Organ-sparing Surgery Research Articles

Organ-sparing surgery is the treatment of choice in benign testicular tumors

Ablation of the testis has been the reference standard for malignant and benign testicular tumors in the past. Nowadays, an organ-sparing surgery (OSS) can be attempted in special cases. Removal of a testis for a benign lesion should be avoided. In this retrospective survey, we analyze the results and long-term follow-up of OSS in benign testicular tumors. Charts of all patients that underwent OSS because of a benign testicular tumor between 1999 and 2011 at our department were searched and the data from patients were collected. Before surgery, all patients underwent ultrasound (US) and complete staging. Surgery was performed under US or palpation guidance. Frozen-section examination of the tumor and tumor bed biopsies was obtained. All patients underwent postoperative follow-up. We retrospectively reviewed surgical technique, histology, epidemiology, and outcome in all patients. In the study period, 40 benign testicular tumors were surgically removed in 37 consecutive patients. Definitive histology did not report of any malignant histopathologic features in all patients. All patients are free of disease after a mean follow-up of 63months (range 10-120). During this period, two patients developed a second leydig cell tumor (LCT) on the contralateral side; another patient had a second LCT within the same testicle, but on the opposite pole. All patients underwent a subsequent organ-sparing tumor resection. An overtreatment for benign testicular tumors should be avoided. Our initial results indicate that OSS in benign tumors is a safe, feasible treatment for patients.

Testis sparing surgery for Leydig cell tumors: New three cases and review of the current literature

IntroductionLeydig cells tumors of the testis are uncommon, representing between 1 and 3% of the testicular tumors and for which the natural history and therapy are debated between radical orchitectomy and organ-sparing surgery. Subjects and methodsWe report three new cases of Leydig cells tumors, treated in our department and we discuss the clinical, diagnostic and therapeutic aspects of this uncommon tumor. ResultsThe mean patient age was 29 years (23–37 years). Medical referral was for a testicular pain in two and gynecomastia in one case. All patients were treated surgically, through an inguinal incision and the procedure included clamping of the spermatic cord. During surgery, frozen section were analyzed in two cases and the tumor enucleation with organ-sparing surgery was performed. The other patient had an unilateral orchidectomy and controlateral tumorectomy. The mean follow-up was 40 months with no local recurrence. ConclusionPatients diagnosed with Leydig cells tumors have a good prognosis; this study shows the safety of conservative surgery treatment, provided it is subsequently followed by close surveillance, as it preserves maximum fertility, and these tumors usually have a favorable prognosis.

Reply

We appreciate the editorial comment on our article. The comment highlighted the 2 most important aspects in organ sparing surgery, cancer control and preservation of function of the native organ. With regard to these aspects, testicular-sparing surgery (TSS) draws comparison with nephron-sparing surgery for renal tumors. Both surgeries aim for complete tumor resection while preserving the functions of the remaining organs, but while nephron-sparing surgery has evolved over many years and is now considered a standard procedure for small renal tumors, TSS is an evolving surgical technique that is not yet widely practiced. Editorial CommentUrologyVol. 81Issue 4PreviewThe authors describe an interesting technique for testicular preservation surgery using a hook wire localization method in conjunction with intraoperative Doppler imaging to remove a testicular mass. A similar technique using placement of a comparable needle adjacent to the tumor was reported by Hallak et al (referenced above) but the current report involves needle deployment directly into the testicular lesion. Both reports advocate cold ischemia resection, but the current article does not use concurrent frozen section assessment of tumor margins. Full-Text PDF

