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Gleason grade (GG) on prostate biopsy is important for risk stratification and clinical decision making. Multiparametric MRI (mpMRI) improved detection of clinically significant disease and some studies suggest that MRI-fusion biopsy combined with systematic biopsy results in fewer upgrades on final surgical pathology. However, the downgrade rate is unclear and there is controversy in the literature. The objectives of this study are to assess the concordance of combination biopsy with final surgical pathology, and furthermore, to specifically determine downgrade rates.In our institutional mpMRI-ultrasound fusion biopsy database, 173 underwent targeted and systematic biopsy followed by radical prostatectomy (RP). GG on targeted, systematic and combination (targeted and systematic) biopsy were compared with GG on RP. Concordance rates between biopsy types were compared with the McNemar test. Proportion of GG upgrade or downgrade at the time of RP was also evaluated.Surgical pathology was concordant with 44.5% of systematic biopsies, 46.8% of targeted biopsies, and 56.7% of combination biopsies. Combination biopsy significantly overestimated the final GG on RP compared to systematic biopsy (16.8% vs. 8.7% RR 1.93, 95% CI 1.36-2.75, P0.001). Downgrade rate from unfavorable to favorable intermediate-risk disease was 46.2%, and from high-risk to intermediate-risk disease was 45.1%.Combination (targeted and systematic) biopsy is associated with the highest concordance rate between biopsy and RP pathology when compared with systematic or targeted biopsy alone. However, targeting MRI lesions and therefore the higher risk components, may at times overestimate the final surgical pathology which can result in overtreatment of what may truly be less aggressive disease.

The goal of radical prostatectomy (RP) is complete removal of the prostate and seminal vesicles with negative surgical margins. Regardless of approach, the occurrence of positive surgical margins (PSMs) remains a risk associated with RP. In addition, PSMs can adversely affect biochemical and cause-specific survival. With the advent of PSA screening and introduction of new RP approaches, surgical technique has become increasingly debated in relationship to margin positivity. The issue, however, is controversial, as underlying clinical and pathologic characteristics of prostate cancer also influence margin control. This article evaluates the impact of surgical technique on margin control during RP. In addition, we evaluate the influence that stage migration, the individual surgeon, new technologic adjuncts, and specimen handling have had on margin control.

Cystoprostatectomy specimens removed for bladder malignancy (1988-2000) at two referral centers (Mayo Clinic, Rochester, MN, The University Hospital of Innsbruck, Innsbruck, Austria) were examined for the coincidental finding of prostate cancer (PCA). Centralized examination of the prostate by a single uropathologist was performed if at the time of surgery the patient's serum PSA wasor =2.0 ng/mL and there were no suspicious lesions by digital prostate examination. Pathologic grade, stage, morphometric volume, number of tumor foci and association with areas of high grade prostatic intraepithelial neoplasia (HGPIN) were assessed by light microscopy. DNA ploidy and cellular proliferative index were assessed through digital image analysis. Clinically significant cancers were defined as tumors withor =0.5 cc volume, Gleason 4 or 5 architecture, pT3, positive surgical margin, multifocality3, nondiploid DNA content or proliferation index5%. From nearly 1600 cystoprostatectomy specimens, 129 met the enrollment criteria. Thirty-patients (23%) within this group had PCA identified. Sixty percent of these tumors met the criteria for a clinically significant cancer. Nondiploid nuclear content was present in 17%. HGPIN was present in 70% and directly abutting carcinoma in 86% of prostates. The biologic activity of PCA appears to be independent of serum PSA. Any future definition of a clinically significant PCA should not be solely based upon histologic criteria, but needs to encompass clinical parameters (age, co-morbidities) and a noninvasive assessment of tumor volume and biologic doubling time.

