Predicting outcomes in partial nephrectomy: is the renal score useful?

INTRODUCTION AND OBJECTIVE: The R.E.N.A.L. nephrometry system (RNS) has been validated in multiple open, laparoscopic and robotic partial nephrectomy series. The aim of this study was to test the accuracy of R.E.N.A.L. nephrometry system in predicting perioperative outcomes in surgical treatment of kidney tumors <7.0cm in a prospective model. MATERIALS AND METHODS: Seventy-one patients were selected and included in this prospective study. We evaluate the accuracy of RNS in predicting perioperative outcomes (WIT, OT, EBL, LOS, conversion, complications and surgical margins) in partial nephrectomy using ROC curves, univariate and multivariate analyses. R.E.N.A.L. was divided in 3 groups: low complexity (LC), medium complexity (MC) and high complexity (HC). RESULTS: No patients in LC group had WIT >20 min, versus 41.4% and 64.3% MC and HC groups respectively (p=0.03); AUC=0.643 (p=0.07). RNS was associated with convertion rate (LC:28.6% ; MC:47.6%; HC:77.3%, p=0.02). Patients with RNS <8 were most often subjected to partial nephrectomy (93% x 72%, p=0.03) and laparoscopic partial nephrectomy (56.8% x 28%, p=0.02), AUC=0.715 (p=0.002). The RNS was also associated with operative time. Patients with a score >8 had 6.06 times greater chance of having a surgery duration >180 min. (p=0.017), AUC=0.63 (p=0.059). R.E.N.A.L. score did not correlate with EBL, complications (Clavien >3), LOS or positive surgical margin. CONCLUSION: R.E.N.A.L. score was a good method in predicting surgical access route and type of nephrectomy. Also was associated with OT and WIT, but with weak accuracy. Although, RNS was not associated with Clavien >3, EBL, LOS or positive surgical margin.

The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy.

INTRODUCTION: This study analyzed the impact of the experience with Robotic-Assisted Laparoscopic Prostatectomy (RALP) on the initial experience with Laparoscopic Radical Prostatectomy (LRP) by examining perioperative results and early outcomes of 110 patients. LRPs were performed by two ro-botic fellowship trained surgeons with daily practice in RALP. PATIENTS AND METHODS: 110 LRP were performed to treat aleatory selected patients. The patients were divided into 4 groups for prospective analyses. A transperitoneal approach that simulates the RALP technique was used. RESULTS: The median operative time was 163 minutes (110-240), and this time significantly decreased through case 40, when the time plateaued (p=0.0007). The median blood loss was 250mL. No patients required blood transfusion. There were no life-threatening complications or deaths. Minor complications were uniformly distributed along the series (P=0.6401). The overall positive surgical margins (PSM) rate was 28.2% (20% in pT2 and 43.6% in pT3). PSM was in the prostate apex in 61.3% of cases. At the 12-month follow-up, 88% of men were continent (0-1 pad). CONCLUSIONS: The present study shows that there are multiple learning curves for LRP. The shallowest learning curve was seen for the operative time. Surgeons transitioning between the RALP and LRP techniques were considered competent based on the low perioperative complication rate, absence of major complications, and lack of blood transfusions. This study shows that a learning curve still exists and that there are factors that must be considered by surgeons transitioning between the two techniques.

First Brazilian Consensus of Advanced Prostate Cancer: Recommendations for Clinical Practice.

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.

Biochemical recurrence rates are similar for pT2-positive surgical margins and pT3a.

