Critical analysis of 30 day complications following radical nephroureterectomy for upper tract urothelial carcinoma.

INTRODUCTION: Patients with upper tract urothelial carcinoma (UTUC) are often elderly and comorbid owing to associated risk factors for developing this malignancy. Perioperative complications may be significant in such a surgical population. We define the incidence and risk factors associated with perioperative complications occurring within 30 days of radical nephroureterectomy (RNU). MATERIALS AND METHODS: Medical records of 92 consecutive patients undergoing RNU were reviewed. Complications occurring within 30 days of surgery were graded using the modified Clavien-Dindo classification. The number, severity, and type of complications were recorded. Minor complications were classified as Clavien II or less, while major complications were Grade III or greater. Univariate and multivariate analyses determined variables associated with complications. RESULTS: Fifty-seven men and 35 women with a median age of 70 years were included. Three-quarters of the cohort underwent a minimally invasive RNU and 45% had a regional lymph node dissection. Final pathology noted that 53% had muscle-invasive and 70% had high grade UTUC. Overall, 35 patients (38%) experienced complications within 30 days of RNU including 11 (12%) with major complications. Ten patients (11%) had multiple complications. Hematologic, gastrointestinal, and infectious etiologies comprised over 75% of complications. On univariate analysis, patient age, ECOG performance status, surgical approach, non-organ confined disease, and cardiac history were associated with complications. In a multivariate model including these variables, only ECOG ≥ 2 (OR 3.9, 95% CI 1.6-7.4, p < 0.001) was independently associated with post-RNU complications. CONCLUSION: Almost 40% of patients in this cohort experienced a perioperative complication after RNU. One-third of complications were Clavien III or greater. Poor performance status conferred a four-fold greater risk of a perioperative complication. Such knowledge may guide patient counseling and surgical expectations for the postoperative period.

An obese body habitus does not preclude a minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy (PN) via open or minimally invasive (MI) techniques is the referent standard for managing renal cell carcinoma (RCC) whenever possible. Outcomes of MIPN in the obese patient population are incompletely defined. We investigate the feasibility of MIPN in obesity class I-III patients via comparison of surgical outcomes to those with a lower body mass index (BMI). MATERIALS AND METHODS: The electronic medical records of 184 consecutive patients undergoing MIPN via laparoscopic (n = 109) or robotic (n = 75) techniques were reviewed. Patients were classified into the following patient cohorts stratified by BMI: 1) BMI < 30; 2) BMI 30-35 - obesity class I; 3) BMI 35-40 - obesity class II; 4) BMI > 40 - obesity class III. The association between obesity class and perioperative and pathologic outcomes was determined. RESULTS: Ninety-five men and 89 women with a median age of 55 years, BMI of 31, tumor size of 2.9 cm, and RENAL nephrometry score of 6 were included. Median operative time was 218 minutes, ischemia duration was 23.5 minutes, estimated blood loss (EBL) was 150 cc, and length of stay was 3.0 days. Of the 184 patients, 71 (39%) were non-obese, 58 (32%) had class I obesity, 33 (18%) patients had class II obesity, and 22 (12%) had class III obesity. Compared to patients with a BMI < 30, neither an obese body habitus nor the degree of obesity was associated with any adverse perioperative or pathologic outcomes. In a multivariate model querying variables associated with complications, only a RENAL nephrometry ≥ 8 (HR 5.1, 95% CI 2.4-7.9, p < 0.001) was significant. CONCLUSION: An increase in obesity classification was not associated with adverse outcomes following MIPN. Increasing nephrometry score was the sole variable associated with perioperative complications. The presence of an obese body habitus alone should not preclude offering appropriate patients a MIPN.

The digital rectal examination (DRE) remains important - outcomes from a contemporary cohort of men undergoing an initial 12-18 core prostate needle biopsy.

