National Utilization of Partial Nephrectomy Pre- and Post- AUA Guidelines: Is This as Good as It Gets?

BACKGROUND: The purpose of the study was to compare utilization and predictors of partial nephrectomy (PN) in the pre- and post-guideline eras. MATERIALS AND METHODS: American Board of Urology certification/recertification operative logs were reviewed from 2003 to 2014. Nephrectomy cases were extracted using Current Procedural Terminology codes. The cases were then stratified according to pre-guidelines (2003-October 2009) and post-guidelines (November 2009-2014). Multivariable logistic regression was used to evaluate patient, surgeon, and practice characteristics as predictors of PN. A general linear model with regression analysis was used to evaluate the change in PN over time relative to the incidence of renal cell carcinoma (RCC). RESULTS: We identified 20,402 and 20,729 nephrectomies in the pre- and post-guidelines eras, respectively. In multivariable analysis, the post-guidelines group was more likely to undergo PN (odds ratio, 1.87; P < .001). The pre- as well as post-guidelines groups had a higher likelihood of undergoing PN with an open approach, higher-volume surgeons, and younger patient age (P < .05). Surgeon subspecialty and US region were no longer significant factors after guidelines publication. Number of PN normalized to the incidence of RCC continued to increase over time (0.14%/y; R2 = 0.77; P < .001). CONCLUSION: Partial nephrectomy in the post-guidelines era is no longer confined to urological subspecialists or certain densely populated US regions. Although rates of PN continue to increase relative to the recently decreasing overall incidence of RCC, the slope has leveled off somewhat. This is likely related to clinical intricacies of the best treatment modality and technologic advances rather than changes related to guidelines publication.

Successful Outcomes in Robot-Assisted Laparoscopic Pyeloplasty Using a Unidirectional Barbed Suture.

INTRODUCTION: Intracorporeal suturing is considered to be the most challenging aspect of laparoscopic and robotic surgery. To overcome this problem, barbed self-retaining sutures have been effectively employed in various minimally invasive endourologic surgeries. However, the use of this suture has been recently cautioned for pyeloplasty due to a high failure rate. Our objective was to report our experience using barbed suture during robotic pyeloplasty. METHODS: We retrospectively identified 13 consecutive patients who underwent robotic pyeloplasty with a barbed monofilament (4-0 V-Loc™) suture for the ureteropelvic anastomosis from 2011 to 2014. We compared these patients to 12 consecutive patients who underwent robotic pyeloplasty with a 4-0 nonbarbed suture from 2007 to 2011. We evaluated patient demographics, operative times, preoperative and postoperative symptoms, renal function, and diuretic renograms (DRG). Successful repair was defined as resolution of preoperative symptoms and/or T½ improvement on DRG to less than 20 minutes. RESULTS: The median age was 26 (interquartile range [IQR] 20.7-38) years and 35 (IQR 18.3-44) years for the barbed and nonbarbed suture groups, respectively. In the barbed suture group, preoperative DRG revealed ureteropelvic junction obstruction (UPJO) in 11 patients, equivocal UPJO (T½ 10-20 minutes) in one patient, and no obstruction in one patient. In the nonbarbed group, preoperative DRG revealed UPJO in 10 patients, equivocal UPJO in one patient, and no obstruction in one patient. In the barbed suture group, postoperative DRG was obtained in 11 patients, which showed no obstruction in 10/11 patients with 92% of patients experiencing symptom resolution. Similarly, postoperative DRG was obtained in 11 patients in the nonbarbed group, which showed no obstruction in 10/11 patients with 100% postoperative symptom resolution. CONCLUSIONS: In the largest series reporting use of V-Loc suture for robotic pyeloplasty, the V-Loc suture was safely and effectively used for robotic pyeloplasty repair.

Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma: population-based and single-institutional analysis.

