Search

Objective: To describe the crucial factors related to the implementation of the da Vinci single‐port (SP) system (Intuitive Surgical Inc., Sunnyvale, CA, USA), and the early outcomes after the introduction of this robot for robot‐assisted radical prostatectomy (RARP). Patients and methods: We prospectively collected data from 50 consecutive patients with prostate adenocarcinoma who underwent RARP using this robot. The median follow‐up was 53 days. We performed a transperitoneal technique. The robotic (multiport) trocar was placed on the supra‐umbilical midline 20 cm from the pubis and an assistant trocar placed in the right lower quadrant. We report our initial experience describing the intra‐ and postoperative outcomes associated with this new robot. Also, we report the early functional and oncological outcomes in the follow‐up period considered. Continuous variables were described as medians and interquartile ranges, while categorical variables as frequencies and proportions. Results: The median total operative time was 118 min, median console time was 80 min, and median estimated blood loss was 50 mL. There were no intraoperative complications or blood transfusions. The final pathology reported 18% Grade Group (GrGp)1, 58% GrGp2, 18% GrGp3, 2% GrGp4, and 4% GrGp5. In all, 40 patients (80%) were pT2 and 20% were ≥pT3a. The overall positive surgical margin rate was 14%. In all, 39 patients (78%) achieved full continence at median of 21 days after RARP. The median pain scale (0–10) score at 8, 12 and 16 h after RARP was 2, 2, and 0, respectively. Conclusion: The use of the da Vinci SP robot with an additional assistant port for RARP is technically safe and feasible, with acceptable short‐term functional and oncological outcomes. However, there is a technical learning curve for this new platform due to the smaller scope of the operative field and the decreased flexibility and strength of the surgical instruments. [ABSTRACT FROM AUTHOR]

Objectives: To obtain the most accurate assessment of the risks and benefits of selective clamping in robot‐assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. Patients and Methods: Data from institutional review board‐approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra‐operative complications, and postoperative outcomes using chi‐squared tests, Fisher's exact tests, t‐tests and Mann–Whitney U‐tests. Results: Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra‐operative outcomes, including estimated blood loss, operating time, and intra‐operative complications were similar in the two groups. Short‐ and long‐term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. Conclusion: In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra‐operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping. [ABSTRACT FROM AUTHOR]

Objectives: To compare outcomes at a 5‐year median follow‐up among different partial nephrectomy (PN) approaches: robot‐assisted (RAPN), laparoscopic (LPN) and open partial nephrectomy (OPN). Patients and Methods: We retrospectively analysed 1 308 patients who underwent PN (RAPN, n = 380; LPN, n = 206; OPN, n = 722) between 2006 and 2012 at one of four academic centres. We performed 1:1:1 propensity‐score‐matching adjustment based on confounding variables among groups, and 366 patients (122 in each group) were included in the final analysis. Survival rates were analysed using the Kaplan–Meier method. Results: The median follow‐up periods were 60, 59.8 and 64.1 months for RAPN, LPN and OPN, respectively. In the matched groups, RAPN resulted in significantly lower mean estimated blood loss compared with LPN (P = 0.025) and OPN (P = 0.040), while LPN was associated with a longer mean operating time compared with RAPN (P = 0.001) and OPN (P = 0.001). The hospital stay was shorter in the RAPN group (P = 0.008). Regarding the oncological outcomes, there were no significant differences among the three groups in local recurrence rate (P = 0.882), distant metastasis rate (P = 0.816) or deaths from cancer (P = 0.779). At latest follow‐up, the incidence of chronic kidney disease (CKD) upstaging was significantly lower in RAPN compared with LPN (20.55% vs 32%; P = 0.035) and OPN (20.5% vs 33.6%; P = 0.038). The 5‐year CKD free‐survival rate was significantly higher (78.4%) in the RAPN group compared with 58.8% and 65.8% in the LPN and OPN groups, respectively (log‐rank P = 0.031). Conclusions: In the present study, RAPN, LPN and OPN had similar local recurrence, distant metastasis and cancer‐related death rates at a 5‐year median follow‐up. In terms of functional outcomes, RAPN was associated with a lower incidence of CKD upstaging compared with OPN and LPN. [ABSTRACT FROM AUTHOR]

