Clint Cary

Kidney Internal Splint/Stent (KISS) Catheter Revisited for Pediatric Pyeloplasty

OBJECTIVES To review our experience using the Kidney Internal Splint/Stent (KISS) (Cook Medical, Bloomington, IN) to provide drainage after pyeloplasty. The KISS combines the attributes of nephrostomy tube diversion and anastomotic stent in a single tube. Since its initial description in 1993, additional reports on its use are limited. METHODS We retrospectively reviewed charts of patients who underwent pyeloplasty by single surgeon, with simultaneous placement of KISS stent from 2003 to 2008. Preoperative and postoperative renal function and t((1/2)) times of the affected renal unit were determined by nuclear renography. Nephrostograms were performed 10 days after surgery. Complications from the use of KISS catheter including premature dislodgement or infection were noted. RESULTS We performed 59 pyeloplasties with KISS stent placement in 57 patients. Mean age of patients was 23 months with follow-up of 32 months (range 6-69). Median preoperative and postoperative renal function was 47% and 49%, respectively. Median preoperative and postoperative t(1/2) times were 80 and 12 minutes, respectively (P = .001). Nephrostograms did not reveal leak in any patient. Unintentional removal of KISS stent did not occur in any patient. Postoperative febrile UTI occurred in 2 patients while the KISS stent was in place. CONCLUSIONS KISS stents can be used safely and effectively in a wide variety of clinical situations surrounding pyeloplasty. The KISS catheter was well tolerated by the patients in our series. The KISS stent offers the combined advantages of nephrostomy tube and internal stent while obviating the second anesthetic that would be necessary with an internal stent.

Contemporary trends in postchemotherapy retroperitoneal lymph node dissection: Additional procedures and perioperative complications

INTRODUCTION Postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) is a mainstay in the treatment of men with metastatic testicular cancer. We sought to determine whether trends in the need for additional intraoperative procedures and development of perioperative complications have changed over time. METHODS Patients undergoing PC-RPLND from 2003 to 2011 were identified in the Indiana University Testis Cancer Database. Trends in the incidence of perioperative complications and additional procedures were assessed over time using regression tests of trend. Complications were classified according to the modified Clavien system. Univariable and multivariable logistic regression was used to determine factors associated with undergoing additional procedures. RESULTS After exclusion criteria, 755 patients were included in the final study cohort. The incidence of additional procedures at PC-RPLND was 22.1% (167 of 755). The rate of additional procedures per year ranged from 17% to 30%, with no significant trend in any direction (Ptrend = 0.66). After adjusting for covariates, preoperative retroperitoneal (RP) mass size, elevated markers, and RP pathology remained significantly associated with the odds of an additional procedure. RP mass size of>10 cm was the strongest predictor (odds ratio = 7.2, 95% CI: 2.6-19.5). Overall, the incidence of perioperative complications was 3.7% (28 of 755). The rate of perioperative complications per year ranged from 0% to 7.3% with no significant trend in any direction (Ptrend = 0.06). CONCLUSION The incidence of perioperative complications is low with no significant trend over the last decade. A substantial number of patients require additional intraoperative procedures during PC-RPLND, which has remained stable at our institution over time.

596 Treatment and clinical outcomes of patients with teratoma with somatic-type malignant transformation (TMT): An international collaboration

Purpose: We assessed prognostic factors, treatments and outcomes in patients with teratoma with malignant transformation, a rare occurrence among germ cell tumors. Materials and Methods: Data on patients diagnosed with teratoma with malignant transformation between June 1981 and August 2014 were collected across 5 referral centers. Chemotherapy was dichotomized as based on germ cell tumor or teratoma with malignant transformation. Cox analyses were done to evaluate prognostic factors of overall survival, the primary end point. Each factor was evaluated in a univariable model. Forward stepwise selection was used to construct an optimal model. Results: Among 320 patients the tumor primary site was gonadal in 287 (89.7%), retroperitoneal in 17 (5.3%) and mediastinal in 16 (5%). Teratoma with malignant transformation and germ cell tumor were diagnosed concurrently in 130 patients (40.6%). A total of 49 patients (16.8%) initially presented with clinical stage I. The remaining patients were at good (123 or 42.3%), intermediate (42 or 14.4%) and poor (77 or 26.5%) risk for metastasis according to IGCCCG (International Germ Cell Cancer Collaborative Group). First line chemotherapy was given for germ cell tumor in 159 patients (49.7%), chemotherapy for teratoma with malignant transformation was performed in 14 (4.4%) and only surgery was done in 147 (45.9%). Median followup was 25.1 months (IQR 5.4e63.8). Five-year overall survival was 83.4% (95% CI 61.3 to 93.5) in patients with clinical stage I and it was also worse than expected in those with metastasis. On multivariable analyses nonprimitive neuroectodermal tumor histology (overall p ¼ 0.004), gonadal primary tumor (p ¼ 0.005) and fewer prior chemotherapy regimens (p <0.001) were independent predictors of better overall survival. Chemotherapy was not independently prognostic. Conclusions: Less heavily pretreated teratoma with malignant transformation with a gonadal primary tumor and nonprimitive neuroectodermal tumor histology appears to be associated with longer overall survival. Generally, teratoma with malignant transformation had a worse prognosis than germ cell tumor. Uncertainties persist regarding optimal chemotherapy. Abbreviations and Acronyms CSI ¼ clinical stage I