The objective of this study was to determine the clinical and biopsy features associated with outcomes at radical retropubic prostatectomy (RRP) in patients with clinically organ-confined prostate cancers and biopsy Gleason scores (GS) of 6 or less. We reviewed 274 biopsies with GS 6 or less cancers from patients with clinically organ-confined disease between 1995 and 1998 to determine statistically significant predictors for the following outcomes at RRP: tumor volume, small (0.5 cc), confined (pT2) tumors with RRP GS of 6 or less (potentially "insignificant" tumors), and extraprostatic extension (EPE). Clinical and pathologic features evaluated included age, serum prostate specific antigen (PSA), clinical stage, percent biopsy cores and surface area positive for cancer (tumor extent), perineural invasion, MIB-I proliferation, and DNA ploidy by digital image analysis (DIA). Multivariate analyses showed that biopsy tumor extent (median percent surface area positive 3.3%; P0.001 and median biopsy cores positive 28.6%; P = 0.001) and PSA (median 5.5 ng/mL; P = 0.009) predicted tumor volume (median 1.4 cc). Biopsy tumor extent (P = 0.002), PSA (P = 0.002), and percent S-phase nuclei (P = 0.050) predicted potentially "insignificant" tumors at RRP (n = 76, 28%). Percent surface area positive for cancer (P = 0.003) predicted EPE (n = 22, 8%). DNA ploidy (n = 211, 79% diploid) and MIB-I proliferation (median 1.4%) did not add information to predict these RRP outcomes. Biopsy tumor extent and serum PSA were significantly associated with tumor volume. Biopsy tumor extent, serum PSA, and percent S-phase nuclei by DIA were predictive of potentially insignificant tumors. Patients with clinically confined disease,5% biopsy surface area positive for cancer,20% biopsy cores positive for cancer, and GS 6 or less, had a 48% chance of having a potentially insignificant tumor at diagnosis if the serum PSA was10 ng/mL. Percent surface area predicted EPE at RRP. DNA ploidy and MIB-I proliferation by DIA did not provide additional information.

Although the prostate specific antigen (PSA) era has altered the clinical and demographic characteristics of men with newly-diagnosed prostate cancer, the impact on patients with high risk disease has been less predictable. We have long advocated aggressive surgical resection for patients with high risk prostate cancer at the Mayo Clinic, including patients with clinical T3 tumors, and have reported our results as well of radical prostatectomy with adjuvant hormonal therapy in the setting of lymph node positive disease. At the same time, multiple predictive models have been developed to assess the risk of disease progression following definitive therapy for prostate cancer. One such model is pretreatment risk group stratification, based on patients' PSA at diagnosis, biopsy Gleason score, and clinical stage. Here, we will review our institution's experience with surgical treatment for men with high risk prostate cancer, and will address the benefits and potential pitfalls of the pretreatment risk group classification model for high risk patients.

To describe the need for treatment and cancer-specific and overall survival in a contemporary active surveillance (AS) cohort.Historical cohort study of men diagnosed with localized prostate cancer between 1997 and 2009 and managed with AS at a tertiary care center. Inclusion criteria were Gleason score ≤ 6 (Gleason score of 7 in select patients),≤ 3/12 cores positive, and prostate-specific antigen (PSA) level20 ng/ml. Survival analyses were conducted using the Kaplan-Meier method.A total of 469 men with median age at diagnosis of 68.1 years (interquartile range [IQR]: 62.5-73.4) were followed up for a median of 4.8 years (IQR: 3.4-7.3). Median PSA level at diagnosis was 5.1 ng/ml (IQR: 4.0-6.9), with 94% of them having PSA level10 ng/ml. Overall, 98.3% (461/469) of patients had a Gleason score of 6 and 1.7% (8/469) had a Gleason score of 3+4 = 7, and 94.0% (441/469) had T1c stage disease. Freedom from treatment was 77% at 5 years and 62% at 10 years. A total of 116 (24.7%) patients received treatment during the course of surveillance. Reasons for treatment included 44.8% (52/116) for pathologic reclassification, 30.2% (35/116) for PSA progression, 12.1% (14/116) for patient preference, 5.2% (6/116) for digital rectal examination progression, and 4.3% (5/116) for metastatic disease. Of the patients treated, 59 (50.1%) received radiation, 26 (22.4%) underwent surgery, 17 (14.7%) received brachytherapy, and 14 (12.1%) received androgen-deprivation therapy. Cancer-specific survival was 100% at 5 and 10 years. Overall survival was 95% at 5 years and 88% at 10 years.In a contemporary cohort of men with low-risk prostate cancer, AS allowed avoidance of treatment most of them. Common reasons for change in management were Gleason upgrading and volume progression on prostate rebiopsy.

