Port site metastasis after laparoscopic radical nephrectomy: A single-center experience.

Objective: To assess the incidence and review the probable etiologies of port site recurrence in patients undergoing laparoscopic radical nephrectomy. Materials and Methods: One hundred thirty-six patients undergoing laparoscopic surgeries for renal malignancy, including 133 radical nephrectomies and 3 partial nephrectomies, from December 1999 to December 2008 at our institution were followed up for a median period of 59 months (12-120 months). Of the procedures, 121 were performed by transperitoneal, 5 by retroperitoneal and 10 by combined approach (retroperitoneal renal artery clipping followed by transperitoneal nephrectomy). Formal lymphadenectomy was not performed. Postoperative surveillance after radical nephrectomy included history and physical examination with blood tests 3-6 monthly, chest X-ray yearly and abdominal contrast-enhanced computed tomography (CECT) 1-2 yearly. The development of port site recurrence was diagnosed by physical examination, CECT and pathological findings. Results: Conversion to open surgery was done in 33 patients. Two (1.47% overall) port site recurrences were observed, both after radical nephrectomies done for renal masses with clinical stages T2N0M0 and TIN0M0. The pathological staging in the two were T2N1M0 Fuhrman's Grade III and T3aN1M0 Grade III, respectively. Conclusion: Our results report that laparoscopic approach does not necessarily increase the risk of port site recurrence, provided the cases are carefully chosen, principles of oncologic surgery are followed, and conditions that increase the risk of port site metastasis are avoided.

Does extended lymph node dissection affect the lymph node density and survival after radical cystectomy.

Background : Diagnostic and therapeutic importance of pelvic lymph node (LN) dissection (PLND) in radical cystectomy (RC) has gained recent attention. A method of pathological analysis of LN affects total number of LN removed, number of LN involved, and LN density. Objective : To compare extended lymphadenectomy to standard lymphadenectomy in terms of LN yield, density, and effect on survival. Materials and Methods : From Jan 2004 - July 2009, 78 patients underwent RC whose complete histopathological report was available for analysis. All were transitional cell carcinoma. From July 2007 onward extended LN dissection was started and LNs were sent in six packets. Twenty-eight patients of standard PLND kept in group I. Group II had 23 patients of standard PLND (LN sent in four packets), and group III had 23 patients of extended PLND (LN sent in six packets). SPSS 15 software used for statistical calculation. Results : Distribution of T-stage among three groups is not statistically significant. Median number of LN harvested were 5 (range, 1-25) in group I, 9 (range, 3-28) in group II, and 16 (range, 1-25) in group III. Although this is significant, we did not find significant difference in number of positive LN harvested. We did not find any patient with skip metastasis to common iliac LN in group 3. Conclusions : Separate package LN evaluation significantly increased the total number of LN harvested without increasing the number of positive LN and survival.

Impact of delay in inguinal lymph node dissection in patients with carcinoma of penis.

Aim: To study the impact of delay in inguinal lymph node dissection (LND) in patients with squamous cell carcinoma of the penis, who have indications for LND at the time of presentation. Materials and Methods: In total, 28 patients (mean age 52.1 ± 12.8 years) with squamous cell carcinoma of the penis, treated from January 2000 to June 2008, were retrospectively studied with regard to clinical presentation, time of LND, and the outcome. The patients were divided into two groups based on the time for LND. Group 1 patients had LND at mean of 1.7 months (range 0-6 months) of treatment of the primary lesion, and group 2 had LND at a mean of 14 months (range 7-24 months) after treatment of the primary lesion. Statistical Analysis: The statistical analysis of survival was done using the Kaplan-Meier method and the Log Rank test, with p < 0.05 considered to be statistically significant. The Mann-Whitney test and Fisher's exact test were used for univariate comparison. Results: Twenty-three of the 28 patients had inguinal LND. In group 1, of 13 patients, 12 were alive, with no recurrence of disease at a mean follow-up of 37 months (8-84) months. In group 2, only two patients were alive and disease-free, at a mean follow-up of 58 months (33-84 months). The five-year cancer-specific survival rates for early and delayed LND were 91 and 13%, respectively, (p = 0.007). Conclusions: When compliance with follow-up is suspect, patients with high grade or T stage (greater than T1) tumor are better treated by inguinal LND during the same hospital admission or within two months of primary treatment.

Prognosticfactors in patients with renal cell carcinoma: is TNM (1997) staging relevant in Indian subpopulation?

BACKGROUND: RCC (Renal Cell Carcinoma) is a common genitourinary malignancy, but its behavior has not been studied in the Indian Subpopulation. AIMS: The aim of this study was to assess the validity of 1997 AJCC TNM staging in Indian subpopulation and also to identify independent predictors for survival in patients having RCC. SETTING AND DESIGN: Retrospective uncontrolled analysis of patients with RCC was performed at our centre. MATERIAL AND METHODS: Medical records of patients of undergoing radical nephrectomy at our center between 1994 to August 2003 were identified retrospectively. Medical records of 178 patients were available for analysis. Patient characteristics, preoperative imaging and surgical details were reviewed. Each tumor was staged according to the 1997 AJCC TNM classification. Nuclear grade was assigned according to the Fuhrman's grading system. STATISTICAL METHODS: Statistical analysis was performed using statistical software and descriptive statistics and survival functions were obtained. Univariate and multivariate analysis of factors affecting outcome of the patient were performed. RESULTS: Mean follow up period was 42.3 months (range 3 to 108 months). Stage wise 5-year Cancer specific survival was 87.2% in stage 1 disease, 74.3% in stage 2, 36.4% in stage 3 and 3.1% in stage 4. Univariate analysis revealed that stage, grade and lymph node status were statistically significant (P=0.009, 0.007 and 0.003 respectively). Sub-classifying stage 1 tumors between tumor of less than 4 cm. and more than 4 cm. did not reveal any statistically significant difference in survival (P=0.32). Multivariate analysis model revealed that Fuhrman's grade and lymph node status were statistically significant (P=0.007 and 0.002 respectively). CONCLUSION: This study validates the TNM (1997) staging for RCC as having significant survival impact in the Indian subpopulation. Sub-classifying stage 1 tumors between tumor of less than 4 cm. and more than 4 cm is not of much importance. Nuclear grade and lymph node involvement are important independent predictors of survival. Organ confined tumors with high nuclear grades need to be followed up more rigorously.