OBJECTIVE: Histological details of positive surgical margins in radical prostatectomy specimens have been related to outcome after surgery in rare studies recently published. Our objective is to assess whether the status of surgical margins, the extent and the Gleason score of positive margins, and the extent of the extraprostatic extension are predictive of biochemical recurrence post-radical prostatectomy. MATERIALS AND METHODS: Three hundred sixty-five radical prostatectomy specimens were analyzed. The length of the positive surgical margin and extraprostatic extension and the Gleason score of the margin were recorded. Statistical analyses examined the predictive value of these variables for biochemical recurrence. RESULTS: 236 patients were stage pT2R0, 58 pT2R1, 25 pT3R0 and 46 pT3R1. Biochemical recurrence occurred in 11%, 31%, 20% and 45.7% of pT2R0, pT2R1, pT3R0 and pT3R1, respectively. The extent of the positive surgical margins and the Gleason score of the positive surgical margins were not associated with biochemical recurrence in univariate analysis in a mean follow up period of 35.9 months. In multivariate analyses, only the status of the surgical margins and the global Gleason score were associated with biochemical recurrence, with a risk of recurrence of 3.1 for positive surgical margins and of 3.8 for a Gleason score > 7. CONCLUSION: Positive surgical margin and the global Gleason score are significant risk factors for biochemical recurrence post-radical prostatectomy, regardless of the extent of the surgical margin, the extent of the extraprostatic extension, or the local Gleason score of the positive surgical margin or extraprostatic tissue. pT2R1 disease behaves as pT3R0 and should be treated similarly.

External validation of a Brazilian predictive nomogram for pathologic outcomes following radical prostatectomy in tertiary teaching institutions: the USP nomograms.

PURPOSES: (a) To externally validate the Crippa and colleagues' nomograms combining PSA, percentage of positive biopsy cores (PPBC) and biopsy Gleason score to predict organ-confined disease (OCD) in a contemporary sample of patients treated at a tertiary teaching institution. (b) To adjust such variables, resulting in predictive nomograms for OCD and seminal vesicle invasion (SVI): the USP nomograms. MATERIALS AND METHODS: The accuracy of Crippa and colleagues' nomograms for OCD prediction was examined in 1002 men submitted to radical prostatectomy between 2005 and 2010 at the University of São Paulo (USP). ROC-derived area under the curve (AUC) and Brier scores were used to assess the discriminant properties of nomograms for OCD. Nomograms performance was explored graphically with LOESS smoothing plots. Furthermore, univariate analysis and logistic regression models targeted OCD and SVI. Variables consisted of PSA, PPBC, biopsy Gleason score and clinical stage. The resulted predictive nomograms for OCD and SVI were internally validated with bootstrapping and the same abovementioned procedures. RESULTS: Crippa and colleagues' nomograms for OCD showed ROC AUC = 0.68 (CI: 0.65-0.70), Brier score = 0.17 and overestimation in LOESS plots. USP nomograms for OCDand SVI showed ROC AUC of 0.73 (CI: 0.70-0.76) and 0.77 (CI: 0.73-0.79), respectively, and Brier scores of 0.16 and 0.08, respectively. The LOESS plots showed excellent calibration for OCD and underestimation for SVI. CONCLUSIONS: Crippa and colleagues' nomograms showed moderate discrimination and considerable OCD overestimation. USP nomograms showed good discrimination for OCD and SVI, as well as excellent calibration for OCD and SVI underestimation.

Expression profile of microrna-145 in urothelial bladder cancer.

PURPOSE: Bladder cancer (BC) is the second most common malignancy of the urinary tract, with high mortality. The knowledge of the molecular pathways associated with BC carcinogenesis is crucial to identify new diagnostic and prognostic biomarkers. MicroRNAs (miRNAs) are short non-coding RNA molecules that play important roles in the regulation of gene expression by acting directly on mRNAs. miR-145 has been considered as a tumor suppressor, which targets the c-MYC, MUC-1 and FSCN1 genes. Our aim was to evaluate the expression profile of miR-145 in low-grade non-invasive and high-grade invasive bladder urothelial carcinomas. MATERIALS AND METHODS: We studied 30 specimens of low-grade, non-invasive pTa and 30 of pT2/pT3 high-grade invasive UC obtained by transurethral resection or radical cystectomy, followed over a mean time of 16.1 months. Normal controls were represented by five samples of normal bladder biopsy from patients who underwent retropubic prostatectomy to treat BPH. miRNA extraction and cDNA generation were performed using commercial kits. Analysis was performed by qRT-PCR, and miR-145 expression was calculated using the 2-(▵▵ct) method; we used RNU-43 and RNU-48 as endogenous controls. RESULTS: miR-145 was under-expressed in 73.3% and 86.7% of pTa and pT2/pT3, respectively, with expression means of 1.61 for the former and 0.66 for the last. There were no significant differences in miR-145 expression and histological grade, tumor stage, angiolymphatic neoplastic invasion and tumor recurrence. CONCLUSION: miR-145 is under-expressed in low-grade, non-invasive and high-grade invasive urothelial bladder carcinoma and may play an important role in the carcinogenesis pathway, being an interesting candidate diagnostic marker.

