Re: Mortality, Morbidity and Healthcare Expenditures after Local Tumour Ablation or Partial Nephrectomy for T1A Kidney Cancer

Re: Mortality, Morbidity and Healthcare Expenditures after Local Tumour Ablation or Partial Nephrectomy for T1A Kidney Cancer

ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS 252 Suggested Reading Viprakasit DP, Sawyer MD, Herrell SD et al: Changing composition of stagho...

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ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS

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Suggested Reading Viprakasit DP, Sawyer MD, Herrell SD et al: Changing composition of staghorn calculi. J Urol 2011; 186: 2285. Matlaga BR, Kim SC, Watkins SL et al: Changing composition of renal calculi in patients with neurogenic bladder. J Urol 2006; 175: 1716. Vargas AD, Bragin SD and Mendez R: Staghorn calculus: its clinical presentation, complications and management. J Urol 1982; 127: 860.

Re: Use of Polymer Conjugates for the Intraperoxisomal Delivery of Engineered Humanalanine:Glyoxylate Aminotransferase as a Protein Therapy for Primary Hyperoxaluria Type I A. Roncador, E. Oppici, M. Talelli, A. N. Pariente, M. Donini, S. Dusi, C. B. Voltattorni, M. J. Vicent and B. Cellini Neuroscience, Biomedicine and Movement Sciences Department, Section of Biological Chemistry and Department of Medicine, Section of General Pathology, University of Verona, Verona, Italy, and Polymer Therapeutics Lab, Centro de Investigacio n Prı´ncipe Felipe, Valencia, Spain Nanomedicine 2017; 13: 897e907. doi: 10.1016/j.nano.2016.12.011

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27993722 Editorial Comment: Type 1 primary hyperoxaluria (PH1) is a rare, autosomal recessive disorder associated with development of kidney stones, systemic oxalosis and end-stage renal disease. This outcome is either due to defective AGT or inability of this enzyme to be targeted to the peroxisomal compartment. This enzyme prevents accumulation of glyoxylate, the immediate precursor of oxalate. These investigators observed that a PEG-PGA block copolymer conjugated to AGT could enter the cell and allow glyoxylate detoxification in a CHO cell model of PH1. This conjugate did not localize to the peroxisomal compartment but was functional. The authors were also able to engineer AGT with certain acid substitutions, which allowed peroxisomal targeting. Many steps will need to be taken to determine if this approach will prove to be an effective treatment strategy for PH1, including demonstrating its effectiveness in a PH1 knockout model and showing that there is no toxicity. Dean G. Assimos, MD

Suggested Reading Lieske JC, Spargo BH and Toback FG: Endocytosis of calcium oxalate crystals and proliferation of renal tubular epithelial cells in a patient with type 1 primary hyperoxaluria. J Urol 1992; 148: 1517. Levin-Iaina N, Dinour D, Romero L et al: Late diagnosis of primary hyperoxaluria type 2 in the adult: effect of a novel mutation in GRHPR gene on enzymatic activity and molecular modeling. J Urol 2009; 181: 2146. Holmes RP and Assimos DG: Glyoxylate synthesis, and its modulation and influence on oxalate synthesis. J Urol 1998; 160: 1617.

Urological Oncology: Adrenal, Renal, Ureteral and Retroperitoneal Tumors Re: Mortality, Morbidity and Healthcare Expenditures after Local Tumour Ablation or Partial Nephrectomy for T1A Kidney Cancer A. Larcher, M. Sun, P. Dell’Oglio, V. Trudeau, K. Boehm, J. Schiffmann, Z. Tian, N. Fossati, U. Capitanio, A. Briganti, F. Montorsi and P. Karakiewicz Cancer Prognostics and Health Outcomes Unit, and Department of Urology, University of Montreal Health Center and Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada, Division of Oncology, Unit of Urology, Urological Research Institute, San Raffaele Hospital, Milan, Italy, Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, and Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York Eur J Surg Oncol 2017; 43: 815e822. doi: 10.1016/j.ejso.2016.08.023

