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INTRODUCTION: A dilemma that urologists face is how to determine which patients with prostate cancer need immediate intervention and which patients can be safely placed on active surveillance. Gene expression profile analysis of biopsy tissue has been proposed as a means of providing more accurate risk stratification for low risk prostate cancer. However, there is a general lack of acceptance and standardization around the integration of genomic testing in clinical practice. The Oncotype DX® prostate cancer assay is a commercially available tissue based assay that assesses the expression of key genes across multiple biological pathways predictive of prostate cancer aggressiveness from the diagnostic biopsy specimen, and reports an individual Genomic Prostate Score. METHODS: With the recommendations set forth in this article we aim to standardize operational best practices for the integration of the Genomic Prostate Score into clinical practice. Its purpose is to provide practical guidance to help physicians understand, run, interpret and communicate actionable results to patients. RESULTS: The Genomic Prostate Score reflects the biology of the underlying tumor to help guide initial treatment decisions at the time of biopsy. This article is based on real-world evidence from the authors' respective experiences at their institutions and practices. The authors were carefully selected based on their depth of experience and knowledge about the Genomic Prostate Score and, as such, it is their expertise that is being leveraged to support the best practices algorithm. CONCLUSIONS: This article provides easy to use, clear-cut and practical guidance for physicians on how to use the Genomic Prostate Score to inform decisions regarding active surveillance.
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Pelvis Renal/cirugía , Terapia por Láser/efectos adversos , Arteria Renal , Enfermedades Ureterales/etiología , Fístula Urinaria/etiología , Fístula Vascular/etiología , Adulto , Femenino , Humanos , Procedimientos Quirúrgicos Urológicos/efectos adversos , Procedimientos Quirúrgicos Urológicos/métodosRESUMEN
OBJECTIVE: To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot-assisted radical prostatectomy (RARP) after the initial 'learning curve', as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate. PATIENTS AND METHODS: We retrospectively reviewed the charts of patients who had RARP between March 2005 and August 2007, and analysed demographic, perioperative variables and pathological data. In all, 510 patient charts were reviewed, identifying 24 patients with a history of previous treatment to the prostate including transurethral resection or incision of the prostate, transurethral microwave therapy, transurethral needle ablation, photoselective vaporization, simple prostatectomy, external beam radiotherapy, brachytherapy, and open bladder neck reconstruction (group 1) and 486 with no previous treatment (group 2). RESULTS: There was no significant difference between the groups in body mass index, clinical stage, grade or prostate volume, but the patients in group 1 were older (70 vs 65 years, P = 0.001). Outcome analysis comparing groups 1 and 2 showed an estimated blood loss of 155 vs 137 mL, length of hospital stay of 2.2 vs 1.5 days, operative duration of 200 vs 186 min and catheter time of 12 vs 8 days, respectively; only the last was statistically significant (P = 0.03). There was an 8.3% and 6.8% complication rate in groups 1 and 2, respectively, and the respective overall positive margin rate was 20.8% and 22.6%. CONCLUSIONS: A history of previous treatment of the prostate does not appear to compromise the perioperative outcomes of RARP.
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Complicaciones Posoperatorias/etiología , Próstata/cirugía , Prostatectomía/métodos , Enfermedades de la Próstata/cirugía , Robótica , Anciano , Índice de Masa Corporal , Humanos , Tiempo de Internación , Masculino , Próstata/patología , Próstata/efectos de la radiación , Prostatectomía/efectos adversos , Prostatectomía/normas , Enfermedades de la Próstata/radioterapia , Reoperación , Estudios Retrospectivos , Resección Transuretral de la Próstata , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: The role of laparoscopic radical nephrectomy (LRN) for very large renal tumors remains to be defined. We review our experience with LRN for very large (> or =10 cm) renal malignancies. PATIENTS AND METHODS: A retrospective analysis of 360 consecutive patients who underwent LRN for renal tumors between October 1999 and May 2007 in a tertiary academic center identified 11 patients with malignancies > or =10 cm. RESULTS: Median age was 67 years (range 48-80 y), operative time was 170 minutes (range 80-240 min), estimated blood loss was 150 mL (range 50-300 mL), and length of stay was 2 days (range 1-6 d). There were two minor postoperative complications (acute renal insufficiency and ileus). Median tumor size was 12 cm (range 10-21 cm). Pathologic stage for patients with renal cell carcinoma was T(2), T(3a), T(3b), and T(4), in five, three, two, and one patient(s), respectively. One patient died after brain metastasis developed. Two patients in whom pulmonary metastases developed were still alive at last follow-up. CONCLUSIONS: LRN was successfully performed in patients with renal tumors up to 21 cm. Important considerations when performing LRN include the individual clinical picture, surgeon experience, tumor location, and patient well-being. LRN for very large tumors is feasible in properly selected patients and can have significant benefits in the palliative setting.
