Increased incidence of Leydig cell tumours of the testis in the era of improved imaging techniques

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Leydig cell tumours (LCTs) of the testis are rare tumours, accounting for 1–3% of all testicular neoplasms. Our data indicate that using scrotal ultrasound with high resolution imaging in routine checkups leads to an earlier detection of LCTs. Most patients underwent an organ‐sparing surgery and no androgen deprivation was observed.

OBJECTIVE

? To report an observed high frequency of Leydig cell tumours (LCTs) diagnosed at our centre.

PATIENTS AND METHODS

? Charts of all patients who underwent surgery for a testicular tumour between 1999 and 2008 at our department were searched and data from patients with LCT were collected. ? Before surgery all patients underwent ultrasound and complete staging. In all but two patients with LCT an organ‐sparing surgery was performed. Surgery was performed under ultrasound or palpation guidance. ? All patients underwent postoperative follow‐up. We retrospectively reviewed surgical technique, histology, epidemiology and outcome in all LCT patients.

RESULTS

? In the study period, 197 testicular tumours were surgically removed of which 29 were diagnosed as LCT (14.7% of 197; further study group) in 25 patients. Mean age of patients with LCT was 45 years (range 21–68 years). ? Tumour size ranged from 1.2 to 80 mm (mean 10.23 mm). In two patients (8%) the lesion was palpable whereas incidental diagnosis was made in seven patients (28%). ? In the remaining patients diagnosis was made by ultrasound performed for testicular pain (six patients, 24%) or during infertility or erectile dysfunction evaluation (10 patients, 40%). ? Definitive histology reported no malignant histopathological features in all but one patient; this particular patient experienced tumour progression after 2 months and died from advanced disease 1 year later. All other patients are free of disease after a mean follow up of 56 months (range 7–93 months). ? During this period one patient developed a second LCT on the contralateral side; another patient had a recurrence within the same testicle, but on the opposite pole. Both underwent a subsequent organ‐sparing tumour resection.

CONCLUSION

? The percentage of LCT (14.7% of all testicular tumours removed) was significantly higher than expected from the literature. One possible explanation for this phenomenon is the increasing use of better ultrasound technology and the subsequent increased detection of small nodules that have not been found in historical series. Use of ‘observation‐only’ for very small lesions detected at infertility clinics is under debate.     

Leydig cell tumour of the testis: presentation, therapy, long-term follow-up and the role of organ-sparing surgery in a single-institution experience

OBJECTIVE

To report our single‐centre experience of patients with Leydig cell tumour (LCT) of the testis, which represents the most frequent interstitial neoplasm of the testis, and for which the natural history and therapy are debated.

PATIENTS AND METHODS

Between 1990 and 2006, 37 patients were treated for LCT of the testis. All patients had testicular markers assessed and 21 (57%) had their hormonal profile assessed (total testosterone, follicle‐stimulating hormone, luteinizing hormone and oestradiol). We analysed the symptoms at presentation, laboratory findings, organ‐sparing vs. radical surgery and oncological and symptomatic follow‐up data.

RESULTS

Medical referral was for a testicular mass in 32% of patients, gynaecomastia in 8%, testicular pain in 8%, infertility in 11%, and isosexual pseudo‐puberty in 5%. The mean (range) diameter of the tumour was 16.5 (6–68) mm. Before surgery testosterone levels exceeded the upper limit in a third of patients, while levels were hypogonadal in 19%. Oestradiol levels were increased in 29% of patients. At surgery, 29 patients (78%) had organ‐sparing surgery. The median (range) follow‐up was 4.6 (0.6–16.2) years; no patient had disease relapse. Gynaecomastia was present in two of six patients at the follow‐up, despite pharmacological treatment. Four patients had a low testosterone level.

CONCLUSION

Patients diagnosed with LCT have a good prognosis; this study shows the safety of conservative surgery. Surgical removal of the tumour is not always associated with resolution of symptoms and abnormal laboratory values.     

Prepubertal testicular tumours and efficacy of testicular preserving surgery

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Testicular tumours in childhood are very rare. Historically, most of these tumours have been considered malignant, but more recent studies indicate that benign lesions, particularly teratoma, are much more frequent than previously thought. Testicular tumours in this age group have traditionally been treated with inguinal radical orchiectomy, but more conservative management has been proposed in view of the higher frequency of benign tumours. In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers.