Editorial Comment

The authors describe an interesting technique for testicular preservation surgery using a hook wire localization method in conjunction with intraoperative Doppler imaging to remove a testicular mass. A similar technique using placement of a comparable needle adjacent to the tumor was reported by Hallak et al (referenced above) but the current report involves needle deployment directly into the testicular lesion. Both reports advocate cold ischemia resection, but the current article does not use concurrent frozen section assessment of tumor margins. Hook Wire Localization for Testis Sparing SurgeryUrologyVol. 81Issue 4PreviewTo describe a novel technique for localizing small testicular mass during testicular-sparing surgery (TSS). Full-Text PDF ReplyUrologyVol. 81Issue 4PreviewWe appreciate the editorial comment on our article. The comment highlighted the 2 most important aspects in organ sparing surgery, cancer control and preservation of function of the native organ. With regard to these aspects, testicular-sparing surgery (TSS) draws comparison with nephron-sparing surgery for renal tumors. Both surgeries aim for complete tumor resection while preserving the functions of the remaining organs, but while nephron-sparing surgery has evolved over many years and is now considered a standard procedure for small renal tumors, TSS is an evolving surgical technique that is not yet widely practiced. Full-Text PDF

Genital lichen sclerosus/balanitis xerotica obliterans in men with penile carcinoma: a critical analysis

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The European Association of Urology guidelines identify lichen sclerosus (LS) as a strong risk factor for penile squamous cell carcinoma (pSCC). However, this statement is based on the findings of case-control studies (Level of Evidence 2a) and a direct causal relationship between LS/balanitis xerotica obliterans (BXO) and pSCC remains to be established. Firm guidelines with respect to the appropriate follow-up policy for LS/BXO are lacking, whereas the impact of synchronous LS/BXO on the prognosis of pSCC remains to be determined. The presence of histologically-confirmed synchronous LS/BXO in patients diagnosed with pSCC is relatively high, although it is not associated with an increased risk of adverse histopathological features. LS/BXO can develop in extragenital skin grafts used for reconstruction after organ-sparing surgery for pSCC. To determine the rate of lichen sclerosus/balanitis xerotica obliterans (LS/BXO) in patients with penile squamous cell carcinoma (pSCC) and establish whether the presence of LS/BXO is associated with adverse histopathological features of pSCC. To report the phenomenon of LS involving non-genital skin grafts in patients who underwent organ-sparing surgery and split-skin graft (SSG) reconstruction Between January 2002 and January 2010, 223 men underwent surgical treatment for pSCC. A group of 52 patients with histologically-confirmed synchronous LS was identified (group A; overall rate of LS/BXO = 23.3%) and compared with a group of patients without synchronous LS (group B; n = 171; 76.7%). A subgroup of patients who underwent surgical excision and SSG reconstruction was also identified The histology reports of graft biopsies obtained during follow-up were reviewed and the rate of LS involving the graft was also recorded. Mean (range) age at diagnosis was 60.9 (34-81) years and 60.7 (28-89) years for groups A and B, respectively (P = 0.958). The mean (range) duration of follow-up was 38.3 (4-92) months for group A and 45.5 (4-107) months for group B (P = 0.162) No statistically significant differences were noted between groups A and B in terms of tumour grade (P = 0.091), stage (P = 0.697), presence of lymphovascular invasion (P = 0.333), histological subtype (P = 0.107), associated carcinoma in situ (P = 0.246) or nodal status at initial diagnosis (P = 0.555). In the subgroup of 188 patients who underwent SSG reconstruction, 41 (21.8%) patients had histologically-confirmed synchronous LS; in this subgroup, 26 (13.8%) patients underwent graft biopsy during follow-up. Genital LS involving the graft was identified in seven specimens, although none of these seven cases had associated recurrent pSCC. The presence of histologically-confirmed synchronous LS in patients with pSCC is relatively high but is not associated with increased rates of adverse histopathological features, including carcinoma in situ. LS can develop in extragenital skin grafts, although its association with the long-term risk for recurrent pSCC is not apparent in the present study.

Retroperitoneoscopic renal pelvis resection as treatment of the urothelial tumor in asolitary kidney

Urothelial carcinoma of the upper urinary tract is relatively rare. The standard treatment is invariably radical nephroureterectomy. In selected cases organ sparing surgery is justified. We present the case of the tumor of the kidney pelvis in a solitary organ where laparoscopic approach was successfully applied.

