Robot-assisted laparoscopic vs open radical cystectomy: comparison of complications and perioperative oncological outcomes in 200 patients.

OBJECTIVE: To compare perioperative morbidity and oncological outcomes of robot-assisted laparoscopic radical cystectomy (RARC) to open RC (ORC) at a single institution. PATIENTS AND METHODS: A retrospective analysis was performed on a consecutive series of patients undergoing RC (100 RARC and 100 ORC) at Wake Forest University with curative intent from 2006 until 2010. Complication data using the Clavien system were collected for 90 days postoperatively. Complications and other perioperative outcomes were compared between patient groups. RESULTS: Patients in both groups had comparable preoperative characteristics. The overall and major complication (Clavien ≥ 3) rates were lower for RARC patients at 35 vs 57% (P = 0.001) and 10 vs 22% (P = 0.019), respectively. There were no significant differences between groups for pathological outcomes, including stage, number of nodes harvested or positive margin rates. CONCLUSION: Our data suggest that patients undergoing RARC have perioperative oncological outcomes comparable with ORC, with fewer overall or major complications. Definitive claims about comparative outcomes with RARC require results from larger, randomised controlled trials.

Is robot-assisted radical cystectomy justified in the elderly? A comparison of robotic versus open radical cystectomy for bladder cancer in elderly ≥75 years old.

BACKGROUND AND PURPOSE: Open radical cystectomy (ORC) or minimally invasive radical cystectomy with pelvic lymph node (LN) dissection carries significant morbidity to the elderly because they often have several medical comorbidities that make a surgical approach more challenging. The objective of this study is to compare robot-assisted radical cystectomy (RARC) and ORC in elderly patients. PATIENTS AND METHODS: A prospective bladder cancer cystectomy database was queried to identify all patients age ≥75 years. A total of 20 patients were identified for each of the RARC and ORC cohorts. A retrospective analysis was performed on these 40 patients undergoing radical cystectomy for curative intent. RESULTS: Patients in both groups had comparable preoperative characteristics and demographics. Patients had significant medical comorbidities with 80% in each cohort having American Society of anesthesiologists classification of 3 and 50% having had previous abdominal surgery. Complete median operative times for RARC was 461 (interquartile range [IQR] 331, 554) vs 370 minutes for ORC (IQR 294, 460) (P=0.056); however, median blood loss for RARC was 275 mL (IQR 150, 450) vs 600 mL for ORC (IQR 500, 1925). The median hospital stay for RARC was 7 days (IQR 5, 8) vs 14.5 days for ORC (IQR 8, 22) (P<0.001). The major complication (Clavien≥III) rate for RARC was 10% compared with 35% for ORC (P=0.024). There were two positive margins in the ORC group compared with one in the RARC group with median LN yields of 15 nodes (IQR 11, 22) and 17 nodes (IQR 10, 25) (P=0.560) respectively. CONCLUSIONS: In a comparable cohort of elderly patients, RARC can achieve similar perioperative outcomes without compromising pathologic outcomes, with less blood loss and shorter hospital stays. For an experienced robotic team, RARC should be considered in elderly patients because it may offer significant advantage with respect to perioperative morbidity over ORC.

Impact of age on clinicopathological outcomes and recurrence-free survival after the surgical management of nonseminomatous germ cell tumour.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? The effect of advancing age on the clinicopathological outcomes of men with germ cell testicular cancers remains uncertain. Through the review and comparison of the present large cohort of men with testis cancer, we report on our experience in men aged ≥50 years. Our results showed similar clinical and pathological characteristics, and survival outcomes that compare favourably with those of men aged <50 years. OBJECTIVE: To determine the impact of age on clinicopathological findings and disease recurrence in men with nonseminomatous germ cell tumour (NSGCT) undergoing retroperitoneal lymph node dissection (RPLND). PATIENTS AND METHODS: We identified 1246 patients with NSGCT who underwent either primary or post-chemotherapy-RPLND (PC-RPLND) between 1989 and 2006 from our prospective testis cancer database. • Perioperative characteristics were compared among men aged < or ≥50 years. • Multivariable models were used to evaluate the association of age with disease-free survival, controlling for established clinical and pathological features. RESULTS: Of 514 men undergoing primary and 732 men undergoing PC-RPLND, 12 (2.3%) and 23 (3.1%) were aged ≥50 years, respectively. • There were no significant differences between men aged < or ≥50 years for perioperative clinicopathological characteristics, with the exception of pre-RPLND CT nodal size. • The pathological distributions at primary RPLND were similar in men aged < or ≥50 years. After PC-RPLND, there were no differences in RPLND histology, number of lymph nodes resected, estimated blood loss, hospital stay, or perioperative complication rate. • Age at surgery was not a significant predictor of disease recurrence when subjected to a multivariable analysis. CONCLUSIONS: Our data suggests that age at RPLND does not predict for disease recurrence and men aged ≥50 years had similar pre- and postoperative characteristics to those aged <50 years. • We conclude that RPLND can be safely performed in men aged ≥50 years and these patients should be offered optimal treatment regimens for NSGCT as directed according to established guidelines.

