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Commentary on Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: Oncological outcomes at 7 years
J.P. Richie / Urologic Oncology: Seminars and Original Investigations 27 (2009) 221–232
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The Spanish Germ Cell Cancer Group launched a prospective study and treated 72 patients at multiple centers, including 18 patients with stage IIa and 54 with stage IIb disease. With excellent follow-up of almost 6 years, 66 of 72 patients remain free of disease with a 5-year progression-free survival of 90% for the entire group. This prospective observational study shows that chemotherapy is highly active in the management of stage IIa and IIb seminoma with excellent progression-free survival. Chemotherapy consisted of either 4 cycles of etoposide platinum or 3 cycles bleomycin, etoposide, and platinum. Three patients received more than 4 cycles of treatment. This study shows that combination chemotherapy is clearly more efficacious than single-agent carboplatin treatment. The question is whether the toxicity, cost, acute and chronic side effects, and long-term toxicity, including possible secondary malignancies, will be less than that of standard dose radiation therapy for stage IIa and IIb patients with seminoma. doi:10.1016/j.urolonc.2009.01.008 Jerome P. Richie, M.D. Commentary on Incidental testicular lesions found during infertility evaluation are usually benign and may be managed conservatively. Eifler JB, King P, Schlegel PN, Brady Urology Foundation, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY. J Urol 2008;180:261– 4; discussion 265. Epub 2008 May 21 Purpose: Hypoechoic lesions on scrotal ultrasonography are often considered germ cell tumors and radical orchiectomy is recommended. We retrospectively reviewed the findings at 1 center in men with ultrasonographically detected testicular lesions found during evaluation of severe male infertility. Materials and Methods: A total of 145 men with nonobstructive azoospermia at 1 center underwent ultrasonographic analysis before diagnostic or therapeutic testicular biopsy. Mean age was 34 ⫾ 0.6 years (range 21– 63). All men were azoospermic. Mean serum follicle-stimulating hormone was 25 IU/l. Of the men 26% had a history of cryptorchidism and 3 patients had a history of testis tumor. No other risk factors for testis cancer were identified for any patient. All sonographic lesions were followed with serial ultrasound examinations or were biopsied/excised. All men had tumor markers tested and the results were negative. Results: Of 145 men referred for azoospermia who underwent ultrasonographic analysis before biopsy, 49 (34%) showed a focal sonographic abnormality. A hypoechoic lesion was seen in 20 patients (14%), a hyperechoic lesion was seen in 10 (7%) and a heterogeneous appearance to a region of testicular parenchyma was seen in 19 patients (13%). Some lesions classified as hypoechoic demonstrated hyperechoic or heterogeneous interior components. Two of the patients with hypoechoic lesions were lost to follow-up. Of the remaining 18 patients, 11 had lesions less than 5 mm in greatest diameter and all of these were confirmed to be benign. Only 1 patient had a seminoma, and that patient had an inguinal testis with a mass detected on routine ultrasound. All other patients with hyperechoic or heterogeneous areas on ultrasound with subsequent tissue diagnoses were found to have benign lesions. Conclusions: Men with severe infertility who are found to have incidental testicular lesions and negative tumor markers, especially lesions less than 5 mm, may be initially observed with serial scrotal ultrasound examinations. Enlarging lesions or those of greater dimension should be considered for histological examination.
Commentary Scrotal ultrasonography with high megahertz scanners results in the delineation of small lesions in asymptomatic patients, especially those evaluated for infertility and possible reproductive assistance. Although standard treatment for such lesions is radical orchiectomy, this approach may decrease the likelihood of reproductive success in patients with infertility. The authors have identified 145 men out of 439 referred for evaluation of nonobstructive azoospermia who had undergone scrotal ultrasonography. One-third showed a focal ultrasound abnormality, generally a hypoechoic lesion. Most of these lesions were less than 5mm in greatest diameter. Only 1 of the 49 patients had seminoma. The authors make a case for conservative management, initially by follow-up with serial ultrasound examinations, in this subset of patients. doi:10.1016/j.urolonc.2009.01.009 Jerome P. Richie, M.D. Commentary on Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: Oncological outcomes at 7 years. Berger A, Haber GP, Kamoi K, Aron M, Desai MM, Kaouk JH, Gill IS, Center for Laparoscopic and Robotic Surgery, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH. J Urol 2008;180:849 –54; Discussion 854 (Epub 2008 Jul 17) Purpose: We present long-term oncological outcomes following laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.