Purpose Angiomyolipomas classically present radiographically as fat containing lesions but some fail to demonstrate fat content. Histologically confirmed angiomyolipomas uniformly follow a benign course but rare epithelioid variants of angiomyolipoma can recur and metastasize. We investigated the clinical, radiographic, and histological characteristics of each angiomyolipoma subtype. Materials and Methods Pertinent data were recorded for 209 patients surgically treated for angiomyolipoma in 219 kidneys from 1981 to 2007. Classic and fat poor angiomyolipomas were classified radiographically based on the presence or absence of fat and classified histologically based on the presence of triphasic, monophasic or epithelioid histology. Results Median radiographic size was 3.2, 4.9, and 10 cm in patients with a single angiomyolipoma (59% of patients), multiple angiomyolipomas, and tuberous sclerosis (probable or definite), respectively. In these three groups 65%, 47%, and 33% of lesions were not suspected radiographically (fat poor angiomyolipoma). Fat poor angiomyolipomas were more commonly single, smaller, and in older patients. Triphasic histology was evident in 76% of angiomyolipomas with 16% demonstrating a predominance of one component and 8% containing epithelioid features. Despite potentially aggressive findings in 18% (e.g., presence within the perinephric fat, lymph node involvement) no angiomyolipoma recurred during a mean follow-up of 3.4 years (range 0 to 24). A total of 28 (13%) patients with angiomyolipoma had concomitant renal cell carcinoma. Conclusions A surprisingly high number of resected angiomyolipomas was not suspected radiographically, indicating the importance of precise radiographic characterization to minimize nephrectomy for fat poor angiomyolipoma, which should remain a research priority. In this sizeable single institution series no triphasic, monophasic, or epithelioid angiomyolipoma recurred despite potentially aggressive findings in a substantial proportion of cases.

Purpose We determined the safety and accuracy of preoperative needle core biopsy for diagnosing benign lesions among small incidental asymptomatic renal masses. Materials and Methods Between February 2000 and December 2007, we received a total of 235 preoperative core biopsies from 222 less than 5 cm incidental renal masses. Biopsy results were correlated with surgical specimen final pathology findings or with patient followup if surgery was avoided. Results Of the 235 biopsies, 184 (78%) were diagnostic, whereas 51 (22%) were nondiagnostic due to insufficient material or contents of only normal, inflammatory, fibrotic or necrotic tissue, or blood clot. Diagnostic biopsies revealed 138 malignant (75%) and 46 benign (25%) lesions. Of these patients, 108 (59%) underwent renal surgery, which showed a 100% biopsy accuracy rate for distinguishing malignant from benign lesions and a 98% rate for determining histological tumor type. Follow-up with radiological imaging was performed for 59 lesions in patients with nondiagnostic biopsies or benign masses, and for 16 low grade malignant tumors in elderly patients. Lesions remained stable in 61 cases, showed minor size changes in 9, and resolved in 5. No patient has shown symptoms or required renal surgery to date. Significant biopsy related complications were noted in only 2 patients (0.9%). Conclusions We found that needle core biopsy was a safe and accurate technique for distinguishing between malignant and benign tumors in small, asymptomatic, incidentally detected renal masses. Biopsy of small tumors is associated with a relatively high rate of technical biopsy failure, although this may be addressed by adopting improved biopsy techniques, as discussed.

Purpose We explored the clinical usefulness of serum carbonic anhydrase 9 as a potential biomarker for conventional renal cell cancer. Materials and Methods This study included 91 patients with conventional renal cell cancer and 32 healthy individuals. Enzyme linked immunosorbent assay was used to measure the carbonic anhydrase 9 level. A follow-up (median 38 months) was performed to track early recurrence after surgery for patients with localized disease. Recurrence-free survival curves were calculated by the Kaplan-Meier method and compared using the log rank test. Results The mean serum carbonic anhydrase 9 level in patients with metastatic conventional renal cell cancer (216.68 ± 67.02 pg/ml) or localized conventional renal cell cancer (91.65 ± 13.29 pg/ml) was significantly higher than in healthy individuals (14.59 ± 6.22 pg/ml, P P = 0.001, respectively). The mean serum carbonic anhydrase 9 level in patients with metastatic conventional renal cell cancer was significantly higher than in those with localized disease ( P = 0.004). Of patients with localized disease, those with recurrence had a significantly higher serum carbonic anhydrase 9 than those without recurrence ( P = 0.001). On univariate analysis serum carbonic anhydrase 9, tumor stage, tumor grade, and tumor size were associated with recurrence. The recurrence-free survival curve indicates that patients with a high serum carbonic anhydrase 9 level had a significantly higher recurrence rate than those with a low serum carbonic anhydrase 9 ( P = 0.001). Conclusions Our data suggest that serum carbonic anhydrase 9 is increased as the tumor progression occurs. A high carbonic anhydrase 9 level is associated with postoperative recurrence.

