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INTRODUCTION: Prostate cancer still represents a major cause of morbidity, and still about 20% of men with the disease are diagnosed or will progress to the advanced stage without the possibility of curative treatment. Despite the recent advances in scientific and technological knowledge and the availability of new therapies, there is still considerable heterogeneity in the therapeutic approaches for metastatic prostate cancer. OBJECTIVES: This article presents a summary of the I Brazilian Consensus on Advanced Prostate Cancer, conducted by the Brazilian Society of Urology and Brazilian Society of Clinical Oncology. MATERIALS AND METHODS: Experts were selected by the medical societies involved. Forty issues regarding controversial issues in advanced disease were previously elaborated. The panel met for consensus, with a threshold established for 2/3 of the participants. RESULTS AND CONCLUSIONS: The treatment of advanced prostate cancer is complex, due to the existence of a large number of therapies, with different response profiles and toxicities. The panel addressed recommendations on preferred choice of therapies, indicators that would justify their change, and indicated some strategies for better sequencing of treatment in order to maximize the potential for disease control with the available therapeutic arsenal. The lack of consensus on some topics clearly indicates the absence of strong evidence for some decisions.
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Consenso , Guias de Prática Clínica como Assunto , Neoplasias da Próstata/terapia , Brasil , Humanos , Masculino , Próstata/patologia , Neoplasias da Próstata/diagnósticoRESUMO
UNLABELLED: Study Type - Harm (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Radical nephrectomy for patients with metastatic renal cell carcinoma results in greater rates of morbidity than for those with less advanced disease. This study systematically characterizes complications associated with nephrectomy for metastatic RCC and identifies patient and disease characteristics that are associated with a greater risk of developing complications. Overall complications were relatively frequent, but major complications (grade 3 or greater) were rare. Increasing age and worsening performance status were associated with increased probability of complications. When complications were sustained, patients were less likely to receive systemic therapy in a timely fashion. These observations may influence the timing or patient selection for surgery or systemic therapy. OBJECTIVE: ⢠To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC). PATIENTS AND METHODS: ⢠We identified patients with mRCC who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1989 and 2009. ⢠Postoperative complications were characterised using a modified version of the Clavien-Dindo classification system. ⢠Patient and disease characteristics, including a previously validated MSKCC risk-stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models. ⢠The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10-fold cross validation. RESULTS: ⢠Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥ 2 complications within 8 weeks of surgery. ⢠Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting. ⢠In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications. ⢠Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12-0.86; P= 0.024). ⢠A multivariable model containing KPS (OR 14.5; 95%CI 4.34-48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01-1.08; P= 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63-0.80) for postoperative complications. CONCLUSIONS: ⢠Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS. ⢠These complications are important because they may delay or deny receipt of subsequent systemic therapy.
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Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Complicações Pós-Operatórias/etiologia , Idoso , Antineoplásicos/uso terapêutico , Carcinoma de Células Renais/secundário , Feminino , Humanos , Indóis/uso terapêutico , Masculino , Pessoa de Meia-Idade , Pirróis/uso terapêutico , Medição de Risco , Fatores de Risco , SunitinibeRESUMO
PURPOSE: We evaluated our experience with laparoscopic donor nephrectomy in patients with multiple renal arteries, comparing operative outcomes and early graft function with patients with a single renal artery. MATERIALS AND METHODS: From January 2003 to February 2009, 130 patients underwent laparoscopic donor nephrectomy at our institution, 108 (83 %) with a single renal artery and 22 (17 %) with multiple arteries. Donor and recipient outcomes for single artery and multiple arteries allografts were compared. RESULTS: The LDN operative time was similar between the single artery and multiple arteries groups (162 vs 163 min, respectively, p = 0.87). Allografts with multiple arteries had significantly longer warm ischemia time (3.9 vs 4.9 min, p = 0.05) and cold ischemia time (72 vs 94 min, p < 0.001) than those with single artery. The conversion rate was similar between single and multiple arteries groups (6 % vs 4.5 %, respectively, p = 0.7). Multiple arteries grafts had a non statistically significant higher rate of poor graft function when compared to single artery grafts (23 % vs 12 %, respectively, p = 0.18). Five patients in the single artery group (4.6 %) and one patient in the multiple arteries group (4.5 %) needed dialysis during the first postoperative week. Overall, recipient complication rates were similar between single and multiple arteries groups (12.9 % vs 18.1 %, respectively, p = 0.51). CONCLUSION: Laparoscopic donor nephrectomy with multiple arteries was associated with a non statistically significant higher rate of poor early graft function. The procedure appears to be safe in patients with multiple arteries, with similar complications rates. Multiple arteries should not be a contraindication for laparoscopic donor nephrectomy.
