Utilization of sperm cryopreservation in patients with testicular cancer.

PURPOSE: We assessed factors that affect the utilization of sperm cryopreservation before 2021, when patients covered expenses, and the influence on quality of life. METHODS: Between 2011 and 2021, testicular cancer survivors (TCS) at our clinic completed a questionnaire, including EORTC QLQ-TC26, covering sperm cryopreservation, sociodemographic details, post-treatment births, and artificial insemination. RESULTS: After 5.7 ± 3.0 years, 279 participants (64%) responded to the questionnaire. Among them, 33% (91/279) of testicular cancer survivors chose sperm cryopreservation prior to treatment, with 11% (10/91) using it for insemination. Conversely, 2% (3/188) without cryopreservation reported unfulfilled desire to have children. Univariate analysis showed TCS with cryopreservation were younger (30.6 ± 7.1 (35 (21-59)) vs. 42.4 ± 10.9 (48 (22-81)) years; p = 0.001), had a lower BMI (24.2 ± 3.3 vs. 26.6 ± 4.6 kg/m2; p = 0.009) and a lower Charlson Score (> 3: 36% vs. 60%; p < 0.001). Multivariate analysis revealed older age (≥ 37 years: OR 13.1 (5.5-31.2), p < 0.001) and lower education (middle school or less: OR 3.3 (1.6-6.9), p = 0.001) as independent factors associated with not undergoing cryopreservation. Regarding quality of life, multivariate analysis identified a lower infertility anxiety score (OR 4.3 (2.0-9.0), p < 0.001) and higher age (≥ 44 years: OR 5.4 (2.6-11.3); p < 0.001) as predictors for the absence of prior cryopreservation. CONCLUSIONS: Age and education seem to impact the choice of undergoing paid sperm cryopreservation. Urologists should inform testicular cancer patients about costs and coverage. Importantly, the occurrence of unmet desires for parenthood is minimal among those who forego cryopreservation.

Retroperitoneal lymph node dissection for testicular cancer is a demanding procedure: detailed real-life data of complications and additional surgical procedures in 295 cases.

PURPOSE: Retroperitoneal lymph node dissection (RPLND) for germ cell tumours is a challenging procedure that may present relevant complications. The purpose was to analyse postoperative complications and identify risk factors for major complications. METHODS: This is a retrospective unicentric analysis of a large cohort of 295 RPLNDs from 1992 to 2020. Early complications (30 days) and late complications (31-180 days) were classified according to the Clavien‒Dindo classification. The influence of surgical, patient-specific, and tumour-specific parameters on grade III-V complications was analysed in univariate and multivariate logistic regression models. RESULTS: A total of 232 were postchemotherapy RPLNDs, and 63 were primary RPLNDs. Early postoperative complications were found to be grades I-II in 58.6% (173/295), grades III-IV in 9.8% (29/295), and grade V in 0.3% (1/295). In 20% (58/295), additional surgical procedures were needed. Grade III-V complications were associated with ≥ 4 cycles of preoperative chemotherapy (OR 3.7 (1.5-8.9); p = 0.004), RPLND specimen (nonseminoma or immature teratoma) (OR 3.1 (1.4-6.6); p = 0.005), transfusions (OR 2.4 (1.1-5.4); p = 0.03), salvage RPLND (OR 4.1 (1.8-9.3); p < 0.001), and preoperatively elevated AFP (OR 5 (2.2-11.7); p < 0.001). In multivariate analysis, the only independent predictor for grade III-V complications was preoperative AFP elevation (OR 3.3 (1.2-9.2); p = 0.02). Limitations include the retrospective study design. CONCLUSIONS: Our results demonstrate that RPLND is a demanding surgical procedure. Patients with a complex tumour history have a higher risk of complications. We recommend treatment of these complex cases in high-volume centres.

PHEOCHROMOCYTOMA CONCEALED BY CHRONIC METHAMPHETAMINE ABUSE.