Objectives: To compare peri-operative outcomes after robot-assisted partial nephrectomy (RAPN) for cT2a (7 to <10 cm) to cT1 tumours. Materials and Methods: Patients with a cT1a (n = 1 358, 76.4%), cT1b (n = 379, 21.3%) or cT2a (n = 41, 2.3%) renal mass were identified from a multi-institutional RAPN database. Intra- and postoperative outcomes were compared for cT2a masses vs cT1a and cT1b masses using multivariable regression models (linear, logistic, Poisson etc.), adjusting for operating surgeon and a modified R.E.N.A.L. nephrometry score that excluded the radius component. Results: The median sizes for cT1a, cT1b and cT2a tumours were 2.5, 5.0 and 8.0 cm, respectively (P < 0.001) with modified R.E.N.A.L. nephrometry scores being 6.0, 6.5 and 7.0, respectively (cT1a, P < 0.001; cT1b, P = 0.105). RAPN for cT2a vs cT1a masses was associated with a 12% increase in operating time (P < 0.001), a 32% increase in estimated blood loss (P < 0.001), a 7% increase in ischaemia time (P = 0.008), a 3.93 higher odds of acute kidney injury at discharge (95% confidence interval [CI] 1.33, 8.76; P = 0.009) and a higher risk of recurrence (hazard ratio [HR] 10.9, 95% CI 1.31, 92.2; P = 0.027). RAPN for cT2a vs cT1b masses was associated with a 12% increase in blood loss (P = 0.036), a 5% increase in operating time (P = 0.062) and a marginally higher risk of recurrence (HR 11.2, 95% CI 0.77, 11.5; P = 0.059). RAPN for cT2a tumours was not associated with differences in complications (cT1a, P = 0.535; cT1b, P = 0.382), positive margins (cT1a, P = 0.972; cT1b, P = 0.681), length of stay (cT1a, P = 0.507; cT1b, P = 0.513) or renal function decline up to 24 months post-RAPN (cT1a, P = 0.124; cT1b, P = 0.467). Conclusion: For T2a tumours RAPN is a feasible treatment option in a select patient population when performed by experienced surgeons in institutions equipped to manage postoperative complications. Although RAPN was associated with greater blood loss and longer operating and ischaemia time in T2a tumours, it was not associated with greater complication or positive surgical margin rates compared with T1 tumours. Renal function preservation rates were equivalent for up to 24 months postoperatively; however, 12-month recurrencefree survival was significantly lower in the T2a group. Extended follow-up is required to further evaluate long-term survival. [ABSTRACT FROM AUTHOR]

Objectives To compare optimum outcome achievement in open partial nephrectomy (OPN) with that in robot-assisted partial nephrectomy (RAPN). Patients and methods Using our institutional partial nephrectomy (PN) database, we reviewed 605 cases performed for unifocal clinical T1 renal masses in non-solitary kidneys between 2011 and 2015. Tetrafecta, which was defined as negative surgical margins, freedom from peri-operative complications, ≥80% renal function preservation, and no chronic kidney disease upstaging, was chosen as the composite optimum outcome. Factors associated with tetrafecta achievement were assessed using multivariable logistic regression, with adjustment for age, gender, race, Charlson comorbidity score, body mass index, chronic kidney disease, tumour size, tumour complexity and approach. Results The overall tetrafecta achievement rate was 38%. Negative margins, freedom from complications, and optimum functional preservation were achieved in 97.1%, 73.6% and 54.2% of cases, respectively. For T1a masses, the tetrafecta achievement rate was similar between approaches (P = 0.97), but for T1b masses, the robot-assisted approach achieved significantly higher tetrafecta rates (43.0% vs 21.3%; P < 0.01). On multivariable analysis, the robot-assisted approach had 2.6-fold higher odds of tetrafecta achievement than the open approach, primarily because of lower peri-operative morbidity, specifically related to wound complications. Positive surgical margin rates and renal function preservation were similar in the two approaches. Conclusions Optimum outcomes are readily achieved regardless of PN approach. The robot-assisted approach may facilitate optimum outcome achievement for 4-7-cm masses by minimizing wound complications. [ABSTRACT FROM AUTHOR]

Objectives To present the Victorian Transperineal Biopsy Collaboration ( VTBC) experience in patients with no prior prostate cancer diagnosis, assessing the cancer detection rate, pathological outcomes and anatomical distribution of cancer within the prostate. Patients and Methods VTBC was established through partnership between urologists performing transperineal biopsies of the prostate ( TPB) at three institutions in Melbourne. Consecutive patients who had TPB, as first biopsy or repeat biopsy after previous negative transrectal ultrasound-guided ( TRUS) biopsy, between September 2009 and September 2013 in the VTBC database were included. Data for each patient were collected prospectively (except for TPB before 2011 in one institution), based on the minimum dataset published by the Ginsburg Study Group. Univariate and multivariate analyses were used to identify factors predictive of cancer detection on TPB. Results In all, 160 patients were included in the study, of whom 57 had TPB as first biopsy and 103 had TPB as repeat biopsy after previous negative TRUS biopsies. The median patient age at TPB was 63 years, with the repeat-biopsy patients having a higher median serum PSA level (5.8 ng/ mL for first biopsy and 9.6 ng/ mL for repeat biopsy) and larger prostate volumes (40 mL for first biopsy, and 51 mL for repeat biopsy). Prostate cancer was detected in 53% of first-biopsy patients and 36% of repeat-biopsy patients, of which 87% and 81%, respectively, were clinically significant cancers, defined as a Gleason score of ≥7, or more than three positive cores of Gleason 6. Of the cancers detected in repeat biopsies, 75% involved the anterior region (based on the Ginsburg Study Group's recommended biopsy map), while 25% were confined exclusively within the anterior region; a lower proportion of only 5% of cancers detected in first biopsies were confined exclusively within the anterior region. Age, serum PSA level and prostate volume were predictive of cancer detection in repeat biopsies, while only age was predictive in first biopsies. Conclusions TPB is an alternative approach to TRUS biopsy of the prostate, offering a high rate of detection of clinically significant prostate cancer. It provides excellent sampling of the anterior region of the prostate, which is often under-sampled using the TRUS approach, and should be considered as an option for all men in whom a prostate biopsy is indicated. [ABSTRACT FROM AUTHOR]

