[Show abstract][Hide abstract] ABSTRACT: Background
Image-based renal morphometry scoring systems are used to predict the potential difficulty of partial nephrectomy (PN), but they are centered entirely on tumor-specific factors and neglect other patient-specific factors that may complicate the technical aspects of PN. Adherent perinephric fat (APF) is one such factor known to make PN difficult.
To develop an accurate image-based nephrometry scoring system to predict the presence of APF encountered during robot-assisted partial nephrectomy (RAPN).
Design, setting, and participants
We prospectively analyzed 100 consecutive RAPNs performed by one surgeon and defined APF as the need for subcapsular renal dissection to isolate the renal tumor for RAPN.
Outcome measurements and statistical analysis
The scoring algorithm to predict the presence of APF was developed with a multivariable logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve.
Results and limitations
Thirty patients (30%; 95% confidence interval, 21–40) had APF. Single-variable analysis noted an increased likelihood of APF in male patients (p < 0.001), higher body mass index (p = 0.003), greater posterior perinephric fat thickness (p < 0.001), greater lateral perinephric fat thickness (p < 0.001), and those with perirenal fat stranding (p < 0.001). Two of these variables, posterior perinephric fat thickness and stranding, were most highly predictive of APF in multivariable analysis and were therefore used to create a risk score, termed Mayo Adhesive Probability (MAP) and ranging from 0 to 5, to predict the presence of APF. We observed APF in 6% of patients with a MAP score of 0, 16% with a score of 1, 31% with a score of 2, 73% with a score of 3–4, and 100% of patients with a score of 5.
MAP score accurately predicts the presence of APF in patients undergoing RAPN. Prospective validation of the MAP score is required.
The Mayo Adhesive Probability score that we we developed is an accurate system that predicts whether or not adherent perinephric, or “sticky,” fat is present around the kidney that would make partial nephrectomy difficult.
[Show abstract][Hide abstract] ABSTRACT: Purpose: To determine whether on-clamp partial nephrectomy (ON-PN) has any significant impact on long-term renal function in a two kidney model. Methods: From November 1999 to July 2013, 607 patients underwent partial nephrectomy at our institution. After excluding patients with solitary kidneys, multiple renal masses, and follow-up less than 90 days, 331 remained. Patient demographics were assessed, as was renal function based on pre- and postoperative MAG-3 renal scans and change in estimated glomerular filtration rate (eGFR) using the preoperative and most recent recorded creatinine levels. Results: There were a total of 236 patients who underwent ON-PN and 95 who underwent off-clamp partial nephrectomy (OFF-PN) during the study period. The longest follow-up was 12.6 years with mean follow-up of 3 years. Mean ischemia time of patients undergoing ON-PN was 25 minutes (ranging from 8 to 63 minutes). No differences were noted between the ON-PN and OFF-PN cohorts with respect to estimated change in eGFR (ON-PN: -6.07 mL/min/1.73 m2 vs OFF-PN: -6.00 mL/min/1.73 m2, p=0.69). No differences were noted in the % change in the MAG-3 renal scans (ON-PN: -0.77% vs OFF-PN: -1.1%, p=0.94). A post-hoc sensitivity analysis of the same two variables stratified by age revealed no differences in change in estimated GFR or % change in differential function on renal scan. Conclusions: In the two kidney model, ischemia does not appear to affect long-term renal function outcomes after partial nephrectomy. These data provide evidence that ON-PN is perfectly acceptable in the appropriately selected patient with two kidneys.
Journal of endourology / Endourological Society 09/2014; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine if massive renal size should be a contraindication for attempting a laparoscopic approach to bilateral native nephrectomies in patients with autosomal dominant polycystic kidney disease (ADPKD).
[Show abstract][Hide abstract] ABSTRACT: Few data on the perioperative outcomes of cystectomy after neoadjuvant chemotherapy (NAC) exist. In this study, we evaluated whether patients who had previously received NAC were at higher risk of developing perioperative complications.
