Incidentalology: A developing urological sub-specialty

Outcomes of robotic-assisted pyeloplasty in symptomatic versus asymptomatic patients

OBJECTIVE

To evaluate the outcome of robotic-assisted laparoscopic pyeloplasty (RAP) in symptomatic patients with ureteropelvic junction obstruction (UPJO) versus patients who were incidentally found to have UPJO.

METHODS

We retrospectively reviewed the records of 141 patients who underwent RAP at Massachusetts General Hospital between 2008 and 2020. Patients were categorized into symptomatic group and asymptomatic group. We compared patient demographics as well as preoperative and postoperative symptoms and functional renal scans.

RESULTS

The study population included 108 patients in the symptomatic group and 33 patients in the asymptomatic group. Mean age was 46 ± 17 years with average follow-up time of 12 ± 18 months. Asymptomatic patients had significantly higher rate of definite obstruction (80% versus 70%) and equivocal obstruction (10% versus 0.9%) on preop renogram (P: 0.001). There was no significant difference in the preop split renal function in symptomatic versus asymptomatic group (39 ± 13 versus 36 ± 13 P: 0.3). Following RAP, 91% of symptomatic patients achieved symptom resolution, while four asymptomatic patients (12%) developed new symptoms postoperatively. Compared to preoperative renogram, RAP resulted in improvement in renogram indices in 61% of symptomatic versus 75% of asymptomatic patients (P: 0.2).

CONCLUSION

Although asymptomatic patients had worse obstructive indices on renogram, both symptomatic and asymptomatic groups had comparable improvement in renal function following robotic pyeloplasty. RAP is a safe and efficacious minimally invasive option to offer symptom resolution in symptomatic patients and improve obstruction in both symptomatic and asymptomatic patients with UPJO.

Combined Open Prostatectomy and Kidney Surgery: Feasibility and 12-Month Outcome

Purpose

There are only a few case reports and case series that investigated combined laparoscopic or robotic surgery for simultaneous prostate and kidney cancer. In this study, we want to close a gap in existing research to assess the feasibility and oncological outcome of combined open prostatectomy and kidney surgery.

Methods

We retrospectively analyzed patients who underwent a combined open prostatectomy and either a partial or complete nephrectomy from 2013 to 2020. Descriptive statistics were used to assess perioperative parameters and the 12-month functional and oncological outcomes after combined surgery.

Results

We identified 10 patients undergoing combined open surgery. Partial nephrectomy was performed in 4, radical nephrectomy in 6 patients. For prostate cancer, histopathological analysis showed a tumor stage ≥ pT2c in all 10 patients. For renal tumors, histopathological analysis showed clear cell renal cell carcinoma in 8 patients and oncocytoma in 2 patients. Operating time was 177 ± 36 minutes. Two perioperative complications (Clavien 2a and 3) were observed. Three months postoperatively, the International Index of Erectile Function (IIEF-5) score was 5.6 ± 5.9, the ICIQ-SF score was 7.3 ± 5.6 and were using 1.9 ± 2.2 pads per day. This improved after 12 months postoperatively, as patients had an IIEF-5 score of 6.33 ± 6.5, an ICIQ-SF score of 4.4 ± 5.7 and were using pads 0.9 ± 1.7 per day.

Conclusion

In this study, we showed that open surgery is a safe and valid approach for combined prostatectomy and renal surgery with acceptable complications and oncological outcomes. The combined open approach could be a good alternative to combined laparoscopic/robotic surgery in this field, especially to treat patients with advanced renal tumors or previous abdominal surgery or radiation.

Outcomes after Robotic-assisted Pyeloplasty in Patients Presenting with Pain Versus Nonpain Presenting Symptoms

OBJECTIVE

To assess the impact of presenting symptom or incidental finding on symptomatic and radiographic outcomes after robotic-assisted pyeloplasty (RAP).

