Surgical Margins in Nephron-Sparing Surgery for Renal Cell Carcinoma.

The oncologic impact of positive surgical margins after nephron-sparing surgery is controversial. Herein, we discuss current data surrounding surgical margins in the operative management of renal cell carcinoma. The prevalence, risk factors, outcomes, and subsequent management of positive surgical margins will be reviewed. Literature suggests that the prevalence of positive surgical margins following kidney surgery varies by practice setting, tumor characteristics, and operation type. For patients undergoing nephron-sparing surgery, it is not necessary to remove a margin of healthy tissue. Tumor enucleation may be appropriate and is associated with comparable outcomes. Reflexive intraoperative frozen section use does not provide beneficial information and many patients with positive margins can be monitored closely with serial imaging. The impact of positive surgical margins on recurrence and survival remains conflicting. Though every effort must be performed to obtain negative margins, a positive surgical margin appears to have a marginal impact on recurrence and survival.

Ureteroarterial fistula: A review of the literature.

Ureteroarterial fistulas are rare, erosive defects that occur between the distal segments of the ureter and the adjacent blood vessels in individuals with urologic and vascular comorbidities. Characterized by diffuse, pulsatile bleeding into the urinary tract, this condition carries a significant mortality rate in the absence of early recognition. Recent treatment efforts have focused on use of endovascular stenting techniques as an alternative to open surgical closure of the underlying defects in hemodynamically stable patients. We provide a literature review detailing the characteristics, mechanism, and management of ureteroarterial fistulas.

Survival benefit with extended lymphadenectomy for advanced renal malignancy: A population-based analysis.

OBJECTIVE: We used population-based data to examine the possible benefit of extended lymphadenectomy for patients with renal malignancy in the setting of more advanced disease. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify non-metastatic, T3-T4 renal cancer patients from 2004-2015 treated with removal of ≥1 lymph node at the time of nephrectomy. Non-parametric bivariate statistics were used to assess associations between covariates of interest and extended lymphadenectomy (≥10 lymph nodes removed). Cancer-specific survival (CSS) and overall survival (OS) benefit was evaluated using Kaplan-Meier analysis. RESULTS: Of the 4397 patients identified, 816 (18.6%) underwent extended lymphadenectomy. For patients with T3a disease, 5-year CSS and OS benefit with extended lymphadenectomy did not reach statistical significance (CSS: hazard ratio [HR] 0.98, 95% confidence interval [CI] 0.77-1.24; OS: HR 0.96, 95% CI 0.77-1.20). Conversely, for those with T3b-T3c disease, extended lymphadenectomy led to statistically significant improvements in both 5-year CSS and OS compared to non-extended lymphadenectomy (CSS: HR 0.78, 95% CI 0.61-0.99; OS: HR 0.72, 95% CI 0.58-0.90). Finally, for those with T4 disease, use of extended lymphadenectomy had OS benefit after 5 years (OS: HR 0.51, HR 0.29-0.90, p = 0.02). CONCLUSION: Based on population-level data, extended lymphadenectomy was associated with improved survival in select patients with advanced renal malignancy treated with surgical nephrectomy. Understanding the basis of these real-world findings in the face of conflicting randomized trial results will be key, moving forward.

Patient Acceptance of Teleurology via Telephone vs Face-to-Face Clinic Visits for Hematuria Consultation at a Veterans Affairs Medical Center.

INTRODUCTION: We evaluated the experience and preferences of patients undergoing hematuria consultation via teleurology compared to a conventional face-to-face clinic visit. METHODS: Patients evaluated for hematuria with teleurology or face-to-face clinic visit were surveyed regarding their experience and preferences. The survey consisted of 27 questions evaluating overall acceptance and satisfaction (8 questions), impact factors (17) and preference (2). RESULTS: A total of 450 patients participated in the survey at a 2-to-1 ratio (300 via teleurology, 150 via face-to-face visits). Overall, patient satisfaction level was higher with teleurology compared to face-to-face clinic visits (mean score 9.2 vs 8.4, p <0.0001). This finding was observed in all 8 domains (acceptance, efficiency, convenience, friendliness, quality of interview, communication and care, provider professionalism and privacy protection, all p <0.001). Transportation related issues were the most common underlying reason that influenced patient opinion, with at least 1 transportation factor being reported by 280 of 300 teleurology patients (93.3%) and 133 of 150 patients seen face-to-face (88.7%). Clinic operation and provider interaction factors similarly impacted patient satisfaction and preference. Time to access was significantly better for teleurology (12 days) compared to face-to-face clinics (72 days, p <0.001). Overall incidence of bladder cancer was 5.6% (25 of 450 patients), which was observed in 6.3% of the teleurology group (19 of 300) and 4.0% of the face-to-face group (6 of 150, p = 0.386). CONCLUSIONS: Patients prefer teleurology to face-to-face clinic visits for the initial evaluation of hematuria. Teleurology positively impacts compliance and access by potentially eliminating common challenges facing patients, and by improving efficiency, convenience and flexibility.

Contrasting patient, family, provider, and societal goals at the end of life complicate decision making and induce variability of care after trauma.

BACKGROUND: End-of-life (EoL) decision making during critical illness and injury is important in facilitating compassionate care that is congruent with patient, family, and societal expectations. Herein, we evaluate factors that may effect and induce variability in practitioner EoL decision making, particularly years in practice, use of advance directives (ADs), and cost. METHODS: An anonymous, online survey was offered to all active members of the Eastern Association for the Surgery of Trauma (n = 1,359) in June 2012. Demographic information and a series of questions dealing with common potentially influential factors were included. Responses were 5-point Likert scale based. RESULTS: A total of 375 responses (27.6%) were received. Ninety-two percent of the respondents were physicians, 70% were male, and 77% were from Level 1 trauma centers. Of respondents, 65.8% rely on family to make EoL decisions most or all of the time, while 80.7% feel family members are rarely or only sometimes in appropriate emotional states to make such choices. A significant number of practitioners felt comfortable making decisions without family input at all, more so with experienced practitioners as compared with those in practice for less than 15 years (38.2% and 24.1% respectively, p < 0.01).Of the practitioners, 59.6% rely on ADs most or all of the time, only 61.1% agree or strongly agree that ADs are useful, and only 56.3% feel families follow their loved one's ADs most or all of the time. A patient's family support or ability to pay for aftercare was rarely or never considered important by 80.1% of the practitioners, despite 85.1% reporting that quality of life postillness/injury was important most or all of the time. CONCLUSION: Practitioner comfort and motivation to influence EoL decision making varies with experience level. ADs are not uniformly perceived to be helpful, and costs are uncommonly considered. To improve EoL quality, these factors need to be considered. LEVEL OF EVIDENCE: Care management study, level IV.