate logistic regression analysis, PW, in addition to pre-operative PSA, biopsy Gleason score and clinical stage, was an independent risk factor for ECE (p<0.001). Similarly, in multi-variate analysis, PW was observed to be a risk factor for PSM (p<0.001). Conclusions: PW is an independent predictor of both ECE and PSM, with an inverse relationship having been demonstrated between both variables. PW should be considered when counseling patients with prostate cancer treatment. No significant financial relationships to disclose.
Journal of Endourology, Apr 1, 2009
Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low... more Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low-risk prostate cancer. However, these glands are routinely removed in every radical prostatectomy. Dissection of the SVs can damage the pelvic plexus, compromise trigonal, bladder neck, and cavernosal innervation, and contribute to delayed gain of continence and erectile function. In this study we evaluated the oncological benefit of routine removal of the SVs in currently operated patients. A total of 1003 patients (mean age, 59.7 years) with prostate cancer underwent robot-assisted radical prostatectomy between February 2003 and July 2007. Seminal vesicle invasion (SVI) was found in 46 of the operated patients (4.6%). Biopsy Gleason score (BGS), preoperative serum PSA, clinical tumor stage, percent of positive cores, and maximal percentage of cancer in a core had all a significant impact on the risk of SVI. Only 4/634 patients (0.6%) with BGS < or =6 suffered from SVI, as opposed to 42/369 (11.4%) with higher Gleason scores. Seminal vesiculectomy does not benefit more than 99% of the patients with BGS < or =6. Considering the potential neural and vascular damage associated with seminal vesiculectomy, we suggest that routine removal of these glands during radical prostatectomy in these cases is not necessary.
Journal of Endourology, Jul 1, 2008
We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-... more We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer. A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively. Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS <or=7. Overall positive surgical margin (PSM) rate was found to be 24.2%. pT(2)- and pT(3)-PSM rate was 6% and 42.3%, respectively. In multivariate logistic regression analysis, PSA <or=10 ng/mL (P = 0.04) and %MCB <or=30% (P = 0.001) were found to be statistically significant predictors of pT(2)N0 disease. Preoperative biopsy GS 8 to 10 predicts a significant likelihood of finding non-organ-confined prostate cancer on the final pathology report. Preoperative PSA <or=10 ng/mL and %MCB <or=30% may be used to predict favorable pathologic outcome for these patients during surgical counseling.
BJUI, Dec 1, 2006
OBJECTIVETo determine whether previously described technical modifications that significantly dec... more OBJECTIVETo determine whether previously described technical modifications that significantly decreased the positive surgical margin (PSM) rate have translated into improved long‐term cancer control, as SM status is generally recognized as an independent risk factor for biochemical recurrence (BR) after radical retropubic prostatectomy (RRP), and is the only factor that can be modified by surgical technique.PATIENTS AND METHODSBetween March 1994 and December 2004, 996 consecutive patients had RRP as the sole treatment for clinically localized prostate cancer. The surgery was done by one surgeon (C.B.B.) and the data were prospectively reviewed.RESULTSThe overall PSM rate was 8.8%; the PSM rate by pathological stage was 1.7%, 24.2% and 27.1% for men with pT2, pT3a and pT3b disease, respectively (P < 0.001). In all, 968 of 996 (97.2%) patients were available for the follow‐up (mean 6.4 years); 69 of 883 (7.8%) with negative SMs (NSMs) developed BR, vs 29 of 85 (34%) with PSMs (P < 0.001). The actuarial 5‐ and 10‐year biochemical disease‐free survival was 92.1% and 89.6%, and 70.6% and 59.9%, for patients with NSM and PSM, respectively (P < 0.001). On multivariate analysis, PSM, pathological stage and Gleason grade were the strongest predictors of BR (P < 0.001). The preoperative prostate‐specific antigen level, and clinical stage T1c and T2a disease were not associated with recurrence. The hazard ratio (95% confidence interval) for BR in patients with PSMs was 3.27 (2.1–5.1).CONCLUSIONSRRP including the previously described surgical modifications not only decreased the PSM rate but also resulted in excellent long‐term cancer control. The importance of meticulous surgical technique in RRP cannot be overemphasised.
