Glickman Urological Institute Research Articles

Complications After Robotic Partial Nephrectomy at Centers of Excellence: Multi-Institutional Analysis of 450 Cases

We evaluated the incidence of perioperative complications after robotic partial nephrectomy. We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system. A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths. Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively.

Is neoadjuvant chemotherapy with gemcitabine plus cisplatin beneficial in patients with muscle-invasive bladder cancer?

Evaluation of: Weight CJ, Garcia JA, Hansel DE et al. Lack of pathologic down-staging with neoadjuvant chemotherapy for muscle-invasive urothelial carcinoma of the bladder. Cancer 115, 792–799 (2009).This study by the Glickman Urological Institute fails to show a beneficial role for neoadjuvant chemotherapy in muscle-invasive bladder cancer. The poor outcomes in the study could be attributed to the use of non-methotrexate, vinblastine, doxorubicin and cisplatin regimens and to excessive delays in performing cystectomy. Randomized trials of neoadjuvant chemotherapy have shown improved survival and increased rates of pathologic complete response when using cisplatin-based combination therapies compared with local therapy alone. A regimen consisting of gemcitabine plus cisplatin has shown similar efficacy and less toxicity in the metastatic setting and further research is warranted before its efficacy can be extrapolated to the neoadjuvant setting.

Editorial Comment

No AccessJournal of UrologyAdult Urology1 Dec 2008Editorial Comment Eric A. Klein Eric A. KleinEric A. Klein More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2008.08.171AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 180(6), p. 2564 Department of Surgery, Cleveland Clinic Lerner College of Medicine, Center for Urologic Oncology, Glickman Urological Institute, Cleveland, Ohio© 2008 by American Urological AssociationFiguresReferencesRelatedDetails Volume 180Issue 6December 2008Page: 2564 Advertisement Copyright & Permissions© 2008 by American Urological AssociationMetricsAuthor Information Eric A. Klein More articles by this author Expand All Advertisement PDF downloadLoading ...

Presentation, location, and overall survival of pelvic recurrence after radical cystectomy for transitional cell carcinoma of the bladder: Dhar NB, Jones JS, Reuther AM, Dreicer R, Campbell SC, Sanii K, Klein EA, Section of Urologic Oncology, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH.

To evaluate the presentation, location, and overall survival of pelvic recurrence after radical cystectomy (RC) for transitional cell carcinoma (TCC) of the bladder. We reviewed a consecutive series of 130 patients who had a limited bilateral pelvic lymph node dissection (PLND) and RC between 1987 and 2000, and who later developed pelvic recurrence. All patients were staged N0M0 before RC and no patient received neoadjuvant radio/chemotherapy. The boundaries of the limited PLND were the pelvic side-wall between the genitofemoral and obturator nerves, and the bifurcation of iliac vessels to the circumflex iliac vein. Pelvic recurrence was defined as a radiographic soft-tissue density of ≥2 cm below the bifurcation of the aorta. Kaplan-Meier and Cox proportional hazards analyses were used to determine if imaging or symptomatic presentation, age, pT stage, and pN status were predictive of overall survival. The median (range) time from RC to pelvic recurrence was 7.3 (1.2–55.4) months. No patients had concomitant distant metastasis. Of the patients, 61.5% were diagnosed with pelvic recurrence because of symptoms, and 38.5% by surveillance computed tomography (CT). Of the 130 patients, 128 died, with a median survival from the time of pelvic recurrence of 4.9 (0.1–129.3) months. The median overall survival time for pelvic recurrence diagnosed with CT was 21.6 months, vs. 10.6 months for symptomatic presentations ( P < 0.001). In the uni- and multivariate models, type of presentation (CT vs. symptomatic) and pT stage were predictors of overall survival, while age and pN status were not. The prognosis of patients with pelvic recurrence after RC for TCC is poor even with subsequent therapy, emphasizing the need for optimum local control at the time of initial treatment.

