Safety and effectiveness of percutaneous renal cryoablation with conscious sedation.

OBJECTIVE: To investigate complications and treatment failure rates of percutaneous renal cryoablation (PRC) for small renal masses under local anaesthesia and conscious sedation (LACS), to assess the safety and effectiveness of this approach, as PRC is typically performed under general anaesthesia (GA). PATIENTS AND METHODS: We retrospectively reviewed PRC under LACS from 2003 to 2017. We analysed perioperative parameters between patients who successfully underwent PRC under LACS and patients with post-procedural complications or treatment failure (renal mass enhancement after successful intraoperative tumour ablation). Two-sided non-parametric and Fisher's exact tests were performed to compare uncomplicated or disease-free PRC with the complication or treatment failure group, respectively. RESULTS: A total of 100 PRCs under LACS were performed during the study period. Of these patients, six patients had at least one postoperative complication (6%), and treatment failure was diagnosed in nine patients (9%) after PRC [mean (SD) follow-up of 42.7 (26.6) months]. The procedural failure rate was 1%. No ablations were converted to GA. The mean tumour size was smaller in patients who had no complications during PRC compared to those who did, at a mean (SD) of 2.2 (0.6) cm vs 3.0 (1.0) cm (P = 0.039). The use of more intraoperative probes during the PRC was also associated with complications, at a mean (SD) 3.0 (1.4) vs 1.8 (0.8) (P = 0.021). CONCLUSIONS: PRC under LACS is an effective and safe procedural approach for managing small renal masses with low complication, treatment failure, and procedural failure rates. Larger renal masses and intraoperative use of multiple probes is associated with an increased risk of PRC complications. ABBREVIATIONS: BMI: body mass index; CCI: Charlson Comorbidity Index; GA: general anaesthesia; LACS: local anaesthesia and conscious sedation; PRC: percutaneous renal cryoablation; R.E.N.A.L.: Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location.

Reducing the Incidence of Retained Double-J Ureteral Stents: A Multidisciplinary Approach.

INTRODUCTION: Double-J® ureteral stents are temporary tubes used for ureteral patency that can cause serious complications if left beyond the allotted time. We developed a streamlined framework that allows for Double-J stent tracking to alert patients to the need for removal. METHODS: By creating a multidisciplinary committee we developed a database of patients with Double-J stents who presented to our facility between 2012 and 2014. The database was populated by a query of the billing system, generating HIPAA compliant stent removal reminder letters. Three queries (A, B and C) were developed using a combination of billing codes and each query was compared to a gold standard list. RESULTS: The ICD-9 ureteral catheterization code used to perform query A was only 28% sensitive. Query B (using CPT or HCPCS codes) was 98% sensitive. However, it incorrectly captured many patients with nonureteral stents. Our final query method, query C, rectified this issue by using the ICD-9 code with CPT or HCPCS codes, resulting in the highest sensitivity (78%) while minimizing undesired stent capture. CONCLUSIONS: We developed an automated and reproducible program that correctly identifies and alerts a high percentage of patients to the need to remove their stent. Repeated audits of our query methods combined with regular meetings of a multidisciplinary Double-J stent committee were integral to developing and maintaining this system. By promoting proactive awareness for patients as well as physicians, we are working to minimize the incidence of retained Double-J stents and associated complications.

Active surveillance of very-low-risk prostate cancer in the setting of active treatment of benign prostatic hyperplasia with 5α-reductase inhibitors.

OBJECTIVE: To review the efficacy of treating benign prostatic hyperplasia and very-low-risk prostate cancer (PCa) in patients receiving active surveillance and 5α-reductase inhibitor (5-ARI; finasteride or dutasteride) treatment. MATERIALS AND METHODS: Eighty-two men with very-low-risk PCa (clinical stage T1c, Gleason score ≤ 6, <3 biopsy cores positive with ≤ 50% involvement, and prostate-specific antigen density ≤ 0.15 ng/mL/g) and benign prostatic hyperplasia (≥ 30 cm(3)) received active surveillance and were treated with a 5-ARI. RESULTS: All 82 men completed 1 year of 5-ARI therapy (n = 79) or underwent early biopsy for cause (n = 3). Restaging biopsies were performed for 76 men (22 underwent a second restaging biopsy and 1 a third restaging biopsy), 4 patients were awaiting biopsy, and 2 were lost to follow-up before the first restaging biopsy. At the first restaging biopsy, of the 76 men, 41 (54%) had no PCa, 16 (21%) continued to have very-low-risk PCa, 15 (20%) had progressed to low-risk PCa (>2 cores positive and Gleason score ≤ 6), and 4 (5%) had progressed to intermediate-risk PCa (Gleason score 7). Of the 76 biopsies, 20 were performed early for cause, with 11 (55%) showing PCa progression. Of the 82 patients, 22 (27%) underwent treatment of PCa. CONCLUSION: Active surveillance of very-low-risk PCa in the setting of 5-ARI therapy for benign prostatic hyperplasia appears to be a safe therapeutic option, because most (57 of 82; 70%) patients maintained very-low-risk PCa or had negative follow-up biopsies during a 3-year follow-up period. Complementary to the Prostate Cancer Prevention Trial, our results indicate that 5-ARI therapy increases prostate-specific antigen sensitivity and can aid the clinician in appropriately targeting biopsies.