OBJECTIVE: Both clinical suspicion and diagnosis of pheochromocytoma (PCC) can be challenging in patients where the presentation can be confused with the pharmacophysiological effects of illicit drugs known to activate the sympathetic nervous system. We report on such a patient and outline considerations that can impact diagnostic decision making. METHODS: Clinical examination, measurement of plasma metanephrines, followed by magnetic resonance imaging, iodine 123-metaiodobenzylguanidine single-photon emission computed tomography, and histopathology of the resected tumor. RESULTS: A 35-year-old male patient was referred to our center because of a right-sided adrenal mass, incidentally found during an abdominal ultrasound performed due to nausea, vomiting, and lumbar pain. Although he had no history of hypertension, he had complained for over 6 years of severe episodic headache, panic attacks, and profuse sweating. He also had a longer history of methamphetamine abuse. Plasma concentrations of metanephrine (10.7 pmol/L) and normetanephrine (3.83 pmol/L) were 25-fold and 5.6-fold above respective upper limits of reference intervals (0.42 and 0.69 pmol/L). This indicated a PCC, which was confirmed after adrenalectomy. Failure to recognize the patient's signs and symptoms as attributable to a PCC was unsurprising given that methamphetamine abuse can result in many of the same signs and symptoms as a catecholamine-producing tumor. CONCLUSION: The abuse of drugs such as methamphetamine can obscure an underlying PCC due to the similarity of several symptoms associated with both conditions. Recognition of a PCC in patients using illicit drugs such as methamphetamine remains challenging.

Surgical resection of locally recurrent renal cell carcinoma after nephrectomy: Oncological outcome and predictors of survival.

OBJECTIVE: To describe the course of disease of patients surgically treated for locally recurrent renal cell carcinoma (LRRCC) after nephrectomy and to identify potential predictive factors for long-term survival. PATIENTS AND METHODS: We, retrospectively, identified 54 patients who underwent surgical resection of LRRCC after open nephrectomy for localized kidney cancer. The median age at time of surgery for LRRCC was 65 years. Survival rates were determined with the Kaplan-Meier method. Mantel-Haenszel hazard ratios were calculated. Comparisons were made with the log-rank test. Cox proportional hazard models were used to analyze combined effects of variables. RESULTS: Median time to local recurrence after nephrectomy was 36 months (5-242 months). Median follow-up after surgery for LRRCC was 39 months. At time of analysis 18 patients (33%) were alive without any evidence of disease, 8 patients (15%) were alive with disease, 20 patients (37%) died of renal cell carcinoma, and 8 patients (15%) died of other causes. A 5-year overall survival (OS) was 60% (95% CI: 0.44-0.73) and 10-year OS was 32% (95% CI: 0.15-0.51). The median survival after surgery for LRRCC was 79 months. In univariate analysis OS differed significantly by the time period between primary surgery and occurrence of LRRCC (<2 years vs. ≥2 years: 10-year OS rate 31% (95% CI: 10.2-55.0) vs. 45% (95% CI: 21.5-65.8; hazard ratio = 0.26; P = 0.0034). In multivariate analysis sarcomatoid features in the primary nephrectomy specimen, positive surgical margins of the LRRCC specimen and a Charlson score of ≥2 were associated with a significantly worse prognosis in this cohort. CONCLUSION: In patients with a disease-free interval of more than 2 years after surgery for the primary tumor, surgical removal of LRRCC may achieve long-term survival in most patients. In those with a shorter disease-free interval, long-term survival is unlikely.

Age, American Society of Anesthesiologists physical status classification and Charlson score are independent predictors of 90-day mortality after radical cystectomy.

PURPOSE: Radical cystectomy (RC) is a major surgical procedure accompanied with meaningful complications and countable perioperative mortality. To identify the risk factors predicting the perioperative morbidity and mortality is essential. The study aimed to identify relevant, patient-specific factors associated with 90-day mortality following RC, which may serve as a foundation for improving healthcare delivery to patients with bladder cancer. METHODS: We investigated a sample of 1015 consecutive patients in order to identify predictors of 90-day mortality after RC. Beside tumor-related parameters, ASA classification, NYHA, Canadian Cardiovascular Society classification of angina pectoris, Charlson score, age, gender and the single conditions contributing to the Charlson score were included in the multivariable analyses. The patient data were collected retrospectively, except the ASA score that was obtained prospectively. RESULTS: We identified a model containing the parameters age (OR 1.05, p = 0.023), ASA classification of 3-4 (OR 6.19, p < 0.001) and Charlson score (OR 1.22, p = 0.003) to predict 90-day mortality. Among the single conditions to the Charlson score, moderate or severe renal disease (OR 3.94, p < 0.001) and liver disease (OR 3.24, p = 0.037) were most closely related to 90-day mortality. CONCLUSIONS: Age, ASA classification and Charlson score as well as moderate or severe renal disease and liver disease appear to be independent predictors of 90-day mortality after RC. Given the highly significant association of ASA score with 90-day mortality and the relative ease and width disposability of this measure, this classification should be, after external validation, incorporated into daily clinical practice in treatment of patients planned to RC.