Objective To characterise the clinical, radiological and histological features of mucinous tubular and spindle cell carcinoma ( MTSCC), as well as oncological outcomes. Patients and methods This is a single institution retrospective analysis of all patients with MTSCC from 2002 to 2011. Patients were excluded if MTSCC could not be confirmed on pathology re-review (four patients). Clinical characteristics, pathology, imaging, and outcomes were reviewed for the 19 included patients. Results The median (range) age at diagnosis was 59 (17-71) years with a female predominance (78.9%). On contrast-enhanced computed tomography, MTSCC enhanced less than the cortex during the corticomedullary phase. The mean (range) tumour attenuation was 36 (24-48), 67 (41-133), 89 (49-152), and 76 (52-106) Hounsfield units in the pre-contrast, corticomedullary, nephrographic and excretory phases, respectively. In all, 16 patients were treated with partial (five patients) or radical nephrectomy (11) for pT1 (62.5%), pT2 (31.3%), and pT3a disease (6.3%). One patient underwent active surveillance. Of three patients (13.0%) managed with energy ablation, there was one recurrence that was treated with salvage surgery. One patient (5.3%) had metastatic disease at diagnosis and died from disease 64.7 months later. A patient with a pT2bN0M0 MTSCC with sarcomatoid dedifferentiation developed bone metastases 9.5 months after diagnosis and was alive at 19.0 months. The remainder were free of recurrence or progression. Conclusion MTSCC is a rare renal cell carcinoma ( RCC) variant. In this largest series to date, MTSCC presented at a broad range of ages and displayed a female predilection. Imaging and pathological features of MTSCC display some overlap with papillary RCC. MTSCC is associated with excellent outcomes overall, but is not universally indolent. [ABSTRACT FROM AUTHOR]

Objectives To evaluate our clinical experience with percutaneous image-guided radiofrequency ablation ( RFA) of 200 renal tumours in a large tertiary referral university institution., Patients and Methods Image-guided RFA (ultrasonography or computed tomography [ CT]) of 200 renal tumours in 165 patients from June 2004 to 2012 was prospectively evaluated. Institutional Review Board approval was granted., The treatment response and technical success were defined by absence of contrast enhancement within the tumour on contrast enhanced CT or magnetic resonance imaging., Both major and minor complications, glomerular filtration rate ( GFR) before and after RFA, the management and outcomes of the complications, as well as oncological outcome were prospectively documented., Multivariate analysis was used to determine variables associated with major complications and also the percentage GFR change after RFA., The overall ( OS), 5-year cancer-specific ( CSS), local recurrence-free ( LRFS) and metastasis-free survival ( MFS) rates are presented using the Kaplan- Meier curves., Results In all, 200 tumours were RF ablated with a mean (range) tumour size of 2.9 (1-5.6) cm and the mean (range) patient age was 67.7 (21-88.6) years with a mean follow-up period of 46.1 months., The primary technical and overall technical success rate was 95.5% and 98.5%, respectively. Two independent predictors of successful RFA in a single sitting were tumour size (<3 cm) and exophytic location in multivariate logistic regression analysis., Major complications included ureteric injury (six patients), calyceal-cutaneous fistula (one), acute tubular necrosis (one) and abscess (two). Two independent predictors of ureteric injury were central location and lower pole position., Within this cohort of patients, only four patients developed significant renal function deterioration i.e. >25% decreased in GFR. In all, 161 (98%) patients of the 165 patients have preservation of renal function. Any change in renal function after RFA was not influenced by tumour factors or solitary kidney status., In our clinical series, this yielded a 5-year OS, CSS, LRFS and MFS rates of 75.8%, 97.9%, 93.5% and 87.7% respectively., Conclusions Image-guided RFA is a safe, nephron sparing and effective treatment for small renal cell carcinoma (RCC) tumours with a low rate of recurrence and has good 5-year CSS and MFS rates. [ABSTRACT FROM AUTHOR]

