Association Between Sarcopenia and Survival of Patients with Organ-Confined Renal Cell Carcinoma after Radical Nephrectomy.

BACKGROUND: We aimed to describe the effect of preoperative sarcopenia on oncologic outcomes of organ-confined renal cell carcinoma (RCC) after radical nephrectomy. PATIENTS AND METHODS: A total of 632 patients with pT1-2 RCC who underwent radical nephrectomy between 2004 and 2014 were retrospectively analyzed. From preoperative computerized tomography (CT) scans, skeletal muscle index (SMI) was measured and gender-specific cutoff values at third lumbar vertebra of 52.4 cm2/m2 for men and 38.5 cm2/m2 for women were used to define sarcopenia. Survivals were compared and associations with sarcopenia were analyzed using Kaplan-Meier log rank tests and Cox proportional hazard regression models. Median follow-up was 83 months. RESULTS: Of 632 patients, 268 (42.4%) were classified as sarcopenic. The sarcopenic group was more advanced in age (57 versus 53 years) and more predominantly male (71.3% versus 59.9%). Sarcopenic patients had lower body mass index (BMI, 23.0 versus 25.9 kg/m2), but there was no difference in tumor size, stage, or nuclear grade. Sarcopenia was associated with poorer overall survival (OS) and cancer-specific survival (CSS; OS 94.0% versus 82.1%; p < 0.001 and CSS 97.5% versus 91.8%; p < 0.001). On multivariate analysis, sarcopenia was an independent risk factor for all-cause mortality [hazard ratio (HR) 2.58; 95% CI 1.02-6.54] and cancer-specific mortality (HR 3.07; 95% CI 1.38-6.83). CONCLUSIONS: Sarcopenia at diagnosis was an independent risk factor for all-cause and cancer-specific mortality after radical nephrectomy for pT1-2 RCC. These findings underscore the importance of assessing presence of sarcopenia for risk stratification even among surgical candidates.

Clinical features and oncological outcomes of primary female urethral cancer.

PURPOSE: Investigation of the clinical features and treatment outcomes of primary female urethral cancer (FUC) at a single institution. MATERIALS AND METHODS: We retrospectively reviewed 32 FUC patients during 1997-2017. We investigated preoperative risk factors predicting overall (overall survival [OS]) and recurrence-free survival (RFS) and reviewed clinical features, treatment modality, and oncologic outcomes according to pathology. The median follow-up duration and age was 56 months (range: 4-229) and 61 years (range: 15-82), respectively. RESULTS: The median OS and RFS were 70 and 16 months, respectively. A total of 19 (59.4%) patients received systemic chemotherapy, including 14 (43.8%) who received radiation therapy. Further, 22 patients (68.8%) underwent surgery. On univariate analysis, >T2, N+, and tumor size ≥3 cm were associated with poorer OS. There were 15 cases of distant metastasis and five local recurrences. Outcomes were poorest in adenocarcinoma (AC), moderate in clear cell carcinoma and transitional cell carcinoma, and best in squamous cell carcinoma (SCC). CONCLUSION: Female urethral lesions should be carefully examined to exclude FUC. Distal urethral SCC was responsive to surgical excision, but proximal urethral AC had poor oncological outcome even after extensive treatment. Due to the heterogeneity and poor prognosis of FUC, multimodal treatment is mandatory.

Solo-surgeon pure laparoscopic donor nephrectomy using passive camera holder: IDEAL stage 2a study.