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Transplante de Rim/métodos , Laparoscopia/métodos , Doadores Vivos , Nefrectomia/métodos , Artéria Renal/transplante , Adulto , Feminino , Sobrevivência de Enxerto , Humanos , Rim/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Reprodutibilidade dos Testes , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
PURPOSE: To our knowledge the benefit of routine drainage after partial nephrectomy has never been investigated, although a drain after partial nephrectomy can be associated with morbidity. We report our initial experience with omitting the drain in select cases of superficial renal cortical tumors. MATERIALS AND METHODS: From a surgery database we identified 512 consecutive open partial nephrectomies performed by a single surgeon between January 2005 and May 2009 using standardized technique. The study group included 75 evaluable patients (14.6%) who did not have a drain placed. Clinical data, surgical information, histological type and postoperative complications within 90 days of the procedure using the modified Clavien system were included in analysis. RESULTS: Median patient age was 64 years (IQR 49, 70) and 56.8% of the patients were male. Median tumor size was 2.0 cm (IQR 1.5, 3.0) and more than 70% were malignant. A total of 38 patients (50.7%) underwent renal artery clamping and cold ischemia with a median clamp time of 30 minutes. The overall complication rate was 13.3% (10 patients). In 4 patients (5.3%) complications were related to an absent drain, including grade I urinary leak, grade II perirenal collection, grade III urinoma requiring percutaneous drainage and grade III urinary leak with urosepsis, respectively. No deaths occurred in this cohort. CONCLUSIONS: Omitting drainage after partial nephrectomy in a select group of patients without collecting system entry is feasible and safe. The decision to place a drain after partial nephrectomy for small renal cortical tumors must be made intraoperatively and should be tailored to each case.
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Drenagem , Neoplasias Renais/cirurgia , Nefrectomia/métodos , Cuidados Pós-Operatórios , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos ProspectivosRESUMO
PURPOSE: Little information exists on conversion from partial to radical nephrectomy. We assessed the intraoperative reasons and predictive factors for conversion in a contemporary series of patients undergoing partial nephrectomy. MATERIALS AND METHODS: We identified all patients at our institution who underwent open or laparoscopic partial nephrectomy with conversion to radical nephrectomy between 2003 and 2008. Renal function was assessed by the glomerular filtration rate using the modification of diet in renal disease equation. We used logistic regression analysis to determine whether tumor site, tumor size, body mass index, American Society of Anesthesiologists score, age or gender was associated with the conversion risk. RESULTS: The rate of conversion to radical nephrectomy was 6% (61 of 1,029 patients). In the open partial nephrectomy group 59 of 865 cases (7%, 95% CI 5-9) and in the laparoscopic partial nephrectomy group 2 of 164 (1.2%, 95% CI 0.01-4) were converted. The most common reasons for conversion were invasion of hilar structures, size discrepancy and insufficient residual kidney. Patients with conversion were more likely to have larger tumors (per 1 cm increase OR 1.41, 95% CI 1.24-1.59), a central site (central vs peripheral OR 7.74, 95% CI 3.98-15) and a lower preoperative glomerular filtration rate (per 10 ml/minute/1.73 m(2) OR 0.78, 95% CI 0.67-0.91), and present with symptoms (any vs none OR 2.78, 95% CI 1.54-5.04) than those without conversion. The median postoperative glomerular filtration rate was 46 vs 61 ml/minute/1.73 m(2) in patients with vs without conversion. CONCLUSIONS: Conversion to radical nephrectomy was rare in patients undergoing partial nephrectomy in this series. Increasing tumor size, central site, lower preoperative glomerular filtration rate and symptoms at presentation were associated with an increased risk of conversion, which increases the likelihood of chronic kidney disease postoperatively.
