Kent T. Perry

Transforming growth factor-β in benign and malignant prostate

The present review summarizes the cellular action of TGF‐β in benign and malignant growth of the prostate.

Risk Factors and Management of Urine Leaks After Partial Nephrectomy

PURPOSE As nephron sparing surgery is used more frequently for select renal tumors, the incidence of urine leaks will likely increase. To our knowledge the risk factors of and management strategies for urine leaks have not been studied. We report our experience with the risk factors of and management for urine leaks after open and laparoscopic partial nephrectomy. MATERIALS AND METHODS We retrospectively reviewed the records of 127 consecutive patients who underwent partial nephrectomy between 2001 and 2007, including 70 with open and 57 with laparoscopic partial nephrectomy, as performed by 3 surgeons. Urine leak was defined as drain output consistent with urine greater than 48 hours after laparoscopic partial nephrectomy. RESULTS Of the patients 21 experienced a urine leak after partial nephrectomy, including 13.3% overall, and 10.5% after laparoscopic and 18.5% after open partial nephrectomy. Patients with a urine leak had significantly greater tumor size (3.2 vs 2.4 cm, p <0.044), endophytic locations (57% vs 19%, p <0.00027) and repair of collecting system defects during partial nephrectomy (95% vs 56%, p <0.00072). There was no association with the number of tumors removed, estimated blood loss, ischemia time, body mass index, age or other surgical complications. The median duration of urine leak was 20 days. While most urine leaks resolved with prolonged drainage, 38% of cases required further intervention. Patient age at surgery was the only factor that correlated with prolonged (greater than 30 days) urine leak. CONCLUSIONS Urine leak is a complication unique to partial nephrectomy that is more commonly noted when a larger endophytic mass involves the renal collecting system. Most leaks resolve with prolonged drainage or replacement of a ureteral stent.

Mixed epithelial and stromal tumor of the kidney and cystic nephroma share overlapping features: reappraisal of 15 lesions.

CONTEXT Cystic nephroma is a rare cystic tumor, which only recently has been recognized as an exclusively adult lesion. Mixed epithelial and stromal tumor of the kidney is also a rare, recently recognized, biphasic tumor composed of tubular and cystic elements embedded in grossly recognizable spindle cell stroma. The histogenesis of both lesions is unclear. OBJECTIVES To compare clinical phenotype, morphology, and immunohistochemistry in mixed epithelial and stromal tumor of the kidney and cystic nephroma in order to explore the relationship between these 2 lesions. DESIGN Fifteen biphasic lesions (8 mixed epithelial and stromal tumors of the kidney and 7 cystic nephromas) were studied. All cases were reviewed and subjected to detailed pathologic studies, and the results were correlated with clinical findings. RESULTS Mixed epithelial and stromal tumor of the kidney occurred exclusively in women aged 36 to 80 years (mean, 49.7 years), all of whom had a history of estrogen therapy and/or obesity. Cystic nephroma occurred in both sexes; patients were aged 22 to 71 years (mean, 50.4 years), and a history of hormonal therapy was present on occasion. All 15 lesions were benign. Lesions varied by size, the proportion of cystic component, and the amount and cellularity of stroma. However, in all lesions tested, the stroma was diffusely positive for smooth muscle actin, and smooth muscle differentiation was confirmed by electron microscopy. In mixed epithelial and stromal tumors of the kidney, the stroma was positive for estrogen and progesterone receptors in 4 of 5 lesions tested. In cystic nephroma, focal positivity for hormone receptors was seen in 2 of 7 tumors tested; both positive lesions were from women. The epithelial lining in both mixed epithelial and stromal tumor of the kidney and cystic nephroma lesions was variable with regard to shape, cytoplasmic appearance, and immunophenotype (with focal positivity for CD10, cytokeratin 7, high-molecular-weight keratin, and Ulex europaeus detectable in both lesions). This pattern suggests variable differentiation, which was confirmed by electron microscopic studies (performed in 1 case). CONCLUSIONS While mixed epithelial and stromal tumor of the kidney has a strong association with the female sex and hormonal milieu, cystic nephroma can affect both sexes and, on occasion, may also have hormonal associations. Morphologically, there is considerable overlap between both lesions, which suggests that they may represent opposite ends of the spectrum of the same process. Our studies also suggest that the tubules may be entrapped rather than comprising an intrinsic component of the tumor. However, further studies, including molecular studies, are needed to support this hypothesis.