BACKGROUND: Solo-surgery can be defined as a practice of a surgeon operating alone using a camera holder, without other surgical members except for a scrub nurse. This study was designed to evaluate the feasibility and safety of solo-surgeon pure laparoscopic donor nephrectomy. METHODS: The study protocol was approved by the Institutional Review Board of Asan Medical Center, Seoul, Korea. The brief study protocol was registered on the Clinical Research Information Service site of the Korea Centers for Disease Control and Prevention. Candidates fulfilling all inclusion and exclusion criteria were enrolled in the clinical trial and underwent solo-surgeon pure laparoscopic donor nephrectomy. The feasibility was assessed by the proportion of subjects who could undergo solo-surgeon pure laparoscopic donor nephrectomy without difficulty. The perioperative complications were identified to assess the safety of solo-surgeon pure laparoscopic donor nephrectomy. RESULTS: Of the 47 potential candidates from November 2018 to August 2019, 40 were enrolled in the clinical trial and seven excluded due to declining participation. The feasibility of solo-surgeon pure laparoscopic donor nephrectomy was 100%, without an occasion of any difficulty requiring conversion to the human assisted pure laparoscopic donor nephrectomy. Fourteen intraoperative complications occurred in 10 patients. The most common intraoperative complication was spleen injury. Two of three cases classified as the Satava classification grade II were due to the incomplete stapling of endoscopic stapler. Seventy-eight postoperative complications occurred in 34 patients. The most common postoperative complication was nausea/vomiting and followed by aspartate aminotransferase/alanine aminotransferase elevation. Most postoperative complication was independent of the solo-surgery itself. CONCLUSIONS: Solo-surgeon pure laparoscopic donor nephrectomy using passive camera holder is technically feasible. In terms of safety, it is necessary to adjust the scope of surgery performed alone. Trial Registration CRIS, KCT0003458. Registered 30/01/2019, Retrospectively registered, https://cris.nih.go.kr/cris/search/detailSearch.do/15868 .

Impact of Prognostic Nutritional Index on Postoperative Pulmonary Complications in Radical Cystectomy: A Propensity Score-Matched Analysis.

BACKGROUND: Radical cystectomy is a standard treatment for muscle-invasive bladder cancer but frequently entails postoperative pulmonary complications (PPCs). Nutrition is closely associated with postoperative outcomes. Therefore, we evaluated the impact of preoperative prognostic nutritional index (PNI) on PPCs in radical cystectomy. METHODS: PNI was calculated as 10 × (serum albumin) + 0.005 × (total lymphocyte count). The risk factors for PPCs were evaluated using multivariate logistic regression analysis. A receiver operating characteristic curve analysis of PNI was performed, and an optimal cut-off value was identified. Propensity score-matched analysis was used to determine the impact of PNI on PPCs. Postoperative outcomes were also evaluated. RESULTS: PPCs occurred in 112 (13.6%) of 822 patients. Multivariate logistic regression analysis identified PNI, age, and serum creatinine level as risk factors. The area under the receiver operating characteristic curve of PNI for predicting PPCs was 0.714 (optimal cut-off value: 45). After propensity score matching, the incidence of PPCs in the PNI ≤ 45 group was significantly higher compared with the PNI > 45 group (20.8% vs. 6.8%; p < 0.001), and PNI ≤ 45 was associated with a higher incidence of PPCs (odds ratio 3.308, 95% confidence interval 1.779-6.151; p < 0.001). The rates of intensive care unit admission and prolonged (> 2 days) stay thereof were higher in patients who developed PPCs. CONCLUSIONS: Preoperative PNI ≤ 45 was associated with a higher incidence of PPCs in radical cystectomy, suggesting that PNI provides useful information regarding pulmonary complications after radical cystectomy.

Technical Notes on Fluoroscopy-Guided Removal of Metallic Ureteral Stents.

This report describes various techniques for fluoroscopy-guided removal of metallic ureteral stents. Fifteen patients underwent 17 fluoroscopy-guided removal procedures of 22 metallic ureteral stents. The simple or modified snare or retrieval hook technique was primarily used for antegrade access, whereas the loop snare technique was primarily used for retrograde access. Overall, 64.7% of the stents were removed using the initial retrieval technique, and 82.4% of the stents were removed using an adjunct technique. Procedure-related complications included hematuria in 41.2% of cases and resolved spontaneously in all patients. Fluoroscopy-guided removal of metallic ureteral stents is safe and effective.

Temporary Covered Metallic Ureteral Stent Placement for Ureteral Strictures following Kidney Transplantation: Experience in 8 Patients.

This brief report presents 8 patients with silicone-covered metallic stent placement for ureteral strictures refractory to double-J stent placement, following kidney transplantation. Stent removal was successfully performed in 7 patients via antegrade (n = 4) or retrograde (n = 3) access 6 weeks to 6 months after stenting for elective removal (6-month interval, n = 3), urothelial hyperplasia (n = 2), or stent migration (n = 2), and their mean primary ureteral patency after stent removal was 15.4 months (range, 2-27 months). Hematuria (n = 2) and pain (n = 3) occurred, but resolved within 1 week. One stent was removed during reconstructive surgery. During follow-up of mean 22.6 months after stent removal, ureteral strictures recurred in 2 patients.

