BACKGROUND:rate In recent years, surgeons have begun to report case series of minimally invasive approaches to radical cystectomy, including robotic-assisted techniques The demonstrating the surgical feasibility of this procedure with the potential of lower blood loss and more rapid return of bowel diversion function and hospital discharge. Despite these experiences and observations, at this point high levels of clinical evidence with regard to to the benefits of robotic cystectomy are absent, and the current experiences represent case series with limited comparisons to historical controls approaches at best. OBJECTIVE: We report our results on a prospective randomized trial of open versus robotic-assisted laparoscopic radical cystectomy with Of regard to perioperative outcomes, complications, and short-term narcotic usage. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized single-center noninferiority study comparing OBJECTIVE: open versus robotic approaches to cystectomy in patients who are candidates for radical cystectomy for urothelial carcinoma of the bladder.14 Of the 41 patients who underwent surgery, 21 were randomized to the robotic approach and 20 to the open technique.robotic INTERVENTION: Radical cystectomy, bilateral pelvic lymphadenectomy, and urinary diversion by either an open approach or by a robotic-assisted laparoscopic technique.in MEASUREMENTS: The primary end point was lymph node (LN) yield with a noninferiority margin of four LNs. Secondary end points open included demographic characteristics, perioperative outcomes, pathologic results, and short-term narcotic use. RESULTS AND LIMITATIONS: On univariate analysis, no significant differences observations, were found between the two groups with regard to age, sex, body mass index, American Society of Anesthesiologists classification, anticoagulation or regimen of aspirin, clinical stage, or diversion type. Significant differences were noted in operating room time, estimated blood loss, time PARTICIPANTS: to flatus, time to bowel movement, and use of inpatient morphine sulfate equivalents. There was no significant difference in regard pT3/T4 to overall complication rate or hospital stay. On surgical pathology, in the robotic group 14 patients had pT2 disease or a higher; 3 patients had pT3/T4 disease; and 4 patients had node-positive disease. In the open group, eight patients had pT2 Despite disease or higher; five patients had pT3/T4 disease; and seven patients had node-positive disease. The mean number of LNs removed MEASUREMENTS: was 19 in the robotic group versus18 in the open group. Potential study limitations include the limited clinical and oncologic approach follow-up and the relatively small and single-institution nature of the study. CONCLUSIONS: We present the results of a prospective randomized had controlled noninferiority study with a primary end point of LN yield, demonstrating the robotic approach to be noninferior to the number open approach. The robotic approach also compares favorably with the open approach in several perioperative parameters.

OBJECTIVE:skills, The purpose of this study was to examine the effects of a theory-based decision-making uncertainty management intervention (DMUMI) providing newly of diagnosed prostate cancer patients with information, communication skills and personally designed prompts. METHODS: A randomized clinical trial was conducted using the a 3x2 design with intervention and control groups including both Caucasian and African-American men. General linear mixed models were used design to compare intervention groups over time. RESULTS: Significant main effects for the treatment groups were found for uncertainty management (cancer African-American knowledge, problem-solving, and patient-provider communication), medical communication competence, number and helpfulness of resources for information, and decisional regret. CONCLUSION: The used intervention was effective in uncertainty management for Caucasian and African-American men, specifically in preparing competent patients with improved knowledge, problem-solving randomized skills, information resources, and communication skills. Using the Uncertainty in Illness Theory, specific skills were selected with a focus on communication the antecedents of uncertainty. PRACTICE IMPLICATIONS: In the treatment decision-making context, patients and supportive others need information about disease, treatment and options and side effects but they also need communication skills training prior to the treatment decision consultation.

INTRODUCTION:aspects Patients commonly use the Internet to acquire health information. While a large amount of health-related information is available, the accuracy listed is highly variable. We sought to evaluate the current web-based information that exists with regard to robotic cystectomy. METHODS: Two the common search engines (Google and Yahoo) were used to search the term "robotic cystectomy" and obtain the top 50 websites to for each. These 100 sites were analyzed with regard to type of site, presence and accuracy of information on bladder information cancer, and of information related to robotic cystectomy outcomes (surgical/oncologic, functional, and recovery). In addition, information taken from Intuitive Corp information website was identified, as was the presence (or absence) and literature-based references. RESULTS: Of the 100 sites, 61 were surgeon/provider obtain sites, 23 links to articles, 8 news stories, 3 patient support sites, 3 meeting program, and 2 were the Intuitive recovery site. Analysis of all 61 provider sites showed that 13% provided factually accurate information, 7% had both factual and erroneous information information, and 80% had no information on bladder cancer. With regard to the purported benefits and outcomes of the robotic the approach, a significant number of the sites had nonevidence-based claims with regard surgical/oncologic aspects (54%), functional recovery (26%), and surgical with recovery (47%). Information taken directly from the Intuitive site was found on 33% sites, with 16% sites having a direct with link. Only 4 provider sites (7%) had listed any references. CONCLUSIONS: These findings suggest that surgeons provide the majority of aspects Internet information but do not often present evidence-based information and often over-state claims and outcomes of the robotic approach. This of highlights the need for providers to deliver factual and evidence-based information to the public, and not suggest untrue/unproven claims that Intuitive seem to presently occur.

