Open radical prostatectomy in the elderly: a case for concern?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Adverse outcomes after radical prostatectomy are more often recorded in the elderly. In the USA, elderly patients undergoing radical prostatectomy are treated at institutions where suboptimal outcomes are recorded.

OBJECTIVE

• ? To assess the rate of adverse outcomes after open radical prostatectomy (ORP) in the elderly and to examine the effect of annual hospital caseload (AHC) and academic institutional status on adverse outcomes in these of patients.

PATIENTS AND METHODS

• ? Within the Health Care Utilization Project Nationwide Inpatient Sample, we focused on ORPs performed between 1998 and 2007. Subsequently, we restricted to patients aged ≥75 years.
• ? In both datasets, we examined transfusion rates, intra‐operative and postoperative complication rates, and in‐hospital mortality rates.
• ? Stratification was performed according to AHC tertiles and academic status.
• ? Multivariable logistic regression analyses were fitted.

RESULTS

• ? Of 115 554 ORP patients, 2109 (1.8%) were aged ≥75 years.
• ? In multivariable analyses performed in the entire cohort, elderly age increased homologous blood transfusion rates (P < 0.001), intra‐operative (P= 0.001) and postoperative (P < 0.001) complication rates, and the mortality rate (P= 0.007).
• ? Most elderly were treated at low or intermediate AHC (68.5%) and non‐academic centres (56.2%).
• ? Within the elderly cohort, intra‐operative (2.9%) and postoperative (22.2%) complications tended to be highest at low AHC institutions compared to institutions of intermediate (2.7% and 17.4%) and high AHC (1.7% and 14.5%). Similarly, intra‐operative (2.7% vs 2.1%) and postoperative complications (19.1% vs 13.9%) tended to be higher at non‐academic than academic centres.
• ? In multivariable analyses performed in the elderly subgroup, low AHC predicted higher intra‐operative complications and higher homologous transfusions, whereas non‐academic status predicted higher postoperative complications.

CONCLUSIONS

• ? Adverse outcomes are more often recorded in the elderly.
• ? Most elderly are treated at institutions where suboptimal outcomes are recorded.

     

Laparoscopic partial nephrectomy: beyond the straightforward T1a

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally‐invasive surgery may be safely extended to patients with more complex renal masses.

OBJECTIVE

• ? To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion.

PATIENTS AND METHODS

• ? Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005–2010.
• ? 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66).
• ? Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra‐ and postoperative complications).

RESULTS

• ? In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases.
• ? Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL).
• ? Operative times were longer in group 2 (190 vs 140min, P < 0.001).
• ? Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547).
• ? There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2).

CONCLUSION

• ? With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally‐invasive surgery to those of nephron‐sparing approach.

     

Prostate cancers detected by saturation repeat biopsy impairs the Partin tables' accuracy to predict final pathological stage

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What's known on the subject? and What does the study add? The Partin tables represent a widely used tool to predict final pathologic stage in men with localized prostate cancer. The study provides a validity assessment of the current Partin tables’ version, and compares data sets from patients with prostate cancers detected by different biopsy schedules for potential differences in predictive accuracy.

OBJECTIVE

• ? To analyse the overall accuracy of Partin tables, with special emphasis to potential limitations resulting from differences between prostate cancers detected by different biopsy schedules.

PATIENTS AND METHODS

• ? Clinical characteristics from 599 patients treated with radical prostatectomy defined the 2007 Partin probabilities of organ confinement (OC), seminal vesicle invasion (SVI) and extracapsular extension (ECE). Prostate cancers were detected by initial biopsy (IBx) with ≤12 cores in 405 patients (67.6%), by conventional repeat biopsy (CRBx) with ≤12 cores in 99 (16.5%) and by saturation repeat biopsy (SRBx) with ≥20 cores in 95 patients (15.9%).
• ? The area under the curve (AUC) estimated by the receiver operating characteristic curve, assessed the predictive accuracy of the 2007 Partin tables.

RESULTS

• ? The Partin tables AUC of the IBx, CRBx and the SRBx groups were 0.730 vs 0.701 vs 0.585 for OC, 0.631 vs 0.689 vs 0.547 for ECE, and 0.775 vs 0.755 vs 0.641 for SVI, respectively.

CONCLUSIONS

• ? The overall accuracy of the 2007 Partin tables was clearly inferior in patients with prostate cancers detected by SRBx.
• ? Prostate cancers detected by SRBx undermine the Partin tables’ overall accuracy, and this group of patients may be miscounselled by vague predictions.