The Canadian Journal of Urology 06/2014; 21(3):7259-7265. · 0.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective-To evaluate outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for non-seminomatous germ cell tumors (NSGCT) and paratesticular rhabdomyosarcoma (RMS) at our institution.Patients and Methods-Between March 2008 to May 2013, seventeen patients underwent RA-RPLND for NSGCT and one for paratesticular RMS.-Data were collected retrospectively on patient demographics, pre-operative tumor characteristics, and peri-operative outcomes including open conversion rate, lymph node yield, rate of positive lymph nodes, operative time, estimated blood loss (EBL), and length of stay (LOS).-Peri-operative outcomes were compared between patients receiving primary RA-RPLND versus post-chemotherapy RA-RPLND-Medium-term outcomes of tumor recurrence rate and maintenance of antegrade ejaculation were recorded.Results-RA-RPLND was completed robotically in 15 of 18 (83%) patients.-Lymph nodes were positive in 8 of 18 patients (44%).-Mean lymph node yield was 22 nodes.-For cases completed robotically, mean operative time was 329 minutes, EBL was 103mL, and LOS was 2.4 days.-At mean follow-up of 22 months (range 1-58), there were no retroperitoneal recurrences and 2 of 17 (12%) patients with NSGCT had pulmonary recurrences.-Antegrade ejaculation was maintained in 91% of patients with a nerve sparing approach.-Patients receiving primary RA-RPLND had shorter operative times compared to those post-chemotherapy (311 vs 369 minutes, p= 0.03). There was no significant difference in node yield (22 vs 18 nodes, p=0.34), EBL (100 vs 313 mL, p=0.13), or LOS (2.75 vs 2.2 days, p=0.36).Conclusion-This initial selected case series of RA-RPLND demonstrates that the procedure is safe, reproducible, and feasible for stage I-IIB NSGCT and RMS in the hands of experienced robotic surgeons. Larger studies are needed to confirm the diagnostic and therapeutic utility of this technique.
[Show abstract][Hide abstract] ABSTRACT: Objective
To examine whether racial disparities in survival exist among black, Hispanic, and Asian patients compared with white patients with clinically localized prostate cancer (CLPC) after adjustment for the effects of treatment.
Patients and Methods
We performed a retrospective cohort study of patients with CLPC diagnosed from January 1, 1995, through December 31, 2003, as documented in the Surveillance, Epidemiology, and End Results registry. Treatment-stratified, risk-adjusted Cox proportional hazards models were constructed.
During the study period, CLPC was diagnosed in 294,160 patients. Of these patients, 123,850 (42.1%) underwent surgery and 101,627 (34.5%) underwent radiotherapy, whereas 68,683 (23.3%) received no treatment. Overall 5-year and 10-year survival rates for Asians (85.6% and 67.6%, respectively), Hispanics (85.9% and 69.0%, respectively), and whites (83.9% and 65.7%, respectively) were higher than for blacks (81.5% and 61.7%, respectively) (P<.001). Prostate cancer–specific survival also varied significantly by race (P<.001). A risk-adjusted model stratified by primary treatment modality revealed that blacks had worse overall survival than whites (hazard ratio, 1.37; 95% CI, 1.33-1.41; P<.001), whereas Asians had better survival compared with whites (hazard ratio, 0.79; 95% CI, 0.76-0.83; P<.001). After the effects of treatment were accounted for, Hispanics had similar overall survival compared with whites (hazard ratio, 0.97; 95% CI, 0.94-1.01; P=.10).
Blacks with CLPC have poorer survival than whites, whereas Asians have better survival, even after risk adjustment and stratification by treatment. These data may be relevant to US regions with large underserved populations that have limited access to health care.
Mayo Clinic Proceedings 03/2014; 89(3):300–307. · 5.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the rates of deep venous thromboembolism (DVT) and pulmonary embolism (PE) after common urologic procedures in the United States.