OBJECTIVE

? To report our experience of testicular tumours in children aged ≤13 years, including our experience with testis‐sparing surgery.

PATIENTS AND METHODS

? A retrospective study was performed of 15 patients with testicular tumours aged ≤13 years who presented at our centre between 1984 and 2008. The use of testis‐preserving surgery according to indication was investigated and outcomes were recorded.

RESULTS

? The clinical presentation was increased testicular size with a palpable mass in 80% of the cases. All 15 patients underwent surgery. The tumour was benign in 12 (80%) patients and malignant in three (20%) patients. ? Organ‐preserving surgery was planned and achieved in 11 patients (73%). ? Pathology of the tumourectomy specimens disclosed benign tumours in all cases: four epidermoid cysts, two teratomas, one juvenile granulosa cell tumour, one haemangioma, one lipoma, one fibrous hamartoma and one splenogonadal fusion. ? In four patients who underwent radical orchiectomy, pathology identified one yolk sac tumour (stage I), two mixed germ cell tumours and one gonadoblastoma.

CONCLUSIONS

? In children, most testicular tumours are benign, especially before puberty. A testis‐sparing procedure should be performed in children with a palpable testicular mass and negative tumour markers. ? The lesion, however, should be thoroughly excised to avoid recurrences.     

Testicular lesions other than germ cell tumours: feasibility of testis-sparing surgery

OBJECTIVE

To review all non‐germ‐cell testicular lesions presenting at our institution and to determine the feasibility of testis‐sparing surgery for these patients.

PATIENTS AND METHODS

All surgery for testicular masses between June 1995 and June 2005 were reviewed retrospectively. Patients with atrophy, germ cell tumours, infection or torsion were excluded. The study comprised men who had radical orchidectomy for suspected germ‐cell tumour but had other final pathology, and those where testis‐sparing surgery was attempted for a presumed benign lesion.

RESULTS

Thirteen patients with lesions appropriate for the study were identified; all but one had a palpable lesion. The lesions could be categorized as inflammatory (three hyalinized fibrosis, two sarcoidosis, one chronic inflammation), cystic (one epidermoid cyst, one unilocular cyst), benign neoplasms (two adenomatoid tumours, one Leydig cell tumour, one capillary haemangioma) or malignant neoplasms (one lymphoma). Based on the preoperative impression, testis‐sparing surgery was attempted in eight of the lesions and was successful in six where it was attempted. In the other five, testis‐sparing surgery was not attempted because the preoperative impression was that of a germ cell tumour. Testis‐sparing surgery was successful in only six of the 13 patients with these lesions.

CONCLUSION

Testis‐sparing surgery might be possible if there is significant suspicion of a benign lesion. If frozen‐section analysis is equivocal, a radical orchidectomy is required. Testis‐sparing surgery was feasible in highly selected cases.     

Extracorporeal high intensity focused ultrasound for renal tumours: a 3‐year follow‐up

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To determine whether primary extracorporeal high‐intensity focused ultrasound (HIFU) is safe, feasible and effective for managing small renal tumours.

PATIENTS AND METHODS

Although surgery currently remains the standard treatment for localized renal cell carcinoma (RCC), the increasing incidence of small renal cancers has led to a shift towards nephron‐sparing surgery, with associated morbidity in 20–25% of cases, and minimally invasive ablative therapies present an alternative management. HIFU results in ‘trackless’ homogenous tissue ablation and when administered via an extracorporeal device, is entirely noninvasive. The study comprised 17 patients (mean tumour size 2.5 cm) with radiologically suspicious renal tumours who underwent extracorporeal HIFU using the Model‐JC System (Chongqing HAIFU^TM, China), under general anaesthesia with one overnight hospital stay. Real‐time diagnostic ultrasonography was used for targeting and monitoring. Patients were followed with a clinical review and gadolinium‐enhanced magnetic resonance imaging at 12 days and every 6 months for a mean of 36 months. The outcomes measures were patient morbidity and oncological efficacy of HIFU treatment.

