Scott Johnson

Laparoscopic Cryoablation for Clinical Stage T1 Renal Masses: Long-term Oncologic Outcomes at the Medical College of Wisconsin

OBJECTIVE To report the long-term oncologic outcomes of laparoscopic cryoablation for clinical stage T1 renal masses at the Medical College of Wisconsin. MATERIALS AND METHODS A retrospective chart review was performed evaluating patients who underwent laparoscopic cryoablation for renal masses at the Medical College of Wisconsin between February 2000 and October 2009. RESULTS A total of 171 renal masses in 144 patients were treated by laparoscopic cryoablation during the study period. After excluding patients with <5 years follow-up and those with >clinical stage I disease, 112 renal masses treated in 92 patients remained for analysis. Mean patient age was 59.6 years (standard deviation [SD], 12.5 years). Mean lesion size was 2.3 cm (SD, 0.94 cm). Mean age adjusted Charlson comorbidity index was 4.55 (SD, 1.69). Mean follow-up was 97.9 months (SD, 24.8 months). Overall survival among all patients was 80.9%. Lesions were biopsy proven to be malignant in 70 patients (76.3%). Of those with biopsy-proven malignancy, there were 6 recurrences, 14 non-cancer-related deaths, and 1 cancer-related death, leading to an overall survival of 77.6%, progression-free survival of 91.0%, and cancer-specific survival of 98.5%. CONCLUSION We report the largest published series of laparoscopic renal cryoablation with the longest follow-up. Our series indicates that laparoscopic cryoablation is both an efficacious treatment for clinical stage T1 renal masses and provides excellent long-term oncologic outcomes.

Non-muscle-invasive bladder cancer: Intravesical treatments beyond Bacille Calmette-Guérin.

An unmet need exists for patients with high‐risk non–muscle‐invasive bladder cancer for whom bacille Calmette‐Guérin (BCG) has failed and who seek further bladder‐sparing approaches. This shortcoming poses difficult management dilemmas. This review explores previously investigated first‐line intravesical therapies and discusses emerging second‐line treatments for the heterogeneous group of patients for whom BCG has failed. The myriad of recently published and ongoing trials assessing novel salvage intravesical treatments offer promise to patients who both seek an effective cure and want to avoid radical surgery. However, these trials must carefully be contextualized by specific patient, tumor, and recurrence characteristics. As data continue to accumulate, there will potentially be a role for these agents as second‐line or even first‐line intravesical therapies. Cancer 2017;123:390–400.

The Effect of Obesity on Perioperative Outcomes for Open and Minimally Invasive Prostatectomy

OBJECTIVE To compare the impact of obesity on perioperative outcomes between open radical prostatectomy (ORP) and minimally invasive prostatectomy (MIP). METHODS Using the National Surgical Quality Improvement Program public use files for 2008-2013, we identified patients undergoing prostatectomy using Current Procedural Terminology codes. Those without body mass index (BMI) or comorbidity information were excluded. BMI was treated as a categorical variable according to the World Health Organization classification. Demographic and comorbid conditions were compared between BMI groups, and multivariable logistical regression was used to identify independent predictors of adverse perioperative events. RESULTS We identified 17,693 MIP and 4674 ORP for analysis. Of the entire cohort, only 18.7% had a BMI within the normal range (18.5-24.9), whereas the remaining 81.3% were at least overweight (BMI > 25). Class I, II, and III obesity accounted for 25.0%, 7.0%, and 2.3% of the cohort, respectively. Overall, complications were higher with ORP (19.0%) than with MIP (5.3%), which held true across all BMI categories. The rate of wound, renal, thromboembolic, infectious, neurologic, Clavien grade III-V, and overall complications among MIP were directly related to BMI. Only wound and renal complications were related to BMI in ORP. In multivariable analysis, obesity was found to be an independent predictor of wound, renal, and thromboembolic complications. CONCLUSION Obesity has a larger impact on morbidity for MIP compared to ORP. Overall morbidity, however, remains lower for MIP across all BMI groups.