Neoadjuvant treatment in advanced renal cell carcinoma: current situation and future perspectives

Neoadjuvant approaches in renal cell carcinoma are currently under investigation, following the demonstration of targeted therapy efficacy in the metastatic setting. It raises the issues of downsizing locally advanced or nonresectable tumor and offering organ-sparing surgery, saety and its potential role in early micrometastatic disease. Relevant studies of the neoadjuvant setting in renal cell carcinoma with targeted therapies were identified from the literature, clinical trial databases and conference abstracts. To date, a neoadjuvant approach appears feasible in terms of saety. Currently available drugs do not achieve major tumor downsizing with primary tumor diameters response rate of 10%. Neoadjuvants should only be considered in clinical trials or as a litmus test in locally advanced patients.

Conservative Surgery for Squamous Cell Carcinoma of the Penis: Resection Margins and Long-Term Oncological Control

We assessed the oncological outcome of penile conserving surgery and identified parameters predicting local recurrence, including resection margins. A total of 179 patients with invasive penile cancer treated with organ sparing surgery at a tertiary center between 2002 and 2010 fulfilled our study criteria. Demographic, histopathological, management and followup data were recorded in a prospective database. Local, regional and distant recurrence rates, time to recurrence and survival rates were calculated. Survival analysis was performed by the Kaplan-Meier method. Multivariate analysis was used to identify predictors of local recurrence. Mean followup was 42.8 months (range 4 to 107). Local, regional and distant metastatic recurrence developed in 16 (8.9%), 19 (10.6%) and 9 patients (5.0%) at a mean of 26.1, 26.8 and 11.7 months, respectively. The 5-year disease specific survival rate after recurrence was 54.7% (95% CI 46.1-63.3). For patients with isolated local recurrence the 5-year disease specific survival rate was 91.7% compared to 38.4% for those with regional recurrence. The overall 5-year local recurrence-free rate was 86.3% (95% CI 82.6-90.4). Tumor grade (p = 0.003), stage (p = 0.021) and lymphovascular invasion (p = 0.014) were identified as predictors of local recurrence on multivariate analysis. Penile conserving surgery is oncologically safe and a surgical excision margin of less than 5 mm is adequate. Higher local recurrence rates are associated with lymphovascular invasion, and higher tumor stage and grade. Local recurrence has no negative impact on long-term survival.

Transoral laser surgery for hypopharyngeal carcinomas

Organ preservation strategies are a major focus of interest in head and neck cancer. There are two ways to preserve the function in the treatment of squamous cell carcinomas of the hypopharynx: organ-sparing surgery or neoadjuvant or concomitant chemoradiotherapy. From the surgical point of view, the possibilities of organ sparing have been increased with the use of transoral carbon dioxide laser surgery. Our purpose is to review this technique as a preservation surgical strategy for hypopharyngeal carcinomas. The role of primary surgery in the initial treatment of head and neck carcinomas is being reviewed. The transoral laser resection of hypopharyngeal carcinomas is the least established of the transoral laser surgical approaches. Recent data suggest that selected hypopharyngeal tumors may be treated with transoral laser surgery, achieving very good oncologic and functional outcomes. Transoral carbon dioxide laser surgery is an alternative to treat hypopharyngeal carcinomas. Early tumors may be removed by a transoral approach with high local control rates and function preservation in most of the patients. For more advanced tumors experience is still limited, and the role of this technique has not yet been defined.

URINARY TRACT INFECTION Acute epididymo-orchitis: staging and treatment

IntroductionAcute epididymo-orchitis (AEO) is an acute inflammatory disease of the epididymis and ipsilateral testis. Treatment should be started immediately after diagnosis and includes antibiotics, analgesics, and, if necessary, surgery.Materials and methodsAfter AEO diagnosis, patients were treated conservatively with analgesics and antibiotics. If no clinical improvement was observed within the first 48-72 hours of conservative treatment, patients underwent surgery. Depending on examination results, 254 patients (pts.) were divided into three groups: 1) with palpable differences between the epididymis and testis (E/T+), and without neither hydrocele, local softening (malacia), nor abscess of the epididymis or testis; 2) with E/T+, absence of malacia, presence of hydrocele, and none, one, or a few small abscesses within the epididymis/testis and 3) without palpatory differentiation between the epididymis and testis, with or without malacia, with hydrocele, and none, one, or more abscesses of any size. We analyzed the clinical outcomes in each group.ResultsAll of patients from the first group were successfully treated with antibiotics. In the second group, conservative treatment was effective in 70 pts. (85.4% of this group), but the other 12 pts. (14.6%) did not show clinical improvement and underwent organ-sparing surgery. The majority of patients from the third group did not demonstrate an objective response to antibacterial treatment during the first 48-72 hours and, therefore, underwent surgery. Based on examination results and clinical outcomes we developed a classification system for AEO, which divides AEO into three stages and recommends an approach to its treatment.ConclusionsOur classification is able to systematize treatment approaches in patients with AEO.

