Long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with autosomal dominant polycystic kidney disease.

PURPOSE: Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with adult dominant polycystic kidney disease presenting with refractory pain. MATERIALS AND METHODS: Between 1994 and 2003, 37 patients with adult dominant polycystic kidney disease underwent laparoscopic cyst decortication at Barnes-Jewish Hospital. A total of 19 patients (4 male, 15 female) with at least 3-year followup were included in the study. Renal function was evaluated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated glomerular filtration rate formula. End stage renal disease was defined as progression to transplant, dialysis or stage 5 chronic kidney disease. Hypertension was evaluated using the antihypertensive therapeutic index. Pain assessment was based primarily on a telephone questionnaire. RESULTS: At a mean followup of 10.9 years (range 6.4 to 16.9), 67% of evaluable patients reported more than 50% improvement in pain. Ten patients had progression to end stage renal disease--3 dialysis, 6 transplant, and 1 chronic kidney disease stage 5. Two patients had stage 5 chronic kidney disease at initial presentation. A comparison of preoperative estimated glomerular filtration rate between patients with and those without end stage renal disease revealed a lower preoperative estimated glomerular filtration rate in the former group (43.4 vs 75.4 ml/minute/1.73 m(2), p = 0.01). Of the patients 53% had an improved or stable antihypertensive therapeutic index at last followup, although no improvement in mean overall antihypertensive therapeutic index was noted (4.7 pre-laparoscopic cyst decortications vs 7.0 post-laparoscopic cyst decortications, p = 0.28). CONCLUSIONS: Durable pain relief but not hypertension control was seen at 10-year followup. Preoperative estimated glomerular filtration rate is a strong predictor of post-laparoscopic cyst decortication progression to end stage renal disease. A cautious approach with laparoscopic cyst decortication should be taken in patients with poor preoperative renal function.

Laparoscopic cryoablation of renal masses: single-center long-term experience.

OBJECTIVE: To evaluate perioperative and long-term functional and oncological outcomes of laparoscopic cryoablation (LCA) performed at Washington University. METHODS: A retrospective chart review was performed evaluating 62 consecutive patients who underwent LCA at our institution between 2000 and 2005. RESULTS: Mean age-adjusted Charlson Comorbidity Index (CCI) was 6.1 (SD, 2.1; 95% confidence interval [CI], 5.6-6.6). Mean tumor size was 2.52 cm (SD, 0.99; CI, 2.3-2.8). Mean operative time was 162.0 minutes (SD, 66.6; CI, 142.0-182.1). Mean estimated blood loss was 84.9 mL (SD, 102; CI, 58.6-111.2). Mean hospital stay was 2.6 days (SD, 1.90; CI, 2.1-3.1). The perioperative complication rate was 9.7% (Clavien 1-2). Among patients with biopsy proven, localized renal cell carcinoma, the 6-year Kaplan-Meier estimated disease-free survival (DFS) was 80%; cancer-specific survival (CSS) was 100%; and overall survival (OS) was 76.2%. Mean follow-up in this subset was 76.0 months (SD, 39.3; CI, 62.7-89.4; n = 35), whereas mean time to cancer recurrence was 27.6 months (SD, 11.2; CI, 15.9-39.3; n = 6). Tumor size ≥2.6 cm was the only predictor of cancer recurrence in a multivariate Cox proportional hazards model (hazard ratio [HR] = 28.9; P = .046; n = 35). Mean preoperative estimated glomerular filtration rate (eGFR) was 68.3 (SD, 22.3; CI, 62.1-74.5), compared to 64.5 mL/min/1.73 m(2) (SD, 28.9; CI, 56.5-72.6) at last follow-up (P = .12; n = 52). Excluding patients requiring secondary ablative or extirpative treatments for recurrent renal cell carcinoma, preoperative eGFR <60 mL/min/1.73 m(2) (odds ratio [OR] = 88.3; P = .036) and age-adjusted CCI ≥6 (OR = 32.4; P = .046) were the only factors predicting renal disease progression on multiple logistic regression (n = 47). CONCLUSION: We report what is by far the longest follow-up to date of postlaparoscopic cryoablation changes in eGFR and note excellent long-term renal functional outcomes. For those willing to accept the potential need for retreatment for recurrent disease, LCA offers excellent long-term CSS.

Robot-assisted pyeloplasty: outcomes for primary and secondary repairs, a single institution experience.

