Islam Ghoneim

Neoadjuvant Systemic Therapy or Early Cystectomy? Single-center Analysis of Outcomes After Therapy for Patients With Clinically Localized Micropapillary Urothelial Carcinoma of the Bladder

OBJECTIVES To analyze the treatment outcomes of patients with micropapillary bladder cancer (MPBC). MPBC is a rare variant of urothelial carcinoma with aggressive clinical behavior. Radical cystectomy is considered the standard approach for treatment of patients with localized disease; however, the role of perioperative systemic therapy has been poorly defined. MATERIAL AND METHODS A retrospective review identified 38 consecutive patients who had been treated at our institution for MPBC from 2000 to 2010. The patient data were analyzed for the pre- and postoperative clinicopathologic features, treatment course, and cancer-specific survival. RESULTS The median follow-up of surviving patients after cystectomy was 17 months (range 2-75). At the initial transurethral biopsy, 28 patients (74%) had clinical Stage T2N0 or less. In this group, 26 (93%) of 28 were upstaged to nonorgan-confined and/or lymph node-positive disease. Overall, 32 patients (86%) had evidence of lymph node metastasis on the final pathologic examination. All patients with cTis-T1 who had undergone initial bladder-sparing therapy with bacille Calmette-Guérin had pathologically advanced disease at cystectomy. All 15 patients who had received perioperative cisplatin-based chemotherapy died of metastatic disease. The 5-year overall survival rate was 40% (95% confidence interval 16-64). CONCLUSIONS MPBC is an aggressive disease with a high likelihood of regional lymph node metastasis at the initial presentation. Although radical cystectomy plays a critical role in treatment, systemic neoadjuvant chemotherapy might be a more appropriate strategy than immediate cystectomy. Because of the poor response to current chemotherapy agents, the development of new and effective drugs for this subset of patients could be needed.

Presacral and Retroperitoneal Lymph Node Involvement in Urothelial Bladder Cancer: Results of a Prospective Mapping Study

PURPOSE We evaluated the incidence of positive lymph nodes in the presacral and retroperitoneal regions in patients who underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer. MATERIALS AND METHODS As part of a prospective mapping study, 143 patients underwent radical cystectomy and extended pelvic lymph node dissection for urothelial bladder cancer between 2006 and 2010. Lymph nodes from 6 separate regions were labeled, including bilateral pelvic and common iliac, presacral and retroperitoneal. We evaluated pathological features, treatment outcomes and cancer specific survival in patients with or without lymph node positive disease in the presacral and retroperitoneal regions. RESULTS A median of 37 lymph nodes (IQR 27-49) were removed. Overall 52 (36%) patients had positive lymph nodes, of whom 24 (46%) had metastatic disease in the presacral or retroperitoneal region. Four patients (3%) had an isolated solitary positive lymph node in these 2 templates. Two-year overall survival in patients without vs with presacral/retroperitoneal lymph node positive disease was 44% (95% CI 24-64) vs 25% (95% CI 5-45) (p = 0.11). In contrast, 2-year cancer specific survival in the 2 groups was 55% (95% CI 33-77) and 29% (95% CI 7-51), respectively (p = 0.02). CONCLUSIONS A substantial proportion of patients have lymph node positive disease in the presacral and retroperitoneal regions, including some with isolated and/or solitary lymph node involvement. While the limited positive lymph node burden in these templates suggests a potential therapeutic role for extending the anatomical boundaries of lymph node dissection, patient survival was poor. Extended lymph node dissection provides important staging information but to our knowledge the therapeutic benefit has yet to be definitively proved.

Minimally invasive surgery for renal cell carcinoma

The oncologic principles of the surgical management of renal cell carcinoma (RCC) have remained essentially the same since first proposed by Robson in 1963. RCC remains a chemo- and radiation-resistant tumor; hence, surgical treatment is still the mainstay of curative therapy. Extirpative management of RCC via open radical nephrectomy (and later open partial nephrectomy) has been the standard of care for decades. With the advent of laparoscopic surgery and its intense application in urology in the early 1990s, a paradigm shift to minimally invasive renal surgery was initiated and has spurred an array of technologies, methods and procedures. Guidelines on the proper selection of patients and treatment modalities have been developed and established, allowing patients to benefit from better oncologic efficacy and reduced morbidity, and requiring urologic surgeons to master minimally invasive procedures alongside the techniques of open surgery. This review focuses on the minimally invasive management of RCC, discussing the advantages and disadvantages of laparoscopy, partial nephrectomy, probe ablation and newer treatment modalities. In order to provide material for this review, a search of the MEDLINE database was performed through January 2009 using the National Center for Biotechnology Information PubMed internet site to review the world literature regarding the minimally invasive treatment of RCC.

