UROLOGICAL ONCOLOGY: RENAL, URETERAL AND RETROPERITONEAL TUMORS

RENAL, URETERAL AND RETROPERITONEAL TUMORS

Robotic Laparoscopic Surgery: A Comparison of the da Vinci and Zeus Systems G. T. SUNG AND I. S. GILL, Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute and Minimally Invasive Surgery Center, Cleveland Clinic Foundation, Cleveland, Ohio Urology, 58: 893– 898, 2001 Objectives. To evaluate two currently available robotic surgical systems in performing various urologic laparoscopic procedures in an acute porcine model. Methods. Robotic laparoscopic surgery was performed in 14 swine. Data were compared between the da Vinci Robotic System and the Zeus Robotic System. Results. During laparoscopic nephrectomy, the da Vinci System (n ⫽ 6) had a significantly shorter total operating room time (51.3 versus 71.6 minutes; P ⫽ 0.02) and actual surgical time (42.1 versus 61.4 minutes; P ⫽ 0.03) compared with the Zeus System (n ⫽ 5). However, the blood loss and adequacy of surgical dissection were comparable between the two groups. For laparoscopic adrenalectomy, the da Vinci System (n ⫽ 5) had a shorter actual surgical time (12.2 versus 26.0 minutes; P ⫽ 0.006) than did the Zeus System (n ⫽ 5). For laparoscopic pyeloplasty, the da Vinci System had a shorter total operating room time (61.4 versus 83.4 minutes; P ⫽ 0.10) and anastomotic time (44.7 versus 66.4 minutes; P ⫽ 0.11). During pyeloplasty anastomosis, the total number of suture bites per ureter was 13.0 for the da Vinci System (n ⫽ 6) and 10.8 for the Zeus System (n ⫽ 6). The complications included an adrenal parenchymal tear each during a da Vinci System-based left adrenalectomy and a Zeus System-based right adrenalectomy. An inferior vena caval tear during a Zeus System-based right adrenalectomy occurred in 1 case, which was suture-repaired telerobotically. Conclusions. Robotic laparoscopic procedures can be performed effectively using either the da Vinci or Zeus System. In this limited study, the learning curve and operative times were shorter and the intraoperative technical movements appeared inherently more intuitive with the da Vinci System. Additional clinical experience is necessary. Editorial Comment: In this study the daVinci robot was superior. This finding is not surprising, given the 6 degrees of freedom of the daVinci unit versus the 4 degrees of freedom of this version of the Zeus. Since publication of this article, the Zeus has subsequently been equipped with articulating instrumentation, which obviously means that a “rematch” is in order. Robotic surgery is rapidly developing in all major surgical disciplines. In urology the robotic laparoscopic prostatectomy has been perfected for the daVinci unit most notably by Menon at the Henry Ford Hospital in Detroit. Developments in this area are occurring rapidly. It would appear that Semm, the father of modern day laparoscopic surgery, may well have been correct when he stated in 1999, “My dear colleagues, please believe me, as a teacher of surgery for over 40 years, when I say that operations performed by robots will be done with greater manual skill than by the training surgeons of today.” Ralph V. Clayman, M.D. Recommended Reading: Pak, C. Y. C. and Resnick, M. I.: Medical therapy and new approaches to management of urolithiasis. Urol Clin North Am, 27: 243, 2000 Ratner, L. E., Montgomery, R. A. and Kavoussi, L. R.: Laparoscopic live donor nephrectomy. A review of the first 5 years. Urol Clin North Am, 28: 709, 2001

UROLOGICAL ONCOLOGY: RENAL, URETERAL AND RETROPERITONEAL TUMORS Enhancement Characteristics of Papillary Renal Neoplasms Revealed on Triphasic Helical CT of the Kidneys B. R. HERTS, D. M. COLL, A. C. NOVICK, N. OBUCHOWSKI, G. LINNELL, S. L. WIRTH AND M. E. BAKER, Department of Radiology, Urological Institute and Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, Ohio AJR Am J Roentgenol, 178: 367–372, 2002 OBJECTIVE. The purpose of this study was to determine whether renal tumor enhancement or heterogeneity on triphasic helical CT scans is predictive of the papillary cell subtype or nuclear grade of renal cell carcinoma. MATERIALS AND METHODS. We reviewed the CT scans of 90 consecutive patients with renal masses who had undergone triphasic renal helical CT before a complete or partial nephrectomy (12 with papillary renal cell carcinomas, 66 with nonpapillary renal cell carcinomas, and 12 with benign lesions). Three

