Jennifer Yates

Incidence of Renal Artery Pseudoaneurysm Following Open and Minimally Invasive Partial Nephrectomy: A Systematic Review and Comparative Analysis

PURPOSE Partial nephrectomy is performed for renal masses as a means of preserving renal function. Renal artery pseudoaneurysm is a potential complication of partial nephrectomy. We determined the incidence of renal artery pseudoaneurysm after open and minimally invasive partial nephrectomy, and performed a comparative analysis. MATERIALS AND METHODS We queried the Ovid Medline® and PubMed® databases to locate published reports of renal artery pseudoaneurysm after partial nephrectomy. Studies were included in comparative analysis if they were in English and showed the total number of procedures performed and perioperative complications. RESULTS Included studies represented a total of 5,229 patients, of whom 2,494 and 2,735 underwent open and minimally invasive partial nephrectomy, respectively. A total of 25 and 52 renal artery pseudoaneurysms were reported after open and minimally invasive procedures (weighted 1.00% and 1.96%, respectively). The difference between these 2 values was statistically significant (p ≤ 0.001). Patients diagnosed with renal artery pseudoaneurysm presented a mean of 14.9 days after surgery and 87.3% of them had gross hematuria at presentation. Almost all patients with renal artery pseudoaneurysm were treated with percutaneous angioembolization with 96% success. CONCLUSIONS Although it is rare, the risk of renal artery pseudoaneurysm after partial nephrectomy is significant and should be high on the differential for a patient who presents postoperatively with gross hematuria. The incidence of renal artery pseudoaneurysm is higher after minimally invasive partial nephrectomy than after an open approach. Angioembolization for renal artery pseudoaneurysm after partial nephrectomy offers an excellent success rate and minimal patient morbidity.

Robot-Assisted Laparoscopic Radical Prostatectomy in the Morbidly Obese Patient

Introduction. Obesity and prostate cancer are among the more common health issues affecting men in the United States. Methods. We retrospectively reviewed morbidly obese (BMI ≥ 40 kg/m2) patients undergoing RALP between 2004–2009 at our institution. Parameters including operative time, estimated blood loss, hospital stay, pathology, and complication rate were examined. Results. A total of 15 patients were included, with a mean BMI of 43 kg/m2. Mean preoperative PSA was 5.78 ng/dL, and Gleason score was 6.6. Mean operative time was 163 minutes, and mean estimated blood loss was 210 mL. The mean hospital stay was 1.3 days. Positive margins were noted in 2 (13%) patients, each with pT3 disease. There were no blood transfusions, open conversions, or Clavien Grade II or higher complications. Conclusions. In our experience, RALP is feasible in morbidly obese patients. We noted several challenges in this patient population which were overcome with modification of technique and experience.

Presence of dextranomer-hyaluronic acid (DxHA) mound on postoperative ultrasound does not predict resolution of vesicoureteral reflux.

OBJECTIVE Dextranomer-hyaluronic acid (DxHA) injection is an accepted treatment for vesicoureteral reflux (VUR), with success rates as high as 85-90% in selected patients. The DxHA mound can often be seen on postoperative ultrasound. We sought to determine whether the presence or absence of this mound on ultrasound can predict resolution of VUR on voiding cystourethrogram (VCUG). MATERIALS AND METHODS A retrospective study evaluating patients who underwent cystoscopy and injection of DxHA from 2003 to the present was performed. Demographic variables, laterality and grade of VUR, postoperative ultrasound findings, and presence of VUR on postoperative VCUG were recorded. RESULTS Fifty-one patients (95 ureters) underwent DxHA injection and had a postoperative ultrasound and VCUG for review. Five patients with persistent voiding dysfunction were excluded, leaving 46 patients and 86 ureters for review. The mean age at time of injection was 5.2 years (range 0.75-11 years) and mean grade of VUR was 2.5 (range 1-5). After DxHA injection, 75% of the ureters showed resolution of VUR, while 25% demonstrated persistent VUR. No correlation was made between the presence of DxHA mound and resolution of VUR on VCUG. CONCLUSION In this series, the presence of a DxHA mound on initial postoperative ultrasound does not predict resolution of VUR. A larger prospective study is needed to evaluate additional parameters.

Robot-Assisted Laparoscopic Partial Nephrectomy for Recurrent Renal-Cell Carcinoma in Patients Previously Treated with Nephron-Sparing Surgery