Purpose Targeted molecular therapies such as bevacizumab, sunitinib, and sorafenib before surgical resection hold promise as rational treatment paradigms for patients with metastatic or locally recurrent renal cell carcinoma. To analyze the safety of this approach, we evaluated surgical parameters and perioperative complications in patients treated with targeted molecular therapies before cytoreductive nephrectomy or resection of retroperitoneal renal cell carcinoma recurrence, and compared them to a matched patient cohort who underwent up-front surgical resection. Materials and Methods We evaluated surgical parameters and perioperative complications in 44 patients treated with targeted molecular therapies before cytoreductive nephrectomy or resection of local renal cell carcinoma recurrence, and in a matched cohort of 58 patients who underwent up-front surgery. Results Cohorts of patients treated with preoperative targeted molecular therapy and initial surgical resection were matched in terms of clinical characteristics, burden of metastatic disease, and number of adverse prognostic factors. A total of 39 complications occurred in 17 (39%) patients treated with preoperative targeted molecular therapy and in 16 (28%) who underwent up-front resection ( P = 0.287). There were no statistically significant differences in surgical parameters, incidence of perioperative mortality, re-exploration, readmission, thromboembolic, cardiovascular, pulmonary, gastrointestinal, infectious, or incision related complications between patients treated with preoperative targeted molecular therapy and those who underwent up-front surgery. Duration, type, and interval from targeted molecular therapy to surgical intervention were not associated with the risk of perioperative morbidity. Conclusions Preoperative administration of targeted molecular therapies is safe, and does not increase surgical morbidity or perioperative complications in patients treated with cytoreductive nephrectomy or resection of recurrent retroperitoneal renal cell carcinoma.

Background The 2002 American Joint Committee on Cancer (AJCC) tumor classification for renal cell carcinoma (RCC) does not take into account concomitant venous invasion and extrarenal tumor extension (ERE). In the current study, the authors evaluated the prognostic significance of venous tumor thrombus (VTT) and its extent, the presence and location of ERE, and a combination of both features on survival after the surgical management of patients with pathologic T3 (pT3) RCC. Methods With Institutional Review Board approval, the institutional nephrectomy database of 3,470 patients treated at the University of Texas, M. D. Anderson Cancer Center from 1990 to 2006 was searched for pT3 RCC patients who were treated with partial or radical nephrectomy. Patients with nonmetastatic, lymph node-negative RCC and a minimum follow-up of 6 months were included in the analysis. Results A total of 419 patients with pT3N0/NxM0 RCC and a mean follow-up of 40.8 months met the study inclusion criteria. In multivariate Cox regression analyses, the 2002 AJCC primary tumor classification was not found to be an independent predictor of cancer-specific mortality. A total of 211 patients with ERE only (50.4%) and 72 patients with VTT only (17.2%) were found to have a similar risk of death from RCC (hazards ratio [HR] of 1.018; P = 0.957), whereas 136 patients harboring both features (32.5%) were found to be significantly more likely to die from RCC (HR of 2.660; P Conclusions The prognostic accuracy of the 2002 AJCC pT3 tumor classification can be improved by subclassifying patients with ERE only and those with VTT only into a prognostic category that is separate from patients with both ERE and VTT.

