Steve K. Williams

Active surveillance; a reasonable management alternative for patients with prostate cancer: the Miami experience

To examine the outcome of patients diagnosed with ‘low‐risk’ prostate cancer managed by active surveillance (AS).

Phase III Comparison of Cisplatin Alone Versus Cisplatin, Doxorubicin and Cyclophosphamide in the Treatment of Bladder (Urothelial) Cancer: A Southeastern Cancer Study Group Trial

A prospective randomized trial compared cisplatin alone versus cisplatin, doxorubicin and cyclophosphamide in the treatment of advanced carcinoma of the bladder, ureter and renal pelvis. Objective responses were noted in 7 of 45 patients (16 per cent) given cisplatin alone and in 9 of 42 (21 per cent) treated with the combination. There was no significant difference in response rate, response duration or survival but the combination was more toxic. Other combination regimens should be evaluated.

Correlation of upper-tract cytology, retrograde pyelography, ureteroscopic appearance, and ureteroscopic biopsy with histologic examination of upper-tract transitional cell carcinoma.

PURPOSE To determine the accuracy of radiographic studies, ureteroscopy, biopsy, and cytology in predicting the histopathology of upper-tract transitional cell carcinoma (TCC). MATERIALS AND METHODS From 1998 to 2006, 46 upper-tract lesions were diagnosed ureteroscopically and underwent nephroureterectomy, and 30 of them were subjected to direct ureteroscopic inspection and biopsy. Fresh samples were delivered to the cytopathology laboratory and histology samples were prepared whenever visible tissue was present. Radiological, ureteroscopic, cytology, and biopsy data were compared to the actual grades and stages of these 30 surgical specimens. RESULTS Retrograde ureteropyelography was suggestive of malignancy in 29 of 30 cases, but did not predict the grade or stage accurately. Cytology was positive for malignancy in 21 of 30 cases (70%). Grading of ureteroscopic specimens was possible in all cases. At nephroureterectomy two cases were found to have no tumor (T(0)). Of the remaining 28 cases, the biopsy grade proved to be identical in 21 (75%). Grade 1 or 2 ureteroscopic specimens had a low-stage (T(0), T(a), or T(1)) tumor in 17 of 25 (68%); in contrast, 3 of 5 (60%) high-grade specimens had invasive tumor (T(2) or T(3)). For patients with grade 2 ureteroscopic specimens, combining exfoliated cell cytology and biopsy grade improved the accuracy in predicting high-stage and high-grade disease. CONCLUSIONS This study confirms previous findings that ureteroscopic inspection and biopsy provides accurate information regarding the grade and stage of upper-tract TCC. Combining exfoliated cell cytology improves the predictive power of biopsy grade 2 disease for high-risk specimen grade and stage. Our data suggest that ureteroscopic findings may predict muscle invasion.

Renal functional outcomes for tumours in a solitary kidney managed by ablative or extirpative techniques

Study Type – Therapy (case series)
 Level of Evidence 4

Expanding the Horizons : Robot-Assisted Reconstructive Surgery of the Distal Ureter

OBJECTIVES To report our single-center experience with robotic ureteroneocystostomy for the treatment of distal ureteral obstruction. METHODS We performed robot-assisted laparoscopic ureteroneocystostomies between May 2005 and October 2007. We retrospectively collected information on patient demographics, and compared renal scans with furosemide washout and radiographic imaging before and after repair to determine radiographic success. Statistical analysis was performed using statistical software via paired Students t test analysis. RESULTS Eight robot-assisted laparoscopic ureteroneocystostomies on seven patients were performed over a 30-month period. The etiology of the ureteric stricture was iatrogenic injury after hysterectomy in three patients, impacted stone in three, and infiltrative endometriosis in one. Mean stricture length was 2.2 cm. Right ureteroneocystostomy was performed in five patients and on the left in one, while one patient had bilateral disease. Mean operative time was 247 minutes (range 120-480), and average blood loss was 109 mL (range 50-200). Mean length of hospital stay was 2 days. All the procedures were completed successfully robotically without open conversion. Of the seven patients, one patient experienced recurrent symptoms. Subsequent imaging confirmed an anastomotic narrowing, which was treated by balloon dilation. There were no intraoperative or postoperative complications. Subsequent (99m)Tc-mercaptoacetyltriglycine scans showed no evidence of obstruction. After a mean follow-up of 18 months (range 5-31), relative renal function of the entire group of patients improved after ureteroneocystostomy, although this did not achieve statistical significance (p = 0.26). CONCLUSIONS Robotic ureteroneocystostomy is a safe and effective treatment option for the management of distal ureteric stricture disease.

