Overtreatment and Underutilization of Watchful Waiting in Men With Limited Life Expectancy: An Analysis of the Michigan Urological Surgery Improvement Collaborative Registry.

OBJECTIVE: To determine rates of watchful waiting (WW) vs treatment in prostate cancer (PCa) and limited life expectancy (LE) and assess determinants of management. MATERIALS AND METHODS: Patients diagnosed with PCa between 2012 and 2018 with <10 years LE were identified from the Michigan Urologic Surgery Improvement Collaborative registry. Multinomial logistic regression models were used to identify factors associated with management choice among NCCN low-risk PCa patients. Data from high-volume practices were analyzed to understand practice variation. RESULTS: Total 2393 patients were included. Overall, WW was performed in 8.1% compared to 23.3%, 25%, 11.2%, and 3.6% who underwent AS, radiation (XRT), prostatectomy (RP), and brachytherapy (BT), respectively. In men with NCCN low-risk disease (n = 358), WW was performed in 15.1%, compared to AS (69.3%), XRT (4.2%), RP (6.7%), and BT (2.5%). There was wide variation in management among practices in low-risk men; WW (6%-35%), AS (44%-81%), and definitive treatment (0%-30%). Older age was associated with less likelihood of undergoing AS vs WW (odds ratio [OR] 0.88, P < .001) or treatment vs WW (OR 0.83, P < .0001). Presence of ≥cT2 disease (OR 8.55, P = .014) and greater number of positive biopsy cores (OR 1.41, P = .014) was associated with greater likelihood of treatment vs WW and Charlson comorbidity score of 1 vs 0 (OR 0.23, P = .043) was associated with less likelihood of treatment vs WW. CONCLUSION: Wide practice level variation exists in management for patients with low- and favorable-risk PCa and <10-year LE. Utilization of WW is poor, suggesting overtreatment in men who will experience little benefit.

Malignant Mesothelioma of the Tunica Vaginalis Testis: Outcomes Following Surgical Management Beyond Radical Orchiectomy.

OBJECTIVE: To describe clinical management and outcomes of a cohort of patients with malignant mesothelioma of the tunica vaginalis testis (MMTVT) who received treatments beyond radical orchiectomy. METHODS: Patients with confirmed MMTVT at a single tertiary care institution were identified. Treatments, pathologic outcomes, and survival were recorded. Prognostic variables associated with survival were analyzed with a Cox proportional hazards model and Kaplan-Meier curves. RESULTS: Overall, 15 patients were included. Initial presentation was a scrotal mass in 7 of 15 (47%) and hydrocele in 5 of 15 (33%) patients. Clinical staging revealed enlarged nodes in 5 of 15 (33%) patients. Radical orchiectomy was the initial treatment in 5 of 15 (33%) patients. Positive surgical margins were found in 6 of 14 (43%) radical orchiectomies and were associated with worse survival (P = .007). The most frequent histologic subtype was epithelioid, associated with better survival (P = .048). Additional surgeries were performed on 12 of 15 (80%) patients. Pathologic examination revealed MMTVT in 6 of 12 (50%) hemiscrotectomies, 7 of 8 (88%) retroperitoneal lymph node dissections, 1 of 7 (14%) pelvic lymph node dissections, and 10 of 10 (100%) groin dissections. Five patients received adjuvant chemotherapy. Two also received adjuvant radiation therapy. Three patients with lymph node involvement remain no evidence of disease over 6 years after diagnosis. After a median follow-up of 3.5 years (interquartile range: 1.2-7.2), 5 patients have died, all of MMTVT; the median overall survival has not been reached. Common sites of relapse were lungs (5 of 7) and groin (3 of 7). CONCLUSION: The pattern of metastatic spread of MMTVT is predominantly lymphatic. Nodes in the retroperitoneum and the groin are commonly involved. Prognosis is poor, but there may be a role for aggressive surgical resection including hemiscrotectomy, and inguinal and retroperitoneal lymph nodes.

Second primary malignancies in renal cortical neoplasms: an updated evaluation from a single institution.