     

Robotic partial nephrectomy in the setting of prior abdominal surgery

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

OBJECTIVE

• ? To evaluate our experience with robotic partial nephrectomy in patients with previous abdominal surgery and evaluate the effect of previous abdominal surgery on perioperative outcomes. We also describe a technique for intraperitoneal access for patients with prior abdominal surgery utilizing the 8 mm robotic camera for direct‐vision trocar placement.

PATIENTS AND METHODS

• ? From a prospective cohort of 197 consecutive patients who underwent robotic renal surgery at a single academic institution, a total of 95 patients underwent transperitoneal robotic partial nephrectomy (RPN).
• ? Patients with and without previous abdominal surgery were compared. Patients with prior abdominal surgery were subcategorized into two groups: upper midline or ipsilateral upper quadrant scar or lower abdominal, contralateral, or minimally‐invasive scar.
• ? Demographic and perioperative variables were compared between the surgery and no surgery groups. Access was obtained using a Veress needle or Hassan technique.
• ? We utilized a technique of direct vision placement of the initial trocar on our 10 most recent cases, using an 8 mm robotic camera placed through the obturator of 12 mm clear‐tipped trocar.
• ? Lysis of adhesions was performed as needed to allow for placement of additional robotic ports.

RESULTS

• ? A total of 95 patients underwent transperitoneal RPN, of which 41 (43%) had a history of prior abdominal surgery and six had upper midline or ipsilateral upper quadrant scars.
• ? There were no statistically significant differences between patients with previous abdominal surgery and patients with no previous abdominal surgery in BMI (30.4 vs 29.4 kg/m²), median tumor size (2.5 cm vs 2.3), median total operative time (246 vs 250 min), median warm ischemia time (21 vs 16 min), median EBL (150 vs100 ml), clinical stage, transfusion rate, or complications.
• ? A total of six patients underwent 7 previous upper midline or ipsilateral upper quadrant surgeries, including open cholecystectomy‐2 patients (33%), open partial gastrectomy‐2 patients (33%) and exploratory laparotomy‐1 patient (17%).
• ? Complications in this group were an enterotomy during lysis of adhesions that was repaired robotically without sequelae and a mesenteric hematoma during Veress needle placement. A total of 35 patients underwent 16 other prior abdominal surgeries, including abdominal hysterectomy‐10 patients (29%), umbilical/inguinal hernia repair‐9 patients (26%) and appendectomy‐7 patients (20%). There were no access related injuries in the 10 cases in which the robotic 8 mm camera was used for initial trocar placement.

CONCLUSIONS

• ? Transperitoneal robotic partial nephrectomy is feasible in the setting of prior abdominal surgery. The majority of these patients can have their procedure performed safely without an increase in complications.
• ? Direct‐vision intraperitoneal placement of initial trocar may be achieved by using an 8 mm robotic camera, without the need to switch between conventional and robotic cameras.

     

Primary full-gland prostate cryoablation in older men (> age of 75 years): results from 860 patients tracked with the COLD Registry

Study Type – Therapy (outcomes research) Level of Evidence 2c What's known on the subject? and What does the study add? Most elderly patient with prostate cancer undergo radiation therapy, but cryoablation has gained popularity. This study demonstrates the safety and efficiency of this new approach.

OBJECTIVE

• ? To report on the largest data set regarding outcomes for whole gland prostate cryoablation as a primary treatment of prostate cancer in older men, which we empirically defined as age >75 years.

MATERIALS AND METHODS

• ? The COLD (Cryo On‐Line Data) Registry consists of case report forms with pre‐ and post‐treatment information obtained from patients undergoing prostate cryoablation.
• ? A total of 860 patients were stratified into low‐, intermediate‐ and high‐risk groups (D'Amico 2003 risk definitions).
• ? Biochemical disease‐free survival (bDFS) was defined according to the traditional American Society for Therapeutic Radiology and Oncology definition (3 increases) and the newer (Phoenix) definition (nadir +2).
• ? Biopsy was performed at physician discretion but most commonly for cause if a patient had an increasing or suspicious prostate‐specific antigen level (PSA).

