Anatomical mapping of lymph nodes in patients receiving salvage lymphadenectomy based on a positive 11C-choline positron emission tomography/computed tomography scan.

INTRODUCTION: This paper aims to assess the diagnostic accuracy of an 11C-choline positron emission tomography/computed tomography (PET/CT) scan in the detection of lymph node (LN) metastases in patients with biochemical recurrence after radically treated prostate cancer (PCa), as compared to histology. The secondary goal is to depict spreading patterns of metastatic LNs in recurrent PCa. MATERIAL AND METHODS: A single center retrospective study comprising of 30 patients who underwent retroperitoneal and/or pelvic salvage lymph node dissection (LND) due to 11C-choline PET/CT-positive nodal recurrences after radical treatment (median Prostate Specific Antigen (PSA) 1.5 ng/ml, range 0.2-11.4). Positive nodes on the preoperative PET/CT scans were mapped and compared to post-operative pathology results.LNs were marked as true positive, false positive, true negative and false negative and a patient- and a region-based analysis was performed. Sensitivity, specificity and positive/negative predictive value (PPV/NPV) were calculated. RESULTS: Sixty positive LNs were detected on PET/CT with a median number of two positive nodes per patient (range 1-6). In 29 patients, a super-extended pelvic LND (PLND) was performed combined with a retroperitoneal LND (RPLND) in 13 of those cases. One patient underwent an inguinal LND. One hundred thirty-seven of 644 resected LNs contained metastases. The 11C-choline PET/CT scan correctly predicted 31 positive nodes (55%) while 25 nodes were falsely positive (45%). One hundred and six histologically proven metastatic nodes were not detected on the 11C-choline PET/CT scan (77%). Sensitivity, specificity, PPV and NPV of the 11C-choline PET/CT were 23%, 95%, 55% and 82%, respectively. CONCLUSIONS: 11C-choline PET/CT has a relatively low detection rate and a moderate PPV for metastatic LNs in patients with biochemical recurrence after radically treated PCa.

Laparoscopic Training in Urology Residency Programs: A Systematic Review.

BACKGROUND/AIMS: Laparoscopy is a widespread surgical approach for many urological conditions. Achieving prof-ciency in laparoscopic surgery requires considerable effort due to the steep learning curve. Several residency programs include standardized laparoscopic training periods in their curricula. Our aim was to systematically analyze the evidence on the current status of training in laparoscopy in different residency programs in urology. METHODS: We performed a systematic review of PubMed/Medline and the Cochrane library, in February 2018, according to the Preferred Reporting Items for the Systematic Review and Meta-Analyses Statement. Identified reports were reviewed according to the previously defined inclusion criteria. Eight publications, comprising a total of 985 urology residents, were selected for inclusion in this analysis. RESULTS: There was a wide variation between training programs in terms of exposure to laparoscopy. Most residents considered that training in lap-aroscopy was inadequate during residency and had a low degree of confidence in independently performing laparo-scopic procedures by the end of the residency. Only North American residents reported high degrees of confidence in the possibility of performing laparoscopic procedures in the uture, whereas the remaining residents, namely from European countries, reported considerably lower degrees of confidence. CONCLUSION: There were considerable differences between national urology residency programs in terms of exposure to laparoscopy. Most residents would prefer higher exposure to laparoscopy throughout their residencies.

Oncological and functional efficacy of nephron-sparing surgery versus radical nephrectomy in renal cell carcinoma stages ≥cT1b: a single institution, matched analysis.

INTRODUCTION: The purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups. MATERIAL AND METHODS: Our single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates. RESULTS: Groups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1-100.5 vs. PN: 38.5 months, range 20.5-72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p <0.03). There was no significant difference in complication rates between the two groups (p = 0.3). The main limitations of this study were its retrospective design and the medium-term follow-up. CONCLUSIONS: Our results demonstrated the efficacy and safety of PN in patients with RCC in clinical stages ≥T1b. We observed no significant difference in oncological outcomes between the PN and RN groups at medium-term follow ups. The surgical method did not influence these outcomes. Renal function was preserved significantly more frequently in the PN than in the RN group, but the groups had similar complication rates.These findings suggested that PN could be considered an oncologically safe procedure for treating large RCC tumors; thus, PN should always be considered, when technically feasible, regardless of tumor stage.

