Jan Ebbing

Urothelial Cancer in Renal Transplant Recipients: Incidence, Risk Factors, and Oncological Outcome

OBJECTIVE To evaluate the incidence and risk factors for urothelial cancer (UC) as well as the oncological outcome and allograft function in renal transplant recipients. SUBJECTS/PATIENTS We conducted a retrospective analysis of 1855 consecutive patients undergoing renal transplantation (TX) between February 1982 and May 2014 at a single center. UC incidence, overall and cancer-specific survival, recurrence and progression rates, risk factors for UC, and renal function were determined. Fishers exact test and log-rank Mantel-Cox test were used as appropriate. RESULTS In renal transplant recipients, incidence of de novo UC was 1.35% (25/1855). Deceased donor transplantation (P = .002), increased age at transplantation (P = .011), and analgesic abuse (P = .005) were significant risk factors for the development of UC post-TX. Progression rate and recurrence rate were doubled for post-TX-UC but stable for patients with pre-TX-UC compared with the general population. Analgesic abuse was associated with worse cancer specific and overall survival in post-TX patients. The overall survival status was significantly lower for post-TX patients at a median of 34 months vs 222 months in control patients. Adjuvant treatment was scarcely used. UC had no significant influence on graft function. CONCLUSION A higher incidence of UC was identified in renal transplant recipients compared with that for the general population. These observations justify screening for UC in renal transplant patients, especially considering that in a large proportion, a tentative diagnosis was possible with noninvasive urine analysis. Prudent adjuvant treatment for UC should be used. Limitations of this study were the retrospective design and the single-center experience.

Dynamics of Urinary Calprotectin after Renal Ischaemia.

Background: Urinary calprotectin has been identified as a promising biomarker for acute kidney injury. To date, however, the time-dependent changes of this parameter during acute kidney injury remain elusive. The aim of the present work was to define the time-course of urinary calprotectin secretion after ischaemia/reperfusion-induced kidney injury in comparison to neutrophil gelatinase—associated lipocalin, thereby monitoring the extent of tubular damage in nephron sparing surgery for kidney tumours. Methods: The study population consisted of 42 patients. Thirty-two patients underwent either open or endoscopic nephron sparing surgery for kidney tumours. During the surgery, the renal arterial pedicle was clamped with a median ischaemic time of 13 minutes (interquartile range, 4.5–20.3 minutes) in 26 patients. Ten retro-peritoneoscopic living donor nephrectomy patients and 6 nephron sparing surgery patients in whom the renal artery was not clamped served as controls. Urinary calprotectin and neutrophil gelatinase—associated lipocalin concentrations were repeatedly measured by enzyme-linked immunosorbent assay and assessed according to renal function parameters. Results: Urinary concentrations of calprotectin and neutrophil gelatinase—associated lipocalin increased significantly after ischaemia/reperfusion injury, whereas concentrations remained unchanged after nephron sparing surgery without ischaemia/reperfusion injury and after kidney donation. Calprotectin and neutrophil gelatinase—associated lipocalin levels were significantly increased 2 and 8 hours, respectively, post-ischaemia. Both proteins reached maximal concentrations after 48 hours, followed by a subsequent persistent decrease. Maximal neutrophil gelatinase—associated lipocalin and calprotectin concentrations were 9-fold and 69-fold higher than their respective baseline values. The glomerular filtration rate was only transiently impaired at the first post-operative day after ischaemia/reperfusion injury (p = 0.049). Conclusion: Calprotectin and neutrophil gelatinase—associated lipocalin can be used to monitor clinical and sub-clinical tubular damage after nephron sparing surgery for kidney tumours. Urinary calprotectin concentrations start rising within 2 hours after ischaemia/reperfusion-induced kidney injury.

Anesthesia-free procedures for benign prostate obstruction: worth it?

Purpose of review Perhaps, 30% of patients with benign prostate obstruction experience no symptom relief with drug therapy, necessitating surgical intervention. General anesthesia can be too dangerous for elderly or frail men, making local anesthesia desirable. Such minimally invasive procedures may offer time-saving, effective, gentle, and well tolerated alternatives. Recent findings Recent interest has focused on the mechanical devices and intraprostatic injections. The commercially available UroLift system demonstrates promising short-term data in randomized multicenter trials. Rezum steam injection therapy is intriguing, although currently study-based with limited data. NX1207 and PRX302 are new intraprostatic injection drugs demonstrating interesting results in phase I and II studies, whereas conflicting results surround the prostatic injection of botulinum toxin A. For transurethral microwave therapy, definitive evaluations regarding the treatment of chronic urinary retention in nonsurgical patients are ongoing. Summary Although none of these minimally invasive procedures must be performed under general anesthesia, all require local anesthesia with possible sedation. In most studies, pain therapy management is rudimentary or not described. Although good short-term results are described, no long-term data are available.