Journal of Endourology, Feb 1, 2008
Purpose: Bladder neck contracture (BNC) following radical prostatectomy has been reported to occu... more Purpose: Bladder neck contracture (BNC) following radical prostatectomy has been reported to occur in 5% to 32% of men following open radical retropubic prostatectomy (RRP), and 0% to 3% following laparoscopic RRP. Optimal anastomotic closure involves creating a watertight, tension-free anastomosis with well-vascularized mucosal apposition and correct realignment of the urethra. The etiology of BNC is poorly understood; however, it is likely to be 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 robotic-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 outcome. Materials and 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's t-test and chi-square analysis. Results: BNC was diagnosed in seven patients (1.1%) with a mean time of presentation of 4.8 months (range 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 minutes; P ؍ 0.04). Conclusions: The incidence of BNC after radical prostatectomy was 1.1% in a large series of men undergoing RLRP. All cases were diagnosed within 1 year. No significant impact on urinary continence or qualityof-life urinary function outcomes was observed after BNC treatment. A running anastomosis, better visualization, improved instrument maneuverability, and decreased blood loss may account for such a low rate.
The Journal of Urology, 2008
Improvement in the prognosis of patient groups due to stage or grade reclassification is called t... more Improvement in the prognosis of patient groups due to stage or grade reclassification is called the Will Rogers phenomenon. We determined the significance of the Will Rogers phenomenon in urological oncology. Studies referring to the Will Rogers phenomenon in urological oncology were identified through a MEDLINE search. Samples of articles not referring to the phenomenon directly but likely to be biased by it, such as articles comparing contemporary data to historical controls, were also reviewed. In prostate cancer the Will Rogers phenomenon is the result of the late 1990s acceptance that Gleason scores 2 to 4 should not be assigned on prostate biopsy. Consequently grade inflation occurred and current readings are almost 1 Gleason grade higher compared to past readings of the same biopsy. The result is an illusion of improvement in grade adjusted prognosis. In bladder cancer the Will Rogers phenomenon arises from improvement in histopathological processing of cystectomy specimens enabling the identification of microscopic perivesical fat infiltration and lymph node metastases not recognized in the past. Up staging from pT2 to pT3 and N0 to N+ may partly explain the improved stage adjusted survival after radical cystectomy observed in contemporary series. The Will Rogers phenomenon may also explain the correlation between the total number of lymph nodes removed at radical cystectomy and survival. As more lymph nodes are removed the probability of identifying metastases and up staging to N+ increases. Comparison of contemporary results to historical controls may be biased by the Will Rogers phenomenon. Ignoring the possibility of stage or grade reclassification may lead to erroneous conclusions.
Journal of Endourology, Nov 1, 2007
Previous reports have suggested that a 2% to 5% device failure rate (FR) be quoted when counselin... more Previous reports have suggested that a 2% to 5% device failure rate (FR) be quoted when counseling patients about robot-assisted laparoscopic radical prostatectomy (RLRP). We sought to evaluate our FR on the da Vinci system. Since February 2003, more than 800 RLRPs have been performed at our institution using a single three-armed robotic unit. A prospective database was analyzed to determine the device FR and whether it resulted in case abortion or open conversion. Intuitive Surgical Systems provided data concerning the system&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s performance, including its fault rate. Error messages were classified as recoverable and non-recoverable faults. Between February 2003 and November 2006, 725 RLRP cases were available for evaluation. There were no intraoperative device failures that resulted in a case conversion. Technical errors resulting in surgeon handicap occurred in 3 cases (0.4%). Four patients (0.5%) had their procedures aborted secondary to system failure at initial set-up prior to patient entrance to the operating room. Data analysis retrieved from the da Vinci console reported on a total of 807 procedures since 2003. Only 4 cases (0.4%) were reported from the Intuitive Surgical database to result in either an aborted or a converted case, which compares favorably with our results. Since the last computer system upgrade (September 2005), the mean recoverable and non-recoverable fault rates per procedure were 0.21 and 0.05, respectively. For all the advanced features the da Vinci system offers, it is surprisingly reliable. Throughout our RLRP experience, device failure resulted in case conversion, procedure abortion, and surgeon handicap in 0, 0.5%, and 0.4% of procedures, respectively. As such, a lowered device FR of 0.5% should be used when counseling patients undergoing RLRP. To avoid futile general anesthesia, a policy should be enforced to ensure that the da Vinci system is completely set up before the patient enters the operating room.
