Laparoscopic intracorporeally constructed ileal conduit after porcine cystoprostatectomy.

PURPOSE: We present our technique of laparoscopic ileal conduit creation after cystoprostatectomy in a porcine model performed in a completely intracorporeal manner. METHODS AND METHODS: After developing the technique in 5 acute animals laparoscopic cystoprostatectomy with intracorporeally performed ileal conduit urinary diversion was performed in 10 surviving male pigs. A 5-port transperitoneal technique was used. All steps of the technique applied during open surgery were duplicated intracorporeally. Specifically cystectomy, isolation of an ileal conduit, restoration of bowel continuity and mucosa-to-mucosa stented bilateral ileoureteral anastomosis formation were performed by exclusively intracorporeal laparoscopic techniques. RESULTS: Surgery was successful in all 10 study animals without intraoperative or immediate postoperative complications. Blood loss was minimal and average operative time was 200 minutes. Stenosis of the end ileal stoma specifically at the skin level was noted in 6 animals. Three deaths occurred 2 to 3 weeks postoperatively. At sacrifice renal function was normal in all surviving animals. No ileo-ureteral anastomotic strictures were noted on pre-sacrifice radiography of the loop or at autopsy examination of the anastomotic sites. CONCLUSIONS: Laparoscopic ileal conduit urinary diversion after cystoprostatectomy may be performed completely intracorporeally in the porcine model. Clinical application of this technique is imminent.

Quality of life and psychological adaptation after surgical treatment for localized renal cell carcinoma: impact of the amount of remaining renal tissue.

OBJECTIVES: To analyze the quality of life and psychological adjustment after surgical therapy for localized renal cell carcinoma. METHODS: Postal questionnaires including measures of quality of life (SF-36) and the impact of the stress of cancer (Impact of Events Scale) were completed by 97 patients who had undergone radical or partial nephrectomy for localized renal cell carcinoma. Data were analyzed for the group as a whole and comparing the partial nephrectomy and radical nephrectomy groups. The variables examined included the impact of the type of partial nephrectomy (elective versus mandatory) and the amount of self-reported renal tissue remaining. RESULTS: The quality of life for the group as a whole was good, with no significant differences between the sample and U.S. norms for an age and sex-matched community sample on both the mental and physical health composite scores. Having undergone a partial versus a radical nephrectomy did not influence the patients' overall quality of life. Multiple linear regression modeling demonstrated that having more remaining renal parenchyma was an independent predictor of better self-reported physical health on the SF-36 (P <0.001). The entire sample had low mean scores on both avoidance and intrusion on the Impact of Events Scale, suggesting a lack of daily anxiety about cancer. Multiple linear regression modeling showed that patients who reported having more remaining renal parenchyma had lower intrusion and avoidance scores (P = 0.002 and 0.01, respectively). Multiple logistic regression modeling also demonstrated that the patients' perception of their remaining renal parenchyma was associated with less concern about cancer recurrence (P = 0.018) and less impact of cancer on patients' overall health (P <0.001). CONCLUSIONS: Most survivors of localized kidney cancer have normal physical and mental health regardless of the type of nephrectomy performed. The quality of life is better for patients with more renal parenchyma remaining after surgery for localized renal cell carcinoma.

Management of synchronous renal neoplasm and abdominal aortic aneurysm.

