[Show abstract][Hide abstract] ABSTRACT: The perioperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for T1-T2 renal cell carcinoma (RCC) are well established. We aim to determine whether LRN is a comparable alternative to open radical nephrectomy (ORN) in the treatment of T3 RCC using a matched pair analysis study design.
A review of a prospectively collected database at the Western General Hospital, Edinburgh, between 2000 and 2011 was conducted. Patient pairs were matched based on age at operation, gender, histological subgroup, maximal tumour diameter, TNM stage and grade. Patient demographics, operative and post-operative outcomes were compared. Overall, cancer-specific and progression-free survival [overall survival, cancer-specific survival (CSS) and progression-free survival (PFS)] were estimated using the Kaplan-Meier method.
From 252 patients with T3 disease, 25 pairs were matched. Patients were of median age 66.2 years, 64 % male. Tumours were all clear cell RCC, were stage pT3a (32 %) or pT3b and had maximal tumour diameters of 8.7 cm for LRN and 10.0 cm for ORN. Estimated blood loss (100 ml LRN; 650 ml ORN, p < 0.001) and length of post-operative hospital stay (4 days LRN: 9 days ORN, p < 0.001) were lower in the LRN group. Operation time and post-operative complication rates were comparable. CSS and PFS were comparable with a mean CSS of 91.3 months for LRN and 88.7 months for ORN.
This study reports the longest median follow-up in a T3 LRN cohort. In matched patients, LRN has been shown to have a superior perioperative profile to ORN for the treatment of pT3a/b RCC, with no adverse effect on midterm oncological outcomes.
World Journal of Urology 03/2014; · 2.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: To determine the stage specific operative, post-operative and oncologic outcomes, for patients undergoing a laparoscopic radical nephrectomy (LRN) for renal cell cancer (RCC) in a single centre, and assess changes over a generation of practice. Patients and Methods: From December 1992 to July 2011, data was collected prospectively for 854 consecutive simple and radical laparoscopic nephrectomies, 397 of which were LRNs for RCC. The first LRN was performed in December 1997. Stage specific surgical and oncologic outcomes were assessed across the study period. Patients were then grouped into three equal, consecutive cohorts. Case mix and surgical outcomes were compared to assess changes with departmental experience. Results: There were 206, 71, 118 and 2 patients across stages pT1, pT2, pT3 and pT4 respectively. Median operating time was significantly shorter for pT1 tumours (125, 150 and 150 min for pT1-3, p<0.021), while median estimated blood loss (EBL) was greater for pT3 tumours (50, 50, 100ml, for pT1-3, p<0.001). Median follow-up time was 31, 30 and 18 months respectively across pT1-pT3. There was a significant difference in 5-year overall survival (82.4%, 68.4%, 58.9%), cancer specific survival (99.5%, 83.6%, 66.5%) and progression free survival (86.5%, 66.3%, 47.5%) across these stage-specific subgroups. Over the three cohorts there was an increase in LRN performed for locally advanced disease and cytoreduction. With greater surgical experience, there was improvement in median operation time and median EBL in localised disease over the three time periods, but no significant changes for locally advanced disease. Conclusion: This is the largest reported series of LRN in the United Kingdom. Departmental experience has resulted in improved surgical outcomes for localised RCC, with expansion of practice in more complex advanced disease. Laparoscopic nephrectomy is both operatively and oncologically safe in T1 and T2 disease, and although technically more demanding it is also safe in selected T3 disease.
Journal of endourology / Endourological Society 05/2013; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Shockwave lithotripsy (SWL) can be used to treat stones at any position within the ureter, as long as the stone is radio-opaque and there is a path for the shockwave to reach the stone. However the results of SWL to distal ureteric calculi, with the patient in a prone position, were inferior to those of treating stones within the upper ureter. The transguteal approach allows the lithotripsy shockwave to reach the lower ureter via the greater selatle foramen. This study shows that this approach for SWL to distal ureteric calculi is more effective than the prone approach. OBJECTIVE: To compare the outcomes of extracorporeal shockwave lithotripsy (ESWL) for distal ureteric stones treated using the prone and transgluteal (supine) approaches in a tertiary referral stone unit using a fourth generation lithotriptor. PATIENTS AND METHODS: We selected consecutive patients undergoing ESWL to distal ureteric stones over 1 year, during which we changed our treatment protocol from a prone to transgluteal (supine) approach. Patients were treated using the Sonolith Vision Lithotriptor (Technomed Medical Systems, Vaulx-en-Velin, France). Outcome was assessed using plain abdominal film of kidney, ureter and bladder (KUB) X-ray taken at 2 weeks then monthly as required. Treatment success was defined as complete clearance of stone fragments and treatment failure was defined as persistence of stone fragments beyond 3 months or the need for ureteroscopy. RESULTS: A total of 38 patients were treated in the prone position and 72 patients using a transgluteal approach. Patient and stone characteristics were identical in both groups. The mean (range) stone size was 7.8 (4-16) mm. The proportions of patients who were stone-free after one treatment session within the prone and transgluteal treatment groups were 40 and 78%, respectively (<0.001). The overall success rates for treatment within the prone and transgluteal groups were 63 and 92%, respectively (<0.001). CONCLUSIONS: Transgluteal ESWL to stones within the distal ureter leads to significantly higher stone-free rates than treatment using the prone approach. The majority of patients are rendered stone-free after one session of treatment and the overall success rates are similar to those of ureteroscopic management.
[Show abstract][Hide abstract] ABSTRACT: PURPOSE: To compare the outcomes of endoscopic surgery (Endo) to laparoscopic nephroureterectomy (LNU) for the management of specifically non-invasive UTUC. MATERIALS & METHODS: A retrospective, database review identified consecutive patients with clinically non-invasive UTUC who underwent Endo (n=59; via ureteroscopic ablation or percutaneous resection) or LNU (n=70) at a single-centre, over 20 years (1991-2011). Overall survival (OS), UTUC-specific survival (DSS), upper-tract recurrence-free survival (UT-RFS), intravesical recurrence-free survival (Bl-RFS), progression-free survival (PFS), and renal unit survival (RUS) were estimated using Kaplan-Meier methods, with differences assessed using the log rank test. RESULTS: The median age and follow-up were 74.8 years and 50 months respectively. Overall renal preservation in the endoscopic group was high (5y RUS 82.5%), although this came at a cost of high local recurrence (Endo 5y RFS 49.3%, LNU 100%, p<0.0001). For G1 UTUC, Endo 5y DSS (100%) was equivalent to LNU (100%). However, LNU demonstrated superior DSS to Endo for G2 disease (91.7% vs 62.5%, p=0.037) and superior PFS for G3 disease (88.9% vs 55.6%, p=0.033). CONCLUSIONS: For G1 UTUC, endoscopic management can provide effective oncological control and renal preservation. However, endoscopic management should not be considered for higher-grade disease, except in compelling imperative cases or in patients with poor life-expectancy, as oncological outcomes are inferior to LNU.
The Journal of urology 12/2012; · 4.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction Laparoscopic nephrectomy (LN) has largely replaced open nephrectomy. The aim of this study was to describe a validated modular system for training urologists in LN in the context of the shorter training times available in the current era. Methods Following attendance at dry and wet lab courses, three mentees (trainee, new consultant and an experienced open surgeon) were mentored through a five module LN training system in our centre followed by the mentee's own hospital. A minimum of 25 independent procedures were then performed by mentees in their own hospital. Results 17-32 mentored cases were required to become competent in LN, followed by up to 5 observed cases in the mentee's own centre. Subsequently, data from the first 105 cases (80 LN and 25 laparoscopic nephroureterectomies (LNU)) performed by the 3 surgeons after the end of their training without observation by their mentor, were retrospectively collected and analyzed. There were 3 conversions (2.9%). For LN and LNU respectively: median operative time was 140mins (65-390mins) and 180mins (90-300mins); median estimated blood loss 30ml (0-2000ml) and 50ml (0-2000ml); median post-operative stay 4d (2-45d) and 6d (3-27d). Four patients (3.8%) required a post-operative transfusion. There was no 30-day mortality. Conclusion Mentees matched the median British Association for Urological Surgeons (BAUS) registry operating time (LN-120-180mins, LNU-180-240mins) and had lower conversion rates (2.9%vs6.4% for BAUS). Mentees matched median BAUS database reported blood loss (LN and LNU-<500ml) and LOS (LN-4d, LNU-5d). This modular training programme allows urologists to become independent in LN after a short period of focused training in the training centre followed by a short period of mentoring in the mentee's own centre.
Journal of endourology / Endourological Society 05/2012; · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Endoscopic management of small, low-grade, non-invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long-term survival outcomes of endoscopically-managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow-up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease-specific survival outcomes. The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long-term follow-up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade-stratified analysis of different outcomes, including upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and disease-specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low-grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres. OBJECTIVE: • To report the long-term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20-year period. PATIENTS AND METHODS: • Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment. • Outcomes were obtained via retrospective analysis of notes, electronic records and registry data. • Survival outcomes, including overall survival (OS), UTUC-specific survival (disease-specific survival; DSS), upper-tract recurrence-free survival, intravesical recurrence-free survival, renal unit survival and progression-free survival, were estimated using Kaplan-Meier methods and grade-stratified differences were analyzed using the log-rank test. RESULTS: • Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years. • All patients underwent ureteroscopy and biopsy-confirmation of pathology was obtained in 81% (n= 59) of the patients. In total, 14% (n= 10) of the patients underwent percutaneous resection. • Median (range; mean) follow-up was 54 (1-223; 62.8) months. • Upper tract recurrence occurred in 68% (n= 50). Eventually, 19% (n= 14) of the patients proceeded to nephroureterectomy. • The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months. CONCLUSIONS: • The present study represents one of the largest reported series of endoscopically-managed UTUC, with high pathological verification and long-term follow-up. • Upper-tract recurrence is common, which mandates regular ureteroscopic surveillance. • However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.
[Show abstract][Hide abstract] ABSTRACT: What's known on the subject? and What does the study add? Endoscopic management of upper tract urothelial carcinoma (UTUC) using either ureteroscopy and laser ablation, or percutaneous resection, is a management option for treating selected low-grade tumours with favourable characteristics. However, the evidence base for such practice is relatively weak, as the reported experience is mainly limited to small case series (level of evidence 4), or non-randomised comparative studies that are unmatched for tumour stage (level of evidence 3b), with variability of follow-up duration and reported outcome measures. The present systematic review comprehensively reviews the outcomes of all studies of endoscopic management of UTUC, including the role of topical adjuvant therapy. It establishes for the first time a structured reference for endoscopic management of UTUC, and is a foundation for further clinical studies.
To systematically review the oncological outcomes of upper tract urothelial carcinoma (UTUC) treated with ureteroscopic and percutaneous management. The standard treatment of UTUC is radical nephroureterectomy (RNU). However, over the last two decades several institutions have treated UTUC endoscopically, either via ureteroscopic ablation or percutaneous nephroscopic resection of tumour (PNRT), for both imperative and elective indications.
For evidence acquisition the Pubmed database was searched for English language publications in December 2011 using the following terms: upper tract (UT) transitional cell carcinoma (TCC), upper tract TCC, UTTCC, upper tract urothelial cell carcinoma, upper tract urothelial carcinoma, UTUC, endoscopic management, ureteroscopic management, laser ablation, percutaneous management, PNRT, conservative management, ureteroscopic biopsy, biopsy, BCG, mitomycin C, topical therapy.
There are no randomised trials comparing endoscopic management with RNU. Most published studies were retrospective case series (and database reviews), or unmatched comparative studies. There was strong selection bias for favourable tumour characteristics in many endoscopically treated groups. There was variation in medical comorbidity and indication for treatment across different study groups. The biopsy verification of underlying UTUC pathology was inconsistent. The follow-up in most studies was limited, typically to a mean 3 years.
There is a high rate of UT recurrence with endoscopically managed UTUC, and a grade-related risk of tumour progression and disease-specific mortality. Overall, renal preservation may be high with ≈20% of patients proceeding eventually to RNU. For highly selected Grade 1 (or low-grade) disease managed in experienced centres, 5-year disease-specific survival (DSS) may be equivalent to RNU, although the small study groups and short follow-ups preclude comments on less favourable Grade 1 (or low-grade) tumour characteristics, or DSS, in the longer-term. For Grade 3 (or high-grade) disease, DSS outcomes are poor and endoscopic management should only be considered for compelling imperative indications in the context of the patient's overall life expectancy and competing comorbidity.
BJU International 04/2012; 110(5):614-28. · 3.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy is a well established treatment for localized RCC, where nephron-sparing approaches are not appropriate. As surgeon and departmental experience grow more extensive tumours will be tackled laparoscopically. However, little is known about the operative safety and oncological outcomes of the laparoscopic approach for locally advanced RCC. The present study describes the largest reported cohort of patients receiving laparoscopic radical nephrectomy for locally advanced RCC. In the context of suitably experienced personnel in an established centre, we have established that this approach is safe from operative, postoperative and oncological standpoints, with comparable data to existing open series.
To determine the operative, postoperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for locally advanced renal cell cancer (RCC), which, as surgeon and departmental experience increases, is being performed more often.
In total, 94 consecutive patients receiving LRN for pathologically confirmed T3 or T4 RCC at a tertiary referral centre between March 2002 and May 2010 were analyzed. Preoperative, operative, tumour and postoperative characteristics were evaluated together with recurrence and outcome data. Survival was estimated using the Kaplan-Meier method. Cox's proportional hazards model was used for multivariate analysis.
In total, 77 patients had LRN with curative intent and 17 patients had LRN with cytoreductive intent. There were six LRNs (6.4%) that were converted to open procedures. Overall, there were two (2.1%) Clavien grade IIIa complications, one (1.1%) grade IVa complication and one (1.1%) postoperative death. Overall median follow-up was 17.4 months. In total, 22 (28.6%) patients receiving curative LRN developed a recurrence after a median of 13.9 months; 12 (54.5%) patients developed distant metastases, five (22.7%) patients had local recurrences and three (13.6%) patients had transcoelomic spread. Median predicted progression free survival was 48.4 months in patients undergoing LRN with curative intent. Median predicted overall survival was 65.6 months after curative LRN and 15.7 months after cytoreductive LRN. Multivariate analysis did not reveal any variables influencing recurrence or survival.
In the context of suitably experienced personnel in an established centre, LRN for locally advanced RCC is safe from an operative and oncological standpoint. Patients clinically staged as T3 RCC must still be selected carefully for LRN in a multidisciplinary setting.
BJU International 01/2012; 110(6):884-90. · 3.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Open nephroureterectomy (ONU) rather than laparoscopic nephroureterectomy (LNU) is still regarded as the standard of care for extirpative surgical management of upper urinary tract urothelial-cell carcinoma (UUT-UCC). The longest published follow-up of LNU is 7 years. We report outcomes for patients having surgery ≥10 years ago.
Consecutive patients with UUT-UCC who were treated with ONU (n=39) or LNU (n=23) between April 1992 to September 2000 were included. Preoperative, tumor, operative and postoperative characteristics, recurrence, and outcomes were collated. Survival was estimated using the Kaplan-Meier method.
Median follow-up of censored patients was 163 months (13.6 y). Estimated mean overall survival (OS) was 111 months for ONU and 103 months for LNU. Mean progression free survival (PFS) was 175 months for ONU and 143 months for LNU. Probability of PFS at 10 years was 79% for ONU and 76% for LNU and was unchanged at 15 years. There was no significant difference between ONU and LNU in terms of OS (P=0.51, log-rank test), PFS (P=0.70) or cancer-specific survival (CSS; P=0.43). There were no prognostic differences between ONU and LNU after correcting for confounding variables. There was no increase in the probability of a bladder cancer recurrence from 10 to 15 years postoperation.
Long-term follow-up of patients who were operated on more than 10 years ago suggests that LNU has oncologic equivalence to ONU because there were no significant differences in OS, PFS, or CSS between ONU and LNU patients followed for a median of 13 years.
Journal of endourology / Endourological Society 08/2011; 25(8):1329-35. · 1.75 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Extracorporeal shock wave lithotripsy (SWL) is a non-invasive treatment for urinary tract stones. This review presents the role of SWL for treating specifically ureteric calculi. The impact of hydronephrosis on SWL success, the use of SWL as emergency treatment (eSWL) for acute ureteric colic, the influence of ureteric stent placement on SWL outcome and the use of medical expulsive therapy to augment SWL success are discussed.
Minerva urologica e nefrologica = The Italian journal of urology and nephrology 06/2011; 63(2):175-82. · 0.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
To identify the most cost-effective treatment for ureteric stones ≤15mm in our department, by using an economic model to compare the total cost of shockwave lithotripsy (SWL) versus ureteroscopy with Holmium:YAG laser lithotripsy (URSL).
British Journal of Medical and Surgical Urology 01/2010; 3(2):65-71.
[Show abstract][Hide abstract] ABSTRACT: Shockwave lithotripsy (SWL) is considered as an initial option for a significant proportion of urinary tract stones. Despite efforts for standardized terminology and methodology, published studies on lithotripsy outcome are very different. This review will focus on a brief description of evidence-based medicine and recent literature results on SWL outcome.
The introduction of hierarchy in scientific evidence is becoming more widespread. Various grading systems have attempted to rank recommendations according to type and amount of evidence. Different levels of evidence have been created for therapy, diagnosis and prognosis. Various authors have developed scoring systems and identified radiographic parameters to predict SWL outcome. The long-term safety of lithotripsy on renal function has been demonstrated. Randomized controlled trials and meta-analysis have shown that medical expulsive therapy and a slower shockwave rate will improve SWL outcome.
Evidence-based medicine is rapidly becoming an indispensable part of everyday medical practice. Common terminology is necessary for proper evaluation of SWL. Different types of studies are required to investigate efficacy, compare SWL to other options, complications and so on. Randomized clinical trials are of the highest value; matched-pair analyses and well designed controlled studies can offer significant help.
Current opinion in urology 11/2009; 20(2):154-8. · 2.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate the issue of shockwave lithotripsy failure by studying the effect of machine crossover to the Technomed Sonolith Vision (TSV) lithotriptor in patients with previously unsuccessfully treated renal stones with the Dornier Compact Delta (DCD). Records were examined for the period between 1998 and 2006. Parameters analysed were: size, multiple/single stones, location, treatments/stone.
Seventy-six patients fulfilled the inclusion criteria. Following lithotripsy with the TSV, the stone-free rate (SFR) at 3 months was 56.7%, and the success rate (stone-free and fragments < or = 4 mm, SR) 86.7%. Twenty-two patients had multiple stones and the majority of the stones were located in the lower calyx (59.2%). Mean size was 8.9 mm prior to treatment with the TSV machine (10.2 mm for DCD). Further analysis followed in a subgroup of 42 patients of the same stone size (+/-2 mm) before and after DCD sessions. Mean stone size was 7 mm. The SFR was 61.9% (62.9% vs. 40.9% for single and multiple stones), and the SR was 88.1%. No difference in SFR was found for single or multiple stones in any of the two groups.
The term 'extracorporeal shockwave lithotripsy (ESWL)-resistant stones' needs to be re-examined, as treatment with a different lithotriptor was successful in a group of stones where another machine had failed. Lithotripters with different shock wave characteristics may result in difference in the results of ESWL. Future research in ESWL should focus on stone characteristics and development of machines with the ability to adapt to specific stone features.
International Journal of Clinical Practice 03/2009; 63(10):1489-93. · 2.43 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To review the results of our experience with a mentorship programme in laparoscopic nephrectomy, set up in 1999 by the British Association of Urological Surgeons Section of Endourology.
Mentors were contacted in 2007 to submit data on the number of visits and the outcome, which included whether a urologist was able to establish an independent laparoscopic practice and sustain it.
Four urologists acting as mentors reported a total of 164 procedures carried out in the training of 39 urologists during 148 visits. There were no conversions to open surgery and only one major complication. Overall, 29 of 39 mentored consultants were able to establish an independent laparoscopic practice and 23 continue to do so. The number of visits was associated with initial success, although this was not statistically significant. Working in a large department was associated with being able to sustain a laparoscopic practice. More experienced consultants were less likely to have initial success, but were more likely to sustain a successful practice.
Mentorship for laparoscopic nephrectomy has been carried out safely thus far. Sustaining a laparoscopic practice requires a critical volume of cases. Future efforts should be focused on trainees rather than consultants.
BJU International 01/2009; 103(8):1111-3. · 3.05 Impact Factor