Can single positive core prostate cancer at biopsy be considered a low-risk disease after radical prostatectomy?

PURPOSE: Single positive core in a prostate biopsy is usually associated with indolent prostate cancer (PCa) and is one of the active surveillance (AS) inclusion criteria. We investigated whether single positive core PCa at biopsy could define an archetype of low-risk disease. MATERIALS AND METHODS: A total of 1320 consecutive patients were enrolled. Among them, 249 patients with single positive core PCa were followed up, and the clinical and pathological parameters influencing prognosis were analyzed. RESULTS: Out of the 249 patients, 172 (69.0%) had pathological findings ≥ pT2c and 87 (34.9%) had an undergraded Gleason Score (GS) based on the biopsy. Positive surgical margins (PSMs), extraprostatic extension (EPE) and seminal vesicle invasion (SVI) were found in 20.8%, 10.0% and 6.0% of patients, respectively. In a comparative analysis, we found that the PSA level, prostate weight and number of cores at biopsy are essential to correctly predict an indolent PCa. A total of 125 patients (67.3%) with nonpalpable tumors became high-risk tumors (pT2c-T3). Analyzing only nonpalpable tumors with a GS of 6 at biopsy (156 patients), we noted that 106 (67.9% of cT1) progressed from cT1c to pT2c-pT3. CONCLUSIONS: Single core PCa have clinically significant disease in the Radical Prostatectomy specimens, with considerable rates of overgrading for the GS, pT2c-pT3, PSMs, EPE and SVI. The treatment plan must be evaluated individually for patients with single core PCa and must take into account other prognostic factors when determining whether a patient should be managed with AS.

Carbonic Anhydrase IX is not a predictor of outcomes in non-metastatic clear cell renal cell carcinoma - a digital analysis of tissue microarray.

INTRODUCTION: The knowledge about the molecular biology of clear cell renal cell carcinoma (ccRCC) is evolving, and Carbonic Anhydrase type IX (CA-IX) has emerged as a potential prognostic marker in this challenging disease. However, most of the literature about CA-IX on ccRCC comes from series on metastatic cancer, with a lack of series on non-metastatic cancer. The objective is to evaluate the expression of CA-IX in a cohort of non-metastatic ccRCC, correlating with 1) overall survival, and 2) with established prognostic parameters (T stage, tumor size, Fuhrman nuclear grade, microvascular invasion and peri-renal fat invasion). MATERIALS AND METHODS: This is a retrospective cohort study. We evaluated 95 patients with non-metastatic clear cell renal cell carcinoma, as to the expression of CA-IX. The analyzed parameters where: overall survival (OS), TNM stage, tumor size (TS), Fuhrman nuclear grade (FNG), microvascular invasion (MVI), peri-renal fat invasion (PFI). We utilized a custom built tissue microarray, and the immunoexpression was digitally quantified using the Photoshop ® software. RESULTS: The mean follow-up time was 7.9 years (range 1.9 to 19.5 years). The analysis of CA-IX expression against the selected prognostic parameters showed no correlation. The results are as follows: Overall survival (p = 0.790); T stage (p = 0.179); tumor size (p = 0.143); grouped Fuhrman nuclear grade (p = 0.598); microvascular invasion (p = 0.685), and peri-renal fat invasion (p = 0.104). CONCLUSION: Carbonic anhydrase type IX expression does not correlate with overall survival and conventional prognostic parameters in non-metastatic clear cell renal cell carcinoma.

Correlation between beta1 integrin expression and prognosis in clinically localized prostate cancer.