Objective • To evaluate imaging methods and prognoses between small renal cell carcinomas (RCCs) and larger tumours according to the era of diagnostics. Patients and Methods • In all, 784 consecutive patients diagnosed with RCC between 1964 and 1997 at the Pirkanmaa Hospital District in Finland were included. • Patients were divided into two groups: tumours of ≤3.0 and >3.0 cm in diameter. • Prognosis was analysed according to the era of diagnostics: (i) pre-computed tomography (CT) and pre-ultrasound (US), (ii) US era and (iii) CT era. Results • Small tumours became more common: in the pre-CT and pre-US era, only 4.4% of tumours were small; however, in the CT era 16% were small tumours. • More diagnostic methods were used in studying small tumours. • CT proved to be the most reliable method, although it was actually better at diagnosing large tumours. • Relapses occurred less frequently among patients with small tumours; more than half of the tumours that developed distant metastases (16.0%) already evinced them at the time of diagnosis. There were no relapses after 14 years of follow-up among small tumours, whereas large tumours relapsed within that time. RCC was the cause of death in 14.9% of patients with small tumours vs 50.7% with large tumours. • The best prognosis was among patients with small tumours diagnosed with CT. Conclusion • Among patients with small tumours, prognosis has improved along with better diagnostics, although some showed relapse during a surveillance period of up to 14 years. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? For patients who are unfit for extirpative surgery, percutaneous cryoablation ( PCA) presents a minimally-invasive alternative for the treatment of renal masses. PCA has been demonstrated to be safe, with complication rates <10% being reported consistently. Studies have suggested that a minimal and insignificant decline in renal function can occur after PCA. Finally, among studies with a follow-up >20 months, treatment success rates range from 75% to 96%. However, longer-term oncological and functional results for patients treated with PCA are relatively limited., The present study profiles one of the largest reported experiences with PCA for renal masses: 129 tumours in 124 patients. Our complication rate was comparable to that observed in other reported studies. At a mean follow-up of 30 months, treatment success was achieved in 87% of tumours, which is in line with published PCA success rates. On multivariable analysis, tumour size >3.0 cm was found to be significantly associated with treatment failure. A minimal but statistically significant renal functional decline was observed, with 20% of patients experiencing a progression in National Kidney Foundation- Chronic Kidney Disease stage. On multivariable analysis, age >70 years, hilar tumour location and postoperative day 1 estimated glomerular filtration rate <60 m L/min/1.73 m2 were found to be significantly associated with renal functional decline. The present study confirms that PCA of renal masses represents a safe alternative to surgery in patients with substantial medical comorbidities. In the present cohort, baseline patient and tumour characteristics probably impact the risk of tumour recurrence, as well as renal disease progression, after PCA., Objective To evaluate perioperative, oncological and functional outcomes after percutaneous cryoablation ( PCA) for renal masses based on our single-centre experience., Patients and Methods We retrospectively identified 124 patients who underwent PCA for 129 renal tumours between March 2005 and June 2011., Patient demographics and baseline clinical characteristics, tumour features, perioperative information, and postoperative outcomes were recorded., Oncological outcomes were defined by radiographic evidence of recurrence on follow-up computed tomography or magnetic resonance imaging., Renal disease progression was defined by a change in National Kidney Foundation- Chronic Kidney Disease stage., Results Patients had mean ( sd) age of 72.6 (10.2) years; mean ( sd) tumour size and nephrometry score were 2.7 (1.1) cm and 6.5 (1.7), respectively., Our overall complication rate was 9% (11/124), whereas the major (greater than Clavien II) complication rate was 2% (2/124)., Significant predictors of renal disease progression following PCA included age ≥ 70 years (odds ratio [ OR], 4.31, P = 0.03), hilar tumour location ( OR, 4.67, P = 0.04), and post operative day 1 estimated glomerular filteration rate ≤60 m L/min/1.73 m2 ( OR, 7.09, P = 0.02)., Our treatment success rate was 87% (112/129) at a mean ( sd) follow-up of 30.2 (18.8) months., Tumour size ≥3.0 cm was significantly associated with PCA failure (hazard ratio, 3.21, P = 0.03)., Conclusion PCA provides a safe and oncologically effective alternative to extirpative surgery for renal masses in patients with significant medical comorbidities. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Simple renal cysts are a common entity, which may need observation and follow-up or treatment. The study, for the first time, systematically reviews the indications for follow-up or radiological treatment of simple renal cysts. To review the conservative and radiological management of simple renal cysts a systematic literature review was performed. Simple renal cysts are commonly found in the adult population. Increasing age is highly associated with its incidence. When they remain asymptomatic they require neither treatment nor follow-up. When the shape of the cyst is slightly irregular follow-up is mandatory to exclude malignant progression. Symptomatic cysts require intervention. Ultrasound or computed tomography guidance have been effectively used for cyst puncture. However, simple fluid aspiration is ineffective leading to cyst recurrence. Aspiration should be accompanied with the injection of a sclerosing agent to destroy renal cyst epithelium. Several issues such as the ultimate technique and agent remain to be clarified. High rates of cyst disappearance and long-lasting cyst volume reduction have been reported with the use of various sclerosants. Ethanol in high concentrations and multiple injections is more commonly used with new agents showing similar efficacy and better complication profile. Studies comparing radiological intervention to surgical excision are lacking. Simple renal cysts may not require treatment when asymptomatic. Radiological intervention with the use of sclerosants needs further evaluation and comparison with other treatment methods. [ABSTRACT FROM AUTHOR]

