Management of small renal masses.

Surgical excision of renal cell carcinoma is the current standard of care for localized disease. Series for small renal masses treated with surgery demonstrate excellent oncologic outcomes with 5-year survival rates over 95%. Minimally invasive ablative technologies, such as cryotherapy and radiofrequency ablation, have recently emerged with similar short- and intermediate-term results. Additionally, recent data on active surveillance have demonstrated survival rates comparable to surgery and ablation in selected patient populations. We review the currently available data regarding the management of small renal masses by excision, ablation, or observation.

Outpatient perineal sling in adolescent boys with neurogenic incontinence.

PURPOSE: Management for urinary incontinence in boys with sphincteric incompetence secondary to a neurogenic etiology is a challenge. Minimally invasive approaches have inconsistent efficacy and may require multiple treatments. Open bladder neck reconstruction requires inpatient hospitalizations and can be associated with a high complication rate. To overcome some of these shortcomings we placed a polypropylene male perineal sling in male adolescents with neurogenic sphincteric incontinence. We retrospectively reviewed the outcome in our initial 6 patients. MATERIALS AND METHODS: Six patients 14 to 20 years old underwent placement of a polypropylene male perineal sling on an outpatient basis. Followup was 27 to 39 months (median 33). All patients had a history of myelomeningocele and underwent urodynamics showing normal compliance, adequate capacity and sphincteric incompetence. A suburethral sling was placed on an outpatient basis through a small perineal incision. Sling tension was adjusted for maximal urethral compression while still permitting uncomplicated urethral catheter passage. RESULTS: All 6 patients reported immediate complete continence after sling placement. Two slings were removed after local infection developed and 1 was replaced. Another sling required revision secondary to incomplete bone anchor fixation. No patients had urethral erosion. All 5 patients with a sling currently in place were fully continent on intermittent catheterization every 3 hours and they reported excellent satisfaction with the procedure. CONCLUSIONS: Our retrospective study suggests that the male urethral sling may be an outpatient option for neurogenic incontinence secondary to sphincteric incompetence. Long-term followup in our initial 6 patients shows encouraging durability. Continued study is required to determine strategies that might decrease the complication rate of this approach.

Focal therapy for kidney cancer: a systematic review.

PURPOSE OF REVIEW: Surgical excision remains the standard of care for treatment of localized small renal masses (SRMs). Laparoscopic and percutaneous minimally invasive ablative technologies are being increasingly employed in current urologic practice. We review recent literature regarding focal ablative treatments of SRMs. RECENT FINDINGS: Most cryoablations are performed using a laparoscopic approach, whereas radiofrequency ablation (RFA) of the SRM is more commonly administered percutaneously. Pretreatment biopsy is performed more often for lesions treated by cryoablation than RFA with a significantly higher rate of indeterminate or unknown pathology for SRMs undergoing RFA versus cryoablation (P < 0.0001). Currently available data suggest that cryoablation results in lower retreatments (P < 0.0001), less local tumor progressions (P < 0.0001) and may be associated with a decreased risk of metastatic progression compared with RFA. It is unclear whether these differences are a function of the technologies or their application. Given the excellent results reported for active surveillance of the SRM in selected patients, the extent to which focal ablation alters the natural history of SRMs has not yet been established. SUMMARY: Currently, data on the ability of interventions for SRMs to affect the natural history of these masses are lacking. Prospective randomized evaluations of available clinical approaches to SRMs are needed.

Age, tumor size and relative survival of patients with localized renal cell carcinoma: a surveillance, epidemiology and end results analysis.