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27692535

ADRENAL, RENAL, URETERAL AND RETROPERITONEAL TUMORS

Editorial Comment: The debate on local tumor ablation (LTA) vs partial nephrectomy (PN) for small renal carcinomas goes on. Although national and international guidelines are still cautious regarding indications for LTA, emerging data on long-term oncologic outcomes and death competing risk yield a new perspective on this procedure. LTA is feasible in the majority of cases by percutaneous approach, remaining minimally invasive and even a salvage procedure when residual/recurrent disease has been found. The authors analyzed the SEER (Surveillance, Epidemiology and End Results)-Medicare database to compare outcomes and health care expenditures (HCEs) for local tumor ablation and partial nephrectomy. They confirm once again the benefit of LTA in terms of overall complication rate (21% for LTA vs 40% for PN, OR 0.30, p <0.001), length of stay and health care expenditures. The 30-day mortality rate was low (less than 2%) and was similar for both procedures. Readmission rates were not different. HCEs, calculated by a propensity score in individuals with complete inpatient claims information, included length of stay and readmission rates. Median HCE was significantly lower for LTA compared to PN, supporting previous cost comparison reports. These data need to be framed in contemporary terms. Data gathered extend through 2000 to 2009. Since then, robot-assisted partial nephrectomy has been expanding, now being standard care for small renal masses at tertiary centers. Data on complications of robot-assisted partial nephrectomy for cT1a tumors, although not randomized or subject to the same limitations the authors express in the discussion, seem better than the historical data reported here. Additionally the conclusions, based on a matched pairs design, are the closest to a randomized controlled trial but the larger group is matched with the smaller group (LTA). For now the conclusions are applicable only in certain sectors of the population harboring a small renal carcinoma, ie the elderly and infirm. M. Pilar Laguna, MD, PhD

Suggested Reading Schmit GD, Thompson RH, Kurup AN et al: Usefulness of R.E.N.A.L. nephrometry scoring system for predicting outcomes and complications of percutaneous ablation of 751 renal tumors. J Urol 2013; 189: 30. Klatte T, Shariat SF and Remzi M: Systematic review and meta-analysis of perioperative and oncologic outcomes of laparoscopic cryoablation versus laparoscopic partial nephrectomy for the treatment of small renal tumors. J Urol 2014; 191: 1209. Williams SB, Amarasekera CA, Gu X et al: Influence of surgeon and hospital volume on radical prostatectomy costs. J Urol 2012; 188: 2198. Ghani KR, Sukumar S, Sammon JD et al: Practice patterns and outcomes of open and minimally invasive partial nephrectomy since the introduction of robotic partial nephrectomy: results from the Nationwide Inpatient Sample. J Urol 2014; 191: 907. Chang X, Zhang F, Liu T et al: Radio frequency ablation versus partial nephrectomy for clinical T1b renal cell carcinoma: long-term clinical and oncologic outcomes. J Urol 2015; 193: 430. Larcher A, Fossati N, Lazzeri M et al: Letter to the editor. J Urol 2014; 192: 1887.

Re: Findings and Impact of Early Imaging after Partial Nephrectomy R. W. Tubre, W. P. Parker, T. Dum, T. Walmann, Z. Hamilton, M. Mirza and D. A. Duchene Departments of Urology, University of Kansas Medical Center, Kansas City, Kansas, Mayo Medical Center, Rochester, Minnesota, and University of San Diego Medical Center, San Diego, California J Endourol 2017; 31: 320e325. doi: 10.1089/end.2016.0568

