Samay Jain

Comparison of 2004 and 1973 World Health Organization Grading Systems and Their Relationship to Pathologic Staging for Predicting Long-term Prognosis in Patients With Urothelial Carcinoma

OBJECTIVES To compare the 1973 and 2004 World Health Organization (WHO) systems for the interval to tumor recurrence (TR), tumor progression (TP), and overall survival (OS) using either the superficial/muscle invasive or strict TMN pathologic staging in patients with urothelial carcinoma with ≥10 years of follow-up. METHODS A total of 269 tumors from an institutional review board-approved bladder tumor registry were graded using the 1973 and 2004 WHO systems. Kaplan-Meier plots, the log-rank test, the chi-square test, and the Cox proportional hazard model were used to relate the clinical and histologic variables. RESULTS The Cox model analyses, which were multivariate and included tumor stage (coded as pT1 or less versus pT2 or greater) as a significant covariate to grade, were performed and in all tumor stages were significant. The 2004 WHO grading system was more closely associated with TR (P = .025) and TP (P = .012) than was the 1973 WHO grading system (P = .47, and P = .046, respectively). OS was similar and significant for both. The OS plots for the 1973 WHO system showed a significant overlap between Stage pT1 or less, grade 2 and 3 tumors. For those with high-grade Stage pTa and high-grade Stage pT1 disease, TR and TP were similar; however, OS was significantly longer (P = .05, log-rank test) for those with Stage pTa. The OS was similar for those with high-grade Stage pT1 disease and those with Stage pT2 or greater (P = .069, log-rank test). For those with pTa, the 2004 system predicted TR and TP, but the 1973 system only predicted TP. Neither predicted OS. CONCLUSIONS The results of our analysis have shown that the 2004 WHO system is superior to the 1973 system for predicting clinical outcomes in patients with urothelial carcinoma, independent of pathologic stage. Its primary usefulness is in those with Stage pTa.

Splenic Injury During Percutaneous Nephrolithotomy: A Case Report with Novel Management Technique

We describe a case of a splenic injury caused by a transsplenic percutaneous nephrostomy tract. The case was completed without incident and the nephrostomy tube was noted to traverse the spleen on routine postoperative imaging. This rare complication was managed by deposition of Gelfoam((R)) pledgets along the transsplenic nephrostomy tract and placement of a ureteral stent. This novel management technique has not been previously described in the literature and was successful in the conservative treatment of the uncommon complication of splenic injury during percutaneous nephrolithotomy.

Partial nephrectomy in two patients with known T3a tumours involving the renal vein

Study Type – Therapy (case series)

Robot-Assisted Laparoscopic Partial Nephrectomy for Recurrent Renal-Cell Carcinoma in Patients Previously Treated with Nephron-Sparing Surgery

BACKGROUND AND PURPOSE With the advent of robotics, it may be more feasible to offer minimally invasive nerve-sparing surgery (NSS), in the form of partial nephrectomy (PN), for patients with metachronous recurrence in the ipsilateral kidney after previous NSS. We studied the outcomes of patients undergoing robot-assisted laparoscopic partial nephrectomy (RAPN) after previous ipsilateral open or laparoscopic NSS for renal-cell carcinoma. METHODS In this Institutional Review Board approved study, a prospectively maintained PN database was reviewed. Of 230 RAPNs performed between 2003 and 2011, five patients underwent RAPN after previous ipsilateral NSS. RESULTS The mean age was 64.2 years, and time between the first and second surgery was 27 months (range 9-60 mos). All patients were men and previously had open (n=4) or laparoscopic (n=1) NSS for clear-cell (n=2), papillary (n=2), and other (n=1) pathology. Average follow-up was 15.6 months (range 8-21 mos). There were no conversions to open surgery or radical nephrectomy. Total and selective arterial clamping were performed in two and two cases, respectively. One RAPN was performed off-clamp. Mean warm ischemia time was 14 minutes (range 0-32 min), and mean blood loss was 220 mL (range 50-400 mL). Average length of stay was 1.4 days (range 1-2 days) with no perioperative complications. The glomerular filtration rate decreased by a mean of 10%. There were no recurrences detected on cross-sectional imaging at the most recent follow-up. CONCLUSION RAPN after previous open or laparoscopic PN is safe and efficacious. It offers satisfactory intermediate functional and oncologic outcomes with minimal morbidity.