Robot-assisted partial nephrectomy is associated with early recovery of renal function: Comparison of open, laparoscopic, and robot-assisted partial nephrectomy using DTPA renal scintigraphy.

OBJECTIVES: To compare the functional outcomes of open, laparoscopic, and robot-assisted partial nephrectomy (OPN, LPN, and RAPN, respectively) using diethylene triamine penta-acetic acid (DTPA). METHODS: We identified 610 patients who underwent partial nephrectomy for renal cell carcinoma (285 open partial nephrectomy [OPN], 96 laparoscopic partial nephrectomy [LPN], and 229 robot-assisted partial nephrectomy [RAPN]) with preoperative and postoperative DTPA within 1 year. We excluded multiple renal masses and history of immunotherapy or chemotherapy. Predictive factors for glomerular filtration rate (GFR) reduction were assessed using multivariate linear regression. RESULTS: Postoperative complications and disease-free survival were similar in the three groups. Within 1 postoperative year, OPN showed a significantly lower mean ipsilateral GFR than LPN and RAPN (28.9 versus 32.4 versus 32.7 mL/min/1.73 m 2 , respectively; P < 0.001). RAPN was associated with a significantly higher total GFR than OPN within 1 year (76.6 versus 71.2 mL/min/1.73 m 2 , respectively; P = 0.001). On multivariate analysis within 1 year, operation type (OPN versus RAPN: ß = 2.82; 95% confidence interval, 1.17-4.48; P = 0.001) was significantly associated with GFR reduction. CONCLUSION: There was no difference in postoperative complications and disease-free survival among operation types. RAPN could help to promote earlier recovery of ipsilateral GFR than OPN.

Prognostic Factors Related to Recurrence-Free Survival for Primary Carcinoma in situ of the Bladder after Bacillus Calmette-Guérin: A Retrospective Study.

INTRODUCTION: Primary carcinoma in situ (P-CIS) of the bladder is rare and its clinical behavior and predictive features have not been well described. The purpose of this study was to evaluate the effects of various factors including angiotensin-2 converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs) on recurrence-free survival (RFS)-related prognosis in patients with P-CIS. MATERIALS AND METHODS: In our medical center, 5,945 patients were diagnosed with bladder cancer from January 1999 to January 2014. Of these, 64 patients were diagnosed with CIS and were treated with at least 6 cycles of Bacillus Calmette-Guérin (BCG). We accessed variables including patient age, sex, initial presenting symptoms, smoking history, P-CIS descriptions, urine cytology, and medication history related to hypertension. RESULTS AND CONCLUSIONS: We evaluated the use of anti-hypertensive medications (ACEIs/ARBs, p = 0.028), the symptom of non-gross hematuria (p = 0.028), and older age (p = 0.015) as significant factors related to RFS. Older age was also a significant factor for influencing the RFS rate. We found that the use of anti-hypertensive medications (ACEIs/ARBs) improves RFS in patients with P-CIS after BCG therapy. The prognosis was poor when there was no gross hematuria and if patients were at older ages at the time of diagnosis of P-CIS.

Adaptive functional change of the contralateral kidney after partial nephrectomy.

Partial nephrectomy aims to maintain renal function by nephron sparing; however, functional changes in the contralateral kidney remain unknown. We evaluate the functional change in the contralateral kidney using a diethylene triamine penta-acetic acid (DTPA) renal scan and determine factors predicting contralateral kidney function after partial nephrectomy. A total of 699 patients underwent partial nephrectomy, with a DTPA scan before and after surgery to assess the separate function of each kidney. Patients were divided into three groups according to initial contralateral glomerular filtration rate (GFR; group 1: <30 ml·min-1·1.73 m-2, group 2: 30-45 ml·min-1·1.73 m-2, and group 3: ≥45 ml·min-1·1.73 m-2). Multiple-regression analysis was used to identify the factors associated with increased GFR of the contralateral kidney over a 4-yr postoperative period. Patients in group 1 had a higher mean age and hypertension history, worse American Society of Anesthesiologists score, and larger tumor size than in the other two groups. The ipsilateral GFR changes at 4 yr after partial nephrectomy were -18.9, -3.6, and 3.9% in groups 1, 2, and 3, respectively, whereas the contralateral GFR changes were 10.8, 25.7, and 38.8%. Age [ß: -0.105, 95% confidence interval (CI): -0.213; -0.011, P < 0.05] and preoperative contralateral GFR (ß: -0.256, 95% CI: -0.332; -0.050, P < 0.01) were significant predictive factors for increased GFR of the contralateral kidney after 4 yr. The contralateral kidney compensated for the functional loss of the ipsilateral kidney. The increase of GFR in contralateral kidney is more prominent in younger patients with decreased contralateral renal function.