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28006956 Editorial Comment: The authors retrospectively categorized initial and subsequent imaging after partial nephrectomy for low risk (pT1a) renal cell carcinoma (RCC) in normal and abnormal radiological reports when radiological findings suggested recurrence, or if additional imaging or intervention was recommended. At initial followup 29.5% of the reports were abnormal. Mean time to initial imaging postoperatively was 6.8 months for patients with normal reports and 4.4 months for those with abnormal reports (p ¼ 0.02). The difference is not surprising since clinical symptoms prompted the imaging investigation in 15 of 53 patients (28%) presenting with abnormal imaging. On subsequent imaging 60% of the abnormal studies were downgraded to normal. This study gives information on the timing and some of the reasons for performing initial imaging as well as on the fate of patients with abnormal initial imaging. Although this study does not completely elucidate the different reasons why early imaging may be prompted, 2 facts demand

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attention. A higher R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system/renal sinus, anterior/posterior, location relative to polar lines) Nephrometry Score was observed between the initial normal and abnormal imaging groups, with 7% of recurrences found at 3 to 6.6 months in the abnormal group and 3% of recurrences found at 9 to 30 months in the normal first imaging group. As for other cancers, surveillance after RCC surgery with curative intent makes sense when functional, quality of life or oncologic repair is possible, and prolongation of cancer specific survival and ultimately overall survival are attained. Oncologic and functional outcomes are good after partial nephrectomy for pT1a RCC, mostly depending on the low aggressiveness of these tumors and on previous or metachronous medical comorbidity. What the present report suggests is that early imaging in these tumors represents overuse of resources in the absence of clinical symptoms, positive surgical margins or familiar RCC syndromes. Major guidelines recommendations concerning imaging surveillance during the first year remain the standard of care. M. Pilar Laguna, MD, PhD

Suggested Reading Lobo JM, Nelson M, Nandanan N et al: Comparison of renal cell carcinoma surveillance guidelines: competing trade-offs. J Urol 2016; 195: 1664. Hafez KS, Novick AC and Campbell SC: Patterns of tumor recurrence and guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. J Urol 1997; 157: 2067. Campbell SC, Novick AC, Belldegrun A et al: Guideline for management of the clinical T1 renal mass. J Urol 2009; 182: 1271. Fergany AF, Hafez KS and Novick AC: Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol 2000; 163: 442. Gill IS, Desai MM, Kaouk JH et al: Laparoscopic partial nephrectomy for renal tumor: duplicating open surgical techniques. J Urol 2002; 167: 469. Donat SM, Diaz M, Bishoff JT et al: Follow-up for clinically localized renal neoplasms: AUA guideline. J Urol 2013; 190: 407.

Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Genital Human Papillomavirus Infection Progression to External Genital Lesions: The HIM Study S. L. Sudenga, D. J. Ingles, C. M. Pierce Campbell, H. Y. Lin, W. J. Fulp, J. L. Messina, M. H. Stoler, M. Abrahamsen, L. L. Villa, E. Lazcano-Ponce and A. R. Giuliano Moffitt Cancer Center and Research Institute, Tampa, Florida, University of Virginia Health System, Charlottesville, Virginia, School of Medicine,  blica, Cuernavaca, Me´xico University of Sa˜o Paulo and Santa Casa de Sa˜o Paulo, Sa˜o Paulo, Brazil, and Instituto Nacional de Salud Pu Eur Urol 2016; 69: 166e173. doi: 10.1016/j.eururo.2015.05.032

Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26051441 Editorial Comment: In men human papillomavirus (HPV) causes 2 types of external genital lesions: condyloma and penile intraepithelial neoplasia (PeIN). In this large ongoing prospective study of more than 3,000 men with HPV infection those with external lesions were evaluated. External lesions were most frequently associated with HPV6, 11 or 16, with the majority being condyloma. Specifically HPV16 positive PeIN developed in 0.5% of men with HPV16 external lesions. Although PeIN is rare, HPV16 related lesions could be prevented by the currently available 4-valent HPV vaccine. Increased administration of vaccine would also reduce the number of external genital lesions associated with HPV. Since our practices should continue to evolve and consider male health issues, the possible benefit of the HPV vaccine should be conveyed to our patients. Sam S. Chang, MD