INTRODUCTION: Indications for prostate needle biopsy (PNB) include elevated serum prostate-specific antigen (PSA) and/or abnormal digital rectal examination (DRE). We evaluated a contemporary cohort of men undergoing PNB to determine cancer detection rates when stratified by DRE status. MATERIALS AND METHODS: The charts of 806 men who underwent a PNB were reviewed. Serum PSA was categorized as normal or abnormal according to age-specific criteria. A normal DRE was defined as a smooth, age-appropriate, asymmetric, or uniformly enlarged prostate. An abnormal DRE was defined by either a nodule or induration. Sensitivity, specificity, and predictive values were determined for an abnormal DRE and the diagnosis of prostate cancer. RESULTS: Within the cohort, 516 patients (64%) had a normal and 290 (36%) an abnormal DRE. Three hundred six (38%) men were diagnosed with prostate cancer of which 136 (44%) had an abnormal DRE. Fourteen percent of patients with prostate cancer had an isolated DRE abnormality. Furthermore, when specifically considering these 136 men with an abnormal DRE and prostate cancer, 43 (31%) had a normal age-specific PSA value. No differences in cancer detection rate were noted when stratifying by type of DRE abnormality. In this select cohort of patients undergoing prostate biopsy, an abnormal DRE had a sensitivity of 44%, specificity of 68%, positive predictive value (PPV) of 46%, and a negative predictive value (NPV) of 67% for detecting prostate cancer on biopsy. CONCLUSION: Almost 50% of men in our cohort diagnosed with prostate cancer had an abnormal DRE. While only 14% of all patients with prostate cancer had an isolated DRE abnormality, 31% of these men had normal age-specific PSA values. Such observations underscore the importance of the DRE for prostate cancer screening.

Complications following prostate needle biopsy requiring hospital admission or emergency department visits - experience from 1000 consecutive cases.

OBJECTIVE: • To review a contemporary cohort of patients undergoing a transrectal ultrasound-guided prostate needle biopsy (TRUS PNBx) at a single centre to determine the incidence of major complications necessitating hospital admission or emergency department (ED) visits. PATIENTS AND METHODS: • The charts of 1000 consecutive patients undergoing TRUS PNBx were reviewed. • All patients received peri-procedural antibiotic prophylaxis with either ciprofloxacin or co-trimoxazole. • Hospital admission and ED visits within 30 days of the procedure were identified for indication, management and outcome. • Patient comorbidities and biopsy characteristics were reviewed for association with complications. RESULTS: • Of the 1000 patients, 25 (2.5%) had post-biopsy complications requiring hospital admission or an ED visit. • Indications included twelve patients (1.2%) with urosepsis, eight (0.8%) with acute urinary retention requiring urethral catheterization, four (0.4%) with gross haematuria requiring bladder irrigation for <24 h, and one (0.1%) with a transient ischaemia attack 1 day after biopsy. • Patients with urosepsis had an average hospitalization of 5 days, and 75% carried quinolone-resistant Escherichia coli organisms. • All patients with urinary retention had catheters removed within 10 days. No patients with haematuria required a blood transfusion. • No demographic or biopsy variables were particularly associated with development of a post-procedure complication. CONCLUSIONS: • In this large contemporary series of TRUS PNBx, we observed a 2.5% rate of major complications requiring hospital admission or an ED visit. • No clinical or biopsy variables were directly associated with development of complications. • These data may be valuable when counselling patients before biopsy.

Significant activity of single agent vinorelbine against small-cell cancer of the bladder as second line chemotherapy: a case series and review of the literature.

Small-cell carcinoma of the urinary bladder is an extremely uncommon form of urologic malignancy, accounting for less that 1% of new cases of bladder cancer. It is an aggressive malignancy which, like its pulmonary counterpart, tends to spread with distant metastases. This malignancy is generally chemotherapy and radiotherapy sensitive. Metastatic disease is typically treated with regimens active against small-cell carcinoma of the lung, such as cisplatin and etoposide. There are no data regarding second-line treatment of this cancer. We report our experience in 3 patients using the second generation vinca alkaloid, vinorelbine, in refractory metastatic small-cell carcinoma of the bladder. These 3 patients had extensive prior therapy but all 3 responded to weekly vinorelbine, with a complete response (CR) in 1, near CR in the second, and partial response in the third. Of note, the patient who sustained a CR has remained without disease and with excellent quality of life for nearly 4 years since starting vinorelbine. Indeed, the therapy was very well tolerated in all 3 patients with grade 2 cytopenia being the only toxicity. We conclude that vinorelbine is well tolerated and has activity in this case series in the second-line treatment of metastatic small-cell carcinoma of the bladder.

Preoperative predictors of surgical approach for partial nephrectomy.

