-
[show abstract]
[hide abstract]
ABSTRACT: INTRODUCTION: Surveillance following urinary diversion should be tailored to capture complications downstream from the initial reconstruction. Most analyses of the morbidity associated with urinary diversion are restricted to the index admission or the immediate postoperative period. We sought to characterize the long-term medical and surgical complications and burden of healthcare utilization following urinary diversion. METHODS: Using the 5% Medicare sample from 1998-2005 we identified individuals undergoing cutaneous and orthotopic continent urinary diversion, ileal conduit, or other type of diversions including enterocystoplasty from physician claims for the index admission. We restricted our sample to subjects with claims 1 year prior to surgery and at least 2 years after the diversion. We included benign and malignant primary diagnoses, and evaluated the incidence of medical and surgical complications 2 and 5 years after surgery. We stratified complications by diversion type, and compared long-term complications after urinary diversion surgery. RESULTS: Of 1,565 subjects identified, 80% underwent ileal conduit urinary diversion, 7% underwent cutaneous or orthotopic continent diversion, and 13% underwent other types of reconstruction. Urinary stone formation, wound complications and fistula complications were more common following continent diversion 5 years following surgery, while ureteral obstruction and renal failure/impairment were more common following ileal conduit diversion. Overall, we estimated that greater than 16% of patients experienced renal failure or impairment following urinary diversion. CONCLUSION: Complications are common after urinary diversion and continue to occur through 5 years postoperatively. Urolithiasis and delayed wound complications appear to occur more commonly following continent diversion than after other urinary diversions. A large proportion of patients experience renal deterioration following diversion. These results highlight the need to survey patients for the diversion-related complications of cystectomy as rigorously as we monitor for cancer recurrence.
The Journal of urology 03/2013; · 4.02 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: Chemokines are involved in cancer-related inflammation and malignant progression. In this study we evaluated expression of CCR8 and its natural cognate ligand CCL1 in patients with urothelial carcinomas of bladder and renal cell carcinomas. EXPERIMENTAL DESIGN: We examined CCR8 expression in peripheral blood and tumor tissues from patients with bladder and renal carcinomas. CCR8-positive myeloid cells were isolated from cancer tissues with magnetic beads and tested in vitro for cytokine production and ability to modulate T cell function. RESULTS: We demonstrate that monocytic and granulocytic myeloid cell subsets in peripheral blood of cancer patients with urothelial and renal carcinomas display increased expression of chemokine receptor CCR8. Up-regulated expression of CCR8 is also detected within human cancer tissues and primarily limited to tumor-associated macrophages (TAMs). When isolated, CD11b+CCR8+ cell subset produces the highest levels of pro-inflammatory and pro-angiogenic factors among intratumoral CD11b myeloid cells. Tumor-infiltrating CD11b+CCR8+ cells selectively display activated Stat3 and are capable of inducing FoxP3 expression in autologous T lymphocytes. Primary human tumors produce substantial amounts of the natural CCR8 ligand CCL1. CONCLUSIONS: This study provides the first evidence that CCR8+ myeloid cell subset is expanded in cancer patients. Elevated secretion of CCL1 by tumors, increased presence of CCR8+ myeloid cells in peripheral blood and cancer tissues indicate that CCL1/CCR8 axis is a component of cancer-related inflammation and may contribute to immune evasion. Obtained results also implicate that blockade of CCR8 signals may provide an attractive strategy for therapeutic intervention in human urothelial and renal cancers.
Clinical Cancer Research 01/2013; · 7.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: PurposeMost analyses of complications after urinary diversion are restricted to the index admission. Given the complexity of these
reconstructions, readmissions occur commonly. We sought to characterize the burden and impact of readmissions in the postoperative
period following urinary diversion.
MethodsUsing 5% Medicare data for the years 1998–2005, we identified patients undergoing ileal conduit, continent, and other urinary
diversions for benign and malignant indications. We examined the 90-day rates of readmission and evaluated factors associated
with readmission after urinary diversion, either to the primary hospital or to a secondary facility. We assessed 90-day and
2-year mortality after urinary diversion and incorporated readmission status as a covariate in these multivariable models.
ResultsOur study sample included 1,565 patients, of whom 491 patients (31%) were readmitted within 90days of their urinary diversion.