Does initial learning curve compromise outcomes for robot-assisted radical cystectomy? A critical evaluation of the first 60 cases while establishing a robotics program.

BACKGROUND AND PURPOSE: Robot-assisted laparoscopic radical cystectomy (RARC) with pelvic lymph node dissection (PLND) has gained popularity as a minimally invasive alternative to open radical cystectomy (ORC) for the treatment of patients with bladder cancer. The learning curve (LC) for laparoscopic and robotic surgery can be steep. We aim to evaluate the effect of the initial LC on operative, postoperative, and pathologic outcomes of the first 60 RARC performed at our newly established robotics program. PATIENTS AND METHODS: After obtaining Institutional Review Board approval, we reviewed the clinical and pathologic data from 60 consecutive patients with clinically localized bladder cancer who underwent RARC with PLND from January 2008 to March 2010. The patients were grouped into tertiles and assessed for effect of LC using analysis of variance. RESULTS: Patient demographics and clinical characteristics were similar across tertiles. The mean total operative time trended down from the 1st to 3rd tertile from 525 minutes to 449 minutes, respectively (P=0.059). Mean estimated blood loss was unchanged across tertiles. Complications decreased as the LC progressed from 14 (70%) in the 1st tertile to 6 (30%) in each of the 2nd and 3rd tertiles (P<0.013). The mean total lymph node yield and number of positive margins were unchanged across tertiles. CONCLUSIONS: RARC with PLND can be performed safely at a high-volume newly established robotic surgery program with an experienced team without compromising operative, postoperative, and short-term pathologic outcomes during the LC for surgeons who are experienced in ORC.

Long-term outcomes after percutaneous radiofrequency ablation for renal cell carcinoma.

OBJECTIVES: To assess the long-term oncological efficacy of radiofrequency ablation (RFA) for treatment of renal cell carcinoma (RCC). METHODS: In this institutional review board-approved, retrospective study, the records and imaging studies for all RCC patients treated with percutaneous RFA before 2005 were reviewed and analyzed. RESULTS: A total of 48 RCCs in 41 patients were treated with RFA. Median size of RCC treated was 2.6 cm (range: 0.7-8.2 cm). Of the 48 treated RCCs, 5 (12%) had recurrent tumor after a single ablation session. The median size of the index lesion in the cases with recurrence was 5.2 cm (interquartile range [IQR]: 4-5.3) compared with 2.2 cm (IQR: 1.7-3.1, P = .0014) without local recurrence. There were no recurrences when RCCs less than 4 cm were treated. Seventeen (41%) patients with 18 treated RCCs died during the follow-up period at a median time of 34 (IQR: 10-47) months. One patient (2%) died of metastatic RCC, whereas 16 died of unrelated causes. Twenty-four patients with 30 RCCs treated with RFA survived. For the remaining 30 RCCs, median follow up was 61 months (IQR: 54-68). No patients in this group of survivors had metastatic RCC, 1 had recurrence diagnosed at 68 months. The long-term recurrence-free survival rate was 88% after RFA. CONCLUSIONS: RFA can result in durable oncological control for RCCs less than 4 cm. RFA is an effective treatment option for patients with RCCs less than 4 cm who are poor surgical candidates. For patients with larger RCCs alternative treatments should be considered.

