Mehmet Özsoy

Hybrid renal cell carcinomas containing histopathologic features of chromophobe renal cell carcinomas and oncocytomas have excellent oncologic outcomes.

BACKGROUND Modern histopathology is able to differentiate chromophobe renal cell carcinomas (cRCCs), oncocytomas, and chromophobe-oncocytic hybrid RCCs; however, the true frequency and clinical courses of these tumors remain unclear. OBJECTIVE To determine the clinical course of hybrid RCC. DESIGN, SETTING, AND PARTICIPANTS Ninety-one surgically treated tumors, originally classified as oncocytoma or cRCC, were slide reviewed and reclassified by an experienced uropathologist. Immunohistochemical cytokeratin-7 (CK7) staining was used to distinguish oncocytoma (CK7 positive in <10% of the cells) and hybrid RCCs (CK7 positive in >10% of the cells). INTERVENTIONS Radical tumor nephrectomy or nephron-sparing surgery. MEASUREMENTS Recurrence-free and tumor-specific survival. RESULTS AND LIMITATIONS Overall, 16 tumors (17.6%) were hybrid RCCs, 32 tumors were cRCCs, and 43 tumors were pure oncocytomas. Perinephric tissue invasion (pT3a) was found in one pure oncocytoma and in two hybrid RCCs. The pathologic stage for cRCC was pT1 in 50% of tumors (n=17), pT2 in 23.5% of tumors (n=8), and pT3a in 26.5% of tumors (n=9). Low-grade RCC was found in 76.5% of tumors (n=26), and vascular invasion was found in 11.8% of tumors (n=4). After a mean follow-up of 50 mo, no oncocytomas or hybrid RCCs were found, but two cRCCs had recurred. The 3-yr tumor-specific survival rates for patients with oncocytoma, hybrid RCCs, and cRCC were 100%, 100%, and 97%, respectively. CONCLUSIONS Hybrid RCCs are more common than expected. The survival rate is 100% for both hybrid RCCs and oncocytomas. Hybrid RCCs may be candidates for active surveillance, and surgery may be unnecessary. CRCCs should be treated because a small proportion of these tumors exhibit aggressive clinical courses.

Comparison of type I and II papillary renal cell carcinoma (RCC) and clear cell RCC.

To compare the pathological features of clear cell renal cell carcinoma (ccRCC) with papillary RCC (pRCC) and further differentiate type I and II pRCC as independent prognosticators for survival.

Novice surgeons: do they benefit from 3D laparoscopy?

In this study, the impact of two-dimensional (2D) and three-dimensional (3D) vision on laparoscopic performance of novice surgeons is examined. Twenty-five novice surgeons were directed to complete four basic tasks from European Training in Basic Laparoscopic Urological Skills (E-BLUS) with both 2D and 3D systems in a random order: task 1: needle guidance, task 2: cutting a circle, task 3: laparoscopic suturing, and task 4: pegs transfer. Quality and quantity scores for each task were measured. Participants completed all of the tasks in one modality of vision and than switched to the other. NASA Task Load Index was used for subjective workload assessment. Statistically significant differences in favor of 3D vision were detected in tasks 1 and 4 both in terms of quality and quantity. In task 2 and task 3, a significantly better performance was observed with the 3D vision only in quantity assessment. The participants who started the tasks in the 3D vision were better in performing the skills in 2D when compared to the participants who started with 2D vision. Overall, the participants reported a better perception of depth and spatial orientation with the 3D mode. Subjective work load was also lower for the tasks performed in 3D. Novice surgeons tended to perform better and felt much more comfortable with 3D in comparison to 2D laparoscopy. Even though previous task experience seemed to have an important impact on laparoscopic performance regardless of imaging modality, 3D laparoscopy seemed to facilitate the learning for novice surgeons.

Validation of Preoperative Risk Grouping of the Selection of Patients Most Likely to Benefit From Neoadjuvant Chemotherapy Before Radical Cystectomy

