-
[show abstract]
[hide abstract]
ABSTRACT: The mainstay of treatment for renal cell carcinoma with invasion of the inferior vena cava (IVC) is complete surgical extirpation. Cases complicated by adherent or invasive tumor thrombus represent a special technical challenge due to the need for resection of a large segment of the IVC. The aim of this review is to describe the indications and surgical approach for radical nephrectomy with en bloc resection of the IVC with or without venous reconstruction. In addition, special attention is paid to the relevant anatomical and hemodynamic considerations related to the development of venous collateral pathways secondary to IVC obstruction.
Urologic Oncology 03/2013; · 3.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Intraoperative tumor embolization is a rare complication during the surgical management of renal cell carcinoma with tumor thrombus of the inferior vena cava (IVC). We -present a case of pulmonary tumor embolism which occurred during liver mobilization immediately following division of the IVC ligament. We hypothesize that this patient's IVC ligament acted as an external barrier to propagation of the tumor thrombus and that its release caused the tumor to -rapidly expand leading to embolization. To our knowledge, this is the first report of a pulmonary tumor embolism occurring immediately following division of the IVC ligament.
Urologia Internationalis 03/2013; · 0.99 Impact Factor
-
BJU International 03/2013; 111(3):E8-9. · 2.84 Impact Factor
-
The Journal of urology 02/2013; · 4.02 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: The surgical management of renal cell carcinoma with invasion of the renal vein or inferior vena cava is associated with significant rates of perioperative morbidity and mortality. In this report we propose a surgical checklist aimed at reducing adverse events associated with the resection of these tumors. METHODS: This review describes the development of an evidence- and experience-based surgical checklist aimed at imrproving the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. RESULTS: Reducing the risk of complications during the surgical management of renal tumors with venous invasion begins with appropriate pre-operative imaging aimed at defining the cranial extent of the tumor thrombus, thus facilitating accurate preoperative planning. Other key elements of the checklist are aimed at ensuring clear and precise pre-, intra- and postoperative communication between members of the multidisciplinary-care team. CONCLUSION: A standardized surgical checklist may help to increase the perioperative safety of patients undergoing radical nephrectomy and tumor thrombectomy. Future validation studies are required to determine the clinical feasibility and post-implementation safety profile of this new checklist.
Patient Safety in Surgery 12/2012; 6(1):27.
-
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: To describe the frequency and severity of atherosclerosis contained within the non-neoplastic tissue of partial nephrectomy (PN) specimens. METHODS: Archived open PN specimens were evaluated for histological evidence of atherosclerosis. Clinically significant atherosclerosis was defined as arterial luminal narrowing of >25 % due to fibrointimal thickening. Histological findings were correlated with clinical data including history of major medical comorbidities and preoperative statin use. RESULTS: The study cohort was comprised of 114 patients (71 men and 43 women). The mean age at the time of surgery was 59.3 years, and 69 (60.5 %) patients had a history of at least one major medical comorbidity including hypertension (54.5 %), diabetes (16.7 %) and coronary artery disease (12.3 %). Clinically significant atherosclerosis was observed in 29 (25.4 %) patients. These individuals were older (p = 0.001), and three times more likely to have greater than one major medical comorbidity (p = 0.002). In addition, only 17 (58.6 %) were prescribed a statin at the time of surgery. CONCLUSIONS: Atherosclerosis is frequently observed in the non-neoplastic tissue of PN specimens. Patients found to have atherosclerosis can potentially benefit from intensive lifestyle modification and medical therapy with lipid-lowering medications. These measures would likely have the greatest clinical impact on those patients without an existing history of major medical comorbidities.
World Journal of Urology 11/2012; · 2.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Renal cell carcinoma with tumor thrombus of the inferior vena cava presents a special surgical challenge. The use of surgical techniques derived from the field of transplantation surgery have previously been shown to enable optimal control of inferior vena cava, allowing for the extirpation of most tumors via a transabdominal approach without the need for venovenous or cardiopulmonary bypass. In this report, we provide a stepwise description of the transplantation techniques employed at the University of Miami/Jackson Memorial Hospital for the resection of renal cell carcinoma with intracaval tumor. In addition, we review the results of centers that have utilized these surgical maneuvers.
Urologic Oncology 09/2012; · 3.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The objective of this report is to describe the oncologic outcomes of men with margin-positive prostate cancer who were managed expectantly following radical prostatectomy.
Between January 1992 and January 2011, 2166 men underwent an open radical prostatectomy by a single surgeon. Of these patients, 1592 (74%) had complete data and met the inclusion criteria of negative lymph nodes and no history of neoadjuvant or adjuvant therapy. This cohort was dichotomized by the presence or absence of at least one positive surgical margin. Groups were compared for differences in recurrence-free and overall survival.
In total, 507 (32%) of 1592 patients had at least one positive surgical margin. Clinical and pathological characteristics of these patients indicated more aggressive disease. The median follow up for biochemical recurrence and overall survival was 3.4 years and 7.7 years, respectively. Of those patients with a positive margin, 147 (29%) recurred, with estimated 5 and 10 year biochemical recurrence rates of 31% and 47%, respectively. Multivariate analysis demonstrated that the presence of a positive margin was associated with a 2.45-fold increased hazard of recurrence (p < 0.001). Despite initial observation, surgical margin status was not associated with a decrease in overall survival on both uni- (p = 0.684) and multivariate analyses (p = 0.177).