RESULTS

Of the 17 patients, 15 were treated according to protocol; two procedures were abandoned due to intervening bowel. There were no major complications related to HIFU. Radiological evidence of ablation was apparent at 12 days in seven of the 15 patients. Before the 6‐month follow‐up one patient had surgery due to persisting central enhancement. Fourteen patients were evaluated at the 6‐month follow‐up; eight tumours had involuted (mean 12% decrease in tumour area). Four patients had irregular enhancement on imaging and had alternative therapies. Ten patients remain on follow‐up at a mean (range) of 36 (14–55) months after HIFU (mean 30% decrease in tumour area). There was central loss of enhancement in all.

CONCLUSIONS

Renal HIFU achieves stable lesions in two‐thirds of patients, with minimal morbidity, and might be appropriate in selected cases. Further trials with accurate histological follow‐up are essential to fully evaluate this novel technique.     

Single-institution experience with primary tumours of the male urethra

OBJECTIVE

To assess primary tumours of the urethra in males.

PATIENTS AND METHODS

We retrospectively reviewed our database from 1986 to 2006 for primary tumours of the male urethra; nine patients with primary tumours of the urethra were analysed and follow‐up information was obtained.

RESULTS

Three patients had tumours of the prostatic urethra, two of which had proliferating focal inflammation and one a low‐grade, superficial urothelial cancer. All patients were treated successfully with transurethral resection. Six patients had carcinoma of the bulbar or penile urethra, including two with previous local percutaneous radiotherapy for prostate cancer. All had primary surgical excision that was adapted to tumour location and extension. One patient had adjuvant chemotherapy after surgery. All but one patient remain recurrence‐free after a median follow‐up of 20 months.

CONCLUSION

Primary carcinoma of the male urethra is a rare entity. Previous radiotherapy might be a predisposing factor. Local surgical tumour control is essential for long‐term survival, but the extent of surgery depends on tumour location and stage. Multimodal therapy might be required to obtain an optimum oncological outcome.     

The impact of family history on pathological and clinical outcomes in non‐syndromic clear cell renal cell carcinoma

Study Type – Prognosis (case series)
Level of Evidence 4

OBJECTIVE

To investigate the impact of family history on pathological and clinical outcomes after surgery for clear‐cell renal cell carcinoma (ccRCC) in patients with non‐syndromic disease.

PATIENTS AND METHODS

We reviewed 2677 patients treated with radical nephrectomy or nephron‐sparing surgery for non‐cystic ccRCC between 1970 and 2004 to identify patients with a family history of ccRCC. Patients with von Hippel–Lindau, tuberous sclerosis, or Birt–Hogg–Dube syndrome were excluded from analysis. Demographics and clinico‐pathological outcomes were compared to patients with ccRCC without a family history of kidney cancer using chi‐squared and Fisher’s exact tests. Postoperative cancer‐specific survival was estimated using the Kaplan–Meier method.

RESULTS

We identified 42 patients (1.6%) with a family history of ccRCC who were treated for non‐cystic ccRCC, with a median follow‐up of 4.7 years (range 1–34). Demographics and tumour characteristics, including tumour stage and grade, were similar between the two groups. Patients with a family history of ccRCC were more likely to have bilateral tumours (11.9 vs 2.2%, P= 0.003). Nevertheless, cancer‐specific survival rates for patients with and without a family history of ccRCC were similar at 5 years (75.7 vs 71.1%) and 10 years (53.9 vs 62.2%).

CONCLUSIONS

Patients with a family history of ccRCC have pathological and clinical outcomes similar to patients with sporadic ccRCC. The increased incidence of bilateral tumours associated with a family history of ccRCC provides further evidence to support a nephron‐sparing surgical approach when feasible.     

Carcinoid tumours of the testis

OBJECTIVE

To review previous reports of carcinoid (an endocrine tumour mostly of the gastrointestinal tract) tumours of the testis.

METHODS

Carcinoid tumours of the testis are rare and can be divided into primary carcinoid (group 1), testicular metastasis from another location (group 2) and carcinoid within a testicular teratoma (group 3). A case of testicular carcinoid within our clinic prompted us to review previous reports; all the cases found were assessed for patient and tumour characteristics, diagnostic tools used, treatment and prognosis.