UNLABELLED: Integrins are transmembrane glycoprotein receptors that regulate cell-matrix interactions, thus functioning as sensors from the environment. They also act as cell adhesion molecules that are responsible for the maintenance of the normal epithelial phenotype. Some studies have reported a correlation between carcinogenesis and changes in integrin expression, especially ß1 integrin, however its role in prostate cancer (PC) is unclear. The aim of our study was to evaluate the expression of ß1 integrin in localized PC and to correlate the pattern of expression with recurrence after surgical treatment. Methods For this case-control study, we retrospectively selected surgical specimens from 111 patients with localized PC who underwent radical prostatectomy. Recurrence was defined as a PSA level exceeding 0.2 ng/mL after surgery, and the median follow-up was 123 months. Integrin expression was evaluated by immunohistochemistry in a tissue microarray containing two samples from each tumor. We employed a semiquantitative analysis and considered a case as positive when the expression was strong and diffusely present. RESULTS: There was a loss of 11 cases during the tissue micro array assembling. ß1 expression was positive in 79 of the 100 evaluated cases (79%). The univariate and multivariate analyses showed that the negative expression of ß1 integrin was associated with biochemical recurrence (p = 0.047) and time to recurrence after radical prostatectomy (p = 0.023). When ß1 was negative, the odds ratio for recurrence was 2.78 times higher than that observed in the positive cases [OR = 2.78, p = 0.047, IC 95% (1.01-7.66)]. CONCLUSIONS: The loss of ß1 integrin immune expression was correlated with biochemical recurrence in patients treated with radical prostatectomy for localized PC.

PGC and PSMA in prostate cancer diagnosis: tissue analysis from biopsy samples.

PURPOSE: The discovery of new diagnostic tools for the diagnosis of prostate cancer (PCa) has become an important field of research. In this study, we analyzed the diagnostic value of the expression of the pepsinogen C (PGC) and prostate-specific membrane antigen (PSMA) genes in tissue samples obtained from prostate biopsies. MATERIALS AND METHODS: This study was comprised of 51 consecutive patients who underwent transrectal ultrasound (TRUS)-guided prostate biopsies between January 2010 and March 2010. The biopsies were performed with 12 cores, and an additional core was randomly retrieved from the peripheral zone from each patient for study purposes. The expression of the PGC and PSMA genes was analyzed from the cDNA from the samples via the qRT-PCR technology. The expression patterns of patients with PCa were compared with those of patients without a PCa diagnosis. RESULTS: PSMA was overexpressed in only 43.4% of PCa cases, and PGC was overexpressed in 72.7% of cases. The median expression of PSMA was 1.5 times (0.1 to 43.9) and the median PGC expression was 8.7 times (0.1 to 50.0) the expression observed in prostatic tissue from TRUS-guided biopsies of normal patients. Analysis of patients with high-risk PCa indicated that PGC was overexpressed in 71.4% of cases (with a median expression of 10.6 times), and PSMA was overexpressed in only 35.7% of cases (with a median expression of 4.5 times). Among patients with low-risk PCa, PGC was also overexpressed in 71.4% of cases (with a median expression of 5.9 times), and PSMA was overexpressed in only 42.8% of cases (with a median expression of 2.5 times). CONCLUSIONS: PGC gene expression is significantly higher in prostatic tissue in men affected by PCa when compared to normal prostates. Further analyses are necessary to confirm our results.

Stage, grade and behavior of bladder urothelial carcinoma defined by the microRNA expression profile.