Organ-sparing surgery for breast cancer

The paper describes the experience in treating 389 breast cancer patients undergoing organ-sparing operations with and without plastic surgery. Both the patients' tissues and their combination with a silicone endoprosthesis were used for repair. The specific features of a recurrence were analyzed after organ-sparing surgery depending on the stage, treatment method (surgical or combination) and histogenesis of a tumor.

Risk factors for recurrent breast cancer after combination treatment

Two hundred and eighteen patients aged 31 to 92 years (mean age 57+1.3 years), who had been treated for breast cancer (BC), were examined. They were divided into 2 groups: 1) 99 patients who had undergone organ-sparing surgery (OSS) and 2) 119 patients after radical mastectomy (RME). The degree of primary tumor differentiation, metastases to regional lymph nodes, and the immunohistochemical pattern of a tumor (ER, PR, and HER-2/neu) were assessed as prognostic factors. The local recurrence rate was found to be 13 and 9% in Groups 1 and 2, respectively. The relapse-free period averaged 53+8 and 56+10 months in Groups 1 and 2, respectively. The degree of tumor differentiation, metastases to regional lymph nodes, the receptor status (ER, PR) of a primary tumor in both groups, and the expression of HER-2/neu after RME do not affect the occurrence of recurrent BC at the 0.05 significance level. In the post-OSS patients, the HER-2/neu-positive primary tumor showed a statistically significant correlation with the rate of recurrent BC at the 0.05 significance level.

Organ-sparing surgery of the bilateral testicular large cell calcifying sertoli cell tumor in patient with atypical Peutz–Jeghers syndrome

Large cell calcifying sertoli cell tumor (LCCSCT) is an exceptionally rare neoplasm originating from sperm cord cells. The tumors have relatively low malignant potential and unlikely proceed to metastasis formation. The lesions may occur in an isolated form or in ca. 40% of cases may be associated with genetic abnormalities, by and large Peutz–Jeghers syndrome and Carney complex. At presentation, 20% of LCCSCT cases are bilateral and/or multifocal. Owning to characteristic skin lesions and particular hyperechoic ultrasound image of the tumor, preliminary diagnosis of the syndromic LCCSCT is possible in the preoperative period. Consequently, testicle organ–sparing procedure can be attempted, which is especially justified in bilateral lesions. Here, we report a case of a bilateral LCCSCT in a 20-year-old man with atypical Peutz–Jeghers syndrome due to amplification of the exon 1 of STK11 gene who was successfully treated with bilateral testicle-sparing tumorectomies.

Organ-sparing Surgery for Penile Cancer: Complications and Outcomes

To evaluate the complications and outcomes of organ-sparing surgery in penile cancer. Thirty-two penile cancer patients had undergone organ-sparing surgery between 2006 and 2010 in Fudan University Shanghai Cancer Center. Applied surgical techniques included radical circumcision and/or wide local excision. Intraoperative frozen section analyses of circumference and deep margins were performed to guarantee complete removal of cancerous tissue. Complications and oncological and functional outcomes were recorded prospectively. Bilateral inguinal lymphadenectomy was routinely performed in patients with invasive penile cancer. Of 32 patients, 8 underwent radical circumcision, 18 were treated with wide local excision, and 6 received wide local excision and circumcision. Postoperatively, only 3 (9.4%) patients had minor complications. With a median follow-up of 26.5 months, local control was achieved in 29 (90.6%) patients, and 3 patients (9.4%) with positive lymph nodes died of disseminated disease. Of 29 patients who completed follow-up surveys of functional outcome, only 1 (4.5%) claimed decreased sexual function and all reported satisfied urination. Organ-sparing surgery, such as radical circumcision and wide local excision is an appropriate treatment option for selected penile cancer patients. It preserves sexual and urination function without significantly increasing the risk of recurrence.