RESULTS

• ? The median age was 79 years (76–91) and the median follow‐up was 16 months (4–60).
• ? The 5‐year [95% confidence interval (CI)] bDFS for the entire population using ASTRO and Phoenix definitions was 79% (4%) and 62.6% (8.3%), respectively.
• ? Stratified by risk group, 5‐year bDFS (ASTRO) was 82.4% (7.9%), 78.3% (5.8%) and 77.6% (7.7%) for low, moderate and high risk, respectively.
• ? Using the Phoenix definition, 5‐year bDFS was 74.9%± 15.3%, 61.4%± 13.2% and 58.0%± 11.9% for low‐, moderate‐ and high‐risk groups, respectively.
• ? Incontinence was reported in eight patients (0.9%).

CONCLUSION

• ? Whole gland cryoablation in older men maintains oncological efficacy similar to that of younger men without increased morbidity.

     

Incidence and clinical significance of arterial injury in varicocele repair

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

OBJECTIVE

• ? This study was performed to histologically determine the rate of arterial injury in varicocele ligation surgery and to determine the clinical significance of these arterial injuries.

MATERIALS AND METHODS

• ? 41 men who underwent varicocele ligation surgery, and had segments of each ligated vessel examined histologically.
• ? The patients were followed prospectively to determine the effect of arterial injury on surgical results and clinical complications.

RESULTS

• ? Arterial ligation was identified in 6 of 41 patients (12%), and in 7 of 132 specimens (5%), which is higher than previous reports.
• ? Arterial injury was not associated with testicular atrophy and there was no apparent effect of arterial injury on surgical outcome.

CONCLUSION

• ? The rate of arterial injury during varicocele repair is higher than previously reported, but the clinical significance of these injuries appears to be limited.

     

Significance of histological prostatitis in patients with urinary retention and underlying benign prostatic hyperplasia or adenocarcinoma of the prostate

What's known on the subject? and What does the study add? It is known that histological prostatitis is associated with a significantly higher risk for acute urinary retention in men with BPH. This study showed that, in men with BPH, histological prostatitis was associated with urinary retention at a significantly younger age and with higher serum PSA levels. In men with ACP, histological prostatitis was associated with urinary retention at an earlier stage of cancer. Study Type – Prognosis (individual cohort) Level of Evidence 2b

OBJECTIVE

• ? To compare the clinical features of patients having urinary retention and benign prostatic hyperplasia (BPH) with those having adenocarcinoma of the prostate (ACP) and to evaluate the significance of histological prostatitis.

PATIENTS AND METHODS

• ? The clinical data and histopathology reports of patients with retention admitted to Tygerberg Hospital between September 1998 and June 2007 were evaluated.
• ? Statistical analysis was performed with Student's t‐test, Mann–Whitney test and Fisher's exact test where appropriate and P < 0.05 was considered to indicate statistical significance.

RESULTS

• ? Prostatic histology was available in 405 patients, 204 with BPH and 201 with ACP.
• ? Comparing those with BPH and those with ACP showed statistically significant differences in mean age (69.5 vs 71.9 years), serum prostate‐specific antigen (PSA) level (18.6 vs 899.5 ng/mL) and histological prostatitis (48 vs 25%) but not duration of catheterization, prostate volume or urinary tract infection (UTI).
• ? Comparing those with BPH only and those with BPH plus prostatitis showed significant differences in mean age (71.9 vs 67.1 year) and PSA level (14.6 vs 22.8 ng/mL) but not prostate volume, UTI or duration of catheterization.
• ? Comparing those with ACP only and those with ACP plus prostatitis showed significant differences in stage T4 cancer (68.1 vs 35.4%) and PSA level (1123.4 vs 232.4 ng/mL) but not age, prostate volume, UTI or duration of catheterization.

CONCLUSIONS

• ? Histological prostatitis was almost twice as common in patients with urinary retention associated with underlying BPH than in patients with ACP, but there was no significant difference in the duration of catheterization, prostatic volume or presence of UTI, suggesting that histological prostatitis more often contributes to the development of retention in patients with underlying BPH than in those with ACP.
• ? In patients with BPH, histological prostatitis was associated with urinary retention at a significantly younger age and with higher serum PSA levels.
• ? In patients with ACP, histological prostatitis was associated with urinary retention at an earlier stage of cancer.

     

Patients aged more than 70 had higher risk of locally advanced prostate cancers and biochemical recurrence in Korea

Study Type – Prognosis (cohort series) Level of Evidence 2b What's known on the subject? and What does the study add? This study reports that patients aged 70 years or older have a higher possibility of locally advanced cancer than younger patients. Instead of conservative management, radical eradication of clinically localized prostate cancer should be actively considered in well‐selected healthy patients older than 70 years.

