OBJECTIVE To compare perioperative and oncologic outcomes between laparoscopic (LCA) and percutaneous cryoablation (PCA) and identify predictors of treatment failure after cryoablation.METHODS Retrospective analysis was performed on 145 patients undergoing LCA and 118 patients undergoing PCA at our institution between July 2000 and June 2011.RESULTS LCA and PCA were performed on 167 and 123 tumors, respectively. Perioperative complication rates were 10% for both the groups. Mean length of stay was significantly shorter for the PCA group (2.1 +/- 0.5 vs 3.5 +/- 3.1 days, P <.01). Both groups had a comparable decline in estimated glomerular filtration rate at most recent follow-up (LCA 3.8 +/- 18.5 mL/min/1.73 m(2) vs PCA 6.6 +/- 17.1 mL/min/1.73 m(2), P= .21). Mean oncologic follow-up was 71.4 +/- 32.1 months for LCA and 38.6 +/- 19.6 months for PCA. Kaplan-Meier estimated 5-year overall and recurrence-free survival were 79.3% and 85.5%, respectively, for LCA and 86.3% and 86.3%, respectively, for PCA. Multivariate Cox proportional hazards analysis demonstrated that cryoablation approach (LCA vs PCA) was not predictive of overall mortality or disease recurrence (P= .36 and .82, respectively). Predictors of overall mortality included age-adjusted Charlson comorbidity index >= 6 (P= .01) and preoperative estimated glomerular filtration rate < 60 mL/min/1.73 m(2) (P= .02). Predictors of recurrence included tumor size >= 3 cm (P <.01), body mass index >= 30 kg/m(2) (P- .01), and endophytic growth (P- .04).CONCLUSION Mean length of stay was shorter for patients undergoing PCA as compared with LCA. Complication rates and decline in renal function at most recent follow-up were similar between groups. Oncologic outcomes were influenced by baseline patient and tumor characteristics rather than the cryoablation approach. UROLOGY 83: 1081-1087, 2014. (C) 2014 Elsevier Inc.

Background: Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function. Objective: To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD.Design, setting, and participants: A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15-60 ml/min per 1.73 m(2)) were identified. Perioperative results of 121 patients were compared against propensity score-matched controls without CKD (eGFR >= 60 ml/min per 1.73 m(2)).Intervention: RPN in patients with or without baseline CKD.Outcome measurements and statistical analysis: Descriptive statistics and propensity score-matched operative and functional outcomes.Results and limitations: After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (-5.1 vs -10.9), which remained significant at a mean follow-up of 12.6 mo (-2.8 vs -9.1, p < 0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p = 0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p = 0.007). The retrospective analysis was the main limitation of this study.Conclusions: RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay. (C) 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 2014MP54-07 ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS WITH BASELINE CHRONIC KIDNEY DISEASE: A MULTICENTER PROPENSITY SCORE MATCHED ANALYSIS Ramesh Kumar, Jesse Sammon, Jihad Kaouk, Sam Bhayani, Michael Stifelman, Mohamad Allaf, Bartosz Kaczmarek, Ali Khalifeh, Michael Gorin, Ganesh Sivarajan, Youssef Tanagho, and Craig Rogers Ramesh KumarRamesh Kumar More articles by this author , Jesse SammonJesse Sammon More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Sam BhayaniSam Bhayani More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Mohamad AllafMohamad Allaf More articles by this author , Bartosz KaczmarekBartosz Kaczmarek More articles by this author , Ali KhalifehAli Khalifeh More articles by this author , Michael GorinMichael Gorin More articles by this author , Ganesh SivarajanGanesh Sivarajan More articles by this author , Youssef TanaghoYoussef Tanagho More articles by this author , and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1596AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for preservation of renal function. We evaluate functional outcomes of RPN in patients with baseline CKD relative to patients undergoing RPN without baseline CKD. Methods A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007-2012 were identified. A total of 172 patients who underwent RPN with pre-existing CKD (estimated glomerular filtration rate [eGFR] 15-60 ml/min) were identified. Perioperative results of 121 patients were compared against propensity score matched controls without CKD (eGFR ≥ 60 ml/min). The propensity score matching considered the following variables: age, gender, race, BMI, ASA, CCI, ischemia time, multiple tumors, solitary kidney, tumor size and R.E.N.A.L. nephrometry score. Results After propensity score matching, patients with baseline CKD had a lower percent eGFR decrease at first follow-up (-5.1 vs. -10.9) that remained significant at a mean follow-up of 12.6 months (-2.8 vs. -9.1, p<0.05) and had less CKD upstaging (11.8% vs. 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs. 56.2%, p=0.006) and had a higher overall rate of surgical complications (21.5 vs. 10.7%, p=0.007). Conclusions RPN in patients with baseline CKD is associated with a smaller decrease in renal function and less CKD upstaging compared to patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e574 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Ramesh Kumar More articles by this author Jesse Sammon More articles by this author Jihad Kaouk More articles by this author Sam Bhayani More articles by this author Michael Stifelman More articles by this author Mohamad Allaf More articles by this author Bartosz Kaczmarek More articles by this author Ali Khalifeh More articles by this author Michael Gorin More articles by this author Ganesh Sivarajan More articles by this author Youssef Tanagho More articles by this author Craig Rogers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PURPOSE:Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon. MATERIALS AND METHODS:A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience. RESULTS:A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher. CONCLUSIONS:Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