Computed Tomography-Determined Stone-Free Rates for Ureteroscopy of Upper-Tract Stones

BACKGROUND AND PURPOSE Most series on ureteroscopy for urolithiasis use postoperative plain radiography of the kidneys, ureters, and bladder (KUB) or intravenous urography (IVU) to determine outcomes. These imaging modalities, however, are not very sensitive and may overestimate stone-free rates (SFRs). The aim of our study was to assess SFRs after ureteroscopy for urolithiasis using CT follow-up. PATIENTS AND METHODS A total of 92 patients underwent 113 ureteroscopic procedures for either renal or ureteral stones. Success of ureteroscopy was then determined by the absence of any stone fragments (stone-free). Stone-clearance rates (SCRs) were also calculated for < or = 2 mm and < or = 4 mm residual stone fragments. RESULTS Each renal unit contained a mean of 1.87 stones with a mean stone diameter of 8 +/- 6 mm. The overall SFR was 50.4%. SFRs were significantly higher for ureteral stones (80%) than renal stones (34.8%) (P = 0.0001). Renal units with multiple stones were less likely to be stone free than those with single stones (P = 0.011). No difference in SFRs was found between lower pole and non-lower-pole stones. CONCLUSIONS Overall SFRs by CT were lower than SFRs reported by radiography of the KUB or IVU criteria. Further studies to identify the clinical significance and natural history of residual stone fragments on CT scan after ureteroscopy are needed.

Laparoscopic Living Donor Nephrectomy: A Look at Current Trends and Practice Patterns at Major Transplant Centers Across the United States

PURPOSE Laparoscopic living donor nephrectomy is now the preferred technique for living donor renal transplantation. To our knowledge we provide the first published multi-institutional consensus describing practice patterns, technical considerations and interesting controversies involved in laparoscopic living donor nephrectomy. MATERIALS AND METHODS We designed a survey with 33 multiple choice questions looking at demographics, patient selection, technical considerations, postoperative care and followup involved in laparoscopic living donor nephrectomy. Surveys were sent to the 58 fellowship training programs in the United States accredited by the American Society of Transplant Surgeons. RESULTS The 32 responding programs performed approximately 40% of laparoscopic living donor nephrectomies in the United States in 2005. We found that almost all centers used a donor committee to screen candidates, enforce a body mass index cutoff, and use right kidneys when necessary and left kidneys in women of childbearing age. Regarding laparoscopic access, pure laparoscopy was favored 2 to 1 over the hand assisted technique and most of those who use nonbladed trocars do not close the fascia. Most surgeons divide the adrenal vein in left cases, use a vascular stapler on the renal artery and vein, and keep the ureter with the gonadal vein in the specimen. At most centers heparin is given before controlling the vessels. Extraction in pure laparoscopic cases is usually performed using a preplaced entrapment bag through a modified Pfannenstiel incision. CONCLUSIONS Our survey describes how most renal transplant centers with accredited fellowship programs in the United States approach laparoscopic living donor nephrectomy. Specifically trends are revealed regarding patient selection, laparoscopic access and surgical technique.

Radiofrequency Ablation–Assisted Robotic Laparoscopic Partial Nephrectomy Without Renal Hilar Vessel Clamping Versus Laparoscopic Partial Nephrectomy: A Comparison of Perioperative Outcomes

OBJECTIVES Radiofrequency ablation (RFA)-assisted laparoscopic partial nephrectomy (LPN) may allow for improved hemostasis without need for renal hilar vessel clamping and elimination of warm ischemia to the kidney. We compare outcomes in patients undergoing radiofrequency ablation-assisted robotic clampless partial nephrectomy (RF-RCPN) and LPN. METHODS Thirty-six patients and 42 patients underwent LPN and RF-RCPN, respectively. In the RF-RCPN group, the Habib 4x RFA device was used to coagulate a margin of normal parenchyma around the renal mass to allow excision of the mass within a bloodless plane. Unlike in the LPN group, renal hilar vascular occlusion was not performed in the RF-RCPN group. RESULTS Tumors treated in the RF-RCPN group tended to be larger (2.8 vs. 2.0 cm) and more often endophytic (52.6% vs. 16.1%). Collecting system reconstruction occurred more often in the RF-RCPN group (78.6% vs. 30.6%). Operative duration was longer in the RF-RCPN group (373 vs. 250 minutes), but this included time for cystoscopy, ureteral stenting, and repositioning of the patient. Blood loss, transfusion rates, renal function, and complication rates did not differ between the two groups. No patients required renal hilar vessel clamping or nephrectomy to control bleeding in the RF-RCPN group. CONCLUSIONS The use of RFA-assistance during robotic partial nephrectomy allows excision of renal tumors without hilar vascular clamping, thus eliminating renal warm ischemia. Larger and more centrally located tumors were excised with RF-RCPN. No differences in blood loss, complication rate, postoperative bleeding, renal function, or recurrence rate were noted compared with LPN.

