Reza Ghavamian

Renal Cell Carcinoma in the Solitary Kidney: An Analysis of Complications and Outcome After Nephron Sparing Surgery

PURPOSE We evaluated surgical techniques, pathological features and extended outcomes in patients with renal cell carcinoma in a solitary kidney treated with surgical excision. MATERIALS AND METHODS Between 1970 and 1998, 76 patients underwent nephron sparing surgery for sporadic renal cell carcinoma in a solitary kidney, including 63 with tissue specimens available for pathological review who comprised the cohort. Six (9.5%) patients had a congenitally absent kidney and 57 (90.5%) had previously undergone contralateral nephrectomy for renal cell carcinoma. The clinical and pathological features examined were patient age at nephron sparing surgery, sex, type of nephron sparing surgery (enucleation, partial nephrectomy or ex vivo resection), tumor size, nuclear grade, histological subtype and 1997 tumor stage. Overall cancer specific, local recurrence-free and metastasis-free survival as well as early (within 30 days of nephron sparing surgery) and late (30 days to 1 year after nephron sparing surgery) complications were assessed. Univariate and multivariate analyses were done to test for the associations of clinical and pathological features with outcome. RESULTS Most patients were treated with enucleation (36.5%), standard partial nephrectomy (38.1%) or the 2 procedures (11.1%) and in 8 (12.7%) ex vivo tumor resection was done. The renal cell carcinoma histological subtypes were clear cell in 82.5% of cases, papillary in 15.9% and chromophobe in 1.6%. Grade was 1 to 3 in 10 (15.9%), 42 (66.7%) and 10 (15.9%) tumors, respectively. At 5 and 10 years the overall survival rate was 74.7% and 45.8%, the cancer specific survival rate was 80.7% and 63.7%, the local recurrence-free survival rate was 89.2% and 80.3%, and the metastasis-free survival rate was 69% and 50.4%, respectively. Tumor stage and nuclear grade were significantly associated with death from any cause, death from renal cell carcinoma and distant metastases on multivariate analysis. Notably no patient with papillary or chromophobe renal cell carcinoma died of renal cell carcinoma, or had recurrence or metastasis. The type of nephron sparing surgery was not significantly associated with outcome, although there were too few patients with recurrence to assess the association of the type of nephron sparing surgery with local recurrence. The most common early complication was acute renal failure in 12.7% of cases, while the most common late complications were proteinuria in 15.9% and renal insufficiency in 12.7%. CONCLUSIONS The 1997 tumor stage and nuclear grade were significant predictors of death from any cause, death from renal cell carcinoma and distant metastases in patients treated with nephron sparing surgery for renal cell carcinoma involving a solitary kidney. Nephron sparing surgery in a solitary kidney can be performed safely and with minimal morbidity.

Radical retropubic prostatectomy plus orchiectomy versus orchiectomy alone for pTxN+ prostate cancer : a matched comparison

PURPOSE Untreated stage pTxN+ prostate cancer is associated with a poor outcome. Monotherapy (surgery, radiation, hormonal therapy) alone is associated with a high progression rate. We evaluate whether radical prostatectomy and pelvic lymphadenectomy plus early adjuvant orchiectomy impart a survival advantage compared to pelvic lymphadenectomy and orchiectomy alone in a matched cohort of patients. MATERIALS AND METHODS Between 1966 and 1995, 382 and 79 patients with stage pTxN+ prostate cancer underwent pelvic lymphadenectomy and radical prostatectomy plus early adjuvant orchiectomy (within 3 months of prostatectomy), and pelvic lymphadenectomy and orchiectomy only, respectively. We selected 79 matched controls from the prostatectomy plus orchiectomy group for the orchiectomy group. Patients were matched according to the number of positive nodes, clinical grade, clinical stage, age, year of surgery and preoperative prostate specific antigen (after 1987). The Kaplan-Meier method and stratified Cox proportional hazards model were used to estimate overall and cause specific survival for the 2 groups. RESULTS There was an overall survival advantage at 10 years for the prostatectomy plus orchiectomy (66+/-6%) compared to the orchiectomy (28+/-6%) group (p <0.001, risk ratio 0.36, 95% confidence interval 0.20 to 0.66). There was also an advantage in cause specific survival at 10 years in the prostatectomy plus orchiectomy (79+/-5%) versus the orchiectomy (39+/-7%) group (p <0.001, relative risk 0.28, 95% confidence interval 0.13 to 0.59). After 1987, when matched on preoperative prostate specific antigen, the apparent survival advantage at 5 years with radical prostatectomy was smaller (79+/-8 versus 63+/-9% orchiectomy) and not significant (p = 0.19). CONCLUSIONS This retrospective study of patients with stage pTxN+ PC suggests that radical prostatectomy with early adjuvant orchiectomy may provide a significant advantage in overall and cause specific survival compared to orchiectomy alone.