Long-Term Outcome of Excisional Organ Sparing Surgery for Carcinoma of the Penis

We present our experience with penile sparing surgery for localized carcinoma in situ and T1 penile squamous cell carcinoma. We report outcomes and recommendations for a penile sparing approach. A total of 60 patients underwent penile sparing surgery for penile squamous cell carcinoma since 1995. Four patients without recurrence had less than 6 months of followup and were excluded from study. Data included disease stage, cellular differentiation, tumor site, penile sparing surgery type and recurrence information. Followup was adequate in 28 patients with carcinoma in situ and in 28 with T1 disease. The overall recurrence rate was 21.4% with equal recurrences of carcinoma in situ and T1 tumors (each 21.4%). Mean ± SD time to recurrence was 4.28 ± 2.81 years (range 0.5 to 11). More than 25% of recurrences developed after 5 years. Mean followup in censored patients was 5.47 ± 3.88 years (maximum 16). There was no difference in time to recurrence after carcinoma in situ and T1 tumors (p = 0.738). T1 tumors on the glans carried a slightly higher risk of recurrence (p = 0.049). At 5 years 13.8% of patients at risk had late recurrence with a mean time to recurrence of 7.25 ± 2.62 years. No patients with carcinoma in situ showed invasion or metastasis. Two patients with T1 disease presented with metastasis and 3 had late metastasis. Penile sparing surgery is a safe option for local control for appropriate carcinoma in situ and T1 squamous cell carcinoma of the penis. Carcinoma in situ recurrence may be re-treated with penile sparing surgery. T1 tumors that recur require more aggressive resection. Our data show significant late recurrences in patients and the need for long-term followup.

Development of male genital lichen sclerosus in penile reconstruction skin grafts after cancer surgery: an unreported complication

• To describe the incidence of the development of male genital lichen sclerosus (LS) in non-genital skin grafts used in penile reconstruction after cancer surgery. • Between 1997 and 2009, 177 patients received surgical treatment for penile cancer in the Urology Department at Sunderland Royal Hospital, the regional penile cancer centre for the north-east of England. • Patients who had organ-sparing surgery and non-genital penile graft reconstructions were identified. • Histology reports for specimens obtained from those grafts were reviewed to identify the presence of male genital LS and the incidence of recurrence of squamous cell carcinoma (SCC). • The mean (range) age of patients at diagnosis was 61.8 (32-89) years. Of the 177 patients, 139 had SCC, 32 had carcinoma in situ and six had verrucous carcinoma. • In total, 56 penile reconstructive procedures were performed using split-thickness skin grafts obtained from the inner thigh. • From those grafts, 18 specimens were obtained later for cosmetic, diagnostic or curative purposes. • Male genital LS was found in six of the 18 specimens, and one of them was associated with recurrent verrucous carcinoma. • This is the first published series to describe the incidence of male genital LS in penile skin grafts taken from a remote site after penile cancer surgery. • These results represent new information that might help explain the aetiology of male genital LS.

Nierenzellkarzinom: Was gibt es Neues im Jahr 2010?

This overview presents new insights into renal cell carcinoma (RCC). The search for new target structures for targeted therapy as well as diagnostic and prognostic markers continues to remain a desirable area of research. Investigations are focusing on the use of well-established and new therapeutic agents for metastatic RCC and an increasingly liberal indication for organ-sparing surgery for renal tumors. The response to systemic treatment in metastatic RCC is also being evaluated in defined subpopulations.