Study Type - Symptom prevalence (prospective cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Evidence that transurethral resection of the prostate (TURP) leads to erectile dysfunction (ED) is conflicting. Several studies claimed significant risk of ED after TURP for benign prostatic hyperplasia with some reporting complete loss of erection. Several studies have been retrospective or have not considered levels of pre-operative ED. ED associated with lower urinary tract symptoms frequently precedes TURP. TURP did not adversely affect erectile function. Pre-operative ED can be improved by TURP and long-term erectile function is maintained following TURP. The improvement was corroborated by the partners in the short, medium and long-term and was statistically significant. OBJECTIVE [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 The increasing use of imaging techniques resulted in an enormous increase of incidentally diagnosed renal cell carcinomas (RCC). At the moment surgery is the only established curative approach for the treatment of RCC. The smaller size of these incidental RCC tumours demands far less invasive treatment techniques, preferably without piercing the tumour. This study presents the latest developments in the field of radiation therapy, which provides treatment alternatives for tumour sites currently not treated with radiation therapy. Real-time magnetic resonance imaging guided radiation therapy might become a valuable non-invasive alternative to treat renal cell carcinoma. To present a new concept for non-invasive renal tumour ablation using real-time magnetic resonance imaging (MRI)-guided radiation therapy. All currently available treatment techniques for localized renal cell carcinoma (RCC) have to be performed in a laparoscopic or percutaneous way. A technical prototype MRI-accelerator which performs real-time 1.5 T MRI imaging during the irradiation has been constructed. We performed a technical feasibility study on real-time MRI-guided arc therapy using repeated breath-holds for renal tumour ablation by (i) investigating renal mobility during breath-holding, (ii) performing dose calculation and (iii) measuring the radiation delivery time on a phantom. The renal mobility during free breathing and end-expiration breath-holding during 15 s was investigated for three patients with renal tumour appearance. Conventional MRI screening data of four patients was used for arc therapy dose calculation. Tumour and normal tissues were delineated and a tumour margin of 3 mm was applied. The radiation delivery time of a 25-Gy arc therapy plan was measured on a phantom. Renal mobility during free breathing varied from 10 to 25 mm, whereas breath-holding resulted in nearly non-moving kidneys (0 to 2 mm) for all patients. Arc therapy dose calculation resulted in an adequate tumour coverage. The radiation delivery time of the arc therapy plan was about 10 min. This means that 20 to 40 repeated breath-holds of 15 to 30 s will be needed for a single session treatment. A higher maximum dose rate would reduce the number of breath-holds needed and improve patient comfort. A phase I study will be started to proof the clinical feasibility. Real-time MRI-guided radiation therapy using an MRI-accelerator might become a valuable non-invasive alternative to the current RCC treatment options. [ABSTRACT FROM AUTHOR]

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 HAIFUTM, 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. [ABSTRACT FROM AUTHOR]