Surgical management of neurovascular bundle in uterine fibroid pseudocapsule.

The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.

Two-step transurethral surgery of the prostate and permanent implant brachytherapy for patients with lower urinary tract symptoms and low- to intermediate-risk prostate cancer.

PURPOSE: Prostate brachytherapy is an increasingly used treatment option for low- to intermediate-risk prostate cancer (PCa). However, patients with preexisting lower urinary tract symptoms (LUTS) and PCa, who would otherwise be good brachytherapy candidates, are often contraindicated because of the risk of postoperative urinary morbidity. We report our clinical experience with limited transurethral resection of the prostate (LTURP) and/or transurethral incision of the prostate (TUIP) months before brachytherapy to treat patients with LUTS and low- to intermediate-risk PCa. METHODS AND MATERIALS: Of 258 men undergoing prostate brachytherapy at our institution between 1998 and 2011, 42 were treated with planned LTURP and/or TUIP well before (mean, 5.7 months) seed implantation. Transurethral surgery was considered before brachytherapy for patients who at presentation required α-blocker therapy for LUTS, had an International Prostate Symptom Score greater than 14 off α-blockers, or had an elevated postvoid residual (>100 mL). Patients only proceeded to brachytherapy once LUTS resolved. RESULTS: All 42 patients in our series underwent TUIP (25), LTURP (7), or TUIP/LTURP (10) with mean 5.7 months before prostate brachytherapy for low- or intermediate-risk PCa. Mean International Prostate Symptom Score, peak flow rate, and postvoid residual significantly improved after transurethral surgery, and improvement persisted at the latest followup. No patient developed retention, urethral necrosis, or urinary incontinence after transurethral surgery or brachytherapy (median followup, 39 months and range, 1-121). CONCLUSIONS: Planned LTURP and/or TUIP more than 4 months before brachytherapy is a safe and effective treatment strategy for men with LUTS and low- to intermediate-risk PCa.

Neurovascular bundle in fibroid pseudocapsule and its neuroendocrinologic implications.

The myoma pseudocapsule is a surgical-anatomical entity surrounding the fibroid that separates the myoma from normal uterine tissue. The myoma pseudocapsule has a delicate vascular network rich with neurotransmitters analogous to the neurovascular bundle surrounding the prostate. The pseudocapsule neurovascular bundle is extremely important during myomectomy to promote uterine myometrial healing and, consequently, for uterine reproductive function. New advancements in surgery, including the use of laparoscopic myomectomy by an intracapsular technique and magnification of the myoma pseudocapsule to enhance visualization are comparable to the dissection during a radical prostatectomy. Fibroid detachment occurring inside the pseudocapsule causes less bleeding, spares the neurovascular bundle and promotes better uterine healing. The maintenance of myometrial integrity after laparoscopic myomectomy maintains uterine function and therefore improves reproductive outcomes, including labor.

Duration and clinical significance of radiographically detected "free air" after laparoscopic nephrectomy.

The purpose of this study was to evaluate the duration and clinical significance of postoperative pneumoperitoneum (PP) after laparoscopic nephrectomy. We reviewed consecutive laparoscopic nephrectomies from 2001 to 2007. The presence and timing of free intraperitoneal air was documented. Postoperative imaging was performed in 135 of 538 patients with 55 patients (41%) noted to have free air. These included 53 hand-assisted laparoscopic nephrectomies and 2 purely laparoscopic radical nephrectomies. There was no difference between patients with and without PP with respect to age, sex, race, length of hospital stay (LOS), operating room time, earliest postoperative film with PP, presence of free air on plain film, or complication rate (P>0.05). Donor nephrectomy patients had the highest incidence of PP (P=0.01). Nineteen patients had benign PP (34.5%) at least 3 days after surgery with the longest interval postsurgery being 9 days. Postoperative free air after laparoscopic nephrectomy is common, even up to 9 days after surgery.