PURPOSE: We identified miRNA expression profiles in urothelial carcinoma that are associated with grade, stage, and recurrence-free and disease specific survival. MATERIALS AND METHODS: The expression of 14 miRNAs was evaluated by quantitative reverse transcriptase-polymerase chain reaction in surgical specimens from 30 patients with low grade, noninvasive (pTa) and 30 with high grade, invasive (pT2-3) urothelial carcinoma. Controls were normal bladder tissue from 5 patients who underwent surgical treatment for benign prostatic hyperplasia. Endogenous controls were RNU-43 and RNU-48. miRNA profiles were compared and Kaplan-Meier curves were constructed to analyze disease-free and disease specific survival. RESULTS: miR-100 was under expressed in 100% of low grade pTa specimens (p <0.001) and miR-10a was over expressed in 73.3% (p <0.001). miR-21 and miR-205 were over expressed in high grade pT2-3 disease (p = 0.02 and <0.001, respectively). The other miRNAs were present at levels similar to those of normal bladder tissue or under expressed in each tumor group. miR-21 over expression (greater than 1.08) was related to shorter disease-free survival in patients with low grade pTa urothelial carcinoma. Higher miR-10a levels (greater than 2.30) were associated with shorter disease-free and disease specific survival in patients with high grade pT2-3 urothelial carcinoma. CONCLUSIONS: Four miRNAs were differentially expressed in the 2 urothelial carcinoma groups. miR-100 and miR-10a showed under expression and over expression, respectively, in low grade pTa tumors. miR-21 and miR-205 were over expressed in pT2-3 disease. In addition, miR-10a and miR-21 over expression was associated with shorter disease-free and disease specific survival. miRNAs could be incorporated into the urothelial carcinoma molecular pathway. These miRNAs could also serve as new diagnostic or prognostic markers and new target drugs.

miR-21 may acts as an oncomir by targeting RECK, a matrix metalloproteinase regulator, in prostate cancer.

BACKGROUND: Prognosis of prostate cancer (PCa) is based mainly in histological aspects together with PSA serum levels that not always reflect the real aggressive potential of the neoplasia. The micro RNA (miRNA) mir-21 has been shown to regulate invasiveness in cancer through translational repression of the Metaloproteinase (MMP) inhibitor RECK. Our aim is to investigate the levels of expression of RECK and miR-21 in PCa comparing with classical prognostic factors and disease outcome and also test if RECK is a target of miR-21 in in vitro study using PCa cell line. MATERIALS AND METHODS: To determine if RECK is a target of miR-21 in prostate cancer we performed an in vitro assay with PCa cell line DU-145 transfected with pre-miR-21 and anti-miR-21. To determine miR-21 and RECK expression levels in PCa samples we performed quantitative real-time polymerase chain reaction (qRT-PCR). RESULTS: The in vitro assays showed a decrease in expression levels of RECK after transfection with pre-miR-21, and an increase of MMP9 that is regulated by RECK compared to PCa cells treated with anti-miR-21. We defined three profiles to compare the prognostic factors. The first was characterized by miR-21 and RECK underexpression (N = 25) the second was characterized by miR-21 overexpression and RECK underexpression (N = 12), and the third was characterized by miR-21 underexpression and RECK overexpression (N = 16). From men who presented the second profile (miR-21 overexpression and RECK underexpression) 91.7% were staged pT3. For the other two groups 48.0%, and 46.7% of patients were staged pT3 (p = 0.025). CONCLUSIONS: Our results demonstrate RECK as a target of miR-21. We believe that miR-21 may be important in PCa progression through its regulation of RECK, a known regulator of tumor cell invasion.

Increased expression of MMP-9 and IL-8 are correlated with poor prognosis of Bladder Cancer.

BACKGROUND: Extracellular matrix homeostasis is strictly maintained by a coordinated balance between the expression of metalloproteinases (MMPs) and their inhibitors. The purpose of this study was to investigate whether the expression of MMP-9, MMP-2 and its specific inhibitors, are expressed in a reproducible, specific pattern and if the profiles are related to prognosis in Bladder Cancer (BC). METHODS: MMP-9, MMP-2 and its specific inhibitors expression levels were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR) in fresh-frozen malignant tissue collected from 40 patients with BC submitted to transurethral resection of bladder. The control group consisted of normal bladder tissue from five patients who had undergone retropubic prostatectomy to treat benign prostatic hyperplasia. RESULTS: MMP-9 was overexpressed in 59.0 % of patients, and MMP-2, TIMP-1, TIMP-2, MMP-14, RECK and IL-8 was underexpressed in most of the patients. Regarding prognostic parameters we observed that high-grade tumors exhibited significantly higher levels of MMP-9 and IL-8 (p = 0.012, p = 0.003). Invasive tumors (pT1-pT2) had higher expression levels of MMP-9 than superficial tumors (pTa) (p = 0.026). The same was noted for IL-8 that was more expressed by invasive tumors (p = 0.015, p = 0.048). Most importantly tumor recurrence was related with higher levels of both MMP-9 (p = 0.003) and IL-8 (p = 0.005). CONCLUSION: We have demonstrated that the overexpression of MMP-9 and higher expression of IL-8 are related to unfavorable prognostic factors of urothelial bladder cancer and tumor recurrence and may be useful in the follow up of the patients.