799

800

RENAL, URETERAL AND RETROPERITONEAL TUMORS

radiologists who were unaware of the patients’ diagnoses retrospectively and independently measured the attenuation of each patient’s tumor, abdominal aorta, and normal renal parenchyma on the scans obtained during all three phases. Ratios of tumor-to-aorta enhancement and tumor-to-normal renal parenchyma enhancement were calculated for both of the phases performed after contrast material had been administered. Tumor heterogeneity was calculated as the difference between the highest and lowest attenuation values divided by the value of the enhancement of the aorta. Values were correlated with cell type and nuclear grade found at surgical pathology. RESULTS. Low tumor-to-aorta enhancement and low tumor-to-normal renal parenchyma enhancement ratios on the vascular phase scans significantly correlated (p ⬍0.001) with papillary renal cell type carcinoma. Homogeneity and tumor-to-parenchyma enhancement ratios on the parenchymal phase scans also significantly correlated (p ⬍0.001) with papillary renal cell type carcinoma. Heterogeneity and tumor enhancement ratios did not correlate with the nuclear grade of the carcinoma. CONCLUSION. Papillary renal cell carcinomas are typically hypovascular and homogeneous. A high tumor-to-parenchyma enhancement ratio (ⱖ25%) essentially excludes the possibility of a tumor being papillary renal cell carcinoma. A low tumor-to-aorta enhancement ratio or tumor-to-normal renal parenchyma enhancement ratio is more likely to indicate papillary renal cell carcinoma. Editorial Comment: The authors demonstrate that papillary renal cell carcinomas tend to be homogeneous and hypovascular. If tumor-to-normal parenchyma enhancement ratio is greater than 25%, then the tumor is not papillary carcinoma. This study quantitates previously appreciated qualitative findings. Fray F. Marshall, M.D. Comparison of Costs and Complications of Radical and Partial Nephrectomy for Treatment of Localized Renal Cell Carcinoma B. SHEKARRIZ, J. UPADHYAY, H. SHEKARRIZ, A. GOES, JR., F. J. BIANCO, JR., R. TIGUERT, E. GHEILER AND D. P. WOOD, JR., Department of Urology, Wayne State University and Barbara Ann Karmanos Cancer Institute, Detroit, Michigan Urology, 59: 211–215, 2002 Objectives. To compare the complications and costs of radical and partial nephrectomy (PN) and to investigate the impact of increasing experience on costs and complications during a 7-year period. Nephronsparing surgery has found increasing applications in the past decade. PN has achieved similar long-term results in localized renal cell carcinoma with respect to cancer control compared with radical nephrectomy (RN). However, data are limited on the direct comparison of complications and hospital costs between these two modalities. Methods. A retrospective case-matched study was performed comparing 60 RNs and 60 PNs during a 7-year period with respect to complications and hospital costs. A longitudinal comparison was also performed between the various periods to assess the impact of surgical experience on these parameters. Results. The mean length of stay was 6.4 ⫾ 3 days in the RN group and 6.4 ⫾ 3.3 days in the PN group. The hospital costs were comparable between the two procedures during the observed interval. The mean operative time was 176.6 ⫾ 51.6 minutes for RN and 220.1 ⫾ 59.6 minutes for PN (P ⫽ 0.0001). This difference was accentuated during the observed period. No differences were found in the blood loss and transfusion rates between the groups. The complication rate was 3.3% and 10% for RN and PN, respectively (P ⫽ 0.2). Conclusions. Our data suggest that RN and PN can be performed with a similar rate of complications and comparable hospital costs. This is of practical importance when comparing these modalities as treatment options for localized renal cell carcinoma. Editorial Comment: Radical nephrectomy was the standard treatment for renal cell carcinoma for years. However, partial nephrectomy has become an accepted form of treatment even with a normal contralateral kidney. This study suggests that there is a similar rate of complications and costs between the procedures, with partial nephrectomy taking slightly more time to perform. Judgment remains a key element in the selection of surgical procedure. Fray F. Marshall, M.D. Cryosurgical Ablation of Renal Tumors Using 1.5-Millimeter, Ultrathin Cryoprobes A. J. PANTUCK, A. ZISMAN, J. COHEN AND A. BELLDEGRUN, Division of Urologic Oncology, Department of Urology, University of California, Los Angeles, School of Medicine, Los Angeles, California, and Division of Urology, Alleghany General Hospital, Pittsburgh, Pennsylvania Urology, 59: 130 –133, 2002 Introduction. To describe an open technique for the cryosurgical ablation of small renal tumors using multiple ultrathin cryoprobes. Renal cryosurgery is an evolving surgical technique, and uncertainties exist regarding the ideal approach to freezing renal tumors. Technical Considerations. Using an open surgical approach, a 3-cm upper pole renal mass was ablated