The National Surgical Quality Improvement Program (NSQIP) database was used to identify common urologic procedures performed between January 1, 2005, and December 31, 2011. A total of 82,808 patients were included.
A total of 633 (0.76%, n=82,808) DVTs occurred within 30 days of surgery in this cohort of patients undergoing common urologic procedures. Among cases performed at least 500 times, the rates of DVT were highest among patients undergoing cystectomy/urinary diversion (3.96% [71/1,792]), partial cystectomy (2.35% [17/722]), and open radical nephrectomy (1.67% [45/2,702]). The rates of DVT were lowest among patients undergoing laparoscopic colpopexy (0.00% [0/707]), placement of a female sling (0.08% [9/10,648]), and hydrocelectomy/spermatocelectomy/varicocelectomy (0.13% [3/2,333]). A total of 349 (0.42%) PEs occurred in this cohort with cystectomy/urinary diversion having the highest rate overall (2.85% [51/1792]). Multivariable logistic regression revealed that age >60, functional status, history of disseminated cancer, CHF, anesthesia time >120 minutes and chronic steroid use were independently associated with DVT/PE formation. A limitation to the study is that no data is available on thromboembolic prophylaxis.
While DVTs and PEs are uncommon after urologic surgery, this is the first study to provide a comprehensive comparison of DVT/PE rates across a full spectrum of various urologic procedures among American patients. This should give the reader a better understanding of the exact risk faced by the patient when undergoing common urologic procedures.
The Journal of urology 03/2014; · 3.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objectives
The purpose of the RAZOR study is to compare open versus robotic radical cystectomy, pelvic lymph node dissection and urinary diversion regarding oncologic outcomes, complications and quality of life measures with a primary endpoint of 2-year progression free survival. Patients and MethodsRAZOR is a multi-institutional, randomized, non-inferior, phase 3 trial that will enroll at least 320 patients with T1-T4, N0-1, M0 bladder cancer with approximately 160 patients in both robotic and open arms at a total of 15 participating institutions.Data will be collected prospectively at each institution regarding cancer outcomes, complications from surgery and quality of life measures and then submitted to trial data management services, Cancer Research and Biostatistics (CRAB) for final analyses. Results306 patients have been randomized to date and accrual to the RAZOR trial is expected to conclude in 2014.In this study, we report RAZOR trial experimental design, objectives, data safety and monitoring and accrual update. Conclusions
The RAZOR trial is a landmark study in urological oncology, randomizing T1-T4, N0-N1, M0 bladder cancer patients to open versus robotic radical cystectomy, pelvic lymph node dissection and urinary diversion.RAZOR is a multi-institutional, non-inferiority trial evaluating cancer outcomes, surgical complications and quality of life measures of open versus robotic cystectomy with a primary endpoint of 2-year progression free survival.Full data from the RAZOR trial are not expected until 2016—2017.
[Show abstract][Hide abstract] ABSTRACT: Background
Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to hepatobiliary surgeons. Previous reports of robotic choledochocele resections in adults have detailed extracorporeal jejunojejunostomies. We describe a total robotic excision of a choledochal cyst with hepaticojejunostomy and intracorporeal Roux-en-Y anastomosis.
A 58-year-old woman underwent a robotic excision of a small choledochocele with hepaticojejunostomy and intracorporeal Roux-en-Y.
Port placement was determined via collaborative surgical discussion and previously reported robotic right hepatectomies. Total operative time was 386 min and total robot working time was 330 min. The hepaticojejunostomy was performed using 5-0 PDS suture with parachute-style back wall and running front wall sutures. The jejunojejunostomy was a stapled anastomosis. Estimated blood loss was less than 100 mL. The patient was ambulating and tolerating oral intake on post-operative day 1, and was discharged home on post-operative day 2.
Robotic resection of choledochal cyst with intracorporeal Roux-en-Y anastomosis is feasible, with advantages over open surgery such as superior visualization, precision, and post-operative patient recovery.