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Nefrectomia/métodos , Idoso , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de TempoRESUMO
PURPOSE: We describe the presentation, endovascular management and functional outcomes of 15 patients with renal arterial pseudoaneurysm following open and laparoscopic partial nephrectomy. MATERIALS AND METHODS: An institutional review board approved, Health Insurance Portability and Accountability Act compliant retrospective review of a prospectively maintained database revealed that 7 of 1,160 patients who underwent open partial nephrectomy and 8 of 301 treated with laparoscopic partial nephrectomy were diagnosed with a pseudoaneurysm of a renal artery branch between 2003 and 2010. Some cases were associated with arteriovenous fistula. RESULTS: Diagnosis of pseudoaneurysm was made a median of 14 days after surgery. Gross hematuria was the most frequent symptom. Median estimated glomerular filtration rate measurements at the preoperative evaluation, postoperatively, on the day the vascular lesion was diagnosed, after embolization and at the last followup were 62, 55, 55, 56 and 58 ml/minute/1.73 m(2), respectively. Median followup was 7.8 months. All patients underwent angiography and superselective coil embolization of 1 or more pseudoaneurysms with or without arteriovenous fistula. Eleven patients had immediate cessation of symptoms while 4 had persistent gross hematuria after the procedure. Of these 4 patients 2 were treated with bedside care, 1 required repeat embolization with thrombin, which was successful, and the remaining patient had coagulopathy and underwent radical nephrectomy for persistent bleeding. CONCLUSIONS: Pseudoaneurysms and arteriovenous fistulas of the renal artery are rare complications of partial nephrectomy. Presentation is often delayed. Superselective coil embolization is a safe, minimally invasive treatment option that usually solves the clinical problem and preserves renal function.
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Falso Aneurisma/diagnóstico , Falso Aneurisma/terapia , Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/terapia , Embolização Terapêutica/métodos , Nefrectomia/efeitos adversos , Artéria Renal , Veias Renais , Adulto , Idoso , Idoso de 80 Anos ou mais , Falso Aneurisma/etiologia , Fístula Arteriovenosa/etiologia , Humanos , Laparoscopia , Pessoa de Meia-Idade , Nefrectomia/métodos , Estudos RetrospectivosRESUMO
PURPOSE: We analyzed characteristics in patients with recurrent renal cell carcinoma 5 years or later after nephrectomy and determined predictors of survival after recurrence. MATERIALS AND METHODS: From July 1989 to October 2008 at total of 2,368 nephrectomies were done for clinically localized, unilateral renal cell carcinoma at our institution. Of 256 patients with disease recurrence 44 had recurrence 5 years or more after nephrectomy. We compared clinicopathological characteristics in patients with disease recurrence before vs after 5 years. Survival from time of recurrence was assessed based on Memorial Sloan-Kettering Cancer Center risk score, symptoms at recurrence, metastasectomy, tumor diameter, and recurrence stage and site. RESULTS: Patients with late recurrence tended to have fewer symptoms at presentation, smaller tumors (median 8.5 vs 7 cm) and less aggressive disease (pT1 in 18% vs 39%). Median overall survival was 6.1 years from time of recurrence. Five-year actuarial survival was 85% in 28 patients at favorable risk and 14% in 10 at intermediate risk (log rank p <0.001). The 5-year estimated overall survival rate was 72% in 31 patients with incidentally detected recurrence and 39% in 11 with symptoms at recurrence (log rank p = 0.01). CONCLUSIONS: Data suggest that patients with cancer recurrence 5 years after nephrectomy are at favorable risk and have long-term median survival. A favorable Memorial Sloan-Kettering Cancer Center risk score and absent symptoms related to metastasis are associated with longer survival in these patients.
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Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Nefrectomia/métodos , Fatores Etários , Idoso , Análise de Variância , Institutos de Câncer , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/patologia , Intervalos de Confiança , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica/patologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Nefrectomia/efeitos adversos , Cidade de Nova Iorque , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Estatísticas não Paramétricas , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: We evaluated predictors of progression after starting active surveillance, especially the role of prostate specific antigen and immediate confirmatory prostate biopsy. MATERIALS AND METHODS: A total of 238 men with prostate cancer met active surveillance eligibility criteria and were analyzed for progression with time. Cox proportional hazards regression was used to evaluate predictors of progression. Progression was evaluated using 2 definitions, including no longer meeting 1) full and 2) modified criteria, excluding prostate specific antigen greater than 10 ng/ml as a criterion. RESULTS: Using full criteria 61 patients progressed during followup. The 2 and 5-year progression-free probability was 80% and 60%, respectively. With prostate specific antigen included in progression criteria prostate specific antigen at confirmatory biopsy (HR 1.29, 95% CI 1.14-1.46, p <0.0005) and positive confirmatory biopsy (HR 1.75, 95% CI 1.01-3.04, p = 0.047) were independent predictors of progression. Of the 61 cases 34 failed due to increased prostate specific antigen, including only 5 with subsequent progression by biopsy criteria. When prostate specific antigen was excluded from progression criteria, only 32 cases progressed, and 2 and 5-year progression-free probability was 91% and 76%, respectively. Using modified criteria as an end point positive confirmatory biopsy was the only independent predictor of progression (HR 3.16, 95% CI 1.41-7.09, p = 0.005). CONCLUSIONS: Active surveillance is feasible in patients with low risk prostate cancer and most patients show little evidence of progression within 5 years. There is no clear justification for treating patients in whom prostate specific antigen increases above 10 ng/ml in the absence of other indications of tumor progression. Patients considering active surveillance should undergo confirmatory biopsy to better assess the risk of progression.
