Systematic Review of Adrenalectomy and Lymph Node Dissection in Locally Advanced Renal Cell Carcinoma

Context

Controversy remains over whether adrenalectomy and lymph node dissection (LND) should be performed concomitantly with radical nephrectomy (RN) for locally advanced renal cell carcinoma (RCC) cT3–T4N0M0.

Objective

To systematically review all relevant literature comparing oncologic, perioperative, and quality-of-life (QoL) outcomes for locally advanced RCC managed with RN with or without concomitant adrenalectomy or LND.

Evidence acquisition

Relevant databases were searched up to August 2012. Randomised controlled trials (RCTs) and comparative studies were included. Outcome measures were overall survival, QoL, and perioperative adverse effects. Risks of bias (RoB) were assessed using Cochrane RoB tools. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

Evidence synthesis

A total of 3658 abstracts and 252 full-text articles were screened. Eight studies met the inclusion criteria: six LNDs (one RCT and five nonrandomised studies [NRSs]) and two adrenalectomies (two NRSs). RoB was high across the evidence base, and the quality of evidence from outcomes ranged from moderate to very low. Meta-analyses were not undertaken because of diverse study designs and data heterogeneity. There was no significant difference in survival between the groups, even though 5-yr overall survival appears better for the RN plus LND group compared with the no-LND group in one randomised study. There was no evidence of a difference in adverse events between the RN plus LND and no-LND groups. No studies reported QoL outcomes. There was no evidence of an oncologic difference between the RN with adrenalectomy and RN without adrenalectomy groups. No studies reported adverse events or QoL outcomes.

Conclusions

There is insufficient evidence to draw any conclusions on oncologic outcomes for patients having concomitant LND or ipsilateral adrenalectomy compared with patients having RN alone for cT3–T4N0M0 RCC. The quality of evidence is generally low and the results potentially biased. Further research in adequately powered trials is needed to answer these questions.     

The correlation between the electrode configuration and histopathology of irreversible electroporation ablations in prostate cancer patients

Purpose

Irreversible electroporation (IRE) is a novel minimally invasive therapy for prostate cancer using short electric pulses to ablate prostate tissue. The purpose of this study is to determine the IRE effects in prostate tissue and correlate electrode configuration with the histology of radical prostatectomy (RP) specimens. We hypothesize that the area within the electrode configuration is completely ablated and that the area within the electrode configuration is predictive for the ablated area after treatment.

Methods

A prospective phase I/II study was conducted in 16 consecutive patients with histopathologically confirmed prostate cancer scheduled for RP. Focal or extended IRE treatment of the prostate was performed 4 weeks prior to RP. The locations of the electrodes were used to calculate the planned ablation zone. Following RP, the specimens were processed into whole-mount sections, histopathology (PA) was assessed and ablation zones were delineated. The area of the tissue alteration was determined by measuring the surface. The planned and the histological ablation zones were compared, analysed per individual patient and per protocol (focal vs. extended).

Results

All cells within the electrode configuration were completely ablated and consisted only of necrotic and fibrotic tissue without leaving any viable cells. The histological ablation zone was always larger than the electrodes configuration (2.9 times larger for the 3 electrodes configuration and 2.5 times larger for the ≥4 electrode configuration). These ablation effects extended beyond the prostatic capsule in the neurovascular bundle in 13 out of 15 cases.

Conclusions

IRE in prostate cancer results in completely ablated, sharply demarcated lesions with a histological ablation zone beyond the electrode configuration. No skip lesions were observed within the electrode configuration.

Clinical trials

ClinicalTrials.gov Identifier: NCT01790451 https://clinicaltrials.gov/ct2/show/NCT01790451

     

Shockwave therapy as first-line treatment for Peyronie's disease: a prospective study

BACKGROUND AND PURPOSE: To assess in a prospective study whether shockwave therapy (SWT) is effective as a first-line treatment for Peyronie's disease. PATIENTS AND METHODS: Forty patients with previously untreated Peyronie's disease underwent SWT with the Epos overhead-module device (Dornier). The pain severity (visual analog pain scale [VAS] 0-5), the degree of penile angulation after vasoactive drug injection, plaque size by ultrasound measurement, and erectile dysfunction (IIEF score) were assessed prior to and after treatment. Of the 40 patients, 7 underwent two sessions and the rest three sessions. The time interval between treatments was 2 weeks. At a power level of 2 to 5 (mean 4), a maximum of 3000 shockwaves per plaque per treatment were applied. The mean follow-up was 12 months. RESULTS: All patients completed the protocol. The tolerance and safety were excellent. Of the 25 patients with pain on erection, 12 (48%) noticed relief after the first session, while 9 more were pain free at the end of the treatment (VAS reduction 2.8; P<0.0001, and 2; P<0.001, respectively). For 25 patients (62.5%), an improvement in penile angulation>20 degrees was observed, with a mean reduction of 35 degrees (range 20 degrees-60 degrees ) (P<0.001). No significant change in plaque size was noted. Among 28 patients with erectile dysfunction, 18 (64.2%) had a marked increase in erection quality (IIEF score change: +4 for 10 patients, +6 for 4 patients, +8 for 2 patients, +9 for 2 patients). CONCLUSION: Our results support SWT as an effective and safe first-line treatment for Peyronie's disease.     

DOES THE MANAGEMENT OF BLADDER PERFORATION DURING TRANSURETHRAL RESECTION OF SUPERFICIAL BLADDER TUMORS PREDISPOSE TO EXTRAVESICAL TUMOR RECURRENCE?

PURPOSE: We evaluated the impact of a bladder perforation during transurethral resection of superficial bladder tumor on extravesical tumor recurrence and patient prognosis. We also defined potential risk factors for extravesical recurrence prospectively giving emphasis to the management of the perforation. MATERIALS AND METHODS: The medical records of 3,410 patients were reviewed. Parameters recorded included patient age and sex, tumor stage, grade, number, size and location at the time of perforation, the type of bladder perforation (extraperitoneal vs intraperitoneal) and the way the perforation was managed (open surgical repair vs conservative treatment). Logistic regression analysis was used to identify risk factors for extravesical recurrence. Cox regression analysis was used to compare cancer specific survival. RESULTS: A total of 34 cases of bladder perforation were recorded, 4 patients were treated with open surgery and 30 treated conservatively. The 4 patients who underwent open surgery presented with extravesical recurrence after a mean followup of 7.5 months. The remaining 30 patients had no evidence of extravesical recurrence after a mean followup of 60 months (p <0.001). Of the patients with extravesical relapse 3 died of disease. The surgical management of bladder perforation was the best predictor of extravesical recurrence (p <0.001, r = 1.13), followed by an intraperitoneal localization of the perforation (p =0.0003, r = 0.67) and tumor size (p =0.01, r = 0.42). CONCLUSIONS: Surgical repair of a bladder perforation during transurethral resection of bladder tumor increases the risk of extravesical tumor cell recurrence and negatively affects patient prognosis.     

Encrusted cystitis and pyelitis

Encrusted cystitis (EC) and encrusted pyelitis (EP) are rare chronic inflammatory diseases of the bladder and renal pelvis, respectively, and are characterized by mucosal inflammation with deposits of ammonium magnesium phosphate on the urothelium. Corynebacterium urealyticum is the pathogen responsible in the vast majority of cases. We report 4 cases of EC and 1 case of EP. In 1 case of EC Ureaplasma urealyticum was isolated as the microorganism responsible. To the best of our knowledge, U. urealyticum-induced EC has never been reported previously.