- Email: [email protected]
Re: Robotic Simple Prostatectomy
LETTERS TO THE EDITOR from the Memorial Sloan-Kettering Cancer Center,2 to indicate that the possible reason for this finding could be increased risk of chronic renal insufficiency. Accepting the methodology, statistics and conclusions drawn by the authors, we would like to go back to the fundamental question of how human subjects of different age groups respond to the reduction in renal mass physiologically, irrespective of the reason for reduction. It is obvious from the current report, as well as other publications, that the median age of patients undergoing surgery for kidney tumors is greater than 55 years.1,2 There is convincing evidence that there is a 20% reduction in the renal mass between the ages of 40 and 80 years. There is an overall decrease in renal blood flow, besides other parameters, and the renal function is preserved at the expense of a complete reduction of renal functional reserve. Renal functional reserve is used to compensate for the increased number of sclerotic glomeruli. The vascular changes after maximal vasodilating stimuli have been demonstrated to be advanced.3 Against the backdrop of the available human and animal studies it would be reasonable to hypothesize that on both sides of the imaginary magical figure of age 65 years (the conclusion of this study) the physiological changes should be similar. However, there is no plausible explanation as to why only subjects younger than 65 die early. There should be no argument regarding the age-old mission of urologists to conserve as much of the nephronal mass as possible, striking a balance with the ideal treatment of cancer. Respectfully, Mahendra Bhandari and Siddharth Siva Vattikuti Urology Institute Henry Ford Hospital System Detroit, Michigan 1.
Huang WC, Levey AS, Serio AM, Snyder M, Vickers AJ, Raj GV et al: Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006; 7: 735. 2. Lau WK, Blute ML, Weaver AL, Torres VE and Zincke H: Matched comparison of radical nephrectomy vs nephronsparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000; 75: 1236. 3. Esposito C, Plati A, Mazzullo T, Fasoli G, De Mauri A, Grosjean F et al: Renal function and functional reserve in healthy elderly individuals. J Nephrol 2007; 20: 617.
Reply by Authors. We appreciate the interest of Bhandari and Siva, and agree that nephron sparing is paramount for patients with small renal masses, regardless of age. These small tumors are often benign, indolent or low grade, and removing the entire kidney unnecessarily invites the risk of chronic kidney disease. The fact that we only observed a statistically significant difference in patients younger than 65 years is likely reflective of our relatively early followup (median 7 years) for an end point such as overall survival. We anticipate that with additional followup and increased number of events a significant difference in overall survival will similarly be observed in patients older than 65 years. In fact, the group from the University of California, Los Angeles recently used the Surveillance, Epidemiology and End Results cancer registry (including patients older than 65
1569
years), and reported that among patients treated between 2000 and 2002 those who underwent radical nephrectomy were at significant risk for death from any cause compared to partial nephrectomy, despite the lack of a significant difference in cancer specific survival.1 The group from Memorial Sloan-Kettering also used the Surveillance, Epidemiology and End Results cancer registry, and reported that among patients with pT1a renal masses treated between 1995 and 2002 those who underwent radical nephrectomy were at significant risk for death from any cause compared to partial nephrectomy, even after controlling for age, sex, race, marital status, general comorbidity and preexisting cardiovascular disease, in a multivariate analysis.2 Collectively, these observations strongly support a nephron sparing approach for small renal masses, since removing the entire kidney, regardless of age, may compromise quality and quantity of life. 1.
2.
Miller DC, Schonlau M, Litwin MS, Lai J, Saigal CS and Urologic Diseases in America Project: Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer 2008; 112: 511. Huang WC, Elkin EB, Jang TL and Russo P: Radical nephrectomy is associated with increased mortality in patients with small renal tumors. J Urol, suppl., 2007; 177: 164, abstract 493.
