Laparoscopic Nephroureterectomy and Management of the Distal Ureter: A Review of Current Techniques and Outcomes

Laparoscopic nephroureterectomy (LNU) is becoming an increasingly common alternative treatment for transitional cell carcinoma (TCC) of the renal pelvis and ureter due to decreased perioperative morbidity, shorter hospitalization, and comparable oncologic control with open nephroureterectomy (ONU). Mobilization of the kidney and proximal ureter may be performed through a transperitoneal, retroperitoneal, or hand-assisted approach. Each technique is associated with its own benefits and limitations, and the optimal approach is often dictated by surgeon preference. Our analysis of the literature reflects equivalent cancer control between LPN and OPN at intermediate follow-up with significantly improved perioperative morbidity following LPN. Several methods for bladder cuff excision have been advocated, however, no individual technique for management of the distal ureter proved superior. Overall, complete en-bloc resection with minimal disruption of the urinary tract should be optimized to maintain oncologic outcomes. Longer follow-up and prospective studies are needed to fully evaluate these techniques

A Multi-Institutional Study on the Safety and Efficacy of Specimen Morcellation After Laparoscopic Radical Nephrectomy for Clinical Stage T1 or T2 Renal Cell Carcinoma

Abstract Introduction and Objective: Specimen morcellation during laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) is controversial. We seek to evaluate the safety and efficacy of specimen morcellation and LRN for treatment of presumed malignant renal lesions. Methods: We retrospectively reviewed all patients who underwent LRN at three academic institutions from 1996 to 2007. One hundred eighty-eight patients underwent specimen morcellation after LRN for enhancing solid or cystic renal masses. Results: LRN was successfully performed on all the patients. Patient age ranged from 36 to 94. One hundred sixty-seven patients were in clinical stage T1, 19 patients T2, and unknown in two. The specimen was manually morcellated within a Cook Lap Sac or Endocatch II bag under laparoscopic or direct observation. On histological review of morcellated specimens, 165 patients were confirmed to have RCC, 17 had an oncocytoma, and 2 had benign cysts. At least 13 patients with RCC were pathologically upgraded to stage T3. Mean operative time was 225 minutes (range 94-650). Mean hospital stay was 2.5 days (range 1-8). In patients with RCC, 11 developed recurrent disease with mean follow-up of 21 months (range 0.3-111). In one patient, a port site recurrence occurred in concert with renal fossa and lymph node metastases. Conclusions: Intracorporeal mechanical morcellation after LRN appears to be safe and effective in clinical stage T1 and T2 RCC. This supports the use of morcellation as an alternative for intact specimen removal in properly selected patients.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78157/1/end.2009.0387.pd

Radiofrequency Ablation-Assisted Zero-Ischemia Robotic Laparoscopic Partial Nephrectomy: Oncologic and Functional Outcomes in 49 Patients

Introduction and Objectives. Robotic partial nephrectomy with peritumoral radiofrequency ablation (RFA-RPN) is a novel clampless technique. We describe oncologic and functional outcomes in a prospective cohort. Methods. From May, 2007, to December, 2009, 49 consecutive patients with renal masses <7 cm underwent RFA-RPN. During this period, only the RFA-RPN technique was utilized for all cases of partial nephrectomy. Pre- and postoperative data were analyzed and compared to 36 consecutive patients who underwent LPN. Results. In total, 49 tumors were treated in the RFA-RPN group and 36 tumors in the comparison group. Mean operative time was longer in the RFA-RPN group (370 min versus 293 min, p<0.001). There were no significant differences in mean EBL (231 cc versus 250 cc, p=0.42), transfusion rate (8.2% versus 11.1%, p=0.7), or hospital stay (3.9 versus 4.4 days, p=0.2). Two patients in the RFA-RPN (4.1%) and 1 (2.7%) patient in the comparison group had a positive surgical margin (p=0.75). 17 (34.7%) patients had a postoperative urine leak in the RFA-RPN group versus 2 (5.6%) patients in the comparison group (p=0.001). Mean follow-up was 54 months versus 68.4 months in the comparison group. There was no significant difference between the two groups regarding change in GFR (p=0.67). There were 3 recurrences (6.1%) in the RFA-RPN group and 0 recurrences in the RPN group (p=0.23). There were 3 deaths (6.1%) in the RFA-RPN group (one cancer specific) and 4 deaths (11.1%) in the RPN group (non-cancer specific) over the follow-up period (p=0.44). Conclusions. Our data suggests that this technique is associated with a similar degree of renal preservation but higher rates of postoperative urine leak and possibly higher rates of recurrence

