Laparoscopic live donor nephrectomy: rationale, techniques, and implications.

Laparoscopic live donor nephrectomy (LDN) was conceived as a means for decreasing donor nephrectomy morbidity and reducing disincentives for kidney donation. Since LDN was first reported in 1995, explosive growth has led to its performance at more than 100 centers worldwide. Despite initial skepticism in some segments of the transplant community, the results of LDN have improved progressively so that it is emerging as a new standard of care for live kidney donation. We review the development and refinement of LDN and its current rationale and applications.

Percutaneous endoscopic management of urothelial tumors of the renal pelvis.

Although nephroureterectomy remains the reference standard for the treatment of transitional cell cancer of the renal pelvis, advances in technology and techniques have made percutaneous management of select lesions feasible. We report our technique of staged percutaneous resection of a large renal pelvic transitional cell cancer.

The pathological interpretation and significance of prostate needle biopsy findings: implications and current controversies.

PURPOSE: The widespread use of prostate specific antigen testing and digital rectal examination has lead to the increasing application of prostate needle biopsy. A larger proportion of men undergoing biopsy have small foci of cancer, which coupled with the overall increase in needle biopsy has led to a surge in the number of equivocal biopsy specimens interpreted. MATERIALS AND METHODS: We reviewed the literature with an overview of the topic of prostate needle biopsy pathology results with an emphasis on current controversies. RESULTS: The diagnosis rendered on prostate needle biopsy pay be placed into 4 major categories, including 1) benign, 2) prostatic intraepithelial neoplasia, 3) atypical and suspicious for cancer, and 4) prostate cancer. Prostatic intraepithelial neoplasia or a diagnosis of atypical and suspicious for cancer mandates re-biopsy in a search for occult prostate cancer. Biopsy findings, including the location of positive cores, may help to guide re-biopsy strategies. Prostate cancer on needle biopsy may be evaluated by numerous techniques of quantifying tumor extent, Gleason score and perineural invasion. These modalities may help clinicians to assess the risk of extraprostatic disease and progression likelihood, and help men with prostate cancer choose among therapeutic options. CONCLUSIONS: The pathology reports returned on needle biopsy specimens may provide a wealth of information beyond the simple presence or absence of prostate cancer that may aid clinicians in patient treatment and counseling.

Clinical significance of denuded urothelium in bladder biopsy.

PURPOSE: Although to our knowledge the significance of denuded urothelium in bladder biopsies has not been studied previously, it is thought to be a problem because benign urothelial cells are cohesive and not expected to shed into the urine. We correlated the pertinent clinical features of patients with denuded bladder biopsies and/or specific pathological features of denuded bladder biopsy specimens with patient outcome in regard to bladder lesions to help predict the subsequent likelihood of diagnosing bladder carcinoma in a patient with a nondiagnostic denuded biopsy. MATERIALS AND METHODS: We studied 51 denuded bladder biopsies from 44 patients in which the average extent of epithelial denudation was 90%. RESULTS: Of the 27 male (69%) and 17 female (31%) patients 22 to 86 years old (mean age 62) 34% had no history of bladder neoplasms. In remainder there were flat carcinoma in situ with or without other tumors (26%), high (20%) and low (14%) grade papillary tumors without carcinoma in situ and miscellaneous conditions (6%). Overall 31% of patients were diagnosed with carcinoma in situ within 24 months (median 5.5) after the denuded specimen was obtained. Parameters that did not correlate with the subsequent diagnosis of carcinoma in situ included cystoscopic impression, history of intravesical chemotherapy, sex, age, tissue inflammation, percent of tissue fragments with any denudation, number of denuded tissue fragments and percent of overall denuded epithelium. A history of carcinoma in situ before denuded biopsy predicted a diagnosis of carcinoma in situ within 24 months after denuded biopsy in 54% of patients in contrast to 19% of those without a history of carcinoma in situ (p = 0.03). Factoring in a history of other bladder tumor types in various combinations did not predict carcinoma in situ after denuded biopsy. The other predictive factor was cold cup biopsy. Carcinoma in situ developed within 24 months in 45% of patients in whom the denuded specimen was obtained by cold cup biopsy in contrast to none who underwent hot wire loop biopsy (p = 0.007). Cold cup biopsy and a history of carcinoma in situ were independently predictive. Carcinoma in situ developed within 24 months in 75% of patients with a history of that condition and a subsequent cold cup biopsy showing denuded epithelium. However, only 29% of those who underwent cold cup biopsy and had no history of carcinoma in situ were diagnosed with carcinoma in situ. CONCLUSIONS: In bladder biopsies obtained by a hot wire loop denudation most likely results from thermal injury when there is a low risk of subsequent carcinoma in situ. When the denuded biopsy sample was obtained by cold cup biopsy, particularly when associated with a history of carcinoma in situ, most cases represent neoplastic cell denudation and a high risk for subsequent carcinoma in situ.