OBJECTIVE

• ? To analyse the differences in the clinicopathological results between two groups of Korean patients aged younger or older than 70 years with clinically localized prostate cancer.

METHODS

• ? A cohort of consecutive male patients who underwent radical prostatectomy was retrospectively analysed. In total, 995 patients (74.6%) were younger than 70 years, and 338 patients (25.4%) were 70 years or older.
• ? Biochemical recurrence (BCR) ‐free survival was evaluated in the patients, who were followed up for more than 24 months.
• ? The Kaplan–Meier method was used to calculate survival estimates for BCR‐free survival. Multivariate Cox proportional hazard regression analysis was performed to predict non‐organ‐confined status and BCR.

RESULTS

• ? Mean preoperative prostate‐specific antigen (PSA) levels and biopsy or pathological Gleason scores showed no differences between the two age groups.
• ? Older patients, aged more than 70 years, displayed significantly higher risk of locally advanced prostate cancer and BCR than younger patients.
• ? Subgroup analysis showed that the risk of the presence of locally advanced disease was significantly increased in patients of 70 years or older when we compared the proportion of locally advanced disease only in patients with PSA <4 ng/mL.
• ? Multivariate analysis showed that old age, high PSA and high Gleason score were significantly associated with non‐organ confined status and BCR.

CONCLUSIONS

• ? Patients aged 70 years or older had a higher possibility of locally advanced cancer than younger patients.
• ? Radical eradication of clinically localized prostate cancer should be actively considered in well‐selected healthy patients older than 70 years.

     

Utility of the RENAL nephrometry scoring system in the real world: predicting surgeon operative preference and complication risk

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? RENAL nephrometry is a quantitative, reproducible scoring system that characterizes RENAL masses and standardizes reporting. Previous work has suggested that the system may be useful in predicting outcomes after partial nephrectomy. This study is the first to correlate RENAL nephrometry score with operative approach or risk of complication in patients undergoing either partial or radical nephrectomy.

OBJECTIVE

• ? To evaluate the utility of the RENAL scoring system in predicting operative approach and risk of complications. The RENAL nephrometry scoring system is designed to allow comparison of renal masses based on the radiological features of (R)adius, (E)xophytic/endophytic, (N)earness to collecting system, (A)nterior/posterior and (L)ocation relative to polar lines.

METHODS

• ? A retrospective review of all patients at a single institution undergoing radical nephrectomy (RN) or partial nephrectomy (PN) for a renal mass between July 2007 and May 2010 was carried out.
• ? Preoperative RENAL score was calculated for each patient. Surgical approach and operative outcomes were then compared with the RENAL score.

RESULTS

• ? In all, 249 patients underwent either RN (158) or PN (91) with average RENAL scores of 8.9 and 6.3, respectively (P < 0.001).
• ? Patients who underwent RN were more likely to have hilar tumours (64% vs 10%, P < 0.001) than patients who underwent PN, but were no more likely to have posteriorly located tumours (50% each).
• ? There were more complications among patients with RN (58%) vs patients with PN (42%, P= 0.02).
• ? RENAL scores were higher in patients with PN who developed complications than in patients with PN who did not develop complications (6.9 vs 6.0, P= 0.02), with no difference noted among patients with RN developing complications (8.9 vs 8.9, P= 0.99).

CONCLUSION

• ? The RENAL system accurately predicted surgeon operative preference and risk of complications for patients undergoing PN.

     

A prospective, randomized trial comparing the Vienna nomogram to an eight-core prostate biopsy protocol

Study Type – Diagnostic (RCT) Level of Evidence 1b What’s known on the subject? and What does the study add? Several studies have shown that increasing the number of prostate biopsy cores will increase the detection rate of prostate cancer, but also risks overdiagnosing insignificant cancer, particularly in the elderly. Our study suggests that there is no significant advantage in using the Vienna nomogram to determine the number of prostate biopsies to be taken, compared to an eight‐core biopsy protocol.

OBJECTIVE

• ? To compare prostate cancer detection rates using the Vienna nomogram versus an 8‐core prostate biopsy protocol. To compare the complication rates of transrectal prostate biopsy in the two groups.