Benefits of biomarker selection and clinico-pathological covariate inclusion in breast cancer prognostic models

Introduction: Multi-marker molecular assays have impacted management of early stage breast cancer, facilitating adjuvant chemotherapy decisions. We generated prognostic models that incorporate protein-based molecular markers and clinico-pathological variables to improve survival prediction. Methods: We used a quantitative immunofluorescence method to study protein expression of 14 markers included in the Oncotype DX™ assay on a 638 breast cancer patient cohort with 15-year follow-up. We performed cross-validation analyses to assess performance of multivariate Cox models consisting of these markers and standard clinico-pathological covariates, using an average time-dependent Area Under the Receiver Operating Characteristic curves and compared it to nested Cox models obtained by robust backward selection procedures. Results: A prognostic index derived from of a multivariate Cox regression model incorporating molecular and clinico-pathological covariates (nodal status, tumor size, nuclear grade, and age) is superior to models based on molecular studies alone or clinico-pathological covariates alone. Performance of this composite model can be further improved using feature selection techniques to prune variables. When stratifying patients by Nottingham Prognostic Index (NPI), the most prognostic markers in high and low NPI groups differed. Similarly, for the node-negative, hormone receptor-positive sub-population, we derived a compact model with three clinico-pathological variables and two protein markers that was superior to the full model. Conclusions: Prognostic models that include both molecular and clinico-pathological covariates can be more accurate than models based on either set of features alone. Furthermore, feature selection can decrease the number of molecular variables needed to predict outcome, potentially resulting in less expensive assays.This work was supported by a grant from the Susan G Komen Foundation (to YK)

Randomized controlled trial comparing three different modalities of lithotrites for intracorporeal lithotripsy in pcnl

Purpose: To compare the efficiency (stone fragmentation and removal time) and complications of three models of intracorporeal lithotripters in percutaneous nephrolithotomy (PCNL). Materials and Methods: Prospective, randomized controlled trial at nine centers in the North America from 2009 to 2016. Patients were randomized to one of three lithotripter devices: the Cyberwand, a dual probe ultrasonic device; the Swiss Lithoclast Select, a combination pneumatic and ultrasonic device; and the StoneBreaker, a portable pneumatic device powered by CO2 cartridges. Since the StoneBreaker lacks an ultrasonic component, it was used with the LUS‐II ultrasonic lithotripter to allow fair comparison with combination devices. Results: 270 patients were enrolled, 69 were excluded after randomization. 201 patients completed the study: 71 in the Cyberwand group, 66 in the Lithoclast Select, and 64 in the StoneBreaker group. The baseline patient characteristics of the three groups were similar. Mean stone surface area was smaller in the StoneBreaker group at 407.8mm2 vs 577.5mm2 (Lithoclast Select) and 627.9mm2 (Cyberwand). The stone clearance rate was slowest in the StoneBreaker group at 24.0 mm2/min vs 28.9 mm2/min and 32.3 mm2/min in the Lithoclast Select and Cyberwand groups respectively. After statistically adjusting for the smaller mean stone size in the StoneBreaker group, there was no difference in the stone clearance rate among the three groups (p=0.249). Secondary outcomes, including complications and stone free rates, were similar between the groups. Conclusions: The Cyberwand, Lithoclast Select, and the StoneBreaker lithotripters have similar adjusted stone clearance rates in PCNL for stones > 2cm. The safety and efficacy of these devices are comparable

The Surgical Infection Society revised guidelines on the management of intra-abdominal infection

Background: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. Methods: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. Results: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. Summary: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline

Knowledge, attitudes, and practice of oncologists and oncology health care providers in promoting physical activity to cancer survivors: An international survey

Objective: To investigate knowledge, attitudes and practices of oncologists towards physical 2 activity (PA) in cancer survivors, and the association between oncologists’ own PA behavior 3 and PA promotion. Methods: Oncologists (n=123) completed a survey based on the Theory of 4 Planned Behavior (TPB). Participants reported PA promotion behavior, PA involvement, 5 attitudes, intentions, social norm, Perceived Behavioral Control (PBC), confidence and 6 knowledge of exercise prescription. Structural equation modelling (SEM) evaluated these 7 associations. Results: Less than half of oncologists reported regularly promoting PA to 8 patients (46%), with 20% providing written information and 23% referrals. Only 26% were 9 physically active. TPB SEM pathways explained 54.6% of the variance in PA promotion 10 (CFI=0.905, SRMR=0.040). Social norm was the only significant pathway to intention, but 11 also a significant indirect pathway to PA promotion (p=.007). Confidence to promote PA, 12 PBC and intentions were direct significant pathways to PA promotion (p\u3c.05). Exploratory 13 SEM pathways explained 19.6% of the variance of PA behavior, which in turn explained 14 13.1% Social Norm, 10.7% Attitude, 10.0% Confidence to Recommend and 17.8% PA 15 promotion behavior (CFI=0.921, SRMR=0.076). Instrumental-attitude was a direct significant 16 pathway to PA behavior (p=.001). PA behavior was a direct significant pathway to social 17 norms, attitude, confidence to recommend, and PA promotion (p \u3c 0.05). Conclusions: 18 Oncologists reported a modest ability to promote PA, low PA promotion rates and limited 19 knowledge of exercise prescription. Patient physical activity promotion may be improved 20 through strategies that increase oncologists’ PBC, confidence and their own personal PA 21 participation

Expert range maps of global mammal distributions harmonised to three taxonomic authorities

AimComprehensive, global information on species' occurrences is an essential biodiversity variable and central to a range of applications in ecology, evolution, biogeography and conservation. Expert range maps often represent a species' only available distributional information and play an increasing role in conservation assessments and macroecology. We provide global range maps for the native ranges of all extant mammal species harmonised to the taxonomy of the Mammal Diversity Database (MDD) mobilised from two sources, the Handbook of the Mammals of the World (HMW) and the Illustrated Checklist of the Mammals of the World (CMW).LocationGlobal.TaxonAll extant mammal species.MethodsRange maps were digitally interpreted, georeferenced, error-checked and subsequently taxonomically aligned between the HMW (6253 species), the CMW (6431 species) and the MDD taxonomies (6362 species).ResultsRange maps can be evaluated and visualised in an online map browser at Map of Life (mol.org) and accessed for individual or batch download for non-commercial use.Main conclusionExpert maps of species' global distributions are limited in their spatial detail and temporal specificity, but form a useful basis for broad-scale characterizations and model-based integration with other data. We provide georeferenced range maps for the native ranges of all extant mammal species as shapefiles, with species-level metadata and source information packaged together in geodatabase format. Across the three taxonomic sources our maps entail, there are 1784 taxonomic name differences compared to the maps currently available on the IUCN Red List website. The expert maps provided here are harmonised to the MDD taxonomic authority and linked to a community of online tools that will enable transparent future updates and version control

Banking and Financial Crises in United States History: What Guidance can History Offer Policymakers?

This paper assesses the validity of comparisons of the current financial crisis with past crises in the United States. We highlight aspects of two National Banking Era crises (the Panic of 1873 and the Panic of 1907) that are relevant for comparison with the Panic of 2008. In 1873, overinvestment in railroad debt and the default of railroad companies on that debt led to the failure of numerous brokerage houses, an antecedent to the modern investment bank. For the Panic of 1907, panic-related deposit withdrawals centered on the less regulated trust companies, which were less directly linked to the existing lender of last resort, similar to investment banks in 2008. The popular press has made numerous references to the banking crises (there were three main ones) of the Great Depression as relevant comparisons to the present crisis. This paper argues that such an analogy is inaccurate in general