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C.J. Kane / Urologic Oncology: Seminars and Original Investigations 27 (2009) 221–232
Materials and Methods: Between December 1997 and August 2005, 100 patients underwent laparoscopic nephroureterectomy for upper tract transitional cell carcinoma at our institution. Data were obtained from a prospectively maintained database, patient charts, telephone follow-up, and a review of the Social Security Death Index. Results: Median patient age at surgery was 73 years. Final pathological stage was pTis/pTa in 28% of patients, pT1 in 31%, pT2 in 13%, pT3 in 24%, and pT4 in 4%. High grade lesions were present in 58% of patients, multifocal disease was present in 23%, and lymphovascular invasion was present in 9%. Positive surgical margins occurred in 7 patients (7%). Median follow-up was 7 years (range 2–10). At 2, 5, and 7 years, overall survival was 81%, 59%, and 50%, cancer specific survival was 91%, 77%, and 72%, and recurrence-free survival was 66%, 50%, and 36%, respectively. Five-year cancer specific survival by stage was 80% for pTis/Ta, 70% for pT1, 68% for pT2, 60% for pT3, and 0% for pT4. On univariate analysis non-organ confined disease and lymphovascular invasion affected cancer specific survival (P ⫽ 0.01 and 0.04, respectively). On multivariate analysis only non-organ confined disease was a significant factor (P ⫽ 0.04). Concomitant bladder tumor at diagnosis was associated with poor recurrence-free survival on univariate and multivariate analysis (P ⫽ 0.02 and 0.01, respectively). Conclusions: To our knowledge, the largest long-term follow-up after laparoscopic nephroureterectomy for upper tract transitional cell carcinoma is presented. Long-term oncological outcomes appear comparable to those of open surgery.
Commentary Berger et al. review the outcomes of 100 patients who underwent laparoscopic nephroureterectomy for upper tract transitional cell carcinoma at the Cleveland Clinic. The patients were treated between 1997 and 2005. The patients were in a prospectively maintained urologic oncology database. Follow-up was augmented by reviewing charts and mortality was augmented by review of the Social Security Death Index. The mean follow-up was 76 months and was a minimum of 24 months for the entire cohort. Typical of upper tract urothelial carcinoma, the average age was 72 and 80% of the patients had an ASA score of 3 or 4. Most of the cases were accomplished retroperitoneally and there were different techniques used for the distal ureter. About half of the patients had an intravesical technique and the other half were performed as open resections. Only 8% of the patients had extravesical stapling and TUR of the ureteral orifice. The overall survival at 2 years was 81%, at 5 years 59%, and at 7 years 50%. The cancer-specific survival in those same time periods was 91%, 77%, and 72%, respectively. Fifty-two percent of the patients did develop a recurrence at a median of 12 months from their laparoscopic procedure, and of the recurrences, 71% were urothelial, the vast majority of which were in the bladder. There were no port site recurrences but there were 3 recurrences in the pelvis. Weaknesses of the study are that there is no lymph node status for these patients, and also the proportion of patients who were available for follow-up in each time period is not well presented. The number of patients lost to follow-up at each time interval is also not presented. This is the longest follow-up available for laparoscopic nephroureterectomy and demonstrates cancer-specific and overall survival outcomes similar to open nephroureterectomy. I agree with the editorial comment by Dr. Peter Schulam of UCLA, who states that in his opinion open management of the bladder cuff is the optimal technique. Open management of the bladder cuff is most efficient and can be performed through the specimen retrieval incision, adding little to the operation in terms of invasiveness. Also, the role of lymphadenectomy at the time of the nephroureterectomy has not been specifically well studied, but there certainly is strong evidence supporting lymphadenectomy for urothelial carcinoma of the bladder. We therefore routinely perform regional lymphadenectomy at the time of nephroureterectomy laparoscopically. The feasibility and outcomes of laparoscopic lymphadenectomy for upper tract transitional cell carcinoma are yet to be well established. doi:10.1016/j.urolonc.2009.01.018 Christopher J. Kane, M.D. Commentary on Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy. Nguyen CT, Lane BR, Kaouk JH, Hegarty N, Gill IS, Novick AC, Campbell SC, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH. J Urol 2008;180:104 –9; Discussion 109 (Epub 2008 May 15) Purpose: Thermal ablative therapies, including cryoablation and radio frequency ablation, have become viable options for the management of small renal tumors. However, initial data have suggested higher local recurrence rates