OBJECTIVES: Renal neoplasm (RN) and abdominal aortic aneurysm (AAA) are occasionally discovered concurrently. The approach to synchronous malignancy and aortic aneurysm is controversial. METHODS: Between 1981 and 1999, concurrent RN and AAA were diagnosed in 50 patients at the Cleveland Clinic Foundation. Twenty-three patients were managed conservatively because of small asymptomatic AAA or metastatic disease; these patients were excluded from the study. The remaining 27 patients underwent operative management of both entities with a staged or simultaneous approach, and they form the basis of this article. RESULTS: AAA diameter ranged from 4.8 to 13 cm (mean, 6.0+/-1.8 cm). RNs were managed with radical nephrectomy in 11 patients (41%), partial nephrectomy in 10 patients (37%), or both in 6 patients with bilateral renal tumors (22%). The AAA repair was performed at the time of the urologic procedure in 11 patients (41%), before the urologic procedure in 13 patients (48%), or after the urologic procedure in 3 patients (11%). The AAA was addressed with open surgical repair in 24 patients (89%); recently, three patients (11%) underwent endovascular repair of the aneurysm and staged partial nephrectomy. The incidence of major perioperative complications was 23% (6 patients). Acute renal failure was the most common complication (3 [11%]) followed by acute respiratory failure (2 [7.4%]), pulmonary embolism (1 [3.7%]), and stroke (1 [3.7%]). At the mean follow-up of 57 months, there were no graft infections reported. The 5-year overall and cancer-specific survival rates were 62% and 81%, respectively. There was a significant difference in 5-year cancer-specific survival when comparing patients managed simultaneously versus staged (80% versus 35%, P =.007). CONCLUSIONS: The concurrent presentation of RN and AAA should not discourage one from treating both entities simultaneously because long-term survival is common. Endovascular repair of AAA holds promise as an attractive strategy in these complex patients.

Contemporary management of renal cell carcinoma with coexistent renal artery disease: update of the Cleveland Clinic experience.

OBJECTIVES: To treat concurrent renal cell carcinoma (RCC) and renal artery disease (RAD), which pose an unusual and challenging management dilemma. METHODS: Before June 1998, 48 patients presented with localized RCC and RAD affecting all the functioning renal parenchyma. These patients were grouped into four distinct categories: group 1, a solitary kidney with RCC and RAD (n = 8); group 2, bilateral RCC and coexistent RAD (n = 9); group 3, unilateral RCC and contralateral RAD (n = 15); and group 4, unilateral RCC and bilateral RAD (n = 16). The most common cause of RAD was atherosclerosis (n = 40), followed by medial fibroplasia (n = 5), renal artery aneurysm (n = 2), and arteriovenous malformation (n = 1). RESULTS: All patients underwent complete surgical excision of RCC. A nephron-sparing operation was performed preferentially (44 patients), and bilateral renal cancer operations were staged. Eleven patients underwent surgical renal vascular reconstruction in conjunction with either partial (n = 9) or radical (n = 2) nephrectomy. In 2 patients, renal revascularization was accomplished by percutaneous transluminal angioplasty before tumor excision. No perioperative deaths occurred. Postoperatively, preservation of renal function was achieved in 47 patients; 1 patient required chronic dialysis. The overall and cancer-specific 5-year patient survival rates in this series were 66% and 90%, respectively. At a mean follow-up of 58 months, 28 patients were alive with no evidence of malignancy. Six patients died of metastatic RCC, and 14 died of unrelated causes with no evidence of malignancy. CONCLUSIONS: Nephron-sparing surgery combined with selective renal arterial reconstruction can yield gratifying results in this complex patient population.

Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup.

PURPOSE: Partial nephrectomy is effective for renal cell carcinoma when preservation of renal function is a concern. We present the 10-year followup of patients treated with nephron sparing surgery at our institution. MATERIALS AND METHODS: Partial nephrectomy was performed in 107 patients with localized sporadic renal cell carcinoma before December 1988. Tumors were symptomatic in 73 patients (68%) and indications for surgery were imperative in 96 (90%). Of the patients 42 (39%) had renal insufficiency preoperatively. All patients were followed a minimum of 10 years or until death. RESULTS: At the end of the followup interval 32 patients (30%) had no evidence of recurrence, 28 (26%) died of metastatic renal cell carcinoma and 46 (42%) died of unrelated causes. Cancer specific survival was 88.2% at 5 and 73% at 10 years, and was significantly affected by tumor stage, symptoms, tumor laterality and tumor size. Long-term renal function was stable in 52 patients (49%). CONCLUSIONS: Partial nephrectomy is effective for localized renal cell carcinoma, providing long-term tumor control with preservation of renal function.