Although a positive surgical margin is associated with an increased risk of biochemical recurrence, patients in our series were not at an increased risk of all-cause mortality.
The Canadian Journal of Urology 06/2012; 19(3):6280-6. · 0.64 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The aim of this report is to describe our surgical technique for robot-assisted laparoscopic bladder diverticulectomy. In this technique, methylene blue is instilled into the bladder to aid in intra-abdominal identification of the diverticular neck.
We retrospectively reviewed the records of patients who underwent robot-assisted bladder diverticulectomy by a single surgeon.
Between September 2008 and January 2011, 5 patients successfully underwent robot-assisted laparoscopic bladder diverticulectomy using 1% intravesical methylene blue. All cases were completed without intraoperative complication or need for open conversion. Mean operative time was 216 minutes, with a mean estimated blood loss of 45 mL. Patients were discharged 1-2 days following surgery. No patient experienced a perioperative complication.
The robot-assisted approach for bladder diverticulectomy is a viable alternative to both open and laparoscopic surgery. The use of intravesical methylene blue greatly aids in identification of the diverticular neck during this procedure.
Journal of Laparoendoscopic & Advanced Surgical Techniques 06/2012; 22(5):492-5. · 1.40 Impact Factor
-
European urology 05/2012; 61(5):1065. · 7.67 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The majority of patients with bladder cancer will be diagnosed following an episode of hematuria. With few exceptions, these patients should be referred for a complete urologic evaluation, including a history and physical examination, flexible cystoscopy, imaging of the upper urinary tract, and optional urine cytology. Those found to have a bladder tumor should undergo transurethral resection for the combined purposes of initial staging and treatment. Delays in diagnosing invasive bladder cancer are associated with adverse outcomes. In this review, we cover the diagnosis and management of bladder cancer. In addition, we discuss ways to improve outcomes through increased public awareness, improvements in tumor detection, accurate staging, and regimented patient surveillance.
Postgraduate Medicine 05/2012; 124(3):28-36. · 1.78 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? The surgical implications of renal cell carcinoma with coexisting bland and tumour thrombi of the inferior vena cava is not well described. In this study we review our experience managing these tumours. On multivariate analysis, we found that the presence of bland thrombus was associated with an increased need for surgical interruption of the inferior vena cava. OBJECTIVE: • To study the role of interruption of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC) and associated bland and tumour thrombi. METHODS: • We reviewed 129 consecutive patients with the preoperative diagnosis of RCC with tumour thrombus who underwent radical nephrectomy and tumour thrombectomy in one academic institution between May 1997 and February 2011. RESULTS: • Percentages of patients with levels I, II, III and IV tumour thrombus were 29%, 13%, 48% and 9%, respectively. • The perioperative mortality rate was 2.3%. There were 29 (22%) perioperative complications recorded. • In all, 19 patients underwent surgical interruption of the IVC by ligation or segmental resection, including one level II, 14 level III and four level IV thrombi. • A total of 15 patients (12%) had bland thrombus associated with the tumour thrombus; four of these underwent intraoperative IVC filter placement and eight underwent surgical IVC interruption. • Advanced level of tumour thrombus was the only significant factor predicting association of bland thrombus (odds ratio [OR]= 2.09, 95% confidence interval [CI]: 1.082-4.037, P= 0.028). • On multivariate analysis, level of thrombus (OR = 3.1, 95% CI: 1.30-7.74, P= 0.011) and association of bland thrombus (OR = 9.07, 95% CI: 2.42-34.01, P= 0.001) were significant factors for IVC interruption. CONCLUSIONS: • Surgical interruption of the IVC is a feasible option in selected patients with chronic IVC obstruction. Association of bland thrombus with tumour thrombus should alert the surgical team to the potential for a challenging surgery. • Precise preoperative imaging to assess the degree of venous obstruction and to help with differentiation between bland and tumour thrombus is key to achieving a surgical outcome with minimal morbidity.
BJU International 04/2012; · 2.84 Impact Factor
-
European urology 04/2012; 61(4):849. · 7.67 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite an increased need, residents of rural communities have decreased access to healthcare and oftenpresentuniquehealthcare challenges associated with their rurality. Ensuring medical students receive adequate exposure to these issues is complicated by the urban location of most medical schools. Health fairs (fairs) conducted in rural communities can provide students exposure to ruralhealth;however, it is unknown how participation affects attitudes regarding these issues.
During the 2010-2011 academic year, first-year medical students were surveyed before and after participating in a rural fair regarding the importance of rural health issues, the need for exposure to rural healthcare, their plans to practice in a rural community,andthe educational impact of fairs.