Outcomes of postchemotherapy retroperitoneal lymph node dissection following high-dose chemotherapy with stem cell transplantation.

Characterizing the role of postchemotherapy retroperitoneal lymph node dissection (PC‐RPLND) after high‐dose chemotherapy (HDCT) has been limited by small sample sizes. This study reports on survival after HDCT with stem cell support and PC‐RPLND as well as histologic findings in the retroperitoneum.

Variation in prostate cancer treatment associated with population density of the county of residence.

Background:We sought to assess variation in the primary treatment of prostate cancer by examining the effect of population density of the county of residence on treatment for clinically localized prostate cancer and quantify variation in primary treatment attributable to the county and state level.Methods:A total 138 226 men with clinically localized prostate cancer in the Surveillance, Epidemiology and End Result (SEER) database in 2005 through 2008 were analyzed. The main association of interest was between prostate cancer treatment and population density using multilevel hierarchical logit models while accounting for the random effects of counties nested within SEER regions. To quantify the effect of county and SEER region on individual treatment, the percent of total variance in treatment attributable to county of residence and SEER site was estimated with residual intraclass correlation coefficients.Results:Men with localized prostate cancer in metropolitan counties had 23% higher odds of being treated with surgery or radiation compared with men in rural counties, controlling for number of urologists per county as well as clinical and sociodemographic characteristics. Three percent (95% confidence interval (CI): 1.2–6.2%) of the total variation in treatment was attributable to SEER site, while 6% (95% CI: 4.3–9.0%) of variation was attributable to county of residence, adjusting for clinical and sociodemographic characteristics.Conclusions:Variation in treatment for localized prostate cancer exists for men living in different population-dense counties of the country. These findings highlight the importance of comparative effectiveness research to improve understanding of this variation and lead to a reduction in unwarranted variation.

Risk for Clostridium difficile infection after radical cystectomy for bladder cancer: Analysis of a contemporary series

INTRODUCTION This study seeks to evaluate the incidence and associated risk factors of Clostridium difficile infection (CDI) in patients undergoing radical cystectomy (RC) for bladder cancer. METHODS We retrospectively reviewed a single institution׳s bladder cancer database including all patients who underwent RC between 2010 and 2013. CDI was diagnosed by detection of Clostridium difficile toxin B gene using polymerase chain reaction-based stool assay in patients with clinically significant diarrhea within 90 days of the index operation. A multivariable logistic regression model was used to identify demographics and perioperative factors associated with developing CDI. RESULTS Of the 552 patients who underwent RC, postoperative CDI occurred in 49 patients (8.8%) with a median time to diagnosis after RC of 7 days (interquartile range: 5-19). Of the 122 readmissions for postoperative complications, 10% (n = 12) were related to CDI; 2 patients died of sepsis directly related to severe CDI. On multivariate logistic regression, the use of chronic antacid therapy (odds ratio = 1.9, 95% CI: 1.02-3.68, P = 0.04) and antibiotic exposure greater than 7 days (odds ratio = 2.2, 95% CI: 1.11-4.44, P = 0.02) were independently associated with developing CDI. The use of preoperative antibiotics for positive findings on urine culture within 30 days before surgery was not statistically significantly associated with development of CDI (P = 0.06). CONCLUSIONS The development of CDI occurs in 8.8% of patients undergoing RC. Our study demonstrates that use of chronic antacid therapy and long duration of antimicrobial exposure are associated with development of CDI. Efforts focusing on minimizing antibiotic exposure in patients undergoing RC are needed, and perioperative antimicrobial prophylaxis guidelines should be followed.

