Role of lymph node dissection at the time of open or minimally invasive nephroureterectomy.

Unlike urothelial carcinoma of the bladder, there is no guideline-based consensus on whether a lymph node dissection (LND) should be performed at the time of radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC). Variable lymphatic drainage based on primary tumor location, lack of prospective trials, and difficulties in developing a risk-adapted approach to LND for UTUC are all challenges to the development of an established approach. The UTUC literature consists of an evidence pool that has historically been limited to single-institution series with heterogenous inclusion criteria for LND and variable LND templates. Areas of controversy exist regarding migration to the great vessel LN beds for mid and distal tumors. A lack of template standardization limits the interpretation of studies relative to one another and a lack of uniformity in reporting templates may lead to inaccuracies in the estimation of lymph node metastasis landing sites. Most clinicians agree that there is a staging benefit to LND for UTUC. Although the data is somewhat heterogenous, it demonstrates a prognostic and staging benefit to LND in higher stages of UTUC. Unlike the staging benefits provided by LND for UTUC, the therapeutic benefits are not as clearly established. Several studies have evaluated differences in cancer-specific survival (CSS) and demonstrated LND to be an independent predictor of CSS when compared to patients not undergoing LND. However, this finding is not consistent across all studies and the literature is again limited by inclusion heterogeneity and inconsistent or lack or template-based resections. LND for UTUC at the time of RNU is a safe and feasible procedure that seems to especially benefit patients with muscle-invasive or locally advanced disease. Prospective, randomized studies with strict inclusion criteria and defined anatomic templates are needed to definitely characterize the role of LND for UTUC.

The current role of cytoreductive nephrectomy for metastatic renal cell carcinoma.

The management of metastatic renal cell carcinoma (mRCC) continues to be a therapeutic challenge; however, the options for systemic therapy in this setting have exploded over the past 20 years. From the advent of toxic cytokine therapy to the subsequent discovery of targeted therapy (TT) and immune checkpoint inhibitors, the landscape of viable treatment options continues to progress. With the arrival of cytokine therapy, two randomized trials demonstrated a survival benefit for upfront cytoreductive nephrectomy (CN) plus interferon therapy and this approach became the standard for surgical candidates. However, it was difficult to establish the role and the timing of CN with the subsequent advent of TT, just a few years later. More recently, two randomized phase III studies completed in the TT era questioned the use of CN and brought to light the role of risk stratification while selecting patients for CN. Careful identification of the mRCC patients who are likely to have a rapid progression of the disease is essential, as these patients need prompt systemic therapy. With the continued advancement of systemic therapy using the immune checkpoint inhibitors as a first line therapy, the role of CN will continue to evolve.

Origin of Subsequent Malignant Neoplasms in Patients with History of Testicular Germ Cell Tumor.

Although genetic changes may be pivotal in the origin of cancer, cellular context is paramount. This is particularly relevant in a progenitor germ cell tumor and its differentiated mature teratoma counterpart when it concerns tumor heterogeneity and cancer dormancy in subsequent second malignancies (subsequent malignant neoplasms (SMNs)). From our tumor registry database, we identified 655 testicular germ cell tumor (TGCT) patients who developed SMNs between January 1990 and September 2018. Of the 113 solid organ SMNs, 42 had sufficient tumor tissue available for fluorescence in situ hybridization (FISH) analysis of isochromosome 12p [i(12p)]. We identified seven additional patients for targeted DNA and RNA sequencing of teratomas and adjacent somatic transformation. Finally, we established cell lines from freshly resected post-chemotherapy teratomas and evaluated the cells for stemness expression by flow cytometry and by the formation of teratomas in a xenograft model. In our cohort, SMNs comprising non-germ cell tumors occurred about 18 years after a diagnosis of TGCT. Of the 42 SMNs examined, 5 (12%) contained i(12p) and 16 (38%) had 12p gain. When comparing a teratoma and adjacent somatic transformation, targeted DNA and RNA sequencing demonstrated high concordance. Studies of post-chemotherapy teratoma-derived cell lines revealed cancer-initiating cells expressing multipotency as well as early differentiation markers. For the first time, we demonstrated the prevalence of i(12p) in SMNs and the presence of progenitor cells embedded within mature teratomas after chemotherapy. Our findings suggest a progenitor stem-like cell of origin in SMN and TGCT and highlight the importance of cellular context in this disease.