Age, prostate-specific antigen, and digital rectal examination as determinants of the probability of having prostate cancer.

OBJECTIVES: The decision to perform prostate biopsy has traditionally been based on an abnormal prostate-specific antigen (PSA) level or abnormal digital rectal examination (DRE) findings. For example, a 60-year-old man with a benign DRE and PSA level of 4.1 ng/mL would be counseled for biopsy, and the same man with a PSA level of 3.9 ng/mL might be counseled against biopsy. However, the difference in these PSA levels and in the likelihood of these two men having prostate cancer is not significant. We constructed a probability nomogram for the likelihood of detecting prostate cancer, thus aiding in the decision of whether to perform a prostate biopsy. METHODS: Using multivariate logistic regression analysis and data from 2054 men (mean age 64 years) participating in the Tyrol Screening Project between January 9, 1993 and January 9, 1997, patient age, PSA level, and DRE findings were analyzed for their ability to determine the likelihood of finding prostate cancer on transrectal ultrasound-guided biopsy. RESULTS: DRE was suspicious in 278 men (13.5%). Overall, 498 (24.5%) of 2054 men biopsied had prostate cancer. The probability of discovering cancer on biopsy was calculated using patient age, DRE findings, and PSA level. CONCLUSIONS: DRE status had a large influence on the likelihood of positive biopsy across all PSA and age ranges. A combination of PSA, DRE result, and age better defined the probability of a positive biopsy than any factor alone. Using this nomogram, the decision to proceed with or defer prostate biopsy can be based on an actual probability of discovering prostate cancer rather than a single PSA-based cutpoint. These data may aid physicians and patients in decision-making.

Are concerns over right laparoscopic donor nephrectomy unwarranted?

OBJECTIVE: To examine the ability of several large, experienced transplantation centers to perform right-sided laparoscopic donor nephrectomy safely with equivalent long-term renal allograft function. SUMMARY BACKGROUND DATA: Early reports noted a higher incidence of renal vein thrombosis and eventual graft loss. However, exclusion of right-sided donors would deprive a significant proportion of donors a laparoscopically harvested graft. METHODS: A retrospective review was performed among 97 patients from seven centers performing right-sided laparoscopic donor nephrectomy. Surgical and postoperative demographic factors were evaluated. Complications were identified and long-term renal allograft function was compared with historical left-sided laparoscopic donor nephrectomy cohorts. RESULTS: Right laparoscopic donor nephrectomy was performed for varying reasons, including multiple left renal arteries or veins, smaller right kidney, or cystic right renal mass. Mean surgical time was 235.0 +/- 66.7 minutes, with a mean blood loss of 139 +/- 165.8 mL. Conversion was required in three patients secondary to bleeding or anatomical anomalies. Mean warm ischemic time was limited at 238 +/- 112 seconds. Return to diet was achieved on average after 7.5 +/- 2.3 hours, with mean discharge at 54.6 +/- 22.8 hours. Two grafts were lost during the early experience of these centers to renal vein thrombosis. Both surgical and postoperative complications were limited, with few long-term adverse effects. Mean serum creatinine levels were higher than open and left laparoscopic donor nephrectomy on postoperative day 1, but at all remaining intervals the right laparoscopic donors had equivalent creatinine values. CONCLUSIONS: These results confirm that right laparoscopic donor nephrectomy provides similar patient benefits, including early return to diet and discharge. Long-term creatinine values were no higher than in traditional open donor or left laparoscopic donor cohorts. These results establish that early concerns about high thrombosis rates are not supported by a multiinstitutional review of laparoscopic right donor nephrectomies.

Prospective double-blind study of effect of ketorolac administration after laparoscopic urologic surgery.