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Neoplasias Renales/patología , Neoplasias Renales/cirugía , Laparoscopía , Nefrectomía/métodos , Anciano , Anciano de 80 o más Años , Humanos , Neoplasias Hepáticas/patología , Neoplasias Hepáticas/secundario , Imagen por Resonancia Magnética , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE: We present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava. PATIENTS AND METHODS: A total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult. RESULTS: Preoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later. CONCLUSION: In patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.
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Laparoscopía/métodos , Nefrectomía/métodos , Venas Renales/cirugía , Trombosis/cirugía , Vena Cava Inferior/cirugía , Anciano , Anciano de 80 o más Años , Carcinoma de Células Renales/cirugía , Humanos , Neoplasias Renales/cirugía , Persona de Mediana Edad , Atención Perioperativa , Cuidados Posoperatorios , Venas Renales/patología , Resultado del Tratamiento , Vena Cava Inferior/patologíaRESUMEN
OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large renal calculi. The most widely used access sheath for PCNL involves two steps including placement of a high-pressure balloon catheter (HPBC) followed by advancement of a sheath over the balloon. A novel PCNL balloon/sheath combination (NSS) has been developed that allows for both dilation and sheath placement in a single step. The objective of this study was to compare the safety and efficacy of the NSS to the HPBC in a porcine model. METHODS: Six farm pigs underwent placement of a standard HPBC in one kidney and the NSS on the contralateral side. We obtained access in the upper pole in 2 animals, middle pole in 2 animals, and lower pole in 2 animals. We obtained data on insertion time, difficulty of insertion, estimated blood loss (EBL), ability to visualize the collecting system, and gross and histopathologic analysis. RESULTS: There was no statistical difference in degree of difficulty in placing the NSS (3 easy, 3 moderate) versus HPBC device (1 easy, 5 moderate; P = 0.07), estimated blood loss (P = 0.10), or the ability to visualize the collecting system (P = 0.32). There was a significantly shorter insertion time in the NSS group compared with the HPBC group (1:37 versus 2:26 minutes, P = 0.04). CONCLUSION: This study demonstrates that the NSS is safe and effective in the porcine model. Trials in patients are currently under way.
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Cateterismo , Nefrostomía Percutánea/instrumentación , Nefrostomía Percutánea/métodos , Animales , Diseño de Equipo , Femenino , PorcinosRESUMEN
OBJECTIVES: There is no consensus as to the management of positive surgical margins after laparoscopic partial nephrectomy (LPN). A recent study revealed no evidence of malignancy in radical nephrectomy specimens removed for this reason, pointing out that a positive margin does not always translate to residual disease. We present results from our institution for the first 80 LPN performed with minimum 2 years' follow-up, focusing on patients with malignancy noted to have positive margin on final pathology. METHODS: We performed a retrospective chart review for patients who had undergone laparoscopic partial nephrectomy for malignancy and a minimal follow-up of 2 years. Patient demographic, operative, and perioperative data were collected. Those cases with positive margins were selected for specific oncologic analysis. RESULTS: Of the 80 LPN performed, 50 were performed for malignancy. Mean tumor size was 2.2 cm. Five patients were found to have positive margin for renal cell carcinoma. All five of these masses were excised without hilar clamping using thermal dissection with energy ablation of the tumor bed. All patients underwent surveillance with a mean follow-up of 56.4 months with no recurrences. One patient with a negative surgical margin experienced a metachronous lesion in the contralateral kidney 3 years later. CONCLUSIONS: Surveillance in selected patients may be adequate without sacrificing oncologic control. However, long-term follow-up is essential. Hilar clamping may allow optimal visualization for tumor excision and allows excision to be performed without energy, potentially decreasing the rate of true- and false-positive margins.