Objective To evaluate the role of microvascular invasion (MVI) in the primary lesion for predicting tumour behaviour in patients with renal cell carcinoma (RCC), as reliable clinical prognostic factors would be very valuable. Patients and Methods MVI was assessed in 230 patients with clinically localized RCC (stages T1-4NxM0) who had a radical nephrectomy and/or nephron-sparing surgery. The median (range) follow-up was 48 (3–130) months. The impact of MVI on disease progression and its correlation with clinical and histopathological factors was analyzed, including whether patients were symptomatic or not at presentation, Fuhrman nuclear grade, tumour size, pathological stage, and lymph node metastasis. Regression analyses and survival curves were used to determine if MVI was associated with the prognosis of RCC. Results There was MVI in 59 patients (26%); of these, 46% developed disease recurrence. Among the 171 patients with no MVI, only 11 (6%) had tumour recurrence. MVI was associated with tumour diameter, nuclear grade, pathological stage, lymph node metastasis, and the presence of sarcomatous elements in the tumour. Multivariate analysis showed that MVI was an independent predictor of disease recurrence and the most important factor related to death. Conclusion MVI is an independent predictor of prognosis in patients with RCC.

We present a case of a prolonged urine leak after partial nephrectomy successfully treated by retrograde ureteroscopic injection of fibrin sealant. The technical aspects of retrograde instillation of sealant into the lower renal pole and outcome are discussed.

The relationship between tumour stage, grade (Fuhrman), performance status (ECOG), a combined score (UCLA Integrated Staging System, UISS), systemic inflammatory response (elevated C-reactive protein concentration), and cancer-specific survival was examined in patients undergoing potentially curative resection for renal clear cell cancer (n = 100). On univariate survival analysis, sex (P = 0.050), tumour stage (P = 0.001), Fuhrman grade (P

Context Current treatment options for metastatic renal cell carcinoma (RCC) are limited and there is a need to identify novel and effective therapies. Sunitinib malate is an oral multitargeted tyrosine kinase inhibitor, which has shown activity in an initial study of cytokine-refractory metastatic RCC patients. Objective To confirm the antitumor efficacy of sunitinib as second-line treatment in patients with metastatic clear-cell RCC, the predominant cell type of this malignancy. Design, Setting, and Patients Open-label, single-arm, multicenter clinical trial. Patients were enrolled between February and November 2004, with follow-up continuing until disease progression, unacceptable toxicity, or withdrawal of consent. The reported data apply through August 2005. Patients ( N = 106) had metastatic clear-cell RCC, which had progressed despite previous cytokine therapy. Intervention Repeated 6-week cycles of sunitinib, 50 mg per day given orally for 4 consecutive weeks followed by 2 weeks off per treatment cycle. Main Outcome Measures Assessment of clinical response, degree of tumor regression on imaging studies using the Response Evaluation Criteria in Solid Tumors (RECIST) guidelines. Primary end point was overall objective response rate (complete plus partial). Secondary end points were progression-free survival and safety. Response was evaluated by independent third-party core imaging laboratory and by treating physicians (investigator assessment). Results All 106 patients received sunitinib and were included in the intent-to-treat population for safety analyses. Of these, 105 patients were evaluable for efficacy analyses. The objective response rate according to an independent third-party assessment resulted in 36 patients with partial response (34%; 95% confidence interval, 25%–44%), and a median progression-free survival of 8.3 months (95% confidence interval, 7.8–14.5 months). The most common adverse events experienced by patients were fatigue in 30 (28%) and diarrhea 21 (20%). Neutropenia, elevation of lipase, and anemia were the most common laboratory abnormalities observed in 45 (42%), 30 (28%), and 27 (26%) patients, respectively. Conclusion The results of this trial demonstrate the efficacy and manageable adverse-event profile of sunitinib as a single agent in second-line therapy for patients with cytokine-refractory metastatic clear-cell RCC. Trial Registration clinicaltrials.gov Identifier: NCT00077974.