[Show abstract][Hide abstract] ABSTRACT: Objective
To evaluate the long-term safety of a novel continuous infusion of ketorolac vs placebo after laparoscopic donor nephrectomy.
We performed a secondary analysis of a previously reported randomized controlled trial conducted from October 7, 2008, to July 21, 2010. Patients aged 18-75 years received a continuous infusion of either ketorolac (treatment [n = 57]) or normal saline (control [n = 54]) for 24 hours immediately after laparoscopic donor nephrectomy. Serum creatinine levels were measured at 1- and 1.5-year follow-ups. Glomerular filtration rate was calculated preoperatively, postoperatively, and at 1- and 1.5-year follow-ups using the Chronic Kidney Disease Epidemiology Collaboration equation. Glomerular filtration rates were compared between treatment and control groups using 2-sample t tests.
Data analysis for the 111 donor nephrectomy patients showed that glomerular filtration rates decreased in both groups over time, but changes were not clinically significant. No difference was found in glomerular filtration rates (in mL/min/1.73 m2) between treatment and control groups at 1-year follow-up (89.29 vs 87.94 mL/min/1.73 m2; P = .58) or at 1.5-year follow-up (88.54 vs 90.25 mL/min/1.73 m2; P = .51).
The novel provision of continuous steady-state ketorolac is safe for postoperative pain control in patients after donor nephrectomy, with no change in glomerular filtration rates between treatment and control groups acutely and at up to 1.5-year follow-up.
[Show abstract][Hide abstract] ABSTRACT: To examine the impact of body mass index, as a measure of obesity, on the surgical outcomes of cystectomy.
The American College of Surgeons National Surgical Quality Improvement Program database was used to acquire data on 1293 cystectomies carried out from 2005 to 2011. Patients were divided into two groups: body mass index <30 kg/m(2) and ≥30 kg/m(2) . A propensity score-matched analysis of perioperative outcomes was carried out.
A total of 869 patients had a body mass index <30, whereas 424 had a body mass index ≥30. Unadjusted comparisons showed higher rates of superficial surgical site infections (8.7% vs 5.3%, P = 0.04), renal insufficiency (4.0% vs 1.7%, P = 0.01) and increased operative times (365.7 min vs 338.6 min, P = 0.0004) in the obese patients, but interestingly lower rates of pneumonia (2.4% vs 4.8, P = 0.03) and cerebral vascular accidents (0.0% vs 0.9%, P = 0.05). However, the latter two observations might be explained by more tobacco use among non-obese patients (26.6 mean pack-years vs 20.0 mean pack-years, P = 0.004). Notably, no differences in 30-day mortality were noted. After adjusting for preoperative demographic and clinical data using propensity score-matching methods, there were no observed differences between the two cohorts except for operative time (P = 0.04).
Obesity is not independently associated with an increased risk of perioperative complications or 30-day mortality after cystectomy.
International Journal of Urology 11/2013; · 1.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Intracorporeal urinary diversion (ICUD) has the potential benefits of a smaller incision, reduced pain, decreased bowel exposure, and reduced risk of fluid imbalance.
To compare the perioperative outcomes of patients undergoing extracorporeal urinary diversion (ECUD) and ICUD following robot-assisted radical cystectomy (RARC).
We reviewed the database of the International Robotic Cystectomy Consortium (IRCC) (18 international centers), with 935 patients who had undergone RARC and pelvic lymph node dissection (PLND) between 2003 and 2011.
All patients within the IRCC underwent RARC and PLND as indicated. The urinary diversion was performed either intracorporeally or extracorporeally.
Demographic data, perioperative outcomes, and complications in patients undergoing ICUD or ECUD were compared. All patients had at least a 90-d follow-up. The Fisher exact test was used to summarize categorical variables and the Wilcoxon rank sum test or Kruskal-Wallis test for continuous variables.
