ABSTRACT
Although Wilms tumor (WT) is the most common pediatric renal tumor, adolescent and adult WT is rare. Nevertheless, adolescent renal tumors as a group are sufficiently uncommon that WT must be included in the differential diagnosis for such patients, and in doing so affects the oncologic considerations of the surgery. Herein, we describe a 14-year-old female presenting with a 1-month history of right flank pain. Subsequent work-up revealed a localized, centrally located, enhancing right renal mass. The patient underwent robotic-assisted laparoscopic radical nephrectomy and pathology demonstrated stage II, favorable histology WT. Herein, we will discuss the pertinent details regarding adolescents with renal tumors and the risks and benefits of using a minimally invasive surgical approach.
Subject(s)
Kidney Neoplasms/surgery , Laparoscopy , Nephrectomy , Robotics , Wilms Tumor/surgery , Adolescent , Antineoplastic Agents/therapeutic use , Female , Humans , Kidney Neoplasms/pathology , Prognosis , Tumor Burden , Wilms Tumor/pathologyABSTRACT
Introduction: Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for postoperative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics after infant robotic pyeloplasty. Methods: We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes, and unscheduled health care encounters within 30 postoperative days. Results: Sixty-three percent (15/24) of patients were male and average age was 12.1 months (range 4-34 months). Fifty-eight percent (9/15) underwent surgery on the left, and 16.7% (4/24) of patients received a single postoperative dose of narcotics in the postanesthesia care unit. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related unscheduled visits or phone calls after discharge. Conclusions: This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Postprocedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.
Subject(s)
Anesthesia, Caudal , Robotic Surgical Procedures , Child, Preschool , Female , Humans , Infant , Male , Narcotics/therapeutic use , Pain, Postoperative/drug therapy , Pain, Postoperative/etiology , Retrospective Studies , Treatment Outcome , Urologic Surgical Procedures/methodsABSTRACT
Transfecting genes into tumors, to upregulate major histocompatibility complex (MHC) class I and class II molecules and inhibit MHC class II associated invariant chain (Ii), induces a potent anti-tumor immune response when preceded by tumor irradiation, in murine RM-9 prostate carcinoma. The transfected genes are cDNA plasmids for interferon-gamma (pIFN-gamma), MHC class II transactivator (pCIITA), an Ii reverse gene construct (pIi-RGC), and a subtherapeutic dose of adjuvant IL-2 (pIL-2). Responding mice rejected challenge with parental tumor and demonstrated tumor-specific cytotoxic T lymphocytes (CTLs). We have extended our investigation to determine the relative roles of each one of the four plasmids pIFN-gamma, pCIITA, pIi-RGC, and pIL-2 in conjunction with radiation for the induction of a curative immune response. Upregulation of MHC class I with pIFN-gamma or class II with pCIITA, separately, does not lead to a complete response even if supplemented with pIL-2 or pIi-RGC. An optimal and specific antitumor response is achieved in more than 50% of the mice when, after tumor irradiation, tumor cells are converted in situ to a MHC class I+/class II+/Ii- phenotype with pIFN-gamma, pCIITA, pIi-RGC, and pIL-2. We demonstrate further that both CD4+ helper T cells and CD8+ cytotoxic T cells are essential for induction of an antitumor response because in vivo depletion of either subset abrogates the response. The radiation contributes to the gene therapy by causing tumor debulking and increasing the permeability of tumors to infiltration of inflammatory cells.
Subject(s)
Gene Expression , Genetic Therapy , Histocompatibility Antigens Class II/genetics , Histocompatibility Antigens Class I/genetics , Nuclear Proteins/genetics , Prostatic Neoplasms/genetics , Prostatic Neoplasms/radiotherapy , Trans-Activators/genetics , Animals , Antigens, Differentiation, B-Lymphocyte/chemistry , Antigens, Differentiation, B-Lymphocyte/genetics , Antigens, Differentiation, B-Lymphocyte/metabolism , CD4-Positive T-Lymphocytes/metabolism , CD8-Positive T-Lymphocytes/metabolism , Cell Survival/physiology , Cell Survival/radiation effects , Colony-Forming Units Assay , Combined Modality Therapy , Histocompatibility Antigens Class II/chemistry , Histocompatibility Antigens Class II/metabolism , Interferon-gamma/genetics , Interferon-gamma/metabolism , Interleukin-2/genetics , Interleukin-2/metabolism , Lymphocyte Depletion , Male , Mice , Mice, Inbred C57BL , Neoplasm Proteins/genetics , Nuclear Proteins/metabolism , Prostatic Neoplasms/immunology , T-Lymphocytes, Cytotoxic/immunology , Trans-Activators/metabolism , Transduction, Genetic , Tumor Cells, Cultured , X-RaysABSTRACT
OBJECTIVE: We aimed to determine the duration and associated complications of postoperative urinary leakage in pediatric patients undergoing open, non-stented dismembered pyeloplasty for ureteropelvic junction obstruction. METHODS: A retrospective review of 100 patients who underwent an open non-stented dismembered pyeloplasty between 2003 and 2008 was performed. Duration of urinary leakage and postoperative complications were tabulated. Patients were considered to have a dry anastomosis if the Penrose drain was removed within one week of surgery. RESULTS: Duration of leakage ranged from 0 to 27 days. 86% had Penrose drain removal within 7 days of surgery and were considered dry.14 patients demonstrated a persistent urinary leakage (PUL) ranging from 7 to 27 days. Complications of any type were significantly more likely in the group with prolonged drainage (p = .0126). UTI and obstruction were not significantly more likely to occur in patients with PUL (p = .0931 and p = .2616 respectively). Only one patient with PUL required placement of a ureteral stent. CONCLUSION: We demonstrate that stentless dismembered pyeloplasty is feasible with a low rate of urinary drainage beyond one week. The character and quality of the slightly increased complications in those that demonstrated PUL were not great and not bothersome enough to warrant routine stenting.