Re: Robotic Simple Prostatectomy R. Sotelo, R. Clavijo, O. Carmona, A. Garcia, E. Banda, M. Miranda and R. Fagin J Urol 2008; 179: 513–515. To the Editor. We read this article with interest. The authors discuss the feasibility of da Vinci® Surgical System simple prostatectomy. The technique has some drawbacks. First, the method is transperitoneal, contrary to the open retroperitoneal technique. Also, it requires 3 to 5 hours for the procedure, compared to 60 to 90 minutes for open surgery. In addition, it uses many ports and other consumables, including da Vinci time. Finally, it involves extended postoperative catheterization (7.5 days) and drainage (3.5 days) at higher cost and little advantage. The da Vinci surgical technique for radical prostatectomy became accepted because of better visualization, less blood loss, a more secure urethrovesical anastomosis, faster postoperative recovery, better continence rates and ease of surgery. However, simple prostatectomy does not involve many of these issues. Although the procedure is neat and feasible, can we recommend it for routine use? Transurethral resection of the prostate (TURP) has stood the test of time. However, its limitation to prostate adenomas larger than 60 gm (more than 100 gm in expert hands) led to the search for other minimally invasive procedures. Increasing use of medical management (alpha-blockers and finasteride) allows the prostate adenoma to grow beyond the limits of TURP by the time surgical intervention becomes necessary. Holmium laser enucleation of the prostate (HoLEP) has shown consistent acceptable results,1– 4 and size is not a limitation. This approach is a cost-efficient and effective procedure with a mean operative time of 60 to 180 minutes,
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LETTERS TO THE EDITOR
mean tissue retrieval of 1 to 1.5 gm per minute, mean catheterization time of 0.6 to 1.3 days, mean hospital stay of 1.1 to 1.2 days and mean blood loss of 0.9 to 2.1 gm/dl.1 The literature supports that large or extremely large glands can be successfully treated using HoLEP, although it requires expertise.3,5 Routine use of normal saline for HoLEP avoids the risk of the transurethral resection syndrome, results in a blood transfusion rate of less than 1% and its safety profile for patients using anticoagulant therapy can be useful for sicker patients.1 Also, recatheterization rates of 2.4% to 3.6%, low reoperation rates compared to TURP and prostate specific antigen decrease of greater than 90% from preoperative values all favor HoLEP.1,3,4 Although HoLEP may be the procedure of choice, a difficult learning curve remains its current limitation and open/robotic surgery will remain as a reserve procedure for anything too complicated. Respectfully, Mahesh C. Goel Department of Surgery Indiana University School of Medicine Indianapolis, Indiana e-mail: [email protected] Reply by Authors. In response to the comments of Goel there are existing data showing similar complications for transperitoneal and extraperitoneal techniques to gain access to the prostate robotically for radical prostatectomy. Therefore, the fact that we perform this procedure transperitoneally is not a disadvantage. However, it is feasible to perform this procedure extraperitoneally. Additionally, in 2 of the cases we also performed concomitant inguinal hernia repair, eliminating the need for what otherwise would have been a combined open procedure. The total procedure time for our series represents our early learning curve. Currently, the procedure takes less than 2 hours, and our operative times continue to decrease. With increasing experience we expect our operative times to equal those of open surgery, just as they have with robotic and open radical prostatectomy. The ports used are reusable metal da Vinci ports and a single reusable non-da Vinci port. The cost of the single use for the reposable da Vinci instruments is $1,000 (a fee that is similar to that of a single use holmium laser fiber). In addition, time using the da Vinci system is not a consumable in and of itself. Finally, at this point in our learning curve our drain time has decreased to 24 hours and our catheterization time is decreasing as well, paralleling the experience of robotic radical prostatectomy. The advantages of da Vinci radical prostatectomy listed by the group from Indiana were certainly not uniformly seen in the early experience of this procedure.5 Similarly, with robotic simple prostatectomy we are already seeing how increasing experience has decreased operative time, catheterization time and drain time while improving our ability to perform a precise and complete enucleation and reconstruction with minimal trauma to the urethra and minimal irritative symptoms. Additionally, we believe there is little basis to make the statement that “HoLEP may be the procedure of choice . . . and open/robotic surgery will remain as a reserve procedure for anything too complicated.” One cannot make this statement without a
prospective randomized study to compare both techniques, evaluating proportion of tissue extracted in relation to transrectal estimated volume, urethral stricture rate, reoperations, total costs and learning curve necessary to achieve the theoretically 1 to 1.5 gm per minute with each procedure. Although further experience from our group as well as others is necessary to compare robotic simple prostatectomy to other minimally invasive techniques for treating massive prostatomegaly, at our institution robotic simple prostatectomy is safe and effective, and laser enucleation is unavailable. 1.