Does lymph node dissection during nephroureterectomy affect oncological outcomes in upper tract urothelial carcinoma patients without suspicious lymph node metastasis on preoperative imaging studies?

PURPOSE: This study aimed to investigate the effects of lymph node dissection (LND) on upper tract urothelial carcinoma (UTUC) without suspicious lymph node (LN) metastasis on preoperative imaging studies. METHODS: From 1998 to 2012, 418 UTUC patients without suspicious LN metastasis on preoperative imaging studies were included. Patients were divided into two groups according to the performance of LND. The effects of LND on oncological outcomes were assessed after adjusting other variables. The mean follow-up duration was 69 months. RESULTS: Among the 132 patients who underwent LND, LN metastasis was pathologically identified in 16 patients (12.1 %). The median number of resected LNs for patients who underwent LND was 7. On multivariate analysis, the number of resected LNs and pathologic T stage was significant predictors of LN metastasis. The 5-year recurrence-free survival was 76.4 % for patients without LND and 65.4 % for patients with LND (p = 0.126). In addition, there was no difference in 5-year overall survival between the 2 groups (without LND; 71.7 % vs. with LND; 72.1 %, p = 0.756). Multivariate analysis showed that pathologic T stage, tumor grade, and lymphovascular invasion were risk factors for recurrence. Age at surgery, tumor size, pathologic T stage, tumor grade, and lymphovascular invasion were significantly associated with overall survival. However, performance of LND was not associated with recurrence and survival. CONCLUSIONS: LND could be selectively performed in patients with clinically LN-negative UTUC based on patient/tumor characteristics and operative findings although sufficient LNs should be removed if LND is to be performed.

Prostatic Arterial Embolization for Control of Hematuria in Patients with Advanced Prostate Cancer.

Nine patients with advanced prostate cancer (stage T4) underwent prostatic arterial embolization (PAE) for refractory prostatic hematuria. Angiograms showed prostatic neovascularity in all cases, and complete PAE was achieved in 8 cases (89% technical success rate). Gross hematuria ceased after PAE in 6 cases, translating to a 67% clinical success rate. There were no PAE-related complications. At 3-month follow-up, 2 cases showed recurrent hematuria, 4 patients had died from PAE-unrelated etiologies, and only 3 patients survived and were without gross hematuria. PAE could represent an alternative option for patients with advanced prostate cancer to control hematuria.

Risk Factors Associated with Decreased Renal Function after Hand-Assisted Laparoscopic Donor Nephrectomy: A Multivariate Analysis of a Single Surgeon Experience.

Background: Hand-assisted laparoscopic donor nephrectomy is a minimally invasive procedure for living kidney donation. The surgeon operative volume is associated with postoperative morbidity and mortality. We evaluated the risk factors associated with decreased renal function after hand-assisted laparoscopic donor nephrectomy performed by a single experienced surgeon. Methods: We included living renal donors who underwent hand-assisted laparoscopic donor nephrectomy by a single experienced surgeon between 2006 and 2013. Decreased renal function was defined as an estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73 m2 on postoperative day 4. The donors were categorized into groups with postoperative eGFR < 60 mL/min/1.73 m2 or ≥ 60 mL/min/1.73 m2. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with decreased renal function after hand-assisted laparoscopic donor nephrectomy. The hospital stay duration, intensive care unit admission rate, and eGFR at postoperative year 1 were evaluated. Results: Of 643 patients, 166 (25.8%) exhibited a postoperative eGFR of < 60 mL/min/1.73 m2. Multivariate logistic regression analysis demonstrated that the risk factors for decreased renal function were age [odds ratio (95% confidence interval), 1.062 (1.035-1.089), P < 0.001], male sex [odds ratio (95% confidence interval), 3.436 (2.123-5.561), P < 0.001], body mass index (BMI) [odds ratio (95% confidence interval), 1.093 (1.016-1.177), P = 0.018], and preoperative eGFR [odds ratio (95% confidence interval), 0.902 (0.881-0.924), P < 0.001]. There were no significant differences in postoperative hospital stay duration and intensive care unit admission rate between the two groups. In addition, 383 of 643 donors were analyzed at postoperative year 1. Sixty donors consisting of 14 (5.0%) from the group of 279 donors in eGFR ≥ 60 mL/min/1.73 m2, and 46 (44.2%) from the group of 104 donors in eGFR < 60 mL/min/1.73 m2 had eGFR < 60 mL/min/1.73 m2 at postoperative year 1 (P < 0.001). Conclusions: Increased age, male sex, higher BMI, and decreased preoperative eGFR were risk factors for decreased renal function after hand-assisted laparoscopic donor nephrectomy by a single experienced surgeon. These results provide important evidence for the safe perioperative management of living renal donors.