Patients readmitted after urinary diversion had higher comorbidity count than those not readmitted (59% of those readmitted
with comorbidity count at least 1 versus 50% of those not readmitted, P=0.002). Other clinical and demographic characteristics did not differ by readmission status (P>0.12 for age, race, type of urinary diversion, and primary diagnosis). Complication rates were higher in readmitted patients
than those not readmitted; 2-year mortality was associated with 90-day readmission status—18.8% of readmitted versus 12.8%
of not readmitted patients died within 2years of surgery (P=0.003).
ConclusionsReadmissions occur commonly after urinary diversion. Many readmitted patients have complications of complex surgery managed
at secondary hospitals, which may portend a quality concern that merits further study.
KeywordsBladder cancer–Urinary diversion–Neobladder–Complications–Readmission–Quality of care
World Journal of Urology 04/2012; 29(1):79-84. · 2.41 Impact Factor
-
Napoleon Santos,
Justin B Wenger,
Pamela Havre,
Yanxia Liu,
Roi Dagan,
Iman Imanirad,
Alison M Ivey,
Robert A Zlotecki,
Chester B Algood, Scott M Gilbert,
Carmen J Allegra,
Paul Okunieff,
Johannes Vieweg,
Nam H Dang,
Hendrik Luesch,
Long H Dang
[show abstract]
[hide abstract]
ABSTRACT: Antiangiogenic therapy has shown promise in the treatment of patients with renal cell carcinoma (RCC). Two classes of antiangiogenic drugs, the anti-vascular endothelial growth factor antibody bevacizumab and the tyrosine kinase inhibitors sorafenib, sunitinib and pazopanib, have shown efficacy in patients with RCC and are approved by the US Food and Drug Administration for treatment of this cancer. In practice, the clinical benefit of antiangiogenic drugs in RCC has been heterogeneous, and in patients who do respond, benefits are modest and/or short-lived. To improve efficacy, combination targeted therapy has been attempted, but with either very limited additional efficacy or nontolerable toxicities. Recent advances in the molecular understanding of tumor angiogenesis and mechanism of resistance, along with the rapid development of targeted drug discovery, have made it possible to further explore novel combination therapy for RCC.
Oncology 11/2011; 81(3-4):220-9. · 2.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Renal cell carcinoma (RCC), the most common human kidney cancer, is frequently infiltrated with tumor-associated macrophages (TAM) that can promote malignant progression. Here, we show that TAMs isolated from human RCC produce substantial amounts of the proinflammatory chemokine CCL2 and immunosuppressive cytokine IL-10, in addition to enhanced eicosanoid production via an activated 15-lipoxygenase-2 (15-LOX2) pathway. TAMs isolated from RCC tumors had a high 15-LOX2 expression and secreted substantial amounts of 15(S)-hydroxyeicosatetraenoic acid, its major bioactive lipid product. Inhibition of lipoxygenase activity significantly reduced production of CCL2 and IL-10 by RCC TAMs. In addition, TAMs isolated from RCC were capable of inducing in T lymphocytes, the pivotal T regulatory cell transcription factor forkhead box P3 (FOXP3), and the inhibitory cytotoxic T-lymphocyte antigen 4 (CTLA-4) coreceptor. However, this TAM-mediated induction of FOXP3 and CTLA-4 in T cells was independent of lipoxygenase and could not be reversed by inhibiting lipoxygenase activity. Collectively, our results show that TAMs, often present in RCCs, display enhanced 15-LOX2 activity that contributes to RCC-related inflammation, immunosuppression, and malignant progression. Furthermore, we show that TAMs mediate the development of immune tolerance through both 15-LOX2-dependent and 15-LOX2-independent pathways. We propose that manipulating LOX-dependent arachidonic acid metabolism in the tumor microenvironment could offer new strategies to block cancer-related inflammation and immune escape in patients with RCC.
