Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy.

INTRODUCTION: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. METHODS: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. RESULTS: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). CONCLUSIONS: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

Mid term outcomes of initial 250 case experience with GreenLight 120W-HPS photoselective vaporization prostatectomy for benign prostatic hyperplasia: comparison of prostate volumes < 60 cc, 60 cc-100 cc and > 100 cc.

INTRODUCTION: The aim of this study was to compare the efficacy of GreenLight 120W-HPS (American Medical Systems, Minnetonka, Minnesota, USA) laser vaporization for men with obstructive benign prostatic hyperplasia (BPH) according to prostate volumes < 60 cc, 60 cc-100 cc and > 100 cc. MATERIAL AND METHODS: The clinical data of 250 men with symptomatic BPH who underwent photoselective vaporization prostatectomy (PVP) by a single surgeon between July 2007 and August 2009 were retrospectively analyzed. Prostate volumes were measured by using transrectal ultrasonography (TRUS). Functional evaluations were performed at 3, 6 and 12 months with a prostate-specific antigen (PSA) obtained at 6 months. All men were stratified into three groups according to TRUS volume. RESULTS: Among the 250 consecutive PVP patients, 134, 76 and 40 men had prostate volumes < 60 cc, 60 cc-100 cc and > 100 cc, respectively. Mean laser time and delivered energy were 31, 44 and 59 minutes; 163, 309 and 473 kJ respectively (p < 0.01 for all). At 1 year, mean International Prostate Symptom Score (IPSS) improved by 69%, 63% and 50%, Qmax increased by 194%, 175% and 162% and post void residual (PVR) decreased by 88%, 81% and 71%, respectively (p < 0.01 for all). Mean decrease in preoperative PSA at 6 months was 63%, 52% and 41% (p < 0.01), respectively. Hospital stay, catheterization time and complication rates were comparable between groups, however retreatment rates were significantly higher for prostates >100 cc (1.5% versus 2.6% versus 9%; p = 0.02). CONCLUSIONS: Although larger prostates require more time and energy delivery, PVP is safe and efficacious for patients with lower urinary tract symptoms (LUTS) regardless of prostate size. Laser vaporization for glands > 100 cc appears to have a reduced reduction in PSA and a higher 9% rate of retreatment indicating that PVP for larger prostates remains to be optimized.

Laparoscopic radical versus laparoscopic partial nephrectomy for clinical T1bN0M0 renal tumors: comparison of perioperative, pathological, and functional outcomes.

AIM: To compare outcomes in patients treated with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for clinical T1bN0M0 renal masses. MATERIALS AND METHODS: Between 2002 and 2008, 33 and 52 consecutive patients who underwent LPN and LRN, respectively, for clinical stage T1bN0M0 tumors were retrospectively identified from a prospectively maintained database of 450 patients undergoing laparoscopic renal surgery. Perioperative, pathological, and postoperative outcomes were compared. RESULTS: The two groups of patients were similar in age, sex, and body-mass index. Mean radiographic tumor size was smaller (4.8 vs. 5.2 cm, p = 0.04) in the LPN group. Mean operative time (228 vs. 175 minutes, p < 0.0001) and mean estimated blood loss (233 vs. 112 mL, p = 0.003) were higher in the LPN group. Intraoperative complication rates of 15.2% versus 5.7% (p = 0.28) and postoperative complication rates of 24.2% versus 13.5% (p = 0.20) were observed in the LPN and LRN groups, respectively. Overall median follow-up was 15 and 21 months for the LPN and LRN cohorts, respectively. A 12.5% and 29.3% decline in estimated glomerular filtration rate was observed (p = 0.002), and 30.3% compared with 55.7% of patients developed an estimated creatinine clearance (eCrCl) < 60 mL/minutes after treatment (p = 0.04) for LPN and LRN, respectively. There were no differences in pathological stage distribution between the two groups. In the LPN group there were no local or systemic recurrences, and one positive surgical margin was observed. One patient developed metastatic disease in the LRN group. CONCLUSIONS: LPN for T1b renal tumors provides superior intermediate-term preservation of renal function compared with LRN. Continued follow-up of these patients is required to evaluate oncological outcomes.

Laparoscopic nephron-sparing surgery in the management of angiomyolipoma: a single center experience.