BACKGROUND AND PURPOSE: To decrease postoperative dependence on narcotics for analgesia, we have evaluated ketorolac as an adjunct to perioperative pain control in patients undergoing laparoscopic urologic surgery. PATIENTS AND METHODS: Sixty-five patients (34 male, 31 female) were randomized to receive either ketorolac tromethamine (15-30 mg IV q 6 h) or placebo prior to laparoscopic surgery. Patient-controlled analgesia in the form of morphine sulfate was provided. Operative factors such as the type of surgery, operative time, and estimated blood loss were recorded. Postoperative factors such as analog pain score (range 0-10), narcotic usage, and length of stay were evaluated. RESULTS: Fifty-five patients completed the study. The average pain score was 2.2 and 4.5 for the ketorolac and placebo groups, respectively (P < 0.005). The mean amounts of total morphine used were 39.2 mg (ketorolac) and 62.5 mg (placebo) (P = 0.077). The length of stay was not significantly different in the ketorolac (2.5 days) and placebo (2.6 days) groups (P = 0.74). Operative times (P = 0.21) and estimated blood loss (P = 0.60) were not significantly different in the two groups. Ketorolac did not adversely affect renal function; serum creatinine changes were not significantly different from those in the patients receiving placebo (P = 0.50). Laparoscopic pyeloplasty necessitated more narcotic analgesia than did other laparoscopic procedures (P = 0.05). CONCLUSION: Ketorolac decreases the subjective perception of pain after laparoscopic urologic surgery. It is suggested that ketorolac administration decreases the amount of narcotic usage as well. Time to resumption of oral intake and length of hospital stay were not influenced by use of ketorolac.

Isolated local recurrence is rare after radical prostatectomy in men with Gleason 7 prostate cancer and positive surgical margins: therapeutic implications.

PURPOSE: We determined whether the high biochemical failure rate in men with Gleason score 7 disease and positive surgical margins after radical retropubic prostatectomy is secondary to distant metastasis or to local tumor recurrence that could be eliminated by immediate adjuvant radiation therapy. MATERIALS AND METHODS: Between 1982 and 1997, 112 men with Gleason score 7 disease and positive surgical margins but no seminal vesicle or lymph node involvement underwent radical retropubic prostatectomy without immediate adjuvant radiation or hormonal therapy. Median followup was 8 years (range 1 to 16) and 45 men (40%) were followed 10 years or more. Kaplan-Meier actuarial survival estimates were used to determine the actuarial 5 and 10-year post-prostatectomy, and 5-year post-radiation recurrence rates. RESULTS: The actuarial 5 and 10-year post-prostatectomy biochemical, local and distant recurrence rates were 40% and 52%, 6% and 6%, and 7% and 16%, respectively. For 20 men who received radiation therapy for isolated prostate specific antigen elevation actuarial 5-year post-radiation biochemical recurrence-free rate was 34%. For 5 men who received radiation therapy for local recurrence actuarial 5-year post-radiation biochemical recurrence-free rate was 20%. CONCLUSIONS: Isolated clinical local recurrence is rare during long-term followup of men with Gleason score 7 disease and positive surgical margins at radical prostatectomy. Radiation therapy given at prostate specific antigen elevation poorly controlled the disease. Because patients with biochemical failure rarely had local recurrence at long-term followup, they most likely harbored subclinical distant metastasis. These data suggest that immediate adjuvant radiation therapy will not have a major impact on outcome because most men with Gleason score 7 disease and positive surgical margins in whom treatment fails most likely had distant metastasis at surgery. To improve the outcome in cases of Gleason score 7 disease and positive surgical margins a systemic approach to adjuvant therapy is necessary.

In vivo measurement of tumor conductiveness with the magnetic bioimpedance method.

A noninvasive electromagnetic method has been developed that can effectively measure the in-vivo conductivity difference between rat tumor lines having a low and high metastatic potential. These tumor lines are used in the study of human prostate tumor.

Prediction of locoregional extension and metastatic disease in prostate cancer: a review.

Despite efforts to enhance the accuracy of prediction of extraprostatic disease, approximately 40% of the men undergoing radical prostatectomy are found at surgery to have non-organ-confined cancer. Predictive algorithms based on multivariate regression analysis and neural networks are widely available and are superior to our standard empirical methods of clinical staging. These algorithms have been validated in diverse and well-characterized patient groups. For enhancement of the predictive value, data input must be standardized and improved input variables must be incorporated. In addition to the three "classic" staging parameters, i.e., pretreatment prostate-specific antigen (PSA), biopsy pathology, and digital rectal examination, new variables now show promise in predicting disease extent and may be integrated in future predictive models. This review focuses on our present methods for prediction of locoregional spread and distant metastases in men with clinically localized prostate cancer.

Adenocarcinoma of the prostate invading the seminal vesicle: prognostic stratification based on pathologic parameters.