Intraoperative and early postoperative complications in postchemotherapy retroperitoneal lymphadenectomy among patients with germ cell tumors using validated grading classifications.

BACKGROUND: Postchemotherapy retroperitoneal lymphadenectomy (PC-RPLND) is an essential, yet potentially morbid, therapy for the management of patients with advanced germ cell tumors. In the current study, the authors sought to define the complication profile of PC-RPLND using validated grading systems for intraoperative adverse events (iAEs) and early postoperative complications. METHODS: Between 2000 and 2018, all patients who underwent PC-RPLND were analyzed for iAEs and early postoperative complications using the Kaafarani and Clavien-Dindo classifications, respectively. Logistic regression models were conducted to assess patient and tumor factors associated with iAEs and postoperative complications. RESULTS: Of the 453 patients identified, 115 patients (25%) and 252 patients (56%), respectively, experienced an iAE and postoperative complication. Major iAEs (grade ≥3) were observed in 15 patients (3%) and major postoperative complications (grade ≥3) were noted in 80 patients (18%). The most common iAE was vascular injury (112 of 132 events; 85%), which occurred in 92 patients (20%), and the most frequent postoperative complication was ileus, which occurred in 121 patients (27%). Original and postchemotherapy retroperitoneal mass size, nonretroperitoneal metastases, intermediate and/or poor International Germ Cell Cancer Collaborative Group classification, previous RPLND, elevated tumor markers at the time of RPLND, and anticipated adjuvant surgical procedures increased the risk of both iAEs and postoperative complications. Patients who experienced an iAE were significantly more likely to experience a postoperative complication (odds ratio, 2.50; 95% confidence interval, 1.58-3.97 [P < .001]). CONCLUSIONS: In what to the authors' knowledge is the first analysis of PC-RPLND using validated classifications for both iAEs and postoperative complications, advanced disease and surgical complexity significantly increased the risks of major iAEs and postoperative complications. Standardized reporting of adverse perioperative events allows providers and patients to appreciate the consequences of PC-RPLND during counseling and decision making.

Semi-rigid ureteroscope as a dilator in renal stone ureteroscopic treatment.

INTRODUCTION: To determine the efficacy and safety of using the semi-rigid ureteroscope as the only ureteral dilator for primary ureteroscopy (URS) in the treatment of renal stones. MATERIALS AND METHODS: A retrospective review of primary URS for renal stone disease was performed on consecutive patients treated by a single provider from 2013 to 2017. Utilizing wire placement under fluoroscopic guidance and direct visual ureteroscopic dilation with a semi-rigid ureteroscope, primary outcome was successful completion of stone treatment. In addition, perioperative safety was evaluated. RESULTS: A total of 126 consecutive cases of primary URS using the semi-rigid ureteroscope as the only ureteral dilator were attempted for renal stone treatment. The renal stones were treated in 124 (98.4%) patients without other forms of active ureteral dilation. Two (1.6%) patients required ureteral stent placement for passive dilation despite attempted other dilating techniques. No intraoperative ureteral perforations were identified. Postoperative radiographic follow up was available for 67% patients with a 91% stone free rate and no hydronephrosis or ureteral strictures were detected. CONCLUSION: Utilizing direct visual semi-rigid ureteroscopic dilation with a semi-ridged ureteroscope prior to flexible ureteroscopy leads to successful primary ureteroscopy for renal stone treatment in most patients. This technique is an effective, safe and possibly cost-effective method of obtaining ureteral access to facilitate primary URS for renal stone treatment.

Optimizing patient selection for cytoreductive nephrectomy based on outcomes in the contemporary era of systemic therapy.