PURPOSE:Expanding indications for robot-assisted partial nephrectomy raise major oncologic concerns for positive surgical margins. Previous reports showed no correlation between positive surgical margins and oncologic outcomes. We report a multi-institutional experience with the oncologic outcomes of positive surgical margins on robot-assisted partial nephrectomy.MATERIALS AND METHODS:Pathological and clinical followup data were reviewed from an institutional review board approved, prospectively maintained joint database from 5 institutions. Tumors with malignant pathology were isolated and statistically analyzed for demographics and oncologic followup. The log rank test was used to compare recurrence-free and metastasis-free survival between patients with positive and negative surgical margins. The proportional hazards method was used to assess the influence of multiple factors, including positive surgical margins, on recurrence and metastasis.RESULTS:A total of 943 robot-assisted partial nephrectomies for malignant tumors were successfully completed. Of the patients 21 (2.2%) had positive surgical margins on final pathological assessment, resulting in 2 groups, including the 21 with positive surgical margins and 922 with negative surgical margins. Positive surgical margin cases had higher recurrence and metastasis rates (p<0.001). As projected by the Kaplan-Meier method in the population as a whole at followup out to 63.6 months, 5-year recurrence-free and metastasis-free survival was 94.8% and 97.5%, respectively. There was a statistically significant difference in recurrence-free and metastasis-free survival between patients with positive and negative surgical margins (log rank test<0.001), which favored negative surgical margins. Positive surgical margins showed an 18.4-fold higher HR for recurrence when adjusted for multiple tumors, tumor size, tumor growth pattern and pathological stage.CONCLUSIONS:Positive surgical margins on final pathological evaluation increase the HR of recurrence and metastasis. In addition to pathological and molecular tumor characteristics, this should be considered to plan appropriate management.

Prostate cancer is a leading cause of morbidity and mortality in men and has significant treatment-associated complications. Prostate cancer chemoprevention has the potential to decrease the morbidity and mortality associated with this disease. Chemoprevention research to date has primarily focused on nutrients and 5 alpha-reductase inhibitors (5ARIs). A large randomized trial (SELECT) found no favorable effect of selenium or vitamin E on prostate cancer prevention. Two large randomized placebo controlled trials (the PCPT and REDUCE trials) have been published and have supported the role of 5ARIs in prostate cancer chemoprevention; however, these trials also have prompted concerns regarding the increase in high-grade disease seen with treatment and have not been approved by the US Food and Drug Administration (FDA) for chemoprevention. Conclusive evidence for the chemopreventive benefit of nutrients or vitamins is lacking, whereas the future role of 5ARIs remains to be clarified.