Three-limb compartment syndrome and rhabdomyolysis after robotic cystoprostatectomy.

The case of a 53 year-old, ASA physical status III man who underwent laparoscopy-assisted cystoprostatectomy, then subsequently developed three-limb compartment syndrome and rhabdomyolysis, is presented. He recovered baseline renal function and the use of his limbs. Well-limb compartment syndrome (WLCS) has a multifactorial etiology and is prevented and managed by avoidance of known risks.

Percutaneous radiofrequency ablation does not affect glomerular filtration rate.

PURPOSE: To study short- and intermediate-term global renal function in patients undergoing a single percutaneous radiofrequency ablation (pRFA) for a solitary renal parenchymal tumor. MATERIALS AND METHODS: We reviewed the records of 62 patients who underwent a single pRFA for solitary renal parenchymal tumor. We used the abbreviated Modified Diet for Renal Disease equation to calculate baseline, 1-month, and 1-year glomerular filtration rate (GFR). We defined normal as >60, moderately diminished as 45-60, and severely diminished GFR as <45 cc/minute/1.73 m². We used the Wilcoxon paired rank sum method to compare 1-month and 1-year GFR to baseline. We fit a linear regression model to test the association of lesion size to GFR controlling for lesion location and baseline GFR. RESULTS: There was no difference in GFR from baseline at 1 month or 1 year (55 vs. 58 cc/minute/1.73 m², p=0.24 and 55 vs. 57 cc/minute/1.73 m², p=0.8, respectively). Tumor size did not affect GFR at 1 month or 1 year after controlling for lesion location and baseline GFR. CONCLUSIONS: A single application of pRFA does not affect GFR in the short or intermediate term.

Robot assisted laparoscopic pelvic lymphadenectomy at the time of radical cystectomy rivals that of open surgery: single institution report.

OBJECTIVE: The purpose of this study was to analyze the pelvic lymph node dissection (PLND) and margin status using a standard technique in the first 35 patients undergoing robot-assisted radical cystectomy (RARC) at our institution while establishing a robotics program, and then to compare the results to the past 35 open radical cystectomy (ORC) performed at our institution. MATERIALS AND METHODS: After obtaining institutional review board approval, we reviewed the clinical and pathologic data from 70 consecutive patients with clinically localized bladder cancer who underwent radical cystectomy with PLND from April 2007 to June 2009. Thirty-five operations were performed open and 35 used the da Vinci robotic system. The PLND was performed in all patients using the same template. RESULTS: There was no significant difference between the ORC and RARC group in regards to patient characteristics, tumor stage (43% ORC and 40% RARC having pT3/pT4 disease), and node status (29% N+ in each group). The median total lymph node yield was similar, with 15 (interquartile range [IQR] 11, 22) in the ORC group and 16 (IQR 11, 24) in the RARC group (P = 0.5). One patient who underwent RARC had a positive margin compared with 3 patients in the ORC group. CONCLUSIONS: The initial 35 RARC with PLND performed at our institution compared with the last 35 ORC resulted in equivalent lymph node yield and similar rates of positive margins. RARC with PLND is feasible, safe, and effective when performed at a high-volume center by an experienced team.

Developing selection criteria for prostate-sparing cystectomy: a review of cystoprostatectomy specimens.

OBJECTIVES: To determine risk factors for prostate pathology, which may serve as guidelines for identifying patients who may be inappropriate for prostate-sparing cystectomy for treatment of transitional cell cancer of the bladder. METHODS: After obtaining Institutional Review Board approval, we reviewed the clinical and pathologic data from consecutive men treated with radical cystoprostatectomy (RCP) between January 2003 and September 2008. We reviewed the RCP pathology for prostatic involvement by transitional cell carcinoma (PI-TCC) as well as presence of prostate cancer (PCa). Univariate analysis was used to test for association of clinical parameters with prostatic involvement in RCP specimens. RESULTS: A total of 96 patients with a median age of 67 (interquartile range: 47, 79) underwent RCP between January 2003 and September 2008. PI-TCC was present in 24 patients (25%) of which 6 (25%) had carcinoma in situ (CIS) only and 18 (75%) had stromal invasion. We identified PCa in 40 patients (42%). CIS (odds ratio, 3.2, P = .018) and tumor situated at or below the trigone (odds ratio, 3.3, P = .046) at the pre-RCP transurethral bladder tumor resection were associated with PI-TCC. CONCLUSIONS: PI-TCC and PCa are common findings at RCP. The location of the bladder tumor situated at or below the trigone and the presence of CIS at transurethral bladder tumor resection is associated with increased risk for PI-TCC and should be considered at least relative contraindications for prostate-sparing cystectomy. A thorough investigation for PCa should be conducted for all possible candidates.

Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy.

PURPOSE: We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture. MATERIALS AND METHODS: From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach. RESULTS: With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p <0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22). CONCLUSIONS: Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands.

Laparoscopic marsupialization before inguinal repair of large abdominoscrotal hydroceles in infants: observation of natural history and description of technique.

OBJECTIVES: To develop a surgical procedure that would minimize the difficult proximal spermatic cord dissection during excision of the abdominal component of abdominoscrotal hydroceles (ASHs). Because the abdominal component is derived from the peritoneum, we postulated that complete removal of all tissue is unnecessary and laparoscopic creation of a wide peritoneal window is sufficient for treatment before inguinal repair of the scrotal component. METHODS: We describe a series of 4 patients who underwent laparoscopic marsupialization of the abdominal component of an ASH before inguinal repair. In addition, we describe the natural history of a patient who had had initial normal evaluation of bilateral scrotal hydroceles on ultrasonography and subsequently developed the abdominal portion during the first year after birth. RESULTS: Four patients underwent successful laparoscopic marsupialization of the abdominal component before inguinal repair of the ASH. No postoperative complications occurred, and no patient required repeat operation. CONCLUSIONS: Laparoscopic marsupialization of the abdominal portion of an ASH is a practical surgical alternative that may reduce the morbidity of extensive dissection.

Preservation of ejaculation in patients undergoing nerve-sparing postchemotherapy retroperitoneal lymph node dissection for metastatic testicular cancer.

OBJECTIVES: To evaluate the clinical parameters associated with the recovery of ejaculation after nerve-sparing postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) for nonseminomatous germ cell tumor. METHODS: We queried our institutional database for all patients who had undergone nerve-sparing PC-RPLND from 1995 to 2005 using a bilateral template. Nerve sparing was performed whenever technically feasible and oncologically prudent. Antegrade ejaculation was defined as any seminal fluid expulsion and was determined by patient report. We evaluated the recovery of antegrade ejaculation using clinical and pathologic parameters and fit a logistic regression model to determine which preoperative variables were associated with antegrade ejaculation. RESULTS: A total of 341 patients had undergone PC-RPLND during the study period, 136 (40%) with nerve-sparing techniques. Postoperative antegrade ejaculation was reported by 107 of 136 patients (79%) with information available. On multivariate analysis, a right-sided primary testicular tumor (odds ratio 0.4, 95% confidence interval 0.1-1.0, P = .044) and residual masses > or = 5 cm (odds ratio 0.1, 95% confidence interval 0.0-0.7, P = .020) were associated with retrograde ejaculation. However, 40 of 54 patients (74%) with right-sided primary tumors and 4 of 9 patients (44%) with a mass > or = 5 cm reported antegrade ejaculation. The 5-year relapse-free survival rate was 98%, with a median follow-up of 39 months (interquartile range 19-66). CONCLUSIONS: Nerve-sparing PC-RPLND is associated with excellent functional return of antegrade ejaculation, is feasible in select patients with bulky disease, and results in excellent oncologic outcomes.

A role for neoadjuvant gemcitabine plus cisplatin in muscle-invasive urothelial carcinoma of the bladder: a retrospective experience.

BACKGROUND: Neoadjuvant cisplatin-based chemotherapy improves survival in muscle-invasive urothelial cancer, with MVAC (methotrexate, vinblastine, doxorubicin and cisplatin) considered the standard regimen. Gemcitabine plus cisplatin (GC) has similar efficacy and less toxicity than MVAC in metastatic disease, but is untested as neoadjuvant treatment. METHODS: The authors retrospectively evaluated patients with muscle-invasive urothelial carcinoma who received neoadjuvant GC before radical cystectomy between November 2000 and December 2006 at Memorial Sloan-Kettering Cancer Center. Post-therapy pathological downstaging to either residual disease at cystectomy (pT0) or no residual muscle-invasion (

Effect of baseline glomerular filtration rate on survival in patients undergoing partial or radical nephrectomy for renal cortical tumors.

