Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma.

PURPOSE: To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation. RESULTS: The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months). CONCLUSION: While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes.

Surgical complications associated with robotic urologic procedures in elderly patients.

INTRODUCTION: Urologic malignancies are often diagnosed at an older age, and are increasingly managed utilizing robotic-assisted surgical techniques. As such, we assessed and compared peri-postoperative complication rates following robotic urologic surgery in elderly and younger patients. MATERIALS AND METHODS: A retrospective analysis of IRB-approved databases and electronic medical records identified patients who underwent robotic-assisted urologic surgery between December 2003-September 2013. Patients were grouped according to surgical procedure (partial nephrectomy, radical cystectomy, radical prostatectomy) and age at surgery (≤ 74 or ≥ 75 years old). Associations between age, comorbidities, Charlson comorbidity index (CCI), and patient outcomes were evaluated within each surgery type. RESULTS: 97.5% and 2.5% of patients were ≤ 74 or ≥ 75 years old, respectively. Cystectomies, partial nephrectomies and prostatectomies accounted for 3.5%, 9.5% and 87.1% of surgeries, respectively. Within cystectomy, nephrectomy and prostatectomy groups, 24.4%, 12.5% and 0.6% patients were ≥ 75 years old. Within each surgical type, elderly patients had significantly elevated CCI scores. Length of stay was significantly prolonged in elderly patients undergoing partial nephrectomy or prostatectomy. In elderly cystectomy, partial nephrectomy and prostatectomy patients, 36.7%, 14.3% and 5.9% suffered ≥ 1 Clavien grade 3-5 complication, respectively. Major complications were not significantly different between age groups. A qualitatively similar pattern was observed regarding Clavien grade 1-2 complications. CONCLUSIONS: The risks of robotic-assisted urologic surgery in elderly patients are not significantly elevated compared to younger patients.

Oncological and functional outcomes of salvage renal surgery following failed primary intervention for renal cell carcinoma

Purpose To assess the oncologic and functional outcomes of salvage renal surgery following failed primary intervention for RCC. Materials and Methods We performed a retrospective review of patients who underwent surgery for suspected RCC during 2004-2012. We identified 839 patients, 13 of whom required salvage renal surgery. Demographic data was collected for all patients. Intraoperative and postoperative data included ischemic duration, blood loss and perioperative complications. Preoperative and postoperative assessments included abdominal CT or magnetic resonance imaging, chest CT and routine laboratory work. Estimated glomerular filtration rate (eGFR) was calculated according to the Modification of Diet in Renal Disease equation. Results The majority (85%) of the patients were male, with an average age of 64 years. Ten patients underwent salvage partial nephrectomy while 3 underwent salvage radical nephrectomy. Cryotherapy was the predominant primary failed treatment modality, with 31% of patients undergoing primary open surgery. Pre-operatively, three patients were projected to require permanent post-operative dialysis. In the remaining 10 patients, mean pre- and postoperative serum creatinine and eGFR levels were 1.35 mg/dL and 53.8 mL/min/1.73 m2 compared to 1.43 mg/dL and 46.6 mL/min/1.73 m2, respectively. Mean warm ischemia time in 10 patients was 17.4 min and for all patients, the mean blood loss was 647 mL. The predominant pathological stage was pT1a (8/13; 62%). Negative surgical margins were achieved in all cases. The mean follow-up was 32.9 months (3.5-88 months). Conclusion While salvage renal surgery can be challenging, it is feasible and has adequate surgical, functional and oncological outcomes. .

Clinical and radiographic characteristics governing the selection of therapy of small renal masses.

INTRODUCTION: Renal masses are commonly managed by partial nephrectomy (PN) or active surveillance (AS). We assessed the impact of patient demographics and clinical indices in determining treatment decisions of renal masses between these two options. MATERIALS AND METHODS: We retrospectively reviewed our renal mass database to retrieve demographic and clinical records of patients who underwent immediate PN or entered a >= 12 month period of AS during February 1999 to May 2014. Age, gender, body mass index (BMI), Charlson Comorbidity Index (CCI) score, follow up time, tumor size, tumor location, renal invasion, creatinine, and estimated glomerular filtration rate (eGFR) were assessed as predictors of the selected treatment option. RESULTS: Seven hundred thirty-five patients with 744 renal masses underwent immediate PN, while 123 patients with 140 renal masses entered active surveillance. PN patients were predominantly male, younger, had elevated BMI, lower CCI scores, elevated eGFR and had larger tumors that invaded further into the renal collecting system. Renal masses in men were more likely to be treated by PN, while patients categorized as overweight or obese were 2-3 fold more likely to have their renal mass being manage by PN (versus patients with BMI in the normal range). Higher CCI scores were associated with a renal mass being more likely to be treated by AS, while increased renal mass size was associated with decisions to treat with PN. Compared to cortical location, renal masses abutting the renal collecting system were more likely to be treated by PN. CONCLUSIONS: Gender, BMI, CCI, tumor size, and tumor invasion into the renal system are useful predictors of renal mass treatment.