RESULTS

In all, 62 cases were assessed and divided into groups 1 (44 patients), 2 (six) and 3 (12), respectively. Seven patients in group 1 developed metastases. A wide variety of diagnostic tools was used to search for other tumour sites. All patients were treated with orchidectomy. Three patients with a primary carcinoid were treated with adjuvant chemotherapy (two) or radiotherapy (one), with unknown results. All but one of the nine patients who died were known to have metastasis, either from a primary testicular carcinoid or testicular metastases from an intestinal carcinoid.

CONCLUSION

When a testicular carcinoid tumour is discovered, other tumour sites should be excluded. The most useful diagnostic tools for this purpose seem to be urinary 5‐hydroxyindoleacetic acid measurement, somatostatin receptor scintigraphy, computed tomography and video‐capsule endoscopy. Localized testicular carcinoid tumours have an excellent prognosis after orchidectomy.     

Nephron‐sparing surgery for pathological stage T3b renal cell carcinoma confined to the renal vein

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To report the functional and oncological outcome of nephron‐sparing surgery (NSS) for pathological stage pT3bNxMx (2002 Tumour‐Node‐Metastasis staging) renal cell carcinoma (RCC) with tumour thrombus confined to the renal vein.

PATIENTS AND METHODS

Of the 305 patients who underwent NSS at our institute from October 2004 to July 2009, seven (2%) were found to have stage T3bNxMx RCC on final pathology. Their charts were reviewed to identify demographic, operative and pathology details of these patients, in addition to obtaining functional and oncological outcome data.

RESULTS

All seven patients had centrally located endophytic tumours. There were absolute indications for NSS in six patients (solitary kidney in five, renal insufficiency in one). The clinical stage was T1a in five and T3b in two patients; in those with cT1a, thrombus was first identified with intraoperative ultrasonography in two and by palpation of the renal vein or during the NSS in the remaining three. Renal surface hypothermia was applied in four cases (mean 77 min) and warm ischaemia in three (mean 38 min). The mean (range) tumour size was 3.9 (2.5–6) cm and all the tumours were clear cell RCC on histology, and all had negative surgical margins. The mean estimated glomerular filtration rate (eGFR) decreased by 24% after surgery. One patient developed new‐onset renal failure (eGFR <30 mL/min/1.73 m²). Postoperative urine leak occurred in one patient successfully managed with a JJ stent. One patient developed a local recurrence with level III inferior vena caval (IVC) tumour thrombus 9 months after NSS and was managed with radical excision and IVC thrombectomy followed by postoperative dialysis. Six other patients were free of recurrence with no need for dialysis at a mean follow‐up of 30 months.

CONCLUSIONS

In selected patients with pathological stage T3b RCC and tumour thrombus confined to the renal vein, NSS is a feasible treatment option with acceptable oncological and renal functional outcomes.     

Long-term outcome of multiple ipsilateral renal tumours found at the time of planned nephron-sparing surgery

OBJECTIVE

To evaluate patients with multiple ipsilateral renal tumours and to determine outcomes of nephron‐sparing surgery (NSS) and radical nephrectomy (RN), as the treatment of unrecognized sporadic multifocal tumours at NSS presents a surgical dilemma.

PATIENTS AND METHODS

In all, 104 patients had surgery between 1970 and 2003 for sporadic multiple ipsilateral renal tumours, at least one of which was renal cell carcinoma (RCC); 114 were treated with RN and 26 with NSS. Cancer‐specific survival (CSS) was estimated using the Kaplan‐Meier method.

RESULTS

More patients treated with NSS had a solitary kidney than those undergoing RN (six, 23%, vs none, P < 0.001). Seventeen of the 114 having RN died from RCC at a median (range) of 3.4 (0.25–10.3) years after RN. The estimated 5‐year CSS was 90.5%. There was metachronous recurrence in nine patients at a median of 5.6 (1–14 ) years after. Two of the 26 patients having NSS died from RCC at 1 and 6 years after NSS; the 5‐year CSS was 95.8%. There was local or metachronous recurrence in three patients at 7 months to 6 years after surgery; all three were alive at the last follow‐up. In 26 (23%) of the 114 patients treated with RN, only one tumour was RCC.