Papel actual de la cirugía en el cáncer de próstata de alto riego / Current role of surgery for high risk prostate cancer

En esta revisión se discute el papel de la cirugía en los pacientes con tumor de características adversas y alto riesgo de progresión tumoral. En la actual era del PSA, la proporción de pacientes que presentan cáncer de próstata (CaP) de alto riesgo se estima que es entre el 15% y 25%, con una supervivencia de 10 años cáncer-específica en el rango de 80-90% de los que recibieron tratamiento local activo. El tratamiento del cáncer de próstata de alto riesgo es un reto contemporáneo. La cirugía en este grupo está ganando popularidad, dado que se han publicado datos de 10 años de supervivencia cáncer-específica del 90%. La prostatectomía radical se debe combinar con linfadenectomía extendida. Los tratamientos adyuvantes o de rescate pueden ser necesarios en más de la mitad de los pacientes, basándose en los hallazgos anatomo-patológicos y el PSA postoperatorio. Lamentablemente no hay ensayos aleatorios controlados que comparen la prostatectomía radical y la radioterapia y no hay ningún tratamiento que pueda ser recomendado universalmente. Este grupo de pacientes de cáncer de próstata de alto riesgo debería ser considerado como un desafío multidisciplinario; sin embargo, la prostatectomía radical, para el paciente adecuadamente seleccionado, ya sea como primer o como único tratamiento puede ser considerada un tratamiento excelente(AU)

In this review, the role of surgery in patients with adverse tumor characteristics and a high risk of tumor progression are discussed. In the current PSA era the proportion of patients presenting with high risk prostate cancer (PCa) is estimated to be between 15% and 25% with a 10-year cancer specific survival in the range of 80-90% for those receiving active local treatment. The treatment of high risk prostate cancer is a contemporary challenge. Surgery in this group is gaining popularity since 10-year cancer specific survival data of over 90% has been described. Radical prostatectomy should be combined with extended lymphadenectomy. Adjuvant or salvage therapies may be needed in more than half of patients, guided by pathologic findings and postoperative PSA. Unfortunately there are no randomized controlled trials comparing radical prostatectomy to radiotherapy and no single treatment can be universally recommended. This group of high risk prostate cancer patients should be considered a multi-disciplinary challenge; however, for the properly selected patient, radical prostatectomy either as initial or as the only therapy can be considered an excellent treatment(AU)

Nefrectomía parcial abierta para tumores complejos y > 4 cm: ¿Es todavía la técnica de referencia en la era mínimamente invasiva? / Open partial nephrectomy for complex tumours and > 4 cm: is it still the gold standard technique in the minimally invasive era?

El objetivo de este artículo es discutir el papel de la nefrectomía parcial abierta (NPA) en tumores renales complejos y tumores grandes > 4 cm en la era mínimamente invasiva. Revisamos el estado actual de la NPA, la nefrectomía parcial laparoscópica (NPL) y la nefrectomía parcial robótica (NPR). Se realiza una búsqueda de la literatura utilizando la base de datos de la Biblioteca Nacional de Medicina (PubMed). La indicación de NPA se ha extendido a tumores T1b (4-7 cm). La nefrectomía parcial y la radical ofrecen resultados oncológicos equivalentes para estos tumores. Además, hay una aplicación creciente de la NPA para tumores complejos (de localización central, hiliares, multifocales). A pesar de la cohorte de pacientes más exigente, no hay un aumento de la morbilidad general de la NPA. En series contemporáneas hay un aumento de pacientes con sobrepeso y una incidencia mayor de tumores centrales tratados con NPA. La NPL se ha extendido a pacientes seleccionados con masas renales más grandes (4-7 cm) y tumores de localización central. La NPL para tumores > 4 cm se asociaba en la primera fase con un aumento de la tasa de complicaciones y con un tiempo de isquemia caliente prolongado. Las tasas de complicaciones descendieron con la mejora de la técnica quirúrgica y la experiencia. La experiencia temprana con la nefrectomía parcial robótica es prometedora y los resultados perioperatorios son al menos comparables con los de la NPL. La NPL y la robótica tienen que competir con los resultados funcionales y oncológicos de la NPA(AU)