The Journal of Urology, Apr 1, 2007
The Journal of Urology, Apr 1, 2009
Journal of Robotic Surgery, Feb 27, 2009
The traditional anatomical description of the seminal vesicles is based on autopsy and imaging st... more The traditional anatomical description of the seminal vesicles is based on autopsy and imaging studies. Trans-peritoneal robotic-assisted laproscopic surgery, with its three-dimensional magnified view and miniature articulated working instruments, provides an opportunity to perform accurate dissections of the seminal vesicles even when extremely long and tortuous. We used specimens obtained by robotic-assisted laparoscopic radical prostatectomy (RLRP) for accurate anatomic assessment of the dimensions of the seminal vesicles. Digital photos of 78 specimens from men (mean age 59 ± 6.1 years) who underwent RLRP were analyzed using the Image Pro Plus software. Seminal vesicle dimensions were correlated with patients’ age, weight, height, prostate weight, sexual function profile (SHIM) and symptom severity score of the lower urinary tract symptoms (IPSS). We found that the length of the seminal vesicles is highly variable (range of 8.5–94.6 mm). The average seminal vesicle length was 31 ± 10.3 mm and its average volume 7.1 ± 5.2 ml. The right seminal vesicle was significantly larger than the left in length, width and volume (P < 0.003). The seminal vesicles were found to be highly asymmetric with a mean difference of 17.8% in length and 24.9% in width between the sides. No correlation between seminal vesicle dimensions and any of the parameters tested was found. We concluded that the normal human seminal vesicles are characterized by marked (11-fold) variation in length and are asymmetric in most patients. The right seminal vesicle is significantly larger than the left. Seminal vesicle dimensions cannot be predicted from other morphometric or physiologic parameters.
European Urology, Mar 1, 2007
Objectives. To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight... more Objectives. To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight and obese patients, defined as those with a body mass index (BMI) of 25 to 30 kg/m 2 and greater than 30 kg/m 2 , respectively. Methods. This was a nonrandomized study evaluating all of our RLRP patients. Patients were divided into three groups: BMI of 25 kg/m 2 or less (group 1), BMI greater than 25 kg/m 2 and less than 30 kg/m 2 (group 2), and BMI of 30 kg/m 2 or more (group 3). Patients were evaluated prospectively with the validated Rand 36-Item Health Survey (version 2) and with the University of California, Los Angeles Prostate Cancer Index questionnaire. Results. Between February 2003 and November 2004, 150 RLRPs were performed at our center. Average follow-up was 8 months. Groups 1, 2, and 3 had 39, 65, and 46 patients, respectively. Average BMIs for all three groups were statistically different (P Ͻ0.01). When compared with group 1, open conversion rates, hospital stay, positive margin, and complication rates were not statistically different for groups 2 or 3. Operative time (P Ͻ0.004) and estimated blood loss (P Ͻ0.03), however, were statistically greater for group 3 compared with group 1. Transfusion rate was highest in group 2 (P ϭ 0.04 compared with group 1). Prostate weights were also statistically greater in groups 2 (P ϭ 0.003) and 3 (P ϭ 0.02) compared with group 1. Overall, BMI did not increase perioperative and postoperative morbidity. Conclusions. Robotic laparoscopic radical prostatectomy is safe in overweight and obese patients and might be the surgical management of choice in this subset of patients. Further long-term follow-up with more patients is required to verify this initial observation.
Journal of Endourology, Nov 1, 2007
Several staging tools have been developed for open radical prostatectomy (ORP) patients. However,... more Several staging tools have been developed for open radical prostatectomy (ORP) patients. However, the validity of these tools has never been formally tested in patients treated with robot-assisted laparoscopic radical prostatectomy (RALP). We tested the accuracy of an ORP-derived nomogram in predicting the rate of extracapsular extension (ECE) in a large RALP cohort. Serum prostate specific antigen (PSA) and side-specific clinical stage and biopsy Gleason sum information were used in a previously validated nomogram predicting side-specific ECE. The nomogram-derived predictions were compared with the observed rate of ECE, and the accuracy of the predictions was quantified. Each prostate lobe was analyzed independently. As complete data were available for 576 patients, the analyses targeted 1152 prostate lobes. Median age and serum PSA concentration at radical prostatectomy were 60 years and 5.4 ng/mL, respectively. The majority of side-specific clinical stages were T(1c) (993; 86.2%). Most side-specific biopsy Gleason sums were 6 (572; 49.7%). The median side-specific percentages of positive cores and of cancer were, respectively, 20.0% and 5.0%. At final pathologic review, 107 patients (18.6%) had ECE, and side-specific ECE was present in 117 patients (20.3%). The nomogram was 89% accurate in the RALP cohort v 84% in the previously reported ORP validation. The ORP side-specific ECE nomogram is highly accurate in the RALP population, suggesting that predictive and possibly prognostic tools developed in ORP patients may be equally accurate in their RALP counterparts.
