Incidence of Local and Port Site Recurrence of Urologic Cancer After Laparoscopic Surgery

Single omental metastasis of renal cell carcinoma after radical nephrectomy: A case report

BACKGROUND

Renal cell carcinoma (RCC) is the third most common malignancy in the genitourinary tract. The lungs, bone, lymph nodes, liver, and brain are common metastatic sites of RCC. However, there is limited literature on single omental metastasis of RCC.

CASE SUMMARY

We present the case of a 44-year-old man with single omental metastasis of RCC after laparoscopic radical nephrectomy. Pathological diagnosis of the resected left kidney revealed pT3a clear cell RCC (Fuhrman grade III). At 6 mo postoperatively, abdominal computed tomography revealed a 12-mm enhancing nodule in the left lower peritoneum. At 7 mo after initial operation, laparoscopic removal of the left omental nodule was performed. The pathological results indicated metastatic clear cell RCC. Currently, the patient is being treated with adjuvant pembrolizumab.

CONCLUSION

Omental metastasis of RCC owing to laparoscopic radical nephrectomy is rare. Urologists should be aware of the diverse nature of RCC.

Robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer: A multicenter collaborative study

OBJECTIVES

To evaluate the perioperative and oncological/functional outcomes of robotic post-chemotherapy retroperitoneal lymph node dissection for testicular cancer.

METHODS AND MATERIALS

In this retrospective study, we included patients who underwent robotic post-chemotherapy retroperitoneal lymph node dissection at 7 academic centers between 2011 and 2021. Patients' characteristics, perioperative findings, as well as oncological and functional outcomes are reviewed. Relationships with the main outcome (90-day complications) were analyzed using multivariable logistic regression.

RESULTS

A total of 90 patients with a median (IQR) age of 30 (25-37) years were included. The main primary histologic type was non-seminomatous germ cell tumor (89%). Seven patients (8%) were electively converted to open. Median estimated blood loss, operative time, and length of hospital stay were 150 ml, 5.6 hours, and 2 days, respectively. Final pathology revealed teratoma in 49 (55%), necrosis/fibrosis in 29 (32%), and viable germ cell tumor in 12 (13%) patients. The 90-day complication rate was 16.7%, most of which were low-grade (Clavien-Dindo < III) and managed conservatively. On multivariable analysis, pure seminoma (odds ratio 17.4) and bilateral dissection template (odds ratio 4.2) were independently associated with 90-day complications. No 90-day hospital readmission was recorded. With a median (IQR) follow-up of 16 (4-32) months, 6 (6.7%) patients had disease recurrence and there was 1 cancer-related death.

CONCLUSION

With appropriate patient selection at centers with expertise in testicular cancer and minimally invasive surgery, robotic post-chemotherapy retroperitoneal lymph node dissection appears safe and effective, although longer follow-up is warranted.

Development and In Vitro Assessment of a Novel Vacuum-Based Tissue-Holding Device for Laparoscopic and Robotic Kidney Cancer Operations

Simple Summary

Depending on the location and configuration of renal tumors, it is sometimes difficult to grasp, excise, and properly remove them. We have designed and developed a device to improve robotic laparoscopic partial nephrectomy. We tested the device on porcine kidneys and livers and embalmed human cadavers. A preliminary evaluation of this surgical tool showed satisfactory device setup, suction, and tissue handling characteristics.

Abstract

In this paper, we describe the development and evaluation of a novel tissue-holding device (THD) for use during robotic-assisted laparoscopic partial nephrectomy. The THD is a vacuum-based apparatus made of either 3D-printed polyethylene or stainless steel. The proximal end connects to suction tubing routed outside the body, while the distal end is conically shaped and designed to firmly interface with the tumor. Device feasibility studies were performed on six porcine kidneys, two porcine livers, and two embalmed human cadavers. A Likert-scale rating was used to assess device setup, suction, and tissue handling. Additional tests were performed using the daVinci Xi® robotic system. Finally, the holding force of the THD was assessed using different standard vacuum systems and pressure settings. In porcine tissue, the device setup, tissue suction, and handling were rated as “good”. THD insertion and removal was uncomplicated. In a simulated transabdominal approach on fixed human cadavers, the device setup, suction, and tissue handling were also rated as “good”. No macroscopic tissue compromise or device deterioration was noted. The handling and holding abilities using the daVinci Xi® robotic system were also rated “good”. The device was able to successfully hold over 300 g of tissue at a suction pressure of −600 mmHg. The preliminary evaluation of the THD demonstrated satisfactory results.