Primary Small Cell Carcinoma Arising from a Bladder Diverticulum

A 66-year-old Caucasian male with a 48 pack-year smoking history presented with gross hematuria and worsening pelvic pain. Laboratory results revealed low grade disseminated intravascular coagulation. Imaging was significant for a bladder diverticulum and lytic lesions of the femurs, pelvis and vertebra. Cystoscopy of the diverticulum revealed a mass larger than 5 cm and transurethral resection was performed. Histopathology of the bladder lesion showed sheets and nests of small neuroendocrine cells with dense intervening fibrous stroma (figs. 1 and 2). Necrosis was present and tumor cells stained positive for synaptophysin. No evidence of urothelial carcinoma (UC) was seen and the final diagnosis was small cell carcinoma of the bladder. Bladder diverticula are formed by herniation of the urothelial mucosa through the detrusor muscle. Bladder diverticula can result in urinary stasis which can lead to infection and resultant inflammation. In recent case series diverticula

V5-09 ROBOT ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR A T2B LESION: TECHNIQUE AND OUTCOMES

introduced a novel non-tissue suturing laparoscopic partial nephrectomy (NTS-LPN) and compared clinical outcomes with conventional laparoscopic partial nephrectomy (C-LPN) in our institution. METHODS: A hundred-eighty five patients who underwent partial nephrectomy since 2004 were divided between NTS-LPN group (NTS) (n1⁄498) and C-LPN group (C) (n1⁄487). The surgical maneuver of NTS differs with C after excising tumor with renal artery clamping. The resected surface was simply coagulated using a soft-coagulation system (a VIO system and an IO electrode) without parenchyma suturing. After declamping, a TachoSil is attached on coagulated surface. Perioperative data including the parenchymal volume of postoperative renal ischemic volume (PRIV) and the change of residual renal volume (RRV) calculated by 3D-CT volumetry, postoperative kidney function and adverse events were compared between 2 groups. RESULTS: Mean operative time and renal ischemic time in NTS (146 34.0min/15.6 7.45min) were dramatically shortened as compared to those in C (236 77.8min/54.8 27.4min). Mean operative blood loss was similar between NTS (43.3 61.5ml) and C (65.9 91.9ml). Renal parenchymal damage as shown PRIV was significantly less in NTS group than that in C at the point of postoperative 3, 6, 12 months (NTS: 4.26 2.29ml, 2.37 1.02ml, 1.67 0.55ml / C: 19.4 5.49ml, 15.9 8.20ml, 13.1 6.00ml). Renal atrophy as shown RRV postoperative 3, 6, 12 months was also significantly less in NTS than that in C (p<0.01). No positive surgical margin was observed in NTS, but only one case in C. Serum creatinine values of each point (1/3/6/12 months) were comparable in both groups. According to Clavien-Dindo classification, major complications of IIIa (postoperative bleeding, minor urinary leakage and peri-renal abscess) were observed in C, whereas 2 cases of minor urinary leakage in NTS. In addition, 6 cases of pseudo aneurysm were only observed in C. CONCLUSIONS: A novel technique of NTS-LPS could spare operative and ischemic time and nephron loss as well without increasing invasiveness compared with conventional tissue-suturing partial nephrectomy.

Cystic nephroma of the kidney.

A 65-year-old female presented to the emergency room with shortness of breath. Chest computerized tomography revealed a pulmonary embolus as well as, a large, complex cystic lesion of the left kidney. Followup imaging confirmed a 16 cm Bosniak III cystic lesion. After reviewing management options, the patient elected laparoscopic radical nephrectomy. Gross examination revealed a 13 cm complex, multiloculated cystic lesion. Microscopic examination showed a well circumscribed lesion composed of cysts of variable size. The cysts were separated by septae with variegated appearance containing fibrous areas, calcified material, ovarian like stroma and histiocytes (fig. 1). Immunostain for estrogen receptor (ER) was diffusely and strongly positive in the areas of ovarian like stroma (fig. 2). No solid areas or clusters of clear cells in the septae were seen. The final diagnosis was cystic nephroma (CN). The World Health Organization defines cystic nephroma as a benign cystic neoplasm of the kidney with cysts lined by a single layer of flattened, low cuboidal or hobnail epithelium and separated by fibrous septa with scant cellularity or cells

Delayed Hem-o-Lok Clip Erosion Following Salvage Radical Prostatectomy

Introduction: Weck Hem-o-Lok (Teleflex Medical, Research Triangle Park, North Carolina) clips are frequently used to achieve hemostasis of the lateral prostatic pedicles during radical prostatectomy. Rarely, these clips can detach and migrate into the bladder wall, leading to postoperative urinary tract complications. Hem-o-Lok clip migration into the bladder is a rare complication of laparoscopic radical prostatectomy that has been reported within 1 year postsurgery. Case Report: We report the case of a 61-year-old white man who presented with urinary stress incontinence, acute urinary retention, and a history of recurrent urinary tract infections more than 2 years after salvage robot-assisted laparoscopic radical prostatectomy for recurrent prostate cancer that was unsuccessfully treated with brachytherapy. As part of his diagnostic workup, cystoscopy demonstrated an open bladder neck with no evidence of contracture and the presence of a calcification near the vesicourethral anastomosis. Unroofing these calcifications via laser lithotripsy revealed two eroded Hem-o-Lok clips, which were subsequently removed from the bladder wall. Conclusion: Salvage prostatectomy after radiotherapy as the primary treatment for prostate cancer may increase the window of time in which intravesical clip migration can occur because of delayed wound healing at the vesicourethral anastomosis. Furthermore, clip migration can present with signs of urinary tract dysfunction in the absence of bladder neck contracture and beyond the time frame initially expected.