PURPOSE: Recent data demonstrate that age may be a significant independent prognostic variable following treatment for renal cell carcinoma. We analyzed data from the SEER (Surveillance, Epidemiology and End Results) database to evaluate the relative survival of patients treated surgically for localized renal cell carcinoma as related to tumor size and patient age. MATERIALS AND METHODS: Patients in the SEER database with localized renal cell carcinoma were stratified into cohorts by age and tumor size. Three and 5-year relative survival, the ratio of observed survival in the cancer population to the expected survival of an age, sex and race matched cancer-free population, was calculated with SEER-Stat. Brown's method was used for hypothesis testing. RESULTS: A total of 8,578 patients with surgically treated, localized renal cell carcinoma were identified. While 3 and 5-year survival for patients with small (less than 4 cm) renal cell carcinoma was no different from that of matched cancer-free controls, patients treated for large (greater than 7 cm) localized renal cell carcinoma experienced decreased 5-year relative survival across all age groups. Therefore, age was not a significant predictor of relative survival for patients with small (less than 4 cm) or large (greater than 7 cm) tumors. However, a statistically significant trend toward lower relative survival with increasing age was demonstrated in patients with medium size tumors (4 to 7 cm). Hypothesis testing confirmed these findings. CONCLUSIONS: These data suggest that relative survival is high in patients with tumors less than 4 cm and lower in patients with tumors larger than 7 cm regardless of age. However, increasing age may be related to worse outcomes in patients with tumors 4 to 7 cm. The cause of this observation warrants further investigation.

Cryoablation or radiofrequency ablation of the small renal mass : a meta-analysis.

BACKGROUND: The incidence of renal cell carcinoma is rising because of incidental detection of small renal masses (SRMs). Although surgical resection remains the standard of care, cryoablation and radiofrequency ablation (RFA) have emerged as minimally invasive treatment alternatives. The authors of this report performed a comparative meta-analysis evaluating cryoablation and RFA as primary treatment for SRMs. METHODS: A search of the MEDLINE database was performed reviewing the world literature for clinically localized renal masses treated by cryoablation or RFA. RESULTS: Forty-seven studies representing 1375 kidney lesions treated by cryoablation or RFA were analyzed. No differences were detected between ablation modalities with regard to mean patient age (P = .17), tumor size (P = .12), or duration of follow-up (P = .53). Pretreatment biopsy was performed more often for cryoablated lesions (82.3%) than for RFA (62.2%; P < .0001). Unknown pathology occurred at a significantly higher rate for SRMs that underwent RFA (40.4%) versus cryoablation (24.5%; P < .0001). Repeat ablation was performed more often after RFA (8.5% vs 1.3%; P < .0001), and the rates of local tumor progression were significantly higher for RFA (12.9% vs 5.2%; P < .0001) compared with cryoablation. The higher incidence of local tumor progression was found to be correlated significantly with treatment by RFA on univariate analysis (P = .001) and on multivariate regression analysis (P = .003). Metastasis was reported less frequently for cryoablation (1.0%) versus RFA (2.5%; P = .06). Cryoablation usually was performed laparoscopically (65%), whereas 94% of lesions that were treated with RFA were approached percutaneously. CONCLUSIONS: Ablation of SRMs is a viable strategy based on short-term oncologic outcomes. Although extended oncologic efficacy remains to be established for ablation modalities, the current data suggest that cryoablation results in fewer retreatments and improved local tumor control, and it may be associated with a lower risk of metastatic progression compared with RFA.

Evaluation and management of gunshot wounds of the penis: 20-year experience at an urban trauma center.

BACKGROUND: Although gunshot injuries to the penis occur relatively infrequently in patients with penetrating trauma, they often present dilemmas of subsequent evaluation and management. We review our extensive experience with gunshot wounds to the penis at a high volume urban trauma center. METHODS: The urologic trauma database was retrospectively reviewed to extract and compile information from the records of 63 patients treated for gunshot wounds to the penis. Data were accumulated for a 20-year period from 1985 to 2004 with regard to findings on physical examination, diagnostic evaluation, associated injuries, management, and outcome. We detail our technique of penile exploration and artificial erection in the management of these injuries. RESULTS: Penile gunshot wounds were associated with additional injuries in 53 of 63 (84%) patients. A total of 48 (76%) patients were taken to the operating room and 44 (70%) penile explorations were performed. Evaluation included retrograde urethrogram in 50 of 63 (79%) patients and was diagnostic for urethral injury in 11 of 12 (92%) cases. Primary urethral repair was performed in 8 of 12 (67%) patients with urethral injury versus 4 of 12 (33%) who underwent urinary diversion by means of suprapubic cystotomy. CONCLUSIONS: Evaluation and management of gunshot wounds to the penis may potentially be complex. Retrograde urethrogram should be performed in all cases except the most insignificant and superficial wounds. We describe our technique of penile exploration and artificial erection, noting excellent results in patients for whom follow-up is available. Additional studies are needed to prospectively evaluate techniques for management of gunshot urethral injuries.

