Determination of risk factors for progression in patients with viable tumor at post-chemotherapy lymph node dissection due to disseminated non-seminomatous germ-cell tumors.

BACKGROUND: To assess the clinical variables that effect progression in patients with viable tumor after post-chemotherapy lymph node dissection due to disseminated non-seminomatous germ-cell tumors. METHODS: We performed a retrospective analysis of 32 patients with viable tumor after PC-RPLND, operated between 1990 and 2016. Patients were categorized into 2 groups as favorable and non-favorable (intermedia and poor) according to International Germ Cell Consensus Classification (IGCCC). Tumor size was determined as the largest dimension of retroperitoneal mass. Clinical factors and adjuvant chemotherapy were evaluated to impact on recurrence free survival (RFS) and overall survival (OS). RESULTS: The median age of the patients and follow-up duration were 28.5 (17-51) years and 51.5 (4-253) months, respectively. 5-year RFS and OS were 57.8-66.8%, respectively. On univariate analysis, percentage of viable tumor, IGCCC risk group, primary site, second-line chemotherapy and surgical margin status were significant for RFS (p = 0.034, p = 0.002, p < 0.001, p = 0.011 and p < 0.001, respectively), while IGCCC risk group, second-line chemotherapy and surgical margin status were significant for OS (p = 0.004, p = 0.010 and p < 0.001, respectively). On multivariate analysis, second-line chemotherapy and surgical margin were independent risk factors for RFS (p = 0.016, HR 4.927 95% CI 1.34-18.02 and p < 0.001, OR 9.147 95% CI 2.61-31.98, respectively) and surgical margin status was the only predictor of OS (p = 0.038, HR 3.874 95% CI 1.07-13.69). CONCLUSION: Retroperitoneal lymph node dissection with negative surgical margin is essential for patients with viable residual tumor after chemotherapy. Need for second-line chemotherapy shows risk of progression.

Pathology associated with adherent perirenal fat and its clinical effect.

INTRODUCTION: The dissection of perirenal fat is of critical importance to kidney surgery and ease of dissection is more important when using minimally invasive approaches. This study aimed to determine the clinical, radiological, and pathological significance of adherent perirenal fat (APF). MATERIALS AND METHODS: This prospective study included 22 patients scheduled for partial nephrectomy and 40 patients for donor nephrectomy. Intraoperative fat dissection time was recorded, and the complexity of perirenal fat dissection was surgeon-classified as easy, moderate, and difficult. Perirenal fat and subcutaneous fat thickness were measured. Measurement of perirenal fat depth and the Hounsfield unit (HU) for both perirenal and subcutaneous fields were performed using computed tomography (CT) images. All specimens were submitted for histopatological analysis. Researchers in each arm were blinded to other researchers' data. RESULTS: Mean age of the patients was 51.3 ± 12.7 years. Mean perirenal fat dissection time was 15.0 ± 13.5 minutes. Patient demographics, BMI, nor occupational status differed between the 3 complexity of perirenal fat dissection groups. Radiological findings showed that there was a significant correlation between perirenal fat depth and complexity of perirenal fat dissection (P < .05), but not with HU measurements or subcutaneous fat thickness. Surgeon classification of the complexity of perirenal fat dissection was in accordance with the duration of dissection (P < .05). Perinephric fat contained more fibrous tissue in the patients with histologically proven APF than in those without (P < .05). CONCLUSIONS: APF is a challenge during kidney surgery. Difficult dissection prolongs the duration of perirenal fat dissection and surgery. Perirenal fat thickness measured via preoperative CT might be used to predict APF.

Long-term follow-up results of multiparametric prostate MRI and the prognostic value of PI-RADS: a single-center retrospective cohort study.

PURPOSE: We aim to examine the long-term outcomes of patients who underwent multiparametric prostate magnetic resonance imaging (mp-MRI) for suspected prostate cancer (PCa), specifically based on their initial Prostate Imaging Reporting and Data System (PI-RADS) categories and various clinical factors. Our secondary aim is to evaluate the prognostic value of the PI-RADS through the National Comprehensive Cancer Network (NCCN) risk group distribution. METHODS: This research was conducted as a single-center retrospective cohort study in a tertiary care hospital. A total of 1,359 cases having at least one histopathological examination after the initial mp-MRI and/or adequate clinical/radiological follow-up data were included in the clinically significant PCa (cs-PCa) diagnosis-free survival analysis. Initial mp-MRI dates were accepted as the start of follow-up for the time-to-event analysis. The event was defined as cs-PCa diagnosis (International Society of Urological Pathology ≥2). Patients who were not diagnosed with cs-PCa during follow-up were censored according to predefined literature-based criteria at the end of the maximum follow-up duration with no reasonable suspicion of PCa and no biopsy indication. The impact of various factors on survival was assessed using a log-rank test and multivariable Cox regression. Subsequently, 394 cases diagnosed with PCa during follow-up were evaluated, based on initial PI-RADS categories and NCCN risk groups. RESULTS: Three main risk factors for cs-PCa diagnosis during follow-up were an initial PI-RADS 5 category, initial PI-RADS 4 category, and high MRI-defined PSA density (mPSAD), with average hazard ratios of 29.52, 14.46, and 3.12, respectively. The PI-RADS 3 category, advanced age group, and biopsy-naïve status were identified as additional risk factors (hazard ratios: 2.03, 1.54-1.98, and 1.79, respectively). In the PI-RADS 1-2 cohort, 1, 3, and 5-year cs-PCa diagnosis-free survival rates were 99.1%, 96.5%, and 93.8%, respectively. For the PI-RADS 3 cohort, 1, 3, and 5-year cs-PCa diagnosis-free survival rates were 94.9%, 90.9%, and 89.1%, respectively. For the PI-RADS 4 cohort, 1, 3, and 5-year cs-PCa diagnosis-free survival rates were 56.6%, 55.1%, and 55.1%, respectively. These rates were found to all be 24.2% in the PI-RADS 5 cohort. Considering the 394 cases diagnosed with PCa during follow-up, PI-RADS ≥4 cases were more likely to harbor unfavorable PCa compared to PI-RADS ≤3 cases (P < 0.001). In the PI-RADS 3 subgroup analysis, a low mPSAD (<0.15 ng/mL2) was found to be a protective prognostic factor against unfavorable PCa (P = 0.005). CONCLUSION: The PI-RADS category has a significant impact on patient management and provides important diagnostic and prognostic information. Higher initial PI-RADS categories are associated with decreased follow-up losses, a shorter time to PCa diagnosis, increased biopsy rates, a higher likelihood of developing cs-PCa during follow-up, and a worse PCa prognosis. Combining mPSAD with PI-RADS categories could enhance diagnostic stratification in the identification of cs-PCa.