Preserving Renal Function through Partial Nephrectomy Depends on Tumor Complexity in T1b Renal Tumors.

This study aimed to determine patients with T1b renal cell carcinoma (RCC) who could benefit from partial nephrectomy (PN) and method to identify them preoperatively using nephrometry score (NS). From a total of 483 radical nephrectomy (RN)-treated patients and 40 PN-treated patients who received treatment for T1b RCC between 1995 and 2010, 120 patients identified through 1:2 propensity-score matching were included for analysis. Probability of chronic kidney disease (CKD) until postoperative 5-years was calculated and regressed with respect to the surgical method and NS. Median follow-up was 106 months. CKD-probability at 5-years was 40.7% and 13.5% after radical and PN, respectively (P = 0.005). While PN was associated with lower risk of CKD regardless of age, comorbidity, preoperative estimated renal function, the effect was observed only among patients with NS ≤ 8 (P < 0.001) but not in patients with NS ≥ 9 (P = 0.746). Percent operated-kidney volume reduction and ischemia time were similar between the patients with NS ≥ 9 and ≤ 8. In the stratified Cox regression accounting for the interaction observed between the surgical method and the NS, PN reduced CKD-risk only in patients with NS ≤ 8 (hazard ratio [HR], 0.054; P = 0.005) but not in ≥ 9 (HR, 0.996; P = 0.994). In T1b RCC with NS ≥ 9, the risk of postoperative CKD was not reduced following PN compared to RN. Considering the potential complications of PN, minimally invasive RN could be considered with priority in this subgroup of patients.

Acute Kidney Injury After Radical Cystectomy for Bladder Cancer is Associated with Chronic Kidney Disease and Mortality.

PURPOSE: The aim of this study was to investigate the prevalence of acute kidney injury (AKI) after radical cystectomy, and evaluate its impact on chronic kidney disease (CKD) and mortality. METHODS: The medical records of 866 patients who underwent radical cystectomy for bladder cancer were reviewed. AKI was assessed within 7 days after surgery according to the Acute Kidney Injury Network criteria. The prevalence of AKI after surgery was examined, and the significance of AKI for CKD and mortality was analyzed. RESULTS: Of 866 patients, 269 (31.1 %) developed AKI in the first week after surgery. Of these, 231 (85.9 %) were at stage 1, 32 (11.9 %) at stage 2, and 6 (2.2 %) at stage 3. Of 722 patients with a preoperative Modification of Diet in Renal Disease estimated glomerular filtration rate (eGFR) of >60 ml/min/1.73 m(2), CKD developed in 23.0 % (118/513) of patients in the non-AKI group and 32.5 % (68/209) of patients in the AKI group. Independent factors predicting new-onset CKD were a preoperative eGFR (p < 0.001), age (p = 0.011), urinary tract complication (p < 0.001) and AKI (p = 0.015). In all, 297 patients died (191 in the non-AKI group and 106 in the AKI group). AKI also correlated significantly with overall survival (p = 0.001). CONCLUSIONS: AKI is not only commonly encountered after radical cystectomy but is also associated with higher CKD rates and mortality. There is a critical need for strategies to increase the identification of patients at risk of postoperative AKI, and to improve the management of patients, with an aim toward preventing AKI and improving the treatment of AKI once it occurs.

Ileal Augmentation Cystoplasty Combined with Ileal Ureter Replacement After Radical Treatment for Cervical Cancer.