PURPOSETo provide a summary of the relevant literature regarding the impact of surgical cyst decortication on hypertension, renal function, and pain management in patients with autosomal dominant polycystic kidney disease (ADPKD).METHODSData collection was conducted via a Medline search using the subject headings autosomal dominant polycystic kidney disease, surgery, decortication, and marsupialization. Additional reports were derived from references included within these articles.RESULTSDespite a trend for improved blood pressure control after cyst decortication in some studies, this cumulative review of the literature did not provide consistent evidence supporting the role of this procedure in blood pressure management in patients with ADPKD. Surgical cyst decortication was associated with renal deterioration in a subset of patients with compromised baseline renal function but did not otherwise appear to have a significant impact on renal function in the majority of studies reviewed. Improvement in chronic pain after this procedure was ubiquitously reported across all studies examined.CONCLUSIONSDespite a potential role in blood pressure management in the setting of ADPKD, surgical cyst decortication has not been definitively shown to alleviate hypertension in this clinical setting. Renal function does not appear to improve following this surgery. Patients with compromised baseline renal function appear to be at increased risk for further deterioration in renal function after cyst decortication, although the role of this procedure in altering the natural trajectory of renal failure in this patient subset needs further investigation. Cyst decortication is highly effective in the management of disease-related chronic pain for the majority of patients with ADPKD, providing durable pain relief in this patient population.

We present a case of persistent pneumaturia of one-year duration in a fifty-five-year-old male with a history of spinal cord injury. The evaluation demonstrated gas throughout the collecting system attributable to a urinary tract infection with a gas-forming organism, Klebsiella pneumoniae.

Background and Purpose: Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis—in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN. Patient and Methods: A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed. Results: Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction. Conclusion: PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Introduction: With the increasing use of minimally invasive techniques in the management of urologic malignancies, reports of port-site metastasis (PSM) have raised concerns regarding the oncologic safety of these approaches.1 The first urologic PSM was reported in 1994, after lymph node dissection for bladder transitional cell carcinoma.2 Using multi-institutional, international data, an estimate for the incidence of PSM in urologic surgery has been reported to be 0.09%,3 and a contemporary review found 51 cases of urologic PSM reported in literature.4 However, renal cell carcinomas (RCC) represent a minority of these reported cases (8/51), and none occurred after robot-assisted partial nephrectomy (RAPN). We present a video describing our case of RCC-PSM after RAPN and demonstrating our technique for laparoscopic resection of the recurrent mass. Patients and Methods: In October 2011, a 68-year-old man underwent RAPN for an incidentally discovered 4-cm right renal mass with a nephrometry score of 10a. At no point during the resection was the mass violated. The final pathology demonstrated a 3.9-cm solid, Fuhrman grade III, clear-cell RCC with negative margins. In March 2012, routine follow-up CT scan revealed a 1.7-cm mass located on the abdominal wall, associated with an RAPN port site, and no other evidence of disease recurrence. Of note, the involved port site was the camera port site, not the specimen extraction site. The patient was completely asymptomatic. Ultrasound-guided biopsy demonstrated metastatic RCC, and in the absence of other metastatic disease, the patient was scheduled for resection of the PSM. With the patient in the left lateral decubitus position, a retroperitoneal approach was used to facilitate visualization of the intraperitoneal PSM. Once the retroperitoneal space was developed, the peritoneum was entered. The mass was well visualized and was circumferentially excised with wide margins. The mass was placed in an entrapment sack. The posterior rectus fascia was reinforced with a 2-0 polygalactin suture, which was secured with Weck Hem-o-lok clips (Teleflex, Research Triangle Park, NC). Hemostasis was ensured as the insufflation pressure was decreased to five mmHg, and the specimen was extracted, and the port-sites were closed. Results and Conclusions: The total operative time was 76 minutes, with a minimal (<10 mL) blood loss. The patient tolerated the procedure well and was discharged home on postoperative day one. The final pathology of the PSM demonstrated a 3.4-cm clear-cell RCC, granular variant, with negative margins. At present, one-month follow-up CT scan has demonstrated no evidence of disease recurrence or metastasis. The patient will be followed closely, with planned repeat imaging in six months. Although technique-related factors pertaining to specimen extraction have been implicated as a cause of PSM, our patient experienced recurrence at the camera port site, underscoring the importance of tumor and local wound-related factors in PSM. Several studies have also suggested that insufflation/desufflation during laparoscopic surgery may have an impact on the movement of tumor cells within the peritoneal cavity, potentially causing implantation at the port sites.5,6 Laparoscopic resection is a feasible minimally invasive alternative to open excision of PSM. No competing financial interests exist. Runtime of video: 5 mins 30 secs