Evaluation of perioperative complications in open and laparoscopic surgery for renal cell cancer with tumor thrombus involvement using the Clavien–Dindo classification

OBJECTIVE To identify risk factors for perioperative complications and morbidity in renal cell cancer (RCC) surgery with tumor thrombus invasion (TTI). PATIENTS AND METHODS Retrospective single-center analysis of 128 patients who underwent open (n = 97) or laparoscopic (n = 31) radical nephrectomy (NT) for RCC between 1999 and 2010. TTI was at Mayo-Level 0, I, II, III, IV in 88, 7, 10, 4, and 19 cases, respectively. Cavotomy was performed in 27, liver mobilisation in 20, and cardiovascular bypass in 17 patients. RESULTS The rate of any early postoperative complication (PC) by Clavien-Dindo classification was 58.6%, while the severe early PC rate was 29.7%. There was a statistically significant difference in multivariate analysis in the incidence of any early PC and of severe early PC by Charlson score (OR:1.584 (95%CI:1.141-2.199), p = 0.006; OR:3.065 (95%CI:1.218-7.714), p = 0.017) and by tumor thrombus level TNM-UICC 2010 T3a/T3c (OR:10.668 (95%CI:1.266-89.871), p = 0.029; OR:10.502 (95%CI:2.981-36.992), p < 0.001). In pT3a cases open NT was associated with a higher early (57.9% vs. 25.8%) and severe (24.6% vs. 9.7%) PC rate compared to laparoscopic NT. The 30-day mortality rate was 0%. The 90-day mortality rate was 6.3% but 100% cancer-related. In Cox regression analysis tumor thrombus level was not predictive for overall survival. CONCLUSIONS The strongest risk factor for early and severe PC in patients with TTI is a supradiaphragmatic tumor thrombus. In cases with severe PC, this fact persists when comparing Mayo-Levels II-III and Level IV. In pT3a cases open NT shows a 2-fold higher early PC rate compared to laparoscopic NT.

Metastasizing pleomorphic adenoma presenting as an asymptomatic kidney tumor twenty-nine years after parotidectomy - urological viewpoint and overview of the literature to date.

Pleomorphic adenomas (benign mixed tumors) are the most common tumors of glandular origin in the head and neck and are one of the few benign neoplasms that can undergo malignant transformation.1 Mixed tumors that are seemingly benign at the microscopic level but metastasize have been termed metastasizing mixed tumors (MZMTs). The entity of metastasizing benign mixed tumors has been reported since the early 1940s, with up to approximately 50 cases described in the literature to date. Despite their bland morphologic appearance, MZMTs have been associated with an overall mortality rate of about 20–40%. We report the case of a MZMT of the kidney almost 30 years after lateral parotidectomy owing to the same tumor entity. For benign mixed tumors, we are unaware of more than two other cases of metastasis to the kidney that have been published, whereas metastases to the bone, lung, and lymph nodes are more common. Parotidectomy is widely accepted as the first choice of treatment,13 but once metastases have occurred the therapeutic strategy is uncertain with surgery being the only curative option in cases with resectable disease. This case report provides information about the rare event of metastatic disease to the kidney and points out therapeutic strategies. However, in view of the general lack of adequate information in the literature, the best therapy for systemic disease still remains unresolved.

Novel low-cost prostate resection trainer—description and preliminary evaluation

Transurethral resection of the prostate (TURP) is a challenging operation for residents with limited endoscopic experience. A number of virtual TURP simulators have been validated in the past. This study is the first description and preliminary evaluation of a non‐virtual, low‐cost TURP trainer as a teaching tool for residents in urology.

MP59-19 OUTCOME OF KIDNEY FUNCTION AFTER ISCHAEMIC AND ZERO-ISCHAEMIC LAPAROSCOPIC AND OPEN NEPHRON-SPARING SURGERY FOR RCC