OBJECTIVES: To stratify the prognosis of lymph node-negative, seminal vesicle-positive tumors in men with prostate cancer after radical retropubic prostatectomy. METHODS: Sixty cases were analyzed for multiple parameters and correlated with postoperative biochemical (prostate-specific antigen) progression. Variables included Gleason score, primary Gleason pattern, percentage of Gleason pattern 4, any presence of Gleason pattern 5, method of seminal vesicle invasion (SVI), margin positivity, SVI extent, SVI bilaterality, vascular invasion, extent of extraprostatic extension, length of tumor extending along the seminal vesicles, presence of intraductal carcinoma within the prostate, bladder neck margin positivity, and tumor volume. RESULTS: We were able to stratify the prognosis based on the combination of a variation of the Gleason score and margin status and vascular invasion status. Using this stratification, a few patients had an excellent long-term prognosis, with most patients split into two groups, one experiencing rapid and the other slower progression. CONCLUSIONS: SVI is not associated with a uniformly poor prognosis. Rather, tumors can be substratified by pathologic parameters into groups with differing prognoses based on routine histologic examination.

Plain abdominal x-ray versus computerized tomography screening: sensitivity for stone localization after nonenhanced spiral computerized tomography.

PURPOSE: Urolithiasis followup with plain abdominal x-ray requires adequate visualization of the calculus on the initial x-ray or computerized tomography (CT) study. We compared the sensitivity of plain abdominal x-ray versus CT for stone localization after positive nonenhanced spiral CT. MATERIALS AND METHODS: We evaluated 46 consecutive nonenhanced spiral CT studies positive for upper urinary tract lithiasis for which concurrent plain abdominal x-rays were available. X-ray and CT studies were compared for the ability to visualize retrospectively a stone given its location by CT. A consensus of 1 radiologist and 3 urologists was reached in each case. Cross-sectional stone size and maximum length were measured on plain abdominal x-ray. RESULTS: Plain abdominal x-ray and scout CT had 48% (22 of 46 cases) and 17% (8 of 46) sensitivity, respectively, for detecting the index stone (p <0.00004). Of the 39 stones overall visualized on plain abdominal x-ray only 19 (49%) were visualized on scout CT. Mean cross-sectional area and length of the stones on scout CT were 0.34 cm.2 (approximately 6 x 5.5 mm.) and 6. 5 mm., respectively, while the average size of those missed was 0.11 cm.2 (approximately 4 x 3 mm.) and 3.6 mm. The mean size differences in the groups were highly significant (p <0.0009). CONCLUSIONS: Plain abdominal x-ray is more sensitive than scout CT for detecting radiopaque nephrolithiasis. Of the stones visible on plain abdominal x-ray 51% were not seen on CT. To facilitate outpatient clinic followup of patients with calculi plain abdominal x-ray should be performed when a stone is not clearly visible on scout CT.

Laparoscopic ileal conduit: five-year follow-up.

OBJECTIVES: To report the techniques used for intracorporeal laparoscopic construction of an ileal conduit urinary diversion and long-term patient follow-up after this procedure. METHODS: A 28-year-old man with cerebral palsy, a neurogenic bladder, and voiding dysfunction was referred for definitive management of his urinary tract after several episodes of pyelonephritis. A conduit urinary diversion was performed using a 5-port, transabdominal approach. An appropriate length of ileum was used for diversion, and ureterointestinal anastomoses were performed using a modified Bricker technique. All aspects of the procedure were performed intracorporeally, including isolation of conduit, bowel reanastomosis, ureteral mobilization, and ureterointestinal anastomosis. A 12-mm port site was enlarged and used as the stoma, which was constructed in routine fashion. RESULTS: Five years after surgery, this patient had normal and stable renal function, with a serum creatinine of 0.8 mg/dL. Serial imaging studies continued to reveal prompt and symmetric renal function and no evidence of obstruction or reflux. CONCLUSIONS: Laparoscopic ileal conduit construction is feasible and can provide durable results. Although technically challenging, ongoing technical refinements will make performance of reconstructive laparoscopy more widely applicable. Larger series with substantial follow-up will help illuminate the place of laparoscopic noncontinent urinary diversion in the surgical armamentarium.

Needle biopsy of recurrent adenocarcinoma of the prostate after radical prostatectomy.