Purpose: We evaluated the early oncological end point of recurrence-free survival in patients with renal cell carcinoma up-staged from cT1 to pT3a after partial nephrectomy. We also aimed to establish preoperative factors associated with pathological tumor up-staging.Materials and Methods: A prospective database of robotic partial nephrectomy cases performed at 5 academic centers was queried for patients who underwent surgery for a solitary cT1 renal mass. Patients with pT1-2 renal cell carcinoma were compared to those with pT3a tumors to determine the difference in recurrence-free survival. Preoperative factors associated with cT1 to pT3a up-staging were studied using multivariate logistic regression analysis.Results: A total of 1,096 patients underwent robotic partial nephrectomy for a cT1 renal mass. At final pathological evaluation 855 tumors (78.0%) were found to be renal cell carcinoma, of which 41 (4.8%) were up-staged to pT3a. The 24-month recurrence-free survival estimates for pT1-2 and pT3a tumors were 99.2% and 91.8%, respectively (p = 0.003). Multivariate analysis revealed that a high vs low R. E. N. A. L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior and location relative to polar lines) nephrometry score was associated with tumor up-staging (OR 2.97, 95% CI 1.20-7.35, p = 0.02). On separate multivariate analysis increasing tumor diameter (OR 1.66, 95% CI 1.32-2.08, p < 0.001) and hilar location (OR 2.83, 95% CI 1.43-5.61, p = 0.003) were also associated with up-staging.Conclusions: At short-term followup patients with renal cell carcinoma upstaged from cT1 to pT3a have reasonable oncological outcomes after partial nephrectomy. Factors associated with tumor up-staging include high tumor complexity, increasing tumor diameter and hilar location. Further studies are needed to determine the comparative efficacy of partial vs radical nephrectomy for small pT3a tumors.

