Renal cell carcinoma with tumor thrombus: A review of relevant anatomy and surgical techniques for the general urologist.

Renal cell carcinoma (RCC) is estimated to account for 4.1% of all new cancer diagnoses and 2.4% of all cancer deaths in 2020 according to the National Cancer Institute SEER database. This will likely total 73,000 new cases and 15,000 deaths. RCC is one of the most lethal of the common cancers urologists will encounter with a 5-year relative survival of 75.2%. Renal cell carcinoma is one of a small subset of malignancies that are associated with tumor thrombus formation, which is tumor extension into a blood vessel. An estimated 4% to 10% of patients with RCC will have some degree of tumor thrombus extending into the renal vein or inferior vena cava at the time of diagnosis. Tumor thrombi change the staging of RCC and therefore are an important part of initial patient workup. It is known that such tumors are more aggressive with higher Fuhrman grades, N+ or M+ at time of surgery and have higher probability of recurrence with lower cancer-specific survival. Aggressive surgical intervention with radical nephrectomy and thrombectomy can be performed with survival benefits. Classifying the level of the tumor thrombus becomes vitally important in surgical planning as it will dictate the surgical approach. Level 0 thrombi may be amenable to simple renal vein ligation while level 4 can require thoracotomy and possible open-heart surgery with coordination of many surgical teams. Here we will review the anatomy associated with each level of tumor thrombus and attempt to construct an outline for surgical techniques that may be used. We aim to give a concise overview so that general urologists may use it to understand these potentially complicated cases.

Nonstented Tubularized Incised Plate Distal Hypospadias Repair: A Single Center 5 Years' Experience.

OBJECTIVES: To report our immediate and delayed outcomes of nonstented tubularized incised plate (TIP) distal hypospadias repair. METHODS: We retrospectively reviewed all charts of children who underwent distal hypospadias repair in a single children's hospital from 2013 to 2018. Patients' demographics, hypospadias characteristics, operative technique, and immediate and delayed outcomes were recorded. RESULTS: Of 280 consecutive distal hypospadias repairs that were identified, 74 were excluded due to the use of a repair other than TIP. Eleven stented TIP repairs were excluded as well. Of 195 nonstented repairs, immediate postoperative voiding complications were recorded in 11 (5.6%) and included multiple/split stream in 6 (3%), dysuria and voiding difficulty in 2 (1%), urinary retention in 2 (1%), and gross hematuria that spontaneously resolved in 1 (0.5%). Late follow up was recorded in 142 of 195 (72.8%) repairs. Delayed urethroplasty/glansplasty complications were recorded in 12 (8.5%) and included urethrocutaneous fistula in 10 (7.0%), meatal stenosis in 6 (4.2%) and glans/urethroplasty dehiscence in 2 (1.4%). CONCLUSION: Avoiding postoperative urethral stents in distal hypospadias TIP repair reduces the morbidity associated with the stent and is a feasible option that carries acceptable immediate and delayed complication rates. Avoiding the stent eliminates stent-related bladder spasms, the need for other medications, and the short-term office visit for stent removal, therefore reducing parental anxiety, patient discomfort, and reducing cost.