RENAL, URETERAL AND RETROPERITONEAL TUMORS

using five, state-of-the-art, 1.5-mm cryoprobes simultaneously under real-time ultrasound guidance. The technique is described and demonstrated in a multisegment, Internet-based video tutorial. The blood loss was minimal, and no intraoperative or postoperative complications were experienced. Follow-up imaging at 3 months suggested shrunken, nonviable tumor. Conclusion. Cryosurgical ablation of renal tumors using multiple 1.5-mm cryoprobes is a safe, feasible approach that may be associated with a decreased risk of bleeding. Editorial Comment: Cryotherapy and radio frequency ablation of small renal tumors can be performed laparoscopically or percutaneously. The smaller 1.5 mm. probes used in this study allowed placement of 5 probes simultaneously in an open operation. At this time cryotherapy appears to be more reliable than radio frequency in terms of real time radiographic verification as well as later definitive tissue destruction. Fray F. Marshall, M.D. SPARC Expression in Primary Human Renal Cell Carcinoma: Upregulation of SPARC in Sarcomatoid Renal Carcinoma N. SAKAI, M. BABA, Y. NAGASIMA, Y. KATO, K. HIRAI, K.-I. KONDO, K. KOBAYASHI, M. YOSHIDA, S. KANEKO, T. KISHIDA, S. KAWAKAMI, M. HOSAKA, Y. INAYAMA AND M. YAO, Departments of Urology, Pathology and Otolaryngology, and Division of Anatomical and Surgical Pathology, Yokohama City University School of Medicine, and Department of Biochemistry, Kanagawa Dental College, Yokohama, Japan Hum Pathol, 32: 1064 –1070, 2001 SPARC (secreted protein acidic and rich in cysteine, also called osteonectin, BM-40, and 43K protein) is a matricellular protein and is associated with cell-matrix interactions during cell proliferation and extracellular remodeling. It is also implicated in the neovascularization, invasion, and metastasis of human malignancies. To investigate a potential role of the SPARC in renal tumorigenesis, we examined primary renal cell carcinomas (RCCs) for SPARC expression by Northern blot analysis and for protein distribution by immunohistochemistry. We found that 6 (100%) of 6 sarcomatoid and 25 (70%) of 36 clear-cell carcinomas had enhanced SPARC transcription compared with that of the corresponding normal kidney tissue. In contrast, papillary and chromophobe RCCs characterized by a hypovascular or avascular tumor phenotype had undetectable SPARC expression. Immunohistochemical analysis showed that SPARC was strongly stained in the cytoplasm of the sarcomatoid neoplastic cells in sarcomatoid RCCs, whereas it was expressed only in the vascular endothelial cells and fibroblasts in clear-cell RCCs. SPARC staining intensity in the stromal cells was increased in the invading portion in some clear-cell RCCs. These findings suggest that tumor development, including neovascularization and invasion in clear-cell RCCs, might be regulated by SPARC from stromal endothelial cells and fibroblasts and that sarcomatoid transformation from commontype RCCs is associated with upregulation of SPARC expression; SPARC may contribute to its aggressive tumor phenotype. Editorial Comment: SPARC, also called osteonectin, is routinely expressed in sarcomatoid renal cell carcinoma. Papillary and chromophobe renal cell carcinomas are hypovascular and do not typically express SPARC. Expression may also manifest in stromal endothelial cells, which suggests that SPARC may be a marker for an aggressive renal cell carcinoma phenotype. Fray F. Marshall, M.D. Nonmyeloablative Blood Stem Cell Transplantation as Adoptive Allogeneic Immunotherapy for Metastatic Renal Cell Carcinoma R. W. CHILDS, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Crit Rev Immunol, 21: 191–203, 2001 Permission to Publish Abstract Not Granted Editorial Comment: Various forms of immunotherapy, such as systemic interleukin-2, have been used in the past. Recently nonmyeloablative allogeneic stem cell transplantation has been used for management of hematological malignancies. Allogeneic immunotherapy appears to demonstrate a graft versus renal cell carcinoma effect. In this study 33 patients with progressive metastatic renal cell carcinoma, most of whom had failed previous treatment, underwent nonmyeloablative allogeneic transplantation using sibling donors. Fifteen patients had disease regression compatible with a graft versus tumor effect (11 partial response, 4 complete response). Transplant related effects were present and all patients had febrile neutropenia. Thirty-nine percent of the patients had cytomegalovirus reactivation. Followup and experience will be required to determine the place of this therapy. However, it appears promising. Fray F. Marshall, M.D.

