Evaluation of perioperative complications in open and laparoscopic surgery for renal cell cancer with tumor thrombus involvement using the Clavien-Dindo classification.

OBJECTIVE: To identify risk factors for perioperative complications and morbidity in renal cell cancer (RCC) surgery with tumor thrombus invasion (TTI). PATIENTS AND METHODS: Retrospective single-center analysis of 128 patients who underwent open (n = 97) or laparoscopic (n = 31) radical nephrectomy (NT) for RCC between 1999 and 2010. TTI was at Mayo-Level 0, I, II, III, IV in 88, 7, 10, 4, and 19 cases, respectively. Cavotomy was performed in 27, liver mobilisation in 20, and cardiovascular bypass in 17 patients. RESULTS: The rate of any early postoperative complication (PC) by Clavien-Dindo classification was 58.6%, while the severe early PC rate was 29.7%. There was a statistically significant difference in multivariate analysis in the incidence of any early PC and of severe early PC by Charlson score (OR:1.584 (95%CI:1.141-2.199), p = 0.006; OR:3.065 (95%CI:1.218-7.714), p = 0.017) and by tumor thrombus level TNM-UICC 2010 T3a/T3c (OR:10.668 (95%CI:1.266-89.871), p = 0.029; OR:10.502 (95%CI:2.981-36.992), p < 0.001). In pT3a cases open NT was associated with a higher early (57.9% vs. 25.8%) and severe (24.6% vs. 9.7%) PC rate compared to laparoscopic NT. The 30-day mortality rate was 0%. The 90-day mortality rate was 6.3% but 100% cancer-related. In Cox regression analysis tumor thrombus level was not predictive for overall survival. CONCLUSIONS: The strongest risk factor for early and severe PC in patients with TTI is a supradiaphragmatic tumor thrombus. In cases with severe PC, this fact persists when comparing Mayo-Levels II-III and Level IV. In pT3a cases open NT shows a 2-fold higher early PC rate compared to laparoscopic NT.

[Propensity score comparison of the various radical surgical techniques for high-risk prostate cancer]. / Propensity Score Vergleich der verschiedenen radikalen Operationstechniken beim high risk Prostatakarzinom.

INTRODUCTION: The optimal surgical treatment of patients with a high risk prostate cancer (PCa) in terms of radical prostatectomy (RP) is still controversial: open retropubic RP (RRP), laparoscopic RP (LRP), or robot-assisted (RARP). We aimed to investigate the influence of the different surgical techniques on pathologic outcome and biochemical recurrence. PATIENTS AND METHODS: A total of 805 patients with a high risk PCa (PSA >20 ng/mL, Gleason Score ≥8, or clinical stage ≥cT2c) were included. A comparison of 407 RRP patients with 398 minimally invasive cases (LRP+RARP) revealed significant confounders. Therefore all 110 RARP cases were propensity score (PS) matched 1:1 with LRP and RRP patients. PS included age, clinical stage, preoperative PSA, biopsy Gleason score, surgeon's experience and application of a nerve sparing technique. Comparison of overall survival (OS) and recurrence-free survival (RFS) was done with the log rank test. Predictors of RFS were analyzed by means of Cox regression models. RESULTS: Within the post-matching cohort of 330 patients a pathologic Gleason score < 7, = 7 and > 7 was found in 1.8, 55.5 and 42.7% for RARP, in 8.2, 36.4, 55.5% for LRP and in 0, 60.9 and 39.1% for RRP (p=0.004 for RARP vs. LRP and p=0.398 for RARP vs. RRP). Differences in histopathologic stages were not statistically significant. The overall positive surgical margin rate (PSM) as well as PSM for ≥ pT3 were not different. PSM among patients with pT2 was found in 15.7, 14.0 and 20.0% for RARP, LRP and RRP (statistically not significant). The respective mean 3-year RFS rates were 41.4, 77.9, 54.1% (p<0.0001 for RARP vs. LRP and p=0.686 for RARP vs. RRP). The mean 3-year OS was calculated as 95.4, 98.1 and 100% respectively (statistically not significant). CONCLUSION: RARP for patients with a high risk PCa reveals similar pathologic and oncologic outcomes compared with LRP and RRP.

De novo Renal Transplantation after Kaposi Sarcoma: Favorable Outcome in a Patient Receiving Sirolimus and Mycophenolate-Based Immunosuppression.

Immunosuppressive treatment increases the risk of infection and malignancy in organ transplant recipients. We report on a 42-year-old male renal transplant recipient who lost his first graft after reduction of immunosuppressive treatment due to Kaposi sarcoma and who successfully underwent a second renal transplant 10 years later. The patient's current treatment consists of low-dose prednisone, and the two antiproliferative immunosuppressants mycophenolate mofetil and rapamycin. 4.5 years after his second transplant, the serum creatinine is 1 mg/dl and the patient has no signs of recurrent disease.

[Incarcerated hernia after laparoscopic drainage of a lymphocele]. / Inkarzerierte Hernie nach laparoskopischer Lymphozelenfensterung.

Laparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.