PATIENTS AND METHODS

• ? In a prospective randomized trial, men with a serum PSA ≥ 2.5 ng/ml were stratified according to serum PSA (I = PSA 2.5–10; II = PSA 10.1–30; III = PSA 30.1–50 ng/mL) and were then randomized to group A (number of cores determined according to the Vienna nomogram) or group B (8‐core prostate biopsy).
• ? Statistical analysis was performed using Student’s t‐test for parametric data, Mann‐Whitney test for nonparametric data and Fisher’s exact test for contingency tables. A two‐tailed p‐value <0.05 was accepted as statistically significant.

RESULTS

• ? In the period July 2006 to July 2009, 303 patients were randomized to group A (n = 152) or group B (n = 151). There were no significant differences in serum PSA, prostate volume, PSA density or post‐biopsy complications between the groups.
• ? The cancer detection rate was lower in group A than in group B for the whole study cohort (35.5% vs 38.4%), for those with PSA < 10 ng/ml (28.1% vs 33%) and for those with prostate volume >50 ml (22% vs 25.8%). These differences were not statistically significant (NSS).

CONCLUSION

• ? These findings suggest that there is no significant advantage in using the Vienna nomogram to determine the number of prostate biopsy cores to be taken, compared to an 8‐core biopsy protocol.

     

Self-retaining barbed suture for parenchymal repair during laparoscopic partial nephrectomy; initial clinical experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This paper reports on outcomes for SRBS during conventional laparoscopic partial nephrectomy. In addition to an improvement in warm ischaemia time, we found that SRBS use during LPN may be beneficial in reducing rates of clinically significant haemorrhage.

OBJECTIVES

• ? To evaluate the efficacy of a self‐retaining barbed suture (SRBS) in achieving a secure and haemostatic renorrhaphy during laparoscopic partial nephrectomy (LPN).
• ? To compare perioperative outcomes for LPN with SRBS with those for LPN with conventional polyglactin suture, with specific attention to warm ischaemia time, blood loss and need for postoperative bleeding interventions.

PATIENTS AND METHODS

• ? Patients who underwent LPN between June 2007 and October 2010 were identified through an Institutional Review Board approved registry of oncological patients.
• ? Before July 2009, parenchymal repair after tumour excision was performed using absorbable polyglactin suture (Group 1), and subsequently, using SRBS (Group 2).
• ? Demographic, clinical, intraoperative and postoperative outcomes were compared for each group.

RESULTS

• ? LPN was performed in 49 patients in Group 1 and 29 in Group 2.
• ? Baseline demographic and clinical features, estimated blood loss, and transfusion and embolization rates were statistically similar for the cohorts.
• ? Mean warm ischaemia time (±SD) was significantly shorter for the SRBS group (26.4 ± 8.3 vs 32.8 ± 7.9; P= 0.0013).
• ? Bleeding requiring intervention (open conversion or transfusion ± embolization) was more common for Group 1 (9/49, 18.4% vs 1/29, 3.4%; P= 0.06).

CONCLUSIONS

• ? The use of SRBS for parenchymal repair during LPN in humans is safe and is associated with a significant reduction in warm ischaemia time.
• ? SRBS use during LPN may also reduce rates of clinically significant bleeding.
• ? Prospective, larger studies to confirm the value of SRBS use in minimally invasive partial nephrectomy are warranted.

     

Is joint hypermobility associated with vesico‐ureteral reflux? An assessment of 50 patients

Study Type – Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Recent studies have already shown associations between generalized joint hypermobility (GJH) and voiding and defecation dysfunction and/or slow transit constipation. Changes in extracellular matrix composition in vesico‐ureteric junction of vesico‐ureteral reflux (VUR) patients were also observed previously. This study is the first to assess joint mobility as a parameter for connective tissue composition in vesico‐ureteral reflux. We convincingly demonstrate that VUR patients have significantly more hypermobile joints compared to controls and this provides a new angle to the intriguing subjects of development of VUR and susceptibility to VUR.

OBJECTIVE

• ? To assess whether there is an increased prevalence of joint hypermobility in patients with vesico‐ureteric reflux (VUR).

MATERIALS AND METHODS

• ? We studied 50 patients with primary VUR and matched controls drawn from a reference population.
• ? Joint mobility was assessed using the Bulbena hypermobility score.

RESULTS

• ? We identified significantly more patients with VUR with generalized joint hypermobility than controls (24% vs 6.7%, P= 0.007).

CONCLUSION

• ? Our findings confirm our clinical observation of an increased rate of joint hypermobility in patients with VUR. We speculate that an altered composition of the connective tissue may contribute to the severity of the (pre‐existing) VUR phenotype.

     

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.