Post-Transplant Lymphoceles: A Critical Look into the Risk Factors, Pathophysiology and Management

To define better the prevalence and pathophysiology of lymphoceles following renal transplantation, we prospectively evaluated 118 consecutive renal transplants performed in 115 patients (96 cadaveric, 22 living-related, 7 secondary and 111 primary). Ultrasonography was performed post-operatively and during rehospitalizations or whenever complications occurred. Perirenal fluid collections were identified in 43 patients (36%). Lymphoceles with a diameter of 5 cm. or greater were identified in 26 of 118 cases (22%). Eight patients (6.8%) had symptomatic lymphoceles requiring therapy. The interval for development of symptomatic lymphoceles was 1 week to 3.7 years (median 10 months). Risk factors for the development of lymphoceles were examined by univariate and multivariate analysis, and included patient age, sex, source of transplants (cadaver versus living-related donor), retransplantation, tissue match (HLA-B/DR), type of preservation, arterial anastomosis, occurrence of acute tubular necrosis-delayed graft function, occurrence of rejection, and use of high dose corticosteroids. Univariate analysis showed a significant risk for the development of lymphoceles in transplants with acute tubular necrosis-delayed graft function (odds ratio 4.5, p = 0.004), rejection (odds ratio 25.1 p < 0.001) and high dose steroids (odds ratio 16.4, p < 0.001). When applying multivariate analyses using stepwise logistic regression, only rejection was associated with a significant risk for lymphoceles (symptomatic lymphoceles--odds ratio 25.08, p = 0.0003, all lymphoceles--odds ratio 75.24, p < 0.0001). When adjusting for rejection, no other risk factor came close to being significant (least p = 0.4). Therapy included laparoscopic peritoneal marsupialization and drainage in 1 patient, incisional peritoneal drainage in 4 and percutaneous external drainage in 3 (infected). All symptomatic lymphoceles were successfully treated without sequelae to grafts or patients. We conclude that allograft rejection is the most significant factor contributing to the development of lymphoceles. Therapy of symptomatic lymphoceles should be individualized according to the presence or absence of infection.

Renal Cell Carcinoma Metastatic to the Pancreas: Clinical and Radiological Features

OBJECTIVE To review the clinical features, computed tomographic (CT) appearance, and treatment outcomes in a case series of patients with renal cell carcinoma (RCC) metastatic to the pancreas. PATIENTS AND METHODS We retrospectively reviewed the records of 23 patients (15 men and 8 women) with RCC metastatic to the pancreas, detected by CT examination between 1986 and 1996. All patients had undergone a previous nephrectomy for RCC. RESULTS Isolated mild elevation in liver function test results (in 5 patients) or in serum amylase level (in 8 patients) was observed. New-onset diabetes was detected in 3 patients. The CT characteristics of the pancreatic metastases generally resembled those of primary RCC with well-defined margins and greater enhancement than normal pancreas with a central area of low attenuation. The mean interval between resection of the primary RCC and detection of the pancreatic metastases was 116 months (range, 1-295 months). In 18 patients (78%), the pancreatic metastases were diagnosed more than 5 years after nephrectomy. The pancreas was the initial metastatic site in 12 patients (52%). Survival was shortened with higher tumor grade (mean survival time of 41 months and 10 months in patients with grade 2 and 3, respectively). Surgical resection was carried out in 11 patients (7 distal and 3 total pancreatectomies and 1 distal pancreatectomy followed 4 years later by total pancreatectomy), with 8 patients alive at a mean follow-up of 4 years, 6 of whom remained free of recurrence. Overall, 12 patients (52%) were alive at a mean of 42 months after diagnosis of metastatic disease. CONCLUSIONS The appearance of metastatic RCC lesions in the pancreas closely resembles the appearance of primary RCC on CT images. Pancreatic metastases from RCC are frequently detected many years after nephrectomy. Patient survival correlates with tumor grade. Histologic analysis of pancreatic masses in patients with a history of resected primary RCC is important since the prognosis for RCC metastatic to the pancreas is much better than that for primary pancreatic adenocarcinoma.