PURPOSE: Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma is unclear. To assess whether PN provides adequate cancer control in high-risk disease (HRD), survival outcomes were compared in both a population-based cohort and an institutional cohort. METHODS: Surveillance, Epidemiology, and End Results database and a prospectively maintained institutional database were queried for patients with RCC who underwent PN or RN for a localized tumor ≤7 cm and were found to have high-grade and/or high-stage disease (HRD). Cancer-specific (CSS) or recurrence-free survival (RFS) and overall survival (OS) were primary outcomes measured and were compared between those who underwent PN and RN using multivariable Cox proportional hazards and propensity analysis. RESULTS: The population cohort consisted of 12,757 (24.9 %) patients with HRD, 85.2 and 14.8 % of which underwent RN and PN, respectively. RN was not associated with CSS (HR 1.23, p = 0.08) but was independently associated with poor OS (HR 1.16, p = 0.031). Propensity analysis showed that RN resulted in a 20 % increased risk of death from all causes (p = 0.008). In the institutional cohort, of 317 patients, 35.9 % had HRD, 56 and 52 of which underwent RN and PN, respectively. Adjusting for age-adjusted Charlson index, RN was a predictor of poor OS (OR 6.20, p = 0.041). Propensity analysis showed that RFS and OS were not related to nephrectomy type (RN HR 0.65, p = 0.627 and RN HR 1.70, p = 0.484). CONCLUSIONS: In patients with pathologic high-risk RCC, partial excision is associated with similar cancer control as compared to radical excision.

Gender disparity in kidney cancer treatment: women are more likely to undergo radical excision of a localized renal mass.

OBJECTIVE: To investigate gender effects on the type of nephrectomy performed for a stage I renal mass and differences that might account for disparity in treatment patterns according to gender. METHODS: Using a single-institution database, patients who underwent nephrectomy at a tertiary referral center for a localized, solitary tumor, ≤ 7 cm with a normal contralateral kidney were identified. Variables thought to affect selection for type of nephrectomy were compared between male and female patients. Using multivariable logistic regression, the effect of gender on the likelihood of radical vs partial nephrectomy and the likelihood of malignancy were assessed. Renal function outcomes were also compared. RESULTS: No difference between genders was seen in age, race, smoking status, body mass index, tumor size, RENAL score or operating surgeon. Only Charlson index and preoperative creatinine significantly differed with women having a more favorable comorbidity profile (Charlson >1 in 38% vs 50%; P = .027) and lower mean preoperative creatinine (0.09 ± 0.3 vs 1.1 ± 0.3; P <.001). Despite lower creatinine, women had inferior preoperative renal function with a mean estimated glomerular filtration rate of 71.4 ± 21 vs 78.9 ± 21 mL/min/1.73 m2 in men (P <.001). Multivariable analysis indicated that female patients were 2.5 times more likely to undergo radical nephrectomy compared with their male counterparts (P = .022). Women were less likely to have malignancy (odds ratio male gender 2.50; P = .013). CONCLUSION: Women are more likely than men to undergo radical vs partial excision of a localized renal mass, despite less comorbid burden, inferior renal function, and increased likelihood of benign disease.

Variation in treatment recommendations of adjuvant radiation therapy for high-risk prostate cancer by physician specialty.

OBJECTIVE: To assess the treatment recommendations from a nationally representative sample of radiation oncologists and urologists on adjuvant radiotherapy for patients with pathologically advanced prostate cancer after radical prostatectomy. METHODS: From a random sample of 1422 physicians (n = 711 radiation oncologists; n = 711 urologists) in the American Medical Association Masterfile, a mail survey queried treatment recommendations for adjuvant radiotherapy that varied by the following pathologic features: extraprostatic extension (pT3a) vs seminal vesicle invasion (pT3b), Gleason 7 vs Gleason 8-10, and margin negative (MN) vs margin positive (MP). Pearson chi-square and multivariable logistic regression were used to test for differences in treatment recommendations by physician specialty. RESULTS: Response rates for radiation oncologists and urologists were similar (44% vs 46%; P = .42). Radiation oncologists were more likely to recommend adjuvant radiotherapy than urologists for all the varying pathologic scenarios from pT3a, Gleason 7, and MN (42.5% vs 9.7%; adjusted odds ratio [OR]: 7.82, P <.001) to pT3b, Gleason 8-10, and MP disease (94.5% vs 89.1%, adjusted OR: 2.46, P <.001). Compared with radiation oncologists, urologists were more likely to recommend salvage radiotherapy pT3a, Gleason 7, and MN (90.3% vs 57.7%; adjusted OR: 7.72, P <.001) to pT3b, Gleason 8-10, and MP disease (10.9% vs 5.5%; adjusted OR: 2.22, P <.001). CONCLUSION: In this national survey, radiation oncologists and urologists have markedly different treatment recommendations for adjuvant and salvage radiotherapy. Patients with adverse pathologic features after radical prostatectomy should consult with both a urologist and radiation oncologist to hear a diversity of opinions to make the most informed decision possible.