Predicting necrosis in residual mass analysis after retroperitoneal lymph node dissection: a retrospective study.

BACKGROUND: Recent studies have demonstrated that pathological analysis of retroperitoneal residual masses of patients with testicular germ cell tumors revealed findings of necrotic debris or fibrosis in up to 50% of patients. We aimed at pursuing a clinical and pathological review of patients undergoing post chemotherapy retroperitoneal lymph node dissection (PC-RPLND) in order to identify variables that may help predict necrosis in the retroperitoneum. METHODS: We performed a retrospective analysis of all patients who underwent PC-RPLND at the University Hospital of the University of São Paulo and Cancer Institute of Sao Paulo between January 2005 and September 2011. Clinical and pathological data were obtained and consisted basically of: measures of retroperitoneal masses, histology of the orchiectomy specimen, serum tumor marker and retroperitoneal nodal size before and after chemotherapy. RESULTS: We gathered a total of 32 patients with a mean age of 29.7; pathological analysis in our series demonstrated that 15 (47%) had necrosis in residual retroperitoneal masses, 15 had teratoma (47%) and 2 (6.4%) had viable germ cell tumors (GCT). The mean size of the retroperitoneal mass was 4.94 cm in our sample, without a difference between the groups (P = 0.176). From all studied variables, relative changes in retroperitoneal lymph node size (P = 0.04), the absence of teratoma in the orchiectomy specimen (P = 0.03) and the presence of choriocarcinoma in the testicular analysis after orchiectomy (P = 0.03) were statistically significant predictors of the presence of necrosis. A reduction level of 35% was therefore suggested to be the best cutoff for predicting the absence of tumor in the retroperitoneum with a sensitivity of 73.3% and specificity of 82.4%. CONCLUSIONS: Even though retroperitoneal lymph node dissection remains the gold standard for patients with residual masses, those without teratoma in the primary tumor and a shrinkage of 35% or more in retroperitoneal mass have a considerably smaller chance of having viable GCT or teratoma in the retroperitoneum and a surveillance program could be considered.

The accuracy of pathological data for the prediction of insignificant prostate cancer.

INTRODUCTION: The widespread screening programs prompted a decrease in prostate cancer stage at diagnosis, and active surveillance is an option for patients who may harbor clinically insignificant prostate cancer (IPC). Pathologists include the possibility of an IPC in their reports based on the Gleason score and tumor volume. This study determined the accuracy of pathological data in the identification of IPC in radical prostatectomy (RP) specimens. MATERIALS AND METHODS: Of 592 radical prostatectomy specimens examined in our laboratory from 2001 to 2010, 20 patients harbored IPC and exhibited biopsy findings suggestive of IPC. These biopsy features served as the criteria to define patients with potentially insignificant tumor in this population. The results of the prostate biopsies and surgical specimens of the 592 patients were compared. RESULTS: The twenty patients who had IPC in both biopsy and RP were considered real positive cases. All patients were divided into groups based on their diagnoses following RP: true positives (n = 20), false positives (n = 149), true negatives (n = 421), false negatives (n = 2). The accuracy of the pathological data alone for the prediction of IPC was 91.4%, the sensitivity was 91% and the specificity was 74%. CONCLUSION: The identification of IPC using pathological data exclusively is accurate, and pathologists should suggest this in their reports to aid surgeons, urologists and radiotherapists to decide the best treatment for their patients.

Can we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors?

