Jordan M. Kurta

Tumor size is associated with malignant potential in renal cell carcinoma cases.

PURPOSE We evaluated our experience with renal cortical tumors to determine whether tumor size is associated with malignant histology and/or nuclear grade. MATERIALS AND METHODS We identified 2,675 patients treated surgically at our institution for renal cell carcinoma or a benign tumor between 1989 and 2007. Histological subtype and tumor size were obtained from our kidney cancer database and logistic regression analysis was performed. RESULTS Of the 2,675 tumors 311 (12%) were benign and 2,364 (88%) were renal cell carcinoma. The OR for the association of malignancy with tumor size was 1.16 (95% CI 1.11-1.22, p <0.001), indicating that each 1 cm increase in tumor size was associated with a 16% increase in the odds of malignancy. The incidence of benign tumors decreased from 38% for tumors less than 1 cm to 7% for tumors 7 cm or greater. In patients with clear cell renal cell carcinoma each 1 cm increase in tumor size increased the odds of high grade disease (Fuhrman grade 3-4) compared with low grade disease (Fuhrman grade 1-2) by 25% (OR 1.25, 95% CI 1.21-1.30, p <0.001). In this subset the incidence of high grade lesions increased from 0% for tumors less than 1 cm to 59% for tumors greater than 7 cm. CONCLUSIONS Our results confirm previous observations suggesting that the risks of malignancy and high grade tumors increase with tumor size. Patients with small renal masses are at low risk for harboring a high grade clear cell malignancy, which may be useful during initial consultation.

Contemporary imaging of patients with a renal mass: does size on computed tomography equal pathological size?

To evaluate the difference between radiographic size on computed tomography (CT) and the pathological size of renal tumours, in contemporary patients.

Focal treatment or observation of prostate cancer: pretreatment accuracy of transrectal ultrasound biopsy and T2-weighted MRI.

OBJECTIVES To test the hypothesis that men with prostate cancer (PCA) and preoperative disease features considered favorable for focal treatment would be accurately characterized with transrectal biopsy and prostate magnetic resonance imaging (MRI) by performing a retrospective analysis of a selected cohort of such patients treated with radical prostatectomy (RP). METHODS A total of 202 patients with PCA who had preoperative MRI and low-risk biopsy criteria (no Gleason grade 4/5, 1 involved core, < 2 mm, PSA density < or = 0.10, clinical stage < or = T2a) were included in the study. Indolent RP pathology was defined as no Gleason 4/5, organ confined, tumor volume < 0.5 mL, and negative surgical margins. MRI ability to locate and determine the tumor extent was assessed. RESULTS After RP, 101 men (50%) had nonindolent cancer. Multifocal and bilateral tumors were present in 81% and 68% of patients, respectively. MRI indicated extensive disease in 16 (8%). MRI sensitivity to locate PCA ranged from 2% to 20%, and specificity from 91% to 95%. On univariate analysis, MRI evidence of extracapsular extension (P = .027) and extensive disease (P = .001) were associated with nonindolent cancer. On multivariate analysis, only the latter remained as significant predictor (P = .0018). CONCLUSIONS Transrectal biopsy identified men with indolent tumors favorable for focal treatment in 50% of cases. MRI findings of extracapsular extension and extensive tumor involving more than half of the gland are associated with unfavorable features, and may be useful in excluding patients from focal treatment. According to these data, endorectal MRI is not sufficient to localize small tumors for focal treatment.

Critical Evaluation of Perioperative Complications in Laparoscopic Partial Nephrectomy

OBJECTIVES To analyze our experience with laparoscopic partial nephrectomy (LPN) to detail postoperative adverse events and identify factors that may contribute to adverse surgical outcomes. Complications from LPN result from a variety of factors, both technical and inherent. METHODS Single-center review of 144 consecutive LPN (4 surgeons) performed between November 2002 and January 2008 was conducted. Identified complications were graded using standard reporting criteria. Univariate and multivariate statistical analysis of variables and their association with complication event and blood loss was performed. RESULTS A total of 39 complications occurred in 29 (20%) cases. Of these, 20 (51%) were urologic and 19 (49%) were nonurologic. Individual adverse events by grade were as follows: grade I, 6 (15.4%); grade II, 19 (48.7%), grade III, 11 (28.2%), and grade IV, 3 (7.7%). No grade V complications occurred. The median tumor size and ischemia time were 2.7 cm and 35 minutes, respectively. Univariate analysis identified increased American Society of Anesthesiologists risk score (odds ratio 2.99, 95% confidence interval [CI] 1.28, 6.94) and ischemia time (odds ratio 1.31; 95% CI 1.00, 1.71) as associated with complication risk. On multivariate analysis, longer ischemia time was associated with increased estimated blood loss (95% CI 3, 57; P = .03). Hospital readmission and reintervention was required in 15 (10.4%) and 9 (6.2%) patients, respectively. CONCLUSIONS Complications from LPN occur in a meaningful proportion of procedures although the majority does not require reintervention and half are not urologic. Increasing ischemia time and American Society of Anesthesiologists score are associated with risk for unfavorable surgical outcomes.

