Salvatore Guaglianone

Laparoscopic versus Open Nephroureterectomy: Perioperative and Oncologic Outcomes from a Randomised Prospective Study

BACKGROUND Laparoscopic nephroureterectomy (LNU) is increasingly being used instead of open nephroureterectomy (ONU) for the treatment of urothelial carcinoma (UC) of the upper urinary tract (UUT), but the evidence of equal oncologic effectiveness is still lacking. OBJECTIVE To present perioperative and oncologic results from a prospective randomised study comparing ONU and LNU. DESIGN, SETTING, AND PARTICIPANTS Eighty patients with nonmetastatic UUT UC and without previous history of UC were enrolled. Of those, 40 patients (group A) randomly received ONU and 40 patients (group B) randomly received LNU. INTERVENTIONS ONU was performed through a flank incision with a lower quadrant incision to allow excision of a bladder cuff. Transperitoneal LNU was performed with a four-trocar technique, and bladder cuff was detached with a 10-mm LigaSure device. MEASUREMENTS Perioperative data were compared with the student t test. Bladder tumour-free survival (BTFS), metastasis-free survival (MFS), and cancer-specific survival (CSS) curves for both groups were compared with the log-rank test before and after stratifying patients for pT category and tumour grade. RESULTS AND LIMITATIONS Operative times were comparable, while mean blood loss and mean time to discharge were significantly lower in group B (both p values <0.001). At a median follow-up of 44 mo, BTFS, CSS, and MFS were not significantly different between the two groups (log rank test; BTFS: p=0.86; CSS: p=0.2; MFS: p=0.124). When matched for pT3 and high-grade tumours, CSS and MFS were significantly different between the two groups in favour of ONU (p=0.039 and p=0.004, respectively, for pT3 tumours; p=0.078 and p=0.014, respectively, for high-grade tumours). The limitations of our study include the small sample size, the single-centre experience, the personal choice of laparoscopic technique, and not performing lymphadenectomies. Perioperative data and preliminary oncologic results were presented at 22nd Congress of the European Association of Urology, Berlin, Germany. CONCLUSIONS In patients with organ-confined UUT UCs, LNU has the advantages of minimal invasiveness and oncologic outcomes comparable to those of ONU, while its effectiveness in patients with advanced stage diseases remains to be proven.

Zero Ischemia Laparoscopic Partial Nephrectomy After Superselective Transarterial Tumor Embolization for Tumors with Moderate Nephrometry Score: Long-Term Results of a Single-Center Experience

PURPOSE To describe a 7-year experience with zero-ischemia laparoscopic partial nephrectomy (LPN) after superselective transarterial tumor embolization (STE) and to report oncologic and functional results of the first 210 consecutive patients. PATIENTS AND METHODS Between August 2003 and January 2010, 210 consecutive patients with nephrometry scores ≥ 6 underwent STE and LPN. Angiographic and surgical procedures were performed consequently. The follow-up schedule included serum creatinine levels at 3-month intervals and technetium 99m Tc diethylenetetramine pentacetic acid renal scintigraphy 3 months and 1 year postoperatively, CT scan and chest radiography together with abdominal ultrasonography alternatively performed at 6-month intervals in cases of renal-cell carcinoma (RCC), and abdominal ultrasonography 6 months postoperatively and yearly thereafter in cases of benign tumors. RESULTS Median tumor size was 4.2 cm(range 2.5-6.5 cm). Median operative time was 62 minutes (35-220 min), median blood loss was 150 mL (20-800 mL), and median hospital stay was 3 days (2-12 d). In one patient, radical nephrectomy (RN) was necessary because of an unexpected total intraparenchymal growth of the tumor. Postoperative complications included urinary fistulas successfully managed with a Double-J stent placement (n=4); hematoma (n=6, 1 managed with percutaneous drainage), delayed hematuria successfully managed with pseudoaneurysm embolization (n=2). At a median follow-up of 46 months, one patient underwent RN for locally recurrent RCC and one patient died of cancer. At 3-month and 1-year follow-up, the median increase of serum creatinine levels was 0.3 mg/dL and 0.24 mg/dL, respectively, and the median decrease of split renal function was 9% and 5%, respectively. CONCLUSIONS STE allowed us to perform a zero-ischemia LPN for tumors with moderate nephrometry score and provided excellent functional results with low complications rate and adequate oncologic results. STE significantly simplifies LPN and combines the advantages of excellent bleeding control without any ischemia and thus without time thresholds within which to perform tumor excision.

Stage-specific impact of extended versus standard pelvic lymph node dissection in radical cystectomy

To evaluate the impact of an extended versus a standard pelvic lymph node dissection on disease‐free survival and cancer‐specific survival of patients with non‐metastatic muscle‐invasive urothelial carcinoma of the bladder treated with radical cystectomy.