Increased incidence of Leydig cell tumours of the testis in the era of improved imaging techniques

To report an observed high frequency of Leydig cell tumours (LCTs) diagnosed at our centre. Charts of all patients who underwent surgery for a testicular tumour between 1999 and 2008 at our department were searched and data from patients with LCT were collected. Before surgery all patients underwent ultrasound and complete staging. In all but two patients with LCT an organ-sparing surgery was performed. Surgery was performed under ultrasound or palpation guidance. All patients underwent postoperative follow-up. We retrospectively reviewed surgical technique, histology, epidemiology and outcome in all LCT patients. In the study period, 197 testicular tumours were surgically removed of which 29 were diagnosed as LCT (14.7% of 197; further study group) in 25 patients. Mean age of patients with LCT was 45 years (range 21-68 years). Tumour size ranged from 1.2 to 80 mm (mean 10.23 mm). In two patients (8%) the lesion was palpable whereas incidental diagnosis was made in seven patients (28%). In the remaining patients diagnosis was made by ultrasound performed for testicular pain (six patients, 24%) or during infertility or erectile dysfunction evaluation (10 patients, 40%). Definitive histology reported no malignant histopathological features in all but one patient; this particular patient experienced tumour progression after 2 months and died from advanced disease 1 year later. All other patients are free of disease after a mean follow up of 56 months (range 7-93 months). During this period one patient developed a second LCT on the contralateral side; another patient had a recurrence within the same testicle, but on the opposite pole. Both underwent a subsequent organ-sparing tumour resection. The percentage of LCT (14.7% of all testicular tumours removed) was significantly higher than expected from the literature. One possible explanation for this phenomenon is the increasing use of better ultrasound technology and the subsequent increased detection of small nodules that have not been found in historical series. Use of 'observation-only' for very small lesions detected at infertility clinics is under debate.

Aesthetic neo-glans reconstruction after penis-sparing surgery for benign, premalignant or malignant penile lesions

PurposeTo describe the technique and results of penis-sparing surgery combined with a cosmetic neo-glans reconstruction for benign, pre-malignant or malignant penile lesions. Patients and methodsTwenty-one patients (mean age 61years) with penile lesions with a broad spectrum of histopathology underwent organ-sparing surgery with neo-glans reconstruction, using a free split-thickness skin graft harvested from the thigh. Three patients were treated by glans-skinning and glans-resurfacing, 10 by glansectomy and neo-glans reconstruction, four by partial penectomy and a neo-glans reconstruction, and four by neo-glans reconstruction after a traditional partial penectomy. ResultsThe mean follow-up was 45months; all patients were free of primary local disease. All patients were satisfied with the appearance of the penis after surgery, and recovered their sexual ability, although sensitivity was reduced as a consequence of glans/penile amputation. ConclusionIn benign, premalignant or malignant penile lesions, penis-sparing surgery combined with a cosmetic neo-glans reconstruction can be used to assure a normally appearing and functional penis, while fully eradicating the primary local disease.

Radical or simple nephrectomy in localized renal cell carcinoma: what is a choice?

IntroductionRenal cell carcinoma (RCC) accounts for approximately 3% of all adult malignancies. Surgery remains the only effective method of renal tumors treatment. In fact, for advanced RCC, radical nephrectomy (RN) should remain a standard treatment. However, in localized RCC (LRCC) a real increase of survival rates realized by RN compared with simple nephrectomy (SN) or organ-sparing surgery is discussable. The aim of our study was to assess the impact of nephrectomy type on the prognosis of LRCC treatment.Material and methodsWe analyzed the long-term outcomes of RN (n = 248 pts.) and SN (n = 170 pts.) in 418 pts. with LRCC. There were no significant statistical differences in tumor stages, age stratification or gender between these two groups. To compare the efficacy of RN and SN we determined overall survival (OS) and cancer-specific survival (CSS) rates in both divided groups. The 3-year OS in RN group was 93.1% vs. 91.8% in SN group.ResultsCSS rates after the same period were 96.8% vs. 94.7% respectively. The 5-year OS in RN group was 91.5% vs. 88.8% in SN group. After 5 years of follow-up, CSS in RN group was 94.4% vs. 92.4% in SN group. Type of nephrectomy does not influence on LRCC outcomes. The 3- and 5-year overall survival rates and cancer-specific survival rates in RN and SN group were almost identical.ConclusionHence, if radical nephrectomy does not ensure better survival than simple nephrectomy, the expediency of vast surgery in localized RCC is doubtful.