BACKGROUND AND PURPOSE: Angioembolization is often the first-line treatment for patients with renal angiomyolipoma (AML). Regrowth and repeated hemorrhage after embolization, however, remain a concern. Laparoscopic partial nephrectomy (LPN) is the definitive, minimally invasive treatment alternative. We compared the outcomes of LPN in patients who had a diagnosis of AML with patients with other renal tumors. PATIENTS AND METHODS: From a prospective LPN database, we identified patients with a final pathologic diagnosis of AML (group 1). The ability of preoperative imaging to predict AML final pathology results was studied. Surgical and postoperative outcomes in group 1 were compared with the outcomes of the rest of our LPN cohort (group 2). RESULTS: Of 184 LPNs that were performed between 2002 and 2008, 14 (7.6%) patients and 15 renal units had a diagnosis of AML. Two patients underwent concomitant LPN and radiofrequency ablation (RFA) for multiple AML lesions. In group 1, only 33% of the patients had a preoperative diagnosis of AML. There were no significant differences in tumor size, age, preoperative estimated creatinine clearance, body mass index, and comorbidities between the groups. The mean estimated blood loss in groups 1 and 2 was 214 mL and 178 mL, respectively (P = 0.5). The complication rates were similar between the groups. With a median follow-up of 15 months, no AML recurrences or bleeding was observed in group 1. CONCLUSIONS: The results of LPN or RFA, when appropriate, in AML patients are comparable to the results of LPN for other renal tumors. The preoperative imaging studies were a poor predictor of AML in patients who were undergoing LPN.

Localized T1a renal lesions in the elderly: outcomes of laparoscopic renal surgery.

OBJECTIVE: The objective of this study was to compare the outcomes of patients >or=70 years of age undergoing laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN), and laparoscopic ablative techniques (LAT) for small renal masses. METHODS: From a prospectively maintained database we identified 19 (LRN), 28 (LPN), and 19 (LAT) patients aged >or=70 who underwent surgery for cT1aN0M0 lesions. Perioperative, surgical, and functional outcomes were compared. RESULTS: The three groups were similar in age, race, body mass index, and estimated creatinine clearance. In the LRN group, mean tumor diameter was larger (3.3 vs. 2.4 cm [LPN] and 2.7 cm [LAT]; p = 0.0005) and there was a higher percentage of central tumors (73.7% vs. 25.0% and 5.3%; p < 0.0005) when compared with the LPN and LAT groups, respectively. Although intraoperative and postoperative complication rates were similar, mean estimated blood loss and operative time were highest in the LPN group (p < 0.05). Moreover, 42.1%, 39.3%, and 42.1% of patients had preoperative stage 3 chronic kidney disease in the LRN, LPN, and LAT groups, respectively. Patients who underwent LRN had a lower follow-up estimated creatinine clearance (43.4 vs. 61.4 mL/min [LPN] and 59.2 [LAT]; p < 0.01) and a higher likelihood of developing stage 3 chronic kidney disease after treatment (100% vs. 25.0% [LPN] vs. 18.2 [LAT]; p < 0.0005). CONCLUSIONS: Impaired renal function is common in elderly patients presenting with renal masses. LPN and LAT provide superior preservation of renal function when compared with LRN in this population. In appropriately selected patients >or=70 years of age presenting with T1a renal lesions, laparoscopic nephron-sparing approaches should be considered.

Laparoscopic partial nephrectomy: a single-center evolving experience.

OBJECTIVES: To review our laparoscopic partial nephrectomy (LPN) experience, examine the evolution of technique, and compare the outcomes between the early and recent experience. The indications and surgical technique of LPN continuously evolve. METHODS: Data for 184 patients who underwent LPN for a tumor between October 2002 and August 2008 was retrieved from a prospective database. Surgical and functional outcomes for the entire cohort were analyzed and the first 50 (group 1) and most recent 50 (group 2) cases were compared. RESULTS: The groups were similar in terms of baseline renal function, body mass index, and comorbidities. The mean tumor size and the proportion of central tumors in groups 1 and 2 were 2.4 vs 3 cm and 12% vs 52%, respectively (P <.003). In group 2 we stopped the use of ureteral catheters and bolster renorrhaphy, and routinely clamped the renal hilum. Mean warm ischemia time in groups 1 and 2 (30 and 27 minute, respectively, P = .3) and the complication rate were similar. Overall, patients with tumors >4 cm had more complications (P = .042). In group 2 the estimated blood loss and hospital stay decreased (243 vs 140 mL, P = .01, 1.4 vs 2.5 days, P <.001). Overall 78% of the tumors were malignant and the positive margin rate was 3%. With a median follow-up of 18 months, no local or distant tumor recurrences were observed. CONCLUSIONS: With growing experience and technical modifications, LPN is now performed for patients with larger and more central tumors. Longer follow-up is necessary to evaluate oncologic outcomes.