Malignant ascites following radical nephrectomy for cystic renal cell carcinoma

A 69-year-old man with a history of laparoscopic radical nephrectomy for papillary renal cell carcinoma presented with a 1-week history of generalised abdominal pain, distension and loss of appetite. Clinical examination and CT imaging demonstrated ascites associated with peritoneal nodules, raising the possibility of metastatic disease. Immunochemistry staining from ascites fluid cytology confirmed renal cell carcinoma. Following multidisciplinary discussions, the patient was commenced on a small-molecule tyrosine kinase inhibitor.

Minimally Invasive Surgery for Patients with Locally Advanced and/or Metastatic Renal Cell Carcinoma

Despite advances in systemic therapy and immunotherapy, surgery continues to have a role in management of advanced renal cell carcinoma (aRCC). Minimally invasive surgery (MIS) is considered standard of care for smaller, localized tumors due to faster recovery without compromising oncologic outcomes. There are concerns about MIS for aRCC due to a potential risk of inferior oncologic outcomes and unusual patterns of disease recurrence. Recent studies, however, suggest that in properly selected patients with aRCC, MIS can provide improved peri-operative outcomes without compromising oncologic control.

Trocar site recurrence after robotic partial nephrectomy to treat of renal cell carcinoma

Introduction:

Wound seeding during surgical excision of malignant tumor is known problem in the oncologic surgery. Trocar site recurrence (TSR) is well described in laparoscopic oncologic surgery. Little has been reported about TSR after robotic partial nephrectomy (RPN) performed for renal cell carcinoma (RCC). Here, we report on the incidence of TSR and demonstrate the presentation of this type of RCC recurrence.

Patients and Methods:

We reviewed prospectively collected data about patient who underwent RPN at our institute from September 2009 to March 2018. We reviewed the medical record of the patients who had the diagnosis of RCC on the final pathology. We identified the patient with TSR and demonstrated their presentation and treatment along with the outcome.

Results:

A total of 335 patients underwent RPN during the study period for renal mass. Two hundred and sixty-nine (80.3%) patients were found to have RCC on the final pathologic evaluation of their mass. We identified two patients (0.7% of all the RCC in the study) who developed TSR during an average follow-up period of 31 months (ranging from 18 to 72 months). The first recurrence appeared 18 months after the surgery. The second recurrence presented 72 months after RPN. Both cases underwent open surgical excision of the trocar site, in which the recurrence appeared.

Conclusion:

TSR is potential type of RCC recurrence after RPN, though it is rare and underreported. Special attention should be given to examine the trocar site during the surveillance follow-up of RCC treated with RPN. It can develop up to 72 months after the surgery.

Images: Port site recurrence on followup imaging after adrenalectomy for adrenocortical carcinoma - first indicator of carcinomatosis

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy of the adrenal cortex. Complete surgical resection is essential for localized tumours because ACC is highly resistant to chemotherapy and radiotherapy.1 Use of a laparoscopic approach for adrenalectomy in the setting of a confirmed or suspected ACC is controversial because it is unknown if laparoscopy provides equivalent oncological outcomes compared to an open approach.

Impact of Accidental Tumor Incision During Laparoscopic Partial Nephrectomy on the Oncologic and Clinical Outcomes

BACKGROUND

To investigate the impact of accidental tumor incision (ATI) during laparoscopic partial nephrectomy (LPN) on the treatment outcome of LPN and to determine the predictive factors for ATI.

PATIENTS AND METHODS

Consecutive 156 patients with renal tumors suspicious of renal cell carcinoma cT1N0M0 undergoing laparoscopic partial nephrectomy at Yokohama City University between May 2003 and November 2014 were retrospectively evaluated. The analyzed clinical factors included maximum tumor diameter, the R.E.N.A.L. Nephrometry Score, occurrence of ATI during surgery, and the postoperative pathological findings including the presence of a pseudocapsule. Port site metastasis, tumor seeding, and local recurrence were investigated by routine follow-up computed tomography during the postoperative period.

RESULTS

Among enrolled 156 procedures, 12 (7.7%) showed ATI during surgery. Positive surgical margin and local tumor recurrence were observed in 5 and 1 cases in the non-ATI group, respectively, as compared with in no cases in the ATI group. Port site metastasis or tumor seeding was not observed in either group. Multivariate analysis indicated that pseudocapsule formation significantly correlated with ATI (P = .022) and that maximum tumor diameter was a possible predictor of ATI (P = .054).