     

Importance of cosmesis to patients undergoing renal surgery: a comparison of laparoendoscopic single-site (LESS), laparoscopic and open surgery

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Studies in other surgical populations have found that scarring is a relatively unimportant preoperative patient consideration when compared with surgical cure and safety, but that younger age was a significant factor influencing preference for ‘scarless’ surgery. The present study corroborates the findings of previous series, among patients who were contemplating kidney surgery.

OBJECTIVE

• ? To evaluate patient attitudes towards cosmesis relative to other considerations, before and after undergoing laparoendoscopic single‐site surgery (LESS) vs laparoscopic/robot‐assisted vs open kidney surgery.

METHODS

• ? Participants were provided with a survey querying demographic information, surgical history and importance of scarring relative to other surgical outcomes and considerations.
• ? The relative importance of each outcome was recorded on a nine‐level ranking scale, ranging from 1 (most important) to 9 (least important).
• ? The median scores for each outcome were compared before and after surgery using the Wilcoxon signed‐rank test, and by surgical approach using the Kruskal–Wallis test.
• ? The importance of scarring was further analysed according to age (≤50 vs >50 years), surgical indication (oncological vs non‐oncological), gender, and proportion of patients who had undergone previous abdominal surgery.

RESULTS

• ? A total of 90 patients completed surveys before surgery, of whom 65 (72.2%) also completed surveys after surgery.
• ? ‘Surgeon reputation’ and ‘no complications’ were the most important considerations before surgery (median scores 2 and 3, respectively) and after surgery (median scores of 2 for both).
• ? ‘Size/number of scars’ was the least important consideration before surgery (median score 8) and the second least important consideration after surgery (median score 7).
• ? The median score for ‘size/number of scars’ was significantly higher for the LESS cohort before surgery (laparoscopic/robot‐assisted vs LESS vs open surgery: 8.5 vs 6 vs 9; P = 0.003), but was nonsignificant after surgery (laparoscopic/robotic vs LESS vs open surgery: 7 vs 6.5 vs 7.5; P = 0.83).
• ? The median score for ‘size/number of scars’ before surgery was significantly higher for younger patients (P = 0.05) and those with non‐oncological surgical indications (P < 0.001), but there was no significant difference in this outcome for these sub‐groups after surgery.

CONCLUSIONS

• ? For most patients contemplating urological surgery, cosmesis is of less concern than surgeon reputation and avoidance of surgical complications.
• ? Cosmesis may be a more important preoperative consideration for younger patients and those with benign conditions, which warrants further investigation.

     

Nicorandil‐induced penile ulcerations: a case series

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Partial nephrectomy is the standard treatment for the management of small renal masses, and laparoscopy has been widely used in this setting as it has all the principles of open procedures combined with the advantages of minimal invasiveness. Laparoscopic partial nephrectomy is feasible and has acceptable pathological results not only for small renal masses but also for large tumours, even if complication rate and ischemia time are still matters of debate.

OBJECTIVE

• ? To investigate the perioperative safety of laparoscopic partial nephrectomy (LPN) for large renal masses (>4 cm).

PATIENTS AND METHODS

• ? After Institutional Review Board approval, data from 100 consecutive patients who had undergone transperitoneal or retroperitoneal LPN at our institution from January 2005 to June 2009 were obtained from our prospectively maintained database.
• ? The patients were divided into two groups according to radiological tumour size: group A (67 patients) with tumours ≤4 cm and group B (33 patients) with tumours >4 cm.
• ? Demographic, perioperative and pathological data were evaluated.

RESULTS

• ? The two groups were comparable in terms of demographic data. Mean tumour size was 2.4 and 5 cm (P= 0.0001) for groups A and B, respectively. Group B tumours were more complex, as reflected by significantly more with a central location (P= 0.002), and by significantly more transperitoneal LPNs, pelvicalyceal repairs and longer warm ischaemia time (WIT; 19 vs 28 min).
• ? Complications were recorded in nine group A patients (13.4%) and nine group B patients (27.2%) (P= 0.09).
• ? There was no difference between preoperative and postoperative serum creatinine levels in either group, while a significant difference was found in postoperative estimated glomerular filtration rate between groups (P= 0.004).
• ? The incidence of carcinoma was comparable between the two groups.
• ? The incidence of positive surgical margins (PSMs) was 3.9% in group A, whereas no PSM was recorded in group B (P= 0.3).