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Neoplasias Renales/patología , Neoplasias Renales/cirugía , Laparoscopía , Nefrectomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Arizona , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Vigilancia de la Población , Estudios RetrospectivosRESUMEN
OBJECTIVE: To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal-dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task. PATIENTS AND METHODS: The study was a retrospective chart review of all patients undergoing BLN for ADPKD. Patient demographics, indications for the procedure, perioperative data, and pathological data were analysed. RESULTS: In all, 12 patients underwent BLN at our institution; eight were performed before transplant, three after transplant, and one with a concomitant kidney transplant. Indications for surgery included abdominal pain, fullness and early satiety, recurrent urinary tract infections, and need for space for future transplant. The mean patient age was 49.6 years, with a body mass index of 27.0 kg/m(2). The mean operative duration was 214 min, estimated blood loss was 169 mL, and the hospital stay was 4 days. There were no conversions to open surgery. The mean (range) pathological kidney mass was 2243 (656-4200) g on the left and 2379 (789-5042) g on the right. No patients with a previous renal transplant had deterioration in postoperative renal function. There was one minor intraoperative complication, one postoperative complication, and one patient with preoperative anaemia required a blood transfusion. CONCLUSIONS: Symptomatic patients with ADPKD due to massively enlarged kidneys should be considered for BLN when performed by an experienced laparoscopic surgeon. This includes patients with an existing renal allograft and candidates for concomitant transplantation. The approach should be tailored to avoid injury to adjacent structures secondary to displacement from the mass effect of these kidneys.
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Trasplante de Riñón , Laparoscopía , Nefrectomía/métodos , Riñón Poliquístico Autosómico Dominante/cirugía , Adulto , Femenino , Humanos , Complicaciones Intraoperatorias/etiología , Masculino , Persona de Mediana Edad , Nefrectomía/efectos adversos , Riñón Poliquístico Autosómico Dominante/patología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Management of the renal vasculature during right laparoscopic donor nephrectomy (LDN) to maximize vessel length has been controversial. The endovascular gastrointestinal anastomosis (GIA) stapler has been used for renal vascular control for our donors since the inception of our LDN program. We evaluated and compared the outcomes of right and left LDNs using a single method for hilar control. STUDY DESIGN: A retrospective review was performed of the first 400 LDNs and respective recipients at our institution. Patient demographics, perioperative variables, graft function, and complications were analyzed. RESULTS: Four hundred LDNs were performed between 1999 and 2007. Forty-one were on the right. There were no statistically significant differences between the donor groups or their respective recipients. There were 4 (1%) stapler malfunctions, all occurring on the left side; 2 of these procedures were converted to open to obtain hemostasis. There were nearly equal rates of vascular complications, 4.9% and 4.7%, in the right and left groups, respectively. The overall immediate graft failure rate was 2.3%. Right and left recipient creatinine levels up to 24 months demonstrated no statistically significant differences. CONCLUSIONS: We propose that the endovascular GIA stapler for left and right laparoscopic donor nephrectomy is safe for the donor. It standardizes the process, minimizes the need for additional maneuvers in securing the renal hilum, and produces similar outcomes for the recipient. The transplant team also plays an equally large role in favorable graft outcomes.
