Alex Gorbonos

The role of cytoreductive nephrectomy in the era of molecular targeted therapy.

While the widespread use of imaging has resulted in an increasing number of incidentally detected renal cancers, up to one third of patients present with metastatic disease and a significant number of those with clinically localized disease subsequently develop metastasis. The prognosis for patients with metastatic disease has traditionally been poor, with a 2‐year survival of only 10 to 20%. However, over the past decade a number of developments have enhanced the treatment of these patients. Phase III trials have demonstrated a significant improvement in overall survival for well‐selected patients undergoing cytoreductive nephrectomy prior to immunotherapy. Meanwhile, the recent introduction of molecular targeted agents has resulted in improved response rates and tolerability compared with immunotherapy, and has prompted a re‐evaluation of the role and timing of surgery in patients with advanced disease. This review examines the role of surgical therapy for patients with metastatic disease in the new era of molecular targeted therapy.

Perinatal testicular torsion in siblings

The management of perinatal torsion remains a controversial topic in pediatric urology. We present two cases of brothers diagnosed with perinatal torsion during the postnatal period. The first brother experienced bilateral torsion, with both testes found to be unsalvageable during emergent surgery on day 4 of life. Two years later the second brother was found on his newborn exam to have findings consistent with unilateral left testicular torsion. Emergent exploration was undertaken that confirmed the left testis to be necrotic. The contralateral testis was found to be normal and a fixation procedure was undertaken.

Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial

BACKGROUND Radical cystectomy is the surgical standard for invasive bladder cancer. Robot-assisted cystectomy has been proposed to provide similar oncological outcomes with lower morbidity. We aimed to compare progression-free survival in patients with bladder cancer treated with open cystectomy and robot-assisted cystectomy. METHODS The RAZOR study is a randomised, open-label, non-inferiority, phase 3 trial done in 15 medical centres in the USA. Eligible participants (aged ≥18 years) had biopsy-proven clinical stage T1-T4, N0-N1, M0 bladder cancer or refractory carcinoma in situ. Individuals who had previously had open abdominal or pelvic surgery, or who had any pre-existing health conditions that would preclude safe initiation or maintenance of pneumoperitoneum were excluded. Patients were centrally assigned (1:1) via a web-based system, with block randomisation by institution, stratified by type of urinary diversion, clinical T stage, and Eastern Cooperative Oncology Group performance status, to receive robot-assisted radical cystectomy or open radical cystectomy with extracorporeal urinary diversion. Treatment allocation was only masked from pathologists. The primary endpoint was 2-year progression-free survival, with non-inferiority established if the lower bound of the one-sided 97·5% CI for the treatment difference (robotic cystectomy minus open cystectomy) was greater than -15 percentage points. The primary analysis was done in the per-protocol population. Safety was assessed in the same population. This trial is registered with ClinicalTrials.gov, number NCT01157676. FINDINGS Between July 1, 2011, and Nov 18, 2014, 350 participants were randomly assigned to treatment. The intended treatment was robotic cystectomy in 176 patients and open cystectomy in 174 patients. 17 (10%) of 176 patients in the robotic cystectomy group did not have surgery and nine (5%) patients had a different surgery to that they were assigned. 21 (12%) of 174 patients in the open cystectomy group did not have surgery and one (1%) patient had robotic cystectomy instead of open cystectomy. Thus, 302 patients (150 in the robotic cystectomy group and 152 in the open cystectomy group) were included in the per-protocol analysis set. 2-year progression-free survival was 72·3% (95% CI 64·3 to 78·8) in the robotic cystectomy group and 71·6% (95% CI 63·6 to 78·2) in the open cystectomy group (difference 0·7%, 95% CI -9·6% to 10·9%; pnon-inferiority=0·001), indicating non-inferiority of robotic cystectomy. Adverse events occurred in 101 (67%) of 150 patients in the robotic cystectomy group and 105 (69%) of 152 patients in the open cystectomy group. The most common adverse events were urinary tract infection (53 [35%] in the robotic cystectomy group vs 39 [26%] in the open cystectomy group) and postoperative ileus (33 [22%] in the robotic cystectomy group vs 31 [20%] in the open cystectomy group). INTERPRETATION In patients with bladder cancer, robotic cystectomy was non-inferior to open cystectomy for 2-year progression-free survival. Increased adoption of robotic surgery in clinical practice should lead to future randomised trials to assess the true value of this surgical approach in patients with other cancer types. FUNDING National Institutes of Health National Cancer Institute.

Ureteral Reimplantation in Adults: Open Versus Robotic

OPEN to 24 open ureteral reimplants. Statistically signifiINDICATIONS for adult ureteral reimplantation include extirpation of malignancy, iatrogenic injury and benign stricture disease. Causes of iatrogenic ureteral injury include complications of gynecologic surgery (hysterectomy), colorectal surgery (low anterior resection and abdominoperineal resection) and urological surgery (ureteroscopy and prostatectomy). Causes of benign ureteral stricture include retroperitoneal fibrosis secondary to vascular bypass grafting and radiation. The definitive management of ureteral strictures and ureteral injury is a common reconstructive problem that the urologist must manage, as endoscopic techniques have marginal long-term success rates. When the distal ureter cannot be reimplanted directly into the bladder due to insufficient length, ancillary techniques are required, which include a psoas hitch and Boari flap. The question has been asked as to whether open or robotic surgery is the optimal method to manage ureteral reimplantation. The psoas hitch was originally described by Witzel in 1896 but did not gain popularity until the work of Zimmerman and Turner-Warwick in the 1960s. While the Boari flap was initially used in an animal model in 1894, it was not described in humans until 1947. Now with more than 50 years of open surgical experience, the data on open reconstructive outcomes are mature. Single center series with as many as 181 patients at 4.5 years of followup document a 97% success rate. In the last 20 years our field has witnessed the evolution and application of minimally invasive surgery to urology, starting with laparoscopy and progressing to robotic assisted surgery. Robotic assisted surgery has been used for prostate cancer, renal cancer and bladder cancer. As with any new surgical approach, comparison to established techniques must be made to assess outcomes, complications and costeffectiveness. Although these data are most mature for prostatectomy, they are still developing for ureteral reconstruction. Our current best level of evidence to compare robotic to open surgical distal ureteral reconstruction is level 3b, based on a case control study by Kozinn et al comparing 10 robotic

The July Effect in Urologic Surgery: Myth or Reality?