CONCLUSIONS

• ? Laparoscopic partial nephrectomy for large tumours is feasible and has acceptable pathological results. However, the complication rate, in particular WIT, remains questionable.
• ? Further studies are required to better clarify the role of LPN in the management of tumours of this size.

     

Survival after partial and radical nephrectomy for the treatment of stage T1bN0M0 renal cell carcinoma (RCC) in the USA: a propensity scoring approach

Study Type – Therapy (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Partial nephrectomy has become the standard of care for T1a renal tumours, and the application of nephron‐sparing techniques has increasingly been expanded to patients with localized T1b cancers. However, the relative efficacy of partial versus radical nephrectomy for these medium‐sized tumours has yet to be definitively established. This study employs a propensity scoring approach within a large US population‐based cohort to determine that no survival differences exist among patients with T1b renal tumours undergoing partial versus radical nephrectomy.

OBJECTIVES

• ? To compare survival after partial nephrectomy (PN) vs radical nephrectomy (RN) among patients with stage TIb renal cell carcinoma (RCC) using a propensity scoring approach.
• ? Propensity score analysis is a statistical methodology that controls for non‐random assignment of patients in observational studies.

PATIENTS AND METHODS

• ? Using the Surveillance, Epidemiology, and End Results registry, 11 256 cases of RCCs of 4–7 cm that underwent PN or RN between 1998 and 2007 were identified.
• ? Propensity score analysis was used to adjust for potential differences in baseline characteristics between patients in the two treatment groups.
• ? Overall survival (OS) and cancer‐specific survival (CSS) of patients undergoing PN vs RN was compared in stratified and adjusted analysis, controlling for propensity scores.

RESULTS

• ? In all, 1047 (9.3%) patients underwent PN. For the entire cohort, no difference in survival was found in patients treated with PN as compared with RN, as shown by the adjusted hazard ratio (HR) for OS (1.10; 95% confidence interval [CI]: 0.91–1.36) and renal‐CSS (HR 0.91; 95% CI: 0.65–1.27).
• ? When the cohort was stratified by tumour size and age, no difference in survival was identified between the groups.

CONCLUSIONS

• ? Even when stratified by tumour size and age, a survival difference between PN and RN in a propensity‐adjusted cohort of patients with T1b RCC could not be confirmed.
• ? If validated in prospective studies, PN may become the preferred treatment for T1b renal tumours in centres experienced with nephron‐sparing surgery.

     

Impact of age on clinicopathological outcomes and recurrence-free survival after the surgical management of nonseminomatous germ cell tumour

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The effect of advancing age on the clinicopathological outcomes of men with germ cell testicular cancers remains uncertain. Through the review and comparison of the present large cohort of men with testis cancer, we report on our experience in men aged ≥50 years. Our results showed similar clinical and pathological characteristics, and survival outcomes that compare favourably with those of men aged <50 years.

OBJECTIVE

• ? To determine the impact of age on clinicopathological findings and disease recurrence in men with nonseminomatous germ cell tumour (NSGCT) undergoing retroperitoneal lymph node dissection (RPLND).

PATIENTS AND METHODS

• ? We identified 1246 patients with NSGCT who underwent either primary or post‐chemotherapy‐RPLND (PC‐RPLND) between 1989 and 2006 from our prospective testis cancer database.
• ? Perioperative characteristics were compared among men aged < or ≥50 years.
• ? Multivariable models were used to evaluate the association of age with disease‐free survival, controlling for established clinical and pathological features.

RESULTS

• ? Of 514 men undergoing primary and 732 men undergoing PC‐RPLND, 12 (2.3%) and 23 (3.1%) were aged ≥50 years, respectively.
• ? There were no significant differences between men aged < or ≥50 years for perioperative clinicopathological characteristics, with the exception of pre‐RPLND CT nodal size.
• ? The pathological distributions at primary RPLND were similar in men aged < or ≥50 years. After PC‐RPLND, there were no differences in RPLND histology, number of lymph nodes resected, estimated blood loss, hospital stay, or perioperative complication rate.
• ? Age at surgery was not a significant predictor of disease recurrence when subjected to a multivariable analysis.

CONCLUSIONS

• ? Our data suggests that age at RPLND does not predict for disease recurrence and men aged ≥50 years had similar pre‐ and postoperative characteristics to those aged <50 years.
• ? We conclude that RPLND can be safely performed in men aged ≥50 years and these patients should be offered optimal treatment regimens for NSGCT as directed according to established guidelines.