BACKGROUND: The management of metastatic renal cell carcinoma (mRCC) has evolved rapidly, and results from the Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques (CARMENA) trial bring into question the utility of cytoreductive nephrectomy (CN). The objective of this study was to examine overall survival (OS) and identify risk factors associated with patients less likely to benefit from CN in the targeted therapy era. METHODS: Patients with mRCC undergoing CN from 2005 to 2017 were identified. Kaplan-Meier methods and Cox proportional hazards regression analyses were used to assess OS and risk-stratify patients, respectively, on the basis of preoperative clinical and laboratory data. RESULTS: Six hundred eight patients were eligible with a median follow-up of 29.4 months. Ninety-five percent of the patients had an Eastern Cooperative Oncology Group performance status less than or equal to 1, and 70% had a single site of metastatic disease. In a multivariable analysis, risk factors significantly associated with decreased OS included systemic symptoms at diagnosis, retroperitoneal and supradiaphragmatic lymphadenopathy, bone metastasis, clinical T4 disease, a hemoglobin level less than the lower limit of normal (LLN), a serum albumin level less than the LLN, a serum lactate dehydrogenase level greater than the upper limit of normal, and a neutrophil/lymphocyte ratio greater than or equal to 4. Patients were stratified into 3 risk groups: low (fewer than 2 risk factors), intermediate (2-3 risk factors), and high (more than 3 risk factors). These groups had median OS of 58.9 months (95% confidence interval [CI], 44.3-66.6 months), 30.6 months (95% CI, 27.0-35.0 months), and 19.2 months (95% CI, 13.9-22.6 months), respectively (P < .0001). The median time to postoperative systemic therapy was 45 days (interquartile range, 30-90 days). CONCLUSIONS: Patients with more than 3 risk factors did not seem to benefit from CN. Importantly, OS in this group was equivalent to, if not higher than, OS for patients in the CN plus sunitinib arm of CARMENA, and this raises the possibility that a well-selected population might benefit from CN.

Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas.

PURPOSE: We evaluate the impact of pelvic radiation and ablative therapy on the surgical repair of rectourethral fistula. MATERIALS AND METHODS: A total of 45 patients with rectourethral fistulas were identified from a prospective database. From 1998 to 2010 a total of 49 surgical reconstructive procedures were performed. Fistula formation was secondary to radiation (brachytherapy, external beam radiation) and ablative therapy (cryotherapy or high intensity focused ultrasound) in 29 patients. The approach for surgical repair and clinical outcomes were analyzed to identify the impact of radiation and ablative therapy on successful fistula repair. RESULTS: Median patient age was 68 years and mean followup was 42 months (IQR 7, 71). A primary repair was more frequently attempted (15 of 16 [94%] vs 6 of 29 [21%], p <0.0001) and successful in nonradiation/ablation cases (13 of 15 [87%] vs 1 of 6 [17%], p = 0.003). Patients with prior radiation/ablation were significantly more likely to require permanent colostomy (25 of 29 [86%] vs 0%, p <0.0001) and permanent urinary diversion as part of fistula management (27 of 29 [93%] vs 1 of 16 [6%], p <0.0001). Of the 6 patients with radiation/ablation induced fistula who underwent primary repair, 4 subsequently required urinary diversion for fistula recurrence, 1 is symptomatic with recurrence and 1 (who presented with a 0.5 cm fistula) has had no evidence of fistula recurrence. CONCLUSIONS: Unlike the repair of a rectourethral fistula after surgical intervention, which is typically amenable to primary repair, most patients with severe radiation and ablation induced fistula will require urinary diversion with or without permanent colostomy. Thus, permanent urinary diversion should be considered early in the surgical management of these cases.

Interaction of adjuvant androgen deprivation therapy with patient comorbidity status on overall survival after radical prostatectomy for high-risk prostate cancer.