Analysis of intracorporeal compared with extracorporeal urinary diversion after robot-assisted radical cystectomy: Results from the international robotic cystectomy consortium

BACKGROUND Intracorporeal urinary diversion (ICUD) has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of fluid imbalance. OBJECTIVE To compare the perioperative outcomes of patients undergoing extracorporeal urinary diversion (ECUD) and ICUD following robot-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS We reviewed the database of the International Robotic Cystectomy Consortium (IRCC) (18 international centers), with 935 patients who had undergone RARC and pelvic lymph node dissection (PLND) between 2003 and 2011. INTERVENTION All patients within the IRCC underwent RARC and PLND as indicated. The urinary diversion was performed either intracorporeally or extracorporeally. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographic data, perioperative outcomes, and complications in patients undergoing ICUD or ECUD were compared. All patients had at least a 90-d follow-up. The Fisher exact test was used to summarize categorical variables and the Wilcoxon rank sum test or Kruskal-Wallis test for continuous variables. RESULTS AND LIMITATIONS Of 935 patients who had RARC and PLND, 167 patients underwent ICUD (ileal conduit: 106; neobladder: 61), and 768 patients had an ECUD (ileal conduit: 570; neobladder: 198). Postoperative complications data were available for 817 patients, with a minimum follow-up of 90 d. There was no difference in age, gender, body mass index, American Society of Anesthesiologists grade, or rate of prior abdominal surgery between the groups. The operative time was equivalent (414 min), with the median hospital stay being marginally longer for the ICUD group (9 d vs 8 d, p=0.086). No difference in the reoperation rates at 30 d was noted between the groups. The 90-d complication rate was not significant between the two groups, but a trend favoring ICUD over ECUD was noted (41% vs 49%, p=0.05). Gastrointestinal complications were significantly lower in the ICUD group (p ≤ 0.001). Patients with ICUD were at a lower risk of experiencing a postoperative complication at 90 d (32%) (odds ratio: 0.68; 95% confidence interval, 0.50-0.94; p=0.02). Being a retrospective study was the main limitation. CONCLUSIONS Robot-assisted ICUD can be accomplished safely, with comparable outcomes to open urinary diversion. In this cohort, patients undergoing ICUD had a relatively lower risk of complications.

Direct Comparison of Surgical and Functional Outcomes of Robotic-Assisted Versus Pure Laparoscopic Radical Prostatectomy: Single-Surgeon Experience

OBJECTIVES To compare the perioperative and functional outcomes of laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic prostatectomy (RALP) in a single-surgeon series. Robotic assistance aids the laparoscopically naive surgeon in performing minimally invasive prostate surgery by offering superior visualization and dexterity. METHODS The initial 75 patients with >/=12 months of functional data who had undergone RALP by a single surgeon were selected. These were compared with 75 patients who had undergone LRP from a confidential database of the same surgeon experienced in LRP toward the end of his experience with this modality (>300 cases). RESULTS The patients in both groups were similar with respect to age, preoperative prostate-specific antigen level, biopsy Gleason score, pathologic stage, and positive margin rate. Statistically significant differences were noted in favor of RALP vs LRP with regard to operative time (199 vs 232 minutes, P < .001), intraoperative blood loss (230 vs 311 mL, P = .004), and length of stay (1.95 vs 3.4 days, P < .0001). The 12-month continence rate was 89% after LRP and 93.3% after RALP (P = .56). The potency rate was 71.1% and 76.5% at 12 months after LRP and RALP (P = .64) for a bilateral nerve-sparing procedure, respectively. CONCLUSIONS Our initial experience has revealed that RALP is an equivalent, if not a superior, minimally invasive surgical option for localized prostate cancer with less blood loss and a shorter operative time and length of stay. Although the potency and continence rates were comparable, a trend was noted toward a faster return of functional outcomes in our early RALP experience.

