Sunai Leewansangtong

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.

INTRARENAL EXTRAMEDULLARY HEMATOPOIESIS AS A RENAL MASS IN A PATIENT WITH THALASSEMIA

Extramedullary hematopoiesis is an extension of marrow beyond its bony casement. It is associated with a number of diseases when the normal function of marrow is disturbed. A large accumulation of extramedullary hematopoiesis may occur at the paravertebral area, mediastinum, spleen and liver. Intrarenal extramedullary hematopoiesis is rare. Only a few cases have been reported of myelofibrosis and idiopathic thrombocytopenic purpura. 1, 2 Extramedullary hematopoiesis at various sites has been reported with thalassemia, which is one of the most common genetic disorders worldwide and one of the most common causes of anemia in Southeast Asia. However, to our knowledge intrarenal extramedullary hematopoiesis has never been reported with thalassemia. We report a case of intrarenal extramedullary hematopoiesis that mimicked renal cell carcinoma. Nephrectomy was avoided by intraoperative tissue diagnosis. CASE REPORT A 35-year-old woman with thalassemia presented elsewhere with fever. During evaluation a left intrarenal mass was incidentally detected on ultrasonography. The patient was referred to us for further treatment. Physical examination revealed an old splenectomy scar and an ill defined mass on the left side of the mid abdomen detected by bimanual palpation. Hemoglobin was 7.3 gm./dl. (normal 12 to 18). Red blood cell morphology was typical of thalassemia. Computerized tomography (CT) of the abdomen demonstrated a large homogeneous circumscribed mass at the lower pole of the left kidney (fig. 1). There was another soft tissue mass, presumably an extramedullary hematopoiesis, at the presacral area. Due to the possibility of renal cell carcinoma the left kidney was explored. A1 03 8 3 6 cm. 3 tense bluish intrarenal mass partially protruding from the lower pole of the kidney was biopsied and submitted for intraoperative diagnosis. The rest of the kidney appeared normal. After frozen sections demonstrated extramedullary hematopoiesis, the wound was closed. The permanent sections confirmed the diagnosis of extramedullary hematopoiesis containing hematopoietic cells at various stages of maturation with predominance of erythroid series (fig. 2). The patient was well at 4-month followup. DISCUSSION

Perioperative outcomes of open radical prostatectomy versus laparoscopic radical prostatectomy in Asian men: comparison of two initial series by the same surgeon

PURPOSE To compare the perioperative outcomes in 2 initial series of open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP) in Asian men with prostate cancer. MATERIALS AND METHODS From March 1999 to February 2007, the first 100 consecutive patients who underwent ORP and the first 100 consecutive patients who underwent LRP by the same surgeon (SL) were assessed. Mean age, clinical stage, preoperative PSA level, Gleason score, operative time, estimated blood loss, blood transfusion rate, perioperative complications, pathological stage and margin status were compared between the 2 groups. RESULTS For each 100 patients in ORP and LRP, mean age and clinical stage were not significantly different. The operative time in LRP was significantly longer than ORP (188 +/- 55 versus 114 +/- 31 minute, p value = 0.01). Mean estimated blood loss and blood transfusion rate in LRP was significantly lower than ORP, 521 +/- 328 versus 809 +/- 510 mL (p value = 0.03) and 27% versus 55% (p value = 0.01), respectively. For pathological organ confined disease, the free surgical margin rate of ORP and LRP was not significantly different (88.9% versus 91.3%, respectively, p = 0.58). There was no significant major complication in either group. CONCLUSIONS For initial experience by a single surgeon, LRP is comparable to ORP with no significant morbidity. LRP had longer operative time. However, LRP decreased blood loss and blood transfusion. For localized prostate cancer, free surgical margin rate of ORP and LRP was not significantly different.

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.

Results of chimney modification technique in ureterointestinal anastomosis of Hautmann ileal neobladder in bladder cancer.

BACKGROUND To evaluate the surgical technique and functional outcome of a new application of the chimney modification to the popular Hautmann ileal neobladder. This modification used 3-5 cm chimney tubularized ileal segment for the bilateral ureterointestinal anastomosis. METHODS Between December 2000 and July 2004, 15 patients (14 men, 1 woman) with invasive bladder cancer underwent radical cystectomy and Hautmann neobladder with chimney modification at Siriraj Hospital, Bangkok. Mean age was 61.7 years (range, 43-72 years). Perioperative morbidity, early and late urinary diversion-related complications, other surgical complications, follow-up results of ureterointestinal anastomosis, renal function and metabolic disorders were evaluated. Patients were interviewed about their continence, voiding function and potency. RESULTS At a mean follow-up of 29.5 months, two patients had died of cancer progression. Of the 15 patients, nine (60%) had 10 early complications. Eight complications were related to the neobladder and two were not. Three (20%) patients had three late complications. Two complications were neobladder-related and one was not. There was no perioperative mortality. There was no ureteroileal anastomosis stricture in this series. Neobladder-ureteral reflux was demonstrated in eight of 22 ureteral units in 11 patients in whom cystography was performed. All patients had normal upper urinary tract without evidence of urinary obstruction. All 14 men (93% of study sample) had spontaneous urination, normal renal function and no metabolic acidosis. Good and satisfactory continence in the day and night were 93% and 73%, respectively. All male patients experienced impotence postoperatively. Only one sought treatment and was successfully treated with sildenafil. The one woman in this study required intermittent catheterization to empty the neobladder completely. She also had renal insufficiency with serum creatinine of 2.2 mg/dL and hyperchloraemic metabolic acidosis. CONCLUSION New chimney modification in Hautmann ileal neobladder is simple and safe. Complications are acceptable. Follow-up results of renal and voiding functions are satisfactory. This operation can maintain good quality of life for patients with bladder cancer undergoing radical cystectomy.

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.