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Biomarcadores Tumorais/sangue , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Conduta Expectante/métodos , Adulto , Idoso , Biópsia por Agulha , Estudos de Coortes , Intervalos de Confiança , Progressão da Doença , Intervalo Livre de Doença , Seguimentos , Humanos , Imuno-Histoquímica , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Neoplasias da Próstata/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de TempoRESUMO
PURPOSE: Renal oncocytosis is a rare pathological condition in which renal parenchyma is diffusely involved by numerous oncocytic nodules in addition to showing a spectrum of other oncocytic changes. We describe our experience with renal oncocytosis, focusing on management and outcomes. MATERIALS AND METHODS: A total of 20 patients with a final pathological diagnosis of renal oncocytosis from July 1995 through June 2009 were included in the analysis. Patient demographics, intraoperative variables and postoperative outcomes are reported. RESULTS: Median age at nephrectomy was 71 years (IQR 59-75). Of the patients 15 (75%) had bilateral disease. There were 23 operations (9 right side, 14 left side) performed on 20 patients, and of these procedures 13 (57%) were partial nephrectomies and 10 (43%) were radical nephrectomies. Median dominant tumor mass diameter was 4.1 cm (IQR 3-6.4, range 1 to 14.6). The most common dominant tumor histology was hybrid tumor between oncocytoma and chromophobe renal cell carcinoma in 13 of 23 specimens (57%), followed by chromophobe renal cell carcinoma in 6 (26%), oncocytoma in 3 (13%) and conventional renal cell carcinoma in 1 (4%). Ten patients (50%) had preexisting chronic kidney disease before nephrectomy and chronic kidney disease developed in 5 more after surgery. After a median followup of 35 months no patients had metastatic disease. CONCLUSIONS: Patients with renal oncocytosis usually present with multiple and bilateral renal nodules. Half of the patients had chronic kidney disease at diagnosis and 25% had new onset of chronic kidney disease. No patient had distant metastatic disease during followup. Our management approach is to perform partial nephrectomy when possible and then use careful surveillance of the remaining renal masses.
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Adenoma Oxífilo , Neoplasias Renais , Nefrectomia , Adenoma Oxífilo/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: ⢠To analyse the clinical characteristics and outcomes of patients who underwent nephrectomy for solitary, isolated metastatic disease to the kidney. PATIENTS AND METHODS: ⢠From July 1989 to July 2009, we identified 13 patients who underwent nephrectomy for solitary metastasis to the kidney. Patients' demographics, intra-operative variables and outcomes are reported. RESULTS: ⢠The median age at nephrectomy was 52 years (range 33-79). Eleven patients (85%) had an incidentally discovered renal mass, whereas two patients (15%) presented with gross haematuria. ⢠Median time from initial surgery at the primary site to development of metastatic disease to the kidney was 63 months (range 9-136). No patient had evidence of disease at other sites at the time of nephrectomy. In seven patients (54%), the kidney was the first site of recurrence. ⢠The most common primary site was the lung in five patients (38%), followed by the colon in two (15%), chest wall in two (15%) and bone, brain, breast and salivary gland in one patient each (8%). ⢠Of the 14 procedures performed, eight (57%) were partial nephrectomy (PN) and six (43%) were radical nephrectomy (RN). ⢠Four patients died after progression from the primary tumour, all within 2 years of nephrectomy. One patient with a primary chondrosarcoma had no evidence of disease at last follow-up and died from other causes 50 months after nephrectomy. The median follow-up for the eight patients who were alive at last follow-up was 30 months after nephrectomy. Four of these patients had no evidence of disease and four patients were alive with metastatic disease. CONCLUSION: ⢠Kidney involvement by metastatic disease can occur as isolated solitary lesions. Some patients will also have the kidney as the first and only site of metastatic involvement. The presence of an isolated renal metastasis should not be considered an end-stage disease, and nephrectomy can be offered for highly selected patients as a therapeutic option.