Temporal trends in perioperative morbidity for radical cystectomy using the National Surgical Quality Improvement Program database

INTRODUCTION Radical cystectomy (RC) is the standard of care for invasive nonmetastatic bladder cancer. Unfortunately, it is a complex procedure and more than half of patients experience a complication. A number of efforts to reduce perioperative morbidity have been made, including alterations in pain management, antibiotics, diet advancement, and anticoagulation. Many of these changes in management have been studied with favorable results; however, it is not clear whether complication rates following RC have improved in recent years. With this in mind we sought to evaluate current temporal trends in postoperative complication rates following RC using a large national dataset. MATERIALS AND METHODS Using the National Surgical Quality Improvement Program participant use files from 2010 to 2015, we identified patients undergoing RC using current procedural terminology codes. Demographic information as well as 30-day complications, length of stay (LOS), readmission and death were compared according to year of operation using univariable and multivariable analysis. RESULTS Over the 6 year period analyzed, 6,510 patients were identified for analysis. Age and comorbidity were similar across the study period. A robotic approach was used in 5.8% of the entire cohort which did not differ among years. A total of 15.9% of patients underwent a continent urinary diversion, with a trend toward decreased use in recent years, 31.5% of patients experienced a complication and this did not differ significantly among years, and 40.7% of patients required a blood transfusion overall with a trend toward decreased use. LOS decreased over time from 10.6 days in 2010 to 9.2 days in 2015 (P<0.01) whereas readmissions increased slightly over the time period to 21.4% in 2015 (P<0.01). CONCLUSIONS RC remains a procedure associated with high morbidity. In the recent era of enhanced recovery protocols, complication rates have not changed significantly, however, there has been a consistent decline in LOS and use of blood transfusion.

Safety and early effectiveness of robot-assisted partial nephrectomy for large angiomyolipomas.

To evaluate a multicentre series of robot‐assisted partial nephrectomy (RAPN) performed for the treatment of large angiomyolipomas (AMLs).

Lessons from 151 ureteral reimplantations for postcystectomy ureteroenteric strictures: A single-center experience over a decade☆

OBJECTIVES Ureteroenteric anastomotic strictures are common after cystectomy with urinary diversion. Endoscopic treatments have poor long-term success, although ureteral reimplantation is associated with morbidity. Predictors of successful open repair are poorly defined. Our objective was to characterize outcomes of ureteral reimplantation after cystectomy and identify risk factors for stricture recurrence. PATIENTS AND METHODS We performed a retrospective review of 124 consecutive patients with a total of 151 open ureteral reimplantations for postcystectomy ureteroenteric strictures between January 2006 and December 2015. Baseline clinicopathologic characteristics and perioperative outcomes were examined. Predictors for stricture recurrence were assessed by univariable testing and univariate Cox proportional hazards regression. RESULTS Most patients underwent preoperative drainage by percutaneous nephrostomy (PCN; 43%) or percutaneous nephroureterostomy (PCNU; 44%). Major iatrogenic injuries included enterotomies requiring bowel anastomosis (3.2%) and major vascular injuries (2.4%). Overall, 60 (48%) patients suffered 90-day complications, of which 15 (12%) patients had high-grade complications. Median length of stay was 6 days [interquartile range: 5, 8] and median follow-up was 21 months [interquartile range: 5, 43]. The overall success rate per ureter was 93.4%. On univariate analysis, the only significant predictor of stricture recurrence was preoperative PCNU placement compared with PCN placement or no drainage (success rates: 85.5% vs. 98.9%, respectively, P = 0.002). Cox proportional hazards regression demonstrated that preoperative PCNU placement yielded a hazard ratio of 10.2 (95% CI: 1.27-82.6) for stricture recurrence (P<0.005). Stricture recurrence was independent of previous endoscopic interventions (P = 0.42). Stricture length was unable to be assessed. CONCLUSIONS Postcystectomy ureteral reimplantation was associated with relatively low rates of major iatrogenic injuries and high-grade complications. Preoperative PCN placement rather than PCNU may yield better results.

National Surgical Quality Improvement Program surgical risk calculator poorly predicts complications in patients undergoing radical cystectomy with urinary diversion

PURPOSE To evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Programs (ACS-NSQIP) surgical risk calculator in patients undergoing radical cystectomy (RC) with urinary diversion. MATERIALS AND METHODS Preoperative characteristics of patients who underwent RC with ileal conduit or orthotropic neobladder (ONB) between 2007 and 2016 were entered into the proprietary online ACS-NSQIP calculator to generate 30-day predicted risk profiles. Predicted and observed outcomes were compared by measuring Brier score (BS) and area under the receiver operating characteristic curve (AUC). RESULTS Of 954 patients undergoing RC, 609 (64%) received ileal conduit and 345 (36%) received ONB. The calculator underestimated most risks by 10%-81%. The BSs exceeded the acceptable threshold of 0.01 and AUC were less than 0.8 for all outcomes in the overall cohort. The mean (standard deviation) predicted vs. observed length of stay was 9 (1.5) vs. 10.6 (7.4) days (Pearsons r = 0.09). Among patients who received ONB, adequate BS (<0.01) was observed for pneumonia, cardiac complications, and death. The receiver operating characteristic curve analysis revealed moderate accuracy of calculator for cardiac complications (AUC = 0.69) and discharge to rehab center (AUC = 0.75) among patients who underwent RC with ONB. CONCLUSIONS The universal ACS-NSQIP calculator poorly predicts most postoperative complications among patients undergoing RC with urinary diversion. A procedure-specific risk calculator is required to better counsel patients in the preoperative setting and generate realistic quality measures.