Laparoscopic partial nephrectomy for tumors larger than 4 cm: a comparative study.

PURPOSE: To compare the perioperative and functional outcomes of patients with clinical T(1a) and T(1b) renal tumors after laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Data of 184 patients who underwent LPN were retrieved from a prospective, Institutional Review Board-approved database. The patients were stratified for analysis into groups: 149 (81%) patients with clinical stage T(1a) (group 1) and 35 (19%) patients with clinical stage T(1b) (group 2). Perioperative and postoperative outcomes were compared. RESULTS: No significant differences between groups 1 and 2 in warm ischemia time, estimated blood loss, operative time, conversion rate, intraoperative complication rate, and hospital stay were observed. The incidence of postoperative complications in group 2, however, was twice that of group 1 (25.7% vs 12%) (P = 0.04). Clinical staging correlated with the pathologic staging in 96% of the patients in group 1 and in only 71% in group 2 (P < 0.001). Upstaging to pT(2) or pT(3) occurred in 29% of the patients in group 2. High-grade tumors were more prevalent in group 2 (36% vs 12%) (P = 0.001). The number of patients with positive margin was higher in group 2, but the difference was not statistically significant. The mean decline in estimated creatinine clearance (median follow-up 18 months) was significantly higher in group 2. CONCLUSIONS: LPN in patients with tumors >4 cm, while safe and feasible in experienced hands, is associated with a higher postoperative complication rate, as well as a higher rate of pathologic upstaging. Such data should be discussed when counseling patients with larger tumors for LPN.

Laparoscopic partial nephrectomy for technically challenging tumours.

STUDY TYPE: Therapy (case series) Level of Evidence 4. OBJECTIVE: To investigate the outcomes of laparoscopic partial nephrectomy (LPN) for endophytic tumours and those located near the hilum or the posterior upper-pole, as these pose a technical challenge. PATIENTS AND METHODS: Technically challenging tumours were defined as endophytic, hilar, or at the posterior upper-pole (group 1), and were compared to tumours in other locations (group 2). We collected data prospectively for all patients undergoing LPN at our institution, including baseline patient and tumour characteristics, surgical and postoperative outcomes. Two-sided t-test or rank-sum test, and chi-square or exact tests were used as appropriate for comparison of continuous and categorical variables, respectively, with P < 0.05 considered to indicate statistical significance. RESULTS: There were 184 patients treated with LPN (42 in group 1 and 142 in group 2) between 2002 and 2008 by one surgeon (A.L.S.). Groups 1 and 2 were similar in terms of baseline variables (age, sex, body mass index, comorbidities, previous surgery, renal function and haematocrit) and in tumour size. LPN for challenging tumours resulted in a higher rate of collecting system repair (78% in group 1, 61% in group 2, P = 0.03). However, operative (surgery time, warm ischaemia time, blood loss, intraoperative complications) and postoperative outcomes (renal function, nadir haematocrit, complication rate, hospital stay and positive margin rate) were similar between the groups. CONCLUSIONS: With developing experience LPN can be safe for technically challenging renal tumours in well selected patients.

Predicting collecting system transection at laparoscopic partial nephrectomy: analysis of tumor parameters.

