Colleen M. Padia

Although their data show otherwise, a group of researchers at the University of Rochester (NY) Medical Center have faith that using a cautery-free approach with Weck clips to preserve the neurovascular bundle during robot-assisted prostatectomy is a better choice than bipolar cautery. 

"With bipolar cautery, we worry about scatter of electricity and heat," said study presenter Seth Capello, MD, a fellow in minimally invasive and laparoscopic surgery at the University of Rochester. "So we've converted from the old bipolar cautery to now using plastic Weck clips." 

However, this particular study did not have the results that the authors were expecting for their presentation at the World Congress of Endourology here. 

The researchers, led by Jean Joseph, MD, MBA, followed 30 consecutive patients who underwent robot-assisted prostatectomy with 4-month follow-up data available. Fifteen patients had their nerve preservation carried out using bipolar cautery (10 with bilateral nerve bundle preservation and five with unilateral bundle preservation). Weck Hem-O-Lock Clips (Teleflex Medical, Bannockburn, IL) were used to preserve the neurovascular bundle in the other 15 patients; 13 of them had bilateral bundle preservation. All of the patients were sexually active and were potent, with a Sexual Health Inventory in Men (SHIM) score of 20. 

 Among the patients in the bipolar cautery group, the mean SHIM score was 12.2, and 10 (66%) were potent. In the group of patients in whom Weck clips were used, the mean SHIM score was 9.1, and five (33.3%) were potent. There was no difference between the groups in terms of blood loss, intraoperative time, and positive margin rate. 

"This was a pilot study to see how the patients we used Weck clips on are doing," Dr. Capello said. "What we saw is that bipolar cautery patients did a little bit better, which is not what we expected. Four months of follow-up is a bit early to draw meaningful conclusions about potency. In addition, there may be a learning curve effect in the placement of the clips. Care must be taken not to include the bundles in the clips." 

Despite the weaker numbers using Weck clips in the early results, the urologists have used them to preserve the neurovascular bundle almost exclusively during robotic prostatectomy. 

"There is some thermal damage that happens with long application of cautery," said Dr. Joseph, who is head of laparoscopy and robotics in the department of urology at the University of Rochester. 

"We're more comfortable knowing that we haven't used any excess electrical energy," Dr. Capello concurred. "Those theoretical benefits outweigh this early data that still needs to mature. I think you'll see that, with more data and longer follow-up, using clips for bundle preservation is a better method." 

He admitted that there are slight disadvantages to the Weck clips, but that they are usually attributed to the learning curve. 

"The clips are slightly larger than the bipolar forceps, so initially it can be difficult to properly place the clips. The assistant must be trained in the proper application of the clips to avoid clipping the bundles," he explained. 

"Adherence to athermal or cautery-free technique is necessary to avoid unintended damage to structures that are vital to the preservation potency," Dr. Joseph said. 

The researchers are continuing to gather data on the patients who have undergone robotic prostatectomy with Weck clips to preserve the nerve bundle, and plan to publish the results. 

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Cleveland-Although their data show otherwise, a group of researchers at the University of Rochester (NY) Medical Center have faith that using a cautery-free approach with Weck clips to preserve the neurovascular bundle during robot-assisted prostatectomy is a better choice than bipolar cautery.

Despite data, cautery-free RAP approach preferred

Preoperative transrectal ultrasound biopsies are not always reliable tools for predicting positive surgical margins and tumor location in nerve-sparing robotic radical prostatectomies. However, this unreliability may be partly due to the biopsy results coming from outside labs and pathologists versus in-house evaluations. 

"We focus a lot on the preoperative biopsy to decide whether or not we're going to do nerve-sparing surgery," Dr. Tewari told attendees at the World Congress of Endourology here. "If we're trying to do nerve sparing, are we doing it intrafascially, extrafascially, or [foregoing] nerve-sparing? I was surprised that 30% of the time when I got a positive margin, it was in an area where there was no cancer in the pre-op biopsy." 

Out of the 150 patients, 10 had positive surgical margins. One case was excluded because of insufficient data. Of the remaining nine cases, three had the positive surgical margin on the same side as the biopsy showed, two had positive surgical margins on the opposite side from what the biopsy had shown, and four had unilateral surgical margins but had bilateral tumor on the biopsy. 

 Dr. Tewari did not mince words about the results of the study. 

"Either we need to do a better job, or we need to find a method for real-time tissue recognition," he said. "That's the only message out of this: that the biopsies don't translate into how close we can come, or we can do a subpartial dissection, which I don't think is a safe approach." 

TRUS biopsy was not accurate enough to be used as a tool for something as precise as optimizing how accurate the surgeon can be regarding nerve-sparing during RAP. 

However, the practice of using biopsies from outside labs and assessments from outside pathologists came under scrutiny during discussion of the study. Using the services of outside labs is often less expensive, but the quality may not be the same as that found within the institution performing the procedure. 

Cleveland-Preoperative transrectal ultrasound biopsies are not always reliable tools for predicting positive surgical margins and tumor location in nerve-sparing robotic radical prostatectomies. However, this unreliability may be partly due to the biopsy results coming from outside labs and pathologists versus in-house evaluations.

TRUS biopsies found not useful for tumor location

In a study from the Feinberg School of Medicine at Northwestern University, Chicago, researchers assessed the levels of anxiety, depression, and strain on marital relationships of couples being evaluated for male factor infertility. 

The results indicated that 56% of the women and 29.8% of the men reported elevated levels of anxiety according to the STAI, and this difference between genders was statistically significant (

=.03). On the CES-D questionnaires, 36.2% of men and 64% of women were above the normal range, consistent with the presence of depression. RDAS scores were 53.1 for men and 53.6 for their female partners-both within the normal range. 

"Despite the elevated levels of depression and anxiety, couples did not report an increased strain on their interpersonal relationships," Dr. Russell said. 

The second study, from Weill Medical College, Cornell University, New York, under the direction of senior author John Mulhall, MD, focused on how the infertility of either partner affected the quality of life of men specifically. Couples seeking treatment for infertility completed the SF-36 Health Survey and the CES-D. Thirty-nine men, with an average age of 37.5 ±7 years, were included in the sample. 

On the Mental Health subscale (MHS) of the SF-36, men in the study reported significantly lower scores compared with those considered normal for the general population (

<.05). Higher SF-36 MHS scores were positively associated with men's age (

<.05) in multivariate analysis. The researchers also observed a trend toward a negative association with being married, but this finding was not statistically significant (

<.10). Based on CES-D results, the data indicated that 23% of the participants had moderate depressive symptoms, and 8% had severe depression. 

Presenter and lead author Michael Ohebshalom, MD, said urologists should work with psychiatrists on treatment for depression in men dealing with infertility. 

"Men could develop a decreased urge for intercourse and, possibly, even erectile dysfunction as effects of the depression," Dr. Ohebshalom explained. 

Atlanta-Two separate studies have found that men and women dealing with infertility suffer from depression and anxiety at a greater rate than the general population.

Author | Colleen M. Padia

Articles

Despite data, cautery-free RAP approach preferred

TRUS biopsies found not useful for tumor location

Infertility takes psychological toll on patients