Laparoscopic radical cystectomy for cancer; oncologic outcomes for up to 5 years: Haber GP, Gill IS, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, OH

Objective To report the oncological outcomes at ≤ 5 years after laparoscopic radical cystectomy (LRC), as open RC is the reference standard treatment for muscle-invasive bladder cancer, but interest in LRC is increasing at selected centers worldwide and, as yet, there are no long-term follow-up data. Patients and Methods Between December 1999 and January 2005, 37 patients (mean age 66 years) had LRC with urinary diversion for invasive bladder cancer; 26 patients (70%) also had an extended pelvic lymphadenectomy. Overall and cancer-specific survival data were obtained from patient charts, radiographic reports, telephone contact, and a check of the Social Security Death Index. Results Most tumors were transitional cell carcinoma (32, 86%), high-grade (Grade III in 29, 78%) and high-stage (≥ pT2 in 26, 70%). Two patients had a positive surgical margin. The median (range) number of lymph nodes excised was 14 (2–24; seven patients (17%) had node-positive disease (pN1). Follow-up data were available for 35 patients (95%); eight (22%) completed ≥ 5 years of follow-up, and the mean (range) follow-up was 31 (1–66) months. At the last follow-up, 24 patients (65%) were alive with no evidence of disease and 11 (30%) were dead, two (5%) from metastasis and nine (24%) from unrelated causes. The 5-year actuarial overall, cancer-specific, and recurrence-free survival was 63%, 92%, and 92%, respectively. Conclusion To our knowledge, this is the first report of ≤ 5-year follow-up after LRC; the data suggest that LRC provides oncological outcomes comparable to contemporary series of open RC.

Lidocaine 2% Gel Versus Plain Lubricating Gel for Pain Reduction During Flexible Cystoscopy: A Meta-Analysis of Prospective, Randomized, Controlled Trials

The current literature shows mixed results for the effectiveness of topical intraurethral lidocaine gel as local anesthesia during flexible cystoscopy. We performed a meta-analysis of randomized, controlled trials of the efficacy of 2% lidocaine vs plain gel for decreasing the pain that male patients incur during flexible cystoscopy. A search of the literature from 1950 to September 2006 yielded 46 applicable articles. Search terms included cystoscopy and pain. Study selection included randomized controlled trials, flexible cystoscopy, males, control groups receiving plain gel and treatment groups receiving 2% lidocaine before cystoscopy. Data extraction was done by 2 of us (ARP and JSJ) who independently reviewed each study and were blinded to identifying features. The primary outcome measured was pain incurred by the patient throughout the entire cystoscopy procedure, as measured using a visual analog score. Data from 9 eligible trials on a total of 817 patients in 7 publications were included in the meta-analysis. Using a random effects model the difference between visual analog scale pain scores in patients receiving 2% lidocaine and plain gel was estimated to be -4.61 (approximate 95% CI -9.6, 0.385), indicating no statistically significant difference. Based on a meta-analysis of 9 randomized controlled trials there is no evidence to suggest a statistically significant difference in the efficacy of pain control between lidocaine gel and plain gel lubrication in men during flexible cystoscopy. This supports the conclusion that its benefit is limited to lubrication and any other perceived benefit is consistent with placebo.

Is new always better?

Corresponding author Howard B. Goldman, MD, FACS Section of Voiding Dysfunction and Female Urology, Glickman Urological Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, 9500 Euclid Avenue/A110, Cleveland, OH 44195, USA. E-mail: goldmah@ccf.org Current Urology Reports 2007, 8:253–254 Current Medicine Group LLC ISSN 1527-2737 Copyright © 2007 by Current Medicine Group LLC

Augmented Anastomotic Urethroplasty

During substitution urethroplasty, if the stricture contains a 1 to 2 cm region that is particularly narrow and/or fibrotic, that portion may be excised with subsequent anastomosis of the dorsal or ventral aspect of the urethra to shorten, widen and optimize the urethral wall onto which an onlay graft is to be placed. This procedure is termed augmented anastomotic urethroplasty. To determine the effectiveness of this approach we reviewed our experience with augmented anastomotic urethroplasty in an 8-year period. We reviewed the records of patients who underwent augmented anastomotic urethroplasty between October 1997 and April 2005. Perioperative characteristics were compared between successes and failures using the Wilcoxon/Kruskal-Wallis and Fisher exact tests. Of 69 patients who underwent augmented anastomotic urethroplasty for recurrent urethral strictures 5 had undergone previous urethroplasty using a genital skin flap or graft. At a median followup of 34 months (range 13 to 103) 62 patients had no evidence of stricture recurrence and required no further intervention for an overall success rate of 90%. Stricture recurrence, defined as the inability to easily pass a standard flexible cystoscope through the area of repair, occurred in 7 patients (10%). Patients with stricture recurrence were significantly older (mean age 52 vs 39 years, p = 0.02) and more likely to experience postoperative urinary tract infection (28% vs 3.2%, p = 0.05) than patients without repeat stricture. Augmented anastomotic urethroplasty is an effective technique that allows the use of a shorter onlay graft. It may optimize overall results due to improvement in the urethral wall and the associated corpus spongiosum.