INTRODUCTION AND OBJECTIVES: Adhesive perinephric fat (APF) increases the complexity of robot-assisted partial nephrectomy (RAPN). The Mayo adhesive probability (MAP) score is an index for quantifying APF and predicting prolonged operation time or increased surgical complication rate. However, the part of the operation influenced by increased MAP score remains unclear. METHODS: The study subjects were 311 patients who underwent RAPN between January 2013 and June 2016 in our institute. MAP score was calculated to quantify APF. The perinephric fat thickness and stranding were used to calculate the MAP score. Operation time was divided into a dissection phase (from robotic manipulation to hilar clamping) and resection phase (from hilar clamping to robotic surgery completion). RESULTS: The patients’ mean age, body mass index (BMI), total operation time, console time, dissection phase time, and resection phase time were 60 13 years, 23.5 3.5 kg/m2, 180.8 40.7 minutes, 132.6 36.5 minutes, 84.9 27.6 minutes, and 47.6 18.3 minutes, respectively. The MAP score was 0 in 98 patients (32%), 1 in 86 (28%), 2 in 21 (7%), 3 in 48 (15%), 4 in 44 (14%), and 5 in 14 (4%). The dissection and resection phase times significantly increased as the MAP scores increased (Figure 1). The dissection phase times were 71.2, 79.1, 88.9, 97.0, 99.7, and 118.8 minutes as the MAP score increased by 1 point from 0 to 5 (p<0.001). The influence of MAP score was more remarkable to the prolongation of the dissection phase than to that of the resection phase. In the patients with MAP scores of 1⁄43, the dissection phase time was not significantly influenced by the learning curve (100.8 25.2, 103.7 29.4, and 98.2 31.4 minutes in 1st100th, 101st-200th, and 201st-311th, respectively). We further examined the factors that influenced the dissection phase time of 100 minutes by using the logistic regression model. In the multivariate analysis, left side, early surgical experience (first 100 cases), the number of the renal arteries to be clamped and MAP score (1⁄43) were the independent factors of prolonged dissection phase. CONCLUSIONS: MAP score is an independent predictive factor of prolonged RAPN dissection phase. The complexity of RAPN in the patients with high MAP scores was still high even for experienced surgeons. Source of Funding: none

Influence of hematuria and infection on diagnostic accuracy of urinary LASP1: a new biomarker for bladder carcinoma

AIM To further promote the clinical use of urinary LASP1 as biomarker for urothelial carcinoma of the bladder regarding limitations and alternative testing systems. PATIENTS & METHODS Urine stabilization, alternative measurement systems and limitations by erythrocyte contamination and infection were investigated in 246 patients. RESULTS Thimerosal allowed sufficient stabilization. Fluorescence-activated cell sorting analysis was not influenced by presence of erythrocytes or leukocytes and reliably urothelial carcinoma of the bladder but cell counts in specimen were low. Cut-off values of <25 leukocytes and <200 erythrocytes/µl resulted in sensitivity, specificity, positive and negative predictive values of 0.59, 0.80, 0.80 and 0.59, respectively. CONCLUSION Hematuria up to 200 erythrocytes/µl but not presence of leukocytes may be tolerated for this promising marker.

MP3-20 PREDICTORS OF PERIOPERATIVE COMPLICATIONS AND REOPERATION IN PATIENTS TREATED WITH PHOTOSELECTIVE VAPORIZATION OF THE PROSTATE

INTRODUCTION AND OBJECTIVES: Photoselective vaporization of the prostate (PVP) is an alternative to transurethral resection of the prostate (TURP). PVP could provide a better hemostatic effect due to a coagulation depth of several millimeters. The objective of the study was to prospectively evaluate tissular consequences of PVP on MRI. METHODS: We prospectively collected the data of ten patients who underwent PVP with the Greenlight laser 180-W XPS by a single surgeon from december 2013 to february 2014. A multiparametric MRI of the prostate (Siemens 3T Verio) was performed the day before surgery and during postoperative period two days, seven days, three and six months after the procedure. Inflammation and depth of necrosis in the prostatic and periprostatic tissues were evaluated in six different areas. Inflammation was evaluated using a score from 0 to 3 based on MRI signal in diffusion sequences. RESULTS: Mean age and prostatic volume were 69 y (64e76) and 53mL (22e76), respectively. Mean Qmax and postvoid residual volume were 6.1ml/s (4.6-10) and 84ml (0e200), respectively. Mean energy delivered was 3.13 KJ/ml of prostate (0.93-5.38) and mean total laser time was 28.9 min (7e49). None postoperative complication was reported. Two days after procedure, mean depth of necrosis was 1.2 mm (0e4) and mean periprostatic oedema was 1.2 (0 to 3). Results were similar on seven day MRI. No necrosis or inflammation was reported three and six months after procedure. CONCLUSIONS: We demonstrated depth of necrosis after PVP with Greenlight XPS 180W is low and homogeneous. Risk for injuries of noble adjacent structures is limited

[Testicular cancer - explanatory models for high cisplatin chemosensibility and new therapeutic options].

This article offers a review about the current facts of chemotherapy in testicular cancer. Besides a short presentation of the guideline-standard therapy the authors deal with the question as to why testicular cancer shows an extraordinarily high chemosensibility compared to other tumours. Furthermore, the current data on alternative chemotherapies as well as of molecular, molecular-genetic and pharmacogenetic therapeutic concepts are explored. Data were obtained from researches in Medline of the Pubmed database.