INTRODUCTION: Robotic Pyeloplasty (RAP) is a technique for management of ureteropelvic junction obstruction (UPJO). PURPOSE: To report outcomes of RAP for primary and secondary (after failed primary treatment) UPJO. MATERIALS AND METHODS: Single institution data of adult RAP performed from 2007 to 2009 was collected retrospectively following approval by our IRB. Database analysis included patient age, race, pre and post-operative imaging studies and perioperative variables including operative time, blood loss, pain and complications. RESULTS: Fifty-five adult patients underwent RAP (26 left/29 right) for UPJO including 9 secondary procedures from 2007 to 2009. Average follow-up was 16 months (1-36). Mean age was 41 years (18-71) with an average BMI of 27 (17-42); 32 were female. Most patients were diagnosed with preoperative diuretic renal scintigraphy and the obstructed side demonstrated mean function of 41% and t1/2 of 70 minutes. Mean operative time was 194 minutes with average blood loss less than 100 mL. Mean hospital stay was 1.7 days with an average narcotic equivalent dose of 15 mg. RAP for secondary UPJO took longer with more blood loss and had a lower success rate. Failure was defined as the need of another procedure due to persistent pain and/or obstruction after diuretic renal imaging. One patient (2%) with primary UPJO failed and 2 patients (22%) with secondary UPJO failed. One major complication occurred. CONCLUSION: RAP is a good option for the treatment of patients with UPJO. Reported series have established that endopyelotomy has inferior success rate for the treatment of primary UPJO which compromises the success of subsequent treatment as demonstrated in our higher failure rate with secondary UPJO repair.

Robot-assisted pyeloplasty: outcomes for primary and secondary repairs, a single institution experience

INTRODUCTION: Robotic Pyeloplasty (RAP) is a technique for management of uretero-pelvic junction obstruction (UPJO). PURPOSE: To report outcomes of RAP for primary and secondary (after failed primary treatment) UPJO. MATERIALS AND METHODS: Single institution data of adult RAP performed from 2007 to 2009 was collected retrospectively following approval by our IRB. Database analysis including patient age, race, pre and post-operative imaging studies and perioperative variables including operative time, blood loss, pain and complications. RESULTS: Fifty-five adult patients underwent RAP (26 left/29 right) for UPJO including 9 secondary procedures from 2007 to 2009. Average follow-up was 16 months (1-36). Mean age was 41 years (18-71) with an average BMI of 27 (17-42), 32 were female. Majority were diagnosed with preoperative diuretic renal scintigraphy with obstructed side demonstrating mean function of 41% and t1/2 of 70 minutes. Mean operative time was 194 minutes with average blood loss less than 100 mL. Mean hospital stay was 1.7 days with an average narcotic equivalent dose of 15 mg. RAP for secondary UPJO took longer with more blood loss and had a lower success rate. Failure was defined as necessitating another procedure due to persistent pain and/or obstruction on diuretic renal imaging. One patient (2%) with primary UPJO failed and 2 patients (22%) with secondary UPJO failed. One major complication occurred. CONCLUSION: RAP is a good option for the treatment of patients with UPJO. Reported series have established that endopyelotomy has inferior success as a treatment for primary UPJO which compromises the success of subsequent treatment as demonstrated in our higher failure rate with secondary UPJO repair.

Laparoscopic retroperitoneal lymph node dissection for low-stage cancer: a Washington University update.

BACKGROUND AND PURPOSE: At present, open retroperitoneal lymph node dissection (RPLND) remains the preferred approach at many high-volume centers for the surgical treatment of patients with low-stage testis cancer. Despite the potential advantages of a minimally invasive approach, including improved cosmesis and shorter recovery times, there remain concerns over the quality of dissection and oncologic control offered through a minimally invasive approach. Our objective was to critically evaluate the safety and intermediate-term oncologic efficacy of laparoscopic RPLND (L-RPLND). PATIENTS AND METHODS: A retrospective chart review was performed, evaluating all patients who underwent L-RPLND between 2003 and 2009. Patient records were updated by telephone interview. RESULTS: A total of 59 patients underwent L-RPLND during the study period, of which 13 had previously undergone chemotherapy. Mean age at treatment was 32 years. Mean operative time and estimated blood loss were 291 minutes (176-620 min) and 184 mL (range 0-1800 mL), respectively. Mean lymph node count was 21.6 (range 5-48). Mean hospital stay was 2 days (range 1-4 d). There were three open conversions because of intraoperative complications. One patient needed a transfusion. Five patients had six (8.5%) postoperative complications: three lymphoceles, two chylous ascites, and one deep venous thrombosis/pulmonary embolus. Of 18 patients with node-positive pathology, 13 received adjuvant chemotherapy and 5 underwent surveillance. Retroperitoneal recurrence did not develop in any patient undergoing surveillance during a mean follow-up of 21.3 months. One postchemotherapy RPLND (1.7%) patient experienced a retroperitoneal recurrence. CONCLUSIONS: L-RPLND is a diagnostic and therapeutic treatment option for patients with low-stage testis cancer, offering excellent oncologic control and acceptable perioperative morbidity. Intermediate-term results suggest that L-RPLND is a viable alternative to the open surgical procedure. Carefully selected patients may be candidates for L-RPLND in the postchemotherapy setting.

Positive margin during partial nephrectomy: does cancer remain in the renal remnant?

