Hofstra Northwell Academic Works (Hofstra Northwell School of Medicine)

    Chapter 9: Surgical and Medical Options in the Management of Renal Cell Carcinoma

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    Laparoendoscopic single-site pyeloplasty: outcomes of an international multi-institutional study of 140 patients

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    OBJECTIVE To report an international, multi-institutional series of laparoendoscopic single-site pyeloplasty (LESS-P) with analysis of functional outcomes. MATERIALS AND METHODS LESS-P cases performed between October 2007 and June 2012 at 7 institutions worldwide per individual institutional protocols, entry criteria, and techniques were included. Patient characteristics, operative indications, perioperative outcomes, and postoperative follow-up were retrospectively collected and analyzed. RESULTS The study included 140 adult patients (age 39.9 +/- 15.7 years; body mass index 24.8 +/- 4.2 kg/m(2); 15% with previous abdominal surgery) who underwent unilateral LESS-P, most of whom (94.3%) had dismembered reconstructions. Mean operative time was 202.1 +/- 47 minutes with an estimated blood loss of 61.2 +/- 44.6 mL. Robotic laparoendoscopic single-site surgery was applied in 31 patients (22.1%). A single 2-3 mm accessory port was used in 44 patients (31.4%) and a single 5-12 mm accessory port was added in 9 patients (6.4%), whereas 10 patients (7.1%) were converted to conventional multiport laparoscopy. No patients required conversion to open surgery, nor were any intraoperative complications reported. Length of hospitalization was 2.4 +/- 1.6 days. The overall 90-day postoperative complication rate was 18.6%, mostly low-grade complications (Clavien I-II). With a mean follow-up of 14.0 +/- 10.8 months, 93.4% had resolution of symptoms and 94.4% had radiographic evidence demonstrating resolution of ureteropelvic junction obstruction. Assessment of drainage with diuretic nuclear renal scan provided evidence of improvement in 86.5% of patients on their first postoperative renal scan. CONCLUSION This study highlights the most comprehensive experience with LESS-P reported to date. Outcome measures parallel those of large published series of conventional laparoscopic pyeloplasty. Despite these encouraging findings, longer follow-up is needed to determine the efficacy and durability of this approach for the treatment of ureteropelvic junction obstruction. UROLOGY 82: 366-372, 2013. (C) 2013 Elsevier Inc

    Pediatric Urologists\u27 Personal Point-of-View of Health Related Quality of Life

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    OBJECTIVE: To assess pediatric urologists\u27 understanding and use of Health Related Quality of Life (HRQOL) resources in clinical practice. HRQOL is becoming an increasingly vital part of patient care. Although HRQOL has been evaluated and instruments developed for its assessment for several pediatric conditions, it is underrepresented in pediatric urology. METHODS: A SurveyMonkey 7 item questionnaire was sent to the members of the Society for Pediatric Urology. The questions inquired as to knowledge of surveys available, views on appropriate age for beginning discussion of HRQOL, patients\u27 and providers\u27 ability to assess patient HRQOL, and the need for disease-specific surveys. RESULTS: One-hundred and eighteen (37.6%) providers completed the survey. Remarkably 85.6% of the responders believe disease-focused HRQOL instruments would be useful specific urologic diseases; however, only 14.4% state use of any HRQOL instrument. Only 5 unique measures were reported. The majority felt the age at which patients can start reporting his/her HRQOL is 6-8 (41.3%) or 9-11 (31.2%) years. A preponderance of providers believed both themselves and parents could somewhat evaluate the patient HRQOL but the majority believe it important to inquire about parents\u27 perceptions of patient HRQOL. CONCLUSIONS: The overwhelming majority of pediatric urologists believe HRQOL is important but only a minority utilize available instruments. Further studies are needed to develop instruments to fill this essential gap

    Statin use not associated with improved outcomes in patients treated with brachytherapy for prostate cancer

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    PURPOSE: To investigate the association between statin use and prostate cancer outcomes in intermediate- and high-risk patients treated with brachytherapy for prostate cancer. METHODS AND MATERIALS: Between 1998 and 2010, 754 men with National Comprehensive Cancer Network intermediate- (n = 627) and high-risk (n = 127) prostate cancer were treated with prostate brachytherapy at our institution. Patients received either low-dose-rate or high-dose-rate brachytherapy as monotherapy or in combination with supplemental external beam radiotherapy. Two hundred eighty-five patients (37.8%) also received androgen-deprivation therapy. Two hundred seventy-three men (36.2%) were identified as taking statin medication before initiating radiation therapy. Prostate-specific antigen relapse-free survival (PSA-RFS), distant metastasis-free survival (DMFS), and overall survival were compared using log-rank tests. Associations of patient and treatment characteristics with outcomes were analyzed with univariate and multivariate regression. The median followup was 48 months. RESULTS: The 8-year PSA-RFS for intermediate-risk, high-risk, and all patients was 92.2%, 64.1%, and 87.7%, respectively. The 8-year DMFS was 97.1%, 82.9%, and 94.9%, respectively. The 8-year overall survival for the entire cohort was 86.6%. There were no significant differences between statin users and nonusers when stratified by risk group, nor when analyzed as a full cohort. On multivariate analysis, Gleason score 4 + 3 = 7 and \u3e7 were significantly associated with worse PSA-RFS (p7 (p = 0.008) and the use of neoadjuvant androgen-deprivation therapy (p = 0.03) was associated with worse DMFS. Statin use did not significantly impact PSA-RFS or DMFS. CONCLUSIONS: Pretreatment statin use is not associated with improved outcomes in intermediate- and high-risk patients undergoing prostate brachytherapy-based regimens for prostate cancer