Safety and outcomes of surgical treatment of renal cell carcinoma in the elderly.

INTRODUCTION: Treatment of the elderly patient with a small renal mass is becoming a common conundrum with scant data available to support treatment decisions. Goals were to assess risk of surgical treatment for renal cell carcinoma (RCC) in the elderly as compared to their younger counterparts. MATERIALS AND METHODS: A prospectively maintained database consisting of all renal tumors between August 2004 and November 2009 was utilized. Patients who underwent extirpative treatment for RCC were divided into groups based on age cutoff of < 75 and ≥ 75 years old. Primary outcome measures were likelihood of partial nephrectomy versus radical nephrectomy, complication rates, and overall and cancer-specific survival. A secondary outcome investigated was renal function. RESULTS: Of 347 patients identified, 273 were < 75, and 74 were ≥ 75 years old. The elderly group was less likely to undergo partial nephrectomy (26% versus 43%, p = 0.045). They also had a higher rate of pT3 disease (20% versus 11%, p = 0.018), worse baseline renal function (46 mL/min/m(2) versus 92 mL/min/m(2), p < 0.001) and a longer length of stay (3.5 days versus 2.2 days, p < 0.001). Complication rates and survival outcomes were similar between the groups. Only Eastern Cooperative Oncology Group (ECOG) ≥ 1 and Charlson index ≥ 2 predicted likelihood of experiencing a complication. CONCLUSIONS: Despite a longer length of stay, renal surgery is safe in selected elderly patients with minimal comorbidity and good functional status. The elderly have reduced baseline renal function indicating nephron sparing should be chosen whenever possible, when surgical intervention is elected.

Perioperative and renal function outcomes of minimally invasive partial nephrectomy for T1b and T2a kidney tumors.

PURPOSE: To compare operative and functional outcomes of minimally invasive partial nephrectomy (MPN) and minimally invasive radical nephrectomy (MRN) for T(1b) and T(2a) renal tumors. PATIENTS AND METHODS: All patients who underwent MPN or MRN for a localized, solitary renal mass 4 to 10 cm were included. Perioperative and renal function outcomes were compared. Propensity analysis was used to account for selection bias in type of nephrectomy when evaluating complication rates. RESULTS: One hundred and eight patients underwent MRN and 45 underwent MPN between August 2004 and September 2010. Preoperative patient and tumor characteristics were similar between groups. Tumor size was larger in the MRN group (5.3 vs 6.8 cm, P<0.001). Operative times and positive margin rates were similar between the groups (P=0.956 and P=0.207, respectively). Estimated blood loss was higher in the MPN group (401.8 vs 157.1 mL, P<0.001), but transfusion rates were similar (P=0.225). Rates of intraoperative (P=0.724), postoperative (P=0.806), and high Clavien-grade postoperative complications (P=0.966) were similar. Propensity analysis indicated that the likelihood of any complication (odds ratio [OR] 0.810, confidence interval [CI] 0.331-1.982, P=0.645) or of a high-grade complication (OR 0.164, CI 0.011-2.513, P=0.194) was unrelated to type of nephrectomy. With similar preoperative renal function parameters, postoperative development of new stage III to V chronic kidney disease (CKD) was greater in the MRN group (58 vs 31%, P=0.011). Propensity analysis showed that the likelihood of new CKD was 2.8 times higher in the MRN group (P=0.048). CONCLUSION: In selected patients and with appropriate surgical expertise, MPN can result in similar rates of complications but superior renal function outcomes in larger kidney tumors.

Impact of cytoreductive nephrectomy on eligibility for systemic treatment and effects on survival: are surgical complications or disease related factors responsible?