Study Type – Symptom prevalence (case series) Level of Evidence 4 OBJECTIVE To determine whether there has been a change in typical symptoms of renal cell carcinoma (RCC), by evaluating the symptoms of patients diagnosed during four decades, as although the increasing incidence of a diagnosis of incidental RCC has been widely reported, the change in other symptoms has not. PATIENTS AND METHODS The study included RCC cases diagnosed in the Pirkanmaa Hospital District between 1964 and 1997. The original medical records of 970 patients with 982 RCC tumours were analysed. Primary symptoms were recorded and changes were analysed in three groups, i.e. diagnoses made before 1980, in the 1980s and in the 1990s. Symptoms were also analysed according to stage, tumour class, gender and age. RESULTS The incidence of haematuria ( P < 0.01) and an increased erythrocyte sedimentation rate ( P < 0.001) decreased, but there was no change in other symptoms. Incidental diagnoses increased from 12% to 19% ( P < 0.01). Less chronic or systemic symptoms were noted more recently. Stage and tumour class were highly correlated with symptoms: systemic symptoms increased (24% in stage I to 72% in stage IV, a highly statistically significant increase) and asymptomatic tumours became rarer (27% in stage I to 8% in stage IV, again a highly significant increase) with increasing stage. Haematuria was more common in male patients, anaemia and flank pain in women. Elderly patients were more often asymptomatic than younger patients, with 70–79-year-olds being the least symptomatic. CONCLUSIONS Incidental cases of RCC have recently become more common. Haematuria, hypersedimentation, chronic and systemic symptoms have decreased. Stage, tumour class, gender and age are correlated with symptoms. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE To determine if preoperative variables, including gender, age and tumour size, influence the decision for active surveillance of renal masses, as due to the increasing detection of incidental renal masses within the ageing population there is a need to identify reliable means of selecting patients who require therapy. PATIENTS AND METHODS We retrospectively identified all renal masses resected at our institution between 1 December 1999, and 1 October 2005. The size of tumour, patient age and gender were compared between those with and without malignancy on final pathology. The influence of these variables in predicting malignancy, high grade, and high stage were assessed by univariate and multivariate analysis using logistic regression models, with a significance level of P < 0.05. Subsets were analysed for the groups of patients with tumours of ≤3 or >3 cm and those aged ≤75 or >75 years. RESULTS Among 466 of 501 patients with evaluable data, univariate analysis showed that both male gender and increasing size positively predicted malignancy (odds ratio 1.13 and 1.40, respectively), but age, treated as a continuous variable, did not. On multivariate analysis both remained independent predictors of malignancy (odds ratio 1.13 and 1.40, respectively). Size was the only independent predictor of high-stage and high-grade disease on both univariate and multivariate analysis. Among 156 patients with tumours of ≤3 cm, on multivariate analysis, male gender was only weakly associated with the risk of malignancy, whereas size remained strongly predictive (odds ratio 1.98, P = 0.076; and 2.16, P = 0.015, respectively). Neither male gender, size nor age increased the risk of high-stage or high-grade disease in this cohort. Patients who were aged >75 years had a greater risk of high-stage disease than those aged <75 years (odds ratio 2.64, P = 0.008). On multivariate analysis, age >75 years remained an independent predictor of malignancy and high-stage, along with size (odds ratio 2.75, P = 0.014; and 1.35, P < 0.001). CONCLUSIONS Increased size of tumour increases the risk of malignancy and the likelihood of high-stage and high-grade disease. Among patients aged >75 years there was a higher risk of malignancy and high-stage disease than in those aged ≤75 years. As such, the decision for observation should not be based upon age alone, and should be approached with caution in patients aged >75 years, particularly for larger lesions. [ABSTRACT FROM AUTHOR]

OBJECTIVES To report our original experience in patients in whom bacille Calmette-Guérin (BCG) therapy has failed for T1 bladder cancer with subsequent progression to T2 disease treated with chemo-radiotherapy, as the management of recurrent high-grade T1 bladder cancer after failed BCG therapy is challenging, and radical cystectomy is the standard treatment because there are no well established second-line bladder-preserving therapies. PATIENTS AND METHODS From 1988 to 2002, 18 patients with T2 recurrence after failure of BCG therapy for T1 bladder cancer were treated with chemo-radiotherapy at the authors’ institution. Patients received a visibly complete transurethral resection of the bladder tumour (TURBT) and concurrent chemo-radiotherapy with a mid-treatment evaluation after 40 Gy. Patients with less than a complete response had a prompt cystectomy; the others completed radiotherapy to 64–65 Gy. The primary treatment outcome was freedom from cystectomy due to recurrence not treatable by conservative measures; secondary outcomes included disease-specific (DSS) and overall survival (OS). RESULTS With a median follow-up of 7.0 years, only one patient had persistent tumour at re-staging TURBT and had an immediate cystectomy. Of the remaining 17 patients, 10 (59%) were free of any bladder recurrence. The actuarial 7-year DSS and OS were 70% and 58%, respectively. At 7 years, 54% of patients were alive with intact bladders and free of invasive recurrence. CONCLUSIONS In this study we specifically evaluated patients with apparently small muscle-invasive recurrences after BCG treatment for T1 bladder cancer. Selective bladder preservation with chemo-radiotherapy is possible, with low morbidity and a high chance of long-term bladder control. If successful in treating T2 recurrences after BCG therapy, it now seems timely to critically evaluate chemo-radiotherapy as an alternative to immediate cystectomy in the management of patients with T1 recurrences after BCG. [ABSTRACT FROM AUTHOR]

