John B. Malcolm

Comparison of rates and risk factors for developing chronic renal insufficiency, proteinuria and metabolic acidosis after radical or partial nephrectomy

To investigate the incidence of and risk factors for developing chronic renal insufficiency (CRI), proteinuria and metabolic acidosis (MA) in patients treated with radical nephrectomy (RN) or nephron‐sparing surgery (NSS).

Risk of new-onset diabetes mellitus and worsening glycaemic variables for established diabetes in men undergoing androgen-deprivation therapy for prostate cancer

To investigate the incidence of new‐onset diabetes mellitus (NODM) and of worsening glycaemic control in established DM after starting androgen‐deprivation therapy (ADT) for prostate cancer, as ADT is associated with altered body composition, potentially influencing insulin sensitivity.

Patterns of sexual and erectile dysfunction and response to treatment in patients receiving androgen deprivation therapy for prostate cancer

To investigate the incidence of patient‐reported erectile (ED) and sexual dysfunction and response to treatment in men after the induction of androgen deprivation therapy (ADT) for prostate cancer, as ADT‐induced changes in serum testosterone can result in changes in libido and sexual function.

Single Center Experience with Percutaneous and Laparoscopic Cryoablation of Small Renal Masses

BACKGROUND AND PURPOSE While partial nephrectomy remains the gold standard for the management of most small renal masses, increasing experience with renal cryoablation has suggested a viable alternative with a favorable morbidity profile and good efficacy. We report intermediate-term oncologic outcomes from a single-center experience with laparoscopic and percutaneous renal cryoablation. PATIENTS AND METHODS We performed a retrospective review of our laparoscopic renal cryoablation (LRC) and percutaneous renal cryoablation (PRC) experience between January 2003 and April 2007. Patients with at least 12 months of follow-up were included in the analysis. Follow-up consisted of imaging and laboratory studies at regular intervals. Persistent mass enhancement or interval tumor growth was considered a treatment failure. RESULTS Sixty-six patients (44% women/56% men; 42% African-American/58% Caucasian/other; mean body mass index, 29.7) with 72 tumors underwent either LRC (n = 52) or PRC (n = 20) with a mean follow-up of 30 months (median 25.1 mos; range 13-63 mos). Average patient age was 66.5 years (range 34-82 yrs). Mean tumor size was 2.33 cm (range 1-4.6 cm). Comorbid conditions were prevalent: 76% hypertension, 36% hyperlipidemia, 24% chronic kidney disease, 29% diabetes mellitus, 36% tobacco use, and 32% heart disease. RESULTS of pretreatment biopsy were 62% renal-cell carcinoma and 38% benign or nondiagnostic. Overall cancer-specific and cancer-free survival were 100% and 97%, respectively. There were two treatment failures (3.8%) in the LRC group and five primary failures in the PRC group (25%) (P = 0.015), four of which were salvaged with repeated PRC with no evidence of recurrence at 6 to 36 months of follow-up. There has been no significant local or metastatic progression. CONCLUSIONS LRC and PRC achieved good oncologic control with minimal morbidity at a mean follow-up of 30 months in a patient cohort characterized by numerous comorbid conditions. PRC had a significantly higher primary treatment failure rate than LRC, but re-treatment offered salvage oncologic control with no significant complications.

Nonoperative management of blunt renal trauma: is routine early follow-up imaging necessary?

BackgroundThere is no consensus on the role of routine follow-up imaging during nonoperative management of blunt renal trauma. We reviewed our experience with nonoperative management of blunt renal injuries in order to evaluate the utility of routine early follow-up imaging.MethodsWe reviewed all cases of blunt renal injury admitted for nonoperative management at our institution between 1/2002 and 1/2006. Data were compiled from chart review, and clinical outcomes were correlated with CT imaging results.Results207 patients were identified (210 renal units). American Association for the Surgery of Trauma (AAST) grades I, II, III, IV, and V were assigned to 35 (16%), 66 (31%), 81 (39%), 26 (13%), and 2 (1%) renal units, respectively. 177 (84%) renal units underwent routine follow-up imaging 24–48 hours after admission. In three cases of grade IV renal injury, a ureteral stent was placed after serial imaging demonstrated persistent extravasation. In no other cases did follow-up imaging independently alter clinical management. There were no urologic complications among cases for which follow-up imaging was not obtained.ConclusionRoutine follow-up imaging is unnecessary for blunt renal injuries of grades I-III. Grade IV renovascular injuries can be followed clinically without routine early follow-up imaging, but urine extravasation necessitates serial imaging to guide management decisions. The volume of grade V renal injuries in this study is not sufficient to support or contest the need for routine follow-up imaging.

Single center comparison of laparoscopic cryoablation and CT-guided percutaneous cryoablation for renal tumors