A Multinational, Multi-institutional Study Comparing Positive Surgical Margin Rates Among 22 393 Open, Laparoscopic, and Robot-assisted Radical Prostatectomy Patients

BACKGROUND Positive surgical margins (PSMs) are a known risk factor for biochemical recurrence in patients with prostate cancer (PCa) and are potentially affected by surgical technique and volume. OBJECTIVE To investigate whether radical prostatectomy (RP) modality and volume affect PSM rates. DESIGN, SETTING, AND PARTICIPANTS Fourteen institutions in Europe, the United States, and Australia were invited to participate in this study, all of which retrospectively provided margins data on 9778 open RP, 4918 laparoscopic RP, and 7697 robotic RP patients operated on between January 2000 and October 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES The outcome measure was PSM rate. Multivariable logistic regression analyses and propensity score methods identified odds ratios for risk of a PSM for one modality compared with another, after adjustment for age, preoperative prostate-specific antigen, postoperative Gleason score, pathologic stage, and year of surgery. Classic adjustment using standard covariates was also implemented to compare PSM rates based on center volume for each minimally invasive surgical cohort. RESULTS AND LIMITATIONS Open RP patients had higher-risk PCa at time of surgery on average and were operated on earlier in the study time period on average, compared with minimally invasive cohorts. Crude margin rates were lowest for robotic RP (13.8%), intermediate for laparoscopic RP (16.3%), and highest for open RP (22.8%); significant differences persisted, although were ameliorated, after statistical adjustments. Lower-volume centers had increased risks of PSM compared with the highest-volume center for both laparoscopic RP and robotic RP. The study is limited by its nonrandomized nature; missing data across covariates, especially year of surgery in many of the open cohort cases; lack of standardized histologic processing and central pathology review; and lack of information regarding potential confounders such as patient comorbidity, nerve-sparing status, lymph node status, tumor volume, and individual surgeon caseload. CONCLUSIONS This multinational, multi-institutional study of 22 393 patients after RP suggests that PSM rates might be lower after minimally invasive techniques than after open RP and that PSM rates are affected by center volume in laparoscopic and robotic cases. PATIENT SUMMARY In this study, we compared the effectiveness of different types of surgery for prostate cancer by looking at the rates of cancer cells left at the margins of what was removed in the operations. We compared open, keyhole, and robotic surgery from many centers across the globe and found that robotic and keyhole operations appeared to have lower margin rates than open surgeries. How many cases a center and surgeon do seems to affect this rate for both robotic and keyhole procedures.

Comparison of clinically nonpalpable prostate-specific antigen-detected (cT1c) versus palpable (cT2) prostate cancers in patients undergoing radical retropubic prostatectomy

OBJECTIVES Serum prostate-specific antigen (PSA) testing has led to increased detection of clinically localized prostate cancer. We analyzed the clinical characteristics and outcome of digitally palpable (cT2) and PSA detected (cT1c) prostate cancers. METHODS We evaluated 4453 patients with clinically localized prostate cancer who underwent radical retropubic prostatectomy (RRP) between 1987 and 1995 at the Mayo Clinic. Overall, 1041 (23.4%), 1076 (24.2%), and 2336 (52.5%) patients had cT1c, cT2a, and cT2b/c disease, respectively. Patients were analyzed with regard to Gleason score, preoperative PSA, pathologic stage, deoxyribonucleic acid (DNA) ploidy, margin status, tumor volume, and adjuvant treatment. Survival outcomes at 5 and 7 years were estimated using the Kaplan-Meier method with respect to the end points of systemic/local clinical progression and clinical and/or PSA progression (greater than 0.2 microg/mL). Multivariate analysis was employed to estimate the relative risk of progression associated with each clinical stage when adjusted for the above factors. RESULTS Clinical T1c tumors were more likely to be organ confined (76% versus 54%), have a Gleason score less than 7 (75% versus 61%), and be diploid (80% versus 70%) than cT2b/c tumors (P <0.001). Clinical T1c disease closely resembled cT2b/c disease with respect to preoperative PSA. Considering pathologic stage, DNA ploidy, and tumor volume, cT1c tumors were comparable to cT2a lesions. Of the patients with T1c cancers, 96.2% had clinically significant cancer on the basis of pathologic grade and tumor volume. The 5 (and 7 year) systemic/local clinical progression-free and PSA progression-free survivals for cT1c tumors were 97.7+/-0.7% (96.4+/-1.1%) and 82.2+/-1.7% (72.9+/-3.8%), respectively. There was a significant survival advantage at 5 and 7 years regarding both end points for cT1c and cT2a compared with cT2b/c tumors (P <0.001). Multivariate analysis revealed a continued benefit in PSA and systemic/local clinical progression for cT1c tumors compared with cT2b/c tumors adjusting for the above factors. CONCLUSIONS Clinical T1c tumors are clinically significant cancers. When compared with digitally palpable tumors, progression-free survival rates for cT1c tumors are similar to cT2a lesions, but are significantly better than cT2b/c lesions. This supports continued use of serum PSA to detect potentially curable prostate cancer.

