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Re: Percutaneous Cryoablation of Stage T1b Renal Cell Carcinoma: Technique Considerations, Safety, and Local Tumor Control
LAPAROSCOPY/NEW TECHNOLOGY
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Laparoscopy/New Technology Re: Percutaneous Cryoablation of Stage T1b Renal Cell Carcinoma: Technique Considerations, Safety, and Local Tumor Control T. D. Atwell, J. J. Vlaminck, S. A. Boorjian, A. N. Kurup, M. R. Callstrom, A. J. Weisbrod, C. M. Lohse, W. R. Hartman, A. H. Stockland, B. C. Leibovich, G. D. Schmit and R. H. Thompson Departments of Radiology, Urology, Biostatistics and Anesthesiology, Mayo Clinic, Rochester, Minnesota J Vasc Interv Radiol 2015; 26: 792e799. doi: 10.1016/j.jvir.2015.02.010.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25824313 Editorial Comment: The authors report the outcomes of 46 patients with stage T1b biopsy confirmed renal cell carcinoma (RCC) who underwent percutaneous cryoablation during an 8-year period. Given the known high RCC case volume at their institution, it can be assumed these were select patients. It is generally accepted that renal tumor ablation (radio frequency ablation and cryoablation) is less effective when treating patients with tumors larger than 3 to 4 cm in diameter. However, the Mayo Clinic group has challenged this finding with several publications, including this one, demonstrating safety and success in tumors as large as 7 cm. In this series several patients required preablation interventions such as tumor embolization, stent placement and bowel hydro displacement to reduce complications. In 36 patients with modest followup (median 2 years) only 1 recurrence was identified. Complications were modest, although 8.7% of cases were complicated by bleeding, which is consistent with the experience reported by others for cryoablation of tumors larger than 3 cm in diameter. Certainly additional experience in a larger series with longer followup is needed before cryoablation should be considered an alternative to surgery for patients with T1b RCC. These results reflect a center of excellence, and confirmation of these outcomes is needed. Until then, this method should remain investigational in this patient population. I question what the advantage of this technique for T1b tumors would be compared to robotic partial nephrectomy. The authors state that prophylactic angioembolization should be considered. However, combined with the increased number of cryoprobes required to complete the procedure, general anesthesia and the almost 9% transfusion rate, I suspect that the cost advantage and morbidity compared to surgery will be small. Jeffrey A. Cadeddu, MD
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.
Re: Prevention of Orchialgia after Left-Sided Laparoscopic Donor NephrectomydA Prospective Study S. K. Sureka, A. Srivastava, S. Agarwal, A. Srivastava, S. An, S. Singh, V. Mittal, N. Patidar, R. Kapoor and M. S. Ansari Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India J Endourol 2015; 29: 696e699. doi: 10.1089/end.2014.0645.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25401724 Editorial Comment: The authors report their experience with modifications in gonadal vein ligation and ureteral transection during left laparoscopic donor nephrectomy. Ipsilateral orchalgia developed in 9 of 30 cases where these structures were divided below the crossing of the iliac vessels, compared to 1 of 85 where these structures were divided above the crossing of the iliac vessels. I have
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
noted similar outcomes in my career and, as such, instruct our residents to avoid transection of the gonadal vessels in all upper tract laparoscopies. I will strive to preserve and minimize dissection of the gonadal vessels and mid ureter in all renal and proximal ureter laparoscopic cases on either side. Jeffrey A. Cadeddu, MD
Re: Endovascular Extraction of Caval Tumor Thrombus to Facilitate Minimally Invasive Cytoreductive Nephrectomy for Metastatic Kidney Cancer C. Rogers, R. Barod, S. Schwartz and M. Menon Vattikuti Urology Institute, Henry Ford Hospital and Department of Interventional Radiology, Henry Ford Health System, Detroit, Michigan Eur Urol 2015; 68: 167e168. doi: 10.1016/j.eururo.2015.03.039.