The Journal of Urology, Apr 1, 2009
METHODS: A retrospective analysis of patients undergoing either radical or partial nephrectomy fo... more METHODS: A retrospective analysis of patients undergoing either radical or partial nephrectomy for RCC in our institution was performed. Patients' data including 2002 TNM stage, tumor size, nuclear grade, and MVI were obtained from medical charts and pathological reports. RESULTS: A total of 270 patients with RCC (pT1a 96, pT1b 60, pT2 35, pT3a 21, pT3b 29,pT3c 2, pT4 6) were included in this study. The mean age of the patients was 61.2 years (range 24-85) and the median follow-up period was 47 months (range 1-244, mean 64). MVI was observed in 24 (15.4%) of pT1, 12 (34.3%) of pT2, 31(93.5%) of pT3, and 6 (100.0%) of pT4. There was MVI in 21 (75.0%) of 28 patients with distant metastasis at surgery and 58 (26.4%) of 220 patients without metastasis. Eighteen patients (7.5%) of 239 patients who underwent curative resection had tumor recurrence and 11 patients (61.1%) with tumor recurrence had MVI. Among 57 MVI positive patients, 11 (19.3%) had tumor recurrence, while 7 (4.3%) of 163 with MVI negative patients had recurrence. The disease-free survival and cancer-specific survival of MVI positive patients were significantly lower than those of MVI negative patients, respectively (p=0.002 and p<0.001) (Fig.1&2). In COX proportional hazard model, the presence of MVI was an independent predictor for tumor recurrence and cancer death (HR 4.939, p=0.004 and HR 4.425, p=0.012, respectively) (Fig.1&2). CONCLUSIONS: MVI is an independent pathological predictor of tumor recurrence and survival in patients with RCC.
The Journal of Urology, Apr 1, 2007
Journal of Endourology, Feb 1, 2008
During standard, six-port set-up, robotic-assisted laparoscopic radical prostatectomy (RLRP) usin... more During standard, six-port set-up, robotic-assisted laparoscopic radical prostatectomy (RLRP) using a three-arm daVinci system (DVS), two assistants are routinely required. The role of the second assistant is often limited to isometric traction during prostate dissection. Due to muscle fatigue and inability of the operator to see the operative field, frequent repositioning of the second assistant is often required. In an attempt to improve efficiency in such surgical situations, we describe the use of the Endoholder, an adjustable articulating instrument holder, to assist during RLRP. During 100 consecutive cases, the Endoholder provided quick, reproducible retraction to facilitate exposure. No complications occurred with its use. The device reduced the need for a dedicated second assistant to stand bedside. We have achieved significant improvements in the safety and efficiency of retraction of the rectum, bladder, and prostate during RLRP with the Endoholder. For urologists working with a three-armed DVS, use of the Endoholder may help facilitate tissue retraction during dissection.
Journal of Clinical Oncology, Jun 20, 2007
The Journal of Urology, Apr 1, 2006
The Journal of Urology, Apr 1, 2006
Canadian Journal of Urology, Feb 1, 2009
Background and purpose: Single renal unit models are invaluable for studies in renal physiology, ... more Background and purpose: Single renal unit models are invaluable for studies in renal physiology, transplantation and response to ischemic injury. Glomerular filtration rate (GFR) is commonly used for evaluation of renal function. Measuring the GFR involves relatively complicated and expensive systems. In this study we determined whether serum creatinine (Scr) can predict the GFR in this model. Materials and methods: Right laparoscopic nephrectomy was performed in 46 female pigs weighing 25 kg-30 kg. Twelve days later the left kidney was exposed to various periods of warm ischemia (30, 60, 90, and 120 minutes). Scr and GFR (using the iohexol clearance method) were determined preoperatively and at postoperative days 1, 3, 8, 15, 22 and 29. A total of 244 pairs of Scr and GFR values were analyzed to determine a formula for predicting GFR (pGFR) from Scr. Results: Scr range was 1.2 mg/dl -29 mg/dl and GFR range was 1.8 ml/min -180.5 ml/min. The empiric formula deduced from the database for calculating pGFR from Scr was: pGFR = (217 divided by Scr) minus 0.2. pGFR correlated well with the actual GFR (R(2) = 0.85). The graphs for pGFR were almost indistinguishable from the graphs for actual GFR in every single animal. The results and conclusions of the experiments using either actual or predicted GFR were identical. Conclusions: We conclude that in a single renal unit porcine model using ischemia as the insult to the kidney, expensive actual measurements of GFR can be reliably replaced by Scr based calculated GFR.