BACKGROUND AND PURPOSE With the advent of robotics, it may be more feasible to offer minimally invasive nerve-sparing surgery (NSS), in the form of partial nephrectomy (PN), for patients with metachronous recurrence in the ipsilateral kidney after previous NSS. We studied the outcomes of patients undergoing robot-assisted laparoscopic partial nephrectomy (RAPN) after previous ipsilateral open or laparoscopic NSS for renal-cell carcinoma. METHODS In this Institutional Review Board approved study, a prospectively maintained PN database was reviewed. Of 230 RAPNs performed between 2003 and 2011, five patients underwent RAPN after previous ipsilateral NSS. RESULTS The mean age was 64.2 years, and time between the first and second surgery was 27 months (range 9-60 mos). All patients were men and previously had open (n=4) or laparoscopic (n=1) NSS for clear-cell (n=2), papillary (n=2), and other (n=1) pathology. Average follow-up was 15.6 months (range 8-21 mos). There were no conversions to open surgery or radical nephrectomy. Total and selective arterial clamping were performed in two and two cases, respectively. One RAPN was performed off-clamp. Mean warm ischemia time was 14 minutes (range 0-32 min), and mean blood loss was 220 mL (range 50-400 mL). Average length of stay was 1.4 days (range 1-2 days) with no perioperative complications. The glomerular filtration rate decreased by a mean of 10%. There were no recurrences detected on cross-sectional imaging at the most recent follow-up. CONCLUSION RAPN after previous open or laparoscopic PN is safe and efficacious. It offers satisfactory intermediate functional and oncologic outcomes with minimal morbidity.

Impact of 2012 USPSTF Screening PSA Guideline Statement: Changes in Primary Care Provider Practice Patterns and Attitudes

Introduction: Prostate specific antigen use in prostate cancer screening has undergone significant changes since the 2012 release of the USPSTF (United States Preventive Services Task Force) guideline statement. The effect on specific primary care provider practice patterns and attitudes is not well characterized. We describe the impact of the USPSTF statement on prostate cancer screening practices, attitudes and knowledge among primary care providers. Methods: A survey composed of 25 questions was mailed electronically to approximately 350 primary care providers within a single academic health care system. Responses were recorded and could not be traced to the respondent. Results: A total of 73 primary care providers (21%) responded to the survey. Of the respondents 75% reported a change in prostate specific antigen screening practices resulting from the USPSTF recommendations and 35% reported a decrease in digital rectal examination use, although the latter test is not explicitly addressed in the guideline statement. A third of respondents believe that prostate specific antigen screening has “likely had no role” in the 2‐decade decline in prostate cancer mortality and 70% agree that prostate specific antigen screening may “impart more harm than good” to the patient. Despite these opinions, there was markedly greater concern for medicolegal consequences of a missed diagnosis compared to over diagnosis. Conclusions: The results of the survey, while limited to a single large academic center, show the impact of the USPSTF 2012 statement on physician attitudes and practice patterns. The results define the need for more educational opportunities for primary care providers regarding the USPSTF statement, American Urological Association guidelines and identification of patients appropriate for prostate specific antigen screening.

Mass Forming Eosinophilic Cystitis in Pediatric Patients.

Eosinophilic cystitis (EC) is an uncommon inflammatory disorder of uncertain etiology that has been described in adult and pediatric populations. We describe 3 recent cases of EC that presented as a mass lesion in pediatric patients from the New England region of the United States. All patients were initially suspected to have a malignancy, and biopsy was performed, which ultimately led to the diagnosis of EC. We propose the use of eosinophil density of >25 eosinophils per high-power field and myocyte degeneration as supportive histopathologic features to make this diagnosis. It is of utmost importance to consider EC in the differential diagnosis when approaching a pediatric patient with a bladder mass.

Metastatic Renal Cell Carcinoma in a Hepatic Hemangioma: A Case Report and Review of the Literature.

We report the case of 55-year-old female with biopsy-proven clear cell renal cell carcinoma with a suspicious lesion found in the liver who presented for right radical nephrectomy and partial hepatectomy. Histologic evaluation of the hepatic specimen demonstrated metastatic renal cell carcinoma within a hepatic hemangioma. Herein we provide a review of the literature for this uncommon scenario.

MP14-17 IMMEDIATE REPEAT BIOPSY IS NOT NECESSARY IN PATIENTS WITH ATYPICAL SMALL ACINAR PROLIFERATION (ASAP): A MULTI-INSTITUTIONAL REVIEW

larger. Analysis for predictors of a lesion becoming RBþ demonstrated that any lesion growth on MRI was a significantly associated with a lesion being RBþ (p1⁄40.012, odds ratio 1⁄4 4.8, 95% CI [1.5, 15.4]). Initial MRI suspicion score, upgrading of MRI suspicion score, initial lesion size < 0.7 cm, and MRI parameters were not significantly associated. CONCLUSIONS: Targeted biopsy negative lesions almost always were benign on serial biopsy. When a lesion was RBþ the vast majority demonstrated low risk disease. Biopsy negative lesions should be re-sampled if they increase in size at an interval of 2 years.

Laparoscopic and Robot-Assisted Adrenalectomy

The surgical approach to the adrenal gland was historically described via an open technique. In recent years, laparoscopic and robot-assisted approaches have become the preferred methods for removal of the adrenal gland when affected by a variety of pathologic disorders. Numerous reports and comparative studies have demonstrated minimally invasive adrenalectomy to be superior to open adrenalectomy with regard to blood loss, cosmesis, analgesic requirements, hospital stay, and recovery time. Laparoscopic and robot-assisted adrenalectomies are efficacious and safe and have become the standard for the majority of surgical adrenal disorders.