OBJECTIVE To develop a reproducible, non-debilitating in vivo murine model of human renal cryoablation using a standard closed argon-delivery system. MATERIALS AND METHODS Custom engineered 2-mm conical tip cryoprobes for use on the standard argon-based cryoablation unit (Endocare, Inc. Irvine, CA, USA) were used to create small controllable iceballs (−160 °C) in the mouse kidney. The time to create a 4-mm cryolesion was compared using a contact vs puncture technique in 10 mice. To show consistency of the induced-freeze injury, a 4-mm iceball was created in 20 murine renal units and the time to creation and the size of the resultant cryolesion measured. To investigate lesion regression and histological changes, we created a 4-mm renal cryolesion in 28 mice and killed four each at 1, 3, 7, 14, 21, 28, and 35 days. The measured coronal cross-sectional area of the cryoablation site at necroscopy was compared to the initial calculated area as a percentage. To assess renal preservation, blood urea nitrogen (BUN) and creatinine levels at 1 week after cryoablation or sham ablation was compared (10 mononephric mice in each group). RESULTS The time to create the desired iceball was 1.9 times quicker using the puncture vs the contact technique. The mean (sd) time to forming a 4-mm iceball was 35.3 (4.8) s with a mean maximum length of the resultant post-thaw injury of 5.7 (0.5) mm and a 9% coefficient of variance. Regression analysis of the two-dimensional cross-sectional coronal area of the cryolesion showed a statistically significant linear pattern of regression over time ( P = 0.037) and classic histological findings. There was no significant difference in the BUN or creatinine levels in mononephric mice 1 week after cryotherapy compared with the sham-ablated controls. CONCLUSIONS We describe a reproducible, non-debilitating, easily manipulated murine model for the study of human renal cryoablation. [ABSTRACT FROM AUTHOR]

OBJECTIVE To report our 5-year experience with laparoscopic and percutaneous cryoablation (LCA and PCA) for managing small renal masses. PATIENTS AND METHODS We retrospectively analysed patients undergoing LCA and PCA between October 2000 and March 2006 at our institution. After approval from the Institutional Review Board, charts were reviewed retrospectively for variables during and after CA, and for clinical outcomes, the latter including the efficacy of the procedure in achieving overall, cancer-specific and recurrence-free survival. RESULTS In all, 78 patients had CA of 88 small renal masses, by LCA in 58 and PCA in 20. The median American Society of Anesthesiology score was 3 and the mean body mass index was 30 kg/m2. All procedures were done under general anaesthesia, with a mean anaesthesia time of 220 min. The mean tumour size was 2.6 cm and the mean hospital stay was 2.1 days. At a mean follow-up of 19 months, the overall, cancer-specific and recurrence-free survival rates were 88.5%, 100% and 98.7%, respectively. Four patients required a repeat treatment due to persistent disease and one had progression to locally advanced disease. Five patients had complications during CA and seven had complications afterward. CONCLUSION This study suggests that CA is a safe, minimally invasive treatment option for patients with small renal masses, at the intermediate-term follow-up. [ABSTRACT FROM AUTHOR]

The article presents medical research into the treatment of renal cell carcinoma with renal cryotherapy and cryosurgery. Cryoablative therapy is indicated for frail elderly patients with localized renal masses of less than four centimeters. Cryosurgery offers a lower late complication rate than laparoscopic partial nephrectomy.

OBJECTIVE To report our experience with the use of 95% ethanol as sclerotherapy for symptomatic simple renal cysts. PATIENTS AND METHODS Sixty patients with 64 symptomatic simple renal cysts were treated by ultrasonography (US)-guided percutaneous aspiration and injection of 95% ethanol (31 men and 29 women, mean age 46 years, sd 22). The main presentation was renal pain in 34 patients, renal mass in nine, hypertension in 11 and haematuria in six; 24 cysts were on the right, 32 on the left and four bilateral. Patients were evaluated after 1 month and then every 6 months by clinical assessment, US and intravenous urography. Success was defined as complete when there was total ablation of the cyst and partial when there was a recurrence of less than half the original cyst volume with the resolution of symptoms. Failure was defined as the recurrence of more than half of cyst volume and/or persistent symptoms. RESULTS After aspiration and ethanol sclerotherapy, there was microscopic haematuria in two patients and low-grade fever (<38.3°C) in two, but no major complications. During a mean (range) follow-up of 19 (14–40) months there was complete cyst ablation in 54 cysts and partial resolution in 10. Pain disappeared or was much improved in all patients. After cyst ablation hypertension was well controlled with no medication in all 11 hypertensive patients and haematuria disappeared in all six affected patients. CONCLUSIONS Ethanol sclerotherapy for symptomatic simple renal cysts is simple, minimally invasive and highly effective. We recommend it as the first therapeutic option in these patients. [ABSTRACT FROM AUTHOR]