Seki N and Naito S: Holmium laser for benign prostatic hyperplasia. Curr Opin Urol 2008; 18F: 41. 2. Gilling P: Holmium laser enucleation of the prostate (HoLEP). BJU Int 2008; 101: 131. 3. Matlaga BR, Miller NL and Lingeman JE: Holmium laser treatment of benign prostatic hyperplasia: an update. Curr Opin Urol 2007; 17: 27. 4. Kuntz RM, Lehrich K and Ahyai SA: Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 2008; 53: 160. 5. Goel MC, Handa SE and Lingeman JE: Holmium laser enucleation of the prostate for very large prostates. J Urol, suppl., 2008; 179: 675, abstract 1966.
Re: The Incidence of Fluoroquinolone Resistant Infections After Prostate Biopsy—Are Fluoroquinolones Still Effective Prophylaxis? J. Feliciano, E. Teper, M. Ferrandino, R. J. Macchia, W. Blank, I. Grunberger and I. Colon J Urol 2008; 179: 952–955. To the Editor. We fully agree with the message brought out by Feliciano et al on the increased incidence of infective complications due to fluoroquinolone resistant organisms. In their review they concluded that fluoroquinolone resistant pathogens were the most likely cause of post-transrectal ultrasound guided prostatic biopsy (TRUSBP) infections, and a list of antibiotics were proposed to be used for these patients. We actually have carried out a similar clinical audit of the infective complications of TRUSBP.1 However, we applied our findings in a different manner, which led to a significant reduction in infective complications. Therefore, we would like to share our experience on this issue. Observing the widespread usage of fluoroquinolones in our community and also the occurrence of several cases of severe urosepsis after TRUSBP, we conducted a clinical audit of the infective complications of TRUSBP in July 2001. A retrospective review of the infective complication of TRUSBP at our institution from January 1998 to June 2001 was performed. At that time our antimicrobial prophylactic regimen was a 3-day course of 250 mg ciprofloxacin twice daily, starting 1 day before the procedure. During this period 467 TRUSBPs were performed. Infective complications developed in 33 patients (7.07%) after TRUSBP. Two of these
Huang WC, Levey AS, Serio AM, Snyder M, Vickers AJ, Raj GV et al: Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 2006; 7: 735. 2. Lau WK, Blute ML, Weaver AL, Torres VE and Zincke H: Matched comparison of radical nephrectomy vs nephronsparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 2000; 75: 1236. 3. Esposito C, Plati A, Mazzullo T, Fasoli G, De Mauri A, Grosjean F et al: Renal function and functional reserve in healthy elderly individuals. J Nephrol 2007; 20: 617.
Reply by Authors. We appreciate the interest of Bhandari and Siva, and agree that nephron sparing is paramount for patients with small renal masses, regardless of age. These small tumors are often benign, indolent or low grade, and removing the entire kidney unnecessarily invites the risk of chronic kidney disease. The fact that we only observed a statistically significant difference in patients younger than 65 years is likely reflective of our relatively early followup (median 7 years) for an end point such as overall survival. We anticipate that with additional followup and increased number of events a significant difference in overall survival will similarly be observed in patients older than 65 years. In fact, the group from the University of California, Los Angeles recently used the Surveillance, Epidemiology and End Results cancer registry (including patients older than 65
1569
years), and reported that among patients treated between 2000 and 2002 those who underwent radical nephrectomy were at significant risk for death from any cause compared to partial nephrectomy, despite the lack of a significant difference in cancer specific survival.1 The group from Memorial Sloan-Kettering also used the Surveillance, Epidemiology and End Results cancer registry, and reported that among patients with pT1a renal masses treated between 1995 and 2002 those who underwent radical nephrectomy were at significant risk for death from any cause compared to partial nephrectomy, even after controlling for age, sex, race, marital status, general comorbidity and preexisting cardiovascular disease, in a multivariate analysis.2 Collectively, these observations strongly support a nephron sparing approach for small renal masses, since removing the entire kidney, regardless of age, may compromise quality and quantity of life. 1.