Reassessing the value of varicocelectomy as a treatment for male subfertility with a new meta-analysis

To determine the efficacy of varicocelectomy as a treatment for male factor infertility by improving the chance of spontaneous pregnancy. Meta-analysis. Cleveland Clinic's Glickman Urological Institute. Infertile men with abnormal results on semen analyses and a palpable varicocele. Surgical varicocelectomy. Spontaneous pregnancy outcome. The odds of spontaneous pregnancy after surgical varicocelectomy, compared with no or medical treatment for palpable varicocele, were 2.87 (95% confidence interval [CI], 1.33-6.20) with use of a random-effects model or 2.63 (95% CI, 1.60-4.33) with use of a fixed-effects model. The number needed to treat was 5.7 (95% CI, 4.4-9.5). Surgical varicocelectomy in infertile men with palpable lesions and at least one abnormal semen parameter improves the odds of spontaneous pregnancy in their female partners. Five studies were included (two randomized, three observational). All were scored for bias. Our study suggests that varicocelectomy in selected patients does indeed have beneficial effects on fertility status.

5-Year Outcomes of Laparoscopic Partial Nephrectomy

Laparoscopic partial nephrectomy is increasingly a definitive therapeutic option in patients with a small renal mass. Intermediate term oncological outcomes after laparoscopic partial nephrectomy are excellent up to a mean followup of 3 years. We present outcomes in 56 patients, each of whom has now completed a minimum of 5 years of followup after laparoscopic partial nephrectomy. Of the 557 laparoscopic partial nephrectomies performed at our institution 58 patients with a localized tumor have completed more than 5 years since surgery. Clinical and renal functional data on 56 patients (97%) were obtained from medical records, radiographic reports and patient contact via telephone. Average patient age was 64 years and 9% were symptomatic at presentation. Average tumor size was 2.9 cm. On histopathology renal cell carcinoma was confirmed in 37 cases (66%) and pathological tumor stage was pT1a in 32 (86%). Final surgical margin was positive for cancer in 1 patient. Median serum creatinine preoperatively and postoperatively was 0.9 and 1.0 mg/dl, respectively. No patient with normal baseline serum creatinine undergoing elective laparoscopic partial nephrectomy had postoperative chronic renal insufficiency (serum creatinine more than 2 mg/dl). At a median followup of 5.7 years (range 5.0 to 6.9) no distant recurrence (0%) and a single local recurrence (2.7%) were detected. Overall and cancer specific survival was 86% and 100%, respectively, at 5 years. To our knowledge this is the initial report in the literature of oncological and renal functional outcomes 5 years after laparoscopic partial nephrectomy with excellent results comparable to those of open nephron sparing surgery. At our center laparoscopic partial nephrectomy is an established alternative to open partial nephrectomy.

Risk of Infection With an Antibiotic Coated Penile Prosthesis at Device Replacement for Mechanical Failure

The inflatable penile prosthesis is well established as an effective treatment for select patients with organic erectile dysfunction. The risk of prosthetic infection at primary implantation is approximately 2%. However, for revision or replacement procedures the risk of infection has been reported to be as high as 13.3%. To minimize the overall risk of prosthetic infection an antibiotic coated inflatable penile prosthesis (InhibiZone) has been developed. To assess the impact on infection rates we reviewed our experience with the use of this device at prosthesis replacement for mechanical failure. We retrospectively reviewed the records of all patients undergoing inflatable penile prosthesis replacement for mechanical failure with an antibiotic coated prosthesis between May 2001 and November 2004. Salvage procedures for clinically infected prostheses were excluded from analysis. Chart review was performed with examination of operative notes, all postoperative contacts and microbiological data. A total of 55 patients underwent replacement of an inflatable penile prosthesis for mechanical failure using a device coated with rifampin and minocycline HCL (InhibiZone). In all patients before reimplantation component spaces were irrigated in standard fashion. With a median followup of 32 months (range 12 to 54) postoperative device infection requiring explantation developed in 1 patient (1.8%). Intraoperative cultures from the pump site grew coagulase negative staphylococcus. Our data suggest that an antibiotic coated inflatable penile prosthesis may lead to decreased infection rates in patients undergoing penile prosthesis replacement for mechanical failure.