PURPOSE: To examine the incidence of secondary primary malignancies in patients with renal cortical neoplasms. METHODS: Between January 1989 and July 2010, 3647 patients underwent surgery at our institution for a renal cortical neoplasm and were followed through 2012. Occurrence of other malignancies was classified as antecedent, synchronous, or subsequent. All patients with antecedent malignancies (n = 498) and a randomly selected half of those with synchronous malignancies (n = 83) were excluded. The expected number of second primaries was calculated by multiplying Surveillance, Epidemiology, and End Results Program incidence rates of renal cortical neoplasms by person-years at risk within categories of age, sex, and year of diagnosis. The standardized incidence ratio (SIR) was calculated as observed cancers divided by expected incidence of the cancer, with approximation to the exact Poisson test used to obtain confidence intervals (CI) and p values. RESULTS: Of 3066 patients with renal cortical neoplasms, 267 had a second primary cancer; the five most common in men were prostate, colorectal, bladder, lung, and non-Hodgkin's lymphoma; the five most common in women were breast, colorectal, lung, endometrium, and thyroid. Men demonstrated higher than expected thyroid cancer rate (SIR 5.0; 95 % CI 1.83-10.88, p = 0.002), and women had higher than expected rates of stomach cancer (SIR 5.0; 95 % CI 1.61-11.67, p = 0.004) and thyroid cancer (SIR 4.62; 95 % CI 1.69-10.05, p = 0.003). CONCLUSIONS: The incidence of certain types of second malignancies may be higher in patients after diagnosis of renal cortical neoplasms compared to the general population. These observations can inform clinical follow-up in kidney cancer survivorship and future research studies.

The prognostic utility of preoperative neutrophil-to-lymphocyte ratio in localized clear cell renal cell carcinoma.

INTRODUCTION: To explore whether the association between preoperative neutrophil-to-lymphocyte ratio (NLR) elevation and worse survival is of use prognostically or merely a reflection of medical comorbidities in clear cell renal cell carcinoma (CC RCC). MATERIALS AND METHODS: We identified 1970 patients treated at Memorial Sloan Kettering Cancer Center from 1998-2012 by partial or radical nephrectomy for non-metastatic CC RCC. NLR was calculated by dividing absolute neutrophil count by absolute lymphocyte count; both were obtained from preoperative complete blood count. Uni- and multivariable Cox proportional hazards regression, which included established prognostic variables, were used to test for association between NLR and recurrence-free (RFS), cancer-specific (CSS), and overall survival (OS). RESULTS: Univariate analysis identified elevated NLR as significantly associated with worse RFS, CSS, and OS (all p < 0.0001). However, upon multivariable analysis, elevated NLR was significantly associated with only worse OS (p < 0.0001). After adding markers of comorbidity that were significantly correlated with NLR elevation-higher American Society of Anesthesiologists class (p = 0.013), older age, and higher estimated glomerular filtration rate (both p < 0.0001)--into the multivariable model, NLR remained significantly associated with OS (p = 0.001). The addition of NLR into the prognostic model for OS did not increase Harrell's concordance index from 0.776. CONCLUSIONS: In our cohort, preoperative NLR elevation is associated with worse OS, but there was no significant association with RFS or CSS on multivariable analysis. Preoperative NLR does not add unique prognostic information for patients undergoing surgical resection of renal tumors.

Non-neoplastic parenchymal changes in kidney cancer and post-partial nephrectomy recovery of renal function.

OBJECTIVE: To explore the association of non-neoplastic parenchymal changes (nNPC) with patients' health and renal function recovery after partial nephrectomy (PN). MATERIALS AND METHODS: This retrospective review identified 800 pT1a patients who underwent PN at Memorial Sloan Kettering Cancer Center from 2007 to 2012. Pathology reports were reviewed for nNPC graded as mild or severe: vascular sclerosis (VS), glomerulosclerosis (GS), and fibrosis/scarring. Correlations between nNPC and known preoperative predictors of renal function [age, sex, African-American race, estimated glomerular filtration rate (eGFR), American Society of Anesthesiologists (ASA) score, body mass index, coronary artery disease, and hypertension (HTN)] were assessed using Spearman's rank correlation (ρ). Multivariable linear regression, adjusted for the described known preoperative risk predictors, was performed to evaluate whether the parenchymal features were able to predict 6-month postoperative eGFR. RESULTS: In this study, 46 % of tumors had benign surrounding parenchyma. We noted statistically significant yet weak associations of VS with age (ρ = 0.19; p < 0.001), ASA (ρ = 0.09; p < 0.001), preoperative eGFR (ρ = -0.14; p < 0.001), and HTN (ρ = 0.14; p < 0.001). GS also significantly correlated with HTN, but the correlation was again small (ρ = 0.12; p < 0.001). After adjusting for known risk predictors, only GS was a significant predictor of 6-month postoperative eGFR. When compared with no GS, mild and severe GS were negatively associated with a decrease of 4.9 and 10.8 mL/min/1.73 m(2) in 6-month postoperative eGFR, respectively. CONCLUSIONS: Presence of VS and GS correlated with patients' baseline health, and presence of GS predicted postoperative renal function recovery.

