Is there an indication for frozen section examination of the ureteral margins during cystectomy for transitional cell carcinoma of the bladder?

PURPOSE: We evaluated the incidence of pathological findings of the ureter at cystectomy for transitional cell carcinoma of the bladder and assessed the usefulness of intraoperative frozen section examination of the ureter. MATERIALS AND METHODS: Histopathological findings of ureteral frozen section examination were compared to the corresponding permanent sections and the diagnostic accuracy of frozen section examination was evaluated. These segments were then compared to the more proximal ureteral segments resected at the level where they cross over the common iliac arteries. The histopathological findings of the ureteral segments were then correlated for upper urinary tract recurrence and overall survival. RESULTS: Transitional cell carcinoma or carcinoma in situ was found on frozen section examination of the distal ureter in 39 of 805 patients (4.8%) and on permanent sections in 29 (3.6%). In 755 patients the false-negative rate of frozen section examination of the ureters was 0.8%. Of the patients with carcinoma in situ diagnosed on the first frozen section examination 80% also had carcinoma in situ in the bladder. Transitional cell carcinoma or carcinoma in situ in the most proximally resected ureteral segments was found in 1.2% of patients. After radical cystectomy there was tumor recurrence in the upper urinary tract in 3% of patients with negative ureteral frozen section examination and in 17% with carcinoma in situ on frozen section examination. CONCLUSIONS: Routine frozen section examination of the ureters at radical cystectomy is only recommended for patients with carcinoma in situ of the bladder, provided the ureters are resected where they cross the common iliac arteries.

Robotic computer-assisted pyeloplasty versus conventional laparoscopic pyeloplasty.

BACKGROUND AND PURPOSE: Laparoscopic pyeloplasty (LP) for the repair of ureteropelvic junction (UPJ) obstruction provides results similar to those of open pyeloplasty with less morbidity, but its use has been limited, as it requires advanced laparoscopic skills. Robotic computer-assisted pyeloplasty (RAP) has the potential to reduce the technical challenges of the reconstructive portion of the operation. We compare our RAP experience with our recent LP cases. PATIENTS AND METHODS: Fourteen patients underwent LP, and 31 underwent RAP. The demographics of the two groups were similar. Three patients in the RAP group had been treated previously for UPJ obstruction. All procedures were performed transperitoneally. For RAP, conventional laparoscopic dissection and exposure preceded robot-assisted reconstruction. A Double-J stent was placed cystoscopically in all patients. Patient demographics and operative, postoperative, and follow-up data were compared. Success was defined strictly as the unequivocal absence of both obstruction and postoperative pain. Also technical success was defined as no evidence of persistent high-grade obstruction, no loss of function, no symptomatic obstruction, and no necessity for further treatment. RESULTS: The diagnosis of UPJ obstruction was confirmed intraoperatively in all cases. No difference was found in operative and postoperative outcomes of the two procedures. Operative time, including cystoscopy, was 299 minutes in the LP group and 271 minutes in the RAP group. The median estimated blood loss was <100 mL in both groups. The median console time for RAP was 76 minutes (range 54-124 minutes) and consisted of preparation and completion of the anastomosis. The median robotic docking and undocking time was 16 minutes (range 5-30 minutes). The anastomotic times for LP were not recorded. There were no conversions to open surgery and no intraoperative complications. The mean length of stay (LOS) was 2 days in both groups. There were two postoperative complications in each group: In the LP group, one large retroperitoneal hematoma and one umbilical hernia; in the RAP group, one nonfebrile urinary-tract infection and one urine leak. The mean follow-up was 10 months (range 1-31 months) for LP and 6 months (range 1-21 months) for RAP. Strict success was seen in 64% of the LP patients and 66% of the RAP patients. There was one technical failure in the RAP group, resulting in a technical success rate of 100% for LP and 97% for RAP. Technical success was seen in two LP patients and five RAP patients with partial obstruction on early postoperative renography and three LP patients and four RAP patients with occasional postoperative pain. CONCLUSION: Robotic computer-assisted pyeloplasty provides short-term results similar to those of conventional laparoscopic pyeloplasty at our institution.

Multi-institutional validation study of neural networks to predict duration of stay after laparoscopic radical/simple or partial nephrectomy.

PURPOSE: We developed models to predict post-laparoscopic radical or simple nephrectomy (LapNx) and post-laparoscopic partial nephrectomy (LapPNx) hospital duration of stay (DOS). MATERIALS AND METHODS: We performed a retrospective review (design group) of all 726 patients (July 1997 to April 2004) who underwent LapNx or LapPNx at the Cleveland Clinic Foundation (CCF). Preoperative findings were recorded. Neural network algorithms were designed to predict the DOS before surgery. The models were then tested on a separate 252 patients from 6 different institutions, namely Tulane University Medical School, University of Arkansas for Medical Sciences, Cedars-Sinai Medical Center, University of Iowa, Mayo Clinic at Scottsdale and CCF. RESULTS: In the CCF design groups, the LapNx model accuracy was 73% to 74% and the LapPNx model 73% to 83%. Overall accuracy in the test groups at all 6 institutions was 72% (area under ROC 0.6 to 0.7) for the LapNx model and 52% to 81% (ROC 0.5 to 0.7) for the LapPNx model. CONCLUSIONS: The LapNx model provides 72% accuracy in predicting the DOS at all 6 institutions. The LapPNx model provided fair accuracy only at CCF and Tulane University Medical School. These models may streamline the delivery of care and continued testing will allow for further refinement.

Laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: The technique of laparoscopic partial nephrectomy has matured significantly over the past decade and is emerging as an oncologically sound procedure for the management of small renal tumors. Methods of tumor excision as well as parenchymal reconstruction in a hemostatically controlled field have evolved to make this procedure safer. Improved techniques to minimize warm renal ischemia are being developed. Finally, methods to prevent positive surgical margins during laparoscopic surgery are crucial to a satisfactory oncologic outcome. These important technical issues, as well as the current results of laparoscopic partial nephrectomy, are discussed. MATERIALS AND METHODS: The urologic peer-review literature related to nephron-sparing surgery was reviewed. Controversial issues with respect to the surgical approach, methods of hemostatic control, acceptable time of warm ischemia, and cooling techniques were reviewed and collated. Perioperative results from larger series of laparoscopic and open partial nephrectomy were evaluated. RESULTS: Open nephron-sparing surgery for renal tumors < or =4 cm has cancer control equivalent to that of open radical nephrectomy. Evidence is now emerging that laparoscopic partial nephrectomy will provide similar oncologic results, although clinical follow-up is still early. Blood loss, postoperative pain, and convalescence seem to be favor the laparoscopic approach. Complication rates, primarily postoperative bleeding and urine leak, may be higher than for open nephron-sparing surgery. Methods of laparoscopic hemostatic control favor soft vascular clamping for larger tumors that are more endophytic and central. Smaller exophytic lesions may be managed without renal vascular control using a variety of coagulative and hemostatic tools. Data related to warm renal ischemia suggest that the time used for tumor excision and renal reconstruction should be 30 minutes or less. Techniques for laparoscopic renal cooling are being developed. CONCLUSIONS: Laparoscopic nephron-sparing surgery is a technique in evolution but with a promising outlook. The urologic peer-review literature reflects an exponential growth in interest, which suggests that this minimally invasive approach is practical and may benefit our patient population so as to allow them to return to normal healthy living more quickly.