Robotic-assisted laparoscopic partial nephrectomy: A comparison of approaches to the posterior renal mass

AIM: To evaluate outcomes of robotic-assisted laparoscopic partial nephrectomy performed for posterior renal tumors via a transperitoneal or retroperitoneal approach.METHODS: Retrospective review was performed for patients who underwent robotic-assisted laparoscopic partial nephrectomy(RALPN) for a posterior renal tumor between 2009-2015. Patient demographic characteristics, operative factors, pathology, oncologic outcomes, renal function, and tumor complexity were obtained. Radius of the tumor, exophytic/endophytic properties of the tumor, nearness of tumor to the collecting system, anterior/posterior position, location relative to the polar line(RENAL) nephrometry scores were calculated. nephrometry scores were calculated. The operative approach was determined by the primary surgeon. RESULTS: A total of 91 patients were identified who underwent RALPN for a posterior renal tumor. Fifty-four procedures were performed via the retroperitoneal(RP) approach, and 37 via the transperitoneal(TP) approach. There were no significant differences in patient factors(race, sex, age and body mass index), RENAL nephrometry scores, tumor size, conversion rates, or margin status. Among procedures performed on-clamp, therewas no significant difference in warm ischemia times. Total operative time(180.7 min for RP vs 227.8 min for TP, P < 0.001), robotic console time(126.9 min for RP vs 164.3 min for TP, P < 0.001), and median estimated blood loss(32.5 m L for RP vs 150 mL for TP, P < 0.001) were significantly lower via the RP approach. Off-clamp RALPN was performed for 31(57.4%) of RP procedures vs 9(24.3%) of TP procedures. Oncologic and renal functional outcomes were equivalent.CONCLUSION: The RP approach to RALPN for posterior renal tumors is superior with regard to operative time and blood loss and the ability to be performed off-clamp.

Adjuvant radiotherapy for pathologically advanced prostate cancer improves biochemical recurrence free survival compared to salvage radiotherapy

AIM: To evaluate the long-term outcomes of patients receiving adjuvant and salvage radiotherapy following prostatectomy with adverse pathologic features and an undetectable prostate specific antigen(PSA).METHODS: A retrospective review was performed of patients who received post-prostatectomy radiation at Loyola University Medical Center between 1992 and 2013. Adverse pathologic features(Gleason score ≥ 8, seminal vesicle invasion, extracapsular extension, pathologic T4 disease, and/or positive surgical margins) and an undetectable PSA following prostatectomy were required for inclusion. Adjuvant patients received therapy with an undetectable PSA, salvage patients following biochemical recurrence(BCR). Post-radiation BCR, overall survival, bone metastases, and initiation of hormonal therapy were assessed. Kaplan-Meier time-to-event analyses and stepwise Cox proportional hazards regression(HR) were performed. RESULTS: Post-prostatectomy patients(n = 134) received either adjuvant(n = 47) or salvage(n = 87) radiation. Median age at radiotherapy(RT) was 63 years, and median follow-up was 53 mo. Five-year post-radiation BCR-free survival was 78% for adjuvant vs 50% salvage radiotherapy(SRT)(Logrank P = 0.001). Patients with radiation administered following a detectable PSA had an increased risk of BCR compared to undetectable: PSA > 0.0-0.2: HR = 4.1(95%CI: 1.5-11.2; P = 0.005); PSA > 0.2-1.0: HR = 4.4(95%CI: 1.6-11.9; P = 0.003); and PSA > 1.0: HR = 52(95%CI: 12.9-210; P < 0.001). There was no demonstrable difference in rates of overall survival, bone metastases or utilization of hormonal therapy between adjuvant and SRT patients. CONCLUSION: Adjuvant RT improves BCR-free survival compared to SRT in patients with adverse pathologic features and an undetectable post-prostatectomy PSA.

Perioperative outcomes and survival of radical cystectomy as a function of body mass index

AIM: To evaluate the perioperative and long term outcomes of cystectomy in obese patients.METHODS: This is a retrospective review of 580 patients for whom radical cystectomy(RC) was performed for primary urothelial bladder cancer between November 1996-April 2013 at a single institution. Body mass index(BMI) was available for 424 patients who were categorized as underweight(< 18.5), normal(18.5-24.9), overweight(25.0-29.9), and obese(≥ 30). Baseline demographics, perioperative outcomes, and survival were assessed. Overall survival(OS) and disease specific survival(DSS) was estimated by Kaplan-Meier method. Medians were compared using the Mann-Whitney U Test. Categorical variables were compared using the χ2 test. A P-value of < 0.05 was considered statistically significant. Statistical analyses were performed using the Software Package for the Social Sciences(SPSS), Version 20(International Business Machines SPSS, Chicago, IL, United States). RESULTS: The median age of all patients was 69 years(inter-quartile range 60-75) and median followup was 23.4 mo(8.7-55.1). Patients were characterized as underweight [9,(2.1%)], normal [113,(26.7%)],overweight [160,(37.8%)], or obese [142,(33.5%)]. Estimated blood loss during RC was higher in the obese group(800 m L) as compared to the normal weight group(500 m L). However, need for transfusion(47.7% vs 52.1%), number of lymph nodes resected(32 vs 30), length of stay(9 d vs 8 d), and 30-d readmission(29.7% vs 25.2%) between obese and normal BMI patients were similar. Obese patients underwent ileal neobladder diversion in 42% of cases, compared to 24% of normal BMI patients(0.003). Normal BMI and obese patients had comparable urinary incontinence(21.4% vs 25.6%, P = 0.343), and need for intermittent catheterization(14.3% vs 5.2%, P = 0.685) at 2 years follow-up. Overall survival was better in obese compared to normal BMI patients on univariate analysis, with median survival of 67 mo vs 37 mo, respectively(P = 0.031). Disease specific survival in these populations followed the same Kaplan Meier curve, with the obese group having a significantly improved OS, P = 0.016. Underweight patients had a significantly worse prognosis, with a median overall survival of 19 mo(P = 0.018). Disease specific survival was significantly worse in the underweight group compared to the obese group, P = 0.007. On multivariate analysis underweight patients remained at increased risk for death(HR = 3.1, P = 0.006), as were older patients(HR = 1.6, P = 0.006), those with multiple nodal metastases(HR = 3.7, P = 0.007), and those who had received neoadjuvant chemotherapy(HR = 2.0, P = 0.015).CONCLUSION: Perioperative outcomes and survival following RC in obese patients is comparable with nonobese patients. Underweight patients have the worst OS and DSS.