You have accessJournal of UrologyKidney Cancer: Evaluation & Staging (II)1 Apr 2013727 URINARY AQUAPORIN-1 AND PERILIPIN-2: POTENTIAL BIOMARKERS FOR EARLY DETECTION OF RENAL CELL CARCINOMA Jonathan Mobley, Jeremiah Morrissey, Sam Bhayani, Goutham Vemana, Joseph Song, Joel Vetter, Youssef Tanagho, Alethea Paradis, Megan Kalin, Evan Kharasch, and Robert Figenshau Jonathan MobleyJonathan Mobley St. Louis, MO More articles by this author , Jeremiah MorrisseyJeremiah Morrissey St. Louis, MO More articles by this author , Sam BhayaniSam Bhayani St. Louis, MO More articles by this author , Goutham VemanaGoutham Vemana St. Louis, MO More articles by this author , Joseph SongJoseph Song St. Louis, MO More articles by this author , Joel VetterJoel Vetter St. Louis, MO More articles by this author , Youssef TanaghoYoussef Tanagho St. Louis, MO More articles by this author , Alethea ParadisAlethea Paradis St. Louis, MO More articles by this author , Megan KalinMegan Kalin St. Louis, MO More articles by this author , Evan KharaschEvan Kharasch St. Louis, MO More articles by this author , and Robert FigenshauRobert Figenshau St. Louis, MO More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.290AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal cell carcinoma (RCC) has a higher lethal potential than any other urological malignancy. Currently, no screening marker exists for RCC. Previous studies have found elevated urine concentrations of aquaporin-1 (AQP1) and perilipin-2 (PLIN2) in patients with RCC compared to healthy controls. We compare pre-operative urine concentrations of AQP1 and PLIN2 in RCC patients with pre-operative urine concentrations in prostate cancer (ACP) and bladder cancer (TCC) patients. Our goal is to demonstrate specificity of these markers to detect RCC among the most common genitourinary malignancies. METHODS Patients were enrolled into the study from February 28, 2012, to October 16, 2012. Pre-operative urine samples were obtained from 35 patients with clear and papillary RCC who underwent either a partial or radical nephrectomy, 27 patients with ACP who underwent a radical prostatectomy, and 28 patients with TCC who underwent either a transurethral resection of bladder tumor or radical cystectomy. Urine AQP1 and PLIN2 concentrations were determined by Western blot procedures normalized to the urinary creatinine excretion. Wilcoxon Rank Sum Test compared urine concentrations of AQP1 and PLIN2 between RCC, TCC, and ACP patients. RESULTS The median urine AQP1 and PLIN2 for RCC patients were 33 and 37 relative absorbance/mg urinary creatinine. Patients with TCC had median AQP1 and PLIN2 concentrations of 2 and 6, while ACP patients had median AQP1 and PLIN2 of 3 and 5. Using the Wilcoxon Rank Sum test, there was a statistical difference in urinary AQP1 and PLIN2 concentrations between RCC patients and both patients with TCC and ACP (p-value <0.0001 for both). CONCLUSIONS There is a statistically significant elevation in the pre-operative urine concentrations of AQP1 and PLIN2 in RCC patients compared to patients with TCC and ACP. Knowing that the urinary concentrations of AQP1 and PLIN2 are elevated in patients with RCC compared to healthy controls, we believe that AQP1 and PLIN2 have high potential to be used as screening biomarkers for RCC. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189 Issue 4S April 2013 Page: e299 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.Metrics Author Information Jonathan Mobley St. Louis, MO More articles by this author Jeremiah Morrissey St. Louis, MO More articles by this author Sam Bhayani St. Louis, MO More articles by this author Goutham Vemana St. Louis, MO More articles by this author Joseph Song St. Louis, MO More articles by this author Joel Vetter St. Louis, MO More articles by this author Youssef Tanagho St. Louis, MO More articles by this author Alethea Paradis St. Louis, MO More articles by this author Megan Kalin St. Louis, MO More articles by this author Evan Kharasch St. Louis, MO More articles by this author Robert Figenshau St. Louis, MO More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

OBJECTIVE To evaluate the outcomes of robotic partial nephrectomy (RPN) for solitary kidney in a large multicenter series.MATERIALS AND METHODS Medical records of 886 consecutive patients who underwent RPN at 5 academic institutions from May 2007 to May 2012 were retrospectively analyzed. Data were prospectively collected in an Investigational Review Board-approved protocol. Experienced robotic surgeons performed all operations. Patient demographics, functional, perioperative, and early oncologic outcomes were analyzed.RESULTS A total of 26 patients with a solitary kidney were identified and included in the analysis; of these, 16 (62%) had solitary kidneys secondary to a previous malignancy. Perioperative outcomes included a median warm ischemia time of 17 minutes (interquartile range, 12, 28 minutes). Only 2 intraoperative complications occurred. One was a renal vein injury and one an aortic vessel tear, and both patients required intraoperative blood transfusions. No conversions to laparoscopy or open surgery occurred. There were 3 postoperative complications (11.5%). Median follow-up was 6 months (interquartile range, 5, 9.7 months). Postoperative renal function did not change significantly as measure by estimated glomerular filtration rate (-15.8%; P = .13). None of the patients required dialysis. Positive margins occurred in 1 patient, with 73% of patients having a renal cell carcinoma.CONCLUSION We report a multi-institutional series of RPN in patients with solitary kidney presenting with small renal masses. Our findings suggest that RPN represents a feasible treatment option in this specific population by offering reliable preservation of renal function, low surgical morbidity, and early oncologic safety in the hands of experienced robotic surgeons. UROLOGY 81: 93-97, 2013. (c) 2013 Elsevier Inc.