Preoperative superselective transarterial embolization in laparoscopic partial nephrectomy: technique, oncologic, and functional outcomes.

INTRODUCTION We report the mid-term oncologic and functional results of a series of 110 patients treated with transperitoneal laparoscopic partial nephrectomy (LPN) after superselective arterial embolization (SEA). MATERIALS AND METHODS Between August 2003 and August 2007, 110 patients underwent LPN after SEA for T1 renal tumors. All data were collected in a prospectively maintained database. Mean age of patients was 61 (range 37-80), and mean tumor size was 4.4 cm (range 2.5-6.5). Angiographic procedure was performed by a single experienced radiologist, and surgical procedure was performed by a single experienced surgeon. Perioperative data were collected and analyzed. Renal function was evaluated by preoperative and 3- and 12-month postoperative (99m)Tc diethylenetetramine pentacetic acid renal scans. RESULTS Mean operative time was 58 minutes (range 35-220), and mean blood loss was 106 mL (range 20-800). No conversion to open surgery occurred; in one patient radical nephrectomy was necessary because of the total intraparenchymal growth of the tumor. Mean hospital stay was 3.2 days (range 2-12). Pathologic analyses found 33 benign tumors in 31 patients and renal cell carcinoma in 79 cases (26 pT1a, 45 pT1b, 6 pT2, and 2 pT3a). At a median follow-up of 41 months, computed tomography scan revealed two local recurrences, one of which not confirmed by pathologic evaluation after radical nephrectomy. One patient died of disease 1 year after surgery. When matching preoperative and 1-year postoperative renal scan, median decrease of glomerular filtration rate was 5% (range 0%-9%). CONCLUSIONS Preoperative SEA allows us to perform LPN without clamping hilum vessels and so without time threshold related to ischemic damage. Oncological outcome is comparable to that of open surgery, and functional results are encouraging, thanks to the optimal preservation of renal function.

‘Zero ischaemia’, sutureless laparoscopic partial nephrectomy for renal tumours with a low nephrometry score

Study Type – Therapy (case series)

Diffusion-weighted magnetic resonance imaging in patients selected for radical cystectomy: detection rate of pelvic lymph node metastases.

Study Type – Diagnostic (exploratory cohort)

Laparoscopic and Robotic Partial Nephrectomy With Controlled Hypotensive Anesthesia to Avoid Hilar Clamping: Feasibility, Safety and Perioperative Functional Outcomes

PURPOSE We evaluated the feasibility and safety of laparoscopic and robotic assisted partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping and eliminate renal ischemia. MATERIALS AND METHODS A total of 60 patients with renal tumors who were candidates for nephron sparing surgery and had no contraindication to hypotensive anesthesia underwent partial nephrectomy without hilar clamping and with controlled hypotension during tumor excision. A total of 40 laparoscopic partial nephrectomies and 20 robotic assisted partial nephrectomies were done. All patients who were candidates for laparoscopic or robotic assisted partial nephrectomy regardless of tumor site, size or growth pattern were included in study. The surgical field was assessed for bleeding and visibility using a numerical rating scale. RESULTS Median tumor size was 3.6 cm (range 1.8 to 10), median operative time was 2 hours (range 1 to 3.5), median blood loss was 200 ml (range 30 to 700 ml) and median hospital stay was 3 days (range 3 to 8). All margins were negative. The median duration of controlled hypotension with a median mean arterial pressure of 65 mm Hg (range 55 to 70) was 14 minutes (range 7 to 16). No patient required intraoperative transfusion but 4 (6.6%) required transfusion postoperatively. Complications developed postoperatively in 3 patients, ie port site bleeding, hemorrhage and hematoma, respectively. Median preoperative and postoperative serum creatinine was 0.9 and 1.10 mg/dl, respectively. The median preoperative and postoperative estimated glomerular filtration rate was 87.20 and 75.60 ml/minute/1.73 m2, respectively. CONCLUSIONS Controlled hypotension allowed laparoscopic and robotic assisted partial nephrectomy to be done without renal hilar clamping. All procedures were completed safely and perioperative outcomes are encouraging.