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Neoplasias Renais/secundário , Nefrectomia/métodos , Adulto , Idoso , Métodos Epidemiológicos , Feminino , Humanos , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
PURPOSE: To generate and present the survey results on critical issues relevant to screening, diagnosis, and staging tools for prostate cancer (PCa) focused on developing countries. METHODS: A total of 36 of 300 questions concern the main areas of interest of this paper: (1) screening, (2) diagnosis, and (3) staging for various risk levels of PCa in developing countries. A panel of 99 international multidisciplinary cancer experts voted on these questions to create recommendations for screening, diagnosing, and staging tools for PCa in areas of limited resources discussed in this manuscript. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this document can be used by physicians to support the screening, diagnosis, and staging of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for screening, diagnosis, and staging of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.
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Países em Desenvolvimento , Neoplasias da Próstata , Consenso , Detecção Precoce de Câncer , Humanos , Masculino , Programas de Rastreamento , Neoplasias da Próstata/diagnósticoRESUMO
PURPOSE: A group of international urology and medical oncology experts developed and completed a survey on prostate cancer (PCa) in developing countries. The results are reviewed and summarized, and recommendations on consensus statements for very low-, low-, and intermediate-risk PCa focused on developing countries were developed. METHODS: A panel of experts developed more than 300 survey questions of which 66 questions concern the principal areas of interest of this paper: very low, low, and intermediate risk of PCa in developing countries. A larger panel of 99 international multidisciplinary cancer experts voted on these questions to create the recommendations for treatment and follow-up for very low-, low-, and intermediate-risk PCa in areas of limited resources discussed in this manuscript. RESULTS: The panel voted publicly but anonymously on the predefined questions. Each question was deemed consensus if 75% or more of the full panel had selected a particular answer. These answers are based on panelist opinion not a literature review or meta-analysis. For questions that refer to an area of limited resources, the recommendations consider cost-effectiveness and the possible therapies with easier and greater access. Each question had five to seven relevant answers including two nonanswers. The results were tabulated in real time. CONCLUSION: The voting results and recommendations presented in this document can be used by physicians to support management for very low, low, and intermediate risk of PCa in areas of limited resources. Individual clinical decision making should be supported by available data; however, as guidelines for treatment for very low, low, and intermediate risk of PCa in developing countries have not been developed, this document will serve as a point of reference when confronted with this disease.
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Médicos , Neoplasias da Próstata , Consenso , Países em Desenvolvimento , Humanos , Masculino , Neoplasias da Próstata/terapiaRESUMO
PURPOSE: Differences in clinical outcome are still unclear between primary and secondary bladder carcinoma in situ. We compared the clinical outcomes of primary and secondary carcinoma in situ, and identified predictive factors. MATERIALS AND METHODS: We retrospectively analyzed the records of 476 patients with high grade cTis, including 221 with primary and 255 with secondary carcinoma in situ, from 1990 to 2008 at a high volume cancer center after transurethral resection and intravesical bacillus Calmette-Guerin therapy. End points were time to progression to invasive disease (cT1 or higher) or radical cystectomy before progression, and progression to muscle invasive disease (cT2 or higher) or radical cystectomy before progression. We used Cox proportional hazards regression models. RESULTS: Patients with primary carcinoma in situ responded significantly more within 6 months of bacillus Calmette-Guerin than those with secondary carcinoma in situ (65% vs 39%, p <0.001). In the primary vs secondary groups the 5-year cumulative incidence of progression to cT1 or higher was 43% (95% CI 36-51) vs 32% (95% CI 27-39) and for progression to cT2 or higher it was 17% (95% CI 12-23) vs 8% (95% CI 5-13). On multivariate analysis primary carcinoma in situ was significantly more likely to progress to cT1 or higher (HR 1.38, 95% CI 1.05-1.81, p = 0.020) and to cT2 or higher, or radical cystectomy (HR 1.72, 95% CI 1.27-2.33, p = 0.001). We found no significance for age, gender or response to bacillus Calmette-Guerin as outcome predictors. Median followup was 5.1 years. CONCLUSIONS: Patients presenting with primary carcinoma in situ have a worse outcome than those with secondary carcinoma in situ, suggesting a need to differentiate these 2 entities in the treatment decision process.