Management of staghorn calculus: single puncture with judicious use of the flexible nephroscope.

Purpose of review To focus on the technique and results of a single percutaneous puncture for the management of staghorn renal calculi. Recent findings The success rate for treating staghorn calculi with a single percutaneous puncture is over 90%. Animal and clinical studies seem to suggest that a single percutaneous access may be associated with reduced morbidity when compared with multiple percutaneous access punctures. Summary A single percutaneous access, whenever feasible, offers reduced morbidity without compromising excellent stone-free rates in the management of staghorn calculi.

Renal thermal ablative therapy.

Energy targeting is greatly enhanced through imaging modalities, which greatly assist needle placement or energy delivery to the optimal location for maximal effectiveness. When vital structures obscure access to the renal lesion, laparoscopic mobilization of these structures with direct visualization of the tumor can increase the likelihood of ablation success and minimize complication risk. Ablative therapies are attractive because of their minimal impact on patient quality of life in addition to their morbidity and cost. Although they show promise of efficacy, they must be evaluated with long-term follow-up before they are considered the standard of oncologic care. Renal masses can be treated with a laparoscopic or percutaneous approach depending on tumor location, size, and the available technology and experience of the center.

A Single Percutaneous Access and Flexible Nephroscopy Is the Best Treatment for a Full Staghorn Calculus

STAGHORN CALCULI are branched stones that occupy a large portion of the collecting system. The AUA Nephrolithiasis Guidelines Panel recommends four modalities as potential treatment alternatives for patients with staghorn calculi.1 These include percutaneous nephrolithotomy (PCNL) monotherapy, combinations of PCNL and shockwave lithotripsy (SWL), SWL monotherapy, and open surgery, typically anatropic nephrolithotomy. Complete removal of the stone is the primary management goal to relieve obstruction, eliminate infection, prevent further stone growth, and preserve renal function. Secondary objectives include reducing complications and morbidity (i.e., bleeding, pneumothorax) without compromising quality-of-life considerations. Monotherapy with PCNL is reported to have the lowest residual stone rate (28%),2 while SWL monotherapy has the highest (56%).3 Combination therapy (i.e., PCNL and SWL) has been suggested as an approach to improve treatment effectiveness.4 We believe that most staghorn calculi can be managed successfully and safely with a staged procedure through a single upper-pole percutaneous access using flexible nephroscopy and the holmium:yttrium-aluminum-garnet laser without the use of SWL.

Synchronous Bilateral Percutaneous Nephrostolithotomy

Various options are available for the treatment of patients with large, bilateral renal stones, including a staged percutaneous nephrostolithotomy (PCNL), synchronous PCNL with contralateral ureterorenoscopy, and synchronous bilateral PCNL. For patients with large bilateral renal stones, a synchronous bilateral PCNL may be offered if particular criteria are met. Overall outcomes reported for synchronous bilateral PCNL include high stone-free rates (95%-97%), low complication rates (9%-12%), short length of hospital stay (4-6 days), and low blood transfusion rates. Detailed cost analysis has revealed a significant cost advantage for synchronous vs staged bilateral PCNL; however, reimbursement practices reveal a significant financial disincentive for the surgeon to perform simultaneous bilateral PCNL. Here, we review the experience and current recommendations with synchronous bilateral PCNL for the treatment of patients with large, bilateral renal calculi.

Angiosarcoma of the Bladder: Case Report and Review of the Literature

Our objective was to present a new case of angiosarcoma of the bladder after therapeutic radiation of the prostate, and discuss the treatment and clinical course of this rare tumor; the role of multimodality treatment is also discussed. We report a case of angiosarcoma of the bladder. Presentation, clinical course, and treatment were outlined and discussed. A MEDLINE search of all reported cases of angiosarcoma in the English language literature was performed. Thirteen previous cases of bladder angiosarcoma have been reported and three previous cases have been reported after therapeutic radiation. Hematuria was the most common presentation. Overall survival is poor, with 5-year survival rates at 35%. Longer-term survival has been demonstrated in patients who have had a multimodal approach to treatment, which combines radical surgery with chemotherapy and radiotherapy. Angiosarcoma of the bladder is a rare disease with overall poor prognosis. Optimal treatment has not been defined, but multimodality approaches appear to have a survival benefit.