Comparison of oncological outcomes for open and laparoscopic radical nephroureterectomy: results from the Canadian Upper Tract Collaboration.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?Open radical nephroureterectomy (ORNU) with excision of the ipsilateral bladder cuff is a standard treatment for upper tract urothelial carcinoma (UTUC). However, over the past decade laparoscopic RNU (LRNU) has emerged as a minimally invasive surgical alternative. Data comparing the oncological efficacy of ORNU and LRNU have reported mixed results and the equivalence of these surgical techniques have not yet been established. We found that surgical approach was not independently associated with overall or disease-specific survival; however, there was a trend toward an independent association between LRNU and poorer recurrence-free survival (RFS). To our knowledge, this is the first large, multi-institutional analysis to show a trend toward inferior RFS in patients with UTUC treated with LRNU. OBJECTIVE: To examine the association between surgical approach for radical nephroureterectomy (RNU) and clinical outcomes in a large, multi-institutional cohort, as there are limited data comparing the oncological efficacy of open RNU (ORNU) and laparoscopic RNU (LRNU) for upper urinary tract urothelial carcinoma (UTUC). PATIENTS AND METHODS: Institutional RNU databases containing detailed information on patients with UTUC treated between 1994 and 2009 were obtained from 10 academic centres in Canada. Data were collected on 1029 patients and combined into a relational database formatted with patient characteristics, pathological characteristics, and survival status. Surgical approach was classified as ORNU (n = 403) or LRNU (n = 446). The clinical outcomes were overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS). The Kaplan-Meier method and Cox proportional regression analysis were used to analyse survival data. RESULTS: Data were evaluable for 849 of 1029 (82.5%) patients. The median (interquartile range) follow-up duration was 2.2 (0.6-5.0) years. The predicted 5-year OS (67% vs 68%, log-rank P = 0.19) and DSS (73% vs 76%, log-rank P = 0.32) rates did not differ between the ORNU and LRNU groups; however, there was a trend toward an improved predicted 5-year RFS rate in the ORNU group (43% vs 33%, log-rank P = 0.06). Multivariable Cox proportional regression analysis showed that surgical approach was not significantly associated with OS (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.63-1.27, P = 0.52) or DSS (HR 0.90, 95% CI 0.60-1.37, P = 0.64); however, there was a trend toward an independent association between surgical approach and RFS (HR 1.24, 95% CI 0.98-1.57, P = 0.08). CONCLUSION: Surgical approach was not independently associated with OS or DSS but there was a trend toward an independent association between LRNU and poorer RFS. Further prospective evaluation is needed.

Is retroperitoneal histology predictive of liver histology at concurrent post-chemotherapy retroperitoneal lymph node dissection and hepatic resection?

PURPOSE: We identified factors predicting liver histology in patients with nonseminomatous germ cell tumor undergoing concurrent post-chemotherapy retroperitoneal lymph node dissection and liver resection. MATERIALS AND METHODS: We reviewed the Indiana University testis cancer database to identify all patients with nonseminomatous germ cell tumor and liver metastasis who underwent post-chemotherapy retroperitoneal lymph node dissection and liver resection between 1976 and 2006. RESULTS: A total of 59 patients met study inclusion criteria. Necrosis, teratoma and cancer were identified in 31%, 46% and 24% of retroperitoneal specimens, and in 73%, 17% and 10% of liver specimens, respectively. Concordance between retroperitoneal and liver histology was 49% overall, including 94% for necrosis, 26% for teratoma and 36% for cancer. Liver necrosis alone was found in 94%, 70% and 50% of patients with retroperitoneal necrosis, teratoma and cancer, respectively. CONCLUSIONS: The overall rate of histological discordance between retroperitoneal and liver histology was 51% with 73% of all liver specimens containing necrosis only. Retroperitoneal necrosis is highly predictive of hepatic necrosis (94%). Management for liver lesions at post-chemotherapy retroperitoneal lymph node dissection must be individualized. Observation may be warranted for liver lesions requiring complicated hepatic surgery regardless of retroperitoneal pathology.