Perioperative complications after radical prostatectomy: open versus robot-assisted laparoscopic approach.

BACKGROUND: The best technique of radical prostatectomy - open versus robot-assisted approach - is controversially discussed. In this study, we compared the complication rates of open and robot-assisted radical prostatectomy during the introduction and subsequent routine use of a da Vinci® robotic device while open surgery remained the standard approach. PATIENTS AND METHODS: Between January 1st, 2006, and June 4th, 2012, 2,754 men underwent radical prostatectomy at our department. Among them, 317 received robot-assisted and 2,438 open surgery. According to the requirements for prostate cancer centers certified by the Deutsche Krebsgesellschaft (German Cancer Society), a prospective database recording perioperative complications was built up. The complication rates of open and robot-assisted radical prostatectomy were compared with the χ(2) or Fisher exact test. The distributions of quantitative variables were compared with U tests. RESULTS: Whereas the demographic factors favored patients selected for robot-assisted radical prostatectomy, there were no differences between open and robot-assisted surgery concerning length of stay, autologous blood transfusion rates and the incidence of perioperative complications. CONCLUSIONS: Open and robot-assisted radical prostatectomy had comparable complication rates. With better patient- and tumor-related parameters as well as decreasing transfusion rates in the robot-assisted subgroup, this observation might reflect the learning curves of the involved robotic surgeons.

Systematic assessment of complications and outcome of radical cystectomy undertaken with curative intent in patients with comorbidity and over 75 years of age.

OBJECTIVE: To evaluate the complications, survival and oncological outcome of patients ≥75 years of age after radical cystectomy for muscle-invasive bladder cancer. PATIENTS AND METHODS: Between April 1993 and August 2010, 765 patients with muscle-invasive bladder cancer underwent radical cystectomy at one high-volume center. Of these, 70 patients were ≥75 years of age. All 70 patients had at least one severe systemic comorbidity with an American Society of Anesthesiologists score of 3. Primary endpoints of this retrospective study were overall and recurrence-free survival with a mean follow-up of 22 months (1-159). Perioperative parameters such as need for blood transfusions, hospital stay, mortality, short- and long-term complications were also assessed. Complications were graded according to the Clavien-Dindo classification. RESULTS: Perioperative complications occurred in 23/70 patients (33%) with a 30-day mortality rate of 1.4%. 16/70 patients (23%) developed late complications requiring hospitalization. Within 30 days of surgery, according to the Clavien-Dindo grading, 27% had no complications, 3% grade 1, 49% grade 2, 14% grade 3, 6% grade 4 and 1.4% grade 5 complications. Within 31-90 days after surgery, 76% had grade 1 complications, 3% grade 2, 6% grade 3, 9% grade 4 and 6% grade 4 complications. The calculated 5- and 8-year overall survival rates were 30 and 25%, respectively, with a recurrence-free survival rate of 52% at 5 and 42% at 8 years. CONCLUSIONS: Radical cystectomy is an appropriate and effective treatment for comorbid elderly patients. The oncological long-term outcome is the same as in younger patients while overall survival is comparatively lower. Mortality and complication-related morbidity are comparable to those in younger patients with modern perioperative management.

Urinary tract-related quality of life after radical prostatectomy: open retropubic versus robot-assisted laparoscopic approach.

BACKGROUND: The best technique of radical prostatectomy--open retropubic versus robot-assisted surgery--is a subject of controversy. PATIENTS AND METHODS: Between January 1st, 2007 and December 31st, 2011, 2,177 men underwent radical prostatectomy at our department. 252 (12%) cases were laparoscopic robot-assisted, the remainder open retropubic procedures. In Germany, certified prostate cancer centers are required to collect urinary tract-related outcome data after radical prostatectomy using the International Consultation of Incontinence Questionnaire Male Lower Urinary Tract Symptoms. The questionnaire data were used to compare both surgical approaches concerning the urinary tract-related outcome 1, 2 and 3 years postoperatively. RESULTS: Neither the voiding score nor the incontinence score or the bother scale sum differed between the two cohorts at any of the measurement times. CONCLUSIONS: Concerning continence recovery, in this series, there were no detectable differences between robot-assisted and open radical prostatectomy.

