Intermediate-term oncological outcomes of hand-assisted laparoscopic versus open bilateral nephroureterectomy for dialysis and kidney transplant patients with upper urinary tract urothelial carcinoma

PURPOSE

To compare the outcomes of hand-assisted laparoscopic bilateral nephroureterectomy (HALBNU) for dialysis and kidney transplant patients with clinically localized upper urinary tract urothelial carcinoma (UUT-UC) with those achieved by open bilateral nephroureterectomy (OBNU).

MATERIALS AND METHODS

Between 1995 and 2006, 49 patients under dialysis or after kidney transplantation underwent simultaneous bilateral nephroureterectomy for clinically presumed localized UUT-UC at our institute. Of those, 33 underwent HALBNU and 16 received conventional open surgery. Perioperative and pathological data and oncological outcomes were collected by chart review. Bladder recurrence, metastasis, and cancer-specific and overall survival were analyzed and compared between both groups.

RESULTS

The median follow-up for HALBNU and OBNU group was 35 and 46 months, respectively. Totally, 40 patients were identified to have pathologically confirmed urothelial carcinoma of upper urinary tract. HALBNU group was associated with less blood loss, earlier bowel recovery, less narcotic use, shorter hospital stay, and earlier convalescence. The operative time and complication rate were comparable between the two groups. There was no open conversion in the HALBNU group. The two groups were similar in regard to bladder recurrence rate. The overall, cancer-specific, and bladder-recurrence-free survival were also equivalent between the HALBNU and OBNU group (all p > 0.05).

CONCLUSION

In dialysis and kidney transplant patients with localized UUT-UC, simultaneous bilateral nephroureterectomy with hand-assisted laparoscopic approach offered less perioperative morbidity and, most importantly, comparable intermediate-term oncological and survival results when compared with its open counterpart. A longer follow-up is required to demonstrate the oncological efficacy of this minimally invasive procedure.

Characterization of membranous and cytoplasmic EGFR expression in human normal renal cortex and renal cell carcinoma

Metastatic renal cell carcinoma (RCC) is highly resistant to conventional systemic treatments, including chemotherapy, radiotherapy and hormonal therapies. Previous studies have shown over-expression of EGFR is associated with high grade tumors and a worse prognosis. Recent studies suggest anticancer therapies targeting the EGFR pathway have shown promising results in clinical trials of RCC patients. Therefore, characterization of the level and localization of EGFR expression in RCC is important for target-dependent therapy. In this study, we investigated the clinical significance of cellular localization of EGFR in human normal renal cortex and RCC. RCC and adjacent normal kidney tissues of 63 patients were obtained for characterization of EGFR expression. EGFR protein expression was assessed by immunohistochemistry on a scale from 0 to 300 (percentage of positive cells x staining intensity) and Western blotting. EGFR membranous staining was significantly stronger in RCC tumors than in normal tissues (P < 0.001). In contrast, EGFR cytoplasmic staining was significantly higher in normal than in tumor tissues (P < 0.001). The levels of membranous or cytoplasmic EGFR expression in RCC tissues were not correlated with sex, tumor grade, TNM stage or overall survival (P > 0.05). These results showed abundant expression of membranous EGFR in RCC, and abundant expression of cytoplasmic EGFR in normal tissues. EGFR expression in RCC was mostly located in the cell membrane, whereas the EGFR expression in normal renal tissues was chiefly seen in cytoplasm. Our results suggest different locations of EGFR expression may be associated with human renal tumorigenesis.

Choosing the ideal length of a double-pigtail ureteral stent according to body height: study based on a Chinese population

OBJECTIVE

We conducted this study to determine the ideal stent length according to body height, as data are limited.

PATIENTS AND METHODS

A total of 408 patients undergoing ureteroscopic lithotripsy and stent insertion (22, 24 or 26 cm) were enrolled. The appropriateness of the stent length was determined according to the plain films and was further compared among patients with different body heights and stent lengths.