Vitamin D deficiency predicts prostate biopsy outcomes

Purpose: The association between vitamin D and prostate biopsy outcomes has not been evaluated. We examine serum vitamin D levels with prostate biopsy results in men with an abnormal prostate-specific antigen and/or digital rectal examination. Experimental Design: Serum 25-hydroxyvitamin D (25-OH D) was obtained from 667 men, ages 40 to 79 years, prospectively enrolled from Chicago urology clinics undergoing first prostate biopsy. Logistic regression was used to evaluate the associations between 25-OH D status and incident prostate cancer, Gleason score, and tumor stage. Results: Among European American (EA) men, there was an association of 25-OH D <12 ng/mL with higher Gleason score ≥ 4+4 [OR, 3.66; 95% confidence interval (CI), 1.41–9.50; P = 0.008] and tumor stage [stage ≥ cT2b vs. ≤ cT2a, OR, 2.42 (1.14–5.10); P = 0.008]. In African American (AA) men, we find increased odds of prostate cancer diagnosis on biopsy with 25-OH D < 20 ng/mL [OR, 2.43 (1.20–4.94); P = 0.01]. AA men demonstrated an association between 25-OH D < 12 ng/mL and Gleason ≥ 4+4 [OR, 4.89 (1.59–15.07); P = 0.006]. There was an association with tumor stage ≥ cT2b vs. ≤ cT2a [OR, 4.22 (1.52–11.74); P = 0.003]. Conclusions: In AA men, vitamin D deficiency was associated with increased odds of prostate cancer diagnosis on biopsy. In both EA and AA men, severe deficiency was positively associated with higher Gleason grade and tumor stage. Clin Cancer Res; 20(9); 2289–99. ©2014 AACR.

Renal Neoplasms in Younger Adults: Analysis of 112 Tumors From a Single Institution According to the New 2004 World Health Organization Classification and 2002 American Joint Committee on Cancer Staging System

CONTEXT Adult renal neoplasms have a predilection for older patients and are clinically and morphologically distinct from renal neoplasms found in pediatric age groups. Relatively rare tumors occur in younger adults (18-45 years of age). Whether these renal tumors are morphologically and clinically distinct from those of older adults has been the subject of controversy. Recent modification of the World Health Organization histologic classification and the American Joint Committee on Cancer staging system of adult renal tumors further highlighted the need for case analysis in this age group. OBJECTIVE To analyze renal tumors in younger adults based on a large surgical series from a single institution. DESIGN Of 780 renal mass nephrectomy (partial, total, or radical) specimens that were available for evaluation and had been obtained between 1986 and 2004 at Loyola University Medical Center, 112 specimens were from patients between 18 and 45 years of age. The tumors were reevaluated according to the 2004 World Health Organization classification and the 2002 American Joint Committee on Cancer staging system. RESULTS The likelihood of clear cell renal cell carcinoma was significantly reduced from 65% in older adults to 53% in younger adults (18-45 years, P = .04). The reduction trend was more significant when comparing an even younger age group. The majority (64%) of clear cell renal cell carcinoma in younger adults was low stage, T1a. Seventeen percent of these tumors had multilocular cystic features involving more than 50% of the tumor volume (55%-85%). The number of oncocytomas was also significantly lower in younger adults than in older adults (2% vs 11%, P < .001), and this presumably age-related benign neoplasm was not identified in patients younger than 40 years in this study. In contrast, the miscellaneous tumor category showed a remarkable increase, from 4% in older adults to 26% in younger adults (P < .001). The youngest patient group (18-35 years) had a higher incidence of miscellaneous tumors, 37%. Younger female adults tended to have more benign miscellaneous neoplasms than did their male counterparts (64% vs 36%, P < .001). Clear cell and chromophobe renal cell carcinoma occurred more frequently in younger male adults than in female adults (2:1 and 8:1, respectively). CONCLUSIONS Renal neoplasms are more heterogeneous in younger adults and have a different distribution pattern compared with that in older adults. Malignant and benign renal neoplasms tend to have a contrasting sex distribution in younger adults.

