Nephron-sparing surgery for bilateral sporadic giant angiomyolipomas

@#A 40-year-old female complains of right flank plain associated with progressive abdominal enlargement. She had stable vital signs and normal renal function. CT urogram revealed bilateral flank masses suggestive of bilateral giant angiomyolipomas. She was counseled on the various treatment options and opted to undergo open surgical excision. She underwent an open clamp-less partial nephrectomy with no intraoperative events. Operative time was 120 minutes and estimated blood loss was 250cc. She was discharged in good clinical condition on postoperative day 4. Final histopathological analysis revealed angiomyolipoma. Genetic testing was positive for mosaic variant of tuberous sclerosis. After a year of follow up, she remains stable and is maintained on everolimus. Open ischemia-free partial nephrectomy may be done safely for giant renal angiomyolipomas. Radical nephrectomy should be reserved for the last option because the presence of contralateral disease may also require surgical excision in the future.

Efficacy of intravesical gemcitabine and docetaxel for non-muscle invasive urothelial bladder cancer: A review of current literature

OBJECTIVE@#To determine the efficacy of sequential intravesical Gemcitabine and Docetaxel (siGD) in patients with non-muscle invasive bladder cancer (NMIBC) in preventing disease recurrence after transurethral resection, as an alternative to BCG-naïve patients or to failed intravesical BCG therapy.@*METHODS@#An extensive literature search on the use of siGD for BCG-naïve or BCG-refractory NMIBC was done using the following terms: non-muscle invasive bladder cancer, intravesical Gemcitabine and Docetaxel. Search results were filtered to include all retrospective studies and randomized controlled trials reporting the oncological outcomes of siGD published over the last 5 years from the conception of this study. Information on the safety profile and adverse events related to therapy were also reported, if available.@*RESULTS@#The authors’ search yielded 8 retrospective articles describing the efficacy of siGD for NMIBC, 5 of which had complete and accessible English manuscripts. A total of 476 low to high-risk NMIBC patients were included in the 5 eligible studies, 31 (6.5%) of which were BCG-naïve, while the rest failed BCG therapy. The reported one and two-year success rates were 54-69% and 34-55%, respectively. The recurrence-free survival rates at 1 and 2 years were 49-60% and 29-46%, respectively. Bladder cancer-specific mortality at 1 and 2-years were 1-3% and 4-11%, respectively. Treatment-related adverse reactions were mostly mild, the most common of which were urinary frequency, urgency, hematuria, and dysuria.@*CONCLUSION@#Sequential intravesical Gemcitabine and Docetaxel is a feasible alternative for BCG-naïve and BCG-refractory NMIBC patients. Oncological outcomes are comparable to BCG therapy with less adverse effects.

Correlation of tumor location and biochemical recurrence in localized and locally-advanced prostate cancer in post-robotic radical prostatectomy patients

OBJECTIVE@#This study aims to determine the tumor location of prostate adenocarcinoma in patientswho underwent Robotic Radical Prostatectomy (RRP) for localized and locally-advanced prostatecancer and the correlation of the tumor location with the incidence of biochemical recurrence.@*PATIENTS AND METHODS@#The authors reviewed the patient database of a single Urological Oncologistfrom January 2015 to April 2017 for patients who underwent RRP for localized or locally-advancedprostate cancer. They also reviewed the histopathologic report of the prostatectomy specimens todetermine pathologic T-stage, prostate volume, and post-operative Gleason score. The histopathologicexamination of specimens was interpreted by a single Urological Pathologist based on the 2014International Society of Urological Pathology Gleason Scoring System. Eligible patients were thendivided into three groups: those with pure anterior tumor location, pure posterior tumor location,and mixed tumor location. Presence of positive surgical margins, mean follow-up period, andbiochemical recurrence were determined for these groups. Patient demographic data were analyzedusing test of proportions. Correlation of tumor location with biochemical recurrence was derivedusing Pearson chi-square test.@*RESULTS@#Of the 113 patients included in the study, 63 (55.8%) were clinically-staged T2 patients while27 (23.9%) and 23 (20.3%) were clinical stage T1 and T3, respectively. On pre-operative prostatebiopsy, 27 (23.9%) patients had a Gleason score of 8-10. Thirty-eight (33.6%) and 30 (26.6%) had aGleason score of 6 (3+3) or 7 (3+4), respectively Average prostate volume was 42.8 grams. Ninety-five (84.1%) of the patients had mixed tumor location, 11 (11.6%) had pure posterior tumor location,and only 7 (6.2%) had pure anterior tumor location. In those with pure anterior or posterior tumorlocations, majority were low-grade prostate cancers (Gleason 6(3+3) and Gleason 7(3+4)) whilethose with mixed tumor location had low to high-grade prostate cancers (Gleason 7 (3+4) and Gleason7 (4+3.)) Majority of the patients had pathologic T2c and T3a tumors across all groups. Positivesurgical margins were present in 31% of those with mixed tumor location and only 0.9% in those withpure anterior or posterior tumor location, respectively. Only 10 patients from the population hadbiochemical recurrence, 9 of which had mixed tumor location while 1 had pure posterior tumorlocation. Pearson chi-square test shows no significant relationship between tumor location andbiochemical recurrence at 95% CI (p= regional involvement 0.695.) Furthermore, there is a very weak positive correlation (R=0.069) between tumor location and biochemical recurrence.@*CONCLUSION@#Majority of patients who underwent RRP have mixed tumor location. There is poorcorrelation between prostate cancer tumor location and biochemical recurrence.