Urology, Mar 1, 2008
The biomechanical and mental strains placed on the surgeon while performing laparoscopic procedur... more The biomechanical and mental strains placed on the surgeon while performing laparoscopic procedures are significantly higher compared with open surgical techniques. We undertook this study to assess the prevalence of surgeons' deleterious perceptions or injuries related to laparoscopic urologic surgery. METHODS Members of endourological society were mailed a questionnaire evaluating their laparoscopic experience, total number of standard laparoscopic surgeries (SLS), hand-assisted laparoscopic surgeries (HALS), and robotic-assisted laparoscopic surgeries (RALS) they performed. The subjects reported any neuromuscular or arthritic injuries sustained during laparoscopic surgery, and graded the degree of pain, numbness, and fatigue they experienced. RESULTS A total of 73 urologists completed the questionnaires. The average responder was 44 years old, had completed a median of 117 procedures, and was performing 3 laparoscopic surgeries per week. Neuromuscular or arthritic symptoms during surgery were reported by 22 responders (30%), the most common was finger paresthesia (18%). At the conclusion of HALS, 45% of the surgeons suffered from hand and wrist numbness and 37% reported pain in these areas. A significant association was observed between the risk of sustaining injury during surgery and the total number of laparoscopic procedures performed by the responder (P ϭ 0.016). RALS was the procedure least associated with injuries, and HALS the most. CONCLUSIONS The laparoscopic operating theater is a hostile ergonomic environment. Surgeons' awareness of the common injuries associated with laparoscopic surgery and careful equipment adjustments before surgery are mandatory to minimize injury. Future improvements in instrument design according to ergonomic principles are highly warranted. UROLOGY 71: 404-407, 2008.
Journal of Clinical Oncology, Jun 20, 2007
15608 Background: Pre-operative prediction of pathological stage represents the cornerstone of pr... more 15608 Background: Pre-operative prediction of pathological stage represents the cornerstone of prostate cancer management. Patient counseling is routinely based on pre-operative PSA, Gleason score and clinical stage. In this study, we evaluated whether prostate weight (PW) is an independent predictor of extracapsular extension (ECE) and positive surgical margin (PSM). Methods: Between February 2003 and November 2006, 709 men underwent robotic-assisted laparoscopic radical prostatectomy (RLRP). Pre-operative parameters (patient age, pre-operative PSA, biopsy Gleason score, clinical stage) as well as pathological data (prostate weight, pathological stage) were prospectively gathered after IRB approval. Evaluation of the influence of these variables on ECE and PSM outcomes were assessed using both univariate and multivariate logistic regression analysis. Results: Mean overall patient age, pre-operative PSA and PW were 59.6 years, 6.5ng/ml and 52.9g (range 5.5–198.7g), respectively. Of the 393, 209 and 107 men with PW &amp;amp;amp;lt;50g, 50-&amp;amp;amp;lt;70g and &amp;amp;amp;gt;70g, ECE was observed in 20.1%, 15.3% and 9.3%, respectively (p=0.015). In the same patient cohorts, PSM was observed in 25.4%, 14.4% and 7.5%, respectively (p&amp;amp;amp;lt;0.001). In a multivariate logistic regression analysis, PW, in addition to pre-operative PSA, biopsy Gleason score and clinical stage, was an independent risk factor for ECE (p&amp;amp;amp;lt;0.001). Similarly, in multi-variate analysis, PW was observed to be a risk factor for PSM (p&amp;amp;amp;lt;0.001). Conclusions: PW is an independent predictor of both ECE and PSM, with an inverse relationship having been demonstrated between both variables. PW should be considered when counseling patients with prostate cancer treatment. No significant financial relationships to disclose.
Journal of Endourology, Apr 1, 2009
Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low... more Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low-risk prostate cancer. However, these glands are routinely removed in every radical prostatectomy. Dissection of the SVs can damage the pelvic plexus, compromise trigonal, bladder neck, and cavernosal innervation, and contribute to delayed gain of continence and erectile function. In this study we evaluated the oncological benefit of routine removal of the SVs in currently operated patients. A total of 1003 patients (mean age, 59.7 years) with prostate cancer underwent robot-assisted radical prostatectomy between February 2003 and July 2007. Seminal vesicle invasion (SVI) was found in 46 of the operated patients (4.6%). Biopsy Gleason score (BGS), preoperative serum PSA, clinical tumor stage, percent of positive cores, and maximal percentage of cancer in a core had all a significant impact on the risk of SVI. Only 4/634 patients (0.6%) with BGS &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; or =6 suffered from SVI, as opposed to 42/369 (11.4%) with higher Gleason scores. Seminal vesiculectomy does not benefit more than 99% of the patients with BGS &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; or =6. Considering the potential neural and vascular damage associated with seminal vesiculectomy, we suggest that routine removal of these glands during radical prostatectomy in these cases is not necessary.
Journal of Endourology, Jul 1, 2008
We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-... more We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer. A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively. Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=7. Overall positive surgical margin (PSM) rate was found to be 24.2%. pT(2)- and pT(3)-PSM rate was 6% and 42.3%, respectively. In multivariate logistic regression analysis, PSA &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=10 ng/mL (P = 0.04) and %MCB &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=30% (P = 0.001) were found to be statistically significant predictors of pT(2)N0 disease. Preoperative biopsy GS 8 to 10 predicts a significant likelihood of finding non-organ-confined prostate cancer on the final pathology report. Preoperative PSA &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=10 ng/mL and %MCB &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=30% may be used to predict favorable pathologic outcome for these patients during surgical counseling.