Predicting length of stay after robotic partial nephrectomy.

INTRODUCTION: To investigate factors predictive of length of stay (LOS) after robotic partial nephrectomy (RPN) in an effort to identify patients suitable for RPN with overnight stay at outpatient surgical facilities. MATERIALS AND METHODS: Retrospective chart review of patients who underwent RPN at Memorial Sloan Kettering Cancer Center from January 2007 to July 2012 was conducted. Univariate and multivariate analyses were performed to identify the main predictors of LOS. The discrimination of the multivariate model was measured using the area under the curve (AUC); tenfold cross-validation was performed to correct for over-fit. RESULTS: One hundred and eighty-six patients were included in the analysis; 84 (45 %) had LOS of ≤1 day (median LOS 2 day; interquartile range 1-2). On univariate analysis, preoperative variables associated with LOS > 1 included larger tumors (P < 0.0001), lower estimated glomerular filtration rate (P = 0.003), older age (P = 0.006), female gender (P = 0.035), and higher comorbidity score (P = 0.015); operative variables associated with LOS > 1 day included greater estimated blood loss (P < 0.0001) and longer operative (P < 0.0001) and ischemia (P < 0.0001) times. The AUC of the preoperative model was 0.61 (95 % CI 0.52-0.69) after tenfold cross-validation. CONCLUSIONS: LOS after RPN is influenced by age, gender, medical comorbidities, and tumor size. However, when analyzed retrospectively, these factors had limited ability to predict LOS after RPN with sufficient accuracy to develop a prediction tool.

Long-term survival rates after resection for locally advanced kidney cancer: Memorial Sloan Kettering Cancer Center 1989 to 2012 experience.

PURPOSE: We analyzed the 23-year Memorial Sloan Kettering Cancer Center experience with surgical resection, and concurrent adrenalectomy and lymphadenectomy for locally advanced nonmetastatic renal cell carcinoma. MATERIALS AND METHODS: We retrospectively reviewed the records of 802 patients who underwent nephrectomy with or without concurrent adrenalectomy or lymphadenectomy for locally advanced renal cell carcinoma, defined as stage T3 or greater and M0. Patients who received adjuvant treatment within 3 months of surgery or had fewer than 3 months of followup or bilateral renal masses at presentation were excluded from analysis. Five and 10-year progression-free and overall survival was estimated by the Kaplan-Meier method. Differences between groups were analyzed by the log rank test. RESULTS: A total of 596 (74%) and 206 patients (26%) underwent radical and partial nephrectomy, respectively. Renal cell carcinoma progressed in 189 patients and 104 died of the disease. Median followup in patients without progression was 4.6 years. Symptoms at presentation, ASA(®) classification, tumor stage, histological subtype, grade and lymph node status were significantly associated with progression-free and overall survival. On multivariate analysis adrenalectomy use decreased with time but lymphadenectomy use increased (OR 0.82 vs 1.16 per year). Larger tumors were associated with a higher likelihood of concurrent adrenalectomy and lymphadenectomy. CONCLUSIONS: In our series of patients with locally advanced nonmetastatic renal cell carcinoma survival was favorable in those in good health who were asymptomatic at presentation with T3 tumors and negative lymph nodes. Further, there has been a trend toward more selective use of adrenalectomy and increased use of lymphadenectomy.

Association between visceral and subcutaneous adiposity and clinicopathological outcomes in non-metastatic clear cell renal cell carcinoma.