Micro‐Abstract Neoadjuvant chemotherapy (NAC) has been demonstrated to be effective in prospective randomized trials for cT2‐cT4a N0 patients. However, this benefit was more evident in patients with clinical stage ≥ T3 disease. On the other hand, toxicity grade 3 and 4 were reported in 35% and 37% of patients who underwent NAC. Following these considerations, we validate here the preoperative risk model proposed by Culp et al as a fundamental tool in the preoperative prediction of patients who will benefit more from NAC administration. Introduction: The aim of this study was to validate the value of preoperative patient characteristics in prognosticating survival after radical cystectomy (RC) to guide treatment decisions regarding neoadjuvant systemic treatment. Methods: We evaluated a single cohort of 449 consecutive patients treated with RC for bladder cancer. Patients treated with neoadjuvant therapy were excluded from the study cohort (n = 24). Patients were stratified based on preoperative characteristics into 2 risk groups. The high‐risk group included patients harboring clinically non–organ‐confined disease (≥ cT3), hydroureteronephrosis, lymphovascular invasion, or variant histology (micropapillary, neuroendocrine, sarcomatoid, or plasmacytoid variants on transurethral resection). The low‐risk group included patients with cT2 disease without any of the aforementioned features. Survival expectancies after surgery were evaluated using competing risk and Kaplan‐Meier analyses. Results: We identified 153 (44.6%) low‐risk and 190 (55.4%) high‐risk patients. The majority of high‐risk patients had only 1 high‐risk feature (n = 111; 58.4%); the most common high‐risk feature was preoperative hydroureteronephrosis (n = 107; 56.3%). The majority of low‐risk patients were upstaged at time of RC (n = 118; 70.6%), whereas a pathologic downstage occurred only in 27 high‐risk patients (14.2%). Cancer‐specific mortality‐free rates at 5 years after RC were 77.4% versus 64.4% for low‐risk versus high‐risk patients, respectively. Conclusions: We confirm that preoperative risk features can stratify patients with muscle‐invasive bladder cancer into differential risk groups regarding survival. Decision‐making regarding neoadjuvant systemic therapy administration is likely to be improved by integrating clinical stage, lymphovascular invasion, variant histology, and hydroureteronephrosis.

Current evidence on lasers in laparoscopy: partial nephrectomy

AbstractIntroduction Laser-assisted partial nephrectomy (PN) can benefit from the excellent coagulative properties of lasers to provide a bloodless tumor excision without the necessity for renal artery clamping. In this review, we aim to determine the current clinical implementation of laser assistance during laparoscopic nephron-sparing surgery.Materials and methodsAn extensive literature evaluation on laser-assisted PN was performed. Experimental work on animals and review articles were excluded.ResultsCurrent literature regarding laser-assisted PN is scarce. Available data consist mostly of small cohorts providing low level of evidence. Even though initial studies with currently available laser modalities demonstrated promising results, several drawbacks in each technique need to be addressed before being widely accepted as a standard care.ConclusionsExperience with laser-assisted laparoscopic PN is steadily increasing and uniformly documenting favorable results. As urologist became more familiar with laser technology by its implementation in other clinical entities and with the increasing interest in nephron-sparing management of renal tumors, the use of laser assistance during PN should be expected to play a major role in future.

Prognostic Role of Neutrophil-to-Lymphocyte Ratio in Primary Non–muscle-invasive Bladder Cancer

Micro‐Abstract The neutrophil‐to‐lymphocyte ratio is associated with poor outcomes in patients with muscle‐invasive bladder cancer. We found that the neutrophil‐to‐lymphocyte ratio is independently associated with disease recurrence and progression in patients with non–muscle‐invasive bladder cancer. Introduction: The purpose of this study was to assess the role of pretreatment neutrophil‐to‐lymphocyte ratio (NLR) as a predictor of clinical outcomes in patients treated with transurethral resection (TURB) for primary non–muscle‐invasive bladder cancer (NMIBC). Patients and Methods: Data from 918 patients treated with TURB for primary NMIBC were retrospectively collected. NLR was evaluated as binary variable with the cut‐point of 3 based on the visual best correlation of the receiver operating curve analyses focusing on disease recurrence. The median follow‐up was 62 months. Cox regression analyses were used to evaluate associations with recurrence (RFS) and progression‐free survival (PFS). Subgroup analyses were done according to risk groups and receipt of intravesical bacillus Calmette‐Guérin therapy. Results: Overall, 293 patients had a NLR ≥ 3. High NLR was associated with pathologic T stage and smoking status. The 5‐year RFS and PFS for NLR < 3 and NLR ≥ 3 were, respectively, 55.5% versus 45.9% (P = .01) and 94.9% versus 89.9% (P = .004). On multivariable analyses, NLR ≥ 3 remained significantly associated with RFS and PFS. The addition of NLR increased the discrimination of a multivariable model by 0.6% and 2.3% for RFS and PFS, respectively. Moreover, NLR showed a trend in the association with outcomes in patients treated with intravesical bacillus Calmette‐Guérin therapy. Conclusions: Integration of NLR in a prediction model could be helpful in predicting RFS and PFS in patients with primary NMIBC and identifying those who are likely to fail therapy and may benefit from an early radical cystectomy. Limitations are associated to the retrospective design.