BJUI, Dec 1, 2006
OBJECTIVETo determine whether previously described technical modifications that significantly dec... more OBJECTIVETo determine whether previously described technical modifications that significantly decreased the positive surgical margin (PSM) rate have translated into improved long‐term cancer control, as SM status is generally recognized as an independent risk factor for biochemical recurrence (BR) after radical retropubic prostatectomy (RRP), and is the only factor that can be modified by surgical technique.PATIENTS AND METHODSBetween March 1994 and December 2004, 996 consecutive patients had RRP as the sole treatment for clinically localized prostate cancer. The surgery was done by one surgeon (C.B.B.) and the data were prospectively reviewed.RESULTSThe overall PSM rate was 8.8%; the PSM rate by pathological stage was 1.7%, 24.2% and 27.1% for men with pT2, pT3a and pT3b disease, respectively (P < 0.001). In all, 968 of 996 (97.2%) patients were available for the follow‐up (mean 6.4 years); 69 of 883 (7.8%) with negative SMs (NSMs) developed BR, vs 29 of 85 (34%) with PSMs (P < 0.001). The actuarial 5‐ and 10‐year biochemical disease‐free survival was 92.1% and 89.6%, and 70.6% and 59.9%, for patients with NSM and PSM, respectively (P < 0.001). On multivariate analysis, PSM, pathological stage and Gleason grade were the strongest predictors of BR (P < 0.001). The preoperative prostate‐specific antigen level, and clinical stage T1c and T2a disease were not associated with recurrence. The hazard ratio (95% confidence interval) for BR in patients with PSMs was 3.27 (2.1–5.1).CONCLUSIONSRRP including the previously described surgical modifications not only decreased the PSM rate but also resulted in excellent long‐term cancer control. The importance of meticulous surgical technique in RRP cannot be overemphasised.
Journal of Endourology, Feb 1, 2008
Purpose: Bladder neck contracture (BNC) following radical prostatectomy has been reported to occu... more Purpose: Bladder neck contracture (BNC) following radical prostatectomy has been reported to occur in 5% to 32% of men following open radical retropubic prostatectomy (RRP), and 0% to 3% following laparoscopic RRP. Optimal anastomotic closure involves creating a watertight, tension-free anastomosis with well-vascularized mucosal apposition and correct realignment of the urethra. The etiology of BNC is poorly understood; however, it is likely to be 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 robotic-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 outcome. Materials and 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's t-test and chi-square analysis. Results: BNC was diagnosed in seven patients (1.1%) with a mean time of presentation of 4.8 months (range 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 minutes; P ؍ 0.04). Conclusions: The incidence of BNC after radical prostatectomy was 1.1% in a large series of men undergoing RLRP. All cases were diagnosed within 1 year. No significant impact on urinary continence or qualityof-life urinary function outcomes was observed after BNC treatment. A running anastomosis, better visualization, improved instrument maneuverability, and decreased blood loss may account for such a low rate.
The Journal of Urology, 2008
Improvement in the prognosis of patient groups due to stage or grade reclassification is called t... more Improvement in the prognosis of patient groups due to stage or grade reclassification is called the Will Rogers phenomenon. We determined the significance of the Will Rogers phenomenon in urological oncology. Studies referring to the Will Rogers phenomenon in urological oncology were identified through a MEDLINE search. Samples of articles not referring to the phenomenon directly but likely to be biased by it, such as articles comparing contemporary data to historical controls, were also reviewed. In prostate cancer the Will Rogers phenomenon is the result of the late 1990s acceptance that Gleason scores 2 to 4 should not be assigned on prostate biopsy. Consequently grade inflation occurred and current readings are almost 1 Gleason grade higher compared to past readings of the same biopsy. The result is an illusion of improvement in grade adjusted prognosis. In bladder cancer the Will Rogers phenomenon arises from improvement in histopathological processing of cystectomy specimens enabling the identification of microscopic perivesical fat infiltration and lymph node metastases not recognized in the past. Up staging from pT2 to pT3 and N0 to N+ may partly explain the improved stage adjusted survival after radical cystectomy observed in contemporary series. The Will Rogers phenomenon may also explain the correlation between the total number of lymph nodes removed at radical cystectomy and survival. As more lymph nodes are removed the probability of identifying metastases and up staging to N+ increases. Comparison of contemporary results to historical controls may be biased by the Will Rogers phenomenon. Ignoring the possibility of stage or grade reclassification may lead to erroneous conclusions.