INTRODUCTION: Visceral adiposity has been inconsistently associated with clinicopathologic features and outcomes of clear cell renal cell carcinoma (ccRCC); however, most studies were conducted in non-Western populations. We evaluated the associations between visceral and subcutaneous adiposity and clinicopathological characteristics of non-metastatic ccRCC patients in a Western population. METHODS: The medical records of 220 surgically treated ccRCC patients with documented preoperative body mass index (BMI) and computed tomography (CT) scans were retrospectively reviewed. Nineteen patients with stage IV disease were excluded. Visceral (VFA) and subcutaneous fat area (SFA) were computed from pre-operative CT scans. Correlations between obesity measures were assessed with Pearson correlation. Associations between obesity measures and pathologic features were evaluated using logistic regression models adjusted for sex. Overall survival (OS) probabilities were estimated using Cox regression analysis. The log-rank test was used for group comparisons. RESULTS: The study cohort comprised 150 men and 51 women. Women had higher SFA (p = 0.01) but lower VFA (p < 0.001) than men. BMI was highly correlated with SFA (r = 0.804) and moderately correlated with VFA (r = 0.542). SFA and VFA were weakly correlated (r = 0.367). An increased BMI was associated with a better OS (p = 0.028). When adjusting for sex, neither SFA nor VFA was significantly associated with tumour grade, stage, or OS. CONCLUSIONS: Consistent with prior reports, our study suggests that increased BMI is associated with a better OS for patient with nonmetastatic ccRCC. Despite the high correlation between SFA and BMI, neither SFA nor VFA were significantly associated with tumour stage, grade, or OS in the current study; however, further studies in larger cohorts are required to validate this finding.

The association of baseline health and gender with small renal mass pathology.

INTRODUCTION: To explore further the association of baseline health and gender with small renal mass pathology as approximately 20% of those masses are benign and women are twice as likely as men to have benign pathology. MATERIALS AND METHODS: We conducted retrospective chart reviews of patients with renal masses ≤ 4 cm who underwent partial and radical nephrectomy from 1998 to 2012. Multivariable logistic regression analysis was performed to determine demographic and clinicopathologic factors associated with malignant pathology. RESULTS: In our cohort of 1726 patients, compared to patients with benign pathology, those with malignant pathology included a higher proportion of men (64.3% versus 42.7%, p < 0.01) and high American Society of Anesthesiologists class (43.8% versus 37.3%, p = 0.04), and had higher preoperative serum creatinine levels (1.1 mg/dL versus 1.0 mg/dL, p < 0.01) and larger tumors (2.5 cm versus 2.2 cm, p < 0.01). Gender-specific multivariable logistic regression analysis showed that in women factors associated with malignant pathology were high American Society of Anesthesiologists class (OR 1.57, 95% CI 1.07-2.32, p = 0.02) and tumor size (OR 1.46, 95% CI 1.19-1.79, p < 0.01). In men, factors associated with malignant pathology were tumor size (OR 1.33, 95% CI 1.06-1.67, p = 0.01) and age (OR 0.97, 95% CI 0.95-0.99, p < 0.01). CONCLUSIONS: Our results are consistent with prior reports, in which male gender and larger tumor size are significantly associated with malignant small renal masses. In addition, poor baseline health as represented by a high American Society of Anesthesiologists class is significantly associated with malignant pathology in women.

Neutrophil-lymphocyte ratio in small renal masses.

Introduction. To evaluate the association between preoperative neutrophil-lymphocyte ratio (NLR) and clinicopathologic characteristics in patients with small renal masses (SRM). Methods. Retrospective chart reviews of patients with renal masses ≤4 cm who underwent nephrectomy from January 2007 to July 2012 were conducted. Multivariable linear regression was used to examine the association between preoperative NLR and clinicopathologic variables. Results. In 1001 patients, we noted higher mean preoperative NLR in men (3.0 ± 1.4 versus 2.6 ± 1.3 in women, P < 0.01) and Caucasians (2.9 ± 1.4 versus 1.9 ± 0.9 in African Americans, P < 0.01) but no significant differences in patients with low (I-II) versus high (III-IV) American Society of Anesthesiologists (ASA) scores (2.8 ± 1.4 versus 2.9 ± 1.5, P = 0.18) or benign versus malignant pathology (2.9 ± 1.4 versus 2.8 ± 1.3, P = 0.75). Spearman correlation analysis (ρ) showed preoperative NLR significantly correlated with age (ρ = 0.15, P < 0.01) and preoperative serum creatinine (Crea) [ρ = 0.13, P < 0.01]. On multivariable linear regression analysis older age, male gender, Caucasian race, and preoperative Crea were predictive of higher preoperative NLR, but ASA score and tumor pathology were not. Conclusions. In patients with SRM, we found no association between preoperative NLR and tumor pathology.

Clinicopathologic features of renomedullary interstitial cell tumor presenting as the main solid renal mass.