Of 935 patients who had RARC and PLND, 167 patients underwent ICUD (ileal conduit: 106; neobladder: 61), and 768 patients had an ECUD (ileal conduit: 570; neobladder: 198). Postoperative complications data were available for 817 patients, with a minimum follow-up of 90 d. There was no difference in age, gender, body mass index, American Society of Anesthesiologists grade, or rate of prior abdominal surgery between the groups. The operative time was equivalent (414min), with the median hospital stay being marginally longer for the ICUD group (9 d vs 8 d, p=0.086). No difference in the reoperation rates at 30 d was noted between the groups. The 90-d complication rate was not significant between the two groups, but a trend favoring ICUD over ECUD was noted (41% vs 49%, p=0.05). Gastrointestinal complications were significantly lower in the ICUD group (p ≤ 0.001). Patients with ICUD were at a lower risk of experiencing a postoperative complication at 90 d (32%) (odds ratio: 0.68; 95% confidence interval, 0.50-0.94; p=0.02). Being a retrospective study was the main limitation.
Robot-assisted ICUD can be accomplished safely, with comparable outcomes to open urinary diversion. In this cohort, patients undergoing ICUD had a relatively lower risk of complications.
[Show abstract][Hide abstract] ABSTRACT: The significance of androgen receptor (AR) expression in triple-negative breast cancer (TNBC) is unclear, and published studies so far have been inconclusive.
A tissue microarray was constructed using tissue obtained from 119 patients with primary TNBC and stained for AR expression. Other tissue types obtained included recurrent TNBC, normal breast tissue, adjacent ductal carcinoma-in situ (DCIS), lymph node (LN) and distant metastases. Positive AR expression was defined as ≥10 % nuclear staining.
Epithelial tissue was present and evaluable in 94 TNBC patients with a total of 177 tissue cores. AR expression in TNBC was 22 of 94 (23 %). AR expression was higher in normal breast tissue (88 %) and adjacent DCIS (73 % overall). All LN metastases from AR-positive TNBC patients were also AR positive; in addition, no AR-negative TNBC patient had AR-positive LNs. AR expression was associated with older patient age (63 vs. 57 years, respectively, p = 0.051) and LN metastases (p = 0.033). Locoregional recurrence and overall/disease-specific survival were similar between AR-positive and AR-negative patients, although AR-positive patients had more advanced disease. On multivariate analysis, the presence of LN metastases was associated with poorer recurrence-free survival in AR-positive patients (hazard ratio, 4.34) (p = 0.031).
The AR is expressed in normal breast tissue, and expression decreases with advancement to DCIS and invasive cancer. AR-positive TNBC was more common in older patients and had a higher propensity for LN metastases. AR-positive TNBC may represent a breast cancer subtype with unique features that may be amenable to treatment with alternative targeted therapies.
Annals of Surgical Oncology 09/2013; · 3.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Currently, there is no reliable tool to predict response to intravesical bacillus Calmette-Guérin (BCG). Based on the fact that BCG is a Th1-polarizing immunotherapy, we attempt to correlate the pretreatment immunologic tumor microenvironment (Th1 or Th2) with response to therapy.
Bladder cancer patients with initial diagnosis of carcinoma in situ (Tis) were stratified based on their response to BCG treatment. A total of 38 patients met inclusion criteria (20 patients who responded and 18 patients who did not respond). Immunohistochemical (IHC) methods known to assess the type of immunologic microenvironment (Th1 vs. Th2) were performed on tumor tissue obtained at initial biopsy/resection: the level of tumor eosinophil infiltration and degranulation (Th2 response); the number of tumor-infiltrating GATA-3(+) (Th2-polarized) lymphocytes; and the number of tumor-infiltrating T-bet(+) (Th1-polarized) lymphocytes. Results obtained from these metrics were correlated with response to treatment with BCG immunotherapy.