OBJECTIVE: To examine the outcomes of patients with a positive surgical margin by gross and/or frozen examination during partial nephrectomy, in whom a re-resection of the margin or a completion nephrectomy was performed. METHODS: Patients with renal cancer who underwent partial nephrectomy were considered. If the patient had a positive margin and underwent completion nephrectomy or re-excision of the margin, they were included. Patients with planned enucleation were excluded from the study. Clinical and pathologic information were reviewed to examine for residual cancer in the additionally resected tissue. RESULTS: In the final cohort, 29 patients with a positive margin and subsequent complete parenchymal re-resection or completion nephrectomy were identified. Eight patients underwent nephrectomy, after which no residual cancer was found in the renal remnant. Twenty-one patients underwent total re-resection of the margin, of which two were found to have carcinoma. Renal functional outcomes revealed a decrease in estimated glomerular filtration rate of 25 mL/min/1.73 m(2) in patients who underwent radical nephrectomy, and 4 mL/min/1.73 m(2) in patients who underwent re-resection of the margin with preservation of the renal unit. CONCLUSIONS: A positive surgical margin does not necessarily mean that cancer remains in the renal remnant in most cases. Therefore, radical nephrectomy or re-resection of the margin is overtreatment in many cases, but a small percentage of patients will harbor residual malignancy. Clinical correlation is recommended before reexcision or completion nephrectomy after a positive surgical margin, with careful consideration of the impact on subsequent renal function weighed against the possibility of residual disease.

Comparison of 2004 and 1973 World Health Organization grading systems and their relationship to pathologic staging for predicting long-term prognosis in patients with urothelial carcinoma.

OBJECTIVES: To compare the 1973 and 2004 World Health Organization (WHO) systems for the interval to tumor recurrence (TR), tumor progression (TP), and overall survival (OS) using either the superficial/muscle invasive or strict TMN pathologic staging in patients with urothelial carcinoma with ≥10 years of follow-up. METHODS: A total of 269 tumors from an institutional review board-approved bladder tumor registry were graded using the 1973 and 2004 WHO systems. Kaplan-Meier plots, the log-rank test, the chi-square test, and the Cox proportional hazard model were used to relate the clinical and histologic variables. RESULTS: The Cox model analyses, which were multivariate and included tumor stage (coded as pT1 or less versus pT2 or greater) as a significant covariate to grade, were performed and in all tumor stages were significant. The 2004 WHO grading system was more closely associated with TR (P = .025) and TP (P = .012) than was the 1973 WHO grading system (P = .47, and P = .046, respectively). OS was similar and significant for both. The OS plots for the 1973 WHO system showed a significant overlap between Stage pT1 or less, grade 2 and 3 tumors. For those with high-grade Stage pTa and high-grade Stage pT1 disease, TR and TP were similar; however, OS was significantly longer (P = .05, log-rank test) for those with Stage pTa. The OS was similar for those with high-grade Stage pT1 disease and those with Stage pT2 or greater (P = .069, log-rank test). For those with pTa, the 2004 system predicted TR and TP, but the 1973 system only predicted TP. Neither predicted OS. CONCLUSIONS: The results of our analysis have shown that the 2004 WHO system is superior to the 1973 system for predicting clinical outcomes in patients with urothelial carcinoma, independent of pathologic stage. Its primary usefulness is in those with Stage pTa.

The Sri Lanka tsunami experience.

The Indian Ocean tsunami of 2004 killed 31,000 people in Sri Lanka and produced morbidity primarily resulting from near-drownings and traumatic injuries. In the immediate aftermath, the survivors brought bodies to the hospitals, which hampered the hospitals' operations. The fear of epidemics led to mass burials. Infectious diseases were prevented through the provision of clean water and through vector control. Months after the tsunami, little rebuilding of permanent housing was evident, and many tsunami victims continued to reside in transit camps without means of generating their own income. The lack of an incident command system, limited funding, and political conflicts were identified as barriers to optimal relief efforts. Despite these barriers, Sri Lanka was fortunate in drawing upon a well-developed community health infrastructure as well as local and international resources. The need continues for education and training in clinical skills for mass rescue and emergency treatment, as well as participation in a multidisciplinary response.

Impact of education on smoking cessation counseling by surgical residents.

BACKGROUND: Surgeons infrequently provide smoking cessation counseling for patients, in part because they lack training to do so. We investigated the efficacy of 2 methods of teaching smoking cessation counseling to surgical residents. METHODS: Residents' knowledge and attitude toward smoking cessation counseling were assessed by written test. Counseling skills were assessed with standardized patients. Residents were randomized for smoking cessation education: a "Role-play" group received a 1-hour lecture plus an hour of role-playing. An evidence-based medicine (EBM) group attended a 1- hour EBM journal club on related articles. Changes in residents' knowledge, attitude, and skills were assessed after education. RESULTS: Sixteen residents completed the study. After either form of education, residents demonstrated significant improvements in knowledge, attitude, and skills in smoking cessation counseling. There was no significant difference in improvement between the EBM and Role-play groups. CONCLUSIONS: A brief educational intervention can significantly improve residents' knowledge, attitude, and counseling skills for smoking cessation.