Journal of Endourology, Nov 1, 2007
Previous reports have suggested that a 2% to 5% device failure rate (FR) be quoted when counselin... more Previous reports have suggested that a 2% to 5% device failure rate (FR) be quoted when counseling patients about robot-assisted laparoscopic radical prostatectomy (RLRP). We sought to evaluate our FR on the da Vinci system. Since February 2003, more than 800 RLRPs have been performed at our institution using a single three-armed robotic unit. A prospective database was analyzed to determine the device FR and whether it resulted in case abortion or open conversion. Intuitive Surgical Systems provided data concerning the system&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s performance, including its fault rate. Error messages were classified as recoverable and non-recoverable faults. Between February 2003 and November 2006, 725 RLRP cases were available for evaluation. There were no intraoperative device failures that resulted in a case conversion. Technical errors resulting in surgeon handicap occurred in 3 cases (0.4%). Four patients (0.5%) had their procedures aborted secondary to system failure at initial set-up prior to patient entrance to the operating room. Data analysis retrieved from the da Vinci console reported on a total of 807 procedures since 2003. Only 4 cases (0.4%) were reported from the Intuitive Surgical database to result in either an aborted or a converted case, which compares favorably with our results. Since the last computer system upgrade (September 2005), the mean recoverable and non-recoverable fault rates per procedure were 0.21 and 0.05, respectively. For all the advanced features the da Vinci system offers, it is surprisingly reliable. Throughout our RLRP experience, device failure resulted in case conversion, procedure abortion, and surgeon handicap in 0, 0.5%, and 0.4% of procedures, respectively. As such, a lowered device FR of 0.5% should be used when counseling patients undergoing RLRP. To avoid futile general anesthesia, a policy should be enforced to ensure that the da Vinci system is completely set up before the patient enters the operating room.
The Journal of Urology, Apr 1, 2007
The Journal of Urology, Apr 1, 2009
Journal of Robotic Surgery, Feb 27, 2009
The traditional anatomical description of the seminal vesicles is based on autopsy and imaging st... more The traditional anatomical description of the seminal vesicles is based on autopsy and imaging studies. Trans-peritoneal robotic-assisted laproscopic surgery, with its three-dimensional magnified view and miniature articulated working instruments, provides an opportunity to perform accurate dissections of the seminal vesicles even when extremely long and tortuous. We used specimens obtained by robotic-assisted laparoscopic radical prostatectomy (RLRP) for accurate anatomic assessment of the dimensions of the seminal vesicles. Digital photos of 78 specimens from men (mean age 59 ± 6.1 years) who underwent RLRP were analyzed using the Image Pro Plus software. Seminal vesicle dimensions were correlated with patients’ age, weight, height, prostate weight, sexual function profile (SHIM) and symptom severity score of the lower urinary tract symptoms (IPSS). We found that the length of the seminal vesicles is highly variable (range of 8.5–94.6 mm). The average seminal vesicle length was 31 ± 10.3 mm and its average volume 7.1 ± 5.2 ml. The right seminal vesicle was significantly larger than the left in length, width and volume (P < 0.003). The seminal vesicles were found to be highly asymmetric with a mean difference of 17.8% in length and 24.9% in width between the sides. No correlation between seminal vesicle dimensions and any of the parameters tested was found. We concluded that the normal human seminal vesicles are characterized by marked (11-fold) variation in length and are asymmetric in most patients. The right seminal vesicle is significantly larger than the left. Seminal vesicle dimensions cannot be predicted from other morphometric or physiologic parameters.
European Urology, Mar 1, 2007
Objectives. To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight... more Objectives. To assess outcomes of robotic laparoscopic radical prostatectomy (RLRP) in overweight and obese patients, defined as those with a body mass index (BMI) of 25 to 30 kg/m 2 and greater than 30 kg/m 2 , respectively. Methods. This was a nonrandomized study evaluating all of our RLRP patients. Patients were divided into three groups: BMI of 25 kg/m 2 or less (group 1), BMI greater than 25 kg/m 2 and less than 30 kg/m 2 (group 2), and BMI of 30 kg/m 2 or more (group 3). Patients were evaluated prospectively with the validated Rand 36-Item Health Survey (version 2) and with the University of California, Los Angeles Prostate Cancer Index questionnaire. Results. Between February 2003 and November 2004, 150 RLRPs were performed at our center. Average follow-up was 8 months. Groups 1, 2, and 3 had 39, 65, and 46 patients, respectively. Average BMIs for all three groups were statistically different (P Ͻ0.01). When compared with group 1, open conversion rates, hospital stay, positive margin, and complication rates were not statistically different for groups 2 or 3. Operative time (P Ͻ0.004) and estimated blood loss (P Ͻ0.03), however, were statistically greater for group 3 compared with group 1. Transfusion rate was highest in group 2 (P ϭ 0.04 compared with group 1). Prostate weights were also statistically greater in groups 2 (P ϭ 0.003) and 3 (P ϭ 0.02) compared with group 1. Overall, BMI did not increase perioperative and postoperative morbidity. Conclusions. Robotic laparoscopic radical prostatectomy is safe in overweight and obese patients and might be the surgical management of choice in this subset of patients. Further long-term follow-up with more patients is required to verify this initial observation.