En la era de la cirugía renal conservadora la NPA sigue siendo el estándar establecido para el tratamiento de los tumores renales T1 en centros sin experiencia en laparoscopia avanzada. Los casos complejos con tumores centrales, tumores en riñón único y lesiones multifocales probablemente se manejen mejor con NPA. La NPL es factible en numerosos escenarios en centros con experiencia en laparoscopia avanzada, pero sigue siendo una operación exigente. Son necesarios estudios a largo plazo para definir mejor el papel del abordaje robótico de la NP(AU)

The objective of this paper is to discuss the role of open partial nephrectomy (OPN) for complex renal tumours and large renal tumours > 4 cm in the minimally invasive era. The current status of OPN, laparoscopic partial nephrectomy (LPN) and robotic PN are reviewed. The literature search is done using the National Library of Medicine database (PubMed).The indication of OPN has been extended to T1b tumours (4-7 cm). PN and radical nephrectomy (RN) provide equivalent oncological outcomes for these tumours. In addition, there is a growing application of OPN for complex tumours (centrally located, hilar, multifocal). Despite the more challenging cohort of patients, there is no increase in the overall morbidity of OPN. In contemporary cohorts there is an increase in overweight patients and a higher incidence of central tumours treated with OPN. LPN has been extended to select patients with larger renal masses (4–7 cm) and centrally located tumours. LPN for tumours > 4 cm was in the early phase associated with increased complication rate and prolonged warm ischemia time (WIT). Complication rates decreased with improvement of surgical technique and expertise. Early experience with robotic PN is promising and perioperative outcomes are at least comparable to LPN. LPN and robotic PN have to compete with the functional and oncological results of OPN. In the era of nephron-sparing surgery (NSS), OPN remains the established standard for the management of T1 renal tumours in centres without advanced laparoscopic expertise. Complex scenarios with centrally located tumours, tumours in a solitary kidney, and multifocal lesions probably are best managed with OPN. LPN is feasible in numerous clinical scenarios in centres with advanced laparoscopic expertise but remains a challenging operation. Long-term studies are needed to further define the role of the robotic approach for PN(AU)

Pathological results and rates of treatment failure in high-risk prostate cancer patients after radical prostatectomy.

OBJECTIVE: • To investigate the pathological characteristics and the rates of biochemical recurrence (BCR) -free survival after radical prostatectomy (RP) in men with high-risk prostate cancer. METHODS: • Of 4760 patients treated with RP for prostate cancer at three institutions, 293 patients (6.2%) had clinical stage T3, 269 (5.7%) had a biopsy Gleason sum ≥ 8, 370 (7.8%) had preoperative PSA ≥ 20 ng/mL and 887 (18.6%) were considered high-risk according to the D'Amico classification (clinical stage ≥ T2c or prostate-specific antigen (PSA) ≥ 20 ng/mL or biopsy Gleason sum ≥ 8). • Actuarial BCR-free survival probabilities after RP and the rate of favourable pathology (organ-confined cancer, negative surgical margin and Gleason ≤ 7) were assessed. RESULTS: • Median follow up was 2.4 years and 1179 (24.8%) patients had follow up beyond 5 years. • The rate of favourable pathology increased in the following order: clinical stage T3 (13.7%), biopsy Gleason ≥ 8 (16.4%), the D'Amico high-risk group (21.4%) and PSA ≥ 20 ng/mL (21.6%). • The 5-year BCR-free survival probabilities were 35.4% for Gleason ≥ 8, 39.8% for PSA ≥ 20 ng/mL, 47.4% for D'Amico high-risk group and 51.6% for clinical stage T3. • Patients with only one risk factor had the most favourable 5-year BCR-free survival (50.3%), relative to patients with two or more risk factors (27.5%) CONCLUSIONS: • Men with clinically localized high-risk prostate cancer do not have a uniformly poor prognosis after RP. • The rate of favourable pathology and of BCR-free survival may vary substantially, depending on the definition used. • RP should be considered a valid treatment modality for high-risk prostate cancer patients, as many can be surgically down-staged.