The use of bovine pericardium for complex urologic venous reconstruction.

OBJECTIVE To describe the use of bovine pericardium (BP) in several scenarios for venous patching and as a tubularized graft in urologic surgery. METHODS BP was used as patch or tubularized graft in 7 patients between 2010 and 2013. Clinical scenarios and operative indications were reviewed. We used BP as a patch graft for the inferior vena cava (IVC) (N = 3) and for the iliac venous system (N = 1) to restore venous outflow. Tubularized grafts were used (N = 2) to replace the left renal vein in oncology procedures and during renal autotransplantation (N = 1). Surgical technique is reviewed in detail. RESULTS We used BP as a venous patching in 4 cases and as a tubularized graft in 3 cases. There was no evidence of venous thrombosis of the replaced system with a mean of 14.8 months (range, 9-26) follow-up. CONCLUSION The use of BP as a patch or tubularized graft is an option for complicated urologic venous reconstruction. Although the follow-up interval is relatively short and this initial series small, our initial results are promising.

Urologic Complications After Kidney Transplantation

This chapter reviews the most common urologic complications that may follow renal transplantation. The recognition of these complications, their proper diagnosis, and effective management can help reduce their deleterious effect on long-term graft survival. A practical approach to these complications is presented.

Kidney Allocation System for Deceased Donor Kidneys in the United States

The allocation system for cadaveric kidneys in USA is the largest such system in existence. The basic elements of this complex system are presented in the context of applicability to clinical practice.

Cytoreductive radical nephrectomy (cRN) and level II-IV infereior vena cava (IVC) thrombectomy for metastatic renal cell carcinoma (mRCC).

382 Background: cRN for mRCC is associated with a modest improvement in survival when combined with cytokine therapy in patients with good performance status. A level II-IV IVC thrombus renders cRN technically challenging with increased risks of perioperative morbidity and mortality. The outcome of these patients relative to the overall cRN population is poorly defined. METHODS Clinical information and follow-up data were obtained from an institutional retrospective data base for patients who underwent cRN and IVC thrombectomy between 1990-2011.The operative outcomes, complications, and cancer outcomes were compared. RESULTS cRN was performed on 56 patients with mRCC and level II (N =19), III (N =25) or IV (N =12) IVC thrombus. Age ranged from 23 to 84 years old and 36 (64%) were male. Predominant sites of metastases were: lung, 22 (39%); liver 3 (5%); mediastinum 3 (5%); multiple sites 17 (30%). Local clinical stage was T3a in 2 (3.6%), T3b in 38 (68%), T3c in 12 (21%), and T4 in 4 (7%). Twenty (36%) patients were clinical N1. Median tumor size was 10.2 cm (range, 1.4-21). Histologic classification was clear cell in 40 (71%), papillary in 4 (7%), and unclassified in 12 (21%). Intraoperatively, 2 patients had embolization of thrombus. Postoperatively, Clavien grade 3-5 complications occurred in 3 (5%) patients, including two (3.6%) mortalities. Follow-up information was available for 49 patients and the median follow-up was 13 months (IQR: 6-33). Of these patients, 31 (63%) received postoperative systemic therapy with cytokines (14), targeted agents (16), or both (1). The overall median survival was 13 months (95% CI: 10-16), and was similar before (median 12 months) and after (median 13 months) the introduction of targeted therapy. CONCLUSIONS Among patients with mRCC with level II-IV IVC thrombus managed at a high-volume kidney center, cRN and IVC thrombectomy is associated with acceptable perioperative morbidity and mortality. The median survival of patients in our cohort is similar to the overall population of patients managed with cRN and cytokine therapy though less than those managed with cRN and targeted therapy based on data from published randomized trials.

Bilateral Pelvicalyceal Duplication with Contralateral Drainage

We report on a peculiar congenital duplication anomaly of the kidney and collecting system. A bifid left renal pelvis receives the ureter draining the lower moiety of a fully duplicated right system. To our knowledge, such an anomaly has not been previously described.