BACKGROUND: To evaluate the impact of adjuvant hormonal therapy after radical prostatectomy on overall survival in high-risk prostate cancer patients, stratified by comorbidity status. METHODS: We identified 1247 patients who underwent radical prostatectomy from 1988 to 2004 for high-risk prostate cancer, as defined by National Comprehensive Cancer Network classification. Comorbidity status was stratified by Charlson Comorbidity Index as 0, 1 or >2, as well as by the presence or absence of cardiovascular disease. Overall survival was estimated by the Kaplan-Meier method, and compared within each comorbidity category/adjuvant hormonal therapy strata with the log-rank test. RESULTS: Median patient age was 65 years, and the median postoperative follow up was 11.2 years. In total, 419 patients (34%) received adjuvant hormonal therapy. The distribution of Charlson Comorbidity Index was 0, 1 and ≥ 2 in 861 (69%), 244 (20%) and 142 (11%) patients, respectively. The 10-year overall survival for patients who received adjuvant hormonal therapy versus those who did not was 75% versus 82% (P=0.54) for patients with Charlson Comorbidity Index=0, 72% versus 76% (P=0.83) with Charlson Comorbidity Index=1, and 70% versus 68% (P=0.33) with Charlson Comorbidity Index ≥ 2. Meanwhile, 155 (12%) patients had cardiovascular disease, and the 10-year overall survival for patients with cardiovascular disease who received adjuvant hormonal therapy was 72%, compared with 76% without adjuvant hormonal therapy (P=0.97). On multivariate analysis, receipt of adjuvant hormonal therapy was not associated with non-prostate cancer mortality (P=0.24). CONCLUSIONS: Adjuvant hormonal therapy after radical prostatectomy for high-risk prostate cancer does not increase non-prostate cancer mortality, even among patients with multiple comorbidities. Additional studies are warranted to determine optimal multimodal treatment approach for high-risk patients.

Standard and saturation transrectal prostate biopsy techniques are equally accurate among prostate cancer active surveillance candidates.

OBJECTIVES: To examine the ability of standard and saturation transrectal prostate biopsy techniques to predict appropriate candidates for active surveillance. METHODS: Between 2005 and 2007, 500 consecutive patients underwent transrectal ultrasound-guided biopsy by a standard template (12 cores) or saturation template (≥18 cores, median 27 cores), with subsequent radical prostatectomy. Using the criteria of Gleason score ≤6, clinical stage T1 or T2a, prostate-specific antigen <10 and ≤33% of cores involved, 218 patients were potential candidates for active surveillance. Pathology results from the prostatectomy specimens were used to determine the accuracy of each biopsy technique. Biochemical failure after prostatectomy was evaluated using logistic and Cox proportional hazards regression. RESULTS: A standard biopsy was carried out for 124 patients and saturation biopsy for 94 patients. There was no statistically significant difference between the groups in terms of median age (P = 0.14), preoperative prostate-specific antigen (P = 0.52) and clinical stage (P = 0.23). Similar rates of Gleason score ≥7 at the time of radical prostatectomy were found, with 14% for standard biopsy and 15% for saturation biopsy (P = 0.70). Upstaging was shown in two standard biopsy patients (1.6%) and no saturation biopsy patients (P = 0.62). A multivariate analysis adjusting for prior prostate biopsy, preoperative prostate-specific antigen and clinical stage showed no difference in the rate of upgrading based on biopsy technique (P = 0.26). During follow up, 5-year biochemical failure-free survival estimates were not significantly different (P = 0.11). CONCLUSIONS: In men with prostate cancer, standard and saturation transrectal prostate biopsies techniques are equally predictive of candidates for active surveillance.

20-Year survival after radical prostatectomy as initial treatment for cT3 prostate cancer.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Despite a lack of randomised controlled trials, most men with locally advanced prostate cancer are recommended to undergo external beam radiotherapy (EBRT), often combined with long-term androgen-deprivation therapy (ADT). Many of these men are not offered radical prostatectomy (RP) by their treating urologist. Additionally, it is know that EBRT with long-term ADT does provide good cancer control (88% at 10 years). We have previously published intermediate-term follow-up of a large series of men treatment with RP for cT3 prostate cancer. We report long-term follow-up of a large series of men treated with RP as primary treatment for cT3 prostate cancer. Our study shows that with long-term follow-up RP provides excellent oncological outcomes even at 20 years. While most men do require a multimodal treatment approach, many men can be managed successfully with RP alone. OBJECTIVE: • To present long-term survival outcomes after radical prostatectomy (RP) for patients with cT3 prostate cancer, as the optimal treatment for patients with clinical T3 prostate cancer is debated. PATIENTS AND METHODS: • We identified 843 men who underwent RP for cT3 tumours between 1987 and 1997. • Survival was estimated using the Kaplan-Meier method. • Cox proportional hazards regression models were used to evaluate the association of clinicopathological features with outcome RESULTS: • The median (range) postoperative follow-up was 14.3 (0.1-23.5) years. • Down-staging to pT2 disease occurred in 26% (223/843) at surgery. • Local recurrence-free, systemic progression-free and cancer-specific survival for men with cT3 prostate cancer after RP was 76%, 72%, and 81%, respectively, at 20 years. • On multivariate analysis, increasing RP Gleason score (hazard ratio [HR] 1.8; P = 0.01), non-diploid chromatin content (HR 1.8; P = 0.01), positive surgical margins (HR 2.1; P = 0.007), and seminal vesicle invasion (HR 2.1; P = 0.005) were associated with a significant risk of prostate cancer death, while a more recent year of surgery was associated with a decreased risk of cancer-specific mortality (HR 0.88; P = 0.01) CONCLUSIONS: • RP affords accurate pathological staging and may be associated with durable cancer control for cT3 prostate cancer, with 20 years of follow-up presented here. • RP as part of a multimodal treatment strategy therefore remains a viable treatment option for patients with cT3 tumours.