     

Active surveillance of small renal masses offers short‐term oncological efficacy equivalent to radical and partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Active surveillance of small renal masses has traditionally been reserved for elderly patients deemed unfit for surgery or ablation. There is increasing evidence showing the safety of active surveillance in the management of small renal masses. In this retrospective study we compared outcomes for patients with small renal masses managed with active surveillance, radical nephrectomy and partial nephrectomy. We showed that active surveillance was safe and appeared as effective as immediate surgery in the management of small renal tumours.

OBJECTIVE

• ? To compare the oncological outcomes of active surveillance (AS), radical nephrectomy (RN) and partial nephrectomy (PN) in the management of T1a small renal masses (SRMs).

PATIENTS AND METHODS

• ? At present AS is used in the treatment of SRMs in elderly patients with multiple co‐morbidities or in those who decline surgery.
• ? We identified all patients with T1a SRMs managed with RN, PN or AS.
• ? Retrospective data were collected from patient case records with survival data and cause of death cross‐referenced with the Oxford Cancer Intelligence Unit.

RESULTS

• ? A total of 202 patients with 234 T1a SRMs (solid or Bosniak IV) were identified; 71 patients were managed with AS, 41 with an RN and 90 by PN.
• ? Over a median follow‐up of 34 months the mean growth rate on AS was 0.21 cm/year with 53% of SRMs managed with AS showing negative or zero growth.
• ? No statistically significant difference was observed in overall (OS) and cancer‐specific (CSS) survival for AS, RN and PN (AS‐CSS 98.6%, AS‐OS 83%; RN‐CSS 92.6%, RN‐OS 80.4%; PN‐CSS 96.6%, PN‐OS 90.0%).

CONCLUSIONS

• ? Active surveillance of SRMs offers oncological efficacy equivalent to surgery in the short/intermediate term.
• ? The results of this study support a multicentre prospective randomized controlled trial designed to compare the oncological efficacy of AS and surgery.

     

Comparison of the rate, location and size of positive surgical margins after laparoscopic and robot-assisted laparoscopic radical prostatectomy

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

OBJECTIVE

• ? To review and compare the rate, location and size of positive surgical margins (PSMs) after pure laparoscopic radical prostatectomy (LRP) and robot‐assisted laparoscopic radical prostatectomy (RALP).

PATIENTS AND METHODS

• ? The study comprised 200 patients who underwent RALP and 200 patients who underwent LRP up to January 2008.
• ? We compared patient age, body mass index, preoperative prostate‐specific antigen (PSA), preoperative stage and grade, prostate size, pathological stage and grade and neurovascular bundle preservation, as well as PSM rate, size and location.
• ? Continuous and categorical data were compared using Student’s t‐test and Pearson’s chi‐squared test.
• ? Multivariate regression analyses were used to identify preoperative and intraoperative predictors of PSMs.

RESULTS

• ? Although the PSM rate was similar between the two groups (LRP: 12% vs RALP: 13.5%; P= 0.76), location and size were not. PSMs after LRP were mostly at the apex (58.3%; P= 0.038), while most PSMs after RALP were posterolateral ([PL] 48%; P= 0.046).
• ? In addition, the median margin size after RALP was significantly smaller than after LRP (RALP: 2 mm vs LRP: 3.5 mm; P= 0.041).
• ? In univariate and multivariate analyses, tumour‐node‐metastasis (TNM) stage and preoperative PSA were the only independent preoperative predictors of PSMs (P= 0.044 and P= 0.01, respectively).

CONCLUSION

• ? The PSM risk is dependent on TNM stage and preoperative PSA and not the surgical technique, when comparing LRP with RALP.

     

EXTENDING THE INDICATIONS AND ANATOMICAL LIMITS OF PELVIC LYMPH NODE DISSECTION FOR PROSTATE CANCER: IMPROVED STAGING OR INCREASED MORBIDITY?

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

OBJECTIVE

• ? To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and anatomical limits of pelvic lymph node dissection (PLND).

PATIENTS AND METHODS

• ? In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003–2007.
• ? Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥2% had a PLND limited to the external iliac nodal group (limited PLND group).
• ? After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group).
• ? The risk parameters were PLND‐related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases.

RESULTS

• ? In the subgroup of patients with a LNI ≥2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003).
• ? The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND.
• ? The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001).

CONCLUSIONS

• ? In patients with LNI ≥2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non‐prohibitive complications rate.
• ? The present study found no evidence that the incidence of complications would be reduced by a limited PLND.