Cancer Research 09/2011; 71(20):6400-9. · 7.86 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Both cancer-related inflammation and tumor-induced immune suppression are associated with expansion of myeloid cell subsets including myeloid-derived suppressor cells. However, little known regarding characteristics of myeloid cells in patients with bladder cancer. In this study, we analyzed myeloid cells from peripheral blood (PBMC) and tumor tissue that were collected from patients with superficial noninvasive and invasive urothelial carcinomas. Our results demonstrate that PBMC from bladder cancer patients contain two major CD11b myeloid cell subsets: granulocyte-type CD15(high) CD33(low) cells and monocyte-type CD15(low) CD33(high) cells. The number of circulating granulocytic but not monocytic myeloid cells in cancer patients was markedly increased when compared to healthy individuals. Both myeloid cell subsets from cancer patients were highly activated and produced substantial amounts of proinflammatory chemokines/cytokines including CCL2, CCL3, CCL4, G-CSF, IL-8 and IL-6. Granulocytic myeloid cells were able to inhibit in vitro T cell proliferation through induction of CD4(+) Foxp3(+) T regulatory cells. Analysis of bladder cancer tissues revealed that tumors were infiltrated with monocyte-macrophage CD11b(+) HLA-DR(+) and granulocytic CD11b(+) CD15(+) HLA-DR(-) myeloid cells. Collectively, this study identifies myeloid cell subsets in patients with bladder cancer. We demonstrate that these highly activated inflammatory myeloid cells represent a source of multiple chemokines/cytokines and may contribute to inflammation and immune dysfunction in bladder cancer.
International Journal of Cancer 04/2011; 130(5):1109-19. · 5.44 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Most analyses of complications after urinary diversion are restricted to the index admission. Given the complexity of these reconstructions, readmissions occur commonly. We sought to characterize the burden and impact of readmissions in the postoperative period following urinary diversion.
Using 5% Medicare data for the years 1998-2005, we identified patients undergoing ileal conduit, continent, and other urinary diversions for benign and malignant indications. We examined the 90-day rates of readmission and evaluated factors associated with readmission after urinary diversion, either to the primary hospital or to a secondary facility. We assessed 90-day and 2-year mortality after urinary diversion and incorporated readmission status as a covariate in these multivariable models.
Our study sample included 1,565 patients, of whom 491 patients (31%) were readmitted within 90 days of their urinary diversion. Patients readmitted after urinary diversion had higher comorbidity count than those not readmitted (59% of those readmitted with comorbidity count at least 1 versus 50% of those not readmitted, P=0.002). Other clinical and demographic characteristics did not differ by readmission status (P>0.12 for age, race, type of urinary diversion, and primary diagnosis). Complication rates were higher in readmitted patients than those not readmitted; 2-year mortality was associated with 90-day readmission status-18.8% of readmitted versus 12.8% of not readmitted patients died within 2 years of surgery (P=0.003).
Readmissions occur commonly after urinary diversion. Many readmitted patients have complications of complex surgery managed at secondary hospitals, which may portend a quality concern that merits further study.
World Journal of Urology 02/2011; 29(1):79-84. · 2.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The Medicare Modernization Act led to moderate reductions in reimbursement for androgen-deprivation therapy (ADT) for prostate cancer, starting in 2004 and followed by substantial changes in 2005. We hypothesized that these reductions would lead to decreases in the use of ADT for indications that were not evidence based.
Using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, we identified 54,925 men who received a diagnosis of incident prostate cancer from 2003 through 2005. We divided these men into groups according to the strength of the indication for ADT use. The use of ADT was deemed to be inappropriate as primary therapy for men with localized cancers of a low-to-moderate grade (for whom a survival benefit of such therapy was improbable), appropriate as adjuvant therapy with radiation therapy for men with locally advanced cancers (for whom a survival benefit was established), and discretionary for men receiving either primary or adjuvant therapy for localized but high-grade tumors. The proportion of men receiving ADT was calculated according to the year of diagnosis for each group. We used modified Poisson regression models to calculate the effect of the year of diagnosis on the use of ADT.
The rate of inappropriate use of ADT declined substantially during the study period, from 38.7% in 2003 to 30.6% in 2004 to 25.7% in 2005 (odds ratio for ADT use in 2005 vs. 2003, 0.72; 95% confidence interval [CI], 0.65 to 0.79). There was no decrease in the appropriate use of adjuvant ADT (odds ratio, 1.01; 95% CI, 0.86 to 1.19). In cases involving discretionary use, there was a significant decline in use in 2005 but not in 2004.
Changes in the Medicare reimbursement policy in 2004 and 2005 were associated with reductions in ADT use, particularly among men for whom the benefits of such therapy were unclear. (Funded by the American Cancer Society.).
New England Journal of Medicine 11/2010; 363(19):1822-32. · 53.30 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To summarize recently published findings regarding functional and health-related quality of life (HRQOL) outcomes associated with conduit and continent urinary diversion, review the evidence (or lack thereof) supporting one diversion type over another, and discuss important factors that impact how patients should likely be counseled regarding choosing between conduit and continent urinary diversions following bladder removal.