Nephron sparing surgery for localized renal cell carcinoma: impact of tumor size on patient survival, tumor recurrence and TNM staging.

PURPOSE: We studied the impact of tumor size on patient survival and tumor recurrence following nephron sparing surgery for localized sporadic renal cell carcinoma. In addition, we evaluated the usefulness of the new TNM staging system in which T1 versus T2 tumor status is delineated by tumor size 7 or less versus more than 7 cm., respectively. MATERIALS AND METHODS: The results of nephron sparing surgery for localized sporadic renal cell carcinoma in 485 patients treated before 1997 were reviewed. Patients were divided into groups according to tumor size as 1--2.5 or less (142), 2--2.5 to 4.0 (168), 3--more than 4 to 7 (125) and 4--more than 7 cm (50). Mean postoperative followup was 47 months. RESULTS: Overall and cancer specific 5-year survival for the entire series was 81 and 92%, respectively. Of 44 patients with recurrent renal cell carcinoma 16 (3.2%) had local recurrence and 28 (5.8%) had metastatic disease. There was no difference in 5-year cancer specific survival or tumor recurrence between groups 1 and 2 or groups 3 and 4. However, these outcome measures were significantly more favorable in groups 1 and 2 combined (tumors 4 cm. or less) compared to groups 3 and 4 combined (tumors more than 4 cm.) (p = 0.001). CONCLUSIONS: Following nephron sparing surgery for localized sporadic renal cell carcinoma cancer-free survival is significantly better in patients with tumors 4 cm. or less compared to those with larger tumors. The usefulness of the current TNM staging system can be improved by subdividing T1 tumors into T1a (4 cm. or less) and T1b (4 to 7 cm.).

Management of small solitary unilateral renal cell carcinomas: impact of central versus peripheral tumor location.

PURPOSE: Recent studies have suggested that nephron sparing surgery and radical nephrectomy provide equally effective therapy for patients with small (less than 4 cm.), solitary, unilateral renal cell carcinoma and a normal contralateral kidney. We evaluate whether central versus peripheral tumor location in the involved kidney is a significant factor affecting treatment outcome in these patients. MATERIALS AND METHODS: Patients with a single, small (less than 4 cm.), localized, unilateral, sporadic renal cell carcinoma were identified from our institutional registry. From 1972 to 1995, 145 patients fulfilling these criteria were treated with either nephron sparing surgery (86) or radical nephrectomy (59). Mean postoperative followup was 51.4 months. Tumor characteristics and outcome measures were analyzed in 35 patients with central versus 110 with peripheral renal cell carcinomas according to the type of treatment. RESULTS: We detected 27 central (77%) and 75 peripheral renal cell carcinomas (68%) incidentally. Nephron sparing surgery was used to treat 19 central (54%) and 67 peripheral (61%) carcinomas. Pathological tumor stage was T1 to 2 in 33 central (94%) and 91 peripheral (82%) cases. Grade 1 to 2 renal cell carcinoma was present in 28 central (80%) and 85 peripheral (77%) tumors. Postoperatively, when comparing patients with central versus peripheral renal cell carcinomas there was no difference in 5-year cancer specific survival (100 versus 97%), tumor recurrence (5.7 versus 4.5%) or renal function (mean serum creatinine 1.43 mg./dl. in both groups). These parameters were also equivalent in patients treated with nephron sparing surgery versus radical nephrectomy overall and within the central versus peripheral renal cell carcinoma subgroups. Nephron sparing surgery was technically more complicated in central renal cell carcinomas with a longer renal ischemia time (55 versus 34 minutes, p <0.05) and more frequent entry of the collecting system (74 versus 47%, p <0.05) compared to peripheral carcinomas. Two patients (2.3%, 1 central, 1 peripheral) had local tumor recurrence after nephron sparing surgery. CONCLUSIONS: There were no significant biological differences between centrally versus peripherally located small solitary unilateral renal cell carcinomas. Nephron sparing surgery is technically more demanding in patients with central tumors. However, treatment with nephron sparing surgery or radical nephrectomy is equally effective regardless of tumor location.