801

802

SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS

Genetic Identification of a Locus, Mot1, That Affects Renal Tumor Size in the Rat R. S. YEUNG, H. GU, M. LEE AND T. A. DUNDON, Departments of Surgery and Medicine (Medical Genetics), University of Washington, Seattle, Washington Genomics, 78: 108 –112, 2001 Prognosis and treatment of solid tumors are directly dependent on the stage of disease. For any type of cancer, tumor characteristics such as size, multiplicity, and metastatic potential are highly heterogeneous among patients. Our understanding of the genetic determinants of tumor burden is rudimentary. Here, rats carrying a germline mutation of the gene Tsc2 were found to develop variable size and number of renal tumors. We hypothesize that “modifier” genes unlinked to Tsc2 affect its expressivity. Using a backcross (BC) analysis between the two strains that showed the greatest difference in tumor size (Fischer344 and Brown Norway), we mapped a quantitative trait locus based on tumor volume to rat chromosome 3q, lying in the interval between D3Mit3 and D3Rat17, with a maximum lod score of 4.4. This locus, Mot1 (modifier of Tsc2 1), accounts for ⬃35% of the genetic variation in tumor size between the two strains. No significant difference in tumor multiplicity was noted between Brown Norway and Fischer344 rats. This suggests that Mot1 modulates the rate of disease progression and not tumor initiation. Candidate genes on rat chromosome 3 included Tsc1, whose product interacts biochemically with the TSC2 protein, but it was excluded on the basis of linkage analysis (LOD ⫽ 0.01). Comparative genomics suggest that the Mot1 region is represented by human chromosomes 15q and 20pq. Our results provide the first evidence of a modifier gene affecting the Tsc2 pathway in the progression of renal tumorigenesis. Editorial Comment: In this study rats carrying a germ line mutation of the tuberous sclerosis complex (TSC2) had development of renal tumors that appeared to be affected by tumor “modifier” genes. A locus MOT1 accounted for approximately 33% of variations in tumor size. It appears that MOT1 acts as a post-initiator factor and implies multiple genetic factors in determining the course of the disease. Fray F. Marshall, M.D.

SOCIOECONOMIC FACTORS, UROLOGICAL EPIDEMIOLOGY AND PRACTICE PATTERNS Assessing Meaningful Change in Quality of Life Over Time: A Users’ Guide for Clinicians M. A. G. SPRANGERS, C. M. MOINPOUR, T. J. MOYNIHAN, D. L. PATRICK, D. A. REVICKI AND THE CLINICAL SIGNIFICANCE CONSENSUS MEETING GROUP, Department of Medical Psychology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, Southwest Oncology Group Statistical Center and Department of Health Services, University of Washington, Seattle, Washington, Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, and Center for Health Outcomes Research, MEDTAP International Inc, Bethesda, Maryland Mayo Clin Proc, 77: 561–571, 2002 The objective of this article is to help clinicians interpret trial-based quality of life (QOL) changes over time. We address a series of questions and provide guidelines that are fundamental to assessing and interpreting change. The issues addressed are as follows: (1) What are the characteristics of the population for whom changes in QOL are reported? (2) Is the QOL questionnaire reliable, valid, and responsive to change? (3) Are the timing and frequency of assessments adequate? (4) Is the study adequately powered? (5) How are multiple QOL outcomes addressed in analyses? (6) How are multiple time points handled? (7) Can alternative explanations account for the observed change or lack of observed change (eg, handling of missing data, survival differences, and changes in patient’s QOL perspective over time)? and (8) How is statistical significance translated into meaningful change? These guidelines will support clinicians in reviewing the clinical trial literature, which in turn can help them use the data in the treatment decision process. Editorial Comment: Urologists interested in quality of life studies should review this report. The authors explore multiple issues that confound studies concerning quality of life. They stress the importance of baseline assessment and an understanding of the natural course of disease. Studies involving patients in early phases of disease pose different problems compared to those involving patients with advanced cancers. The timing of the administration of survey instruments and issues surrounding respondent burden are reviewed. In addition, issues surrounding multiple assessments and study power are analyzed. This article is easy to read and provides a wealth of relevant information. Peter C. Albertsen, M.D.