METHODS

We retrospectively reviewed the records of 143 patients at our institution who received pyeloplasty from 2001-2017. Patients without both pre- and postoperative radiographic data were excluded. Patients were grouped by primary presenting symptom into either pain at presentation (pain) or nonpain primary presenting symptom, including incidental findings (nonpain). Primary outcomes were persistence of postoperative symptoms and improvement in diuretic renogram half-times.

RESULTS

The study inclusion criteria was met by 105 patients. Pain was the most common presenting symptom (70.0%), followed by incidental finding (10.5%), infection (7.6%), hematuria (4.8%), hypertension (2.8%), elevated creatinine (2.8%), and nausea (1.0%). Patients with nonpain presentations were significantly more likely to have postoperative symptoms (P = .04), and less likely to improve on diuretic renogram (P = .03). Incidental presentation was found to be associated with greater likelihood of persistent postoperative symptoms compared with other presentations (36.3% vs 8.5%, P = .02).

CONCLUSION

Ureteropelvic junction obstruction (UPJO) patients presenting with pain, experience better symptom and radiographic improvement following RAP compared with patients presenting without pain. Incidental UPJO was the most common nonpain presentation and is associated with less symptomatic and radiographic benefit after RAP. These findings will help reconstructive urologists counsel patients with UPJO regarding outcomes of RAP.

Predictive Ability of Preoperative CT Scan in Determining Whether the Adrenal Gland is Spared at Radical Nephrectomy

INTRODUCTION

The aim of this study was to assess whether preoperative multiple detector computed tomography (MDCT) accurately predicts adrenal involvement for patients undergoing non-adrenal sparing radical nephrectomy for renal cell carcinoma.

METHODS AND MATERIALS

A retrospective observational study based on a composite patient population of two university teaching hospitals who underwent radical nephrectomy. Sensitivity, specificity, overall accuracy, positive and negative predictive values and likelihood ratios were calculated from radiological reports.

RESULTS

Total 579 patients underwent radical nephrectomy, of which 199 (34.4%) patients underwent a non-adrenal sparing radical nephrectomy, in which 128 (64.3%) were male and 118 (59.3%) were left side tumors. Mean tumor size was 8.2 cm (range 1.4-20cm). MDCT was found to have a sensitivity of 100% and specificity of 95.2% for identifying adrenal invasion. Total 179 patients (89.9%) had a radiographically normal ipsilateral adrenal gland, of which none were found to have adrenal involvement. Therefore, the negative predictive value of preoperative cross-sectional imaging for identification of adrenal involvement was 100%.

CONCLUSION

Cross- sectional MDCT imaging accurately predicts adrenal involvement and the decision to remove or spare the adrenal gland should be made preoperative planning regardless of tumour size or location at the time of multi-disciplinary discussion unless there is intraoperative evidence of adrenal invasion.

NYPD Cancer Incidence Rates 1995-2014 Encompassing the Entire World Trade Center Cohort

OBJECTIVE

The aim of this study was to compare cancer incidence rates (CIRs), between preexposure (1995-2000) and postexposure (2002-2014) periods in the entire New York City Police Department cohort exposed to the 2001 World Trade Center (WTC) disaster.

METHODS

CIR derived from active duty officer records, including postexposure data on retired officers.

RESULTS

We observed 870 cancer cases in 859 officers (1995-2014), including 193 active duty cases pre-WTC and 677 cases (484 active duty, 193 retired) post-WTC. Overall, median CIR increased 1.44-fold compared with pre-WTC, with brain cancer increasing 3.27-fold, and kidney cancer increasing similarly. Thyroid cancer and non-Hodgkin's lymphoma increased 2.29 and 1.68-fold, respectively.

CONCLUSIONS

Findings should be interpreted cautiously, given the small number of cancers at specific sites, and possibility of confounders. However, apparent increases in cancers overall, and in highlighted sites, remain of concern, underscoring the need for continued monitoring of this cohort.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes

INTRODUCTION

We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN).

METHODS

We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression.

RESULTS

The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement.

CONCLUSIONS

The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.