CONCLUSION

Patients undergoing either RN or NSS for multiple ipsilateral renal tumours have a favourable CSS. A planned NSS is safe if small satellite lesions are resectable.     

Partial nephrectomy in two patients with known T3a tumours involving the renal vein

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although nephron‐sparing surgery (NSS) has became accepted therapy for T1 tumours, radical nephrectony is considered the best therapy for T3a tumours involving the renal vein. NSS can be considered in T3a or greater tumours if imperative indications exist, such as bilateral disease or solitary kidney. However, there is little published data on the characteristics of these patients, the impact of surgery on their renal function, and long‐term oncologic outcomes. This study profiles single‐institution experience with nephron‐sparing surgery for known T3a tumours involving the renal vein, including patient characteristics, tumour characteristics, preoperative and follow‐up imaging, preoperative and follow‐up estimated glomerular filtration rate, length of temporary postoperative haemodialysis, and oncologic outcome. Additionally, we compare this to other published data on nephron‐sparing surgery for similar tumors.

OBJECTIVE

• ? To present two patients with T3a tumours involving the renal vein who underwent nephron‐sparing surgery (NSS) for imperative reasons.

PATIENTS AND METHODS

• ? Retrospective chart review of patients who underwent NSS for renal cell carcinoma (RCC) with known renal vein tumour thrombus (RVTT).
• ? Both patients underwent open partial nephrectomy and renal vein thrombectomy of a solitary kidney.
• ? Primary outcomes of the study include radiographic evidence of recurrence, haemodialysis requirement and estimated glomerular filtration rate (eGFR) before and after surgery.

RESULTS

• ? Patient 1 is 24 months from NSS and has no evidence of recurrence based on CT scan. His final pathology revealed a 9‐cm, T3a, clear cell, Fuhrman grade II carcinoma. He spent 42 days on haemodialysis and is now off all dialysis. His preoperative and most recent eGFR are 48 and 23 mL/min/1.73 m² based on the Modification of Diet in Renal Disease (MDRD) equation and 69.4 and 29.8 mL/min by the Cockcroft–Gault equation.
• ? Patient 2 is 9 months from NSS and has no evidence of recurrence based on CT scan. Her final pathology revealed a 6‐cm, T3a, clear cell, Fuhrman grade II–III carcinoma. She spent 30 days on haemodialysis and is now off all dialysis. Her preoperative and most recent eGFR are 58 and 30 mL/min/1.73 m² based on the MDRD equation and 62.2 and 32.8 mL/min by the Cockcroft–Gault equation.

CONCLUSION

• ? Based on our review, preservation of renal function and favourable oncological outcome can be accomplished with NSS in patients with known stage T3a RCC with RVTT and should be considered in carefully selected patients.

     

Kidneys from patients with small renal tumours: a novel source of kidneys for transplantation

OBJECTIVE

To report the use of a novel donor source as a further option to increase the number of patients who might be able to receive a renal transplant.

PATIENTS AND METHODS

Between May 1996 and July 2007, 43 kidneys were transplanted using kidneys obtained from patients with small (<3 cm diameter) incidentally detected tumours. After bench surgery to excise the tumour, they were all successfully transplanted into patients who were elderly or had significant comorbidities.

RESULTS

Apart from four patients who died from unrelated illnesses, all grafts continued to function with a median and mean follow‐up of 25 and 32 months. The follow‐up, which included 3‐monthly renal ultrasonography and chest X‐rays, showed only one case of tumour recurrence, which occurred 9 years after transplantation; the patient remains stable under observation after 18 months.

CONCLUSIONS

From our experience we consider that where nephrectomy is used for small, localized, incidentally detected renal tumours, the kidney should be considered for transplantation into carefully selected patients. Such patients with numerous medical comorbidities might benefit from renal transplantation, but not survive the waiting period if they are dependent on a deceased donor graft. Paradoxically the use of these marginal kidneys has the potential to increase the quality and length of life of these patients, despite the apparent contradiction of an intuitive principle of organ transplantation and immunosuppression.     