Excise, ablate or observe: the small renal mass dilemma--a meta-analysis and review.

PURPOSE: The incidence of renal cell carcinoma is increasing due to the incidental detection of small renal masses. Resection, predominantly by nephron sparing surgery, remains the standard of care due to its durable oncological outcomes. Active surveillance and ablative technologies have emerged as alternatives to surgery in select patients. We performed a meta-analysis of published data evaluating nephron sparing surgery, cryoablation, radio frequency ablation and observation for small renal masses to define the current data. MATERIALS AND METHODS: A MEDLINE search was performed for clinically localized sporadic renal masses. Patient age, tumor size, duration of followup, available pathological data and oncological outcomes were evaluated. RESULTS: A total of 99 studies representing 6,471 lesions were analyzed. Significant differences in mean patient age (p <0.001), tumor size (p <0.001) and followup duration (p <0.001) were detected among treatment modalities. The incidence of unknown/indeterminate pathological findings was significantly different among cryoablation, radio frequency ablation and observation (p = 0.003), and a significant difference in the rates of malignancy among lesions with known pathological results was detected (p = 0.001). Compared to nephron sparing surgery significantly increased local progression rates were calculated for cryoablation (RR = 7.45) and radio frequency ablation (RR = 18.23). However, no statistical differences were detected in the incidence of metastatic progression regardless of whether lesions were excised, ablated or observed. CONCLUSIONS: Nephron sparing surgery, ablation and surveillance are viable strategies for small renal masses based on short-term and intermediate term oncological outcomes. However, a significant selection bias exists in the application of these techniques. While long-term data have demonstrated durable outcomes for nephron sparing surgery, extended oncological efficacy is lacking for ablation and surveillance strategies. The extent to which treatment alters the natural history of small renal masses is not yet established.

Tumor size predicts synchronous metastatic renal cell carcinoma: implications for surveillance of small renal masses.

PURPOSE: Active surveillance of small incidental renal masses is associated with slow radiographic growth and a low risk of metastatic progression. Radiographic tumor size, in the absence of histological data, is the only prognostic indicator available when considering active surveillance. To better define the relationship between tumor size and the metastatic potential of small renal masses, we investigated whether radiographic tumor size predicts for the presence of synchronous metastases in renal cell carcinoma. MATERIALS AND METHODS: We reviewed our institutional tumor registry to identify sporadic pathologically verified renal cell carcinoma treated during an 8-year period. We analyzed data regarding primary tumor size and the presence of biopsy proven synchronous metastatic disease at presentation. All N+M0 and nonpathologically confirmed M+ disease was excluded from analysis. RESULTS: We compared 110 cases of renal cell carcinoma with biopsy proven synchronous metastatic disease at presentation to 250 controls with clinically localized renal cell carcinoma. Tumors associated with synchronous metastasis were significantly larger than localized lesions (median 8.0 cm [range 2.2 to 20.0] vs 4.5 cm [range 0.3 to 17.5], p <0.0001). The probability of synchronous metastasis increased with increasing primary tumor size (p <0.0001). There were no patients with tumors 2 cm or smaller who presented with biopsy confirmed metastatic disease and less than 5% (5 of 110) of all synchronous metastasis occurred in tumors 3.0 cm or smaller. Logistic regression models determined that the odds of synchronous metastasis increased by 22% for each 1 cm increase in tumor size. CONCLUSIONS: Radiographic tumor size is a significant clinical predictor of the presence of biopsy proven synchronous metastatic renal cell carcinoma. In our series the odds of presenting with synchronous, biopsy proven metastatic disease increased by 22% with each 1 cm increase in tumor size. A 100% odds increase, or doubling of the risk of metastasis, occurs with a 3.5 cm increase in primary tumor size. These data have important implications for extent of disease evaluations in patients with large tumors and for the active surveillance of small enhancing renal masses.

Enhancing renal masses with zero net growth during active surveillance.