Open partial nephrectomy for tumor in a solitary kidney: Experience with 400 cases: Fergany AF, Saad IR, Woo L, Novick AC, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, OH

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.

Editorial comment

No AccessJournal of UrologyAdult urology1 Sep 2006Editorial comment J. Stephen Jones J. Stephen JonesJ. Stephen Jones More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2006.04.124AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial comment." The Journal of Urology, 176(3), pp. 963–964 References 1 : Late angiographic stent thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol2005; 45: 2088. Google Scholar 2 : Optimal duration of antiplatelet therapy in recipients of coronary drug-eluting stents. Drugs2005; 65: 725. Google Scholar 3 : How soon can a patient undergo noncardiac surgery after receiving a drug-eluting stent?. Cleve Clin J Med2005; 72: 818. Google Scholar Glickman Urological Institute, Department of Surgery (Urology), Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio© 2006 by American Urological AssociationFiguresReferencesRelatedDetails Volume 176Issue 3September 2006Page: 963-964 Advertisement Copyright & Permissions© 2006 by American Urological AssociationMetricsAuthor Information J. Stephen Jones More articles by this author Expand All Advertisement PDF downloadLoading ...

Time Dependent Changes in Diabetic Cystopathy in Rats Include Compensated and Decompensated Bladder Function

Diabetic bladder dysfunction is among the most common and bothersome complications of diabetes mellitus. While bladder filling and voiding problems have been reported, the precise functional changes in diabetic bladders remain unclear. We investigated time dependent changes in bladder function in streptozotocin induced diabetic rats. Cystometrograms and detrusor muscle contractility were examined in male age matched control and diabetic Sprague-Dawley rats (Harlan, Indianapolis, Indiana) 3, 6, 9, 12 and 20 weeks after diabetes induction with streptozotocin. Diabetes decreased average body weight and increased bladder weight, capacity and compliance. Peak detrusor leak pressure increased gradually from weeks 3 to 6 to 9 in diabetic rats (mean +/- SEM 47.3 +/- 2.5, 50.8 +/- 3.0 and 56.0 +/- 3.6 cm H(2)O) and in controls (36.9 +/- 1.4, 37.7 +/- 1.5 and 41.6 +/- 1.81 cm H(2)O, respectively). However, at 12 and 20 weeks diabetic rats deviated strongly from this trend with peak detrusor leak pressure decreasing vs controls (41.6 +/- 2.8 and 37.3 +/- 0.9 vs 45.2 +/- 1.7 and 49.6 +/- 1.4 cm H(2)O, respectively) and post-void resting pressures increasing from 9-week levels vs controls (interactions p <0.0001). In contractility studies increased contractile force responses of diabetic animals to carbamylcholine chloride, potassium chloride, adenosine 5'-triphosphate and electric field stimulation peaked at 6 or 9 weeks but at 12 to 20 weeks they generally reverted toward those of controls (carbamylcholine chloride and electrical field stimulation interactions p = 0.0022 and 0.01, respectively). Diabetic bladders may undergo a transition from a compensated to a decompensated state and transition in the streptozotocin rat model may begin 9 to 12 weeks after induction.

Role of Oxidative Stress in the Pathophysiological Mechanism of Erectile Dysfunction