Metastatic potential of a renal mass according to original tumour size at presentation.

OBJECTIVE: To determine the metastatic potential of renal masses based on original tumour size. MATERIALS AND METHODS: We identified 2651 patients who had undergone surgical resection for a unilateral, sporadic renal tumour between 1990 and 2006. Associations of tumour size with synchronous metastasis at presentation [M1 renal cell carcinoma (RCC)] and development of metastases, death from RCC, and death from any cause after surgery were evaluated using logistic and Cox proportional hazards regression. RESULTS: Of the 2651 patients studied, 182 (6.9%) presented with M1 RCC. Tumour size was significantly greater in patients with M1 RCC than in patients with M0 RCC (a median size of 10 vs 4.5 cm; P < 0.001). Only 1 of the 629 patients (0.2%) with a tumour <3 cm had M1 RCC and that tumour was 2.5 cm. The risk of M1 RCC increased from 1.1% for patients with tumours 3-3.9 cm to 16.5% for patients with tumours ≥7 cm. Of the 2124 patients with M0 RCC, 430 developed distant metastases at a median (range) of 1.4 (0.1-16.2) years after surgery. Only 9 of the 498 patients (1.8%) with a tumour <3 cm developed distant metastases after surgery. Each 1-cm increase in tumour size increased the risk of death from RCC by 20%[hazard ratio (HR) 1.20; 95% confidence interval (CI) 1.18-1.22; P < 0.001] and death from any cause by 10% (HR 1.10; 95% CI 1.09-1.12; P < 0.001). For the 1346 patients who were still alive at last follow-up, the median (range) duration of follow-up was 6.9 (0.1-19.7) years. CONCLUSIONS: Tumour size is significantly associated with metastases in patients with renal masses. Patients with tumours <3 cm have a low risk of synchronous metastatic disease.

Open radical retropubic prostatectomy using high anterior release of the levator fascia and constant haptic feedback in bilateral neurovascular bundle preservation plus early postoperative phosphodiesterase type 5 inhibition: a contemporary series.

BACKGROUND: Patients with newly diagnosed localized prostate cancer who choose surgery want cure and decent quality of life, namely, pad-free urinary control and, often, erectile function satisfactory for sexual intercourse. OBJECTIVE: Determine in a prospective study the positive surgical margin rate and functional outcomes for a consecutive series of patients undergoing open radical retropubic prostatectomy (ORRP) with bilateral neurovascular bundle preservation (BNVBP) performed by one experienced surgeon. DESIGN, SETTING, AND PARTICIPANTS: Of 197 consecutive patients undergoing BNVBP during 2008, 123 were evaluable, allowing both immediate postoperative phosphodiesterase type 5 inhibition (PDE5i) and a third-party questionnaire with validated urinary and erectile function domains provided preoperatively and at 3, 6, and 12 mo postoperatively. INTERVENTION: Two interventions were used: (1) ORRP with ×4.3 optical loupes and constant digital tactile monitoring during BNVBP preceded by high anterior release (HAR) of levator fascia and neurovascular bundles and (2) early postoperative PDE5i. MEASUREMENTS: Age; biopsy Gleason score; clinical stage; preoperative prostate-specific antigen level; pathologic grade; stage; margin status; University of California, Los Angeles Prostate Cancer Index domain for urinary pad use and bother; and International Index of Erectile Function-5 (IIEF-5) were used. RESULTS AND LIMITATIONS: Surgical margins were positive in 1 of the 123 evaluable patients (1%). At 1 yr, 95% of patients were pad-free. Satisfactory erectile function was achieved by 109 patients (89%): 82 (67%) scored an IIEF-5 of 22-25, and 27 (22%) scored <22-25 with ≥4 on either satisfaction or confidence questions or achieved "full" erection within the first year. Mean hospital stay was 1.3 d. Limitations were (1) observational, noncomparative, single-surgeon series and (2) in third-party methodology, failure to capture patient answers for all questionnaire intervals with resultant inability to address durability of functional results for all patients. CONCLUSIONS: ORRP using ×4.3 optical loupe magnification, constant haptic feedback in BNVBP with HAR, and immediate postoperative PDE5i yielded satisfactory outcomes.