PURPOSE: The natural history of small renal masses is generally to slowly increase in size. However, a subset of lesions does not show radiographic growth. We compared clinical, radiographic and pathological characteristics of enhancing renal masses under active surveillance with zero net radiographic growth vs those with positive growth. MATERIALS AND METHODS: We identified 106 enhancing renal masses that were observed for 12 months or greater. Lesions were grouped according to growth characteristics. Group 1 consisted of lesions demonstrating zero or negative growth. Group 2 tumors showed positive growth during surveillance. Clinical, radiographic and pathological parameters were then compared. A MEDLINE search was performed regarding zero growth lesions during observation for suspected renal cell carcinoma in the world literature. RESULTS: Group 1 consisted of 35 lesions (33%) with a median growth rate of 0.0 cm yearly. Group 2 included 70 lesions (67%) showing growth at 0.31 cm yearly (p<0.0001). No differences were detected with regard to patient age (p=0.96), lesion size (p=0.41), solid/cystic appearance (p=1.00) or the incidental detection rate (p=0.38). While 17% of group 1 lesions (6 of 35) underwent intervention, 51% (36 of 71) in group 2 were ultimately treated (p=0.001). Pathological assessment showed a similar incidence of malignancy in groups 1 and 2 (83% and 89%, respectively, p=0.56). A literature review revealed that 78 of 295 observed lesions (26%) failed to demonstrate radiographic growth. CONCLUSIONS: We were unable to identify definable clinical characteristics to predict the future growth of enhancing renal masses under active surveillance. Our analysis demonstrated that 26% to 33% of these tumors do not demonstrate growth at 29 months median followup. These lesions have similar rates of malignancy compared to growing lesions and rates of progression to metastatic disease are similarly low. A brief period of active surveillance may be feasible with treatment limited to lesions that increase in size.

Adjuvant therapy for high-risk renal cell carcinoma patients.

For most cases of renal cell carcinoma (RCC), the standard of care is surgical resection as monotherapy or as part of a multimodal approach. In patients with early localized disease, radical nephrectomy is associated with a favorable prognosis, whereas patients with advanced disease are rarely cured. A significant number of patients undergoing surgery for localized RCC experience recurrence, suggesting that there are some individuals in whom surgical excision is necessary but insufficient. In these patients, the development of effective adjuvant strategies is imperative. In this article, we review the prognostic variables and comprehensive staging algorithms for identifying patients at high risk for disease recurrence. Additionally, we review data from completed adjuvant RCC trials and highlight relevant ongoing trials.

Delayed diagnosis of traumatic ureteral injuries.

PURPOSE: We review our experience with traumatic ureteral injuries missed at exploration. We also conduct meta-analysis to define factors contributing to missed injury, comparing outcomes of early vs late diagnosis. MATERIALS AND METHODS: Our genitourinary trauma database was retrospectively reviewed from 1995 through 2004. A total of 40 ureteral injuries were identified including 5 with delayed diagnosis. Previously published series of ureteral trauma were then analyzed for injuries with delayed diagnosis, with data extracted and collated for meta-analysis. RESULTS: A total of 40 patients with traumatic ureteral injuries was identified, all of whom underwent laparotomy. Five (12.5%) injuries were discovered at a mean of 6.0 +/- 3.0 days after laparotomy. The number of associated injuries for early and delayed diagnosis was 3.2 and 2.6 (p = 0.25), respectively. Mean hospital stay was 19.2 vs 36.6 days (p = 0.18) for those with immediate vs delayed diagnosis, respectively. Only 2 of 5 (40%) patients achieved satisfactory results during initial hospitalization. Literature review revealed 48 missed ureteral injuries, representing 11.1% of all patients with ureteral injuries who underwent laparotomy. Rates of nephrectomy for early and late diagnosis were 2.4% and 18.4% (p = 0.0001). Mortality related to traumatic injuries occurred in 6.1% with early diagnosis and 13.2% with missed injuries (p = 0.089). CONCLUSIONS: Despite preoperative studies and intraoperative inspection, ureteral injury may remain undiagnosed until after laparotomy. We report intraoperative exploration to have a sensitivity of 88.9% across multiple series for traumatic ureteral injuries. Delayed diagnosis of ureteral injuries produces an association with prolonged hospital stay, and meta-analysis reveals a statistically significant increase in the rate of nephrectomy when ureteral injury is missed at exploration.