Reduced bladder tumour recurrence rate associated with narrow‐band imaging surveillance cystoscopy

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Narrow‐band imaging cystoscopy is a new imaging modality developed to enhance conventional standard white‐light cystoscopy to evaluate bladder tumors. The current paper suggests that fulguration of low‐risk papillary bladder tumours using NBI cystoscopy results in fewer subsequent tumour recurrences than fulguration using standard cystoscopy. How, or if, NBI cystoscopy will become integrated into routine management of non‐invasive bladder tumours remains for further study.

OBJECTIVE

To evaluate frequency of recurrences among patients with papillary bladder tumours followed sequentially with conventional white‐light (WLI) cystoscopy and narrow‐band imaging (NBI) cystoscopy.

PATIENTS AND METHODS

A cohort of 126 patients with recurrent low‐grade papillary bladder tumours were followed every 6 months for 3 years by conventional WLI cystoscopy, and then over the next 3 consecutive years by NBI cystoscopy. Recurrent tumours detected were treated by outpatient fulguration or transurethral resection. We compared the tumour recurrence rate during follow‐up with WLI and NBI cystoscopy, using patients as their own controls.

RESULTS

Of the 126 patients, 94% had tumour recurrences during WLI cystoscopy vs 62% during NBI cystoscopy. The mean number of recurrent tumours was 5.2 with WLI cystoscopy vs 2.8 with NBI cystoscopy, and the median recurrence‐free survival time was 13 vs 29 months (P= 0.001).

CONCLUSION

Compared with follow‐up with WLI cystoscopy, NBI cystoscopy was associated with fewer patients having tumour recurrences, fewer numbers of recurrent tumours, and a longer recurrence‐free survival time.     

Varicocele surgery: a decade’s experience at a children’s hospital

OBJECTIVES

To review our experience at a children’s hospital over a 10‐year period with the Palomo, Ivanissevich, subinguinal and laparoscopic techniques for varicocele, assessing the success and complication rates according to specific procedure, and the added effect that the modifications of microsurgery and artery‐sparing has had on these rates. A second objective was to assess the rate of testicular compensatory growth after surgery for testicular hypotrophy.

PATIENTS AND METHODS

Ninety‐two patients with >1 year of follow‐up between 1996 and 2006 were assessed retrospectively. The median (range) age at surgery was 15 (8–21) years. Patients were stratified based on the surgical technique used by eight different urology faculty members. Microsurgery and attempted artery‐sparing were applied to some Palomo, Ivannisevich, and subinguinal cases but not to laparoscopic procedures.

RESULTS

The laparoscopic (100%) and Palomo (93%) techniques had significantly higher success rates than the Ivanissevich approach (69%). The success rate with the subinguinal technique (88%) was intermediate between the more successful supra‐inguinal and less successful inguinal approaches. There was a higher hydrocele rate (32%) in the laparoscopic approach. Artery sparing significantly lowered hydrocele rates but had no effect on success rates. Incorporating microsurgery also had no effect on success rates but resulted in no hydrocele formation. One case of testicular atrophy occurred in a patient undergoing microsurgical artery‐sparing subinguinal spermatic vein ligation. There was compensatory growth in 68% of patients operated on for testicular hypotrophy.

CONCLUSIONS

During our 10‐year experience the laparoscopic and Palomo approaches were the most successful. The subinguinal approach (usually incorporating microsurgery and artery sparing) had an intermediate success rate. The Ivanissevich approach was least successful. Hydroceles did not occur when microsurgery was used, and were significantly less common with artery sparing. The only case of testicular atrophy was with a microsurgical artery‐sparing subinguinal approach. When the spermatic vein was ligated for testicular hypotrophy there was compensatory growth in two‐thirds of testes.     

Metachronous renal tumours after surgical management of oncocytoma

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Oncocytoma is a benign renal tumour that cannot be differentiated from renal cell carcinoma radiographically. Follow‐up after surgery for oncocytoma is highly variable and the natural history of surgically treated renal oncocytoma is poorly defined. We sought to assess the risk of metachronous renal tumours in a cohort of patients treated surgically for renal oncocytoma. We report a large cohort of oncocytoma patients following surgical management. This study defines the risk of metachronous renal tumours after surgical treatment of renal oncocytoma. Our findings suggest that patients with metachronous renal tumours after treatment of renal oncocytoma may have a smaller risk of renal cell carcinoma compared with patients presenting with a primary renal mass. Our findings did not support concern for increased risk of renal cell carcinoma following surgical treatment of primary renal oncocytoma.