OBJECTIVE: To understand the impact of cytoreductive nephrectomy on the ability to receive systemic therapy in patients with metastatic renal cell carcinoma. Causes of delayed eligibility and effect on overall survival (OS) were investigated. METHODS: Patients with metastatic renal cell carcinoma who underwent cytoreductive nephrectomy between 2002 and 2010 were identified. Those ineligible to receive systemic therapy>2 months after surgery were considered delayed. Reasons for delay and effect on OS were investigated, including a thorough analysis of surgical morbidity. RESULTS: Of 65 patients identified, 28% experienced delayed eligibility for systemic therapy. Reasons for delay were related to surgery in 33%, disease progression in 56%, and both in 11%. Of the entire cohort, pT4 and sarcomatoid disease predicted poor outcomes with median OS of 9.8 and 7.6 months, respectively. Comparison of the delay vs no delay groups revealed more intraoperative complications (P=.01), a trend toward more high-grade postoperative complications (17% vs 4%, P=.09), and a median OS of 4.8 vs 18.9 months. Controlling for grade and stage, delay and sarcomatoid features independently predicted poor OS (HR, 2.61; P=.01 and HR, 2.25; P=.02, respectively). CONCLUSION: Delay in eligibility for systemic therapy after cytoreductive nephrectomy adversely affects OS and is most commonly caused by disease-related factors, although high-grade complications may contribute. Those with evidence of T4 or sarcomatoid disease features may best be served by systemic therapy followed by cytoreductive nephrectomy only in those exhibiting response.

Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy.

BACKGROUND: Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. OBJECTIVE: Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. DESIGN, SETTINGS, AND PARTICIPANTS: We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. INTERVENTION: All patients underwent nephroureterectomy. MEASUREMENTS: All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. RESULTS AND LIMITATIONS: Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. CONCLUSIONS: eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.

Is surveillance of small renal masses safe in the elderly?

OBJECTIVE: To determine if preoperative variables, including gender, age and tumour size, influence the decision for active surveillance of renal masses, as due to the increasing detection of incidental renal masses within the ageing population there is a need to identify reliable means of selecting patients who require therapy. PATIENTS AND METHODS: We retrospectively identified all renal masses resected at our institution between 1 December 1999, and 1 October 2005. The size of tumour, patient age and gender were compared between those with and without malignancy on final pathology. The influence of these variables in predicting malignancy, high grade, and high stage were assessed by univariate and multivariate analysis using logistic regression models, with a significance level of P < 0.05. Subsets were analysed for the groups of patients with tumours of ≤ 3 or > 3 cm and those aged ≤ 75 or > 75 years. RESULTS: Among 466 of 501 patients with evaluable data, univariate analysis showed that both male gender and increasing size positively predicted malignancy (odds ratio 1.13 and 1.40, respectively), but age, treated as a continuous variable, did not. On multivariate analysis both remained independent predictors of malignancy (odds ratio 1.13 and 1.40, respectively). Size was the only independent predictor of high-stage and high-grade disease on both univariate and multivariate analysis. Among 156 patients with tumours of ≤ 3 cm, on multivariate analysis, male gender was only weakly associated with the risk of malignancy, whereas size remained strongly predictive (odds ratio 1.98, P = 0.076; and 2.16, P = 0.015, respectively). Neither male gender, size nor age increased the risk of high-stage or high-grade disease in this cohort. Patients who were aged > 75 years had a greater risk of high-stage disease than those aged < 75 years (odds ratio 2.64, P = 0.008). On multivariate analysis, age > 75 years remained an independent predictor of malignancy and high-stage, along with size (odds ratio 2.75, P = 0.014; and 1.35, P < 0.001). CONCLUSIONS: Increased size of tumour increases the risk of malignancy and the likelihood of high-stage and high-grade disease. Among patients aged > 75 years there was a higher risk of malignancy and high-stage disease than in those aged ≤ 75 years. As such, the decision for observation should not be based upon age alone, and should be approached with caution in patients aged >75 years, particularly for larger lesions.

Para-anastomotic haematoma volume predicts the presence of anastomotic extravasation after radical retropubic prostatectomy.