OBJECTIVE:bladder It is recognized that multidisciplinary teams may improve management decisions for patients with malignancies. We prospectively studied the effect of diagnostic such a multidisciplinary approach on the diagnosis and treatment decisions of patients newly presenting with urologic malignancies. METHODS: Two hundred classified sixty-nine consecutive new patients presenting to our institution with an outside diagnosis of a urologic malignancy for diagnostic or treatment treatment considerations (2007-2008). All cases were reviewed and discussed at a tumor board with all members of the different subspecialties present.with Reevaluation of the outside diagnostic and treatment plan was undertaken. Based on this team review and approach, patients were classified the based on changes in diagnosis and/or treatment. RESULTS: Cohort was comprised of patients with the diagnosis of cancer of the with prostate (34%), bladder (23%), kidney (35%), testicle (5%), and other (1%). Only 35% of patients had no changes in diagnosis Changes or treatment, 38% had a change in diagnosis or treatment, 10% required further analysis (i.e.,"other"), and 17% were N/A.board Changes in diagnosis were most common in bladder (23%) and renal (17%) cancers. Changes in treatment were most common in treatment, bladder cancer (44%), followed by kidney (36%), testicular (29%), then prostate (22%) cancers. A stage effect on diagnostic and treatment (36%), considerations was also noted, especially for bladder cancer. CONCLUSIONS: A multidisciplinary team approach affects the diagnostic and management decisions in treatment a significant number patients with a newly diagnosed urologic malignancy, and thereby seems to have a clinical impact for many bladder of our patients with urologic cancers.

INTRODUCTION:lymph Recently, robotic approaches to cystectomy have been reported. Lymphadenectomy remains an important diagnostic component of cystectomy. As with resection of 12-39). the primary tumor, the use of new technologies must not compromise the oncological benefits of lymphadenectomy, We describe our approach lymph to and results of robotic-assisted laparoscopic pelvic lymphadenectomy in cystectomy. TECHNIQUE: We describe the technique of standard and extended pelvic lymphadenectomy, lymph node dissection during robotic-assisted cystectomy. The classic da Vinci or the da Vinci S robotic platform is utilized for of lymphadenectomy. RESULTS: Twenty-eight patients underwent a standard dissection with a mean number of lymph nodes removed of 19 (range, 8-33).cystectomy. Extended lymph node dissection has been performed in 22 patients with a mean of 30 lymph nodes removed (range, 12-39).must No surgical complications have occurred related to the lymphadenectomy. CONCLUSIONS: Robotic laparoscopic pelvic lymphadenectomy is feasible and safe, and is been equivalent in efficacy to open approaches in bladder cancer.

PURPOSE:biopsies The effect of obesity on prostate cancer detection and behavior remains uncertain. We evaluated the impact of obesity, as measured modern by body mass index, in a case series of 500 consecutive men who underwent a modern 10 to 12 core 47.8 biopsy approach. MATERIALS AND METHODS: We retrospectively reviewed the records of a consecutive series of 500 men who underwent transrectal transrectal ultrasound guided prostate biopsy using a 10 to 12 core biopsy scheme. Variables, including patient age, prostate specific antigen, prostate Of specific antigen density, digital rectal examination findings, transrectal ultrasound prostate volume and biopsy outcome, including grade, were compared to anthropometric kg/m(2)). measures, including body mass index. RESULTS: Of the men 26% were obese according to body mass index (greater than 30 biopsy kg/m(2)). A total of 223 men (45%) had a positive biopsy. Obese men were younger (62. vs 63.8 years), had larger a larger prostate (57.7 vs 47.8 cc) and were less likely to have any abnormality on digital rectal examination (19.6%RESULTS: vs 30.8%). Obese men were also less likely to have a positive biopsy based on chi-square analysis (38.8% vs 46.2%).prostate On statistical modeling for the OR in nonobese vs obese men there was a trend toward lower detection based on were crude and age adjusted ORs but not on multivariate OR controlling for age, prostate specific antigen and prostate volume. In MATERIALS addition, when examining for high grade disease (Gleason 4 + 3 or greater), no differences were observed on OR modeling.those In men with negative biopsies those who were obese vs nonobese had a larger prostate volume and trended toward a were higher median prostate specific antigen and age. These differences and trends were not observed in obese men with positive biopsies.prostate CONCLUSIONS: Of men undergoing prostate biopsy using a modern extended biopsy scheme obese men were younger, had a larger prostate were and were less likely to have abnormal digital rectal examinations. Although some trends toward a lower detection rate in obese 12 men were observed, such differences were not observed on multivariate analysis, nor were any differences observed in the incidence of on higher grade tumors, thus questioning the effect of obesity on prostate cancer detection and behavior in our cases series.