OBJECTIVE

? To assess the risk of metachronous renal cell carcinoma (RCC) and benign renal tumours after surgical treatment of primary renal oncocytoma.

PATIENTS AND METHODS

? Patients treated for primary renal oncocytoma between 1970 and 2007 were identified. Tumours were reviewed by a urological pathologist and patients were followed for subsequent renal tumours.

RESULTS

? Of 424 patients with a median follow up of 7.1 year, 17 (4.0%) patients were diagnosed with a metachronous renal tumour at a median of 3.0 years (range 0.3–16 years). Of the 17 metachronous tumours, eight were oncocytoma, four were RCC and five were not resected or biopsied. ? Eleven metachronous tumours occurred after solitary unilateral oncocytoma, five occurred after multifocal unilateral oncocytoma, and one occurred after multifocal bilateral oncocytoma. ? Estimated 10‐year tumour‐free and RCC tumour‐free survival was 94.8% and 98.7%, respectively. Patients with primary multifocal oncocytoma were at higher risk of metachronous tumour (hazard ratio 4.0; P = 0.007). Initial oncocytoma size (hazard ratio 1.1; P = 0.11) was not highly associated with risk of tumour recurrence.

CONCLUSIONS

? To our knowledge, we report the largest cohort of oncocytoma after surgical management. Metachronous renal neoplasm in a patient with previous oncocytoma is more likely to be benign compared with patients who present with a renal tumour for the first time. Multifocal primary oncocytoma is associated with metachronous renal tumours. ? Overall, the risk of metachronous RCC in a patient with an oncocytoma is similar to that of the general population, which does not support the use of routine cross‐sectioning imaging surveillance.     

Tumour in solitary kidney: laparoscopic partial nephrectomy vs laparoscopic cryoablation

Study Type – Therapy (cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Tumour in a solitary functioning kidney represents an absolute indication for nephron‐sparing surgery whenever technically feasible. We report the longest follow‐up data comparing laparoscopic partial nephrectomy and laparoscopic cryoablation in patients with solitary kidney with oncological follow‐up to five years.

OBJECTIVES

? We compare perioperative, functional and intermediate‐term oncological outcomes of laparoscopic partial nephrectomy (LPN) vs laparoscopic cryoablation (LCA) for small renal tumour in patients with a solitary kidney. ? A treatment algorithm is also proposed.

PATIENT AND METHODS

? Over a 10‐year period (02/1998‐09/2008), 78 patients with a small tumour in a functionally solitary kidney underwent LPN (n= 48) or LCA (n= 30). ? Baseline, perioperative, and follow‐up data were collected prospectively and analyzed retrospectively.

RESULTS

? Demographic data were similar between the LPN and LCA groups. Tumours were somewhat larger (3.2 vs 2.6 cm) in the LPN group. LPN was associated with greater blood loss (391 vs 162 mL; P= 0.003), and trended towards more post‐operative complications (22.9% vs 6.7%; P= 0.07). ? By 3 months post‐operative, eGFR decreased by 14.5% and 7.3% after LPN and LCA, respectively (P= 0.02). Post‐operative temporary dialysis was required after 3 LPN (6.2% vs 0%, P= 0.16). ? Median follow‐up time for LPN and LCA was 42.7 and 60.2 months, respectively. ? Local recurrence was detected in 4 (13.3%) LCA patients only (P= 0.02). ? Overall survival was comparable between LPN and LCA at 3 and 5 years, respectively (P= 0.74). The LPN group had superior cancer‐specific and recurrence‐free survival at 3 and 5 years compared to the LCA group (P < 0.05, for all comparisons).

CONCLUSIONS

? Given adequate technical expertise, both LPN and LCA are viable nephron‐sparing options for patients with tumour in a solitary kidney. ? Although LCA is technically easier and has superior functional outcomes, oncologic outcomes are superior after LPN.     