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Carcinoma in Situ/patologia , Carcinoma in Situ/terapia , Neoplasias da Bexiga Urinária/secundário , Neoplasias da Bexiga Urinária/terapia , Adjuvantes Imunológicos/uso terapêutico , Idoso , Vacina BCG/uso terapêutico , Cistectomia , Progressão da Doença , Feminino , Humanos , Masculino , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: Prolonged warm ischemia time and increased intra-abdominal pressure caused by pneumoperitoneum during a laparoscopic donor nephrectomy could enhance renal ischemia reperfusion injury. For this reason, laparoscopic donor nephrectomy may be associated with a slower graft function recovery. However, an adequate protective response may balance the ischemia reperfusion damage. This study investigated whether laparoscopic donor nephrectomy modified the protective response of renal tissue during kidney transplantation. METHODS: Patients undergoing live renal transplantation were prospectively analyzed and divided into two groups based on the donor nephrectomy approach used: 1) the control group, recipients of open donor nephrectomy (n = 29), and 2) the study group, recipients of laparoscopic donor nephrectomy (n = 26). Graft biopsies were obtained at two time points: T-1 = after warm ischemia time and T+1 = 45 minutes after kidney reperfusion. The samples were analyzed by immunohistochemistry for the Bcl-2 and HO-1 proteins and by real-time polymerase chain reaction for the mRNA expression of Bcl-2, HO-1 and vascular endothelial growth factor. RESULTS: The area under the curve for creatinine and delayed graft function were similar in both the laparoscopic and open groups. There was no difference in the protective gene expression between the laparoscopic donor nephrectomy and open donor nephrectomy groups. The protein expression of HO-1 and Bcl-2 were similar between the open and laparoscopic groups. Furthermore, the gene expression of B-cell lymphoma 2 correlated with the warm ischemia time in the open group (p = 0.047) and that of vascular endothelial growth factor with the area under the curve for creatinine in the laparoscopic group (p = 0.01). CONCLUSION: The postoperative renal function and protective factor expression were similar between laparoscopic donor nephrectomy and open donor nephrectomy. These findings ensure laparoscopic donor nephrectomy utilization in renal transplantation.
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Transplante de Rim , Laparoscopia/métodos , Doadores Vivos , Nefrectomia/métodos , Coleta de Tecidos e Órgãos/métodos , Adulto , Creatinina/sangue , Função Retardada do Enxerto/fisiopatologia , Feminino , Expressão Gênica , Heme Oxigenase-1/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Reação em Cadeia da Polimerase em Tempo Real , Traumatismo por Reperfusão/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Fator A de Crescimento do Endotélio Vascular/sangue , Isquemia Quente/métodosRESUMO
BACKGROUND: Although oncologic outcomes appear to be similar after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN), data on renal function are lacking. OBJECTIVE: To evaluate the change over time in renal function after LPN and OPN. DESIGN, SETTING, AND PARTICIPANTS: We identified 987 patients with a single sporadic tumor and a normal contralateral kidney who were treated by LPN (n=182) and OPN (n=805) between January 2002 and July 2009. INTERVENTION: All patients underwent LPN or OPN at Memorial Sloan-Kettering Cancer Center. MEASUREMENTS: Estimated glomerular filtration rate (GFR) was calculated using the abbreviated Modification of Diet in Renal Disease formula. We created a multivariable generalized estimating equations linear model that predicted GFR based on the time from surgery, preoperative GFR, tumor size, American Society of Anesthesiologists score, and ischemia time. RESULTS AND LIMITATIONS: Mean patient age, tumor size, and ASA score were similar between LPN and OPN patients. The baseline preoperative GFR was lower in the laparoscopic group (67 ml/min per 1.73 m(2) vs 73 ml/min per 1.73 m(2); p<0.001). The mean ischemia time was shorter after LPN than OPN (35 min vs 40 min, respectively; p<0.001). In a multivariable model, the interaction term between time from surgery and approach was statistically significant (p=0.045), indicating that there was a differential effect on recovery of renal function over time by approach. Laparoscopically treated patients maintained a slightly higher renal function than those treated via an open approach. The 2-mo and 6-mo predicted GFR for a typical patient increased slightly from 65 ml/min per 1.73 m(2) to 67 ml/min per 1.73 m(2), respectively, for those treated laparoscopically but remained constant at 62 ml/min per 1.73 m(2) after OPN. CONCLUSIONS: Our data suggest that the surgical approach has a small effect on the recovery of renal function after partial nephrectomy. Laparoscopically treated patients maintained slightly higher renal function.