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Nefrectomía/instrumentación , Grapado Quirúrgico/instrumentación , Adulto , Femenino , Humanos , Laparoscopía , Donadores Vivos , Masculino , Persona de Mediana Edad , Nefrectomía/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: A novel 1-step percutaneous access sheath NS has been developed that allows the insertion of a dilating balloon and renal access sheath in a single step. We present the initial human experience with this sheath. MATERIALS AND METHODS: We performed a retrospective chart and database review of the initial 30 consecutive patients undergoing percutaneous nephrostolithotomy using the NS. Data collected included patient demographics, operative and recovery parameters, and complications. RESULTS: Mean patient age was 50.4 years (range 11 to 81), mean body mass index was 31.63 kg/m(2) (range 17.1 to 65) and mean preoperative stone area was 6.23 cm(2) (range 1 to 14.6). Six and 3 patients had full and partial staghorn calculi, respectively. Access was achieved via the upper pole in 16 patients, middle pole in 7 and lower pole in 7. Mean operative time was 114.8 minutes (range 61 to 237). Mean estimated blood loss was 145.5 cc (range 10 to 500) and mean postoperative hospital stay was 4.89 days (range 2 to 14). A total of 23 patients (76.7%) had no residual calculi on postoperative computerized tomography, 5 (16.7%) had residual fragments 4 mm or less and 2 (6.7%) had residual stone fragments greater than 4 mm. There were no complications related to the NS. CONCLUSIONS: The NS is safe, easy to use and has potential advantages compared to currently available renal access sheaths.
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Cálculos Renales/cirugía , Nefrostomía Percutánea/instrumentación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Diseño de Equipo , Humanos , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE: To compare the efficacy of nonabsorbable polymer ligating (NPL) and titanium clips applied with and without a 1-mm vascular cuff at physiologic and supraphysiologic pressures. MATERIALS AND METHODS: An in vitro equine-vessel model was created to test clip occlusion strength. Ten-millimeter NPL and standard Ti clips were applied to veins (10 mm) and arteries (10, 6, and 5 mm) with and without a 1-mm cuff and tested until they held a pressure of 300 mm Hg (veins) or 760 mm Hg (arteries) for 2 minutes or leaked. RESULTS: The NPL clip was statistically more secure on 10-mm veins with and without a cuff, 10-mm arteries with and without a cuff, and 6-mm arteries with a cuff than was the Ti clip. Leaving a 1-mm cuff resulted in a statistically higher leak point in all vessels tested except the 6-mm arteries secured with the Ti clip. CONCLUSIONS: The NPL clip was more secure than the Ti clip on larger arteries and veins. A 1-mm vascular cuff enhances the security of both NPL and Ti clips in vessels of all sizes. The NPL clip is secure and reliable in securing both arteries and veins.
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Hemostasis Quirúrgica/instrumentación , Polímeros , Titanio , Animales , Caballos , Ligadura/instrumentación , Ensayo de Materiales , Modelos Animales , Estrés MecánicoRESUMEN
BACKGROUND: The large and variable size of the renal vein has prompted most surgeons to select linear stapling devices to secure the vein during laparoscopic donor nephrectomy. Although effective, these stapling devices have a potential for misfire. Use of the nonabsorbable polymer ligating (NPL) clip during laparoscopic donor nephrectomy provides increased graft vessel length compared with the stapling device, and the NPL clip has a locking mechanism which may increase security compared with standard titanium clips. The objective of this study was to evaluate the safety and efficacy of the NPL clip for control of the renal artery and vein during hand-assisted laparoscopic donor nephrectomy (HALDN). METHODS: A retrospective chart review of 50 consecutive HALDN patients was conducted where two parallel NPL clips were used to control both the renal artery and vein. Information collected included demographic data, operative and postoperative data, and complications. RESULTS: Mean donor age was 33.4 years and body mass index was 25.8 kg/m2. Mean operative time was 266.0 min, mean hospital stay was 3.2 days, and mean warm ischemia time was 123.3 seconds. There were no transfusions, open conversions, or complications related to use of the NPL clip. A US 16,300 dollars disposable cost savings was seen during this 1-year period alone. CONCLUSIONS: The NPL clip was 100% safe and effective in controlling the renal artery and vein during HALDN, allowed for additional vessel length, and resulted in a disposable cost savings of US 362 dollars per patient.