INTRODUCTION: While some studies show that patients submitted to radical nephrectomy have a higher risk of developing chronic kidney disease (CKD), some studies report that carefully selected living kidney donors do not present a higher risk for CKD. Here, we aim to study predictive factors of CKD after radical nephrectomy. MATERIALS AND METHODS: Between January 2006 to January 2010, 107 patients submitted to radical nephrectomy for cortical renal tumors at our institution were enrolled in this study. Demographic data were recorded, modified Charlson-Romano Index was calculated, and creatinine clearance was estimated using abbreviated Modification of Diet in Renal Disease (MDRD) study equation. Pathological characteristics, surgical access and surgical complications were also reviewed. The end-point of the current study was new onset estimated glomerular filtration rate (eGFR) less than 60 and less than 45 mL/minute/1.73 m(2). RESULTS: Age, preoperative eGFR, Charlson-Romano Index and hypertension were predictive factors of renal function loss, when the end-point considered was eGFR lower than 60 mL/minute/1.73 m(2). Age and preoperative eGFR were predictive factors of renal function loss, when the end-point considered was eGFR lower than 45 mL/minute/ 1.73 m(2). Moreover, each year older increased 1.1 times the risk of eGFR lower than 60 and 45 mL/minute/1.73 m(2). After multivariate logistic regression, only age remained as an independent predictive factor of eGFR loss. CONCLUSION: Age is an independent predictive factor of GFR loss for patients submitted to radical nephrectomy for cortical renal tumors.

Anatrophic nephrotomy as nephron-sparing approach for complete removal of intraparenchymal renal tumors.

OBJECTIVE: Partial nephrectomy for small kidney tumors has increased in the last decades, and the approach to non-palpable endophytic tumors became a challenge, with larger chances of positive margins or complications. The aim of this study is to describe an alternative nephron-sparing approach for small endophytic kidney tumors through anatrophic nephrotomy. PATIENTS AND METHODS: A retrospective analysis of patients undergoing partial nephrectomy at our institution was performed and the subjects with endophytic tumors treated with anatrophic nephrotomy were identified. Patient demographics, perioperative outcomes and oncological results were evaluated. RESULTS: Among the partial nephrectomies performed for intraparenchymal tumors between 06/2006 and 06/2010, ten patients were submitted to anatrophic nephrotomy. The mean patient age was 42 yrs, and the mean tumor size was 2.3 cm. Mean warm ischemia time was 22.4 min and the histopathological analysis showed 80% of clear cell carcinomas. At a mean follow-up of 36 months, no significant creatinine changes or local or systemic recurrences were observed. CONCLUSION: The operative technique described is a safe and effective nephron-sparing option for complete removal of endophytic renal tumors.

Robotic-assisted laparoscopic partial nephrectomy: initial experience in Brazil and a review of the literature.

CONTEXT AND PURPOSE: Partial nephrectomy has become the standard of care for renal tumors less than 4 cm in diameter. Controversy still exists, however, regarding the best surgical approach, especially when minimally invasive techniques are taken into account. Robotic-assisted laparoscopic partial nephrectomy (RALPN) has emerged as a promising technique that helps surgeons achieve the standards of open partial nephrectomy care while offering a minimally invasive approach. The objective of the present study was to describe our initial experience with robotic-assisted laparoscopic partial nephrectomy and extensively review the pertinent literature. MATERIALS AND METHODS: Between August 2009 and February 2010, eight consecutive selected patients with contrast enhancing renal masses observed by CT were submitted to RALPN in a private institution. In addition, we collected information on the patients ' demographics, preoperative tumor characteristics and detailed operative, postoperative and pathological data. In addition, a PubMed search was performed to provide an extensive review of the robotic-assisted laparoscopic partial nephrectomy literature. RESULTS: Seven patients had RALPN on the left or right sides with no intraoperative complications. One patient was electively converted to a robotic-assisted radical nephrectomy. The operative time ranged from 120 to 300 min, estimated blood loss (EBL) ranged from 75 to 400 mL and, in five cases, the warm ischemia time (WIT) ranged from 18 to 32 min. Two patients did not require any clamping. Overall, no transfusions were necessary, and there were no intraoperative complications or adverse postoperative clinical events. All margins were negative, and all patients were disease-free at the 6-month follow-up. CONCLUSIONS: Robotic-assisted laparoscopic partial nephrectomy is a feasible and safe approach to small renal cortical masses. Further prospective studies are needed to compare open partial nephrectomy with its minimally invasive counterparts.