Spontaneous bladder perforation unrelated to trauma or surgery.

Urinary bladder ruptures (UBR) typically result from either blunt or penetrating trauma, or from iatrogenic surgical injuries. Patients typically present with symptoms including lower abdominal pain, haematuria, dysuria and anuria. Here, we report on a rare case of spontaneous bladder perforation. A 60-year-old, Caucasian woman initially presented with lower abdominal pain and diarrhoea, and was subsequently found to have an elevated serum creatinine level. A CT cystogram revealed a leak from the bladder. The patient consented to exploratory laparotomy and repair of the non-traumatic bladder perforation. At the time of the last follow-up, given the fact that the patient's urodynamics were unremarkable and that she was emptying her bladder well (repeat postvoid residual was zero), the patient was informed that she did not require future urological follow-up unless difficulties arise.

Single-stage renal transplantation-urinary diversion: a novel surgical approach.

INTRODUCTION: This article reports outcomes of 2 patients who received a single-stage renal transplantation and concomitant urinary-diversion procedure. TECHNICAL CONSIDERATIONS: We followed the clinical diagnosis and outcome of 2 patients who underwent renal transplantation and urinary diversion as a single-stage procedure by retrospectively reviewing a Hartford Hospital Institutional Review Board-approved kidney database. Patient demographics, renal function, and surgical outcomes were examined. CONCLUSION: Two patients underwent a simultaneous renal transplantation-ileal conduit creation to surgically manage their end-stage renal disease. One patient did not have any surgical complications, whereas the other suffered from a postoperative ileus (Clavien grade 3a), atrial fibrillation (Clavien grade 2), hypertension (Clavien grade 2), methicillin-resistant Staphylococcus aureus at the incisional site (Clavien grade 2), and a positive urine culture managed using antibiotics (Clavien grade 2). No major complications were observed and both have favorable outcomes at 23 and 19 months after surgery, respectively. This report demonstrates the feasibility and safety of single-stage renal transplantation and urinary diversion in select patients with end-stage renal disease status after cystectomy. To our knowledge, this is the first report of this novel technique.

Malignant renal angiomyolipoma without tuberous sclerosis.

A 68-year-old woman presented with abdominal pain, fatigue, anorexia and night sweats. Imaging studies identified a vascular mass extending from the upper pole of the right kidney with anterior displacement to the abdominal midline, consistent with renal cell carcinoma. A radical nephrectomy and right pelvic lymph node dissection was performed. Pathology determined a grade 4 malignant epithelioid angiomyolipoma that invaded hilar and perinephric adipose tissue. Gross tumour was also present within the renal vein, sinus, pelvis, capsule and perinephric fat. The tumour was HMB-45 positive, supporting the diagnosis of a typical angiomyolipoma in association with the high-grade epithelioid tumour.

Fibroepithelial ureteral polyps presenting as ureteropelvic obstruction.

A 57-year-old woman presented with bilateral abdominal pain and flank discomfort. Imaging studies, consisting of CT scan, diethylene triamine pentaacetic acid renal scan with Lasix and a retrograde pyelogram, indicated an obstruction at the uteropelvic junction (UPJ), possibly due to fibroepithelial polyps within the ureter. A robotic pyeloplasty revealed a ureteral diverticulum and a thin, still-attached fibroepithelial polyp of approximately 2 cm in length. The patient tolerated the procedure well and was discharged one day postpyeloplasty with no reported complications. This rare clinical scenario should be considered when formulating a diagnosis for a UPJ obstruction.

An unusually large leiomyoma of the prostate.

Prostate leiomyomas are benign mesenchymal smooth muscle tumors devoid of glandular elements within the prostate or juxta-prostatic position. Leiomyomas develop in organs containing smooth muscle, including the kidney, bladder and seminal vesicle. Prostate leiomyomas are either a pure form or associated with benign prostate hyperplasia, and diagnosis is challenging, with definitive identification relying on pathology. However, imaging techniques, such as MRI, have proven to be useful diagnostic tools. We report on a 57-year-old male with lower urinary tract symptomatology who was diagnosed with a large prostate leiomyoma and underwent an open radical cystoprostatectomy and ileal conduit urinary diversion.