OBJECTIVE: To review the clinical, pathologic, and radiographic features of renomedullary interstitial cell tumor (RMICT). This is a rare benign renal tumor formerly known as medullary fibroma and is indistinguishable from other renal cortical tumors by imaging. METHODS: After institutional review board approval, we reviewed data on patients from the Memorial Sloan-Kettering Cancer Center kidney tumor database from 1989 to 2012 (4898 patients) with a pathologic diagnosis of RMICT or medullary fibroma as the main resected tumor. Data collected included procedure, age, gender, presentation, preoperative tumor characteristics (size, location, nearness to collecting system, and RENAL nephrometry score), and final pathologic size. RESULTS: Ten patients (0.2%) with RMICT were identified. All patients had undergone partial nephrectomy for 10 tumors (9 right). Clinical presentation was incidental to abdominal imaging performed for another clinical reason in 6 patients, as part of a hematuria evaluation in 2 patients, and as part of nephrolithiasis follow-up imaging in 2 patients. The mean patient age was 52 years (range, 39-73), and 8 patients were female. The mean preoperative and final pathologic tumor size was 1.65 cm (range, 1.0-2.5) and 0.96 cm (range, 0.3-1.7), respectively. The location of the tumors was medullary (0-9 mm from the collecting system) in 8 patients and cortical (2.5 cm mostly exophytic and 1.5 cm mostly endophytic tumor) in 2 patients. CONCLUSION: Our data demonstrate a female predominance, a mean tumor size of <2 cm, and medullary location consistent with its pathologic origin. To our knowledge, this is the largest single-institution series of RMICT.

Clinical outcomes of local and metastatic testicular sex cord-stromal tumors.

PURPOSE: We evaluated pathological variables of testicular sex cord-stromal tumors, management options and clinical outcomes. MATERIALS AND METHODS: We retrospectively reviewed the records of 48 patients with testicular sex cord-stromal tumors treated at Memorial Sloan-Kettering Cancer Center between 1997 and 2012. Clinical outcomes were compared based on treatment and previously described pathological factors associated with metastatic potential. RESULTS: Of the 48 patients 37 underwent surveillance without retroperitoneal lymph node dissection, including 34 with no high risk feature and 3 with 1. Median followup was 14.5 months (IQR 6.9-32.5). No patient experienced recurrence. Retroperitoneal lymph node dissection was performed in 11 patients, including 6 with clinical stage I disease and 2 or more high risk features who underwent early dissection, 2 with clinical stage IIa disease at diagnosis who underwent early dissection and 3 with clinical stage I disease and 2 or more high risk features who were observed elsewhere but referred to our institution due to retroperitoneal disease. Six patients with clinical stage I disease underwent early dissection, 4 had no evidence of disease at a median followup of 6.6 years and 2 experienced recurrence and died of disease. Neither of the 2 patients with IIa disease at diagnosis experienced relapse. All 3 patients with delayed dissection experienced relapse and 1 died of disease. CONCLUSIONS: Patients with testicular sex cord-stromal tumors and 1 or no high risk feature can be safely observed without retroperitoneal lymph node dissection but longer followup is needed. Given the lack of effective alternative treatments, early retroperitoneal lymph node dissection may be beneficial in those with 2 or more high risk features, or clinical stage IIa disease.

Analysis of lymph node dissection in patients with ≥7-cm renal tumors.

PURPOSE: To analyze the role of lymph node dissection (LND) in patients with large renal tumors. METHODS: We performed a retrospective study of patients with renal cell carcinoma ≥7 cm in size undergoing surgery between 1990 and 2012. Primary outcome measures were recurrence-free and overall survival of patients who did and did not undergo LND. Cox proportional hazards regression models were created to account for known risk factors for recurrence and survival. Secondary outcomes were recurrence-free and overall survival by lymph node status, lymph node template and number of lymph nodes removed. RESULTS: Of 524 patients, 164 had disease recurrence and 197 died. Median follow-up was 5 and 5.5 years for patients who did not die or have a recurrence, respectively. A total of 334 (64 %) patients underwent LND, and node-positive disease was identified in 26 (8 %). For patients who did and did not undergo LND, 5-year recurrence-free survival was 64 and 77 %, respectively. Five-year overall survival was 75 and 78 %, respectively. LND was not a predictor of recurrence or survival in multivariate analysis. Node-positive disease was associated with recurrence (p < 0.0005) and mortality (p = 0.032), although node-positive patients had a 5-year overall survival of 65 %. CONCLUSIONS: We did not find a difference in recurrence-free or overall survival in patients with ≥7-cm tumors whether or not they underwent LND. Node-positive disease was associated with worse outcomes, suggesting that LND provides important staging information that can be important in the design of adjuvant clinical trials.