OBJECTIVE: Repair of renal collecting system (CS) during laparoscopic partial nephrectomy (LPN) requires advanced skills and nevertheless prolongs renal ischemia time. We assessed tumor parameters that may predict CS transection and thus improve preoperative planning. METHODS: Data were prospectively collected for 184 consecutive LPN cases performed at our institution between 2002 and 2008 by a single senior surgeon. Twelve patients were excluded because of open conversion and seven because of missing data. Among the rest (n = 165), CS was transected in 115 (61%). Tumor parameters (radiographic appearance-solid vs. cystic, size, polar location, and depth) were evaluated with univariate and multivariate logistic regression analysis. Classification and Regression Tree analysis was applied to define the optimal cutoff for tumor size. RESULTS: In univariate analysis, tumor size (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.8, 4.3; p < 0.0001) and tumor appearance (solid: OR 2.1, 95% CI 1.1, 4.3) achieved statistical significance, while tumor depth (endophytic: OR 3.1, 95% CI 0.8, 11.0; p = 0.08) trended toward significance. In multivariate analysis, size (p < 0.0001) and solid tumor appearance (p = 0.006) were independent predictors. In Classification and Regression Tree analysis, 2.5 cm was found to be the optimal cutoff for the tumor size. CONCLUSIONS: The odds of CS transection during LPN triple with each additional centimeter in tumor size, are 10-fold higher for tumors >2.5 cm, and are almost twice higher for solid tumors, compared with cystic. These findings may be useful in LPN planning.

Laparoscopic partial nephrectomy: predictors of prolonged warm ischemia.

PURPOSE: The kidney is often exposed to warm ischemia during laparoscopic partial nephrectomy. Warm ischemia time is associated with acute and possible long-term renal damage, particularly beyond a 30-minute threshold. We evaluated patient and tumor characteristics that might predict prolonged warm ischemia time. MATERIALS AND METHODS: A prospective institutional database was searched for patients who underwent laparoscopic partial nephrectomy with renal vessel clamping. Warm ischemia time was treated as a continuous and a categorical (more or less than 30 minutes) variable. The association between warm ischemia time, and preoperative and surgical parameters was evaluated using linear and logistic regression analysis. The latter analysis was used to develop and internally validate a preoperative nomogram to predict warm ischemia time longer than 30 minutes. RESULTS: On multivariate linear regression analysis tumor size (coefficient 1.6, 95% CI 0.7-2.6, p = 0.001), body mass index (coefficient 0.3, 95% CI 0.1-0.5, p = 0.005) and central tumor location (coefficient 3.7, 95% CI 0.5-7, p = 0.02) were independent predictors of longer warm ischemia time. Patients with 2 or more of certain risk factors, including body mass index greater than 30 kg/m(2), tumor greater than 4 cm and a centrally located tumor, were 5 times more likely to have warm ischemia time greater than 30 minutes than patients without the risk factors (p = 0.002). A nomogram incorporating predictors of longer warm ischemia time showed 75.4% accuracy. CONCLUSIONS: Greater tumor size, central tumor location and higher body mass index are associated with longer warm ischemia time. By incorporating these 3 risk factors into a nomogram prolonged warm ischemia time (greater than 30 minutes) can be accurately predicted preoperatively.

Barriers to diagnosis of occupational asthma in Ontario.

BACKGROUND: Occupational asthma (OA) refers to asthma caused by workplace-specific substances. A longer duration of symptoms while continuing to be exposed has been associated with a worse prognosis. Evidence suggests a significant period of time exists between symptom onset and diagnosis of OA, the reasons for which have not been investigated. The purpose of this study was to examine whether primary health care and/or socio-economic factors account for delays in Ontario. METHOD: Two hundred and forty-seven (247) chart reviews were undertaken of patients referred to the University Health Network Asthma Centre for evaluation of OA, with clinic visits from 1997-2002. Forty-two (42) patients fulfilling objective OA criteria were administered a structured telephone interview to examine the chronology and nature of health care consultation and reasons for possible delay in diagnosis. RESULTS: The mean time to diagnosis was 4.9 years (3.4 years excluding 4 outliers). On average, patients waited 7.4 months before discussing the work-relation of symptoms with a physician. Main self-reported reasons for delay were lack of enquiry about work relatedness by the primary care physician (41%) and fear of losing work time (37%). Reported increases in time during secondary care were related to difficulties associated with completion of investigations (35%). Lower education level (p = 0.04) and household income (p = 0.03) were significantly associated with an increased time to diagnosis. INTERPRETATION: Physicians who assess working adults with asthma need to ask pertinent work-related questions when taking a history in order to initiate timely investigations and referral. Socio-economic factors are also associated barriers to early diagnosis of occupational asthma.