OBJECTIVE: To evaluate the effect of baseline renal function and comorbidity index on survival in patients with renal tumors. PATIENTS AND METHODS: We retrieved demographic, clinicopathologic, body mass index (BMI), and comorbidity data (assessed by Charlson-Romano index and hypertension) for 1479 patients who underwent partial or radical nephrectomy between January 4, 1995, and June 9, 2005, for localized renal tumors. We used the abbreviated Modified Diet and Renal Disease equation to estimate glomerular filtration rate (eGFR) using the last preoperative serum creatinine measurement. Body mass index and eGFR time trends were analyzed with linear regression. The effect of BMI, comorbidity, and baseline eGFR on disease-free and overall survival was studied using Cox regression controlling for pathologic stage, nodal status, and metastasis. RESULTS: Over a 10-year interval, median BMI increased from 27 (interquartile range [IQR], 24-31) to 28 (IQR, 25-31; P=.004), and median baseline eGFR decreased from 70 (IQR, 58-80) to 63 mL/min per 1.73 m(2) (IQR, 57-78; P<.001). Multivariate regression demonstrated an association between year of surgery and baseline eGFR (P<.001) even after adjusting for age, sex, comorbidity, BMI, and tumor size. We repeated the analysis for patients aged 18 to 70 years, and this association persisted (P<.001). Baseline eGFR, BMI, and comorbidity were not associated with disease-free survival after controlling for stage. However, moderately reduced baseline eGFR (45-60 mL/min per 1.73 m(2)) and severely reduced eGFR (<45 mL/min per 1.73 m(2)) were significantly associated with overall survival (hazard ratio, 1.5; P<.003; and hazard ratio, 2.8; P<.001; respectively). CONCLUSION: Baseline eGFR has declined over the past decade. Nephron-sparing techniques should be considered for patients with severely diminished baseline eGFR.

Survival rates after resection for localized kidney cancer: 1989 to 2004.

BACKGROUND: Mortality rates from kidney cancer have continued to rise despite increases in the detection of smaller renal tumors and rates of renal surgery. To explore the factors associated with this treatment-outcome discrepancy, the authors evaluated how changes in tumor size have affected disease progression in patients after nephrectomy for localized kidney cancer, and they sought to identify the factors associated with disease progression and overall patient survival after resection for localized kidney cancer. METHODS: In total, 1618 patients with localized kidney cancer were identified who underwent nephrectomy at Memorial Sloan-Kettering Cancer Center from 1989 to 2004. Patients were categorized by year of surgery: from 1989 to 1992, from 1993 to 1996, from 1997 to 2000, and from 2001 to 2004. Tumor size was classified according to the following strata: <2 cm, from 2 cm to 4 cm, from 4 cm to 7 cm, and >7 cm. Disease progression was defined as the development of local recurrence or distant metastases. Five-year progression-free survival (PFS) was calculated for patients in each tumor size strata according to the year of operation using the Kaplan-Meier method. The patient-, tumor-, and surgery-related characteristics associated with PFS and overall survival (OS) were explored using univariate analysis, and all significant variables were retained in a multivariate Cox regression analysis. RESULTS: Overall, the number of nephrectomies increased for all tumor size categories from 1989 to 2004. A tumor size migration was evident during this period, because the proportion of patients with tumors <2 cm and with tumors from 2 cm to 4 cm increased, whereas the proportion of patients with tumors >7 cm decreased. One hundred seventy-nine patients (11%) developed disease progression after nephrectomy. Sixteen patients (1%) developed local recurrences, and 163 patients (10%) developed distant metastases. When 5-year PFS was calculated for each tumor size strata according to 4-year cohorts, trends in PFS did not improve or differ significantly over time. Compared with historic cohorts, patients in more contemporary cohorts were more likely to undergo partial nephrectomy rather than radical nephrectomy and were less likely to undergo concomitant lymph node dissection and adrenalectomy. Multivariate analysis demonstrated that pathologic stage and tumor grade were associated with disease progression, whereas patient age and tumor stage were associated with overall patient survival. CONCLUSIONS: Despite an increasing number of nephrectomies and a size migration toward smaller tumors, trends in 5-year PFS and OS did not improve or differ significantly over time. These findings require further research to identify causative mechanisms, and they argue for the consideration of active surveillance for patients who have select renal tumors and a re-evaluation of the current treatment paradigm of surgically removing solid renal masses on initial detection.