Partial Cystectomy after Neoadjuvant Chemotherapy: Memorial Sloan Kettering Cancer Center Contemporary Experience.

Objective. To report our contemporary experience with partial cystectomy after neoadjuvant chemotherapy. Patients and Methods. Retrospective review of patients who underwent neoadjuvant chemotherapy and partial cystectomy for urothelial cell carcinoma of the bladder at Memorial Sloan Kettering Cancer Center from 1995 to 2013. Log-rank test and Cox regression models were used to analyze variables possibly associated with recurrence-free, advanced recurrence-free (free from recurrence beyond salvage with intravesical therapy or radical cystectomy), and overall survival. Results. All 36 patients had a solitary tumor <5 cm in size. Twenty-one patients (58%) achieved cT0 following neoadjuvant chemotherapy with 7 (33%) having residual disease at PC. At last follow-up, 19 (53%) patients had recurrence, 15 (42%) had advanced recurrence, 10 (28%) died of disease, and 22 (61%) maintained an intact bladder. Median follow-up of those who were with no evidence of disease was 17 months. On univariable analysis, after neoadjuvant chemotherapy positive nodes on imaging and positive surgical margin at partial cystectomy were both associated with worse recurrence-free, advanced recurrence-free, and overall survival. Five-year recurrence-free, advanced recurrence-free, and overall survival were 28%, 51%, and 63%, respectively. Conclusion. Partial cystectomy following neoadjuvant chemotherapy provides acceptable oncologic outcomes in highly selected patients with muscle-invasive bladder cancer.

Is laparoendoscopic single-site surgery a viable approach for radical nephrectomy with renal vein thrombus? Comparison with multiport laparoscopy.

OBJECTIVE: To compare laparoendoscopic single-site surgery (LESS) and multiport laparoscopy (MPL) for radical nephrectomy and renal vein thrombectomy (RN-RVT) because concerns continue regarding the suitability of LESS for advanced renal tumors. METHODS: We initiated a retrospective analysis of 26 patients who underwent RN-RVT (11 LESS, 15 MPL) between January 2006 and September 2011. LESS transperitoneal access was obtained by a periumbilical incision through which all trocars were inserted. LESS-RN-RVT recapitulated steps of MPL-RN-RVT, including stapled RVT and intact specimen extraction. Demographic factors and tumor characteristics, perioperative variables, and complications and outcomes were analyzed. Primary outcome was discharge visual analog pain score. RESULTS: Median follow-up was 20.8 months. The 15 MPL cases were successfully completed laparoscopically; 1 of 11 LESS cases required insertion of an additional 5-mm port at a separate site. There were no significant demographic differences between the 2 groups. For LESS-RN-RVT and MPL-RN-RVT, mean tumor diameter was 7.1 and 7.9 cm (P = .346), mean RENAL nephrometry score was 10.2 and 10.5 (P = .407), mean operative time was 147 and 161 minutes (P = .331), and mean estimated blood loss was 122 and 170 mL (P = .282). Significantly lower visual analog pain score at discharge (1.1 vs 2.7, P = .001), narcotic requirement (8.3 vs 14 mg, P = .049), and hospital stay (2.6 vs 3.7 days, P = .032) were noted for LESS vs MPL patients. Both groups had negative margins. There were no significant differences in complications or transfusions or in disease-free and overall survival. CONCLUSION: LESS was comparable to MPL-RN-RVT for perioperative parameters and may confer benefit with pain and hospital stay. Further study is requisite to establish the role of LESS in the management of renal neoplasms with RVT.

Comparison of transrectal and transvaginal hybrid natural orifice transluminal endoscopic surgery partial nephrectomy in the porcine model.