Journal of Endourology, Nov 1, 2007
Several staging tools have been developed for open radical prostatectomy (ORP) patients. However,... more Several staging tools have been developed for open radical prostatectomy (ORP) patients. However, the validity of these tools has never been formally tested in patients treated with robot-assisted laparoscopic radical prostatectomy (RALP). We tested the accuracy of an ORP-derived nomogram in predicting the rate of extracapsular extension (ECE) in a large RALP cohort. Serum prostate specific antigen (PSA) and side-specific clinical stage and biopsy Gleason sum information were used in a previously validated nomogram predicting side-specific ECE. The nomogram-derived predictions were compared with the observed rate of ECE, and the accuracy of the predictions was quantified. Each prostate lobe was analyzed independently. As complete data were available for 576 patients, the analyses targeted 1152 prostate lobes. Median age and serum PSA concentration at radical prostatectomy were 60 years and 5.4 ng/mL, respectively. The majority of side-specific clinical stages were T(1c) (993; 86.2%). Most side-specific biopsy Gleason sums were 6 (572; 49.7%). The median side-specific percentages of positive cores and of cancer were, respectively, 20.0% and 5.0%. At final pathologic review, 107 patients (18.6%) had ECE, and side-specific ECE was present in 117 patients (20.3%). The nomogram was 89% accurate in the RALP cohort v 84% in the previously reported ORP validation. The ORP side-specific ECE nomogram is highly accurate in the RALP population, suggesting that predictive and possibly prognostic tools developed in ORP patients may be equally accurate in their RALP counterparts.
The Journal of Urology, Apr 1, 2009
METHODS: A retrospective analysis of patients undergoing either radical or partial nephrectomy fo... more METHODS: A retrospective analysis of patients undergoing either radical or partial nephrectomy for RCC in our institution was performed. Patients' data including 2002 TNM stage, tumor size, nuclear grade, and MVI were obtained from medical charts and pathological reports. RESULTS: A total of 270 patients with RCC (pT1a 96, pT1b 60, pT2 35, pT3a 21, pT3b 29,pT3c 2, pT4 6) were included in this study. The mean age of the patients was 61.2 years (range 24-85) and the median follow-up period was 47 months (range 1-244, mean 64). MVI was observed in 24 (15.4%) of pT1, 12 (34.3%) of pT2, 31(93.5%) of pT3, and 6 (100.0%) of pT4. There was MVI in 21 (75.0%) of 28 patients with distant metastasis at surgery and 58 (26.4%) of 220 patients without metastasis. Eighteen patients (7.5%) of 239 patients who underwent curative resection had tumor recurrence and 11 patients (61.1%) with tumor recurrence had MVI. Among 57 MVI positive patients, 11 (19.3%) had tumor recurrence, while 7 (4.3%) of 163 with MVI negative patients had recurrence. The disease-free survival and cancer-specific survival of MVI positive patients were significantly lower than those of MVI negative patients, respectively (p=0.002 and p<0.001) (Fig.1&2). In COX proportional hazard model, the presence of MVI was an independent predictor for tumor recurrence and cancer death (HR 4.939, p=0.004 and HR 4.425, p=0.012, respectively) (Fig.1&2). CONCLUSIONS: MVI is an independent pathological predictor of tumor recurrence and survival in patients with RCC.
The Journal of Urology, Apr 1, 2007
Journal of Endourology, Feb 1, 2008
During standard, six-port set-up, robotic-assisted laparoscopic radical prostatectomy (RLRP) usin... more During standard, six-port set-up, robotic-assisted laparoscopic radical prostatectomy (RLRP) using a three-arm daVinci system (DVS), two assistants are routinely required. The role of the second assistant is often limited to isometric traction during prostate dissection. Due to muscle fatigue and inability of the operator to see the operative field, frequent repositioning of the second assistant is often required. In an attempt to improve efficiency in such surgical situations, we describe the use of the Endoholder, an adjustable articulating instrument holder, to assist during RLRP. During 100 consecutive cases, the Endoholder provided quick, reproducible retraction to facilitate exposure. No complications occurred with its use. The device reduced the need for a dedicated second assistant to stand bedside. We have achieved significant improvements in the safety and efficiency of retraction of the rectum, bladder, and prostate during RLRP with the Endoholder. For urologists working with a three-armed DVS, use of the Endoholder may help facilitate tissue retraction during dissection.
Journal of Clinical Oncology, Jun 20, 2007