No Abstract Editorial Comment: This is a case report of an innovative technique to downsize an inferior vena caval thrombus and allow for a less challenging laparoscopic nephrectomy. The authors used a commercially available percutaneous endovascular suction thrombectomy device that requires an extracorporeal venous bypass circuit to mechanically remove a short intracaval thrombus, leaving only the right renal vein component. The patient subsequently underwent minimally invasive nephrectomy, avoiding the complexity of inferior vena caval thrombectomy and reconstruction. It must be emphasized that the patient already had high volume metastases such that potential tumor cell dissemination was less of a concern. The limitations of this technique are clear but I suspect that we will see more such cases. Jeffrey A. Cadeddu, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Immediate versus Deferred Chemotherapy after Radical Cystectomy in Patients with pT3-pT4 or ND M0 Urothelial Carcinoma of the Bladder (EORTC 30994): An Intergroup, Open-Label, Randomised Phase 3 Trial C. N. Sternberg, I. Skoneczna, J. M. Kerst, P. Albers, S. D. Fossa, M. Agerbaek, H. Dumez, odore, M. G. Leahy, J. D. Chester, A. Verbaeys, G. Daugaard, L. Wood, M. de Santis, C. The J. A. Witjes, R. de Wit, L. Geoffrois, L. Sengelov, G. Thalmann, D. Charpentier, F. Rolland, L. Mignot, S. Sundar, P. Symonds, J. Graham, F. Joly, S. Marreaud, L. Collette and R. Sylvester; European Organisation for Research and Treatment of Cancer Genito-Urinary nitales; National Cancer Research Cancers Group; Groupe d’Etude des Tumeurs Uroge Institute Bladder Cancer Study Group; National Cancer Institute of Canada Clinical Trials Group, and German Association of Urologic Oncology Department of Medical Oncology, San Camillo and Forlanini Hospitals, Rome, Italy, Maria Sklodowska Curie Memorial Cancer Centre, Gliwice, Poland, and Department of Medical Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands Lancet Oncol 2015; 16: 76e86. doi: 10.1016/S1470-2045(14)71160-X.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25498218 Editorial Comment: In this open-label, randomized, phase III trial patients with pT3 to pT4 and/or node positive disease (pN1 to pN3) were randomized to undergo either immediate cisplatin based chemotherapy or delayed chemotherapy at relapse. The primary end point was overall survival. Of the planned 660 patients 284 were recruited. With a median followup of 7 years the authors report that there was no significant difference in the primary end point of overall survival between
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Laparoscopy/New Technology Re: Percutaneous Cryoablation of Stage T1b Renal Cell Carcinoma: Technique Considerations, Safety, and Local Tumor Control T. D. Atwell, J. J. Vlaminck, S. A. Boorjian, A. N. Kurup, M. R. Callstrom, A. J. Weisbrod, C. M. Lohse, W. R. Hartman, A. H. Stockland, B. C. Leibovich, G. D. Schmit and R. H. Thompson Departments of Radiology, Urology, Biostatistics and Anesthesiology, Mayo Clinic, Rochester, Minnesota J Vasc Interv Radiol 2015; 26: 792e799. doi: 10.1016/j.jvir.2015.02.010.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25824313 Editorial Comment: The authors report the outcomes of 46 patients with stage T1b biopsy confirmed renal cell carcinoma (RCC) who underwent percutaneous cryoablation during an 8-year period. Given the known high RCC case volume at their institution, it can be assumed these were select patients. It is generally accepted that renal tumor ablation (radio frequency ablation and cryoablation) is less effective when treating patients with tumors larger than 3 to 4 cm in diameter. However, the Mayo Clinic group has challenged this finding with several publications, including this one, demonstrating safety and success in tumors as large as 7 cm. In this series several patients required preablation interventions such as tumor embolization, stent placement and bowel hydro displacement to reduce complications. In 36 patients with modest followup (median 2 years) only 1 recurrence was identified. Complications were modest, although 8.7% of cases were complicated by bleeding, which is consistent with the experience reported by others for cryoablation of tumors larger than 3 cm in diameter. Certainly additional experience in a larger series with longer followup is needed before cryoablation should be considered an alternative to surgery for patients with T1b RCC. These results reflect a center of excellence, and confirmation of these outcomes is needed. Until then, this method should remain investigational in this patient population. I question what the advantage of this technique for T1b tumors would be compared to robotic partial nephrectomy. The authors state that prophylactic angioembolization should be considered. However, combined with the increased number of cryoprobes required to complete the procedure, general anesthesia and the almost 9% transfusion rate, I suspect that the cost advantage and morbidity compared to surgery will be small. Jeffrey A. Cadeddu, MD
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.