Surgery for renal cell cancer extending into the inferior vena cava - evaluation of survival and perioperative complications using a standardized classification system.

OBJECTIVE: • To present a single-centre experience of surgery for kidney cancer involving vena cava thrombus with surgical technique, complications and outcome using a standardized classification system for perioperative complications. PATIENTS AND METHODS: • Sixty-eight consecutive cases were retrospectively analysed. Thrombus extension was at level I (but inside the vena cava) in 10 cases, level II in 28 cases, level III in 18 cases and level IV in 12 cases; 18 patients had distant metastases. • Radical tumour nephrectomy was performed in all cases. Complete liver mobilization was carried out in 23 cases and cardiovascular bypass with circulatory arrest was performed in five cases. • Follow-up was available for 66 patients. Median follow-up was 29 months (interquartile range 30.75). RESULTS: • The 28-day mortality was 0%. • According to the Clavien-Dindo classification there were two grade 1, 54 grade 2, two grade 3a, two grade 3b and two grade 4a perioperative complications. • The factors pN, grading and metastases at presentation predicted overall survival in univariate analyses. In a multivariate model none of the factors age, metastases at presentation, pN, WHO-grading, American Society of Anesthesiologists score, tumour size and thrombus level significantly predicted survival. • Immediate target therapy with neoadjuvant intention in three patients did not result in surgical therapy. CONCLUSIONS: • Aggressive surgical treatment causes no perioperative mortality and leads to a low rate of grade 3 and grade 4 complications (8.8%). • A median overall survival of 47 months shows that surgical treatment has favourable results in these patients.

Comparison of transperitoneal versus retroperitoneal approach in laparoscopic radical nephrectomy for renal cell carcinoma: a single-center experience of 63 cases.

BACKGROUND: We report our experience with the retroperitoneal (RP) and transperitoneal (TP) approaches for laparoscopic nephrectomy for clinically localized renal cell carcinoma. METHODS: Sixty-three patients with renal cell carcinoma were treated with laparoscopic nephrectomy, 34 by TP and 29 by RP approach between June 1999 and June 2003. Average age, ASA score, tumor stage and tumor size were similar in both groups. Early complications within 30 days and surgical time were retrospectively reviewed. RESULTS: Surgical time was with a mean of 183 and 190 minutes equal for the TP and RP approach. Intraoperative complications occurred in 4 patients and were vascular, requiring blood transfusion in 2 patients each per group. Postoperative complications were thromboembolism in 1 patient and subcutaneous seroma in 1 patient, both in the TP group. CONCLUSIONS: Although the sample size is small, it appears that the tumor control and surgical time in laparoscopic nephrectomy are not significantly influenced by the approach.

Outcome of surgical treatment of isolated local recurrence after radical nephrectomy for renal cell carcinoma.

PURPOSE: Isolated local recurrences after radical nephrectomy for renal cell carcinoma occur in 2% to 3% of cases. Today local recurrences can be detected at an early stage due to modern imaging techniques. It remains controversial whether an aggressive surgical approach to this problem can prolong survival. MATERIALS AND METHODS: We retrospectively analyzed 16 patients who were treated surgically at our institution for suspected isolated local renal cell carcinoma recurrence during the last 10 years. All patients had undergone extensive staging and had no evidence of distant metastases with the local recurrence. Surgical exploration confirmed carcinoma recurrence in 13 of the 16 cases and all 13 patients underwent complete resection of the local recurrence. Three patients were found to have had false-positive computerized tomography findings on surgical exploration. RESULTS: Mean time to recurrence was 45.5 months (range 7 to 224). Only 2 patients were symptomatic, while in 11 disease had been detected at routine followup. Mean size of the recurrent tumor was 5.92 cm. (range 2 to 10). All patients survived surgery without major complications. Of the patients 7 died of metastatic disease after a mean survival of 23.1 months (range 4 to 68) following recurrence removal and 6 are alive with a mean survival of 53.0 months (range 18 to 101) (p = 0.09). Time to recurrence after nephrectomy was significantly longer (p <0.05) and size of recurrence significantly smaller (p <0.04) in the patients still alive. In 1 surviving patient evidence of metastatic disease developed 9 months after surgery for recurrence. CONCLUSIONS: Careful followup after radical nephrectomy for renal cell carcinoma allows the diagnosis of small local recurrences before they become symptomatic in the majority of cases. Although most of these patients will eventually have and die of metastatic disease, an aggressive surgical approach is justified and can result in prolonged survival.