Intravesical therapy for bladder cancer

Importance of the field: Although transurethral resection of bladder tumor (TURBT) is effective therapy, up to 45% of patients will have a recurrence within 1 year after TURBT alone. Further, there is a 3 – 15% risk of tumor progression to muscle invasive and/or metastatic cancer. Depending on patient and tumor characteristics, a number of patients may benefit from some form of intravesical therapy. Adjuvant therapy is effective in avoiding post-TURBT implantation of tumor cells, eradicating residual disease, preventing tumor recurrence, and to delay or reduce tumor progression through direct cytoablation or immunostimulation. Areas covered in this review: The role of risk assessment in the management of nonmuscle invasive bladder cancer (NMIBC) and the indications for the use of intravesical agents are discussed. Findings from major randomized clinical trials on BCG, interferon and various chemotherapeutic agents are summarized; key aspects of drug pharmacology, drug efficacy, side effects, and toxicity are also covered. What the reader will gain: The reader will gain a basic understanding of the role of risk assessment in determining the need for intravesical therapy, as well as an overview of the different types of agents in use in the United States today. Take home message: The type of intravesical therapy used is based on the risk groups as noted in the European prognostic tables. Bacillus Calmette–Guerin (BCG) is the most commonly used first-line agent immunotherapeutic agent for prophylaxis and treatment of carcinoma in situ and high-grade bladder cancer. Other immunotherapeutic options include the interferons, interleukins 2 and 12, and tumor necrosis factor, all of which have activity in BCG refractory patients, although with low durable remission rates. Studies have shown that chemotherapy prevents recurrence but not progression. The available data on intravesical chemotherapy do not indicate that any single agent currently in use is clearly better than any other. Therefore, the selection of a chemotherapeutic agent is usually based on cost, toxicity, and availability as well as on physician preference and experience.

Renal Artery Pseudoaneurysm Following Laparoscopic Partial Nephrectomy

OBJECTIVES To present our experience with the management of renal artery pseudoaneurysms following laparoscopic partial nephrectomy (LPN). METHODS Our bi-institutional LPN database of 259 patients from July 2001 to April 2008 was queried for patients diagnosed with a postoperative renal artery pseudoaneurysm. Demographic data, perioperative course, complications, and follow-up studies in identified subjects were analyzed. Postembolization success was defined as symptomatic relief, resolution of hematuria, and a stable hematocrit and serum creatinine. RESULTS We identified 6 patients (2.3%) who were diagnosed with a renal artery pseudoaneurysm after LPN. The mean age of our cohort was 61.2 years (49-76), mean operative time was 208 minutes (140-265), and mean estimated blood loss was 408 mL (50-800). Patients presented at a mean of 12.6 days (5-23) after the initial surgery. Five patients had gross hematuria and a decreased hematocrit, with 1 patient presenting with clinical symptoms of hypovolemia. The sixth patient was incidentally diagnosed. The diagnosis of a renal artery pseudoaneurysm was confirmed in all cases by angiography. Selective angioembolization was successfully performed in all patients. At a median follow-up of 8.3 months all patients (100%) remained without any evidence of recurrence. CONCLUSIONS Although pseudoaneuryms are a rare postoperative complication of LPN, they are potentially life-threatening. Early identification and proper management can help reduce the potential morbidity associated with pseudoaneurysms. Our experience demonstrates the feasibility and supports the use of selective angioembolization as an excellent first-line option for patients who present with this form of delayed bleeding.