2.
Miller DC, Schonlau M, Litwin MS, Lai J, Saigal CS and Urologic Diseases in America Project: Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer 2008; 112: 511. Huang WC, Elkin EB, Jang TL and Russo P: Radical nephrectomy is associated with increased mortality in patients with small renal tumors. J Urol, suppl., 2007; 177: 164, abstract 493.
Re: Robotic Simple Prostatectomy R. Sotelo, R. Clavijo, O. Carmona, A. Garcia, E. Banda, M. Miranda and R. Fagin J Urol 2008; 179: 513–515. To the Editor. We read this article with interest. The authors discuss the feasibility of da Vinci® Surgical System simple prostatectomy. The technique has some drawbacks. First, the method is transperitoneal, contrary to the open retroperitoneal technique. Also, it requires 3 to 5 hours for the procedure, compared to 60 to 90 minutes for open surgery. In addition, it uses many ports and other consumables, including da Vinci time. Finally, it involves extended postoperative catheterization (7.5 days) and drainage (3.5 days) at higher cost and little advantage. The da Vinci surgical technique for radical prostatectomy became accepted because of better visualization, less blood loss, a more secure urethrovesical anastomosis, faster postoperative recovery, better continence rates and ease of surgery. However, simple prostatectomy does not involve many of these issues. Although the procedure is neat and feasible, can we recommend it for routine use? Transurethral resection of the prostate (TURP) has stood the test of time. However, its limitation to prostate adenomas larger than 60 gm (more than 100 gm in expert hands) led to the search for other minimally invasive procedures. Increasing use of medical management (alpha-blockers and finasteride) allows the prostate adenoma to grow beyond the limits of TURP by the time surgical intervention becomes necessary. Holmium laser enucleation of the prostate (HoLEP) has shown consistent acceptable results,1– 4 and size is not a limitation. This approach is a cost-efficient and effective procedure with a mean operative time of 60 to 180 minutes,
1570
LETTERS TO THE EDITOR
mean tissue retrieval of 1 to 1.5 gm per minute, mean catheterization time of 0.6 to 1.3 days, mean hospital stay of 1.1 to 1.2 days and mean blood loss of 0.9 to 2.1 gm/dl.1 The literature supports that large or extremely large glands can be successfully treated using HoLEP, although it requires expertise.3,5 Routine use of normal saline for HoLEP avoids the risk of the transurethral resection syndrome, results in a blood transfusion rate of less than 1% and its safety profile for patients using anticoagulant therapy can be useful for sicker patients.1 Also, recatheterization rates of 2.4% to 3.6%, low reoperation rates compared to TURP and prostate specific antigen decrease of greater than 90% from preoperative values all favor HoLEP.1,3,4 Although HoLEP may be the procedure of choice, a difficult learning curve remains its current limitation and open/robotic surgery will remain as a reserve procedure for anything too complicated. Respectfully, Mahesh C. Goel Department of Surgery Indiana University School of Medicine Indianapolis, Indiana e-mail: [email protected] Reply by Authors. In response to the comments of Goel there are existing data showing similar complications for transperitoneal and extraperitoneal techniques to gain access to the prostate robotically for radical prostatectomy. Therefore, the fact that we perform this procedure transperitoneally is not a disadvantage. However, it is feasible to perform this procedure extraperitoneally. Additionally, in 2 of the cases we also performed concomitant inguinal hernia repair, eliminating the need for what otherwise would have been a combined open procedure. The total procedure time for our series represents our early learning curve. Currently, the procedure takes less than 2 hours, and our operative times continue to decrease. With increasing experience we expect our operative times to equal those of open surgery, just as they have with