An Analysis of the Effect of Statin Use on the Efficacy of Bacillus Calmette-Guerin Treatment for Transitional Cell Carcinoma of the Bladder

PURPOSE Bacillus Calmette-Guerin is an effective immunotherapy for carcinoma in situ of the bladder and it reduces recurrence from resected papillary transitional cell carcinoma of the bladder. Many patients receiving bacillus Calmette-Guerin therapy are concurrently taking statin agents, which have known immunomodulatory properties and may alter the performance of bacillus Calmette-Guerin. Some data have suggested that patients taking a statin while on bacillus Calmette-Guerin therapy experience reduced clinical efficacy. MATERIALS AND METHODS We conducted a retrospective review of 952 consecutive patients from 1978 through 2006. Time to recurrence and progression to surgery were compared between those taking and those not taking a statin by Kaplan-Meier methods and multivariable Cox regression controlling for stage and grade. RESULTS There were 245 (26%) patients taking a statin before bacillus Calmette-Guerin therapy and 707 not on statin therapy (74%). A total of 796 patients had recurrence overall with 214 in the statin group and 582 in the other group. Median time to recurrence was similar between those who did and those who did not use a statin. On multivariable analysis statin use was not significantly associated with recurrence (hazard ratio 1.04; 95% CI 0.81, 1.34; p = 0.7) or progression to surgery (hazard ratio 0.77; 95% CI 0.52, 1.13; p = 0.17) after bacillus Calmette-Guerin therapy. CONCLUSIONS This retrospective study in a large cohort of patients showed no statistically significant association between statin use and recurrence or progression to open surgery in patients treated with bacillus Calmette-Guerin for transitional cell carcinoma of the bladder. Based on these data patients should not be discouraged from taking statins while undergoing bacillus Calmette-Guerin treatment.

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

Comparison of gelatine matrix-thrombin sealants used during laparoscopic partial nephrectomy

To compare haemostasis and other outcomes after the use of bovine‐derived or porcine‐derived gelatine matrix‐thrombin sealants (GMTS) in a continuous series of patients during and for 6 months after laparoscopic partial nephrectomy (LPN).

Cold Intravascular Organ Perfusion for Renal Hypothermia During Laparoscopic Partial Nephrectomy

PURPOSE We report initial data on the safety and functional outcomes of renal hypothermia with arterial cold perfusion during partial nephrectomy. MATERIALS AND METHODS From June 2007 to June 2009, 31 consecutive patients underwent laparoscopic partial nephrectomy with hypothermia using renal arterial perfusion with cold, lactated Ringers solution during renal ischemia. Doppler echography was done intraoperatively to evaluate renal perfusion. Complication data were reported prospectively. Median followup was 57 weeks (IQR 28, 83). RESULTS The lowest recorded renal temperature during ischemia was 14C. Median tumor size was 4.0 cm (IQR 2.7, 6.2). Median estimated blood loss was 150 cc (IQR 100, 275). Median ischemia time was 35 minutes (IQR 26, 41). Doppler echography identified intrarenal arterial blood flow postoperatively in all cases. The median change in the estimated glomerular filtration rate from preoperatively to postoperative day 2 was 4 ml per minute (IQR -29, 19). Two months postoperative in 20 patients the median change was 3.5 ml per minute (IQR -6, 16.5). At last followup in 31 patients the overall change in the estimated glomerular filtration rate was -0.5 ml per minute (IQR -6, 6). Six complications developed in a total of 5 patients, of which 5 were grade 2 or less. One grade 3 postoperative hemorrhage from an arteriovenous fistula at the tumor resection site was treated with angiography and selective embolization. CONCLUSIONS Cold intravascular perfusion during laparoscopic partial nephrectomy can achieve renal hypothermia below 15C. It is not associated with an immediate risk of renal vascular injury or thrombosis, as measured by Doppler echography in this series. Early changes in postoperative estimates of renal function appear minimal.

PEYRONIE'S DISEASE HAS A NEGATIVE IMPACT ON THE DURABILITY AND COMPONENT MALFUNCTION RATES IN PATIENTS UNDERGOING INFLATABLE PENILE PROSTHESIS IMPLANTATION

at the penoscrotal junction and repositioned with skin hook retractors along the area of maximum penile shaft convexity--a ventral paramedian incision was favored for plication of predominantly lateral deformities. Multiple plicating sutures with 2-0 permanent braided suture were placed in the tunica alguginea according to the Lue “16-dot” technique for straightening. RESULTS: Among 35 men who underwent penoscrotal plication (PSP), 90% had primarily dorsal or dorsolateral penile deformity. Median patient age was 59.1 years; median follow-up was 9.2 months. Among those with detailed intraoperative measurements, mean angle of deformity was reduced by 38° (from an average of 54° preoperatively to 16° postoperatively) using an average of 6 sutures (“24 dots”). Three patients had transient painful erections postoperatively which resolved spontaneously within 3 months of observation; one was dissatisfied with the degree of correction and is awaiting revision; another required reoperation for removal of a distal tunical suture causing persistent discomfort. While 30% of men were encouraged to use a PDE5 inhibitor for marginal erectile function and four reported mild worsening of erectile function during follow-up, none became impotent as a result of the PSP procedure. CONCLUSIONS: Most men with Peyronie’s disease have primarily dorsal or lateral curvature of moderate severity, and are thus readily amenable to penoscrotal correction. PSP is a safe, minimally invasive approach for correction of significant penile curvature which provides excellent functional and cosmetic outcomes. Circumcising incisions and graft techniques are unnecessary for the vast majority of Peyronie’s patients undergoing surgical correction.