Of the 121participating students, 77% and 61% completed pre- and post-fair surveys, respectively. Few had lived in a rural area or planned to practice primary care. Participants strongly agreed that the delivery of healthcare in rural areas was important, and that all physicians should receive rural health training (4.8 and 3.7 out of 5, respectively) despite less than halfplanning to practice in a rural community. After participating in a rural fair, student attitudes were unchanged, although 87% of participants strongly agreed their involvement had contributed to improving patient health and 70% that the fairs provided rural medicine experience.
Among urban medical school students with varied interests in primary care, there was strong interest in volunteering at rural fairs and appreciation for the importance of rural health. Fairs provided interested students with rural medicine experience that reinforced student attitudes regarding rural health. Further, students felt their participation improved patient health.
Journal of research in medical sciences 03/2012; 17(3):298-303. · 0.46 Impact Factor
-
Transplantation 02/2012; 93(4):e16-7. · 4.00 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To describe a modified open surgical technique for the resection of renal cell carcinoma with level I or II tumor thrombus.
In our modified technique, the renal artery is ligated early and the tumor thrombus is secured ahead of kidney mobilization by either milking into the renal vein or with extirpation from the inferior vena cava. We retrospectively studied patients who were managed with this technique.
Between September 2006 and June 2010, 20 patients with a median age of 65 years underwent surgery for renal cell carcinoma with level I (n=15) or II (n=5) tumor thrombus using the modified technique. Median blood loss was 275 mL with 75% of patients requiring at least 1 transfused unit of blood. No case was complicated by an intraoperative tumor embolism. Following surgery, patients stayed a median of 5 days in the hospital and none experienced a perioperative complication.
The described surgical technique allows for the safe and effective resection of renal cell carcinoma with level I or II tumor thrombus. This technique enables vascular control of the inferior vena cava with a minimal risk of tumor embolization.
Urology 02/2012; 79(2):478-81. · 2.43 Impact Factor
-
European urology 02/2012; 61(2):254-6; discussion 256-7. · 7.67 Impact Factor
-
Urology 02/2012; 79(2):481-2. · 2.43 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: To identify preoperative factors associated with surgical complications and successful diagnostic renal biopsy in both laparoscopic and percutaneous radiofrequency ablation (RFA) of renal masses in order to help aid in preoperative patient counseling for renal RFA. METHODS: We reviewed our Institutional Review Board approved database from November 2001 to January 2011, containing 335 tumors treated with either laparoscopic (LRFA) or percutaneous RFA (CTRFA). Preoperative patient demographics, tumor characteristics, and intraoperative surgical data were collected along with biopsy results and clinicopathologic outcomes. RESULTS: RFA was performed on 335 renal tumors (124 LRFA, 211 CTRFA). Non-diagnostic biopsy occurred in 18 (5.5%) tumors. Of the 317 procedures performed, 121 complications occurred in 103 (30.7%) procedures. Multivariate analysis only showed CTRFA (vs LRFA) to increase the likelihood of non-diagnostic biopsy (OR 5.1, 95% CI 1.2-22, p = 0.032). Increased tumor size (p = 0.007) and synchronous ablations (p = 0.019) increased the risk for major complications, while decreased surgeon experience (p = 0.003) and tumors close to the collecting system (p = 0.005) increased the risk of any complication. CONCLUSIONS: Preoperative recommendations can be made to patients in the future. We suggest counseling patients that when undergoing RFA, percutaneous approach increases the risk of non-diagnostic biopsy, increased tumor size increases the risk of major complications, having more than 1 tumor ablated increases the risk of a major complication, and tumors close to the collecting system may increase the risk of complications.
World Journal of Urology 01/2012; · 2.41 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Thermal ablation is a well established treatment option for the management small renal masses. Increasingly, renal ablation is performed via a percutaneous approach. However, most urologists are not formally trained in image-based deployment of ablation needles. To address this need, we created a novel training model to teach urologists to perform precise and accurate percutaneous needle placement. This teaching model was implemented as part of a recent training course on tissue ablation organized by the American Urological Association.
Two fresh frozen human cadavers (Anatomic Gifts Registry, Hanover, Maryland) were used in the model. Plumber's Putty (Oatey, Cleveland, Ohio) and nonpitted olives soaked in Isovue (Bracco Dianostics, Inc, New York, New York) were used to create ablation targets. Course participants underwent a tutorial on the computed tomography (CT)-guided deployment of a 19-gauge Yueh Needle (Cook Medical, Bloomington, Indiana) or Cool-tip radio-frequency ablation (RFA) probe (Covidien, Inc, Boulder, Colorado). After each needle placement, a CT scan was performed to assess successful deployment. Participants were then queried regarding their experience.
A total of 18 urologists performed needle or radio-frequency ablation probe placement on 2 cadavers. A mean of 3.39 (range 2-5) attempts was required to hit targets. Subjectively, participants noted an increase in confidence performing percutaneous needle deployment. The cadaver laboratory exposed participants to pretreatment planning, tactile feel of needle placement, needle readjustment, and 3-D spatial relationships of a percutaneous approach.
The presented cadaveric model is an effective tool for teaching percutaneous needle placement. All urologists evaluated noted increased confidence in this technique after training on the model.
01/2012; 69(1):30-3. · 1.07 Impact Factor