Re: Prevention of Orchialgia after Left-Sided Laparoscopic Donor NephrectomydA Prospective Study S. K. Sureka, A. Srivastava, S. Agarwal, A. Srivastava, S. An, S. Singh, V. Mittal, N. Patidar, R. Kapoor and M. S. Ansari Department of Urology and Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India J Endourol 2015; 29: 696e699. doi: 10.1089/end.2014.0645.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25401724 Editorial Comment: The authors report their experience with modifications in gonadal vein ligation and ureteral transection during left laparoscopic donor nephrectomy. Ipsilateral orchalgia developed in 9 of 30 cases where these structures were divided below the crossing of the iliac vessels, compared to 1 of 85 where these structures were divided above the crossing of the iliac vessels. I have
BLADDER, PENIS AND URETHRAL CANCER, AND BASIC PRINCIPLES OF ONCOLOGY
noted similar outcomes in my career and, as such, instruct our residents to avoid transection of the gonadal vessels in all upper tract laparoscopies. I will strive to preserve and minimize dissection of the gonadal vessels and mid ureter in all renal and proximal ureter laparoscopic cases on either side. Jeffrey A. Cadeddu, MD
Re: Endovascular Extraction of Caval Tumor Thrombus to Facilitate Minimally Invasive Cytoreductive Nephrectomy for Metastatic Kidney Cancer C. Rogers, R. Barod, S. Schwartz and M. Menon Vattikuti Urology Institute, Henry Ford Hospital and Department of Interventional Radiology, Henry Ford Health System, Detroit, Michigan Eur Urol 2015; 68: 167e168. doi: 10.1016/j.eururo.2015.03.039.
No Abstract Editorial Comment: This is a case report of an innovative technique to downsize an inferior vena caval thrombus and allow for a less challenging laparoscopic nephrectomy. The authors used a commercially available percutaneous endovascular suction thrombectomy device that requires an extracorporeal venous bypass circuit to mechanically remove a short intracaval thrombus, leaving only the right renal vein component. The patient subsequently underwent minimally invasive nephrectomy, avoiding the complexity of inferior vena caval thrombectomy and reconstruction. It must be emphasized that the patient already had high volume metastases such that potential tumor cell dissemination was less of a concern. The limitations of this technique are clear but I suspect that we will see more such cases. Jeffrey A. Cadeddu, MD
Urological Oncology: Bladder, Penis and Urethral Cancer, and Basic Principles of Oncology Re: Immediate versus Deferred Chemotherapy after Radical Cystectomy in Patients with pT3-pT4 or ND M0 Urothelial Carcinoma of the Bladder (EORTC 30994): An Intergroup, Open-Label, Randomised Phase 3 Trial C. N. Sternberg, I. Skoneczna, J. M. Kerst, P. Albers, S. D. Fossa, M. Agerbaek, H. Dumez, odore, M. G. Leahy, J. D. Chester, A. Verbaeys, G. Daugaard, L. Wood, M. de Santis, C. The J. A. Witjes, R. de Wit, L. Geoffrois, L. Sengelov, G. Thalmann, D. Charpentier, F. Rolland, L. Mignot, S. Sundar, P. Symonds, J. Graham, F. Joly, S. Marreaud, L. Collette and R. Sylvester; European Organisation for Research and Treatment of Cancer Genito-Urinary nitales; National Cancer Research Cancers Group; Groupe d’Etude des Tumeurs Uroge Institute Bladder Cancer Study Group; National Cancer Institute of Canada Clinical Trials Group, and German Association of Urologic Oncology Department of Medical Oncology, San Camillo and Forlanini Hospitals, Rome, Italy, Maria Sklodowska Curie Memorial Cancer Centre, Gliwice, Poland, and Department of Medical Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands Lancet Oncol 2015; 16: 76e86. doi: 10.1016/S1470-2045(14)71160-X.
Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25498218 Editorial Comment: In this open-label, randomized, phase III trial patients with pT3 to pT4 and/or node positive disease (pN1 to pN3) were randomized to undergo either immediate cisplatin based chemotherapy or delayed chemotherapy at relapse. The primary end point was overall survival. Of the planned 660 patients 284 were recruited. With a median followup of 7 years the authors report that there was no significant difference in the primary end point of overall survival between
63