for ablation compared with partial nephrectomy. We evaluated options for salvage of ipsilateral tumor recurrence after previous ablation. Materials and Methods: Records of renal surgeries performed at our institution between September 1997 and December 2006 were reviewed to identify patients with ipsilateral tumor recurrence after radio frequency ablation or cryoablation, and clinical characteristics and treatment were defined. Results: Recurrence rates at our hospital were 13 of 175 (7.4%) after cryoablation and 26 of 104 (25%) after radio frequency ablation, and 3 additional cases of post-cryoablation recurrence were referred from elsewhere. Overall repeat ablation was performed in 26 patients who experienced postablative recurrence. However, 12 patients (33%) were not candidates for repeat ablation due to large tumor size, disease progression, or repeat ablative failure. In this group, 1 patient received systemic therapy, 1 refused further treatment, and 10 underwent attempted extirpation. Partial nephrectomy was only possible in 2 patients and both required an open approach. The remainder of the patients were treated with radical nephrectomy (7) or had the procedure aborted due to strong patient preference to avoid dialysis (1). Laparoscopic surgery was only possible in 4 cases. Extensive perinephric scarring was encountered in all salvage operations following cryoablation.
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The Spanish Germ Cell Cancer Group launched a prospective study and treated 72 patients at multiple centers, including 18 patients with stage IIa and 54 with stage IIb disease. With excellent follow-up of almost 6 years, 66 of 72 patients remain free of disease with a 5-year progression-free survival of 90% for the entire group. This prospective observational study shows that chemotherapy is highly active in the management of stage IIa and IIb seminoma with excellent progression-free survival. Chemotherapy consisted of either 4 cycles of etoposide platinum or 3 cycles bleomycin, etoposide, and platinum. Three patients received more than 4 cycles of treatment. This study shows that combination chemotherapy is clearly more efficacious than single-agent carboplatin treatment. The question is whether the toxicity, cost, acute and chronic side effects, and long-term toxicity, including possible secondary malignancies, will be less than that of standard dose radiation therapy for stage IIa and IIb patients with seminoma. doi:10.1016/j.urolonc.2009.01.008 Jerome P. Richie, M.D. Commentary on Incidental testicular lesions found during infertility evaluation are usually benign and may be managed conservatively. Eifler JB, King P, Schlegel PN, Brady Urology Foundation, Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY. J Urol 2008;180:261– 4; discussion 265. Epub 2008 May 21 Purpose: Hypoechoic lesions on scrotal ultrasonography are often considered germ cell tumors and radical orchiectomy is recommended. We retrospectively reviewed the findings at 1 center in men with ultrasonographically detected testicular lesions found during evaluation of severe male infertility. Materials and Methods: A total of 145 men with nonobstructive azoospermia at 1 center underwent ultrasonographic analysis before diagnostic or therapeutic testicular biopsy. Mean age was 34 ⫾ 0.6 years (range 21– 63). All men were azoospermic. Mean serum follicle-stimulating hormone was 25 IU/l. Of the men 26% had a history of cryptorchidism and 3 patients had a history of testis tumor. No other risk factors for testis cancer were identified for any patient. All sonographic lesions were followed with serial ultrasound examinations or were biopsied/excised. All men had tumor markers tested and the results were negative. Results: Of 145 men referred for azoospermia who underwent ultrasonographic analysis before biopsy, 49 (34%) showed a focal sonographic abnormality. A hypoechoic lesion was seen in 20 patients (14%), a hyperechoic lesion was seen in 10 (7%) and a heterogeneous appearance to a region of testicular parenchyma was seen in 19 patients (13%). Some lesions classified as hypoechoic demonstrated hyperechoic or heterogeneous interior components. Two of the patients with hypoechoic lesions were lost to follow-up. Of the remaining 18 patients, 11 had lesions less than 5 mm in greatest diameter and all of these were confirmed to be benign. Only 1 patient had a seminoma, and that patient had an inguinal testis with a mass detected on routine ultrasound. All other patients with hyperechoic or heterogeneous areas on ultrasound with subsequent tissue diagnoses were found to have benign lesions. Conclusions: Men with severe infertility who are found to have incidental testicular lesions and negative tumor markers, especially lesions less than 5 mm, may be initially observed with serial scrotal ultrasound examinations. Enlarging lesions or those of greater dimension should be considered for histological examination.