Does body mass index "dilute" the predictive property of prostate-specific antigen for tumor volume at radical prostatectomy?

OBJECTIVE: To evaluate the effect of the body mass index (BMI) as it relates to the predictive value of the preoperative prostate-specific antigen (PSA) level regarding the tumor volume at radical prostatectomy. Stage migration with the widespread use of PSA screening is well documented; however, the association between the PSA level and tumor volume is less defined. Additionally, the effect of obesity on the serum PSA level might cause relative hemodilution and account for the decreased predictive ability of the PSA level to determine the tumor volume in the modern era. METHODS: We identified 14 293 patients who had undergone radical prostatectomy for prostate cancer from 1987 to 2007 and had a documented BMI. Using the clinicopathologic variables, we examined the relationship among the BMI, preoperative PSA level, and tumor volume at radical prostatectomy using multiple linear regression analysis. RESULTS: An elevated BMI was associated with an increased pathologic Gleason score (P < .0001), increased tumor volume (P < .0001), and increased prostate size (P < .0001). The preoperative PSA level correlated significantly with the tumor volume (P < .0001). No significant correlation was found between the BMI and preoperative PSA level (P = .39). On multivariate analysis, controlling for the BMI, the preoperative PSA level remained a significant predictor of the tumor volume (P < .0001). The interaction between the preoperative PSA level and BMI in the prediction of the tumor volume was not statistically significant (P = .56), suggesting that the BMI does not affect the association between the PSA level and tumor volume. CONCLUSION: Our results have shown that the predictive ability of the PSA level for tumor volume is not affected by the BMI. There does not appear to be a need to correct the serum PSA level in relation to the BMI when used in preoperative prediction models of the tumor volume.

Long-term complications of conduit urinary diversion.

PURPOSE: We evaluated long-term surgical complications and clinical outcomes in a large group of patients treated with conduit urinary diversion. MATERIALS AND METHODS: We identified 1,057 patients who underwent radical cystectomy with conduit urinary diversion using ileum or colon at our institution from 1980 to 1998 with complete followup information. Patients were followed for long-term clinical outcomes and analyzed for the incidence of diversion specific complications. RESULTS: A total of 844 patients died at a median of 4.1 years (range 0.1 to 28.1) following cystectomy. Median followup of the surviving 213 patients was 15.5 years (range 0.3 to 29.1). There were 643 (60.8%) patients with 1,453 complications directly attributable to the urinary diversion performed with a mean of 2.3 complications per patient. Bowel complications were the most common, occurring in 215 patients (20.3%), followed by renal complications in 213 (20.2%), infectious complications in 174 (16.5%), stomal complications in 163 (15.4%) and urolithiasis in 162 (15.3%). The least common were metabolic abnormalities, which occurred in 135 patients (12.8%), and structural complications, which occurred in 122 (11.5%). Increasing age at cystectomy (HR 1.21, p <0.001), increasing Eastern Cooperative Oncology Group performance status (HR 1.23, p = 0.02) and recent era of surgery (HR 1.68, p <0.001) were significantly associated with a higher incidence of complications. CONCLUSIONS: Conduit urinary diversion is associated with a high overall complication rate but a low reoperation rate. Long-term followup of these patients is necessary to closely monitor for potential complications from the urinary diversion that can occur decades later.

Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy with a minimum of three years follow-up.

We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36 months' follow-up. Median follow-up was 62 months (range 36-84) and mean age was 67 (43-83) years. Mean operating time was 3.1 (2.15-5) h with a median operating time of 2.9 h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3-4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3 years' follow-up.

Metachronous renal tumours after surgical management of oncocytoma.

OBJECTIVE: • To assess the risk of metachronous renal cell carcinoma (RCC) and benign renal tumours after surgical treatment of primary renal oncocytoma. PATIENTS AND METHODS: • Patients treated for primary renal oncocytoma between 1970 and 2007 were identified. Tumours were reviewed by a urological pathologist and patients were followed for subsequent renal tumours. RESULTS: • Of 424 patients with a median follow up of 7.1 year, 17 (4.0%) patients were diagnosed with a metachronous renal tumour at a median of 3.0 years (range 0.3-16 years). Of the 17 metachronous tumours, eight were oncocytoma, four were RCC and five were not resected or biopsied. • Eleven metachronous tumours occurred after solitary unilateral oncocytoma, five occurred after multifocal unilateral oncocytoma, and one occurred after multifocal bilateral oncocytoma. • Estimated 10-year tumour-free and RCC tumour-free survival was 94.8% and 98.7%, respectively. Patients with primary multifocal oncocytoma were at higher risk of metachronous tumour (hazard ratio 4.0; P = 0.007). Initial oncocytoma size (hazard ratio 1.1; P = 0.11) was not highly associated with risk of tumour recurrence. CONCLUSIONS: • To our knowledge, we report the largest cohort of oncocytoma after surgical management. Metachronous renal neoplasm in a patient with previous oncocytoma is more likely to be benign compared with patients who present with a renal tumour for the first time. Multifocal primary oncocytoma is associated with metachronous renal tumours. • Overall, the risk of metachronous RCC in a patient with an oncocytoma is similar to that of the general population, which does not support the use of routine cross-sectioning imaging surveillance.

Multifactorial, site-specific recurrence model after radical cystectomy for urothelial carcinoma.

BACKGROUND: A scoring algorithm of site-specific disease recurrence after cystectomy for urothelial carcinoma was designed. METHODS: Identified were 1388 patients who underwent radical cystectomy for nonmetastatic urothelial carcinoma between 1980 and 1998. Clinical, surgical, and pathologic features were evaluated for associations with 4 locations of site-specific disease recurrence: upper urinary tract, abdomen/pelvis, thoracic region, and bone. Recurrence-free survival rates were estimated using the Kaplan-Meier method. Cox proportional hazards models were fit to test associations with disease recurrence. RESULTS: A total of 493 (35.5%) patients experienced at least 1 recurrence. There were 67, 388, 143, and 145 patients with recurrences to the upper tract, abdomen/pelvis, thoracic region, and bone at a median of 3.1 years, 1.1 years, 1.3 years, and 1.0 years, respectively. Pathologic T4 stage (hazard ratio [HR], 2.84; P=.006), positive ureteral margins (HR, 5.71; P<.001), and multifocality (HR, 2.07; P=.009) were found to be independent predictors of upper tract recurrence. Pathologic T3 (HR, 2.30; P<.001) and T4 stage (HR, 3.55; P<.001), lymph node invasion (HR, 1.97; P<.001), extent of lymphadenectomy (pNx [HR, 1.66; P=.002] and <10 lymph nodes [HR, 1.52; P<.001]), multifocality (HR, 1.80; P<.001), and prostatic involvement (HR, 1.45; P=.019) were found to be independent predictors of abdominal/pelvic recurrence. Features independently associated with thoracic recurrence included pathologic T3 (HR, 2.61; P<.001) and T4 (HR, 3.39; P<.001), lymph node invasion (HR, 2.64; P<.001), extent of lymphadenectomy (pNx [HR, 1.89; P=.019] and <10 lymph nodes [HR, 1.58; P<.030]), and multifocality (HR, 1.79; P<.001). Pathologic T3 (HR, 3.45; P<.001) and T4 stage (HR, 3.87; P<.001), lymph node invasion (HR, 1.79; P=.006), occupational exposure to radiation (HR, 2.97; P=.003), and a positive urethral margin (HR, 2.28; P=.039) were found to be independent predictors of osseous recurrence. Macroscopic hematuria (HR, 0.52; P=.009) and obesity (HR, 0.59; P=.027) were found to be protective and negatively associated with upper tract and osseous recurrence, respectively. Scoring algorithms to predict the likelihood of disease recurrence to these sites were developed using regression coefficients from the multivariable models. CONCLUSIONS: Scoring algorithms based on independent predictors of site-specific recurrence were presented. These models may be used to tailor postoperative surveillance to the individual patient based upon clinicopathologic features at the time of cystectomy.