RESULTS

In patients <160 cm, the use of a 22-cm stent was significantly more appropriate than a 24- or 26-cm stent (86.5, 51.9 and 46.4%). In patients between 160 and 175 cm, a 22- or 24-cm stent was significantly more appropriate than a 26-cm stent (79.2, 66.7 and 46.3%), while the difference between the use of a 22- and 24-cm stent was not significant. In patients >175 cm, a 24- or 26-cm stent might be more appropriate.

CONCLUSIONS

Body heights can predict the ideal stent length. Based on a Chinese population, a 22-cm stent length is more appropriate for those <175 cm. A longer, 24- or 26-cm stent may be suitable for those >175 cm.

5-HT2C-like receptors in the brain of Xenopus laevis initiate sex-typical fictive vocalizations

Vocalizations of male and female African clawed frogs (Xenopus laevis) are generated by brain stem central pattern generators. Serotonin (5-HT) is likely important for vocal initiation because, when applied in vitro, sex-typical fictive vocalizations are evoked from isolated brains. To explore the mechanisms underlying vocal initiation, we identified the types of serotonin receptors mediating vocal activation pharmacologically using a whole brain, fictive preparation. The results showed that 5-HT(2C)-like receptors are important for activation of fictive vocalizations in the sexes. 5-HT(2C) receptor agonists elicited fictive vocalizations, and 5-HT(2C) receptor antagonists blocked 5-HT-induced fictive vocalizations, whereas agonists and antagonists of 5-HT(2A) and 5-HT(2B) receptors failed to initiate or block 5-HT-induced fictive vocalizations in the sexes. The results indicate that serotonin initiates fictive vocalizations by binding to 5-HT(2C)-like receptors located either within or upstream of the vocal central pattern generator in both sexes. We conclude that the basic mechanism of vocal initiation is shared by the sexes despite the differences in the actual vocalizations between males and females. Sex-typical vocalizations, therefore, most likely arise from activation of different populations of 5-HT(2C) receptor expressing cells or from differential activation of downstream pattern generating neurons.

Long-term outcome of hand-assisted laparoscopic nephroureterectomy for pathologic T3 upper urinary tract urothelial carcinoma

PURPOSE

To determine the feasibility and long-term outcomes of hand-assisted laparoscopic nephroureterectomy (HALNU) compared with open nephroureterectomy (ONU) in the management of pT(3)N0 upper urinary tract urothelial carcinoma (UUT-UC).

PATIENTS AND METHODS

Between January 1994 and December 2005, 21 patients who underwent HALNU for stage pT(3)N0 UTT-UC were matched and compared with 31 patients who underwent ONU. The oncologic out-comes, including bladder recurrence, recurrence-free survival, cancer-specific survival, and overall survival, were statistically analyzed.

RESULTS

The median follow-up period in the HALNU group was 72 months (range 33-111 months) and 115 months in the ONU group (range 24-161 months). Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant difference between the two groups. The HALNU group had statistically less blood loss than the ONU group (113 mL versus 487 mL; P = 0.02). The average hospital stay and doses of narcotic analgesics were significantly less in the HALNU group than the ONU group. The complication and bladder recurrence rates were similar between the two groups. The 5-year recurrence-free survival, cancer-specific survival, and overall survival were also comparable in both groups.

CONCLUSIONS

HALNU is a safe and efficacious procedure with comparable long-term oncologic outcomes in comparison with ONU in treating patients with locally advanced pT(3)N0UUT-UC.

Laparoscopic management of potentially malignant or complex adrenal cysts abiding by the principles of surgical oncology

BACKGROUND AND PURPOSE

Few articles have illustrated minimally invasive management of potentially malignant adrenal cysts. The aim of this study was to evaluate the feasibility of laparoscopic adrenalectomy for potentially malignant adrenal cysts.