Commentary Scrotal ultrasonography with high megahertz scanners results in the delineation of small lesions in asymptomatic patients, especially those evaluated for infertility and possible reproductive assistance. Although standard treatment for such lesions is radical orchiectomy, this approach may decrease the likelihood of reproductive success in patients with infertility. The authors have identified 145 men out of 439 referred for evaluation of nonobstructive azoospermia who had undergone scrotal ultrasonography. One-third showed a focal ultrasound abnormality, generally a hypoechoic lesion. Most of these lesions were less than 5mm in greatest diameter. Only 1 of the 49 patients had seminoma. The authors make a case for conservative management, initially by follow-up with serial ultrasound examinations, in this subset of patients. doi:10.1016/j.urolonc.2009.01.009 Jerome P. Richie, M.D. Commentary on Laparoscopic radical nephroureterectomy for upper tract transitional cell carcinoma: Oncological outcomes at 7 years. Berger A, Haber GP, Kamoi K, Aron M, Desai MM, Kaouk JH, Gill IS, Center for Laparoscopic and Robotic Surgery, Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH. J Urol 2008;180:849 –54; Discussion 854 (Epub 2008 Jul 17) Purpose: We present long-term oncological outcomes following laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.
224
C.J. Kane / Urologic Oncology: Seminars and Original Investigations 27 (2009) 221–232
Materials and Methods: Between December 1997 and August 2005, 100 patients underwent laparoscopic nephroureterectomy for upper tract transitional cell carcinoma at our institution. Data were obtained from a prospectively maintained database, patient charts, telephone follow-up, and a review of the Social Security Death Index. Results: Median patient age at surgery was 73 years. Final pathological stage was pTis/pTa in 28% of patients, pT1 in 31%, pT2 in 13%, pT3 in 24%, and pT4 in 4%. High grade lesions were present in 58% of patients, multifocal disease was present in 23%, and lymphovascular invasion was present in 9%. Positive surgical margins occurred in 7 patients (7%). Median follow-up was 7 years (range 2–10). At 2, 5, and 7 years, overall survival was 81%, 59%, and 50%, cancer specific survival was 91%, 77%, and 72%, and recurrence-free survival was 66%, 50%, and 36%, respectively. Five-year cancer specific survival by stage was 80% for pTis/Ta, 70% for pT1, 68% for pT2, 60% for pT3, and 0% for pT4. On univariate analysis non-organ confined disease and lymphovascular invasion affected cancer specific survival (P ⫽ 0.01 and 0.04, respectively). On multivariate analysis only non-organ confined disease was a significant factor (P ⫽ 0.04). Concomitant bladder tumor at diagnosis was associated with poor recurrence-free survival on univariate and multivariate analysis (P ⫽ 0.02 and 0.01, respectively). Conclusions: To our knowledge, the largest long-term follow-up after laparoscopic nephroureterectomy for upper tract transitional cell carcinoma is presented. Long-term oncological outcomes appear comparable to those of open surgery.