Background The prognostic relevance of disseminated cytokeratin-positive (CK+) tumor cells in the bone marrow of patients with different types of carcinoma has been demonstrated in several studies. In this prospective study, the frequency and prognostic value of CK+ tumor cells was investigated in the bone marrow of 55 consecutive patients with metastatic renal cell carcinoma (M1 RCC) in comparison with 256 M0 RCC patients from a previous study. Methods Aspiration of bone marrow from the anterior iliac crest was performed immediately before tumor resection in RCC patients. Cytospins were made and stained by immunocytochemistry using the APAAP (alkaline phosphatase-antialkaline phosphatase) protocol and monoclonal antibodies CK2 and A45-B/B3. Twenty-seven patients with no evidence of any malignant disease served as a control group. Results CK+ tumor cells were detected in 42% (23 of 55 patients) of the M1 patients and 25% (63 of 256 patients) of the M0 patients (P or = 3 CK+ cells; P or = 3 CK+ cells in the bone marrow was found to be an independent prognostic factor (P Conclusions The results of the current study indicate that disseminated CK+ cells play a role in the biology of tumor spread of RCC, and that their immunocytochemical detection can be useful in assessing the prognosis of patients with M1 disease

Purpose We identify and report on a large number of patients treated with active surveillance for incidentally diagnosed renal masses at our institution. Materials and Methods We identified all patients 75 years or older evaluated in our department for a renal mass between January 2000 and December 2006. A total of 110 patients with enhancing renal masses were initially treated with active surveillance, and this group made up the cohort for our study. Medical records were reviewed for clinical and radiological follow-up, and vital status was obtained from the Social Security Death Index. Clinical and radiographic follow-up was available for review on 104 and 89 patients, respectively. Results Patients had a median age of 81 years (range 76 to 95) with a median Charlson comorbidity index of 2 (range 0 to 7) at diagnosis. Patients had as many as 9 tumors being followed (median of 1) with a median tumor size of 2.5 cm (range 0.9 to 11.2). During a median follow-up of 24 months (range 1 to 90) mean tumor growth rate was 0.26 cm per year. Of the 89 patients with radiological follow-up, 38 (43%) exhibited no tumor growth on active surveillance. Comparison of the clinical and radiographic features of patients with tumor growth and those with stable disease revealed no statistical differences. Four patients (3.6%) were treated as a result of disease progression 12 to 54 months after diagnosis. At the conclusion of the study, 34 patients (31%) were deceased. To our knowledge, the renal mass did not contribute to the cause of death in any patient. Conclusions Active surveillance of incidental renal masses appears to be a viable option for older patients with multiple medical co-morbidities and a limited life expectancy.

Objective To compare the intermediate term outcomes of patients with clinical T1a renal tumors who were treated with nephron-sparing surgery by partial nephrectomy (PN), the preferred approach for small (cT1a) renal tumors, or radiofrequency ablation (RFA), recently offered to selected patients as an alternative, less morbid technique. Patients and Methods We identified patients with stage T1a renal masses who had ≥2 years of follow-up; those with bilateral synchronous or metachronous tumors, metastatic disease at presentation, or a family history of renal cell carcinoma were excluded. From July 1996 to January 2004, 110 PNs were identified in our database; 37 patients who fulfilled the inclusion criteria had either open (30) or laparoscopic PN (7), and 40 had either percutaneous (26) or laparoscopic (14) RFA. Results The mean (range) follow-up for the RFA and PN groups was 30 (18–42) and 47 (24–93) months, respectively; the respective mean tumor size was 2.41 and 2.43 cm. There was 1 incomplete ablation and 2 local recurrences in the RFA group, and 2 recurrences in the PN group (1 local and 1 in the contralateral kidney). There were no disease-specific deaths. The overall actuarial disease-free probability for the PN and RFA groups, respectively, was 95.8% and 93.4% ( P = 0.67). Conclusions This initial 3-year actuarial analysis showed that RFA for cT1a renal tumors has comparable oncological outcomes to PN; however, longer term data are still needed.