PCA3 in prostate cancer and tumor aggressiveness detection on 407 high-risk patients: a National Cancer Institute experience

BackgroundProstate cancer (PCa) is the most common male cancer in Europe and the US. The early diagnosis relies on prostate specific antigen (PSA) serum test, even if it showed clear limits. Among the new tests currently under study, one of the most promising is the prostate cancer gene 3 (PCA3), a non-coding mRNA whose level increases up to 100 times in PCa tissues when compared to normal tissues. With the present study we contribute to the validation of the clinical utility of the PCA3 test and to the evaluation of its prognostic potential.Methods407 Italian men, with two or more PCa risk factors and at least a previous negative biopsy, entering the Urology Unit of Regina Elena National Cancer Institute, were tested for PCA3, total PSA (tPSA) and free PSA (fPSA and f/tPSA) tests. Out of the 407 men enrolled, 195 were positive for PCa and 114 of them received an accurate staging with evaluation of the Gleason score (Gs). Then, the PCA3 score was correlated to biopsy outcome, and the diagnostic and prognostic utility were evaluated.ResultsOut of the 407 biopsies performed after the PCA3 test, 195 (48%) resulted positive for PCa; the PCA3 score was significantly higher in this population (p < 0.0001) differently to tPSA (p = 0.87). Moreover, the PCA3 test outperformed the f/tPSA (p = 0.01). The sensitivity (94.9) and specificity (60.1) of the PCA3 test showed a better balance for a threshold of 35 when compared to 20, even if the best result was achieved considering a cutoff of 51, with sensitivity and specificity of 82.1% and 79.3%, respectively. Finally, comparing values of the PCA3 test between two subgroups with increasing Gs (Gs ≤ 6 versus Gs ≥ 7) a significant association between PCA3 score and Gs was found (p = 0.02).ConclusionsThe PCA3 test showed the best diagnostic performance when compared to tPSA and f/tPSA, facilitating the selection of high-risk patients that may benefit from the execution of a saturation prostatic biopsy. Moreover, the PCA3 test showed a prognostic value, as higher PCA3 score values are associated to a greater tumor aggressiveness.

Salvage radical prostatectomy for recurrent prostate cancer after radiation therapy

Salvage radical prostatectomy is considered for patients with locally recurrent prostate cancer after external beam radiotherapy. Between 2001 and 2004, 32 men treated with curative intent with radiotherapy for prostate cancer were subsequently treated with salvage surgery for clinically localized prostate cancer. We assessed the morbidity associated with this procedure and the outcome of the patients. Thirty‐two patients underwent salvage radical prostatectomy. Initial pre‐radiation median prostate‐specific antigen was 13 ng/ml. Pre‐radiation disease was clinical stage T1b in five cases, T2a in 10, T2b in 10 and T3a in seven. Mean operative time was 122 minutes, intraoperative blood loss was 550 ml and hospital stay and catheterization time were 5 and 12 days, respectively. There was biochemical failure in eight patients after salvage radical prostatectomy and 24 patients are biochemical non evidence of disease (bNED). In recurrent prostate local disease with prostate‐specific antigen <10 ng/ml and life expectancy greater than 10 years, salvage radical prostatectomy is a reasonable treatment option.

Prostatic Capsule and Seminal Vesicle-Sparing Cystectomy: Improved Functional Results, Inferior Oncologic Outcome

OBJECTIVES To retrospectively evaluate the functional and oncologic results of 20 prostatic capsule and seminal vesicle-sparing cystectomies. METHODS From June 2002 to January 2006, we performed 360 radical cystectomies, for 20 of which we used a prostatic capsule and seminal vesicle-sparing technique. Patients with Stage T1G3 bladder cancer resistant to intravesical immunotherapy or monofocal T2G3 tumors at transurethral resection of the bladder (TURB) and with preoperative normal sexual function met our inclusion criteria and underwent this procedure. Patients with involvement of the prostatic urethra or multiple tumors were excluded. Prostate-specific antigen measurement, digital rectal examination, and transrectal ultrasonography were performed preoperatively in order to avoid incidental prostate cancer findings. No patient had a preoperative prostate-specific antigen level greater than 4 ng/mL; therefore, no patient underwent preoperative prostate biopsy. The mean patient age was 57.1 years (range 39 to 66). RESULTS Sexual function recovery and daytime and nighttime continence were reached for all patients. The local recurrence rate in our series was 20% at 2 years of follow-up. Moreover, the distant failure rate was 30%. The 1-year cancer-specific mortality rate was 10% and the 2-year rate was 20%. All disease progressions occurred in patients with Stage T2G3 tumor at TURB. CONCLUSIONS At last follow-up, patients with Stage T1G3 tumor at TURB had not experienced disease progression. Longer follow-up and a larger cohort of patients are necessary to confirm the safety of this procedure in these patients. In our series, the local recurrence and distant metastasis rates were too high compared with those of the patients who underwent radical cystectomy without the sparing technique. Eight of ten patients with muscle invasive bladder cancer at TURB, 8 had disease progression after seminal vesicle-sparing cystectomy.