Commentary Berger et al. review the outcomes of 100 patients who underwent laparoscopic nephroureterectomy for upper tract transitional cell carcinoma at the Cleveland Clinic. The patients were treated between 1997 and 2005. The patients were in a prospectively maintained urologic oncology database. Follow-up was augmented by reviewing charts and mortality was augmented by review of the Social Security Death Index. The mean follow-up was 76 months and was a minimum of 24 months for the entire cohort. Typical of upper tract urothelial carcinoma, the average age was 72 and 80% of the patients had an ASA score of 3 or 4. Most of the cases were accomplished retroperitoneally and there were different techniques used for the distal ureter. About half of the patients had an intravesical technique and the other half were performed as open resections. Only 8% of the patients had extravesical stapling and TUR of the ureteral orifice. The overall survival at 2 years was 81%, at 5 years 59%, and at 7 years 50%. The cancer-specific survival in those same time periods was 91%, 77%, and 72%, respectively. Fifty-two percent of the patients did develop a recurrence at a median of 12 months from their laparoscopic procedure, and of the recurrences, 71% were urothelial, the vast majority of which were in the bladder. There were no port site recurrences but there were 3 recurrences in the pelvis. Weaknesses of the study are that there is no lymph node status for these patients, and also the proportion of patients who were available for follow-up in each time period is not well presented. The number of patients lost to follow-up at each time interval is also not presented. This is the longest follow-up available for laparoscopic nephroureterectomy and demonstrates cancer-specific and overall survival outcomes similar to open nephroureterectomy. I agree with the editorial comment by Dr. Peter Schulam of UCLA, who states that in his opinion open management of the bladder cuff is the optimal technique. Open management of the bladder cuff is most efficient and can be performed through the specimen retrieval incision, adding little to the operation in terms of invasiveness. Also, the role of lymphadenectomy at the time of the nephroureterectomy has not been specifically well studied, but there certainly is strong evidence supporting lymphadenectomy for urothelial carcinoma of the bladder. We therefore routinely perform regional lymphadenectomy at the time of nephroureterectomy laparoscopically. The feasibility and outcomes of laparoscopic lymphadenectomy for upper tract transitional cell carcinoma are yet to be well established. doi:10.1016/j.urolonc.2009.01.018 Christopher J. Kane, M.D. Commentary on Surgical salvage of renal cell carcinoma recurrence after thermal ablative therapy. Nguyen CT, Lane BR, Kaouk JH, Hegarty N, Gill IS, Novick AC, Campbell SC, Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH. J Urol 2008;180:104 –9; Discussion 109 (Epub 2008 May 15) Purpose: Thermal ablative therapies, including cryoablation and radio frequency ablation, have become viable options for the management of small renal tumors. However, initial data have suggested higher local recurrence rates for ablation compared with partial nephrectomy. We evaluated options for salvage of ipsilateral tumor recurrence after previous ablation. Materials and Methods: Records of renal surgeries performed at our institution between September 1997 and December 2006 were reviewed to identify patients with ipsilateral tumor recurrence after radio frequency ablation or cryoablation, and clinical characteristics and treatment were defined. Results: Recurrence rates at our hospital were 13 of 175 (7.4%) after cryoablation and 26 of 104 (25%) after radio frequency ablation, and 3 additional cases of post-cryoablation recurrence were referred from elsewhere. Overall repeat ablation was performed in 26 patients who experienced postablative recurrence. However, 12 patients (33%) were not candidates for repeat ablation due to large tumor size, disease progression, or repeat ablative failure. In this group, 1 patient received systemic therapy, 1 refused further treatment, and 10 underwent attempted extirpation. Partial nephrectomy was only possible in 2 patients and both required an open approach. The remainder of the patients were treated with radical nephrectomy (7) or had the procedure aborted due to strong patient preference to avoid dialysis (1). Laparoscopic surgery was only possible in 4 cases. Extensive perinephric scarring was encountered in all salvage operations following cryoablation.