Robotic radical prostatectomy experience of a single practitioner at and beyond the learning curve

OBJECTIVE@#To determine the proficiency of a single Urological Oncologist in performing RoboticRadical Prostatectomy (RRP) for localized prostate adenocarcinoma based on the following surgicaland functional outcomes: 1) operative time, 2) estimated blood loss, 3) positive surgical margin rate,4) postoperative complication rate, 5) open conversion rate, and 6) urinary continence rate.@*MATERIALS AND METHODS@#The authors reviewed the records of a single Urological Oncologist fromJanuary 2010 to September 2017 for patients who underwent RRP for prostate adenocarcinoma.Patients were divided into 3 groups: Group 1 consisted of the first 30 cases done by the surgeon,Group 2 consisted of the next set of 30 cases, and Group 3 consisted of his cases done thereafter. Themean operative time, mean estimated blood loss, positive surgical margin rate, site of positive surgicalmargins (apex, midgland, or base), postoperative complication rate, open conversion rate, and urinarycontinence rate at 4, 8, and 12 weeks post-op were compared among the 3 groups.@*RESULTS@#A total of 30 patients were included in Group 1, another 30 were included in Group 2, and 45patients were included in Group 3 for a total of 105. There is significant difference in the meanoperative times among the 3 groups with a Group 1 having a mean operative time of 302.1 minutes,170.3 minutes for Group 2, and 146.7 minutes for Group 3 (p<0.0001.) There is a statisticallysignificant difference in mean estimated blood loss among the 3 groups (706.9 mL, 528.2 mL and386.3 mL, respectively; p<0.0001.) No open conversion was performed in all 105 patients and only3 complications were noted in this study. There was no statistical significance with regards to positivesurgical margin rates among the 3 groups (5.7%, 11.4% and 15.2%, respectively.) with the apex beingthe most common site of positive margin in this study. There is a statistically significant difference in8-week urinary continence rate among the 3 groups (12.4%, 20% and 36.2%, respectively; p=0.005).@*CONCLUSION@#Robotic Radical Prostatectomy is quickly becoming a feasible and safe option in themanagement of localized and locally-advanced prostate cancer in the local setting. The learningcurve of 30 cases, based on the experiences of the Urological Oncologist, is sufficient in establishingproficiency in performing the said procedure.

Outcome predictive values of the Society of Fetal Urology (SFU) Grading System and Urinary Tract Dilation (UTD) Classification in patients with high-grade ureteropelvic junction obstruction-like prenatal hydronephrosis

Objectives@#This study aimed to determine the surgical predictive value of both SFU and UTD classifications in a specific subset of patients presenting with high-grade (SFU 3 and 4; UTD P2 and P3) UPJO-like hydronephrosis on prenatal ultrasound. Furthermore, this study also aimed to determine the likelihood of spontaneous resolution of high grade UPJO-like hydronphrosis based on both grading systems. @*Methods@#Patients who presented with high-grade hydronephrosis on prenatal ultrasound based on the SFU grading system (Grades 3 and 4) were included in this study. The prenatal renal ultrasounds of these patients were reclassified by a single interpreter according to the UTD classification. Logistic regression was used to test the predictive value of SFU and UTD; ROC curves were plotted accordingly. Kaplan-Meier curves were used to model time to operation and mean time to operation was computed with a 95% confidence interval. Breslow Test was used to determine significant differences in survival curves across the different SFU grades and UTD classifications.@*Results@#Of the 163 patients in the database who presented with prenatal hydronephrosis, 25 patients presented with high-grade UPJO-like hydronephrosis (50 renal units). Logistic regression revealed that the SFU grading system was able to explain only 18.7% of the variance of the occurrence of pyeloplasty, thus, was a poor predictor of the occurrence of surgery. In contrast, logistic regression of the UTD classification was able to explain 47.3% of the occurrence of pyeloplasy with an accuracy of 86% making it a good predictor of surgical intervention. Both SFU and UTD classifications were poor predictors of spontaneous resolution. Mean time to pyeloplasty from the time of diagnosis was 2.98 years (95% CI: 2.45-3.53) Kaplan-Meier curve analysis for the time of pyeloplasty for the SFU grading system revealed no significant difference in the time to operation among the different SFU grades (p=0.110) while for the UTD classification, there was a significant difference in time to pyeloplasty across the different UTD classes with the higher classes correlating to a shorter time to pyeloplasty. (p<0.05) @*Conclusion@#The UTD classification system is a good predictor of surgery in patients presenting with high-grade UPJO-like hydronephrosis on prenatal ultrasound with a predictive accuracy of 86%. High-grade hydronephrosis based on the UTD classification equates to a shorter time to surgical intervention from the time of diagnosis necessitating closer follow-up of these patients.