Sittiporn Srinualnad

Outcomes of surgical treatment for upper urinary tract transitional cell carcinoma: Comparison of retroperitoneoscopic and open nephroureterectomy

ObjectivesTo determine the surgical and oncologic outcomes in patients who underwent retroperitoneoscopic nephroureterectomy (RNU) in comparison to standard open nephroureterectomy (ONU) for upper urinary tract transitional cell carcinoma (TCC).Patients and methodsFrom April 2001 to January 2007, 60 total nephroureterectomy were performed for upper tract TCC at Siriraj Hospital. Of the 60 patients, thirty-one were treated with RNU and open bladder cuff excision, and twenty-nine with ONU. Our data were reviewed and analyzed retrospectively. The recorded data included sex, age, history of bladder cancer, type of surgery, tumor characteristics, postoperative course, disease recurrence and progression.ResultsThe mean operative time was longer in the RNU group than in the ONU group (258.8 versus 190.6 min; p = 0. < 001). On the other hand, the mean blood loss and the dose of parenteral analgesia (morphine sulphate) were lower in the RNU group (289.3 versus 313.7 ml and 2.05 versus 6.72 mg; p = 0.868 and p = 0.018, respectively). There were two complications in each group. No significant difference in p stage and grade in both-groups (p = 0.951, p = 0.077). One patient with RNU had lymph node involvement, three in ONU. Mean follow up was 26.4 months (range 3–72) for RNU and 27.9 months (range 3–63) for ONU. No port metastasis occurred during follow up in RNU group. Tumor recurrence developed in 11 patients (bladder recurrence in 9 patients, local recurrence in 2 patients) in the RNU group and 14 patients (bladder recurrence in 13 patients, local recurrence in 1 patient) in the ONU group. No significant difference was detected in the tumor recurrence rate between the two procedures (p = 0.2716). Distant metastases developed in 3 patients (9.7%) after RNU and 2 patients (6.9%) after ONU. The 2 year disease specific survival rate after RNU and ONU was 86.3% and 92.5%, respectively (p = 0.8227).ConclusionRetroperitoneoscopic nephroureterectomy is less invasive than open surgery and is an oncological feasible operation. Thus, the results of our study supported the continued development of laparoscopic technique in the management of upper tract TCC.

Outcomes of Radical Prostatectomy in Thai Men with Prostate Cancer

OBJECTIVE Radical prostatectomy remains the standard treatment for early prostate cancer. Few data in the literature are from South East Asia. This study was conducted to evaluate the outcome of radical prostatectomy in Thai men. METHODS A total of 151 patients with prostate cancer underwent radical prostatectomy at Siriraj Hospital, Bangkok, between 1994 and 2003. Clinical staging, preoperative prostate-specific antigen (PSA) and Gleason score were evaluated with pathological stage and margin status. Follow-up PSA monitoring and survival were analysed. RESULTS Of 121 patients with clinical localized disease, 79 (65.3%), 40 (33.1%) and two (1.6%) had localized, locally advanced and metastatic disease, respectively, on pathology. The chance of localized disease with a preoperative PSA of 10 ng/mL or less, more than 10-50 ng/mL and more than 50 ng/mL was 75.5%, 50% and 12.5%, respectively (all p < 0.001). The chance of localized disease with a Gleason score of 2-4, 5-7 and 8-10 was 85%, 55.1% and 20.8%, respectively (all p < 0.02). Mean follow-up was 30 months. Among 140 evaluable patients, 51 (36.4%) had adjuvant therapy and 136 (97.1%) had undetectable PSA without clinical progression. The cumulative PSA progression-free survival among patients with pathological T1N0, T2N0 and T3N0 disease was 0.83 at 82 months, 0.48 at 85 months and 0.31 at 57 months, respectively. CONCLUSION Radical prostatectomy in Thai men shows excellent results. The trend is the same as in Western series. The chance of organ-confined disease and free margin was high in patients with clinical T2 or less, PSA less than 10 ng/mL and low Gleason score. PSA progression-free survival was high in patients with organ-confined disease.

Laparoscopic Live-Donor Nephrectomy: A Comparison with the Open Technique and How to Reach Quality Standards: A Single-Center Experience in Thailand