BACKGROUND AND PURPOSE Cryoablation has demonstrated therapeutic effectiveness for selected renal tumors. We compared our perioperative and short-term outcomes of laparoscopic (LAP) v percutaneous (PERC) renal cryoablation. PATIENTS AND METHODS Thirty-four patients (18 men/16 women) underwent a LAP and 26 patients (19 men/7 women) underwent a PERC procedure between September1998 and January 2007. LAP cryoablation was performed transperitoneally with ultrasonographic monitoring. PERC cryoablation was performed with CT guidance. Follow-up imaging was obtained at regular intervals. RESULTS Mean follow-up was 25 months. Average age (years) was 67.0 for the LAP and 69.7 for the PERC procedure (P = 0.307). Mean body mass index (kg/m(2)) was 29.8 for those undergoing LAP and 28.7 for those undergoing PERC procedures (P = 0.543). Mean tumor size (cm) was 2.9 for LAP patients and 3.1 for PERC patients (P = 0.432). Anterior tumors comprised 61.7% of LAP and 15.4% of PERC procedures (P < 0.001). Posterior tumors comprised 32.4% of LAP and 65.4% of PERC procedures (P = 0.01). Mean procedure time (minutes) was 165.7 for LAP and 106.6 for PERC procedures (P < 0.001). Hospital stay (days) was 2.6 for those undergoing LAP and 1.8 for those undergoing PERC procedures (P < 0.001). Both LAP patients (82.4%) and PERC patients (19.2%) needed postoperative narcotics (P < 0.001). Atelectasis developed in 70.6% of LAP patients and 34.6% of PERC patients (P = 0.005). Residual enhancement was seen in 11.5% of PERC patients and 2.9% of LAP patients (P = 0.192). Complications developed in 14.7% of LAP patients and 26.9% of PERC patients (P = 0.248). 1-year, 2-year, and 3-year disease-specific survival for the two groups was 100%. Tumor size > 4 cm and endophytic location were significantly associated with residual enhancement. CONCLUSIONS LAP and PERC renal cryoablation have similar short-term outcomes. Significantly more anterior tumors were approached laparoscopically and significantly more posterior tumors were approached percutaneously. The PERC approach may offer advantages regarding hospital stay, narcotic need, and development of atelectasis. Longer-term data are needed to establish success of this approach.

Second Prize: Recurrence Rates After Percutaneous and Laparoscopic Renal Cryoablation of Small Renal Masses: Does the Approach Make a Difference?

BACKGROUND AND PURPOSE As radiologic detection of small renal masses increases, patients are increasingly offered percutaneous renal cryoablation (PRC) or transperitoneal laparoscopic renal cryoablation (TLRC). This multicenter experience compares these approaches. PATIENTS AND METHODS Between September 1998 and May 2010, review of our PRC and TLRC experience was performed. Patients with ≥ 12-month follow-up were included for analysis. Post-treatment surveillance consisted of laboratory studies and imaging at regular intervals. Treatment failure was considered if persistent mass enhancement or interval tumor growth was radiographically evident. Repeated biopsy and re-treatment were recommended in the event of recurrence. RESULTS Sixty-one patients underwent PRC and 84 patients underwent TLRC. No significant differences were noted with respect to demographic factors. Mean tumor size was 2.7 ± 1.1 cm (PRC) and 2.5 ± 0.8 (TLRC) cm (P = 0.090). Mean follow-up was 31.0 ± 15.9 months (PRC) and 42.3 ± 21.2 (TLRC) months (P = 0.008), with local tumor recurrence noted in 10/61 (16.4%) PRC and 5/84 (5.9%) TLRC (P = 0.042). For PRC, disease-free survival (DFS) and overall survival (OS) were 93.7% and 88.9%, respectively, with four patients having evidence of disease at last follow-up. DFS and OS were 91.7% and 89.3% for TLRC, with seven patients having evidence of disease at last follow-up. DFS (P = 0.654) and OS (P = 0.939) were similar. CONCLUSIONS In this multicenter study of well-matched cohorts, PRC had higher primary treatment failure rates than TLRC. While no differences were noted between DFS and OS, analysis is limited by intermediate follow-up. Further study is necessary to discern reasons for the higher recurrence rates in PRC and to determine what long-term consequences exist.

Comparison of rates and risk factors for development of osteoporosis and fractures after radical or partial nephrectomy.

OBJECTIVE To examine incidence of and risk factors for development of osteoporosis and fractures in patients who underwent radical nephrectomy (RN) and partial nephrectomy (NSS), as osteoporosis is an important cause of morbidity in chronic kidney disease. METHODS This was a retrospective review of 905 patients (mean age 57.5 years, mean follow-up 6.4 years) who underwent RN or NSS for renal tumors at 2 institutions from July 1987 to June 2007. Demographics, renal function, metabolic parameters, and history of preoperative and postoperative osteoporosis and fractures were recorded. Data were analyzed within subgroups based on treatment (RN vs NSS). Multivariate analysis was conducted to elucidate risk factors for developing osteoporosis following surgery. RESULTS A total of 610 patients underwent RN and 295 underwent NSS. Tumor size (cm) was significantly larger for RN (RN 7.0 vs NSS 3.7, P<.0001). No significant differences were noted with respect to demographic factors and preoperative osteoporosis (RN 8.7% vs NSS 9.5%, P=.785) and fractures (RN 1.7% vs NSS 0.7%, P=.382). Postoperatively, significantly less osteoporosis (NSS 12.5% vs RN 22.6%, P<.001) and fewer fractures (NSS 4.4% vs RN 9.8%, P=.007) developed in the NSS cohort. MVA demonstrated female (OR 1.85, P=.001), Caucasian (OR 2.33, P<.0001), preoperative eGFR<60 mL/min/1.73 m2, (OR=3.02, P<.0001), preoperative metabolic acidosis (OR=4.22, P=.0006), and RN (OR 2.59, P<.0001) were risk factors for developing osteoporosis. CONCLUSIONS Patients undergoing RN had a significantly higher incidence of osteoporosis and fractures compared with a well-matched cohort of patients who underwent NSS. In addition to RN, female gender, Caucasian background, preoperative eGFR<60, and preoperative metabolic acidosis were associated with developing osteoporosis.

Peyronie's disease compromises the durability and component-malfunction rates in patients implanted with an inflatable penile prosthesis

Study Type – Therapy (case series)
Level of Evidence 4

Survival outcomes in men receiving androgen-deprivation therapy as primary or salvage treatment for localized or advanced prostate cancer: 20-year single-centre experience

To evaluate the overall survival (OS) and disease‐specific survival (DSS) in men receiving primary androgen‐deprivation therapy (PADT) or salvage medical ADT (SADT) for prostate cancer.