Hand-assisted laparoscopic partial nephrectomy after 60 cases: comparison with open partial nephrectomy.

BACKGROUND: Partial nephrectomy is the surgical standard of care for favorably located, small renal tumors. As the incidence of renal cell carcinoma (RCC) and detection of small kidney masses have increased over the past 20 years, minimally invasive management of these lesions has become more common. We report our single-institution experience with hand-assisted laparoscopic partial nephrectomy (HALPN) compared with open partial nephrectomy (OPN). METHODS: Relevant outcome and demographic information was collected prospectively for HALPNs (N = 60) and retrospectively for OPNs (N = 40). A p-value of < 0.05 denotes statistical significance. RESULTS: Average tumor size (2.6 cm HALPN versus 2.6 cm OPN, p = 0.97) was similar. Mean operative times were shorter for HALPN compared with OPN (161 versus 191 min, p = 0.027). HALPN was also associated with less blood loss (mean 120 cc versus 353 cc, p = 0.0003). Warm ischemia time was shorter for HALPN (mean 27.0 min versus 33.0 min, p = 0.035), as was hospital stay (mean 4.9 days versus 6.9 days, p = 0.007). Although four HALPN renal tumors required intraoperative margin re-excision (based on immediate gross evaluation by a pathologist), the final positive margin rate was 0%. A 5% final positive margin rate was observed in the OPN group. There were two conversions from HALPN to HAL radical nephrectomy and no conversions to an open technique. The HALPN minor complication rate was 18.3% versus 32.5% for OPN (p = 0.10). Complications included delayed bleeding (1, 2.5% OPN), urine leak (2, 5% OPN; 2, 3.3% HALPN), hypoxia, and nausea or fever lasting >3 days. Tumor pathology was as follows: 80.7% and 80% RCC, 12.3% and 8% oncocytoma, and 7% and 12% angiomyolipoma, for HALPN and OPN, respectively in each case. CONCLUSIONS: HALPN is associated with diminished blood loss, operating time, warm ischemia time, positive margin rates, and length of stay compared with OPN. In our institution, HALPN is the standard approach for patients with small, surgically accessible renal tumors.

Strategies in the management of renal tumors amenable to partial nephrectomy.

PURPOSE: The laparoscopic approach to radical and partial nephrectomy is becoming the standard of care for treating patients with renal tumors. Hand-assisted laparoscopic partial nephrectomy (HALPN) provides some advantages over the pure laparoscopic approach which include manual manipulation of the kidney, tactile feedback, and timely specimen removal. MATERIALS AND METHODS: We describe our technique for HALPN and emphasize the implementation of an in-room pathologist to examine gross margins during the period of renal arterial occlusion. Between 2004 and 2007, 46 patients underwent HALPN performed by the same surgeons. Mean patient age was 59.5 years and mean tumor size was 2.55 cm. Twelve of these patients underwent significant concomitant procedures. RESULTS: Our mean operating time was 173.26 min (range 90-306 min) and our mean warm ischemic time was 28.32 min (range 14-54 min). Average estimated blood loss was 116.82 ml (range 10-1000 ml) with no transfusions. Thirty-six (78%) tumors were renal cell carcinoma, seven (15%) were oncocytomas, and three (7%) were angiomyolipomas. The average length of stay was 5.17 days (range 3-9 days) and there were no positive margins. There was one postoperative bleed (2%) and two postoperative urine leaks (4.3%). DISCUSSION: In our institution, the hand-assist approach to laparoscopic partial nephrectomy has resulted in favorable perioperative outcomes. The use of an in-room pathologist to provide real-time assessment of gross tumor margins has allowed us to achieve a 0% positive final margin rate. We believe that the use of an in-room pathologist during the timely extraction of the specimen made possible by the hand-assisted approach provides a great advantage over pure laparoscopic partial nephrectomy. This low positive margin rate is also the result of maintaining a bloodless field of resection with temporary renal arterial occlusion as well as the avoidance of visual tissue distortion with cold, sharp scissor dissection.

Minimal access cancer management.