The purpose of this article is to provide an update on the current literature evaluating outcomes with laparoscopic prostatectomy. The reported perioperative, oncologic, and functional outcomes with this approach are reviewed and comparisons are made to the open and robotic-assisted approaches.

Retrieval of foreign bodies from the genitourinary system, most commonly inserted for sexual satisfaction or as a result of a psychiatric illness, can pose a significant surgical challenge. Due to their breadth of size, shape, and location within the genitourinary system, endoscopic management can be difficult. Here, we review the management of four cases of foreign object insertion into the genitourinary system and their outcomes and management.

Laparoscopic renal surgery is associated with reduced blood loss, shorter hospital stay, enhanced cosmesis, and more rapid convalescence relative to open renal surgery. Laparoscopic partial nephrectomy (LPN) is a minimally invasive, nephron-sparing alternative to laparoscopic radical nephrectomy (RN) for the management of small renal masses. While offering similar oncological outcomes to laparoscopic RN, the technical challenges and prolonged learning curve associated with LPN limit its wider dissemination. Robot-assisted partial nephrectomy (RAPN), although still an evolving procedure with no long-term data, has emerged as a viable alternative to LPN, with favorable preliminary outcomes. This article provides an overview of the role of RAPN in the management of renal cell carcinoma. The clinical indications and principles of surgical technique for this procedure are discussed. The oncological, renal functional, and perioperative outcomes of RAPN are also evaluated, as are complication rates.

You have accessJournal of UrologyKidney Cancer: Localized (III)1 Apr 20131450 POSITIVE SURGICAL MARGINS IN ROBOT ASSISTED PARTIAL NEPHRECTOMIES: A MULTI-INSTITUTIONAL ANALYSIS OF ONCOLOGICAL OUTCOMES Ali Khalifeh, Sam Bhayani, Craig Rogers, Mohamad Allaf, Michael Stifelman, Youssef Tanagho, Ramesh Kumar, Michael Gorin, Ganesh Sivarajan, and Jihad Kaouk Ali KhalifehAli Khalifeh Cleveland, OH More articles by this author , Sam BhayaniSam Bhayani St Louis, MO More articles by this author , Craig RogersCraig Rogers Detroit, MI More articles by this author , Mohamad AllafMohamad Allaf Baltimore, MD More articles by this author , Michael StifelmanMichael Stifelman New York, NY More articles by this author , Youssef TanaghoYoussef Tanagho St Louis, MO More articles by this author , Ramesh KumarRamesh Kumar Detroit, MI More articles by this author , Michael GorinMichael Gorin Baltimore, MD More articles by this author , Ganesh SivarajanGanesh Sivarajan New York, NY More articles by this author , and Jihad KaoukJihad Kaouk Cleveland, OH More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2804AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The expanding indications of robot-assisted partial nephrectomy that include larger and more complex tumors, raises a major oncological concern of positive surgical margins. Previous literature reviews have found that positive surgical margins have no effect on recurrence and metastasis rates. We herein report a multi-institutional experience with oncological outcomes of positive surgical margins in robot-assisted partial nephrectomy. METHODS Pathological and clinical follow up on 1,222 patients were reviewed from IRB approved prospectively maintained databases of five major institutions. Tumors with malignant pathology were isolated and statistically analyzed for demographics and oncological follow up. Patients with positive surgical margins were counseled and closely followed with serial postoperative imaging. The Kaplan-Meier method was used to estimate recurrence and metastasis free survival for the population as a whole and the Log-rank test to compare between those with positive surgical margins and those without. Proportional hazard was also used to assess the influence of multiple factors, including positive surgical margins on recurrence and metastasis occurrence. RESULTS Total procedures performed for one or more malignant tumors were 947. Of those 20 (2.1%) had positive surgical margins on the final pathology report. Patients with positive surgical margins had higher rates of recurrence and metastasis (p<0.001). Recurrence free survival and metastasis free survival at 5 years were 94.8% and 97.5% respectively as projected by the Kaplan-Meier method for the population as a whole (with follow up to 63.6 months). There was a statistically significant difference in recurrence and metastasis free survival between patient with and without positive margins (Log-Rank<0.001) favoring those with negative surgical margins. Positive surgical margins were found to increase risk of recurrence and metastasis when adjusted for multiple tumors, size, solitary, growth pattern and pathologic stage. CONCLUSIONS In the experience of 5 major institutions, positive surgical margins on final pathology pose an additional risk for recurrence and metastasis. A close clinical follow up and discussion of risks and interventional options with patients is advised. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e595 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ali Khalifeh Cleveland, OH More articles by this author Sam Bhayani St Louis, MO More articles by this author Craig Rogers Detroit, MI More articles by this author Mohamad Allaf Baltimore, MD More articles by this author Michael Stifelman New York, NY More articles by this author Youssef Tanagho St Louis, MO More articles by this author Ramesh Kumar Detroit, MI More articles by this author Michael Gorin Baltimore, MD More articles by this author Ganesh Sivarajan New York, NY More articles by this author Jihad Kaouk Cleveland, OH More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