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Materiales Biocompatibles/química , Trasplante de Riñón/métodos , Laparoscopía/métodos , Nefrectomía/métodos , Polímeros/química , Arteria Renal/cirugía , Venas Renales/cirugía , Grapado Quirúrgico/métodos , Recolección de Tejidos y Órganos/métodos , Obtención de Tejidos y Órganos/métodos , Adulto , Transfusión Sanguínea , Femenino , Hemostasis Quirúrgica , Humanos , Isquemia , Trasplante de Riñón/economía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Instrumentos Quirúrgicos , Factores de Tiempo , Recolección de Tejidos y Órganos/economíaRESUMEN
BACKGROUND AND PURPOSE: Gelatin matrix hemostatic sealant (GMHS) has been used for hemostasis during partial nephrectomy with hilar clamping. The objective of this study was to determine the ability of GMHS to achieve hemostasis without hilar clamping in the porcine model. MATERIALS AND METHODS: In this feasibility study, eight farm pigs underwent a left-hand-assisted laparoscopic partial nephrectomy (HALPN). The lower fourth of the kidney was removed with cold scissors, and GMHS was applied laparoscopically. Samples were collected for measurement of serum hemoglobin (Hb) and creatinine (Cr) prior to surgery and at 4 and 30 days after HALPN. The kidneys were harvested at 30 days, and retrograde pyelograms and pathologic analysis were performed. RESULTS: Application of GMHS achieved complete hemostasis in all eight animals. The mean estimated blood loss was 40 mL, and the operating time was short (mean 92.5 minutes). In three kidneys, a significant collecting system opening was noted but not repaired. At harvest, there were no hematomas, infections, or urine leaks in any animals. In one animal, a 2-cm contained fluid collection was identified. There was no difference in the preoperative and harvest Hb (9.63 v 9.21 g/dL; P = 0.49), but there was a slight increase in Cr (1.21 v 1.46 mg/dL; P = 0.01) possibly because of the decreased renal mass after partial nephrectomy. CONCLUSION: Even without hilar occlusion, GMHS was 100% safe and effective in controlling bleeding after HALPN in the porcine model. Avoidance of hilar occlusion may reduce the risk associated with warm renal ischemia and the extra dissection required to isolate the hilum in preparation for clamping.
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Técnicas Hemostáticas , Laparoscopios , Nefrectomía/instrumentación , Nefrectomía/métodos , Adhesivos Tisulares , Animales , Fibrosis , Gelatina , Esponja de Gelatina Absorbible , Hemostáticos , Riñón/irrigación sanguínea , Riñón/patología , Riñón/cirugía , Modelos Animales , Sus scrofaRESUMEN
OBJECTIVES: To determine the effect of a laparoscopic approach on warm renal ischemia in the pig with a solitary kidney. Although the maximal safe duration for warm ischemia during open partial nephrectomy is commonly accepted to be 30 minutes, the maximal safe ischemic time during laparoscopic partial nephrectomy has not been previously determined. METHODS: Sixteen farm pigs underwent unilateral laparoscopic right nephrectomy. Two weeks later, the pigs underwent complete laparoscopic mobilization of the remaining left kidney and were randomized to complete hilar clamp times of 0, 30, 60, or 90 minutes. Serum creatinine was evaluated before right nephrectomy and at days 0, 2, 4, 7, 14, and 30 after renal ischemia during laparoscopy. All renal specimens were evaluated by an experienced nephropathologist in a blinded fashion. RESULTS: The serum creatinine remained stable at all points in the control and 30-minute ischemia groups. The serum creatinine level rose initially on days 2 and 4 in the 60-minute and 90-minute ischemia groups but returned to baseline by day 7. At harvest, no statistically significant difference was found among the groups in serum creatinine or histologic features. CONCLUSIONS: Renal ischemic times up to 90 minutes during laparoscopy were well tolerated by the solitary porcine kidney. Possible explanations for this finding include the protective effect of a solitary kidney and the potential protective effect of relative ischemic preconditioning provided by the pneumoperitoneum.