OBJECTIVE: To compare the feasibility of porcine transrectal (TR) and transvaginal (TV) hybrid natural orifice transluminal endoscopic surgery (NOTES) partial nephrectomy (PN), as NOTES nephrectomy has recently been performed in the porcine model. MATERIALS AND METHODS: A total of 10 female pigs (weight 45 kg) underwent TR (n = 5) or TV (n = 5) NOTES PN. The pneumoperitoneum was created by a periumbilical 12-mm trocar, through which a laparoscope was advanced for intra-abdominal visualization. For TV-NOTES PN, a gastroscope was used to obtain TV peritoneal access. For TR-NOTES PN, a horizontal incision was made 2 cm above the dentate line, and a submucosal tunnel was created in the posterior rectal wall. The gastroscope was advanced through the submucosal tunnel and retroperitoneum to the kidney, and a peritoneal window was created. For both TR- and TV-NOTES PN, the gastroscope was exchanged for the SPIDER Surgical System. Flexible dissecting instruments and hook cautery introduced through the SPIDER Surgical System were used to mobilize the kidney. A harmonic scalpel introduced periumbilically was used to excise a portion of the lower pole. LAPRA-TY-secured sutured renorrhaphy was performed, followed by TR or TV specimen extraction. RESULTS: TR- and TV-NOTES PN was successfully performed in all 10 pigs. A comparison of TR- and TV-NOTES PN revealed no significant differences in the mean access time (29.2 vs 29.6 minutes, P = .944), operative time (196.0 vs 183.0 minutes, P = .631), and estimated blood loss (59.0 vs 54.0 mL, P = .861). Necropsy did not demonstrate abdominal injuries. CONCLUSION: We have demonstrated proof-of-principle for TR and TV-NOTES PN in swine, with comparable perioperative parameters. Preclinical survival studies are requisite to assess the potential of TR-NOTES as an alternative to TV-NOTES.

Does radical nephrectomy increase the risk of erectile dysfunction compared with partial nephrectomy? A cohort analysis.

UNLABELLED: Study Type - Therapy (prospective cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Erectile dysfunction (ED) is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). We hypothesized that partial nephrectomy (PN) would limit development of ED compared with radical nephrectomy (RN), primarily due to renal function preservation, and found that patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN; in addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. To our knowledge, this is the first study demonstrating an increased risk of ED after RN compared with PN. OBJECTIVES: • To evaluate prevalence and risk factors for development of erectile dysfunction (ED) in patients who underwent radical nephrectomy (RN) and partial nephrectomy (PN). • ED is a form of endothelial dysfunction that is prevalent in patients with chronic kidney disease (CKD). PN confers superior renal functional preservation compared with RN; however, the impact on ED is unclear. METHODS: • This was a retrospective study of 432 patients (264 RN/168 PN, mean age 58 years, mean follow-up 5.8 years) who underwent surgery for renal tumours between January 1998 and December 2007. • The primary outcome was rate of de novo ED postoperatively. Secondary outcomes included development of CKD (estimated GFR < 60 mL/min/1.73 m(2) ) and response to phosphodiesterase-5 inhibitors. • Multivariate analysis was performed to determine risk factors for de novo ED postoperatively. RESULTS: • RN and PN groups had similar demographics and comorbidities. • Tumour size (cm) was larger for RN (RN 7.0 vs PN 3.7, P < 0.001) and more preoperative ED existed in PN vs RN (P= 0.042). No differences were observed for preoperative CKD, hyperlipidaemia and diabetes mellitus. • Postoperatively, higher rates of de novo ED (29.5% vs 9.5%, P < 0.001) and CKD (33.0% vs 9.8%, P < 0.001) developed in RN vs PN cohorts, respectively. • Of men with ED, 63% responded to phosphodiesterase inhibitors, without significant difference between the two groups (P= 0.896). • Multivariate analysis demonstrated de novo ED to be associated with RN (odds ratio [OR] 3.56, P < 0.001), hypertension (OR 2.32, P= 0.014), preoperative (OR 8.77, P < 0.001) and postoperative (OR 2.64, P= 0.001) CKD, and postoperative diabetes mellitus (OR 2.93, P < 0.001). CONCLUSIONS: • Patients undergoing RN had significantly higher de novo ED compared with a contemporary, well-matched cohort undergoing PN. In addition to RN, hypertension, CKD and diabetes mellitus were associated with developing ED. • Further investigation on effects of surgically induced nephron loss on ED is requisite.

Factors affecting renal function after open partial nephrectomy-a comparison of clampless and clamped warm ischemic technique.