Objectives Percutaneous renal tumor cryoablation is being evaluated as a treatment option for small renal tumors. However, when tumors are located centrally, involvement of the collecting system by the radiographic iceball can occur. We reviewed our series of computed tomography (CT)-guided percutaneous renal tumor cryoablation to identify those cases in which there appeared to be involvement of the collecting system by the radiographic iceball and to determine any clinical sequelae of such involvement. Methods Retrospective review of the medical records identified 6 patients who had undergone CT-guided percutaneous renal tumor cryoablation with evidence of collecting system involvement. Measurements of the tumor size, size of the radiographic iceball, and the size of the immediate postprocedure “cryozone” (region of apparent treatment on contrast-enhanced CT) were obtained from the preprocedure, intraprocedure, and immediate postprocedure CT scans. Follow-up imaging was obtained beginning at 3 to 6 months. Results Six patients were identified who met the inclusion criteria and had at least 3 months of documented follow-up. Despite the apparent involvement of the collecting system during the cryoablation procedure, no patient developed clinical signs or symptoms or radiographic evidence of a urine leak or fistula formation. Furthermore, no evidence of ureteral narrowing or stricture formation has been found to date, with a mean follow-up of 167.7 days (range 90 to 288). Conclusions We observed no clinically appreciable urine leaks despite what appeared to be obvious involvement of the collecting system by the radiographic iceball. However, care should be exercised to avoid this insult when possible until additional research has confirmed its safety.

Purpose We report our experience with LC for small renal tumors. Materials and Methods Patients who underwent LC at our institution between February 2000 and September 2004 were included in the study. A retrospective chart review was done for perioperative and postoperative parameters as well as clinical outcomes. Results A total of 65 LCs were performed in 59 patients during the period reviewed. Overall 81 renal tumors were cryoablated. Median patient age was 62 years. Median tumor size was 2.5 cm. Median operative time was 190 minutes. Median estimated blood loss was 50 ml. Median hospital stay was 2 days. Conversion to open surgery occurred in 2 patients. Nephrectomy for bleeding occurred in 1 patient. Median followup was 26.8 months. Two recurrences were identified after LC. Conclusions LC is an alterative modality to laparoscopic partial nephrectomy or open partial nephrectomy for small renal tumors. Tumor recurrence rates in the studies published to date are comparable to those of partial nephrectomy, although longer followup is needed.

Purpose We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function. Materials and Methods A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in 184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative and postoperative parameters were evaluated at a mean followup of 44 months. Results In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398 patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery. Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time of contralateral nephrectomy were noted to be significantly associated with postoperative renal function. Conclusions Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney. Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases.

Objective To compare the outcomes of patients who had a elective partial nephrectomy (PN) or radical nephrectomy (RN) for clear cell renal cell carcinoma (RCC) of 4–7 cm. Patients and Methods From March 1998 to July 2004, 45 and 151 patients underwent PN and RN, respectively, for clear cell RCC. A multivariate Cox model was constructed for disease-free survival with adjustment for markers of disease severity, and a propensity-score approach used as a confirmatory analysis. Results In the PN and RN cohorts the treatment failed in one and 20 patients, respectively; the median follow-up was 21 months. The hazard ratio (95% confidence interval) for PN after adjusting for disease severity was 0.36 (0.05–2.82; P = 0.3). Using planned PN as a predictor (intent-to-treat analysis) the hazard ratio was 1.06 (0.32–3.53; P = 0.9). In the propensity-score model, planned PN was associated with a hazard ratio of 1.75 (0.50–6.14; P = 0.4). The serum creatinine level 3 months after surgery was significantly lower in patients who had PN, with a difference between the means of 0.36 (0.23–0.48; P Conclusions Renal function was preserved after PN for 4–7 cm clear cell RCC tumours. When comparing the outcomes of PN and RN it is important to consider the intended operation as an independent variable. There was no clear evidence that PN was associated with worse cancer control, although a continued follow-up of this and other cohorts is warranted.

Purpose: We prospectively determined the accuracy of computerized tomography (CT) and needle biopsy of solid renal masses.Materials and Methods: A total of 100 patients with a solid renal mass who were scheduled for operation were prospectively evaluated. CT was performed before radical or partial nephrectomy. Biopsy of the surgical specimens was done twice through the tumor using an 18 gauge biopsy gun. Specimens were sent for permanent section and review by 2 pathologists blinded to each other and to the whole tissue specimens. Images were reviewed by 2 radiologists blinded to each other and to the results of pathological analysis. Results of CT and permanent biopsy were compared with the results of whole tissue specimen analysis.Results: Specimens were obtained from 59 radical and 41 partial nephrectomies. Malignant neoplasms were present in 85 patients (85%). Overall accuracy was 77% and 72%, the nondiagnostic rate was 20% and 21%, sensitivity was 81% and 83%, and specificity was 60% and 33%. ...