Radical prostatectomy for prostate cancer after ileal pouch-anal anastomosis offers oncologic control and sustains quality of life.

BACKGROUND: We evaluated the feasibility and oncologic durability of performing prostate biopsy and open radical retropubic prostatectomy (RRP) in patients who have previously undergone proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA). STUDY DESIGN: We performed a retrospective review of all patients at our institution who underwent an RRP after a PC-IPAA between June 1992 and February 2009. Variables evaluated included demographic characteristics, biopsy technique, tumor pathology, surgical technique, complications, and functional and oncologic outcomes. RESULTS: Sixteen patients were identified. Mean prostate-specific antigen was 9.3 ng/mL (median, 5.9 ng/mL; range, 4.3 to 26.8 ng/mL). Prostatic biopsy was performed without complication by a variety of radiographic techniques. Successful RRP was achieved in all patients without pouch violation or pouch-related postoperative complications. The most common intraoperative finding was pelvic adhesions between the posterior prostate/seminal vesicles and the IPAA. Neurovascular bundle preservation was not altered by pelvic adhesions in any patient in whom this was the goal of the operation. Urinary continence was restored by 3 months in 94% of patients and erectile function returned without the use of medication in 73% who had neurovascular bundle preservation. Overall pouch function was subjectively unchanged postoperatively. Biochemical recurrence occurred in 3 patients and local recurrence in 2 patients. Only 1 recurrence occurred within 5 years of RRP during a mean follow-up of 5.7 years (median, 3.8 years; range, 0.3 to 14.5 years). CONCLUSIONS: Despite altered pelvic anatomy from previous PC-IPAA, prostate biopsy and RRP can be done safely and effectively. Previous PC-IPAA should not be a contraindication to RRP in men with clinically localized prostate cancer.

Percutaneous nephrolithotomy for large or multiple upper tract calculi and autosomal dominant polycystic kidney disease.

PURPOSE: Percutaneous nephrolithotomy is standard therapy for upper tract calculi larger than 2 cm. However, the role of percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease has not been well evaluated. We report our experience with percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients with autosomal dominant polycystic kidney disease and subsequent renal calculi managed by percutaneous nephrolithotomy from October 1981 to the present. RESULTS: We identified 9 patients. Percutaneous nephrolithotomy was performed in 11 kidneys. Flank pain was the presenting symptom in 6 patients. Average stone burden was 2.5 cm (range 1.6 to 3.6). Two access tracts were necessary in 5 kidneys. No intraoperative complications occurred. In 2 kidneys a second stage endoscopic procedure with ultrasonic lithotripsy was required to achieve stone-free status. Nephrostogram 24 hours after the final procedure showed no residual stone fragments in 9 of 11 kidneys (82%). The remaining 2 patients underwent percutaneous basket extraction to render them stone-free. There were no postoperative complications or recurrent stones. No patient required blood transfusion. Mean followup was 2.7 years (range 0.3 to 4). Mean calculated creatinine clearance was stable at 85.6 (range 45.9 to 126.6) and 89.5 mg/dl per minute (range 39.6 to 126.6) preoperatively and at last followup, respectively (p = 0.783). CONCLUSIONS: Autosomal dominant polycystic kidney disease increased operative complexity, the need for multiple percutaneous access tracts and the likelihood of repeat endoscopy. Despite the altered anatomy percutaneous nephrolithotomy was a safe, efficacious approach for autosomal dominant polycystic kidney disease. At last followup there was no stone recurrence and renal function was stable.