Polymorphism of GSTM1 and GSTT1 genes in prostate cancer: a study from North India.

BACKGROUND: Glutathione-S-transferases (GSTs) are active in the detoxification of wide variety of endogenous or exogenous carcinogens. The genetic polymorphisms of GSTM1 and GSTT1 genes have been studied earlier to evaluate the relative risk of various cancers. AIM, SETTING AND DESIGN: In the present study, we examined the association of the GSTM1 and GSTT1 gene polymorphisms with sporadic prostate cancer patients in north Indian population. MATERIAL AND METHODS: This case control study was undertaken over a period of 24 months and included 103 prostate cancer patients and 117 controls; both patients and controls originated from northern part of India. The GSTT1 and GSTM1 genotypes were identified by multiplex PCR in peripheral blood DNA samples. STATISTICAL ANALYSIS: Difference in genotype prevalence and association between case and control group were assessed by the Chi square and Fisher Exact tests. RESULTS: Frequencies of null genotypes in GSTT1 and GSTM1, was 11% (13/117) and 30% (35/117) respectively in control individuals. The frequencies of GSTT1 and GSTM1 null genotypes in prostate cancer patients were 34% (35/103) and 53% (55/103) respectively. CONCLUSION: Our study demonstrates that the null genotypes of GSTT1 and GSTM1 are substantially at higher risk for prostate carcinoma as compared to the normal healthy controls. The GSTT1 and GSTM1 null genotypes did not show significant association with tobacco usage in prostate cancer patients. However, the null genotypes were significantly stratified in 50-60 year-old patients when incidence of prostate cancer is high.

Correlation of radiological and clinical features of metanephric neoplasms in adults.

The main objective was to determine the clinical and radiological features of metanephric neoplasms. The tumors were diagnosed on histopathological examination. The clinical data and imaging features were retrospectively analyzed. Between 1998 and 2003, 3 patients underwent radical nephrectomy for renal masses turning out as metanephric neoplasms on histopathology. Two of these tumors were metanephric adenoma (MA) and one was metanephric adenofibroma (MAF). Clinical and radiological features were reviewed. All patients were adult females who presented with flank pain. Tumor was detected on screening ultrasound as a hyperechoic lesion. In all cases CT showed a hyper-attenuating exophytic lesion with cystic areas that enhanced with IV contrast. Based on combination of clinical and imaging features it may be possible to prospectively identify metanephric neoplasms and thus avoid unnecessary radical nephrectomy in favor of conservative surgery.

Stones associated renal pelvic malignancies.

BACKGROUND: The clinico-pathological characteristics of renal pelvic malignancies associated with stones were retrospectively analyzed. AIMS: The main objective was to define the biological behavior and prognostic factors for these malignancies. SETTINGS & DESIGN: The tumors were classified according to the pathological types. The clinical data, imaging features and pathological features were analyzed with relation to prognosis. MATERIAL AND METHODS: Eighteen cases of malignancies associated with stone disease were retrospectively studied. The institute review board permitted the study. RESULTS: High incidence (15/18) of squamous cell carcinoma (SCC) was noted. The prognosis in this group of patients was uniformly poor. The median survival time was 3.6 months in the SCC group, 7.5 months in the Transitional Cell Carcinoma (TCC) group and 24 months in the Adenocarcinoma (AC) group. Infectious and systemic symptoms were noted in the majority of the patients. Preoperative Imaging techniques revealed tumor in only 2 cases. Both underwent radical extirpation and the median survival is 18 months till date. In the other 16 patients, where the initial diagnosis was made only on histological analysis of incomplete nephrectomy specimens, the survival was 3.56 months. All patients had prolonged history of staghorn stone disease with associated non-functioning kidney. We found that the main prognostic factor was the stage of the disease. CONCLUSIONS: Malignancies associated with stone disease have insidious onset of clinical symptoms and need a high degree of suspicion to identify them pre-operatively. The grave prognosis associated with incomplete excision makes it imperative to diagnose them earlier.

Renal & prostatic disorders in the elderly.

The population of aged people is increasing in number all over the world along with the problems associated with senescence. The functional and morphological changes that occur with ageing are accompanied by an increased risk of certain conditions like drug-induced nephrotoxicity and acute tubular necrosis. Elderly patients of end-stage renal disease can undergo renal replacement therapy with acceptably good results. If free from any medical and other illnesses, elderly persons can be considered for kidney donation without any increased risk for surgery or anaesthesia. However, such kidneys are functionally not as good as kidneys from young individuals. Prostatic diseases like prostatic hyperplasia and cancer are more a concern of the aged than the younger population. Besides, there is an apprehension about the increased risk of anaesthesia due to the frequent presence of other co-existent illnesses in the senile population. Less morbid therapeutic methods are available to deal with prostatic disorders but one should not hesitate to undertake major open or endoscopic surgeries in such patients, should it be necessary.