The number of Mini-Reviews per issue is being increased to three for the foreseeable future. As mentioned before, I believe they add to the reader-friendliness of the journal, and are enjoyable and informative. This month, the controversial topics of T1 G3 bladder cancer, surgery for penile fractures and managing patients on warfarin are dealt with. I hope that readers will feel free to write to me if they have strong feelings about these or any other subjects in the Journal. [ABSTRACT FROM AUTHOR]

Objective To determine the relative prognostic importance of microvascular invasion in apparently localized renal cell carcinoma (RCC). Patients and methods A retrospective clinical and pathological review was conducted of 176 consecutive patients identified from pathology records who had a nephrectomy for RCC with a median follow-up of 44 months. Vascular invasion was recorded and categorized by the level of microvascular invasion (MVI), renal vein invasion (RVI) and inferior vena cava invasion (IVCI). Tumour type, grade and size were also assessed. These variables were assessed by univariate and multivariate analysis to determine their effect on disease-free survival. Results In the univariate analysis tumour size, grade, vascular invasion and young age each predicted reduced disease-free survival. On multivariate analysis for all 176 patients, grade, vascular invasion and young age were the significant independent predictors of reduced disease-free survival. In a subgroup of 149 patients from whom those with very high risk determinants were excluded (those with grade 4 tumours and/or IVCI) most of the risk of metastasis could be accounted for by vascular invasion and young age alone (MVI vs no vascular invasion, hazard ratio 3.18, 95% confidence interval 1.29–7.84; RVI vs no vascular invasion 2.41, 0.989–5.89; and age per year 0.963, 0.94–0.992). Conclusions Grade, vascular invasion and young age are the main independent predictors of relapse in clinically localized RCC after nephrectomy. For most patients, who do not have very high risk indicators, the main adverse predictors are vascular invasion and young age. These findings are important when selecting patients for trials of adjuvant therapy and have implications for pathological staging. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery. Patients and methods A series of 167 patients with RCC, free from distant metastases at diagnosis, and who underwent radical nephrectomy at our hospital between January 1990 and October 1997, was reviewed. The mean (median, range) follow-up was 51 (45, 19–112) months. Of the 167 patients, 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional LND limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery. Of these 59 patients, 49 had no evidence of nodal metastases before or during surgery. The probability of survival was estimated by the Kaplan–Meier method, using the log-rank test to estimate differences among levels of the analysed variables. Results The overall 5-year survival was 79%; the 5-year survival rate for the 108 patients who underwent radical nephrectomy alone was 79% and for the 49 who underwent LND was 78%. Of the 49 patients with no suspicion of lymph node metastases, one (2%) was found to have histologically confirmed positive nodes. Conclusion These results suggest that there is no clinical benefit in terms of overall outcome in undertaking regional LND in the absence of enlarged nodes detected before or during surgery. [ABSTRACT FROM AUTHOR]

Examines the efficacy of laparoscopic adrenalectomy for the management of renal pathology. Effects on the increased use of abdominal computed tomography on causing diagnosed benign and malignant renal lesions; Details of the procedure; Advantages and disadvantages on the use of the treatment procedure.

The article presents medical research into the treatment of renal cell carcinoma (RCC) with radiofrequency ablation. An electric current applied in the radiofrequency range results in ion agitation of tissue. Radiofrequency ablation is a minimally invasive technology that helps deal with the increased incidence of small renal tumors.

Objective To evaluate the mode of detection of 400 renal tumours as a prognostic factor compared with the usual clinical and pathological prognostic variables. Patients and methods The data were reviewed for 400 patients operated for a renal tumour at our institution between 1984 and 1999, analysing the prognostic value of age, sex, tumour size, stage, grade, vein invasion, adrenal gland invasion, lymph node invasion, metastasis, and mode of detection (incidental or not). The survival rates were assessed using the Kaplan-Meier method and log-rank test, and the data evaluated using multivariate analysis with the Cox proportional-hazard model. Results In all, 151 (38%) renal tumours were discovered incidentally. There was no significant difference in the percentage of renal cell carcinoma found between the groups of patients discovered incidentally or not (94.4% vs 93.9%). Tumours were smaller in the incidental group (5.7 cm vs 8.7 cm, P < 0.001). In the incidental group, 15.2% of the tumours were treated with partial nephrectomy, against 1.2% in the symptomatic group ( P < 0.001). The specific survival was significantly better in patients with renal tumours discovered incidentally (log-rank test, P < 0.001). The multivariate analysis showed that the mode of detection, stage, grade, metastasis (all P < 0.001), and lymphatic extension ( P = 0.005) were independent prognostic factors. Conclusion The incidental discovery of renal tumours gives a supplementary benefit to patients in terms of survival, and should be considered as a prognostic factor in addition to stage and grade. [ABSTRACT FROM AUTHOR]