Clinico‐pathological correlation of hepatic angiomyolipoma: a series of 23 resection cases

Background

Angiomyolipomas are rare neoplasms of mesenchymal origin and are derived from perivascular epithelioid cells. They usually develop in the kidney and rarely in the liver. Due to their rarity, most hepatic angiomyolipomas have been misinterpreted as hepatocellular carcinoma (HCC) or other hypervascular liver tumours on imaging studies. We aimed to assess the clinico‐pathological correlation of hepatic angiomyolipoma.

Methods

We identified 23 patients with hepatic angiomyolipoma through an institutional database search.

Results

Of 5680 cases of primary liver tumours, 23 (0.4%) had angiomyolipomas (mean age, 43.6 ± 12.4 years; 16 female patients). Hepatitis B virus infection was noted in four patients, whereas a liver mass was incidentally detected on routine health screening in 13 patients. The preoperative diagnoses, before liver biopsy, included HCC in 14, angiomyolipoma in six, focal nodular hyperplasia in two and hepatic adenoma in one patient. Eventually, the preoperative diagnoses were changed to HCC in 12 and hepatic angiomyolipoma in 11 patients. The tumour size was 5.3 ± 4.6 cm, and 22 patients had a single tumour. All tumours exhibited positive findings for human melanoma black?45 and smooth muscle actin staining. During a follow‐up period of 52.2 ± 23.7 months, none of the patients exhibited tumour recurrence or mortality.

Conclusions

Hepatic angiomyolipoma is a rare form of primary liver tumour and is often misdiagnosed as other hypervascular tumours. Although angiomyolipoma is benign in nature, it also has malignant potential; hence, resection is indicated if the tumour grows or malignancy cannot be excluded. Surgical resection is a definitive curative treatment of hepatic angiomyolipoma.     

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoscopic nephron‐sparing procedures have been increasingly utilized. However, in the presence of multiple tumours the procedure choice is usually shifted to radical nephrectomy. In view of favourable perioperative outcomes, the benefits of minimally‐invasive, nephron‐sparing surgery in experienced hands could be safely extended to patients presenting with multiple ipsilateral renal masses.

OBJECTIVE

• ? To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses.

PATIENTS AND METHODS

• ? Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed.
• ? The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12).
• ? The groups were compared with regards to demographic and peri‐operative variables.

RESULTS

• ? Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4–4.0) and 4.0 cm (2.3–5.9) in groups 1 and 2, respectively.
• ? Median secondary tumour size in group 2 was 1.0 cm (1.0–1.8).
• ? Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009).
• ? Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar.

CONCLUSIONS

• ? LPN is a viable option for the treatment of multiple ipsilateral renal tumours.
• ? Peri‐operative outcomes are similar to standard LPN with the exception of longer operative time.
• ? In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

     

Thulium laser resection via a flexible cystoscope for recurrent non‐muscle‐invasive bladder cancer: initial clinical experience

OBJECTIVE

To present our initial experience of thulium laser resection via a flexible cystoscope for recurrent non‐muscle‐invasive bladder cancer (ThuRBT), as transurethral resection for bladder tumour (TURBT) is regarded as the reference standard for treating this disease, but alternative laser resection or ablation is suitable especially for recurrent tumours.

PATIENTS AND METHODS

From January 2005 to October 2005, 32 patients with early recurrent bladder tumour (recurrent within a year after TURBT) were treated with ThuRBT via a flexible cystoscope. The follow‐up included urine analysis, ultrasonography and cystoscopy every 3 months.

RESULTS

All patients were treated successfully with ThuRBT in one session, with no bladder haemorrhage, obturator nerve reflex or vesicle perforation. Randomized biopsies taken after surgery on and adjacent to the resection surface revealed no residual tumours. The mean (range) tumour diameter was 1.5 (0.5–3) cm and the mean operative duration was 25 (15–35) min. During the first year of follow‐up, local and heterotopic recurrences were found in three and six patients, respectively. The accumulated recurrence rates at 3, 6 and 12 months were 9%, 22% and 28%, respectively.

CONCLUSIONS

ThuRBT is a reliable therapy with minimal morbidity and invasiveness for selected patients with bladder cancer.