    Utilization of a novel valveless trocar system during robotic-assisted laparoscopic prostatectomy

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    PURPOSE: To evaluate the effect of a novel valveless trocar system (VTS) on perioperative outcomes in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). METHODS: A single-institution retrospective review was performed of 792 patients undergoing RALP. Preoperative patient variables, tumor characteristics, and perioperative variables were collected and analyzed. The first 150 patients were excluded from analysis to account for the learning curve of robotic surgery. Univariate and multivariate linear regression models were used to assess factors affecting operative time (ORT). RESULTS: A total of 257 and 385 patients underwent RALP utilizing the VTS and conventional insufflation, respectively. There were no significant differences in American Society of Anesthesiologist score, body mass index (BMI), prostate volume, final Gleason score, estimated blood loss, and complications between the cohorts. The only difference noted was a significantly shorter mean ORT in the VTS cohort (149.5 vs. 170.1 min, p \u3c 0.0001). In light of this finding, further analysis was performed to identify associations with ORT. Multivariable analysis demonstrated that VTS, BMI, final Gleason score, prostate volume, surgeon, and node dissection were significantly associated with ORT. The use of the VTS decreased mean ORT by 23.2 min when controlling for confounding factors (p \u3c 0.001). The performance of a nerve sparing operation was found to decrease ORT by 15.9 min (p \u3c 0.001), though more often performed for lower-risk disease. CONCLUSION: The use of a novel VTS demonstrated decreased ORT in patients undergoing RALP when controlling for confounding factors. Prospective randomized trials are needed to evaluate its ultimate benefit in various surgical cohorts

    Review of appendiceal onlay flap in the management of complex ureteric strictures in six patients

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    Objectives To evaluate appendiceal onlay flap ureteroplasty for repairing complex right proximal and mid-ureteric strictures. Patients and Methods Between August 2006 and August 2012 four women and two men (mean age 34.2 years) underwent right laparoscopic appendiceal onlay flap ureteroplasty. The mean stricture length was 2.5 cm. Stricture formation was secondary to impacted ureteric stones in three patients and failed pyeloplasty for congenital pelvi-ureteric junction obstruction in the remaining three. Each patient had ipsilateral flank pain before surgery. Results The mean operating time, estimated blood loss and hospital stay were 244 min, 175 mL and 3.2 days, respectively. No intraor peri-operative complications were noted. The objective success rate was 100% (all patients had radiographic and/or endoscopic resolution of their ureteric strictures). The subjective success rate was 66%, (two patients developed recurrent discomfort, which upon exploration was found to be attributable to fibrosis away from the appendiceal onlay graft, where the gonadal vessels crossed the ureter). Both patients with recurrent pain underwent laparoscopic ureterolysis and bladder advancement flap proximal to the appendiceal onlay, which markedly improved one patient\u27s pain but the other patient continued to have discomfort, ultimately resulting in a laparoscopic nephroureterectomy. Conclusions Appendiceal onlay ureteroplasty is a viable treatment option for patients with complex right proximal and mid-ureteric strictures, while minimising the potential morbidity of appendiceal and ileal interposition

    Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy

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    PURPOSE: Clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding-related complications often prompts discontinuation of therapy prior to surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively. MATERIALS AND METHODS: 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into two groups, on-aspirin and off-aspirin, based on perioperative status of aspirin use. Primary endpoints evaluated included estimated intraoperative blood loss and incidence of bleeding-related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, readmission rate, and surgical margin status. RESULTS: Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 patients (16.8%). One patient in the on-aspirin group developed bleeding postoperatively period requiring angioembolization. Conversely, one myocardial infarction was observed in the off-aspirin cohort. There was no significant difference in incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay, and readmission rate. Operative time was increased with continued aspirin use (181 min vs. 136 min, p=0.01). CONCLUSIONS: Laparoscopic partial nephrectomy is safe and effective among patients on chronic antiplatelet therapy who require perioperative aspirin for cardio-protection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well better characterize associated bleeding risk

    Bioprinting Complex Cartilaginous Structures with Clinically Compliant Biomaterials

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    Bioprinting is an emerging technology for the fabrication of patient-specific, anatomically complex tissues and organs. A novel bioink for printing cartilage grafts is developed based on two unmodified FDA-compliant polysaccharides, gellan and alginate, combined with the clinical product BioCartilage (cartilage extracellular matrix particles). Cell-friendly physical gelation of the bioink occurs in the presence of cations, which are delivered by co-extrusion of a cation-loaded transient support polymer to stabilize overhanging structures. Rheological properties of the bioink reveal optimal shear thinning and shear recovery properties for high-fidelity bioprinting. Tensile testing of the bioprinted grafts reveals a strong, ductile material. As proof of concept, 3D auricular, nasal, meniscal, and vertebral disk grafts are printed based on computer tomography data or generic 3D models. Grafts after 8 weeks in vitro are scanned using magnetic resonance imaging and histological evaluation is performed. The bioink containing BioCartilage supports proliferation of chondrocytes and, in the presence of transforming growth factor beta-3, supports strong deposition of cartilage matrix proteins. A clinically compliant bioprinting method is presented which yields patient-specific cartilage grafts with good mechanical and biological properties. The versatile method can be used with any type of tissue particles to create tissue-specific and bioactive scaffolds
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