INTRODUCTION: To evaluate preoperative parameters of patients undergoing partial nephrectomy to determine variables that impact selection of operative approach. MATERIALS AND METHODS: The charts of 229 consecutive patients undergoing partial nephrectomy were reviewed. Clinical data points and associated axial imaging were evaluated to determine factors which contributed to selection of an open (versus laparoscopic) operation. RESULTS: A total of 140 men and 89 women with a mean age of 57 years, body mass index (BMI) of 31, and glomerular filtration rate (GFR) of 82 mL/min/1.73 m(2) were included. Twenty-three percent of patients had prior abdominal surgery and 7% had a history of contralateral renal cell carcinoma (RCC). The mean tumor size was 3.4 cm (range, 0.7-11) with 23% of lesions being endophytic, 38% involving the collecting system, and 29% being hilar. Thirty-four patients (15%) had multifocal lesions. Overall, 130 patients underwent an open partial nephrectomy (OPN) and 99 a laparoscopic partial nephrectomy (LPN). On univariate analysis, preoperative GFR (p = 0.05), a history of contralateral RCC surgery (p = 0.02), tumor size (p = 0.04), renal sinus/collecting system involvement (p = 0.001), renal hilar location (p = 0.001), tumor multifocality (p = 0.004), surgeon laparoscopic case volume of <25 cases (p = 0.03), and lack of fellowship laparoscopic training (p = 0.02) all were associated with an open surgical approach. In a logistic regression model incorporating these eight variables, only renal hilar location (OR 2.63, 95% CI 1.17-5.88, p = 0.02) remained significantly associated with OPN. CONCLUSIONS: Many parameters including increasing BMI, preoperative GFR, prior abdominal surgery, endophytic tumor location, and renal sinus/collecting system involvement do not necessarily preclude a minimally invasive partial nephrectomy. In our experience, renal hilar tumors were over 2.5 fold more likely to be managed by OPN owing to the complexity of resection.

Superficial bladder cancer metastatic to the lungs: two case reports and review of the literature.

Bladder cancer remains a significant cause of morbidity and mortality in the United States, with mortality related predominantly to metastasis. Approximately 70% of newly diagnosed cases of bladder cancer represent superficial disease that, despite a high risk of local recurrence, rarely progress to invasive or metastatic disease. The present cases demonstrate isolated pulmonary metastases associated with low-grade superficial bladder cancer, without previous evidence of muscle-invasive disease. Distant spread of low-grade superficial tumors is extremely unusual, and we review the literature and discuss the management of this rare entity.

Initial results using a running vesicourethral anastomosis following open radical retropubic prostatectomy.

PURPOSE: We assessed the results of early catheter removal following radical prostatectomy using a continuous suture vesicourethral anastomosis. MATERIALS AND METHODS: From March 2001 through December 2003, 76 patients underwent open radical prostatectomy, as performed by a single surgeon. A continuous 3-zero polyglactin suture was used for the vesicourethral anastomosis in 72 patients. Drain fluid creatinine on postoperative day 1 was used to assess anastomotic leakage. A cystogram was done before catheter removal in the initial 25 patients. Subsequently a cystogram was performed only if there was suspicion of urine leakage. RESULTS: Early catheter removal was possible in 63 of 72 patients (88%). Catheter removal occurred a mean of 3.4 days (range 1 to 6) postoperatively in this group. Ten of the 14 men who required catheter reinsertion for urinary retention had the catheter removed before postoperative day 4. In the remaining 9 patients early catheter removal was not attempted. Catheter removal occurred a mean of 10.1 days (range 7 to 14) postoperatively in this group. Overall the urethral catheter was successfully removed on or before postoperative day 6 (range 1 to 6) in 78% of patients. There was no incidence of urinoma, pelvic abscess or bladder neck contracture at a mean followup of 31 months (range 2 to 46). CONCLUSIONS: A running vesicourethral anastomosis following open radical retropubic prostatectomy allows reliable early catheter removal by postoperative days 4 to 6 in most patients with no increase in morbidity.

Urothelial carcinoma in a man with hereditary nonpolyposis colon cancer.

Although most upper tract urothelial carcinomas are believed to be acquired, patients with hereditary nonpolyposis colon cancer (HNPCC) may have more than 20 times the risk of the normal population for these cancers. Certain mismatch repair mutations are now known to be associated with the disease. Screening and surveillance regimens are still evolving, but urinalysis, urine cytology, cystoscopy, and periodic upper tract imaging are the mainstays. HNPCC should be considered in any patient who develops an upper tract urothelial cancer or has a suggestive family history.