The IHC metrics of the tumor immune microenvironment prior to BCG treatment were each statistically significant predictors of responders (R) vs. nonresponders (NR). Eosinophil infiltration and degranulation was higher for R vs. NR: 1.02±0.17 vs. 0.5±0.12 (P = 0.01) and 1.1±0.15 vs. 0.56±0.15 (P = 0.04), respectively. Ratio of GATA-3(+) (Th2-polarized) lymphocytes to T-bet(+) (Th1-polarized) lymphocytes was higher for R vs. NR: 4.85±0.94 vs. 0.98±0.19 (P<0.001). The 3 markers were combined to create a Th2 signature biomarker, which was a statistically significant (P<0.0001) predictor of R vs. NR. All IHC markers demonstrated that a preexisting Th1 immunologic environment within the tumor was predictive of BCG failure.
The Th1 vs. Th2 polarization of bladder tumor immune microenvironment prior to treatment with BCG represents a prognostic metric of response to therapy. If a patient has a preexisting Th1 immunologic response within the tumor, there is no value in using a therapy intended to create a Th1 immunologic response. An algorithm integrating 3 IHC methods provided a sensitive and specific technique that may become a useful tool for pathologists and urologists to predict response to BCG in patients with carcinoma in situ of the bladder.
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To determine the extent to which the year of diagnosis, year of birth, and age at diagnosis influence the incidence trends of kidney cancer in the United States. METHODS: Cancer registry data from the National Cancer Institute's Surveillance, Epidemiology, and End-Results (SEER) program were obtained for 64,041 patients with kidney cancer diagnosed between 1973 and 2008. Overall and age-specific incidence rates were calculated and adjustments were made for birth cohort and period effects. Results were stratified by race and sex. Age-period-cohort analysis was used to examine the effects of age, year of diagnosis (period), and year of birth (cohort) on incidence trends. RESULTS: The overall age-standardized annual incidence per 100,000 increased during the study period (1973 to 2008) by race, from 6.75 (95% confidence interval, 6.18-7.36) to 19.56 (18.85-20.20) among whites, from 5.31 (3.50-7.71) to 25.38 (23.00-27.92) among blacks, and from 5.61 (3.50-8.50) to 13.98 (12.41-15.71) among other races; and by sex, from 9.44 (8.49-10.47) to 26.48 (25.39-27.60) among men and from 4.21 (3.65-4.84) to 13.38 (12.64-14.11) among women. Age-period-cohort analysis revealed a strong influence from period and cohort effects. The 1983 birth cohort, for example, had a 2-fold increase in kidney cancer (incidence rate ratio, 1.93 [1.63-2.25]) compared with the referent 1948 cohort. CONCLUSION: From 1973 to 2008, the incidence rate of kidney cancer increased for each sex and race across all age groups. Age-period-cohort models revealed that period-related factors, although significant, cannot alone account for these unfavorable temporal trends.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: To evaluate outcomes of primary (first-occurrence) treatment of renal transplant ureteral strictures using tandem parallel internal double-pigtail stents. MATERIALS AND METHODS: A retrospective electronic chart review, including demographics, medical history, stricture intervention, and outcomes, was performed of patients with renal transplants with first-occurrence ureteral obstructions or leaks reported in a transplant nephrology database over a 4-year period, with a focus on patients treated primarily with tandem stents. RESULTS: Of 27 patients with first-occurrence ureteral obstruction or ureteral leak, 18 (67%) were treated primarily using tandem internal stents, with 15 (83%) of 18 stent-free for a minimum 90 days of follow-up. There was no significant difference between outcomes for male versus female patients (P>.99) or early versus late strictures (P = .53). Urinary tract infections (UTIs) occurred in 14 (78%) of 18 patients with tandem stents in place. Four patients were hospitalized<48 hours with UTI and sepsis; there were no other major complications. CONCLUSIONS: Patients with renal transplants can be successfully managed nonsurgically using tandem ureteral stents for the primary treatment of first-occurrence ureteral stricture. These patients may require more intensive monitoring for UTIs.
Journal of vascular and interventional radiology: JVIR 04/2013; · 1.81 Impact Factor