Early Experience with Robot-assisted Laparoscopic Radical Prostatectomy

We assessed the feasibility of a robot-assisted laparoscopic radical prostatectomy (rLRP) programme through a review of our early experience. Patients and Methods: Seventeen patients underwent rLRP between 1 February 2003 and 31 December 2003 at Singapore General Hospital. All patients had histologically confirmed adenocarcinoma on prostate biopsy and a negative bone scan. The Da Vinci robot was employed. The Montsouris technique was used for our first eight patients, and the Vattikuti Institute Prostatectomy technique was used for all subsequent patients. We studied perioperative parameters and early surgical outcome prospectively. Results: The mean age at diagnosis was 63.9 ± 5.6 years. The median Gleason sum was 6 (range, 5–9), and mean pretreatment prostate-specific antigen level was 10.5 ± 5.4 ng/mL. The mean set-up time was 34 ± 18 minutes, and mean dissection time was 247 ± 43 minutes. Perioperative blood loss averaged 494 ± 330 mL, and three patients required blood transfusion. Normal diet was resumed after 1.7 ± 0.6 days. The mean duration of bladder catheterization was 9.8 ± 6.1 days, and mean hospital stay was 2.7 ± 1.3 days. There was no perioperative mortality or major complications, and no conversion to open radical prostatectomy. From Case 9 onwards, there was significant reduction in operating time (284 vs 215 minutes), blood loss (650 vs 400 mL) and hospital stay (3.8 vs 1.8 days). Conclusions: rLRP is feasible in a practice with a low volume of radical prostatectomies. Significant improvement in perioperative parameters occurs after the first eight cases. This technique confers the benefits of enhanced precision and dexterity for complex laparoscopic work in the pelvic cavity

Prognostic Factors for Upper Tract Transitional Cell Carcinoma: A Retrospective Review of 66 Patients

We assessed the prognostic factors on recurrence and disease-specific survival of patients treated for upper tract transitional cell carcinoma (TCC). METHODS: Data on 66 patients who were treated for upper tract TCC in a single centre over a 13-year period were analysed. Mean follow-up time was 49.2 months. Fifty-five out of 66 (83.3%) underwent nephroureterectomy with excision of a bladder cuff. Four (6.1%) patients had nephrectomy alone while three (4.5%) had renal-sparing surgery. Four patients did not receive surgery due to advanced age and other comorbidities. Age, sex, tumour location, stage and grade were analysed as prognostic factors for disease recurrence and disease-specific survival using log rank univariate analysis. RESULTS: Disease recurrence occurred in 45 (68.2%) patients at a median time of 11.0 months. Recurrences were found in the bladder in 27.3%, the contralateral renal pelvis in 4.5%, local retroperitoneum in 19.7%, distant sites in 13.6%, with simultaneous local and distant metastases occurring in 3.0%. Tumour stage was the only significant prognostic factor for recurrence. Presence of extraurothelial recurrence, stage and grade were significant prognostic factors for disease-specific survival. CONCLUSION: Tumour stage was the most consistent predictor of both disease recurrence and survival. These findings would guide the need for any adjuvant chemoradiotherapy

Renal Cell Carcinoma of 4 cm or Less: An Appraisal of Its Clinical Presentation and Contemporary Surgical Management

Greater availability and utilization of modern radiological imaging modalities have resulted in an increase in the incidental discovery of renal cell carcinoma. Such tumours tend to be smaller than their symptomatic counterparts and may potentially be adequately treated using nephron-sparing surgery. Methods: A retrospective review of all patients who were diagnosed with renal cell carcinoma of 4 cm or less between January 1990 and December 2001 was conducted to review clinical presentation, surgical management and survival. Results: The cohort comprised 102 patients who underwent surgery, of 402 patients diagnosed with renal cell carcinoma over the study period. Sixty-eight patients (67%) had tumours detected incidentally. Thirty patients (29%) were managed with partial nephrectomy and 72 (71%) with radical nephrectomy. The median tumour size was 3.0 cm (range, 1.5-4.0 cm). Overall, median follow-up was 60 months (range, 1-148 months). Overall 5-year survival for patients who underwent partial nephrectomy and radical nephrectomy was 96.6% and 85.8%, respectively. Cancer-specific 5-year survival was 100%. Conclusion: A significant proportion of patients had incidental diagnosis of small renal cell carcinoma. Local control may be achieved with either radical or partial nephrectomy, with excellent survival expected

Laparoscopic Nephrectomy: New Standard of Care?

The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period. Methods: From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery. Results: Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was S$4,943 compared with S$4,479 for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (S$7,500 versus S$7,907). Conclusion: The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures