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ABSTRACT: Objective Managing patients with renal cell carcinoma (RCC) after prior retroperitoneal surgery (renal or adrenal) is technically challenging. We present our initial experience with laparoscopic renal interventions (LRI) after prior open retroperitoneal surgery in patients requiring ipsilateral renal intervention. Here we report on feasibility, functional and oncologic outcomes of LRI after prior open retroperitoneal surgery. Materials and Methods We reviewed records of patients undergoing attempted laparoscopic or robot-assisted renal intervention after at least one prior open ipsilateral retroperitoneal surgery. We identified 34 patients who underwent 39 staged attempted LRI after 48 prior open ipsilateral renal or adrenal surgeries. The LRI included 20 minimally invasive partial nephrectomies (MIPN), 11 laparoscopic RFAs (LRFA), and 8 laparoscopic nephrectomies (LTN). Demographic, perioperative, renal functional, and oncologic outcome data were collected. Statistical analyses were performed to identify risks for conversion to open surgery. Results No attempted nephron sparing procedure resulted in kidney loss. Overall conversion rate of the cohort was 28% and was highest in the MIPN group (40%). On univariate analysis only multiple tumors treated significantly increased chances of open conversion (p<0.01). Subset analysis demonstrated similar rates of blood loss, operative times, and conversion rates in patients undergoing partial nephrectomy having prior open partial nephrectomy compared to prior open adrenal surgery only. There was no significant difference in preservation of renal function between MIPN and LRFA, with over 85% of preoperative renal function preserved. Mean follow up of 11.9 months (range 1-97.5) metastasis-free survival and overall survival was 94.1% and 97%, respectively. Conclusions LRI after prior open ipsilateral retroperitoneal surgery is feasible. Repeat partial nephrectomy has the highest conversion risks amongst the laparoscopic renal interventions and appears to be independent of prior renal or adrenal procedure. Attempting repeat LRI for multiple tumors is a significant risk factor for open conversion. Renal functional and oncologic outcomes are encouraging at early follow up.
Journal of endourology / Endourological Society 09/2012; · 1.75 Impact Factor
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ABSTRACT: Partial adrenalectomy has recently been advocated to preserve unaffected adrenal tissue during resection of pheochromocytoma.
To describe a robot-assisted laparoscopic partial adrenalectomy (RALPA) technique and to report on early functional and oncologic outcomes.
From 2007 to 2010, 15 RALPA were performed on 12 consecutive patients with pheochromocytoma. Follow-up data of >1 yr are available on 11 procedures. Median follow-up for the entire cohort was 17.3 mo (range: 6-45).
Positioning and port placement is designed for adequate reach and visualization of the upper retroperitoneum. The plane between the adrenal cortex and pheochromocytoma pseudocapsule is identified visually and with laparoscopic ultrasound. The tumor is dissected away from normal adrenal cortex, preserving normal adrenal tissue.
Preoperative, perioperative, pathologic, and functional outcomes data were analyzed.
Fourteen of 15 cases were completed robotically. Among 15 procedures, 4 were performed on a solitary adrenal gland. Four cases required resection of multiple tumors (up to six) with two performed in a solitary gland. The mean age of the patients was 30 yr, and the mean body mass index was 27. The mean operative time was 163 min, the median estimated blood loss was 161 ml, and the median tumor size was 2.7 cm (range: 1.3-5.5). There was one conversion to an open procedure in a patient requiring reoperation on a solitary adrenal gland. One patient who underwent RALPA on a solitary adrenal gland required postoperative steroid supplementation at last follow-up. At a median follow-up of 17.3 mo (range: 6-45), there were no recurrences or metastatic events. Study limitations include small sample size and short follow-up.
RALPA for the treatment of pheochromocytoma is feasible and safe and provides encouraging functional and oncologic outcomes, even in patients with a solitary adrenal lesion or multiple ipsilateral lesions.
European urology 07/2011; 60(1):118-24. · 7.67 Impact Factor
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ABSTRACT: Managing oncocytoma in the setting of bilateral renal masses is a challenging scenario. Nevertheless, to our knowledge the pathological concordance of an oncocytic neoplasm in 1 kidney with tumors in the contralateral kidney is not known. We evaluated the influence of germline Birt-Hogg-Dubé mutation on concordance rates to assist in managing these cases.
We reviewed the records of patients at the National Institutes of Health between 1983 and 2009 who had bilateral renal masses, known pathology bilaterally and oncocytoma or an oncocytic neoplasm in at least 1 kidney. Oncocytoma or an oncocytic neoplasm in 2 renal units was considered concordant. Demographic, pathological and clinical data were collected.
The population consisted of 40 patients, including 23 with and 17 without a diagnosis of Birt-Hogg-Dubé syndrome. Patients with the syndrome were younger (p <0.01) but there were no other differences between the 2 groups. However, patients with the syndrome had statistically lower histological concordance between bilateral masses than patients without the diagnosis (Fisher's exact test p <0.01). Also, the 8 patients without Birt-Hogg-Dubé syndrome who had multifocal renal masses showed 100% oncocytoma concordance between renal units.
Of patients with bilateral renal masses those with Birt-Hogg-Dubé syndrome have significantly lower histological concordance than those without the syndrome. Patients with Birt-Hogg-Dubé syndrome should be monitored and treated differently than those without detected genetic mutations, especially patients with multifocal oncocytomas. Genetic testing for Birt-Hogg-Dubé should be considered in the treatment algorithm of patients with bilateral renal masses and known oncocytoma.
The Journal of urology 06/2011; 185(6):2050-5. · 4.02 Impact Factor
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ABSTRACT: Significant advances have been made in the field of minimally invasive urologic surgery since the use of laparoscopy was initially
described. Minimally invasive surgery was originally considered the realm of laparoscopic surgeons, often with additional
subspecialty training. The development of robotic surgery broadened the field of urologic surgeons capable of using minimally
invasive techniques for radical prostatectomy.
12/2010: pages 401-410;
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ABSTRACT: The introduction of robotic surgery has revolutionized the treatment of urologic malignancy. Initially established for radical
prostatectomy, robotic techniques are now being applied in the management of renal cancer. The feasibility and safety of robotic-assisted
partial nephrectomy (RAPN) has been demonstrated in several small, single-institution studies [1–10]. Recently this technique
has been applied successfully in patients with hilar, endophytic, and multiple renal masses [8–10]. Features of the da Vinci
Surgical System (Intuitive Surgical Corp., Sunnyvale, California, USA) include 3D vision, articulating instruments, and motion
scaling to reduce tremor. These amenities may allow the surgeon the ability to replicate established “open” maneuvers and
allow for complex tumor extirpation and renal reconstruction which is challenging in a pure laparoscopic manner.
KeywordsNephron-sparing surgery-Robotics-Kidney cancer-Minimally invasive surgery-Techniques
12/2010: pages 55-71;
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ABSTRACT: Although the safety and feasibility of partial adrenalectomy in patients with von Hippel-Lindau syndrome have been established, long-term outcomes have not been examined. In this study we evaluate the recurrence and functional outcomes in a von Hippel-Lindau syndrome cohort treated for pheochromocytoma with partial adrenalectomy with a followup of at least 5 years.
We reviewed the records of patients with von Hippel-Lindau syndrome treated with partial adrenalectomy for pheochromocytoma at the National Cancer Institute. Demographic, germline mutation status, surgical indication, oncologic and functional outcome data were collected. Local recurrence was defined as radiographic evidence of recurrent tumor on the ipsilateral side of partial adrenalectomy. Patients were considered steroid dependent if they required steroids at most recent followup.
A total of 36 partial adrenalectomies for pheochromocytoma were performed in 26 patients with von Hippel-Lindau syndrome between September 1995 and December 2003. Of these cases 23 were performed open and 13 were performed laparoscopically. Prior surgical history was obtained for all patients. At a median followup of 9.25 years (range 5 to 46) metastatic pheochromocytoma had not developed in any patients. In 3 patients (11%) there were 5 local recurrences treated with surgical extirpation or active surveillance. All recurrences were asymptomatic and detected by radiographic imaging on followup. In addition, 3 of 26 patients (11%) subsequently required partial adrenalectomy for pheochromocytoma on the contralateral adrenal gland. In the entire cohort only 3 patients became steroid dependent (11%).
Outcomes of partial adrenalectomy in patients with von Hippel-Lindau syndrome with pheochromocytoma are encouraging at long-term followup and should be recommended as a primary surgical approach whenever possible. Adrenal sparing surgery can obviate the need for steroid replacement in the majority of patients. Local recurrence rates appear to be infrequent and can be managed successfully with subsequent observation or intervention.
The Journal of urology 11/2010; 184(5):1855-9. · 4.02 Impact Factor
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ABSTRACT: To evaluate the feasibility of performing robot-assisted laparoscopic partial adrenalectomy (RALPA) in patients seen at the National Cancer Institute and report the results of our initial experience.
We reviewed the records of patients with adrenal masses who underwent attempted RALPA from July of 2008 until January of 2010. Demographic, perioperative, and pathologic data were collected. The functional and early oncological outcomes were examined by the need for steroid replacement and development of recurrent disease, respectively.
Ten patients underwent a total of 13 attempted RALPAs for removal of 19 adrenal tumors. There was one open conversion with successful completion of partial adrenalectomy. Of the patients, 80% had a known hereditary syndrome predisposing them to adrenal tumors. One patient had bilateral multifocal adrenal masses with unknown germ line genetic alteration and 1 patient had a sporadic adrenal mass. Of the 19 tumors removed, 17 were pheochromocytoma and 2 were adrenal-cortical hyperplasia. Two patients underwent partial adrenalectomy on a solitary adrenal gland, with one subsequently requiring steroid replacement postoperatively. On postoperative imaging, all but one operated adrenal gland demonstrated contrast enhancement. No patient developed local recurrence at a median follow-up of 16.2 months (range, 2-29).
RALPA appears safe and feasible in our early experience. Only 1 patient in our series required steroid replacement. Local recurrence rates are low but will require longer follow-up.
Urology 11/2010; 77(4):775-80. · 2.43 Impact Factor
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ABSTRACT: To evaluate the initial results of salvage robotic-assisted radical prostatectomy (SRARP) after recurrence following primary radiotherapy (RT) for localized prostate cancer.
Between December 2002 and January 2008, 11 patients had SRARP with pelvic lymph node dissection by one surgeon from one institution. Six patients had brachytherapy, three had external beam RT (EBRT), one intensity-modulated RT, and one received brachytherapy with an EBRT boost. All patients had prostate cancer on biopsy after RT, with negative computed tomography and bone scan. The mean (range) follow-up was 20.5 (1-77) months.
The mean interval from RT to SRARP was 53.2 months; the mean preoperative prostate-specific antigen (PSA) level was 5.2 ng/mL, the operative duration 183 min and the estimated blood loss 113 mL. One patient had prolonged lymphatic drainage, one had an anastomotic leak, and one had an anastomotic stricture requiring direct vision internal urethrotomy at 3 months. The mean duration of catheterization was 10.4 days and the hospital stay 1.4 days. Three patients had a biochemical recurrence, at 1, 2 and 43 months. In one of two patients with node-positive carcinoma of the prostate the PSA level failed to reach a nadir of zero after surgery. In patients with a minimum follow-up of 2 months, eight of 10 are continent (defined as zero to one pad per day) and two have erections adequate for intercourse with the use of phosphodiesterase-5 inhibitors.
SRARP after RT-resistant disease recurrence is feasible with minimal perioperative morbidity. Early functional outcomes appear to be at least equivalent with historical salvage RP series. Robotic extended pelvic lymph node dissection is safe and can improve the accuracy of surgical staging. A longer follow-up is necessary to better assess the functional and oncological outcomes.
BJU International 01/2009; 103(7):952-6. · 2.84 Impact Factor
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The Journal of urology 12/2008; 181(1):333. · 4.02 Impact Factor
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ABSTRACT: A potassium-titanyl-phosphate (KTP) laser through robotic endo-wrist instrument has been evaluated as an ablative and hemostatic
tool in robotic assisted laparoscopic partial nephrectomy (RALPN). Ten RALPN were performed in five domestic female pigs.
The partial nephrectomies were performed with bulldog clamping of the pedicle. Flexible glass fiber carrying 532-nm green
light laser was used through a robotic endowrist instrument in two cases. Power usage from 4 to 10W was tested. The laser
probe was explored both as a cutting knife and for hemostasis. The pelvicalyceal system was closed with a running suture.
Partial nephrectomies using KTP laser were performed without complications. Mean operative times and warm ischemia times for
laser cases were 96 and 18min, respectively. Mean estimated blood loss was 60ml compared with 50ml for non-laser cases.
Complete hemostasis with the laser alone could be achieved with a power of 4W and was found to be effective. In our hands
the laser fiber powered up to 10W was not effective as a quick cutting agent. Histopathologic analysis of the renal remnant
revealed a cauterized surface effect with average laser penetration depth less than 1mm and minimal surrounding cellular
injury. The new robotic endowrist instrument carrying flexible glass fiber transmitting 532-nm green light laser is a useful
addition to the armamentarium of the robotic urologic setup. Its control by the console surgeon enables quicker and more complete
hemostasis of the cut surface in renal sparing surgery using a porcine model. Histologically proven lased depth of less than
1mm suggests minimal parenchyma damage in an acute setting. Laser application as a cutting agent, however, requires further
investigation with interval power settings beyond the limits of this preliminary study. We estimate that effective cutting
should be possible with a setting lower than traditionally recommended for solid organs.
Journal of Robotic Surgery 11/2007; 1(3):185-189.
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ABSTRACT: To compare perioperative, functional and oncological outcomes of a single surgeon's experience with retropubic (RRP), perineal (RPP), and robotic assisted (RARP) radical prostatectomy.
Results from 150 radical prostatectomies performed by a single surgeon were compared. The groups consisted of the last 50 consecutive RRP (group 1) and RPP patients (group 2) and his first 50 RARP patients (group 3). He had significant experience in RRP and RPP and extensive training prior to performing RARP. The data was obtained from record review and patient survey. Patient demographics, operative parameters, pathological characteristics, complications, and functional outcomes were compared between groups.
The groups were comparable with respect to patient demographics. Hospital stay, blood loss, and transfusion requirements were significantly better in the robotic group. Complications were least in the robotic group. Urinary continence (one pad or less) at 12 months was 96% in RRP, 96% in RPP, and 96% in RARP group. Positive surgical margins in organ confined disease were significantly lower for RARP although overall positive margins were similar. Potency data was still maturing and was not included in this analysis.
There were no major differences in outcomes between the RRP and RPP groups. The RARP group had equal or better perioperative outcomes in all analyzed categories with the least complications. Urinary function outcomes were excellent in all groups. Prior open experience and extensive training facilitate encouraging outcomes for robotic prostatectomy even in a surgeon's initial series of patients.
The Canadian Journal of Urology 07/2007; 14(3):3566-70. · 0.64 Impact Factor
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ABSTRACT: We report an interesting case of ureteral tumor involving both limbs of an incompletely duplicated ureter. Such a case has not been reported in the literature. A 51-year-old female presented with refractory hematuria. A complete evaluation revealed an incompletely duplicated right system with an isolated distal ureteral tumor extending proximally into both arms of the ureter. The patient underwent a successful right nephroureterectomy. Pathology revealed low grade papillary urothelial cancer confined to both arms of the ureter. A brief review of the literature and management is detailed herein.
International Urology and Nephrology 02/2006; 38(3-4):473-4. · 1.47 Impact Factor