Hybrid Laparoscopic and Robotic Ultrasound-guided Radiofrequency Ablation-assisted Clampless Partial Nephrectomy

INTRODUCTION To describe a clampless approach made possible by creating an avascular plane of tissue with radiofrequency ablation. Laparoscopic partial nephrectomy is slowly gaining acceptance as a method to treat small (<4 cm) and select moderate (<7 cm) renal masses. The intricacies of laparoscopic suturing, which result in prolonged warm ischemia times, have delayed the widespread acceptance of this technique among urologists. Laparoscopic suturing to close the collecting system was done using the da Vinci robot. TECHNICAL CONSIDERATIONS An avascular plane of tissue from coagulation necrosis was achieved with the Habib 4X radiofrequency ablation device and the Rita 1500X generator. Typically, we used a power setting of 50 W but have found settings as low as 25 W necessary to provide hemostasis for larger vessels. The tumor was then sharply excised with a negative margin using robotic scissors and electrocautery to facilitate tissue cutting. Retrograde injection of methylthioninium chloride and saline through an externalized ureteral catheter allowed for precise sutured closure of the collecting system. FloSeal and BioGlue were then applied, making surgical bolsters or parenchymal sutures unnecessary. Intraoperative histologic evaluation of the surgical margin and repeat resection of the tumor bed was possible because the renal hilum was not clamped, and no warm ischemia was used. CONCLUSIONS This technique, which combines the improving technologies of robotic surgery, intraoperative laparoscopic ultrasonography, and radiofrequency ablation, might make more surgeons comfortable with the intricacies of laparoscopic suturing and eliminate prolonged warm ischemia times. Overall, this method should result in more patients being able to undergo minimally invasive laparoscopic partial nephrectomy.

THE EFFICACY AND SAFETY OF SYNCHRONOUS BILATERAL EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY

PURPOSE Bilateral renal calculi have traditionally been managed by staged extracorporeal shock wave lithotripsy (ESWLdagger) due to concern about bilateral obstruction. We evaluated the safety and efficacy of synchronous bilateral ESWL in a large series of patients treated at our institution to determine the safety and efficacy of this controversial technique in what is to our knowledge the largest series to date. MATERIALS AND METHODS We retrospectively evaluated the records of 120 patients with a mean age of 48 years who underwent bilateral synchronous ESWL between 1987 and 1996. Of the patients 71 (59%) were male. Average followup was 21 months. ESWL was performed using a Dornier HM3 lithotriptor in all cases. Intraoperative technique and postoperative factors were analyzed using the Pearson product moment correlation, the 2-tailed t test and multiple regression analysis. RESULTS Mean stone size was 13 and 15 mm. on the left and right sides, respectively. There was an average of 1.7 stones per renal unit. After 1 treatment 72 of the 120 patients (60%) were stone-free bilaterally, while 72% and 73% of left and right renal units, respectively, were also stone-free. Mean creatinine was similar preoperatively and postoperatively (1.46 and 1.41 mg./dl., respectively, p = 0.73). There was 1 or more complications in 18 cases. The majority of complications were minor with no long-term morbidity or death and there was no case of bilateral obstruction or renal failure. Additional procedures were required in 19 patients (16%) due to significant residual stone disease or obstruction during followup. Multiple regression analysis revealed that only patient age, a right ureteral stent and the number of shocks correlated with the complication rate. Stone size and number independently increased the probability of treatment failure and a repeat procedure (p <0.05). Patients with stones 20 mm. or greater were at particularly high risk for treatment failure and additional procedures. A total of 27 of the 35 patients (77%) with residual calculi and 13 of the 19 (68%) requiring additional procedures were in this high risk subgroup. CONCLUSIONS Bilateral synchronous ESWL is safe and effective monotherapy for bilateral urolithiasis. No patient had bilateral obstruction or renal failure and no deterioration of renal function was detected at followup. Knowing which patient populations are at higher risk for failure or complications may guide decision making.