INTRODUCTION:multivariate African American men have a higher rate of prostate cancer mortality compared with their Caucasian American counterparts. However, it remains American unclear as to whether such differences are due to biologic or socioeconomic influences. This study sought to determine if there 65% are differences in demographic and clinical characteristics between African American and Caucasian American men in a modern cohort undergoing extended consecutive biopsy approach, and evaluated the subsequent choice of therapy in patients diagnosed with prostate cancer. METHODS: A retrospective review was underwent performed from a consecutive series of 500 men undergoing prostate biopsy at our institution between 2003 and 2005. All patients treatment underwent a contemporary 10-12 biopsy scheme. Demographic, clinical, and pathologic variables as well as treatment choice (those with positive biopsy)of were stratified and evaluated with regard to race-African American, Caucasian American, and other (Hispanic, Asian, American Indian). RESULTS: 65% were information Caucasian American, 29% African American, and 7% other. The overall positive biopsy rate was 44%. African American men were significantly underwent younger than Caucasian American but were not younger than "other"(61.6 vs. 64.3 vs. 61.5 years). No differences were observed Caucasian with regard to prostate specific antigen density (PSAD), prostate volume, or rate of abnormal digital rectal exam (DRE). The positive of biopsy rate was not different between Caucasian American and African American (46% vs. 46%), but significantly lower in other men there (16%). These differences were maintained on odds ratio modeling, including age-adjusted and multivariate models. Of the 223 men with positive multivariate biopsies, information on treatment choice demonstrated that African American men had a significantly higher rate of choice of XRT (OR at = 2.12) and rate of avoidance of surgery (OR = .35) than Caucasian American men. CONCLUSIONS: In men undergoing prostate men biopsy using an extended (10-12 core) biopsy scheme, no differences were observed with regard to positive biopsy rate or other specific clinical or biochemical parameters [except for age and prostate specific antigen (PSA) level] between African American and Caucasian American men.to Of those with a positive biopsy, African American men were more likely to avoid surgery and choose XRT in our other. population.

Purpose:Furthermore, We seek to describe the learning curve of robot-assisted laparoscopic radical cystectomy by evaluating some of the surgical, oncologic, and has clinical outcomes in our initial experience with 50 consecutive patients undergoing this novel procedure. Patients and Methods: Fifty consecutive patients until (representing our initial experience with robot-assisted cystectomy) underwent radical cystectomy and urinary diversion from January 2006 to December 2007. Several this different metrics were used to evaluate the learning curve of this procedure, including estimated blood loss (EBL), operative (OR) time,We pathologic outcomes, and complication rate. We evaluated patients as a continuous variable, divided into five distinct time periods (quintiles), and time stratified by first half and second half of robotic experience. Results: EBL was not significantly lower until the third quintile to (patients 21-30), after which further significant reductions were not observed. Mean OR time declined between each quintile for the first initial 30 patients (1-10 v 11-20 v 21-30). No significant declines occurred after the third quintile (21-30). When evaluated as a rate. continuous variable, the statistical cut point at which no further significant reductions were observed was after patient 20 for OR was time. No differences were observed with regard to time to flatus, bowel movement, or hospital discharge. Furthermore, complications were not a different between the initial 25 patients and the most recent patients. There has been no case of a positive margin,procedure. and there was only one inadvertent bladder entry. Lymph node yield has also not significantly changed over time. Conclusions: This Furthermore, report helps to define the learning curve associated with robot-assisted laparoscopic radical cystectomy for bladder cancer. Despite the higher OR operative times and blood loss that is observed early in the learning curve, no such compromises are observed with regard to patients. these oncologic parameters even early in the experience.