Comparison of Laparoscopic,Hand-Assisted,and Open Surgical Nephroureterectomy

Background and Objectives:

The aim of this study was to compare oncologic outcomes after laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy for upper urinary tract urothelial cancer.

Methods:

Between April 1995 and August 2010, 189 patients underwent laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, or open nephroureterectomy for upper urinary tract urothelial cancer. Of these patients, 110 with no previous or concurrent bladder cancer or any metastatic disease were included in this study. Cancer-specific survival, recurrence-free survival, and intravesical recurrence-free survival rates were analyzed by the Kaplan-Meier method and compared with the log-rank test. The median follow-up period for the cohort was 70 months (range, 6–192 months).

Results:

The 3 groups were well matched for tumor stage, grade, and the presence of lymphovascular invasion and concomitant carcinoma in situ. The estimated 5-year cancer-specific survival rates were 81.1%, 65.6%, and 65.2% for laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy, respectively (P = .4179). The estimated 5-year recurrence-free survival rates were 33.8%, 10.0%, and 41.2% for laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy, respectively (P = .0245). The estimated 5-year intravesical recurrence-free survival rates were 64.8%, 10.0%, and 76.2% for laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy, respectively (P < .0001).

Conclusion:

Although there was no significant difference in cancer-specific survival rate among the laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy groups, hand-assisted laparoscopic nephroureterectomy may be inferior to laparoscopic nephroureterectomy or open nephroureterectomy with regard to recurrence-free survival and intravesical recurrence-free survival rates.     

Studies on incidental carcinoma of the prostate]

We reviewed 157 patients retrospectively with incidental carcinoma of the prostate who had been treated at our collaborating hospitals during the past ten years. Of 5212 patients with benign prostatic hyperplasia who received subcapsular prostatectomy or transurethral resection of the prostate (TUR-P), 157 (3.0%) were diagnosed as having an incidental carcinoma of the prostate, which was somewhat lower than that in previously published reports. Of these, 30 and 127 patients were in stage A1 and A2, respectively. Well, moderately and poorly differentiated carcinomas were found in 44.6%, 36.7% and 18.5% of the patients, respectively. The incidence of poorly differentiated carcinoma in the study seemed to be higher than that in the previous reports. A positive correlation was identified in TUR-P specimens between the carcinoma differentiation and its extension which was evaluated by cancer-positive chip ratio. Atypical adenomatous hyperplasia and intraductal dysplasia were identified in 36.9% and 85.3% of the patients with incidental carcinoma, respectively. These incidences tended to become lower as the carcinoma became less differentiated or more extended. Further studies will be necessary to define the significance of these pathological findings as a direct biological precursor of prostatic carcinoma. Six out of the 157 patients with incidental carcinoma showed a progression during the follow-up period. All of these patients were in stage A2 and all but one showed a histology of moderately or poorly differentiated carcinoma at the time of diagnosis. Radical prostatectomy or radiation therapy as well as endocrine therapy should be considered as treatment modalities for stage A2 patients, when staging lymphadenectomy shows no pelvic lymph node metastasis.     

Torsade de pointes (TdP) observed during general anesthesia for cerebral aneurysm clipping in a patient with QT prolongation

A 55-year-old woman underwent emergency cerebral aneurysm clipping for subarachnoid hemorrhage (SAH). Her past and family history was unremarkable. Preoperative blood examinations were within normal ranges except for a slight decrease in serum potassium level. ECG showed a prolonged QTc interval (0.54 sec). General anesthesia was induced with propofol, fentanyl and vecuronium, and maintained with 1-1.5% sevoflurane, 50% nitrous oxide in oxygen and intermitted doses of fentanyl. About three hours after starting the operation, bigeminal pulse appeared followed by torsade de pointes. This arrhythmia returned to sinus rhythm by continuous infusion of lidocaine, and operation was performed completely. At the end of the operation, prolonged QT interval (QTc 0.71 sec) was noted. Her postoperative course was unremarkable and she was discharged on postoperative day 44. QT prolongation is a frequently seen ECG abnormality in a patient with SAH. In anesthetic management in this situation, it is important to monitor QT interval closely as well as to use anesthetics that would not exacerbate QT interval prolongation.