Center for Advanced Research in HumanReproduction, Infertility and Sexual Function, GlickmanUrological Institute, Cleveland Clinic Foundation, Glickman Urological Institute, Marymount Hospital,and the `Department of Internal Medicine and Pediatrics,Case Western Reserve University, MetroHealth MedicalCenter, Cleveland, Ohio.Erectile dysfunction (ED) is defined as the inability toachieve or maintain erections sufficient for satisfactorysexual intercourse (NIH Consensus Conference, 1993).It is estimated that the prevalence of ED will double inthe next 25 years. Normal erectile function depends ona precise balance between psychological, hormonal,neurological, vascular, and cavernosal factors. There-fore, an alteration in any one or combination of thesefactors may lead to ED. For many years, the complexinteraction between the origin of impulse and thenormal erectile response was not clearly understood. Itwas not until the early 1990s when the roles of centraland peripheral phenomena in the normal erectileresponse was proposed. The identification of the rolesof various mediators, as well as their interactions, innormal erectile function is a major development in thestudy of ED.Production of nitric oxide (NO) plays a centralphysiological role in erections. The endothelium is theprimary source of NO (Burnett, 1997). The pathophys-iological mechanism of endothelial dysfunction ismultifactorial, and the major outcome is impairedrelease of NO, which leads to ED. Although NO-mediated relaxation plays a central role in erections,other mediators, such as prostaglandins, endothelin, andbradykinins, are also important in maintaining peniletone. Researchers have made great strides in the pasttwo decades in identifying the pathophysiologicalmechanism in ED. However, the precise pathophysio-logical mechanism is still unclear.There is a growing interest among researchers re-garding the role of oxidative stress in the pathophysi-ological mechanism of ED. Oxidative stress occurs whenthere is an imbalance between pro-oxidants and theability of the antioxidants to scavenge excess reactiveoxygen species. The role of oxidative stress and reactiveoxygen species has been extensively evaluated in thepathophysiological mechanisms of male and femaleinfertility. However, its role in ED has not beeninvestigated comprehensively. Initial reports from bothin vitro and in vivo studies have shown a significantassociation between the production of reactive oxygenspecies and erectile dysfunction, especially in diabeticanimal models.In this article, we discuss the role of oxidative stress inthe pathophysiological mechanism of ED and thetherapeutic interventions and preventive strategies thatmay be beneficial in restoring endothelial function andnormal erectile function.

Open Partial Nephrectomy for Tumor in a Solitary Kidney: Experience With 400 Cases

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. 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. 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. 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.

Real-Time Transrectal Ultrasound Guidance During Laparoscopic Radical Prostatectomy: Impact on Surgical Margins

We evaluated whether intraoperative real-time TRUS navigation during LRP can decrease the incidence of positive surgical margins. Since March 2001, 294 patients with clinically organ confined prostate cancer undergoing LRP have been retrospectively divided into 2 groups, including group 1-217 who underwent LRP without TRUS from March 2001 to February 2003 and group 2-77 who have undergone LRP with TRUS since March 2003. Various baseline parameters were similar between the groups. Before March 2001 the senior surgeon had already performed more than 50 cases of LRP, thus, gaining reasonable familiarity with the technique. Compared to group 1, group 2 had a significantly decreased rate of positive surgical margins in patients with pT3 disease (57% vs 18%, p = 0.002). Positive margin rates also decreased in our overall experience (29% vs 9%, p = 0.0002). Intraoperative TRUS correctly predicted pT2 and pT3 disease in 85% and 86% of patients, respectively. Of the 54 TRUS visualized hypoechoic lesions at sites corresponding to biopsy proven cancer extracapsular extension was suspected in 31, leading to a real-time recommendation of calibrated wider, site specific dissection to achieve negative surgical margins. Intraoperative TRUS monitoring during LRP allows individualized, precise dissection tailored to the specific prostate contour anatomy, thus, compensating for the muted tactile feedback of laparoscopy. In what is to our knowledge the initial experience real-time TRUS guidance significantly decreased the incidence of positive surgical margins during LRP. In the future this concept of rectum based, intraoperative real-time navigation may facilitate a more sophisticated performance of radical prostatectomy.