PATIENTS AND METHODS

Eight patients with potentially malignant or complex cysts were treated by laparoscopic adrenalectomy in the past 10 years at our institution. The operative techniques strictly abided by the principles of surgical oncology. The entire adrenal gland, including the cyst, was excised en bloc via a lateral transperitoneal laparoscopic approach and moved into a LapSac bag. After protecting the exterior abdominal surface, we pulled the LapSac's opening out of the periumbilical wound and opened the cyst wall to siphon all the fluid content with a sucker tip dipped into the cyst cavity. Then the remaining cyst components and the adrenal gland were removed with the bag.

RESULTS

All of the laparoscopic operations were successful without intraoperative or postoperative morbidity, open conversion, or mortality. Mean operative time was 135 minutes with minimal blood loss. Mean hospital stay was 3.4 days. Histopathologic examinations revealed five hemorrhagic pseudocysts, two endothelial cysts, and a cystic pheochromocytoma. There was involvement of periadrenal adipose tissues by the chromium-staining tumor cells in the cystic pheochromocytoma, and malignancy could not be excluded. At a mean follow-up of 40 months, all patients were asymptomatic and had no radiographic evidence of recurrence or dissemination.

CONCLUSIONS

To our knowledge, this report represents the largest series of laparoscopic excisions for complex adrenal cysts. This technique is safe and feasible, while maintaining the benefits of minimal invasiveness.

Lymphovascular invasion predicts poor outcome of urothelial carcinoma of renal pelvis after nephroureterectomy

OBJECTIVE

To evaluate the significance of lymphovascular invasion (LVI) to predict cancer-specific survival (CSS) in patients with renal pelvic urothelial carcinoma (UC).

PATIENTS AND METHODS

In all, 76 patients with primary renal pelvic UC were treated by nephroureterectomy (NU). Inclusion criteria included nonmetastatic renal pelvic UC with no previous history of bladder cancer, concomitant ureteric lesion, or neoadjuvant chemotherapy. Age, gender, adrenalectomized or not, pathological T stage, grade, and LVI were examined by univariate and multivariate analyses to determine which were independent risk factors.

RESULTS

In all, 38 men and 38 women were included with a mean (range) age of 66 (41-93) years. The median (range) follow-up was 48 (15-88) months. At follow-up, eight cancer-related deaths (10.5%) were censored, and 66 patients (85.9%) were alive and disease-free. LVI was the only significant predictor of CSS in the univariate and multivariate analyses.

CONCLUSIONS

Adrenal metastases from primary renal pelvic UCs were rare. The present results suggest that ipsilateral adrenalectomy is not necessary during radical NU for treating patients with renal pelvic UCs. LVI appears to be a better prognostic factor for predicting poor outcome of renal pelvic UC than pT stage or tumour grade when using the current tumour-nodes-metastases staging system.

Bilateral renal infarction

A 34-year-old man was admitted for acute onset of left lower abdominal pain associated with fever. His medical history was unremarkable, and the physical examination revealed bilateral flank tenderness. Bilateral renal infarction was diagnosed and demonstrated by computed tomography.

Acute lobar nephronia in a renal allograft: a case report and literature review

We report a diabetic renal transplant recipient who presented with fever and right lower quadrant abdominal pain. Acute appendicitis was considered initially and she underwent emergent appendectomy. However, persistent symptoms postoperatively made us perform an imaging study to identify the problems. Abdominal and pelvic computed tomography disclosed several focal wedge-shaped lesions of low attenuation in the renal allograft. Acute lobar nephronia was successfully managed with parenteral antibiotics. The patient recovered without any sequela. A renal allograft in the right iliac fossa complicates the diagnosis among acute renal infection, malignancy, acute rejection, and even acute appendicitis. Biopsy of the renal allograft is sometimes needed due to clinically ambiguous imaging results. In this report, we not only detail the clinical course of such a rare case, but also review the previous 3 cases of acute lobar nephronia in renal allografts in the literature.