Introduction: The July effect is the widely held belief that medical care is compromised at the beginning of the academic year due to transitioning medical trainees. We determined its impact on surgical outcomes in urological surgery. Methods: The Healthcare Cost and Utilization Project State Inpatient Database, State Ambulatory Surgery and Services Database and State Emergency Department Database for California were used for the years 2007 to 2011. Patients were identified who underwent surgery in July, August, April and May, and separated into early (July and August) and late (April and May) cohorts. Surgical outcomes for early vs late surgery were compared for academic centers. Adjusted multivariate models were fit to determine the effect of early surgery as a predictor of adverse outcomes. Results: For major urological surgery July/August timing had no impact on length of stay, 30-day readmission, 30-day emergency room visits, never events, perioperative complications or mortality (all values p >0.05). Similarly, for stone, groin, bladder outlet and cystoscopic bladder procedures, July/August surgery had no impact on rates of urinary retention, emergency room visits within 30 days, clot evacuations within 30 days, perioperative complications or 30-day readmissions (all values p >0.05). At the end of the year cystectomies had increased odds of intraoperative complications (OR 0.63, 95% CI 0.4–0.97) while nephrectomies had higher odds of major complications (OR 0.69, 95% CI 0.53–0.89). Conclusions: Surgical outcomes are not compromised by having surgery at the beginning of the academic year, despite resident turnover, representing appropriate oversight during this potentially vulnerable time.

Pushing Boundaries: Robotic Nephrectomy of an Auto-transplanted Kidney for Recurrent Renal Cell Carcinoma

Advances in robotic technology continue to expand the boundaries of minimally invasive approaches in transplant surgery. A single report has previously described the use of the robotic approach in transplant nephrectomy for a failed allograft. Our objective is to describe our technique and experience for the first reported robotic nephrectomy of an auto-transplanted solitary kidney for a recurrence of renal cell carcinoma (RCC). We highlight technical considerations during allograft mobilization and hilum dissection with the additional demands of a previously operated auto-transplant kidney.

Metastatic Involvement of the Prostatic Anterior Fat PadImplications for the Pathologist

Objectives There is little information regarding the utility of pathologic evaluation of the prostatic anterior fat pad (PAFP) in patients with a low preoperative probability of recurrence. Our study aimed to determine the utility of PAFP pathologic examination, especially for this group of patients. Methods We analyzed a tertiary care academic centers radical prostatectomy (RP) specimens from 2009 to 2017. Results Of 602 RP specimens, 420(70%) included the PAFP; four of 420 (1%) had lymph node involvement (LNI) in the PAFP. In two of four cases with LNI in the PAFP, this was the only site of LNI. Of these two cases, one occurred in a patient with low probability of recurrence and involved a nonpalpable PAFP lymph node. Conclusions Pathologic evaluation of the PAFP may be useful even in patients with low probability of recurrence because it may change staging by detecting metastatic involvement of small PAFP lymph nodes.

V3-10 ROBOTIC-ASSISTED LAPAROSCOPIC NEPHRECTOMY OF AN AUTO-TRANSPLANTED KIDNEY FOR RECURRENT RENAL CELL CARCINOMA

INTRODUCTION AND OBJECTIVES: To perform nephronsparing surgery, arterial clamping is often required. Operative bleeding control is difficult in laparoscopic techniques. We imagined a novel technique for “zero ischemia” nephron-sparing surgery using a hybrid opearating room: clampless laparoscopic partial nephrectomy was performed after superselective tumoral embolization. Our objective is to describe this new technique. METHODS: The patient is a 46 year old patient with no prior medical history, who had a 3 cm large localized renal tumor on the convexity of the left kidney. The lesion was heterogeneous, medial, partially endophytic and of moderate complexity (RENAL 8p). The procedure was realized in a hybrid operating room by a double team: interventional radiologist and urologist. RESULTS: A first renal arteriography was made to visualize the arterial vascularization of the left kidney. With a guidance software, the tumoral artery was catheterized superselectively. The tumor and its arteries were embolized by microspheres and coils. A 3D arteriography showed the exclusion of the tumor from the renal vascularization. Then, the patient was positionned for laparoscopic partial nephrectomy, thas was performed without dissecting the renal pedicule, nor clamping of the renal artery. Operative bleeding was insignificant. No suture was necessary. A final control 3D arteriography showed no arterial bleeding and preservation of healthy renal parenchyma. Follow-up was uneventful. Preoperative renal function was maintained. The tumor was a clear cell renal carcinoma. Surgical margins were negative. CONCLUSIONS: This is the first experience of superselective tumoral embolization followed immediately by laparoscopic partial nephrectomy in a hybrid operating room. Resection of a localized renal cancer of moderate complexity was performed clampless, sutureless and without intraoperative bleeding. Source of Funding: none