Patterns of tumor recurrence and guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma.

PURPOSE: We delineated patterns of tumor recurrence and developed guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. MATERIALS AND METHODS: Before December 1994, 327 patients underwent nephron sparing surgery for sporadic localized renal cell carcinoma at our clinic. Mean postoperative followup was 55.6 months. The course and outcome for patients with postoperative recurrent renal cell carcinoma were reviewed in detail. RESULTS: Renal cell carcinoma recurred after nephron sparing surgery in 38 patients (11.6%), including 13 (4.0%) who had local tumor recurrence with (7) or without (6) metastatic disease and 25 (7.6%) who had metastatic disease without local tumor recurrence. Recurrent renal cell carcinoma was detected by associated symptoms in 25 patients and by a followup chest x-ray or abdominal computerized tomography (CT) in 13. The respective incidences of postoperative local tumor recurrence and metastatic disease according to initial pathological tumor stage were 0 and 4.4% for stage T1, 2.0 and 5.3% for stage T2, 8.2 and 11.5% for stage T3a, and 10.6 and 14.9% for stage T3b disease. The peak postoperative intervals until local tumor recurrence were 6 to 24 months (7 of 10 patients with stage T3 renal cell carcinoma) and longer than 48 months (all 3 with stage T2 disease). Patients with isolated local tumor recurrence had better survival compared to those with local tumor recurrence and metastatic disease or metastases only. CONCLUSIONS: Followup for recurrent malignancy after nephron sparing surgery for renal cell carcinoma can be tailored according to the initial pathological tumor stage. All patients should be evaluated yearly with a medical history, physical examination and select laboratory studies. Patients with stage T1 renal cell carcinoma require no additional monitoring, while those with stage T2 disease should also undergo a yearly chest x-ray and abdominal CT every 2 years. The same recommendations are offered for patients with stage T3 renal cell carcinoma except that abdominal CT should be done every 6 months for the first 2 years postoperatively.

Renal hemodynamic effects of lovastatin in a renal ablation model.

OBJECTIVES: Patients with renal mass reduction of more than 50% are at increased risk for progressive renal failure. Lipid-lowering agents have been shown to preserve renal function in various models of chronic renal failure. This study was performed to evaluate the hemodynamic effects of lovastatin, a 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, in the remnant kidney model. METHODS: Two groups of animals were studied. Group 1 (n = 9) served as controls and group 2 (n = 14) received lovastatin, 15 mg/kg/day orally, for 2 weeks after renal ablation. Glomerular filtration rate (GFR, inulin clearance), renal blood flow (RBF, ultrasonic flow probe), and 24-hour protein excretion were measured in anesthetized rats. RESULTS: Two weeks after renal ablation, GFR was 0.28 +/- 0.09 mL/min/gkw (gram kidney weight) in group 1, whereas in group 2, lovastatin preserved GFR at 0.58 +/- 0.3 mL/min/gkw (P < 0.05). RBF in group 1 was 1.2 +/- 0.2 mL/min/gkw and increased to 2.1 +/- 0.4 mL/min/gkw in group 2 (P < 0.05), representing a 43% increase. Protein excretion decreased significantly to 13 +/- 1.7 mg/24 hr in group 2. The lovastatin-treated group had a lower serum cholesterol (59 +/- 3 mg/dL versus 71 +/- 2 mg/dL, P < 0.05), but serum triglyceride levels were not different between the two groups. CONCLUSIONS: Lovastatin preserves renal function in a renal ablation model after 2 weeks of treatment. It specifically increased total RBF. Therefore, in addition to its known cholesterol lowering effect, lovastatin also has the direct renal hemodynamic effect of increasing RBF and maintaining GFR.