Risk stratification for positive lymph nodes in prostate cancer.

PURPOSE: To evaluate the risk of positive lymph nodes using preoperative clinical parameters. METHODS AND MATERIALS: We reviewed our prospectively collected database for all patients who received RRP and PLND between January 1993 and November 2005 as primary therapy for prostate cancer. We excluded patients who had hormonal ablation or radiation therapy prior to surgery and patients with missing PSA, clinical stage, or biopsy Gleason score. We evaluated risk for nodal disease using the following definitions: low risk: PSA or=T(2b), or Gleason score of 7; and high risk: PSA >or=20 ng/mL, or clinical stage >or=T(2c), or Gleason score >or=8. Logistic regression was used to determine the association between the risk groups and pathologic lymph node involvement, and a receiver operating characteristics (ROC) curve was constructed to evaluate the performance of the stratification scheme in detecting nodal disease. RESULTS: A total of 760 patients with 43 (5.7%) patients with node-positive disease were available for analysis. Risk classification was significantly associated with positive nodes (P<0.001), even after controlling for year of surgery and age. The area under the ROC curve was 0.77 (95% CI: 0.69, 0.83). Omitting PLND in the low-risk group would have spared 368 (49.2%) of the entire cohort with a false-negative rate of 5/369 (1.3%) for the low-risk group, and 5/760 (0.7%) for the entire cohort. Sensitivity was 88.4%, and negative predictive value was 98.7%. CONCLUSION: Patients can be risk stratified for node-positive disease and potentially excluded from lymphadenectomy with minimal risk.

Positive surgical margins at partial nephrectomy: predictors and oncological outcomes.

PURPOSE: The prognostic significance and optimal management of positive surgical margins following partial nephrectomy remain ill-defined. We combine data from 2 tertiary care intuitions, and report predictors of positive surgical margins and long-term oncological outcomes for patients with positive surgical margins. MATERIALS AND METHODS: Clinical, pathological and followup data on 1,344 patients undergoing 1,390 partial nephrectomies for kidney cancer were analyzed. Patients with positive surgical margins on final pathology were treated expectantly. Univariate and multivariable logistic regression models were fit to determine clinicopathological features associated with positive surgical margins. The Kaplan-Meier method was used to estimate freedom from local disease recurrence and metastatic progression. Cox proportional hazards models were used to assess whether positive surgical margin predicted local recurrence or metastatic disease adjusting for tumor size, pathological stage, histological subtype and presence of a solitary kidney. RESULTS: Positive surgical margins were documented in 77 cases (5.5%). Decreasing tumor size and presence of a solitary kidney carried a significantly higher risk of positive surgical margins. The overall 10-year probability of freedom from local disease recurrence was 93% (95% CI 89, 95) and from metastatic progression 93% (95% CI 90, 95), with no significant difference between patients with positive vs negative margins (p = 0.97 and 0.18, respectively). Positive surgical margins were not associated with an increased risk of local recurrence or metastatic disease. CONCLUSIONS: Positive surgical margins in partial nephrectomy specimens do not uniformly portend an adverse prognosis. While every effort should be taken to ensure clear margins, our data suggest that select patients with a positive surgical margin can be safely offered vigilant monitoring without compromising long-term disease-free survival.

Risk assessment of prostatic pathology in patients undergoing radical cystoprostatectomy.