Associations between comorbidity, and overall survival and bladder cancer specific survival after radical cystectomy: results from the Alberta Urology Institute Radical Cystectomy database.

PURPOSE: We determined the associations between comorbidity, and overall survival and bladder cancer specific survival after radical cystectomy. MATERIALS AND METHODS: The Alberta Urology Institute Radical Cystectomy database is an ongoing multi-institutional computerized database containing data on all adult patients with a diagnosis of primary bladder cancer treated with radical cystectomy in Edmonton, Canada from April 1994 forward. The current study is an analysis of consecutive database patients treated between April 1994 and September 2007. Comorbidity information was obtained through a medical record review using the Adult Comorbidity Evaluation 27 instrument. The outcome measures were overall survival and bladder cancer specific survival. Cox proportional regression analysis was used to determine the associations between comorbidity, and overall survival and bladder cancer specific survival. RESULTS: Of the database patients 160 (34%), 225 (48%) and 83 (18%) had no/mild comorbidity, moderate comorbidity and severe comorbidity, respectively. Compared to patients with no or mild comorbidity, multivariate Cox proportional regression analyses that included age, adjuvant chemotherapy, surgeon procedure volume, pathological T stage, pathological lymph node status, total number of lymph nodes removed, surgical margin status and lymphovascular invasion showed that increased comorbidity was independently associated with overall survival (moderate HR 1.59, 95% CI 1.16-2.18, p = 0.004; severe HR 1.83, 95% CI 1.22-2.72, p = 0.003) and bladder cancer specific survival (moderate HR 1.50, 95% CI 1.04-2.15, p = 0.028; severe HR 1.65, 95% CI 1.04-2.62, p = 0.034). CONCLUSIONS: Increased comorbidity was independently associated with an increased risk of overall mortality and bladder cancer specific mortality after radical cystectomy.

Retroperitoneal lymph node dissection in testicular cancer.

With long-term survival in excess of 90% across all stages, testicular cancer has come to represent the model for successful multidisciplinary cancer care. Retroperitoneal lymph node dissection (RPLND) remains an integral component of testis cancer management strategies for both early- and advanced-stage disease. Commensurate with improvements made in clinical staging and in our understanding of the natural history of testis cancer, lymphatic spread, and neuroanatomy, considerable modifications in the technique and template of RPLND have taken place. The morbidity of primary RPLND and postchemotherapy RPLND is low when performed by experienced surgeons. This article reviews the evolution, role, and technique of RPLND in contemporary practice.

Laparoscopic versus open adrenalectomy for surgical adrenal disease.

OBJECTIVE: To compare the intraoperative and postoperative outcomes of laparoscopic versus open adrenalectomy for surgical adrenal disease. MATERIALS AND METHODS: Prospectively collected data from 22 consecutive laparoscopic adrenalectomies, performed by one surgeon (MGH) over a period of 18 months at the Royal Alexandra Hospital, Edmonton, Alberta, were reviewed. Laparoscopic adrenalectomy was performed by both the transperitoneal and retroperitoneal approaches. In addition, a retrospective chart review was performed for all open adrenalectomies, performed at the same institution, over a 6 year period. Exclusion criteria were locally invasive lesions and masses greater than 8 cm in diameter. Adrenal pheochromocytomas were included in both groups. The two groups were evaluated with respect to intraoperative and postoperative outcomes. RESULTS: Twenty-two laparoscopic and 19 open adrenalectomies were reviewed. Both groups were similar with regard to gender, age, body mass index, and ASA class. Two laparoscopic cases, both with a history of prior ipsilateral adrenal surgery, were converted to the open approach. The laparoscopic group had a longer mean operative time (171 minutes versus 104 minutes), yet had a lower estimated blood loss (146 cc versus 455 cc), blood transfusion rate (0% versus 16%), and intraoperative complication rate (5% versus 16%). Both groups were similar with regard to specimen size and pathology. The laparoscopic group required less post-operative analgesia (44 mg morphine versus 478 mg morphine), resumed a regular diet sooner (1.1 days versus 3.7 days), and had a shorter hospital stay (2.2 days versus 5.4 days). CONCLUSIONS: In our experience, prior ipsilateral adrenal surgery greatly increases the risk of open conversion. This study is consistent with the findings of a number of previously reported studies, supporting the emergence of laparoscopic adrenalectomy as the standard of care for surgical management of benign adrenal disease.