Laparoscopic Partial Nephrectomy in Solitary Kidney

We report our experience with LPN for tumor in a solitary kidney. Of 430 patients undergoing LPN since February 1999 at our institution 22 (5%) underwent LPN for tumor in a solitary kidney, as performed by a single surgeon. The laparoscopic technique that we used duplicated open principles, including hilar clamping, cold cut tumor excision and sutured renal reconstruction. Mean tumor size was 3.6 cm (range 1.4 to 8.3, median 3 cm), median blood loss was 200 cc (range 50 to 500), warm ischemia time was 29 minutes (range 14 to 55), total operative time was 3.3 hours (range 2.2 to 4.5) and hospital stay was 2.8 days (range 1.3 to 12). Two cases (9%) were electively converted to open surgery. Pathological findings confirmed renal cell carcinoma in 16 patients (73%) with negative surgical margins in all those with LPN. Major complications occurred in 3 patients (15%) and minor complications developed in 7 (32%). Median preoperative and postoperative serum creatinine (1.2 and 1.5 mg/dl) and estimated glomerular filtration rate (67.5 and 50 ml per minute per 1.73 m2) reflected a change of 33% and 27%, respectively, which appeared proportionate to the median amount of kidney parenchyma excised (23%). One patient (4.5%) required temporary hemodialysis. At a median followup of 2.5 years (range 0.5 to 4.5) cancer specific and overall survival was 100% and 91%, respectively. No patient with LPN had local or port site recurrence, or metastatic disease. LPN can be performed efficaciously and safely in select patients with tumor in a solitary kidney. To our knowledge we present the largest series in the literature. Advanced laparoscopic experience and expertise are necessary in this high risk population.

Renal cryoablation: Outcome at 3 years: Gill IS, Remer EM, Hasan WA, Strzempkowski B, Spaliviero M, Steinberg AP, Kaouk JH, Desai MM, Novick AC, Section of Laparoscopic and Minimally Invasive Surgery, Glickman Urological Institute and Department of Radiology, Cleveland Clinic Foundation, Cleveland, OH

We report intermediate term oncological followup data on 56 patients undergoing laparoscopic renal cryoablation, of whom each completed a 3-year followup. Since September 1997, 56 patients undergoing laparoscopic renal cryoablation have completed a followup of 3 years each. The postoperative followup protocol comprised serial magnetic resonance imaging (MRI) at 1 day, months 1, 3, 6, 12, 18 and 24, and yearly thereafter for 5 years. Computerized tomography guided needle biopsy of the cryolesion was performed 6 months postoperatively and repeated if MRI findings were abnormal. Followup data were obtained prospectively. For a mean renal tumor size of 2.3 cm mean intraoperative size of the created cryolesion was 3.6 cm. Sequential mean cryolesion size on MRI on postoperative 1 day, and at 3 and 6 months, and 1, 2 and 3 years was 3.7, 2.8, 2.3, 1.7, 1.2 and 0.9 cm, representing a 26%, 39%, 56%, 69% and 75% percent reduction in cryolesion size at 3 and 6 months, and 1, 2 and 3 years, respectively. At 3 years 17 cryolesions (38%) had completely disappeared on MRI. Postoperative needle biopsy identified locally persistent/recurrent renal tumor in 2 patients. In the 51 patients undergoing cryotherapy for a unilateral, sporadic renal tumor 3-year cancer specific survival was 98%. There was no open conversion, kidney loss, urinary fistula, dialysis requirement, or perirenal or port site recurrence in any patients. Three-year outcomes following renal cryoablation are encouraging. Longer term (5-year) data are necessary to determine the proper place of renal cryotherapy among minimally invasive, nephron sparing options.

LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR CYSTIC MASSES

Although laparoscopic partial nephrectomy (LPN) has emerged as an effective treatment option in select patients with a solid renal tumor, scant data are available on cystic renal tumors. We report our experience with LPN in 50 patients with a cystic renal lesion. Of 284 patients undergoing LPN at our institution since August 1999 preoperative computerized tomography identified a suspicious cystic lesion in 50 (17.6%) (group 1). Data were retrospectively compared with those on 50 matched, consecutive patients undergoing LPN for a solid renal mass (group 2). All patients with Bosniak II/IIF cysts were advised to undergo watchful waiting. Surgery was offered if the cyst changed in character or if that was the patient preference. Median tumor size was 3 cm in group 1 and 2.6 cm in group 2 (p = 0.07). Groups 1 and 2 were comparable in regard to perioperative parameters. In patients with Bosniak II (9), IIF (4), III (12) and IV (21) cysts final histopathology revealed renal cell carcinoma in 22%, 25%, 50% and 90%, respectively. All 100 patients had a negative surgical margin. No patient in group 1 had intraoperative puncture/spillage of the cystic tumor. In group 1 during a mean followup of 14 months (range 1 month to 3 years) 1 patient had retroperitoneal recurrence at 1 year despite negative surgical margins during initial LPN. Surgical outcomes of LPN for suspicious cystic masses are similar to those of LPN for solid tumors. However, extreme caution and refined laparoscopic technique must be exercised to avoid cyst rupture and local spillage.