A rare and overlooked mechanical complication of partial nephrectomy: Accelerated hypertension due to renal artery stenosis.

Secondary hypertension accounts for 5% to 10% of all hypertensive cases, and renal artery stenosis is one of the most common causes of secondary hypertension. Although atherosclerotic vascular disease and fibromuscular dysplasia are the leading causes of renal artery stenosis, there are other, rare etiologies, such as vasculitis and trauma. A partial nephrectomy is the standard of care treatment option for early stage renal carcinoma patients. Traumatic renal artery stenosis can occur during this surgical intervention, though it is a very rare adverse event, and only a few case reports have been reported in the literature. This report is the description of successful percutaneous treatment of accelerated hypertension secondary to traumatic renal artery stenosis after a partial nephrectomy.

Percutaneous Nephrolithotomy in Solitary Kidneys: 17 Years of Experience.

OBJECTIVE: To compare the demographics and the results of patients who underwent percutaneous nephrolithotomy (PCNL) with solitary and bilateral kidneys. MATERIALS AND METHODS: Between January 1998 and August 2014, 2268 patients underwent PCNL at Hacettepe University Hospital. We retrospectively analyzed the data of 91 patients with a solitary kidney and 2177 patients with bilateral kidneys treated by PCNL. We compared the success and complication rates between patients with solitary and bilateral kidneys. Additionally, we determined the factors affecting success and serious complications for patients with a solitary kidney. All statistical analyses were performed using SPSS 17.0 for Windows. The threshold for statistical significance was set at P <.05. RESULTS: The median age was 48 years and 61 patients (67%) were male. The median stone burden was 400 mm2. The stones were located in the renal pelvis in 27 patients (30%), in calices in 50 patients (55%), and in the staghorn in 14 patients (15%). A total of 57 patients (62%) underwent a left-side surgery. The comparison between solitary and nonsolitary patients showed that stone free, transfusion, and postoperative urinary tissue infection rates were similar. Complication rates, postoperative JJ stent requirements, and length of hospital stay were statistically higher in patients with a solitary kidney. The presence of a staghorn stone, the stone number (single-multiple), and male gender were found to have a negative impact on success. The existence of upper-pole stones was found to be the only factor that led to serious complications (Clavien 3-4). CONCLUSION: PCNL is an effective but more complicated option in patients with a solitary kidney, with stone-free rates similar to patients with bilateral kidneys.

Laparoscopic upper pole heminephrectomy in adults for treatment of duplex kidneys.

PURPOSE: To present our results of laparoscopic upper pole heminephrectomy in adult patients with duplex kidney. MATERIALS AND METHODS: A total of 10 patients with an age range of 27 to 54 years old underwent laparoscopic upper pole heminephrectomy for complete duplication of the renal collecting system. The key point of the technique included the placement of a catheter in the normal ureter at the beginning of the procedure. The patient was positioned in a 45-90 degrees lateral decubitus position and a 4-port transperitoneal or 3-port retroperitoneal technique was applied followed by the mobilization of the upper pole ureter away from the renal hilum. Afterwards, the vasculature supplying the upper pole was precisely identified and ligated. Followed by transection of the ureter and its transposition cephalad to the hilum, the upper pole moiety was fully transected using the harmonic scalpel. RESULTS: Eight patients were operated on using the transperitoneal approach and 2 using the retroperitoneal technique. One patient required preoperative percutaneous drainage due to pyonephrosis. The operation time ranged between 150 to 350 min with minimal blood loss (0-200 mL). Hemostasis was achieved with an Argon laser in one patient. The lower pole calyceal system was perforated in one patient and repaired intracorporally. No major intraoperative complications occurred. All of the patients except two had their drains removed in 72 h after the operation and were generally discharged on postoperative day 3. CONCLUSION: Laparoscopic upper pole heminephrectomy for an ectopic ureter is safe and reproducible and offers benefits of laparoscopic surgery even in patients with complicated urinary tract infection.