BACKGROUND AND PURPOSE:American Urological Association guidelines endorse partial nephrectomy as the preferred treatment for patients with small renal masses, while considering patients with significant comorbidities potential candidates for ablative therapy. We compared perioperative, renal functional, and oncologic outcomes of renal cryoablation and robot-assisted partial nephrectomy (RAPN) based on our long-term institutional experience.PATIENTS AND METHODS:A retrospective review evaluated 267 patients who underwent laparoscopic or percutaneous cryoablation (July 2000-June 2011) and 233 patients who underwent RAPN (June 2007-September 2012) for enhancing renal masses at Washington University.RESULTS:The perioperative complication rate was 8.6% in the cryoablation group vs 9.4% in the RAPN group (P = 0.75). There was no significant difference in complication risk between the two treatment modalities on multivariate analysis. Estimated glomerular filtration rate (eGFR) at last follow-up was 6% lower than preoperative eGFR in the cryoablation group and 13% lower in the RAPN group (P<0.01). The advantage of cryoablation in preserving renal function persisted on multivariate analysis (P = 0.02). In patients with pathologically proven renal-cell carcinoma, 5-year Kaplan-Meier disease-free survival (DFS), cancer-specific survival (CSS), and overall survival was 83.1%, 96.4%, and 77.1% in the cryoablation cohort vs 100%, 100%, and 91.7% in the RAPN group. Mean time to recurrence was 16.2 months (range 0.03-42.0 mos). Cryoablation was associated with increased recurrence risk (hazard ratio [HR] = 11.4, P = 0.01) on multivariate analysis.CONCLUSIONS:Cryoablation and RAPN are safe alternatives for managing renal masses amenable to nephron-sparing interventions, offering acceptable morbidity and excellent renal preservation. While RAPN offers improved DFS, for those willing to undergo close postoperative monitoring and accept the potential need for re-treatment of recurrent disease, cryoablation offers excellent long-term CSS.

This article provides an overview of extirpative laparoscopic and robotic procedures used in the management of renal cell carcinoma, including laparoscopic radical nephrectomy, laparoscopic partial nephrectomy, and robotic-assisted partial nephrectomy. The clinical indications and principles of surgical technique for each of these procedures are discussed. The oncologic, renal functional, and perioperative outcomes of these procedures are also assessed and compared, as are complication rates.