Fistulous Complications following Radical Cystectomy for Bladder Cancer: Analysis of a Large Modern Cohort

Purpose Fistula formation is a rare and poorly described complication following radical cystectomy with urinary diversion. We sought to identify patients who experienced any type of fistulous complication and we analyzed risk factors for formation as well as management outcomes. Materials and Methods We retrospectively reviewed the records of patients who underwent radical cystectomy for bladder cancer at our institution. Patients who experienced any fistula were identified. Risk factors, management strategies and outcomes were analyzed. Patients underwent initial conservative treatment and those in whom this treatment failed underwent surgical repair. Univariable and multivariable analyses were performed to identify predictors of fistula formation as well as the need for surgical repair. Results Of the 1,041 patients 31 (3.0%) experienced fistula formation. Median time to fistula presentation was 31 days. Enterodiversion was the most common fistula type, noted in 54.8% of patients, followed by enterocutaneous and diversion cutaneous treatment in 29.0% and 12.9%, respectively. On multivariable analyses a history of radiation therapy (OR 3.1, p = 0.03) and an orthotopic neobladder (OR 3.1, p = 0.04) were predictors of fistula formation. Conservative management was successful in 41.9% of cases. There were no predictors of failed conservative management. Of patients who required surgical repair success was achieved in 94.4% at a single operation. Conclusions Fistulas are rare after radical cystectomy and they are most common between the urinary diversion and the small bowel. A history of radiation therapy and a orthotopic neobladder are risk factors for formation. When required, surgical repair is generally successful at a single operation.

Primary angiosarcoma of the testis with retroperitoneal metastasis

While uncommon, angiosarcomas predominately occur in superficial soft tissue and rarely present in the viscera. While also rare in the general population, testicular germ cell tumors (GCT) are the most common malignancy diagnosed in males 15–44 years old. Primary angiosarcoma of the testis is extremely rare with the first published report by Hughes et al., in 1991 subsequently followed by sporadic case reports of primary or dedifferentiated testicular angiosarcoma. Interestingly, Idress and colleagues published evidence suggesting that metastatic angiosarcoma may arise secondary to clonal progression following systemic treatment of mixed type GCT. As it remains exceedingly rare, there is a paucity of data on the proper management of testicular angiosarcoma.

Clinical and Radiographic Predictors of Great Vessel Resection or Reconstruction During Retroperitoneal Lymph Node Dissection for Testicular Cancer

OBJECTIVE To evaluate whether specific clinical or radiographic factors predict inferior vena cava (IVC) or abdominal aortic (AA) resection or reconstruction (RoR) at the time of postchemotherapy retroperitoneal lymph node dissection (RPLND) for germ cell tumors of the testicle. MATERIALS AND METHODS Two hundred seventy-seven patients undergoing postchemotherapy RPLND at two institutions between 2005 and 2015 were identified. Preoperative imaging was reviewed with radiologists blinded to operative details. Univariable and multivariable logistic regressions were performed, and a model was created to predict the need for great vessel RoR using radiographic and clinical factors. RESULTS Of 97 patients with preoperative imaging and clinical data available, 16 (17%) underwent RoR at RPLND. On univariable analysis dominant mass size, degree of circumferential vessel involvement, and vessel deformity were associated with RoR (all P <.05). No patients with clinical stage IIA or IIB disease at diagnosis required RoR. In the multivariable model, mass involvement of the IVC >135° (odds ratio 65.5, 7.8-548, P <.01) and involvement of the AA >330° (odds ratio 29.0, 3.44-245, P <.01) were predictive for RoR. These thresholds yielded a PPV of 48% and 50% and a NPV of 92% and 97% for IVC and AA RoR, respectively. CONCLUSION Degree of circumferential involvement of the great vessels is an independent predictor for resection or reconstruction of the IVC or AA at postchemotherapy RPLND. Patients at high risk of great vessel reconstruction should be informed accordingly and have the proper teams available for complex vascular reconstruction.