Surveillance for the Management of Small Renal Masses

Surveillance is a new management option for small renal masses (SRMs) in aged and infirm patients with short-life expectancy. The current literature on surveillance of SRM contains mostly small, retrospective studies with limited data. Imaging alone is inadequate for suggesting the aggressive potential of SRM for both diagnosis and followup. Current data suggest that a computed tomography (CT) or magnetic resonance imaging (MRI) every 3 months in the 1st year, every 6 months in the next 2 years, and every year thereafter, is appropriate for observation. The authors rather believe in active surveillance with mandatory initial and followup renal tumor biopsies than classical observation. Since not all SRMs are harmless, selection criteria for active surveillance need to be improved. In addition, there is need for larger studies in order to better outline oncological outcome and followup protocols.

Lymphocyte-to-monocyte ratio and neutrophil-to-lymphocyte ratio as biomarkers for predicting lymph node metastasis and survival in patients treated with radical cystectomy.

To evaluate the role of lymphocyte‐to‐monocyte ratio (LMR) and neutrophil‐to‐lymphocyte ratio (NLR) as pre‐operative markers for predicting extravesical disease and survival outcomes in patients undergoing radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

Modular training for percutaneous nephrolithotripsy: The safe way to go.

Abstract Objectives should be describe a modular training scheme (MTS) which aims to provide training in percutaneous nephrolithotripsy (PCNL) and ensure the safety of the patients. Subjects and methods: Two trainees with no experience in PCNL attended the MTS under the supervision of an experienced mentor. The MTS included five modules, comprising an initial animal laboratory course (using pigs), to acquire basic skills (Module 1), and Modules 2–5 included making the puncture, tract dilatation, single-stone and large-stone management in clinical cases, respectively. Each participant progressed from one module to the next under constant mentoring and evaluation by the mentor. When the trainees completed the MTS they proceeded to perform 60 PCNL procedures independently while the mentor performed 25 for comparison purposes. A global rating scale was used for the objective evaluation of the trainees. Peri-operative variables were recorded and statistically compared as appropriate. Statistical significance was defined as P < 0.05. Results: One pig and 16 patients, and two pigs and 22 patients, were necessary to complete the MTS by each subject. There were no significant differences among the characteristics of the independently performed operations. The duration of surgery and fluoroscopy achieved a plateau similar to those of the mentor after ≈ 30 patients. The decrease in haemoglobin level, stone-free and complication rates in the patients were similar among the two trainees and the mentor. The complication rate of the trainees and the mentor never exceeded 13.3%. Conclusion: The MTS successfully combined animal and stepwise clinical training based on a standardised technique and objective evaluation.

Preoperative anemia is associated with disease recurrence and progression in patients with non–muscle-invasive bladder cancer

PURPOSE To evaluate the effect of preoperative anemia (PA) on oncological outcomes in a multicenter cohort of patients with non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB) and adjuvant intravesical therapies. We hypothesize that PA represents a marker of disease aggressiveness and could be used to improve the discrimination of prognostic tools for the prediction of disease recurrence and progression. METHODS This multicenter retrospective study included 1,117 patients from 4 different centers. The presence of PA was assessed according to the World Health Organization classification as a preoperative hemoglobin level of≤13g/dl in men and≤12g/dl in women. PA evaluation was done at each institution, generally 1 to 3 days before surgery. Multivariable Cox regression models were performed to evaluate the prognostic effect of PA on survival outcomes. RESULTS Overall, 381 (34%) patients with NMIBC treated with TURB, had PA. Median follow-up for patients alive at last follow-up was 62.7 months (interquartile range: 25-110.7). On multivariable Cox regression analyses that accounted for the effect of standard clinicopathologic prognosticators, PA was independently associated with recurrence-free survival (P = 0.045) and progression-free survival (P = 0.01). Adding PA to a model for the prediction of disease recurrence and progression improved the discrimination of the prognostic models marginally from 69.8% to 70.3% and from 71.6% to 73.1%, respectively. CONCLUSIONS PA was found in more than one-third of patients with NMIBC treated with TURB. PA was associated with poor oncological outcomes and was an independent predictor of intravesical disease recurrence and progression. However, the additional prognostic information provided by PA remains limited.