robotic and open radical prostatectomy. The ports used are reusable metal da Vinci ports and a single reusable non-da Vinci port. The cost of the single use for the reposable da Vinci instruments is $1,000 (a fee that is similar to that of a single use holmium laser fiber). In addition, time using the da Vinci system is not a consumable in and of itself. Finally, at this point in our learning curve our drain time has decreased to 24 hours and our catheterization time is decreasing as well, paralleling the experience of robotic radical prostatectomy. The advantages of da Vinci radical prostatectomy listed by the group from Indiana were certainly not uniformly seen in the early experience of this procedure.5 Similarly, with robotic simple prostatectomy we are already seeing how increasing experience has decreased operative time, catheterization time and drain time while improving our ability to perform a precise and complete enucleation and reconstruction with minimal trauma to the urethra and minimal irritative symptoms. Additionally, we believe there is little basis to make the statement that “HoLEP may be the procedure of choice . . . and open/robotic surgery will remain as a reserve procedure for anything too complicated.” One cannot make this statement without a
prospective randomized study to compare both techniques, evaluating proportion of tissue extracted in relation to transrectal estimated volume, urethral stricture rate, reoperations, total costs and learning curve necessary to achieve the theoretically 1 to 1.5 gm per minute with each procedure. Although further experience from our group as well as others is necessary to compare robotic simple prostatectomy to other minimally invasive techniques for treating massive prostatomegaly, at our institution robotic simple prostatectomy is safe and effective, and laser enucleation is unavailable. 1.
Seki N and Naito S: Holmium laser for benign prostatic hyperplasia. Curr Opin Urol 2008; 18F: 41. 2. Gilling P: Holmium laser enucleation of the prostate (HoLEP). BJU Int 2008; 101: 131. 3. Matlaga BR, Miller NL and Lingeman JE: Holmium laser treatment of benign prostatic hyperplasia: an update. Curr Opin Urol 2007; 17: 27. 4. Kuntz RM, Lehrich K and Ahyai SA: Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol 2008; 53: 160. 5. Goel MC, Handa SE and Lingeman JE: Holmium laser enucleation of the prostate for very large prostates. J Urol, suppl., 2008; 179: 675, abstract 1966.
Re: The Incidence of Fluoroquinolone Resistant Infections After Prostate Biopsy—Are Fluoroquinolones Still Effective Prophylaxis? J. Feliciano, E. Teper, M. Ferrandino, R. J. Macchia, W. Blank, I. Grunberger and I. Colon J Urol 2008; 179: 952–955. To the Editor. We fully agree with the message brought out by Feliciano et al on the increased incidence of infective complications due to fluoroquinolone resistant organisms. In their review they concluded that fluoroquinolone resistant pathogens were the most likely cause of post-transrectal ultrasound guided prostatic biopsy (TRUSBP) infections, and a list of antibiotics were proposed to be used for these patients. We actually have carried out a similar clinical audit of the infective complications of TRUSBP.1 However, we applied our findings in a different manner, which led to a significant reduction in infective complications. Therefore, we would like to share our experience on this issue. Observing the widespread usage of fluoroquinolones in our community and also the occurrence of several cases of severe urosepsis after TRUSBP, we conducted a clinical audit of the infective complications of TRUSBP in July 2001. A retrospective review of the infective complication of TRUSBP at our institution from January 1998 to June 2001 was performed. At that time our antimicrobial prophylactic regimen was a 3-day course of 250 mg ciprofloxacin twice daily, starting 1 day before the procedure. During this period 467 TRUSBPs were performed. Infective complications developed in 33 patients (7.07%) after TRUSBP. Two of these