Open versus laparoscopic radical prostatectomy: a prospective comparison of postoperative urinary incontinence rates.

PURPOSE: We compared the 12-month postoperative urinary incontinence rates of open radical retropubic and laparoscopic radical prostatectomy. MATERIALS AND METHODS: This prospective study included all men with clinically localized prostate cancer scheduled for radical prostatectomy (open retropubic or laparoscopic) at the University of Alberta between October 1999 and July 2002. Preoperative evaluation included a 24-hour pad test, fluid volume voiding diary and International Prostate Symptom Score questionnaire. Postoperative evaluation included a 24-hour pad test at 3 and 12 months, as well as a voiding diary and International Prostate Symptom Score questionnaire at 3, 6, 9 and 12 months. RESULTS: A total of 239 patients met the eligibility criteria and consented to participate (172 open radical retropubic prostatectomy, 67 laparoscopic radical prostatectomy). Of the patients 87% (148) treated with open radical retropubic prostatectomy and 88% (57) of those treated with laparoscopic radical prostatectomy completed 12-month followup (p = 0.50). According to 24-hour pad testing 13% of those treated with open radical retropubic prostatectomy and 17% of those treated with laparoscopic radical prostatectomy remained incontinent at 1 year (p = 0.26). There was no difference in 24-hour pad weight, urinary symptom score and urinary quality of life at 1 year between the open and laparoscopic groups overall, or when stratified according to 12-month continence status. The majority of subjects in both groups described mild symptoms and a general satisfaction with urinary quality of life. CONCLUSIONS: Based on objective and subjective measures, there were no differences in urinary functional outcomes 1 year after open radical retropubic prostatectomy or laparoscopic radical prostatectomy. Urinary incontinence was found to affect a similar proportion of patients who underwent open (13%) and laparoscopic (17%) radical prostatectomy 12 months postoperatively.

Externalized urachal suture: novel approach to bowel and bladder retraction during transperitoneal laparoscopic radical prostatectomy.

INTRODUCTION: Although laparoscopic radical prostatectomy (LRP) has emerged as a legitimate minimally invasive surgical alternative to open radical retropubic prostatectomy, the technical difficulty of this advanced laparoscopic procedure remains an obstacle to its widespread use. We report a novel surgical technique for the purpose of bowel and bladder retraction during transperitoneal LRP that improves visualization and negates the need for additional working ports or steep Trendelenburg positioning. TECHNICAL CONSIDERATIONS: A 35-cm absorbable suture is secured intracorporeally to the urachus. The distal end of the suture is then pulled out through the left subcostal abdominal wall in the midaxillary line using a Carter-Thomason CloseSure device. Application of tension on the suture retracts the bladder superiorly and prevents bowel from entering the surgical field. This maneuver provides excellent exposure of the bladder neck and prostate and minimizes the need for additional fan retraction or steep Trendelenburg positioning. In 20 consecutive procedures, this step added an average of 2.2 minutes to the operative time, which averaged 169 minutes overall. CONCLUSIONS: Incorporation of an adjustable externalized urachal suture allows for excellent retraction of both bowel and bladder. This allows transperitoneal LRP to be performed using a four-port approach with minimal need for additional retraction or steep Trendelenburg positioning. In light of these benefits, the urachal suture has been incorporated as a routine step in transperitoneal LRP at our institution.