CONCLUSION

To our knowledge, there are no previous studies to evaluate the impact of ATI, and we here, for the first time, report that the risk of ATI is influenced by the presence of a pseudocapsule, and, to some degree, by the tumor size. Moreover, we also show that ATI during laparoscopic partial nephrectomy is not necessarily associated with poor outcomes such as local tumor recurrence.

Port site metastasis in prostate cancer

Port-site metastasis of prostatic adenocarcinoma is rare and usually associated with poor prognosis. We report a case of a young man with a rising prostate-specific antigen (PSA) 4.5 years after robot-assisted laparoscopic prostatectomy (RALP) and extended pelvic lymphadenectomy (ePLND) for a Gleason 7 (4+3) prostate cancer (pT3b pN0 cM0). Choline positron emission tomography-computed tomography (PET-CT) demonstrated a PET positive subcutaneous recurrence in a previous trocar site accompanied by a PET positive ipsilateral inguinal lymph node. Excision of both lesions was performed, confirming the diagnosis of metastatic prostate cancer. The patient's PSA dropped significantly postoperatively enabling postponement of androgen deprivation treatment up to this date. The etiology of port-site metastasis is multifactorial, including patient and surgery related factors. Such metastases have been scarcely reported following ePLND with or without RALP. Certain surgical precautions can be made to prevent the occurrence. We summarize previously reported mechanisms of development and possible precautionary measures.

Laparoscopic treatment of renal cancer in children: a multicentric study and review of oncologic and surgical complications

OBJECTIVE

The aim was to report a multicentric study with a longer follow-up to evaluate the laparoscopic radical nephrectomy in children with renal cancer.

MATERIAL AND METHODS

This was a retrospective multicentric study, from October 2005 to January 2012, of children who underwent a laparoscopic radical nephrectomy for small renal malignant tumors.

RESULTS

Seventeen children were included in this study. Sixteen underwent chemotherapy before surgery according the SIOP (Société Internationale d'Oncologie Pédiatrique) protocol and one was treated by surgery only for a carcinoma. All except one could be treated by laparoscopy; the biggest tumoral size was 8 cm. The median hospital stay was 3 days (2-10). The pathologic examination showed 15 Wilms' tumors, one clear cell sarcoma and one TFE3 renal cell carcinoma. With a median follow-up of 42 months (range 12 and 77 months) after laparoscopic radical nephrectomy, 15 children had no oncological complications (port site or local recurrence, pulmonary metastasis) and one had a local recurrence without intraoperative tumoral rupture. The child with TFE3 renal cell carcinoma died 4 years after surgery from brain and lung metastases without local recurrence. No small bowel obstruction occurred.

CONCLUSIONS

Radical nephrectomy in children for Wilms' tumor or other renal cancer can be safely performed laparoscopically and our indications can be summarized, for trained laparoscopic surgeons, by small tumors under about 8 cm diameter, especially without crossing the lateral edge of the vertebra on the CT scan at the time of surgery.

Tumor seeding incidentally found two years after robotic-Assisted radical nephrectomy for papillary renal cell carcinoma. A case report and review of the literature

INTRODUCTION

Port-site metastasis or peritoneal spread after laparoscopic surgery for urological malignancies is a rare phenomenon accounting for 0.09% and 0.03% of the cases respectively.

PRESENTATION OF CASE

We present a case of tumor seeding in the omentum found in a female patient after previous transperitoneal robotic-assisted radical nephrectomy (RARN) for papillary renal cell carcinoma (RCC). Two years after the robotic operation, the patient was diagnosed with cervical clear cell carcinoma and underwent radical hysterectomy with lymphadenectomy and omentectomy. A neoplastic omental nodule was incidentally identified intraoperatively. Pathological characteristics and immunohistochemistry revealed features of papillary RCC. Two years after the hysterectomy, the patient is clinically cancer free, without any adjuvant therapy for her cervical cancer.

DISCUSSION

To the best of our knowledge, we report the first case of tumor seeding in the omentum following RARN for organ confined low grade papillary (T2aN0M0) RCC. No risk factors that could explain the tumor seeding were identified. The neoplastic cells had a low proliferative index (Ki-67<5%) and a decreased capability to metastasize.

CONCLUSION

Tumor seeding as a result of robotic assisted laparoscopic nephrectomy, although rare, might represent a novel way of tumor inoculation deprived of or with low malignant potential.