OBJECTIVES: To determine the incidence and location of prostate adenocarcinoma (PCa) and prostatic urothelial carcinoma (PUC) for patients undergoing radical cystoprostatectomy (RCP) for bladder cancer and to ascertain what preoperative information may be useful in predicting PUC or PCa in patients who may be candidates for prostate-sparing cystectomy. METHODS: Between 2001 and 2004, 235 consecutive patients underwent RCP and had whole-mount sections of the prostate. We reviewed our prospective radical cystectomy database for preoperative clinicopathological information associated with each patient. The bladder and whole-mount prostate sections were re-reviewed to determine the location and depth of the bladder tumor as well as the presence of any associated PCa and PUC. RESULTS: We identified 113 of 235 (48%) and 77 of 235 (33%) men with PCa and PUC, respectively. Among patients with PCa, 33 (29%) had Gleason score of > or = 7, 25 (22%) had PCa tumor volume > 0.5 cc, and 15 (13%) had extracapsular extension. On multivariable analysis, only increasing age was significantly associated with PCa (odds ratio=1.3, p=0.046). Of the 77 with PUC, 28 (36%) had in situ disease only, while 49 (64%) had prostatic stromal invasion. Bladder tumor location in the trigone/bladder neck (p<0.001) and bladder carcinoma in situ (p<0.001) was strongly associated with PUC in the final specimen. Overall, 158 (67%) had either PCa or PUC in the prostate. CONCLUSIONS: PCa and/or PUC is present in a majority of RCP specimens. Current preoperative staging and tumor characteristics are not adequate for determining who can safely be selected for prostate-sparing cystectomy.

Tumor location does not affect long-term renal function after partial nephrectomy.

OBJECTIVES: To study the effect of central tumor location on the glomerular filtration rate (GFR) after partial nephrectomy for renal cortical tumor. METHODS: We reviewed our institutional database to identify patients who had undergone partial nephrectomy from January 1995 to July 2005. Central tumors were defined as those encroaching on the collecting system or renal sinus or that did not distort the renal contour; all others were categorized as peripheral on preoperative abdominal imaging. We calculated the GFR preoperatively, during the hospital stay, and at 1 and 12 months after surgery. Linear regression models were fit to determine the association of tumor location with the changes in GFR at each period, after controlling for age, sex, operative and ischemic times, comorbidities, and blood loss. RESULTS: A total of 248 central and 333 peripheral tumors were available for analysis. Patients with central tumors were younger than those with peripheral tumors (62 versus 59 years, P = 0.014) and experienced longer intraoperative renal ischemia times (40 versus 29 minutes, P <0.001) and longer operations (195 versus 179 minutes, P = 0.004). On multivariate analysis, tumor location was not significantly associated with the change in GFR at any of the intervals, after adjusting for the covariates. CONCLUSIONS: The results of our study have indicated that tumor location does not appear to affect long-term renal function. Thus, partial nephrectomy should not be withheld from this subset of patients.

Perioperative clinical thromboembolic events after radical or partial nephrectomy.

OBJECTIVES: To evaluate the incidence of, and identify the risk factors for, clinical thromboembolic events after radical/partial nephrectomy. Cancer is an established risk factor for deep vein thrombosis (DVT) and pulmonary embolism (PE); however, their incidence after nephrectomy for renal tumors has been poorly studied. METHODS: We reviewed our prospective institutional renal database and identified 2208 patients who underwent renal tumor surgery from January 1989 to July 2005. The clinical parameters evaluated were age, sex, race, body mass index, smoking history, medical comorbidities, American Society of Anesthesia grade, procedure type, estimated blood loss, and length of hospitalization. Hospital records, discharge "International Classification of Diseases, Ninth Revision" codes, and 30-day postoperative morbidity and mortality data were reviewed to identify patients diagnosed with perioperative DVT or PE. RESULTS: A total of 34 (1.5%, 95% confidence interval 1.1% to 2.1%) thromboembolic events (20 PEs and 14 DVTs) were identified in 33 patients. Patients with a preoperative history of arrhythmia (P = 0.02) or prior DVT (P = 0.053) were more likely to experience PE. The estimated blood loss was directly associated with an increased risk of PE (P = 0.001). Patients with coronary artery disease (P = 0.050) or of advanced age (P = 0.02) were more likely to experience DVT (P = 0.02). CONCLUSIONS: To our knowledge, this is the first study on the incidence of thromboembolic events after nephrectomy. Thromboembolic events are rare but are more likely to occur in patients with coronary artery disease, cardiac arrhythmia, prior DVT, Stage 3 or 4 tumors, or a large estimated blood loss.