OBJECTIVE: To determine the mechanism for delayed healing of the urinary anastomosis after radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: The volumes of the para-anastomotic haematoma (PHV) and anastomotic extravasation were measured by ultrasonography in 95 men after RRP. The performance characteristics of PHV for predicting urinary extravasation were ascertained and compared with that of postoperative blood loss, measured as the difference between the haematocrit immediately after RRP and that at discharge. RESULTS: The sensitivity and specificity of PHV for predicting urinary extravasation at a threshold of 37 mL was 100% and 96%, respectively. PHV was superior to postoperative blood loss in predicting anastomotic extravasation, as shown by an area under the receiver operating curve of 0.99 vs 0.91, respectively. CONCLUSIONS: Our findings provide compelling evidence that delayed healing of the anastomosis after RRP is due to distraction forces secondary to a pelvic haematoma. The accuracy of PHV as a predictor of anastomotic extravasation suggests that this measurement might replace cystography for assessing anastomotic integrity after RRP.

Bosniak category IIF designation and surgery for complex renal cysts.

PURPOSE: We investigated whether adding the IIF categorization improved the accuracy of Bosniak renal cyst classification, as evidenced by a low rate of progression in IIF lesions and a high rate of malignancy in category III lesions. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with complex renal cysts categorized as a Bosniak IIF or III. Surveillance imaging and pathological outcomes of category IIF cysts were recorded to determine radiological predictors of progression. Pathological outcomes of category III cysts were recorded to determine the malignancy rate. RESULTS: A total of 112 patients met study inclusion criteria, of whom 81 were initially diagnosed with a category IIF cyst and 31 had a Bosniak category III cyst. At a median followup of 15 months 14.8% of Bosniak IIF lesions progressed in complexity with a median time to progression of 11 months (maximum greater than 4 years). There were no differences in tumor or patient characteristics between cysts that progressed and those that remained stable. In the 33 patients with Bosniak III lesions who underwent surgical extirpation the malignancy rate was 81.8%. Most patients had low stage, low grade disease and remained recurrence-free at a median followup of 6 months. CONCLUSIONS: Adding the IIF category has increased the accuracy and clinical impact of the Bosniak categorization system, as evidenced by a low rate of progression in category IIF cysts and an increased rate of malignancy in surgically treated category III lesions compared to those in historical controls.

Effect of warm ischemia time during laparoscopic partial nephrectomy on early postoperative glomerular filtration rate.

PURPOSE: We evaluated the effect of warm ischemia time on early postoperative renal function following laparoscopic partial nephrectomy. MATERIALS AND METHODS: Of 453 patients who were surgically treated for renal tumors between May 2001 and September 2007, and who were identified in our database 128 underwent laparoscopic partial nephrectomy. Of these 128 patients 101 who were evaluable had complete demographic, operative, preoperative and early postoperative data available. Renal function was estimated using the glomerular filtration rate. Warm ischemia time was stratified into 4 interval groups and also analyzed based on different time cutoffs. Ultimately we also tested the relationship between postoperative renal failure, and preoperative factors and warm ischemia time. RESULTS: Warm ischemia time interval analysis was not significant. However, when analyzing the effect of warm ischemia time cutoffs, patients with warm ischemia time greater than 40 minutes had a significantly greater decrease in the glomerular filtration rate (p = 0.03) and a lower glomerular filtration rate postoperatively. The incidence of renal function impairment was more than 2-fold higher in those with a warm ischemia time of greater than 40 minutes than in the other groups (p = 0.077). Warm ischemia time was significant on univariate analysis when only patients with a preoperative glomerular filtration rate of 60 ml per minute per 1.73 m(2) or greater were analyzed. However, this did not hold as an independent predictor of postoperative renal function impairment on multivariate analysis. The preoperative glomerular filtration rate was the only independent predictor of postoperative renal function impairment. CONCLUSIONS: A warm ischemia time of 40 minutes appears to be an appropriate cutoff, after which a significantly greater decrease in renal function occurs after laparoscopic partial nephrectomy. The preoperative glomerular filtration rate was the only independent predictor of an increased risk of renal insufficiency following laparoscopic partial nephrectomy.