Modified retroperitoneal lymph node dissection for post-chemotherapy residual tumour: a long-term update

To update previously reported outcomes of modified‐template post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND) in appropriately selected patients with metastatic non‐seminomatous germ cell tumour (NSGCT), as our previous report was criticised for short follow‐up and so we now provide a long‐term update on this cohort.

The Evolution and Technique of Nerve-Sparing Retroperitoneal Lymphadenectomy

The evolution of retroperitoneal lymph node dissection technique and associated template modifications for nonseminomatous germ cell tumors have resulted in significant improvement in the long-term morbidity. Through the preservation of sympathetic nerves via exclusion from or prospective identification within the boundaries of resection, maintenance and recovery of antegrade ejaculation are achieved. Nerve-sparing strategies in early-stage disease are feasible in most patients. Postchemotherapy, select patients can be considered for nerve preservation. This article describes the anatomic and physiologic basis for, indications and technical aspects of, and functional and oncologic outcomes reported after nerve-sparing retroperitoneal lymphadenectomy in testicular cancer.

A Randomized Study of Intraoperative Autologous Retropubic Urethral Sling on Urinary Control after Robotic Assisted Radical Prostatectomy

Purpose: We evaluated whether placement of a retropubic urethral sling fashioned from autologous vas deferens during robotic assisted radical prostatectomy would improve recovery of continence. Materials and Methods: In a phase 2, single blind trial age stratified patients were randomized to undergo robotic assisted radical prostatectomy by multiple surgeons with or without sling placement. The outcomes were complete continence (0 urinary pads of any type) and near continence (0, an occasional or 1 pad per day) at 6 months, which was assessed by the Fisher exact test and logistic regression. The Kaplan‐Meier method and the log rank test were used to evaluate time to continence. EPIC‐UIN (Expanded Prostate Cancer Index Composite‐Urinary Inventory) and I‐PSS (International Prostate Symptom Score) 1, 3 and 6 months after catheter removal were evaluated by mixed models for repeated measures. Results: Of 203 patients who were recruited 95 and 100 were randomized to undergo sling and no sling placement, respectively, and completed postoperative interviews. Six months after surgery the proportions reporting complete and near continence (66% and 87%, respectively) and times to complete and near continence were similar in the groups. Younger age was associated with a higher likelihood of complete continence (OR 1.74 per decreasing 5‐year interval, 95% CI 1.23–2.48, p <0.01) and near continence (OR 2.18 per decreasing 5‐year interval, 95% CI 1.21–3.92, p <0.01) adjusting for clinical, urinary and surgical factors. Adjusted EPIC‐UIN and I‐PSS scores changed with time but did not differ between the groups. No serious adverse events were observed. Conclusions: This trial failed to demonstrate a benefit of autologous urethral sling placement at robotic assisted radical prostatectomy on early return of continence at 6 months. Continence was related to patient age in adjusted models.

Management of Duodenal Involvement During Retroperitoneal Lymph Node Dissection for Germ Cell Tumors.

OBJECTIVE To describe patient characteristics and outcomes after duodenal repair during postchemotherapy retroperitoneal lymph node dissection (PC-RPLND) and to identify treatment and management patterns. METHODS The Indiana University Testis Cancer database was used to identify all patients who underwent simultaneous partial duodenectomy and PC-RPLND from 1983 to 2013. Patient records were reviewed to describe patient and tumor characteristics, type of duodenal restoration, postoperative management, and complications. RESULTS Of the 2223 PC-RPLND performed during the study period, we identified 39 patients who underwent simultaneous duodenectomy, with 1 patient requiring 2 duodenal procedures for a total of 40 duodenal procedures. The postchemotherapy median tumor mass size was 8.95 (2.5-17) cm. Fifty percent of cases were standard PC-RPLND; the remainders were redo, desperation, or late relapse cases. Preoperative gastrointestinal symptoms were present in 21% of patients and included bowel obstruction (8%) or gastrointestinal bleeding (13%). Retroperitoneal pathology consisted of teratoma (48%), cancer (33%), and necrosis (20%). Duodenal involvement was managed with primary duodenorrhaphy (68%), duodenojejunostomy (18%), duodenoduodenostomy (13%), or pancreaticoduodenectomy (3%). Starting in the year 2000, duodenostomy and gastrostomy tubes were no longer used. The most common postoperative complication was ileus (45%) with a 3% duodenal fistula rate. CONCLUSION Duodenal tumor involvement during PC-RPLND is most commonly managed with primary duodenorrhaphy after partial duodenectomy with an acceptable duodenal fistula rate. The routine use of duodenostomy or gastrostomy tubes is not recommended.