Functional and HRQOL outcomes have become an important aspect of outcome assessment following urinary diversion. Early research has been limited by the lack of disease-specific instruments and a dearth of reliable, responsive and valid measures. Recently, several disease-specific HRQOL questionnaires have been developed using more robust methods and are in the early phase of outcome assessment. Ultimately, data from these assessments may be used to aid in the decision-making process. However, to date, surveys have not exhibited significant differences when comparing various diversion types, including ileal conduit and orthotopic continent neobladder. A review of the recent literature confirms this finding. Instead of attempting to prove the superiority of one diversion type over another, future studies should endeavor to evaluate the relationship between preoperative health status, diversion choice based on patient preference, and postoperative clinical outcomes.
Although postoperative HRQOL outcomes are an important component of counseling prior to urinary diversion procedures, the decision-making process concerning the appropriate type of diversion involves patient education, participation, and in-depth discussion of patient preferences given the preference-sensitive nature of choosing between a conduit and continent diversion.
Current opinion in urology 09/2010; 20(5):421-5. · 2.50 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: On June 7, 2000 President Clinton issued an executive memorandum directing Medicare payment for routine patient care in qualifying clinical trials. We estimated the proportion of older patients with prostate cancer who were examined as part of a qualifying clinical trial, and the association between participation and patient characteristics.
We performed an observational study using the Surveillance, Epidemiology and End Results Medicare database to determine participation in qualifying clinical trials in a sample of 37,216 men 66 years old or older who were enrolled in Medicare and diagnosed with prostate cancer between September 2000 and December 2002.
Within 3 years of diagnosis 211 men (0.567%) received routine patient care in a qualifying clinical trial. These participants were more likely to be younger than 70 years (OR 1.687, 95% CI 1.27-2.24) and less likely to be less educated and reside in low income, metropolitan neighborhoods. White men were more likely to participate in clinical trials than nonwhite men but this association was not statistically significant (OR 1.426, CI 0.97-2.09). Participation varied significantly by registry site (0% to 1.2%) but not by tumor grade or stage, or prostate specific antigen status.
Few older patients with prostate cancer participated in qualifying trials between 2000 and 2002. Those who participated were not representative of the general population of older patients with prostate cancer. Greater efforts are required to expand trial enrollment and decrease disparities in research participation.
The Journal of urology 09/2010; 184(3):901-6. · 4.02 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Patients undergoing radical cystectomy with neobladder for bladder cancer are hypothesized to tolerate worse urinary function than ileal conduit patients because of improved body image. The purpose of this study was to compare body image and quality of life between the 2 diversion types after surgery.
Patients who underwent radical cystectomy at the University of Michigan from November 1999 onwards and completed follow-up between July 2007 and August 2008 were eligible for the study. Patients who had cystoscopy for bladder cancer were enrolled as a reference group. Urinary, bowel, and sexual outcomes were assessed using the Bladder Cancer Index, and body image was evaluated using the EORTC Body Image Scale. Cross-sectional analysis at baseline, 1 month, 6 months, and 1, 2, 4, 6, and 8 years after treatment was performed.
A total of 139 neobladder, 85 conduit, and 112 cystoscopy patients were studied. After cystectomy, both conduit and neobladder groups had worse body image scores that improved over time, although the neobladder group did not return to baseline. Age was associated with score but gender was not. Urinary function was better in conduit patients but urinary bother was the same in both diversion types.
Radical cystectomy has a significant impact on body image that improves slowly over time. No difference in body image scores between ileal conduit and neobladder patients exists after surgery. Factors other than just body image are likely involved in the patient's acceptance of worse urinary function associated with a neobladder.
Urology 05/2010; 76(3):671-5. · 2.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We developed and validated a reliable, responsive multidimensional instrument to measure disease specific health related quality of life in bladder cancer survivors treated with local cancer therapy.
Instrument content was based on qualitative information obtained from a panel of bladder cancer providers and from patient focus groups. Draft items were piloted and revised, resulting in the 36-item Bladder Cancer Index consisting of urinary, bowel and sexual health domains. Internal consistency, test-retest reliability, convergent validity, concurrent validity and criterion validity were then assessed.