OBJECTIVE: To analyze factors impacting postoperative renal function after open partial nephrectomy using both the clampless and clamped warm-ischemic technique. METHODS: We studied a cohort of patients who underwent clamped partial nephrectomy (n = 164) and clampless partial nephrectomy (n = 64) from March 2002 to March 2009 with ≥ 12-months follow-up. Clamped partial nephrectomy used hilar occlusion before resection. Clampless partial nephrectomy used focal radio frequency coagulation to facilitate hemostasis before resection, nonischemic dissection/resection with hydro-dissection, or sharp resection after local compression. Demographics, tumor characteristics/RENAL nephrometry scores, perioperative variables, and complications were compared between the two methods. Multivariable analysis was performed to identify factors predicting de novo estimated glomerular filtration rate <60. RESULTS: Patient characteristics were similar between groups. Mean RENAL score was greater in clamped (6.9) vs clampless (6.4, P = .026); complications (P = .430) and urine leaks (clampless partial nephrectomy 3.1% vs clamped-PN 7.3%, P = .360) were similar. Mean warm ischemia time (min) was 24.5 for clamped partial nephrectomy. De novo estimated glomerular filtration rate <60(%) at last follow up was 13.5 (clamped) vs 3.1 (clampless) (P = .071). Multivariable analysis of the entire cohort revealed increasing body mass index (OR 1.1, P = .042) and RENAL score (OR 1.71, P = .002) as being independently associated with development of postoperative de novo estimated glomerular filtration rate <60. Multivariable analysis of the clamped subgroup demonstrated increasing body mass index (OR 1.12, P = .028), RENAL score (OR 1.56, P = .010), and ischemia time (OR 1.15, P = .042) as independent factors associated with de novo estimated glomerular filtration rate <60. CONCLUSION: Body mass index and RENAL score were factors predictive of development of de novo estimated glomerular filtration rate <60 after partial nephrectomy, with increasing warm ischemia time also being predictive in clamped partial nephrectomy patients. Further investigation and long-term functional data are requisite.

Comparison of laparoendoscopic single-site and multiport laparoscopic radical and partial nephrectomy: a prospective, nonrandomized study.

OBJECTIVE: To prospectively compare outcomes of laparoendoscopic single-site and multiport laparoscopic radical nephrectomy and partial nephrectomy, focusing on postoperative pain and analgesic requirement. METHODS: Nonrandomized, prospective comparison of laparoendoscopic single-site and multiport laparoscopic radical nephrectomy and partial nephrectomy. Thirty-four patients underwent laparoendoscopic single-site (17 radical nephrectomy/17 partial nephrectomy); 42 underwent multiport laparoscopy (28 radical nephrectomy/14 partial nephrectomy) from February 2009 to February 2010. Laparoendoscopic single-site transperitoneal access was obtained by periumbilical incision through which all trocars were inserted. Laparoendoscopic radical nephrectomy/partial nephrectomy recapitulated steps of multiport laparoscopic radical nephrectomy/partial nephrectomy. Demographics/tumor characteristics, outcomes, and complications were analyzed. RESULTS: Forty-two of 42 multiport laparoscopic and 32/34 laparoendoscopic single-site cases were successfully performed. Mean follow-up was 16.2 months. For laparoendoscopic single-site and multiport laparoscopy groups mean operating room time (min) was 159.3 vs 158.9 (P = .952); mean estimated blood loss (mL) was 175.7 vs 156.1 (P = .553); percent transfused was 2.9% vs 0% (P = .925). No significant differences in complications were noted (P = .745). Significant decrease in analgesic use (6 morphine equivalents vs 11.6, P < .001) and discharge pain score (1.7 vs 2.7, P < .01) were noted in laparoendoscopic single-site vs multiport laparoscopic radical nephrectomy. For laparoendoscopic single-site partial nephrectomy and multiport laparoscopic partial nephrectomy, no significant differences were noted for tumor diameter (1.8 vs 2.0 cm, P = .57), RENAL score (0.962), ischemia time (28.6 vs 27.5 minutes, P = .70), and preoperative (P = .78)/postoperative creatinine (P = .32). For laparoendoscopic single-site radical nephrectomy and multiport laparoscopic radical nephrectomy, no significant differences were noted for mean tumor diameter (5.6 vs 5.3 cm, P = .63), RENAL score (P = .815), and mean operative time (142.3 vs 155.4 minutes P = .13). CONCLUSION: In this well-matched, prospective comparison, laparoendoscopic single-site is comparable with multiport laparoscopic surgery in terms of perioperative parameters and may confer benefit with respect to analgesic requirement. Randomized evaluation and longer-term follow-up are necessary.