Trends in nephron-sparing surgery for renal neoplasia.

OBJECTIVES: To determine the extent that laparoscopy has replaced open surgery for nephron-sparing surgery in a mature laparoscopic environment. METHODS: The records of all patients at Washington University who underwent nephron-sparing surgery for localized renal masses from 1999 to 2003 were examined for clinical and pathologic information. Information regarding the mass size, surgery type performed, and surgeon training was obtained. RESULTS: A total of 271 patients underwent nephron-sparing surgery from January 1999 to December 2003. During the study period, the total number of partial nephrectomies increased from 33 per year to 91 per year. The proportion of laparoscopic partial nephrectomy increased from 3% of total cases to 56% of total cases. Open partial nephrectomy decreased from 97% of cases to 24% of cases; however, the absolute number of open partial nephrectomies only decreased from 32 to 22 per year. Laparoscopic cryoablation increased from 0% of cases to 20% of cases. Endourologists increased their frequency of performing open partial nephrectomy, and oncologists increased their frequency of performing laparoscopic renal surgery. CONCLUSIONS: Laparoscopic nephron-sparing surgery has not completely replaced open partial nephrectomy for low-stage renal neoplasia; however, the number of laparoscopic partial nephrectomies has increased rapidly in recent years. Laparoscopic approaches are being performed by all urologists treating renal malignancies at our institution and this reflects changes in the surgical treatment of renal cancer.

Development of exophytic tumor model for laparoscopic partial nephrectomy: technique and initial experience.

OBJECTIVES: To develop and test a porcine model to help teach the techniques needed to perform laparoscopic partial nephrectomy (LPN), which is a technically challenging procedure with necessary reconstructive skills that are difficult to transfer. METHODS: A tumor model was created by unilateral subcapsular percutaneous injection of liquid plastic (Smooth-Cast 320) in five pig kidneys. Five Washington University urologists performed LPN and assessed the efficacy of the tumor model. Subsequently, the tumor model was evaluated as a tool for teaching LPN during the Washington University Advanced Laparoscopic and Robotic Urologic Oncology Course. Twenty-eight participants performed unilateral porcine LPN with the tumor model. Questionnaires were used to assess the utility of this tumor model. RESULTS: Unilateral tumors were successfully created in five pigs and remained intact during all LPN procedures. Visually, the tumors appeared as white exophytic masses. Ultrasonography revealed a well-circumscribed, hypoechoic lesion and a mean diameter of 2.02 cm. The mean operative time was 32.4 minutes. In subsequent testing, 24 (86%) of the 28 participants returned the questionnaire, and 96% responded that the tumor model had enhanced their LPN learning experience. Seven course participants (29%) reported problems with hemostasis, ultrasonography, or laparoscopic instrumentation. Two tumor model-related complications occurred. During the initial evaluation, one pig experienced a fatal pulmonary embolism of the plastic. During the course, a second animal experienced extravasation of the solution into the renal collecting system. CONCLUSIONS: For surgical education purposes, the Smooth-Cast model is an effective surgical tool for LPN. Most of the surgeons in this evaluation believed the model enhanced their learning experience.

Effects of pretransplantation treatment with rituximab on outcomes of autologous stem-cell transplantation for non-Hodgkin's lymphoma.

PURPOSE: To analyze the effects of preautografting treatment with rituximab (R) on stem-cell mobilization, post-transplantation complications, engraftment, disease-free survival, and overall survival in patients with non-Hodgkin's lymphoma (NHL). PATIENTS AND METHODS: Single-institution retrospective comparative outcome analysis in a cohort of 273 relapsed chemosensitive NHL patients of whom 127 (47%) received R pretransplantation. RESULTS: R was administered a median of 3 months before autologous transplantation. When compared to the nonrituximab group, R patients were older (56 v 50 years; P < .001), and had delays in post-transplantation platelets recovery (39 v 27 days; P = .001). Pretransplantation R did not affect stem-cell mobilization, post-transplantation early complications, duration of hospitalization, or mortality rates at days 30 and 100. In contrast to patients with low-grade NHL, both disease-free and overall survival rates were significantly better when R was included in the pretransplantation salvage therapy for patients with intermediate-grade NHL. CONCLUSION: In this large, single-center retrospective analysis, pretransplantation treatment with R was associated with improved survival in patients with intermediate-grade NHL, at the price, however, of a delay in platelet engraftment.