Minimal access approaches in the treatment of a variety of solid tumors of the stomach, large bowel, and genitourinary system are now being advocated in several surgical specialty areas. The laparoscope has evolved from a diagnostic tool to a modality that allows for removal of tumors using small incisions and the application of pneumoperitoneum with carbon dioxide. Through studies using animal models and patient investigation, the immunologic benefits of laparoscopic cancer procedures appear to be beneficial when compared with conventional laparotomy. Overall benefits of analgesic reduction, more rapid postoperative recovery, and patient satisfaction are the byproducts of minimal access approaches. Patients with cancers of the stomach, colon, and kidney show similar long-term outcomes when compared with conventional open techniques. Caution, however, should be exercised in recommending laparoscopic approaches for routine management of primary tumors of the rectum and adrenal gland.

Castleman disease of the hyaline-vascular type confined to the kidney.

The case is a 38-year-old man in whom a solitary subcapsular left renal cortical mass was successfully resected. Comorbidities included a benign epididymal cyst and a history of nephrolithiasis. Computed tomographic imaging demonstrated a 1.8-cm enhancing mass in the anterior midregion of the kidney. An open partial nephrectomy was performed, and histopathologic examination established a diagnosis of the hyaline-vascular type of Castleman disease (CD). The patient had an uneventful postoperative course and has experienced no local or metastatic recurrence in the 10 months since surgery. CD localized in the kidney is an exceptionally rare occurrence but should be included in the complete differential diagnosis of solitary renal cortical mass lesions.

Role of quality of life in men with metastatic hormone-refractory prostate cancer: how does atrasentan influence quality of life?

OBJECTIVE: Progression of hormone-refractory prostate cancer (HRPC) is associated with skeletal complications and bone pain, which contribute to deterioration in quality of life (QOL). The effects of new HRPC therapies on patients' QOL need to be studied. Patient-based assessments that help quantify the risk-benefit profile of HRPC therapies are warranted. This review summarizes the known QOL literature and estimates the potential effect of atrasentan, a novel, selective endothelin A receptor antagonist (SERA), on the QOL of HRPC patients. METHODS: Published studies were identified through a structured, detailed literature review. Clinical studies that report QOL data were reviewed, along with recent QOL data from atrasentan studies. RESULTS: HRPC studies have begun to use QOL assessments as primary endpoints, but different assessments and therapies are not comparable. Very few data integrate QOL with clinical endpoints. Atrasentan clinical trials demonstrated a statistically significant difference in the prostate cancer-specific QOL in favor of atrasentan (p=.032) and an increased quality-adjusted time to progression in men with HRPC. CONCLUSIONS: Atrasentan provides QOL benefits relevant to HRPC. The quality-adjusted analyses applied in the atrasentan studies have begun to lay the foundation for interpreting clinical endpoints in conjunction with QOL. These analyses will facilitate better QOL comparisons within studies and across trials. Further evaluation of atrasentan in HRPC is warranted.

Clinical use of fluorodeoxyglucose F 18 positron emission tomography for detection of renal cell carcinoma.

PURPOSE: We evaluate the role of fluorodeoxyglucose F 18 positron emission tomography (PET) in patients with renal cell carcinoma (RCC) by retrospective review. To our knowledge this series is the largest reviewing the use of PET in patients with RCC. MATERIALS AND METHODS: A total of 66 patients who underwent 90 PET scans for suspected or known RCC were identified. Dictated reports of PET, chest computerized tomography (CT), abdominal/pelvic CT and bone scan were examined with confirmation of results by histopathology or followup of at least 1 year. The accuracies of PET and conventional imaging modalities were compared. RESULTS: PET exhibited a sensitivity of 60% and specificity of 100% for primary RCC tumors (abdominal CT demonstrated 91.7% sensitivity and 100% specificity). For retroperitoneal lymph node metastases and/or renal bed recurrence, PET was 75.0% sensitive and 100.0% specific (92.6% sensitivity and 98.1% specificity for abdominal CT). PET had a sensitivity of 75.0% and a specificity of 97.1% for metastases to the lung parenchyma compared to 91.1% and 73.1%, respectively, for chest CT. PET had a sensitivity of 77.3% and specificity of 100.0% for bone metastases, compared to 93.8% and 87.2% for combined CT and bone scan. In 39 scans (32 patients) PET failed to detect RCC lesions identified by conventional imaging. CONCLUSIONS: The role of fluorodeoxyglucose F 18 PET in the detection of RCC is limited by low sensitivity. With superior specificity PET may have a complementary role as a problem solving tool in cases that are equivocal on conventional imaging.