BACKGROUND: This study reviewed the outcomes for patients who underwent simultaneous bladder and ureter reconstructive surgery using the ileum after radical treatment for cervical cancer. METHODS: The medical records of seven patients who underwent augmentation ileocystoplasty with ileal ureter replacement between September 2006 and May 2013 were reviewed. Data on indications for surgery, underlying urologic comorbidities, type of ureteral replacement, postoperative complications, and changes in renal function were obtained. RESULTS: The median age of the patients was 56 years. The primary tumor was cervical cancer in all the patients, and the majority of the patients (4/7, 57.1 %) were previously treated with radical hysterectomy plus radiotherapy. Ileal ureter replacement was performed on 11 renal units, and bilateral ileal ureter substitution was performed for four patients, with the largest ureteral defect being 15 cm. The median length of the ileum used for augmentation and ureter substitution was 30 cm (range 15-40 cm), and the median hospital stay was 23 days (range 18-47 days). The overall rate of major complications (grade ≥3) was 57.1 % (4 of 7 patients). The median preoperative and immediate postoperative serum creatinine levels were respectively 1.2 mg/dL and 0.9 mg/dL. During a mean follow-up duration of 38 months, none of the patients experienced deterioration of renal function after surgery. CONCLUSION: Ileal ureter substitution combined with augmentation ileocystoplasty is a useful surgical technique for bridging long ureteral defects caused by ureteric stenosis from surgery, radiotherapy, or both for pelvic tumors in contracted low-compliance bladders.

Simple renal cyst and renal dysfunction: A pilot study using dimercaptosuccinic acid renal Scan.

AIM: Little is known about the association between renal cyst and renal dysfunction. We evaluated the deterioration of renal function in patients with unilateral, large, simple renal cysts. METHODS: Fifty patients with unilateral, simple renal cysts measuring ≥ 4 cm (cyst group) and 50 kidney donors (control group) were enrolled. Dimercaptosuccinic acid (DMSA) renal scans were performed to calculate split renal function. The differences between split renal function were calculated and compared. Clinical factors affecting decreased renal function in the cyst group were assessed. RESULTS: The mean age of the patients in the cyst group was higher than the control group (59.1 vs 39.2 years; P = 0.001). Patients with renal cysts tended to be diagnosed with hypertension (P = 0.001), However, the two groups did not significantly differ in terms of the other characteristics. The median cyst size was 7.2 cm (range, 4.5-14.2), and 31 of the 50 patients (60.2%) in the cyst group demonstrated decreased renal function in the cystic kidney units (median: 5.8%; range, 0.2-33). Although there were no differences in split renal function (50.1% vs 49.9%; P = 0.629) in the control group, the relative renal function of the cystic kidney units were significantly lower than the contralateral kidney units in the cyst group (48.3% vs 51.7%; P = 0.001). The decrease in relative renal function (>8%) in the cystic kidney units was associated with a higher serum uric acid levels and higher RENAL complexity (P = 0.035 and P = 0.007, respectively). CONCLUSION: A significant proportion of unilateral, large, simple renal cysts are associated with decreased relative renal function on DMSA renal scans.

Treatment of Anastomosis Stricture after Bilateral Ileal Ureter Reconstruction by Contralateral Retrograde Approach: Case Report.

A 37-year old woman with locally advanced uterine cervical cancer post concurrent chemoradiation, presented with an early anastomotic stricture after ileal ureter replacement due to the ischemic process during the reconstruction procedure. A bilateral ureteral stent was considered in order to relieve the obstructive uropathy. Multiple attempts were made to cannulate the stricture point between the right renal pelvis and ileal ureter, although all of them failed. The percutaneous contralateral nephrostomy tract was accessed and successfully used to perform retrograde approach cannulation. Balloon dilation at the stricture point and ureteral stent placement were successfully performed without any complications. Therefore, the contralateral retrograde approach for ureteral stent placement during bilateral ileal ureter reconstruction has been demonstrated to be both feasible and safe.

Hand-assisted laparoscopic bladder cuff excision via the same hand port as that used for nephroureterectomy.