Immune expression of E-cadherin and α, ß and γ-Catenin adhesion molecules and prognosis for upper urinary tract urothelial carcinomas.

INTRODUCTION: Cell adhesion molecules (CAM) are required for maintaining a normal epithelial phenotype, and abnormalities in CAM expression have been related to cancer progression, including bladder urothelial carcinomas. There is only one study that correlates E-cadherin and Α-, Β- and y-catenin expression with prognosis of upper tract urothelial carcinomas. Our aim is to study the pattern of immune expression of these CAMs in urothelial carcinomas from the renal pelvis and ureter in patients who have been treated surgically. Our goal is to correlate these expression levels and characteristics with well-known prognostic parameters for disease-free survival. MATERIALS AND METHODS: We evaluated specimens from 20 patients with urothelial carcinomas of the renal pelvis and ureter who were treated with nephroureterectomy or ureterectomy between June 1997 and January 2007. CAM expression was evaluated by immunohistochemistry in a tissue microarray and correlated with histopathological characteristics and patient outcomes after a mean follow-up of 55 months. RESULTS: We observed a relationship between E-cadherin expression and disease recurrence. Disease recurrence occurred in 87.5% of patients with strong E-cadherin expression. Only 50.0% of patients with moderate expression and 0% of patients with weak or no expression of E-cadherin had disease recurrence (p = 0.014). There was also a difference in disease-free survival. Patients with strong E-cadherin expression had a mean disease-free survival rate of 49.1 months, compared to 83.9 months for patients with moderate expression (p = 0.011). Additionally, an absence of Α-catenin expression was associated with tumors that were larger than 3 cm (p = 0.003). CONCLUSIONS: We demonstrated for the first time that immune expression of E-cadherin is related to tumor recurrence and disease-free survival rates, and the absence of Α-catenin expression is related to tumor size in upper tract urothelial carcinomas.

Underexpression of MMP-2 and its regulators, TIMP2, MT1-MMP and IL-8, is associated with prostate cancer.

OBJECTIVE: Extracellular matrix homeostasis is strictly maintained by a coordinated balance between the expression of metalloproteinases (MMPs) and their regulators. The purpose of this study was to investigate whether MMP-2 and its specifi c regulators, TIMP-2, MT1-MMP and IL-8, are expressed in a reproducible, specific pattern and if the profiles are related to prognosis and clinical outcome of prostate cancer (PCa). MATERIALS AND METHODS: MMP-2, TIMP-2, MT1-MMP and IL-8 expression levels were analyzed by quantitative real-time polymerase chain reaction (qRT-PCR) in freshly frozen malignant and benign tissue specimens collected from 79 patients with clinically localized PCa who underwent radical prostatectomies. The control group consisted of 11 patients with benign prostate hyperplasia (BPH). The expression profile of the MMP-2 and its regulators were compared using Gleason scores, pathological stage, pre-operative PSA levels and the fi nal outcome of the PCa. RESULTS: The analysis of 79 specimens of PCa revealed that MMP-2, TIMP-2, MT1-MMP and IL-8 were underexpressed at 60.0%, 72.2%, 62.0% and 65.8%, respectively, in malignant prostatic tissue in relation to BPH samples. Considering the prognostic parameters, we demonstrated that high Gleason score tumors (≥ 7) overexpressed MMP-2 (p = 0.048) and TIMP-2 (p = 0.021), compared to low Gleason score tumors (< 7). CONCLUSION: We have demonstrated that MMP-2 and its regulators are underexpressed in PCa. Alternatively, overexpression of MMP-2 and TIMP-2 was related to higher Gleason score tumors. We postulate that alterations in metalloproteinase expression may be important in the control of tissue homeostasis related to prostate carcinogenesis and tumor behavior.