OBJECTIVE We report our experience with laparoscopic donor nephrectomy (LDN) compared with open donor nephrectomy (ODN). Prognostic factors associated with adverse outcomes in LDN were identified. METHODS From January 2000 to December 2009, 243 consecutive live-donor nephrectomies were performed, including 129 LDNs and 114 ODNs. We compared patient demographics, perioperative outcomes, and recipient graft function in each group. Prognostic factors for adverse outcomes in LDN were investigated using uni- and multivariate analyses. RESULTS Patient demographics, except mean donor age (P=.032), were similar between groups. Mean operative time (219 vs 163 minutes; P<.001) and warm ischemia time (WIT; 3.1 vs 1.7 minutes; P<.001) were significantly longer in LDN. Conversely, mean analgesic requirement (9.2 vs 14.7 mg morphine; P<.001) and postoperative hospital stay (6.5 vs 7.1 days; P=.003) were significantly lower with LDN. Mean estimated blood loss (EBL) was slightly lower in LDN (P=.15). There were 7 conversions from LDN to ODN. Complication rates were similar between the groups (P=.38). Delayed graft function (10.9% vs 1.7%; P=.016) and mean serum creatinine level at 1 month (1.47 vs 1.3 mg/dL; P=.04) were higher for LDN. However, 5-year allograft survival was not inferior among LDN (90% vs 85%; P=.42). Mean operative time (268 to 175 minutes; P<.001), EBL (316 to 66 mL; P<.001), and complication incidence (8 to 0 cases; P<.002) gradually decreased from the initial 43 cases to the last 43 cases of LDNs. Among surgeons who had performed-30 LDNs, the mean operative time and WIT were 197 mL and 2.8 minutes, respectively. CONCLUSIONS Based on our evidence, LDN was a feasible and safe surgical option for live-donor nephrectomy, even in a small volume center. Better results can be achieved after a learning curve of experience for both the surgeon and the institution.

Extraperitoneal Laparoscopic Radical Prostatectomy: Early Experience in Thailand

OBJECTIVE The transperitoneal approach is the conventional technique for laparoscopic radical prostatectomy. There are, however, several disadvantages of the approach, such as damage to intraperitoneal organs and long-term ileus. To prevent these complications, we propose an extraperitoneal approach that has been successfully used for open radical prostatectomy in treating patients with localized prostate cancer. The aim of this study was to evaluate the feasibility of extraperitoneal laparoscopic radical prostatectomy (ELRP). The outcomes of ELRP and open radical prostatectomy were also assessed and compared. METHODS There were two groups of patients with localized prostate cancer confirmed by transrectal ultrasound biopsy. Patients were included if they had no previous hormonal treatment and no previous transurethral prostatectomy. Group I comprised patients in whom open radical prostatectomy was performed between February 2001 and August 2005 ( n = 55). Group II comprised patients in whom ELRP was performed between December 2005 and October 2006 (n = 41). Early postoperative results, clinical outcomes and complications were analysed among the two groups using Chi-squared, t and Mann-Whitney tests. RESULTS Group I and Group II did not show significant differences regarding age, clinical staging, hospitalization time, or pathological stage. Group II had a longer mean operative time than Group I (t test, p< 0.001). Median blood loss was significantly less in Group I (Mann-Whitney test, p < 0.001). Group II also demonstrated shorter catheter removal time (Mann-Whitney test, p = 0.003). In Group II, there were two rectal complications, including rectal injury and rectal necrosis, which were treated laparoscopically and conservatively without long-term problems. CONCLUSION With experience, ELRP is feasible with equal oncological outcomes to open radical prostatectomy. Although a certain disadvantage was presented by ELRP, the less invasive surgery and reduction in operative blood loss were major advantages. It is suggested that a large and longitudinal trial be conducted to investigate the effectiveness of such an approach in managing functional outcomes.

The Impact of Arterial Clamping Technique in Robot-Assisted Partial Nephrectomy on Renal Function and Surgical Outcomes: Six-Year Experience at Siriraj Hospital, Thailand

Introduction: Robot-assisted partial nephrectomy (RAPN) with different arterial clamping techniques has increasingly been performed to avoid ischemic injury to nephron. However, postoperative renal function remains controversial. We determine the impact of each renal arterial clamping on surgical and renal outcomes after RAPN. Materials and Methods: Patients who underwent RAPN at Siriraj Hospital from 2010 to 2016 were retrospectively reviewed and stratified into 3 cohorts: main-clamp (MAC), selective-clamp, and off-clamp. Results: Main, selective, and off-clamping were performed in 27, 38, and 12, respectively. Median tumor size and Radius, Exophytic or endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to polar lines (RENAL) score were 3 cm and 7, respectively. Longer operative time was observed in MAC (p = 0.002) although estimated blood loss, transfusion rate, and complication were comparable. Warm ischemia time was not different between cohorts. However, number of patients with prolonged ischemia time in MAC were greater (p ≤ 0.01). All margins were negative. Median postoperative and latest glomerular filtration rate reduction were 3.8 and 5.3 mL/min/1.73 m2, respectively without significant difference between cohorts. On multivariable analysis, hypertension independently associated with reduced renal function preserved (p = 0.03). Median follow-up was 18 months. Conclusions: Our study is the first to report surgical and renal functional outcomes after RAPN in Southeast-Asian population. Based on our experience, clamping techniques does not impact on renal functions and complication rate was low even in small-volume center.