PURPOSE: The aim of this study was to report our technique of hand-assisted laparoscopic bladder cuff excision through the same hand port as that used for nephroureterectomy and evaluate its benefits and short-term oncologic outcomes. MATERIALS AND METHODS: We included 67 consecutive patients treated by a single surgeon between June 2011 and November 2014 with hand-assisted laparoscopic bladder cuff excision through the same hand port as that used for nephroureterectomy. We retrospectively analyzed procedure-related clinical data and short-term oncologic outcomes. RESULTS: The mean patient age was 66.2 ± 10.6 years. The mean follow-up period was 17.6 months (range 1-37 months). The mean operation time was 243.5 ± 60.4 min. There were no major accidents or open conversions. Forty-two patients (63 %) underwent immediate mitomycin C instillation without complications. There was one high-grade complication (prolonged lymphatic leakage) that required reoperation and multiple hospitalizations. Thirty patients (45 %) underwent regional lymph node dissection. The pathological stages included CIS in 2 (3 %), Ta/T1 in 32 (48 %), T2 in 6 (9 %), T3 in 27 (40 %), and N+ in 4 (6 %) cases. G1, G2, and G3 were seen in 3 (5 %), 21 (31 %), and 43 (64 %) patients, respectively. Eighteen patients (26 %) underwent postoperative adjuvant chemotherapy. Two patients died during the study period, and nine patients (13 %) had bladder recurrences. CONCLUSIONS: HAL bladder cuff excision through the same hand port used for nephroureterectomy is a feasible technique that is both amenable to oncologic principles and can reproduce the open surgical technique.

Analysis of pre-operative variables for identifying patients who might benefit from upfront cytoreductive nephrectomy for metastatic renal cell carcinoma in the targeted therapy era.

OBJECTIVE: The aim of the study is to identify pre-operative variables for selection of patients who would benefit from upfront cytoreductive nephrectomy for metastatic renal cell carcinoma. METHODS: We reviewed the medical records of 171 patients who were presented with synchronous metastatic renal cell carcinoma and who had received no systemic therapy before enrollment. Of these, 96 underwent cytoreductive nephrectomy followed by targeted therapy (cytoreductive nephrectomy group) and 75 treated with targeted therapy alone (non-cytoreductive nephrectomy group). A Cox proportional hazards regression model was used to estimate the prognostic significance of pre-operative characteristics predicting overall survival in the cytoreductive nephrectomy group. The significant variables were designated as pre-operative factors to identify patients who would benefit from cytoreductive nephrectomy. RESULTS: The median overall survival was 19.9 and 11.7 months in the cytoreductive nephrectomy and non-cytoreductive nephrectomy groups (P < 0.001). Karnofsky performance status (<80; hazard ratio 9.497, P < 0.001), hemoglobin (less than lower limit of normal; hazard ratio 1.913, P = 0.025), neutrophils (greater than upper limit of normal; hazard ratio 6.533, P < 0.001) and clinical N stage (N2; HR 2.714, P = 0.001) were independent pre-operative risk factors of mortality. Only those patients with risk factor <2 who had undergone upfront cytoreductive nephrectomy had a better median overall survival than patients who received targeted therapy alone (28.2 vs. 18.4 months, P = 0.018). CONCLUSIONS: Four pre-operative risk factors (Karnofsky performance status, hemoglobin, neutrophils and clinical N stage) were identified as suitable for selection of patients who would not benefit from undergoing cytoreductive nephrectomy.

Is intravesical Bacillus Calmette-Guérin therapy superior to chemotherapy for intermediate-risk non-muscle-invasive bladder cancer? An ongoing debate.

The objective of this study was to evaluate the risk of recurrence in patients with intermediate-risk non-muscle-invasive bladder cancer (NMIBC) after intravesical instillation with chemotherapeutic agents or Bacillus Calmette-Guérin (BCG) therapy. A cohort of 746 patients with intermediate-risk NMIBC comprised the study group. The primary outcome was time to first recurrence. The recurrence rates of the transurethral resection (TUR) alone, chemotherapy, and BCG groups were determined using Kaplan-Meier analysis. Risk factors for recurrence were identified using Cox regression analysis. In total, 507 patients (68.1%), 78 patients (10.5%), and 160 (21.4%) underwent TUR, TUR+BCG, or TUR+chemotherapy, respectively. After a median follow-up period of 51.7 months (interquartile range=33.1-77.8 months), 286 patients (38.5%) developed tumor recurrence. The 5-yr recurrence rates for the TUR, chemotherapy, and BCG groups were 53.6%±2.7%, 30.8%±5.7%, and 33.6%±4.7%, respectively (P<0.001). Chemotherapy and BCG treatment were found to be predictors of reduced recurrence. Cox-regression analysis showed that TUR+BCG did not differ from TUR+chemotherapy in terms of recurrence risk. Adjuvant intravesical instillation is an effective prophylactic that prevents tumor recurrence in intermediate-risk NMIBC patients following TUR. In addition, both chemotherapeutic agents and BCG demonstrate comparable efficacies for preventing recurrence.