The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review.

PURPOSE: We describe the literature base pertaining to adrenalectomy at radical nephrectomy and present a pragmatic approach based on primary tumor and disease characteristics. MATERIALS AND METHODS: Literature searches were performed via the National Center for Biotechnology Information databases using various keywords. Articles that pertained to the concomitant use of adrenalectomy with radical nephrectomy were surveyed. RESULTS: The incidence of solitary, synchronous, ipsilateral adrenal involvement, ie that which is potentially curable with ipsilateral adrenalectomy along with nephrectomy, is much lower than previously thought at 1% to 5%. Evidence to date supports increased size and T stage, multifocality, upper pole location and venous thrombosis as risk factors for adrenal involvement. Cross-sectional imaging is now accurate at demonstrating the absence of adrenal involvement but still carries a significant risk of false-positives. The morbidity of adrenalectomy is minimal except in those patients with metachronous contralateral adrenal metastasis in whom the impact of adrenal insufficiency can be devastating. Disease specific and overall survival of those undergoing radical nephrectomy, with or without adrenalectomy, are similar. The survival of patients with widespread metastatic disease is historically poor regardless of whether adrenalectomy is performed. There is evidence for a survival advantage in patients with isolated adrenal metastasis, although this group comprises no more than 2% of those undergoing surgery for renal tumors. CONCLUSIONS: The apparent benefit of ipsilateral adrenalectomy does not support it as a standard practice in all patients with normal imaging. However, it should be considered in select cases in which there are risk factors for adrenal involvement.

Lymph node dissection during the surgical treatment of renal cancer in the modern era.

The increasing use of routine CT scan, along with advances in imaging technology, have facilitated the early diagnosis of incidental renal masses. This has resulted in the reduction in the rate of metastatic disease diagnosis. Although surgery remains the mainstay in the treatment of renal tumors, the decreasing incidence of lymph node involvement has created controversy regarding the importance and the ideal extent of lymph node dissection, formerly considered mandatory at the time of radical nephrectomy. In this review, we critically assessed the role of lymph node dissection at the time of radical nephrectomy. To date, randomized trials have failed to show a benefit of lymph node dissection when broadly employed. This is likely due to the low prevalence of lymph node metastasis at the time of presentation, the unpredictable pattern of lymph node metastasis from renal tumors, and the continued downward stage migration of the disease. As a result, lymph node dissection for renal cancer is currently not recommended in the absence of gross lymphadenopathy. In high risk patients, lymph node dissection may be considered, but it remains controversial and more clinical evidence is warranted. Extended lymph node dissection is still recommended in individuals with isolated gross nodal disease or those with lymphadenopathy at the time of cytoreductive surgery prior to systemic therapy. A practical approach is summarized in an algorithm form.

Transperitoneal laparoscopic radical nephrectomy for large (more than 7 cm) renal masses.

OBJECTIVES: To evaluate our laparoscopic radical nephrectomy (LRN) series to determine whether any significant increases have occurred in operative morbidity when resecting large (7 cm or greater) renal masses. LRN is becoming the reference standard for treating suspicious renal masses not amenable to nephron-sparing surgery. METHODS: We retrospectively reviewed the charts of 164 consecutive patients who had undergone laparoscopic radical nephrectomy performed for suspicious renal masses by two surgeons from February 2000 and December 2006. After institutional review board approval, we reviewed the patient charts to determine whether patients with 7-cm or larger lesions had significant differences in age, body mass index, American Society of Anesthesiologists class, operative time, estimated blood loss, conversion rate, positive margin rate, postoperative creatinine, and hematocrit compared with patients with lesions smaller than 7 cm. RESULTS: The data from 164 patients were reviewed. Of these 164 patients, 124 had less than 7-cm masses and 40 had lesions 7 cm or larger. The mean tumor size in the less than 7-cm group was 4.2 cm (range 1.8 to 6.9) and was 9.2 cm (range 7 to 14) in the 7-cm or larger group. The patients with large tumors had a significantly longer operative time, greater estimated blood loss, and increase in postoperative serum creatinine than those with smaller tumors but all other perioperative variables were similar. Two conversions to open radical nephrectomy occurred in both groups. CONCLUSIONS: Our data have clearly shown that larger tumors can safely be resected with transperitoneal laparoscopic nephrectomy. Open nephrectomy for large tumors can be associated with increased morbidity and the use of LRN could minimize this increased risk. Urologists with laparoscopic experience should consider expanding their indication for LRN.