Single-session laparoscopic total urinary tract exenteration without repositioning for multifocal urothelial carcinoma in dialysis-dependent patients

OBJECTIVES

To report our experience of single-session, en bloc, laparoscopic total urinary tract exenteration in dialysis-dependent patients with multifocal urothelial carcinoma.

METHODS

From June 2005 to April 2008, 5 dialysis-dependent patients (4 women and 1 man) diagnosed with synchronous upper urinary tract and bladder urothelial carcinoma underwent single-session, en bloc, laparoscopic total urinary tract exenteration. Bilateral nephroureterectomy was facilitated by rotating the operating table with or without alternative inflation of the tourniquet cuffs on either side of the patient's back to allow adequate spontaneous bowel displacement by gravity, thereby avoiding the need to reposition the patient. After completing bilateral nephroureterectomy, we performed radical cystectomy with the patient in the Trendelenburg position. All specimens, including the 2 kidneys, ureters, and bladder, were collected in an endobag and were intended to be retrieved using the Pfannenstiel incision in male patients and the vaginal route in the female patients. The demographic and perioperative information were collected and analyzed.

RESULTS

All the laparoscopic procedures were completed successfully without major complications. Although 1 patient developed a minor complication owing to paralytic ileus, she recovered after conservative treatment. The continuity of all the urothelial epithelium was maintained intact throughout the procedure to avoid tumor spillage.

CONCLUSIONS

In our experience, laparoscopic total urinary tract exenteration is a technically feasible and safe alternative modality to the open counterpart to treat dialysis-dependent patients with end-stage renal disease with multifocal urothelial carcinoma for experienced surgeons with advanced laparoscopic skills. Furthermore, it can be performed successfully without the need for repositioning the patient, and this probably decreased the incidence of associated complication in the high-risk patients.

Surgical management of metastatic adrenal tumors: Decision-making factors in imaging

The present study aimed to clarify decision-making factors based on imaging for laparoscopic adrenalectomy (LA) or open adrenalectomy (OA) for adrenal metastasis (AM) based on our previous experience. From November 2003 to November 2006, 11 adrenalectomies were performed for AM for malignancies such as lung cancer, renal cell carcinoma (RCC) and breast cancer at Tokai University Hospital. A diagnosis of AM for these malignancies was suspected whenever a newly diagnosed adrenal mass was located, characterized by a basal computed tomography (CT) density superior to 10 Hounsfield units, strong or heterogeneous vascular enhancement following contrast injection and/or increasing size in sequential imaging studies. There was no evidence of extra-AM. The approach to surgical management using LA or OA was determined on the basis of CT and/or magnetic resonance imaging. The patients were reviewed every 2 or 3 months by physical examination and systemic CT. We analyzed the decision-making factors based on imaging for surgical management with LA or OA from the results of oncological outcome, imaging, intraoperative and pathohistological findings. In this study, 9 patients underwent 11 adrenalectomies (9 laparoscopic and 2 open procedures). Non-small cell lung cancer was the most common primary malignancy (5 adrenalectomies of 4 patients), followed by RCC (4 adrenalectomies of 4 patients) and breast cancer (2 adrenalectomies of 1 patient). The median tumor size for the LA group was 3.1±0.7 cm (range 2.1-4.3) and for the OA group, 6.1±0.8 cm (5.5 and 6.7 cm) (p=0.001). The operative time for the LA group was 127±42 min (range 90-215) and for the OA group, 224±47 min (190 and 257 min) (p=0.018). Blood loss for the LA group was 49±63 g (range 3-207) and for the OA group, 340±10 g (333 and 347 g) (p<0.001). No complications were noted and no conversion of LA to OA occurred. All 9 adrenal tumors selected for LA were removed safely without strong adhesion to the surrounding tissue. Two adrenal tumors removed by OA had a strong adhesion to the surrounding tissue. All 9 patients had complete resection, without capsular disruption and a negative margin in the pathological findings. No port-site and local recurrences occurred. No patients presented with local relapse or port-site metastasis. Disease-free survival rate for the LA group was 57% and for the OA group, 50% (p=0.661). LA is a less invasive treatment than OA for AM. However, for complete resection, OA should be selected for cases where resection by LA is difficult. Therefore, in the decision making towards the appropriate surgical management with LA or OA, it is important to closely assess pre-operative imaging. Imaging features supporting OA include no detection of fatty tissue between the tumor and proximal organs, tumors with an irregular contour, large tumors and tumors with a cystic component.