The objective of this study was to evaluate needle biopsy of recurrent prostate cancer after radical prostatectomy. We evaluated 37 cases of recurrent prostate cancer after radical prostatectomy that were diagnosed by needle biopsy between March 1984 and July 1998. Fifteen were from consultations in which contributors were uncertain of the diagnosis, and 22 were from men who had come to The Johns Hopkins Hospital for treatment. The median interval from radical prostatectomy to biopsy showing recurrent tumor was 40 months. There was no correlation between the interval to recurrence and either pathologic features of the biopsy and radical prostatectomy or various clinical features. The mean extent of adenocarcinoma in the biopsies was 3.2 mm (range, 0.1 to 18 mm; median, 2 mm). The length of recurrent cancer on biopsy correlated with an abnormal rectal examination (P = .001). The mean Gleason score for the recurrent tumors was 6.5, which correlated with the grade of the radical prostatectomy cancer (P = .005). The cancers often lacked overt histologic features of malignancy. Benign prostatic acini were seen in five cases (14%), usually separate from the cancer. In 5 (33%) of the consultation cases, we would not have been able to diagnose cancer if not for the fact that atypical prostate glands should not be present after radical prostatectomy. In well-sampled radical prostatectomies, margins were almost always positive, as was extraprostatic extension. In cases with less sampling, there was a higher incidence of organ-confined disease and margin-negative disease implying suboptimal processing of the radical prostatectomy. After radical prostatectomy, recurrent cancer on needle biopsies may be focal and difficult to diagnose and must be assessed differently than in patients who have not had surgery.

The prognostic significance of tertiary Gleason patterns of higher grade in radical prostatectomy specimens: a proposal to modify the Gleason grading system.

The Gleason grading system of prostatic adenocarcinoma does not account for the existence of a tertiary (third most prevalent) pattern, and there are no studies concerning the latter's prognostic influence. The authors analyzed 114 radical prostatectomies with small tertiary components, which mostly occupied less than 5% of whole tumors. These specimens were compared with a prostatectomy database comprised of 2,276 cases without a tertiary component. The pathologic stages of "typical" Gleason score 5 to 6 tumors (Gleason scores 2 + 3 = 5, 3 + 2 = 5, 3 + 3 = 6), which contained tertiary patterns 4 or 5, were significantly higher than those of "typical" Gleason score 5 to 6 tumors without pattern 4 (p = 0.018) but lower than those of "typical" Gleason score 7 tumors (p = 0.021; Gleason scores, 3 + 4 = 7, 4 + 3 = 7). Typical Gleason score 7 tumors with a tertiary pattern 5 showed significantly worse pathologic stages than typical Gleason score 7 tumors (p = 0.008) without pattern 5 and were not different statistically from typical Gleason score 8 (Gleason score, 4 + 4 = 8) tumors. Both typical Gleason score 5 to 6 and 7 tumors with tertiary components revealed significantly higher progression rates than typical Gleason score 5 to 6 tumors (p <0.0001) and Gleason score 7 tumors (p = 0.003) without tertiary components, and progressed like typical Gleason score 7 and 8 tumors respectively. Tertiary high-grade components have an adverse impact on biologic behavior. The authors propose that the Gleason system for radical prostatectomy specimens be modified to take into account small volumes of patterns 4 and 5, which are important prognostically.

Molecular and immunohistochemical staging of men with seminal vesicle invasion and negative pelvic lymph nodes at radical prostatectomy.

BACKGROUND: Patients with seminal vesicle invasion (SVI) at radical retropubic prostatectomy (RRP) have a poor prognosis. Routine microscopic examination of pelvic lymph nodes (LNs) can miss small metastases and, thereby, confuse tumor staging and clinical decision-making. The authors used immunohistochemical and molecular methods to examine archival paraffin-embedded LNs of men who had undergone RRP for clinically localized prostate carcinoma and who had tumors demonstrating SVI and negative LNs at surgery. METHODS: Between June 1982 and June 1997, 2151 consecutive men underwent RRP for clinically localized prostate carcinoma. Of these, 109 (5.1%) tumors had SVI with negative LNs. The actuarial likelihood of having a tumor that was undetectable by testing prostate-specific antigen (PSA) 5 and 10 years after surgery was 45% and 29%, respectively, for men with isolated SVI. Archival LN specimens were available for 102 men who had isolated SVI. Reverse transcription polymerase chain reaction (RT-PCR) was performed for PSA and prostate-specific membrane antigen (PSMA). All specimens were examined concurrently by immunohistochemistry (IHC). RESULTS: Careful reevaluation of pelvic LNs demonstrated metastases in 9 (8.8%) men originally classified as metastasis-free. Reevaluation by hematoxylin and eosin (H&E) staining identified three previously unrecognized cases of LN metastases. IHC identified six cases, three of which were missed by H&E. RT-PCR identified four cases, three of which were not revealed by other methods. CONCLUSIONS: The poor prognosis of patients with SVI does not seem due to occult LN metastases. The low yield of unsuspected foci of prostate carcinoma in the LNs of men with SVI and negative LNs by routine staging does not justify IHC or molecular examination to find occult carcinoma.