Internal consistency was high at 0.77 to 0.91. Test-retest reliability was also high at 0.73 to 0.95. Correlations among the 3 domains were low (r < or = 0.39), indicating interscale independence. Health outcome discrimination was apparent in clinically distinct treatment groups. Moderate correlation was observed with existing external measures, indicating that the Bladder Cancer Index detects aspects of health related quality of life related to bladder cancer treatments that are not recorded by more general measures.
The Bladder Cancer Index is a robust, multidimensional measure of bladder cancer specific health related quality of life and to our knowledge is the first available validated instrument to assess health outcomes across a range of local treatments commonly used for bladder cancer.
The Journal of urology 03/2010; 183(5):1764-9. · 4.02 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This article in the Users' Guide to the Urological Literature series examines studies that provide information about prognosis for evidence-based clinical practice.
Studies of prognosis are introduced to the reader in the context of a clinical scenario that raises questions about the expected outcome for a patient. Critical appraisal of prognostic studies addresses the 3 questions. 1) Are the results valid? 2) What are the results? 3) Can I apply the results to the care of my patients?
To assess the validity of a cohort study that addresses a question of prognosis, the reader should first ask whether the sample of patients under investigation were representative and sufficiently homogeneous with respect to prognostic risk. Investigators should measure all plausible determinants of outcome (prognostic or risk factors) and present results for all subgroups in which the prognosis differs substantially. The reader should ask whether followup was sufficiently complete, and whether investigators used objective, unbiased and patient relevant outcomes. The results should address the likelihood of the outcomes of interest and the precision of the estimates. Finally the reader should ask how similar the study patients and treatment are to his/her patients, and whether followup was sufficiently long.
Questions of prognosis have an important role in the practice of urology and are usually best answered by nonrandomized, observational studies. Urologists should critically appraise these studies for validity, impact and applicability before using the results to guide patient care.
The Journal of urology 02/2010; 183(4):1303-8. · 4.02 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The attendant requirement of urinary diversion following radical cystectomy results in several functional consequences that
impact health-related quality of life (HRQOL) in bladder cancer patients managed with surgery. While significant developments
in urinary reconstruction have increased the availability of several different forms of continent diversion, the majority
of cystectomy patients still receive an incontinent urinary reconstruction. Many surgeons argue, that improved techniques
have resulted in reduced complications from continent urinary diversion, and that these types of reconstruction offer better
functional and health-related quality of life outcomes compared to incontinent diversion. Certainly, this premise holds intuitive
validity; however, this has not been demonstrated reliably to date.
While research aimed to address the relative benefit of continent urinary diversion from the perspective of functional outcomes
and HRQOL has been an active area of investigation for many years, limitations in methodology and a lack of reliable disease-specific
instruments to measure these outcomes have resulted in a lack of progress. To date, high-quality evidence indicating that
one type of urinary diversion is superior to another does not exist. Addressing issues related to problematic measurement
and improving the quality of research are imperatives to moving the field forward. Currently, there are several disease-specific
instruments in various stages of development and testing. A validation of these measures, and systematic assessment of HRQOL
will inform the debate regarding the optimal type of urinary diversion.
KeywordsBladder cancer-Urinary diversion-Health-related quality of life-Functional outcomes-Complications
12/2009: pages 190-199;
-
[show abstract]
[hide abstract]
ABSTRACT: Androgen deprivation therapy (ADT) for prostate cancer increased substantially through the 1990s, but more recent national trends regarding incident and prevalent use have been incompletely characterized.
Linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to study patterns of ADT utilization. Prevalence of ADT in the male Medicare population was estimated by examining a cohort of prostate cancer patients and a 5% noncancer control population, from 1991 to 2005. ADT use across different indications was examined for men with incident cancers from 2000 to 2002. Nested logit models were used to examine determinants of ADT use in men with lower risk prostate cancer not treated definitively by surgery or radiation.
Prevalent ADT use increased through the 1990s, peaked in 2000 at 3.17% of all male Medicare beneficiaries, subsequently stabilized, then dropped in 2005 to 2.92%. Between 2000 and 2002, use in incident prostate cancer was stable, with 44.8% use in all cases, 15% of cases as an adjuvant with radiation, and 14% as a primary therapy. In the nested logit model, predictors of ADT use in a lower risk setting were older age, higher stage and grade, and elevated prostate-specific antigen levels.
Following a period of rapid expansion during the 1990s, incident and prevalent use of ADT has leveled, and may be starting to decline. Further research is needed to monitor how reductions in reimbursement for GnRH agonists will affect appropriate use of ADT as well as use in settings where its benefits may be marginal.
Urologic Oncology 11/2009; 29(6):647-53. · 3.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: For several cancers, the number of lymph nodes removed during surgery is associated with survival. Observational studies supporting this association have prompted considerable debate regarding the extent of lymphadenectomy, and in some dieases, absolute lymph node counts have been suggested as a measure of the quality of cancer care. However, for most cancers, lymph node counts may not directly influence survival in a causal manner. In fact, several randomized clinical trials addressing the question in lung, gastric, and pancreatic cancers have not shown more extensive lymph node dissections to be linked with improved survival. Despite this negative evidence, however, lymph node counts have remained a target process in quality initiatives. Misinterpretation of the evidence may be driving some of the pressure to broadly implement more extended lymph node dissections. As a process for more accurate disease staging and as a potential marker for the completeness of surgery, lymph node counts are likely linked to quality, at least indirectly. However, a causal association between lymph node counts (and extented lymphadenectomy) and survival is tenuous and has not been supported by high-level evidence.
Journal of the National Comprehensive Cancer Network: JNCCN 02/2009; 7(1):58-61. · 4.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Preservation of periprostatic neurovascular tissue at the time of radical prostatectomy has been correlated with subsequent erectile function and urinary continence. We evaluated whether the amount of neurovascular tissue identified on prostatectomy specimens correlated with surgeon's intention of nerve-sparing and/or predicted quality of life outcomes.
Radical prostatectomy specimens from 60 patients were evaluated by 2 pathologists for residual neurovascular bundle tissue. Reviewable pathology was available for 17, 19, and 19 patients with bilateral, unilateral, and non-nerve-sparing radical prostatectomy, respectively. The patients completed the Expanded Prostate Cancer Index Composite, a validated quality of life questionnaire. Differences between neurovascular tissue thickness, surgeon's intent at nerve-sparing, and quality of life among patients in each group were analyzed using standard statistical software.
Neurovascular tissue thickness identified on radical prostatectomy specimens did not correlate with surgeon's intent at performing a nerve-sparing procedure, nor was it found to be predictive of postoperative quality of life. Surgeon's intent at neurovascular preservation, however, was associated with improved sexual and urinary function scores at 1 year (both P < 0.05).
Surgeon intent, regardless of the amount of neurovascular tissue identified on radical prostatectomy specimen, is predictive of postoperative sexual-related and urinary quality of life. This suggests that factors other than the amount of neurovascular tissue spared contribute to postoperative sexual and urinary function.
Urologic Oncology 12/2008; 28(5):487-91. · 3.22 Impact Factor
-
Canadian Urological Association journal = Journal de l'Association des urologues du Canada 09/2008; 2(4):407-9. · 1.24 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We use a tailored approach to laparoscopic partial nephrectomy based on tumor depth of penetration and proximity to the renal sinus. We evaluated differences in perioperative outcomes to determine the value of this paradigm.
The surgical approach to hilar clamping and tumor bed management during laparoscopic partial nephrectomy included no clamp or suture, clamp with no suture, and clamp and suture. The end points assessed retrospectively were differences in perioperative, pathological and complication outcomes among these groups.
Our surgical paradigm was used in 174 patients, including no clamp or suture in 36, clamp with no suture in 25, and clamp and suture in 113. Compared to the other patients those with a clamp and suture procedure were older with larger and deeper tumors that were closer to the renal sinus-collecting system and more likely to be malignant. Operative time was shortest in the no clamp or suture group and in the 2 clamp groups warm ischemia and operative times were shorter than in the no suture group. Estimated blood loss, hospital stay, surgical margins, complications and recurrences did not differ among the groups. A creatinine increase of 0.3 mg/dl or greater was seen in 33 patients (19%) following surgery, which was attributable to conversion to nephrectomy in 4, contralateral nephrectomy or partial nephrectomy in 3 and underlying medical renal disease in 1. In the remaining 25 patients no other cause was apparent except renal hilar clamping and tumor resection.
A tailored approach based on tumor location and proximity to the renal sinus-collecting system can limit operative and ischemia times, and technically simplify the procedure without adversely impacting morbidity, convalescence and oncological outcomes.
The Journal of urology 09/2008; 180(4):1273-8. · 4.02 Impact Factor
-
Scott M Gilbert
Cancer 07/2008; 112(11):2331-3. · 4.77 Impact Factor
