Fossa Navicularis Strictures Due to 22F Catheters Used in Robotic Radical Prostatectomy

Background and objectivesFossa navicularis strictures following radical prostatectomy are reported infrequently. We recently experienced a series of fossa strictures following robot-assisted laparoscopic radical prostatectomy. Fossa strictures are usually procedure-induced, arising from urethral trauma or infection; catheter size has not been reported as a factor. We describe herein our experience to determine and prevent fossa navicularis stricture development.MethodsFrom June 2002 until February 2005, 248 patients underwent robot-assisted laparoscopic prostatectomy with the da Vinci surgical system at our institution. Fossa strictures were diagnosed based on acute onset of obstructive voiding symptoms, IPSS and flow pattern changes, and bougie calibration. During our series, we switched from an 18F to a 22F catheter to avoid inadvertent stapling of the urethra when dividing the dorsal venous complex. All patients had an 18F catheter placed after the anastomosis for 1 week. Parameters were evaluated using Fisher's exact test and the Student t test for means.ResultsThe 18F catheter group (n=117) developed 1 fossa stricture, whereas the 22F catheter group (n=131) developed 9 fossa strictures (P=0.02). The fossa stricture rate in the 18F group was 0.9% versus 6.9% in the 22F group. The 2 groups had no differences in age, body mass index, cardiovascular disease, International Prostate Symptom Score, urinary bother score, SHIM score, preoperative PSA, operative time, estimated blood loss, cautery use, prostate size, or catheterization time.ConclusionsUsing a larger urethral catheter size during intraoperative dissection appears to increase the risk 8-fold for fossa stricture as compared with the 18F catheter. The pneumoperitoneum and prolonged extreme Trendelenberg position could potentially contribute to local urethral ischemia

Update on Robotic Laparoscopic Radical Prostatectomy

The da Vinci surgical robot has been shown to help shorten the learning curve for laparoscopic radical prostatectomy (LRP) for both laparoscopically skilled and na surgeons[1,2]. This approach has shown equal or superior outcomes to conventional laparoscopic prostatectomy with regard to ease of learning, initial complication rates, conversion to open, blood loss, complications, continence, potency, and margin rates. Although the data are immature to compare oncologic and functional outcomes to open prostatectomy, preliminary data are promising.Herein, we review the technique and outcomes of robotic-assisted laparoscopic radical prostatectomy (RALP)

Hypothermic Cooling Measured by Thermal Magnetic Resonance Imaging; Feasibility and Implications for Virtual Imaging in the Urogenital Pelvis.

OBJECTIVE: To study the combination of thermal magnetic resonance imaging (MRI) and novel hypothermic cooling, via an endorectal cooling balloon (ECB), to assess the effective dispersion and temperature drop in pelvic tissue to potentially reduce inflammatory cascade in surgical applications. METHODS: Three male subjects, before undergoing robot-assisted radical prostatectomy, were cooled via an ECB, rendered MRI compatible for patient safety before ECB hypothermia. MRI studies were performed using a 3T scanner and included T2-weighted anatomic scan for the pelvic structures, followed by a temperature mapping scan. The sequence was performed repeatedly during the cooling experiment, whereas the phase data were collected using an integrated MR-high-intensity focused ultrasound workstation in real time. Pelvic cooling was instituted with a cooling console located outside the MRI magnet room. RESULTS: The feasibility of pelvic cooling measured a temperature drop of the ECB of 20-25 degrees in real time was achieved after an initial time delay of 10-15 seconds for the ECB to cool. The thermal MRI anatomic images of the prostate and neurovascular bundle demonstrate cooling at this interface to be 10-15 degrees, and also that cooling extends into the prostate itself ~5 degrees, and disperses into the pelvic region as well. CONCLUSION: An MRI-compatible ECB coupled with thermal MRI is a feasible method to assess effective hypothermic diffusion and saturation to pelvic structures. By inference, hypothermia-induced rectal cooling could potentially reduce inflammation, scarring, and fistula in radical prostatectomy, as well as other urologic tissue procedures of high-intensity focused ultrasound, external beam radiation therapy, radioactive seed implants, transurethral microwave therapy, and transurethral resection of the prostate

Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study

BackgroundThe presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population.MethodsData were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR).ResultsOf the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP.ConclusionsThere was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy

Salvage robot-assisted radical prostatectomy with pelvic lymph node dissection after cryotherapy failure.

We report the first case of post-cryotherapy salvage radical prostatectomy for local recurrence performed laparoscopically with the da Vinci robot. Total operative time was 210 minutes and blood loss was 50ml. There were no intraoperative or postoperative complications. The hospital stay was 24 hours and the Foley catheter was removed on postoperative day 7. The patient achieved a pad free status 4 weeks postoperatively. Pathology showed extensive disease, pT3bN0, Gleason score of 5+3 and positive margins. The patient continued on complete androgen deprivation therapy and his follow up PSA at 10 months was <0.1. Further studies are needed to evaluate both functional and oncological results with this approach