A matched-cohort comparison of laparoscopic cryoablation and laparoscopic partial nephrectomy for treating renal masses.

OBJECTIVE: To compare the surgical outcomes of elderly patients with renal masses treated with laparoscopic partial nephrectomy (LPN) or laparoscopic cryoablation (LCA). PATIENTS AND METHODS: All 15 patients who had LCA at the authors' institution between May 2003 and July 2005 were included, and compared with a matched cohort of 15 patients selected by patient age and tumour size, from a pre-existing database of 104 patients who had LPN from July 2002 to July 2005. The two groups were compared for gender, number of comorbidities, American Society of Anesthesiologists status (ASA), body mass index (BMI), baseline renal function and haematocrit, location and size of lesion, length of stay, operative time, estimated blood loss (EBL), transfusion rate, number and type of complications, conversion rate, and postoperative renal function and haematocrit. RESULTS: The two groups were similar in age, sex, BMI, ASA, baseline renal function, haematocrit, size and side of tumour, the percentage of exophytic tumours, and the likelihood of more than one comorbidity. Surgical outcomes between the groups were also relatively similar. The length of stay, creatinine and haematocrit levels after surgery did not differ between the groups. The LPN group had a significantly longer operation (248 vs 152 min, P < 0.001) and higher EBL (222 vs 59 mL, P = 0.007) than the LCA group, but only one patient required a transfusion and there was no discernible difference in discharge haematocrit values. No recurrences were detected in either group, with a similar mean follow-up of 9.8 and 11.9 months, respectively. CONCLUSION: Although this matched-cohort comparison showed that LPN had a higher mean EBL, a longer operation and higher relative risk of open conversion, the overall clinical outcome was similar in terms of complication rates, length of stay and changes in creatinine and haematocrit after surgery. In this small retrospective evaluation, there was similar morbidity, treatment outcome and short-term efficacy with LCA and LPN. At present, although still experimental, LCA is a good choice for elderly patients with comorbidities precluding blood loss or renal ischaemia. However, in experienced hands, LPN is a preferred option for most elderly patients and should be considered when contemplating definitive treatment of renal masses.

Obesity and prostate cancer.

The relationship between obesity and prostate cancer is currently a hotly debated topic, but despite the number of publications devoted to the topic, the actual nature of the relationship remains uncertain. Obesity has been shown to have a direct relationship with the incidence of prostate cancer in a number of studies but an equal number of studies have shown no association. The relationship is further obscured with recent findings that obesity in younger obese men may actually be protective against prostate cancer. Confounding factors include the lack of correlation of body mass index (BMI) as a measure of central obesity and the lack of consistency in timing of BMI measurements, i.e. before or after diagnosis and in young or advanced adulthood. Evidence for increased BMI as a risk factor for prostate cancer is unclear, but less ambiguous is the mounting substantiation that obesity is associated with prognostically worse disease, poorer post-surgical outcomes and increased prostate cancer mortality, irregardless of margin status. From a biologic perspective, one can put forth a number of potential mechanisms by which obesity might promote prostate cancer and/or prostate cancer progression including; low levels of testosterone, increased levels of estrogen, co-existing diabetes or metabolic syndrome, increased circulating insulin-growth factor-one (IGF-1), increased levels of leptin, decreased levels of adiponectin and increased dietary saturated fats. Evidence for the association of these factors with prostate cancer are examined herein. The timing of serum measurements is crucial in elucidating whether these factors have causative influence on prostate cancer or rather are produced by the prostate cancer cells and are better understood as markers of disease. The interaction between obesity and prostate cancer is important to clarify because it will have impact on the prevention, prognostication and treatment of prostate cancer. Future study with careful attention to avoid the methodological pitfalls of the past need be accomplished to bear out the nature of the interaction of obesity and prostate cancer.