Faculty Bibliography

This Practice Point commentary discusses the study by Denzinger et al. in which patients with high-grade T1 (HGT1) bladder cancer were treated by transurethral resection with either white-light cystoscopy or fluorescence cystoscopy. Over a median follow-up duration >7 years, the recurrence-free survival was significantly improved in the fluorescence cystoscopy group. No difference was observed between the two groups, however, in the rate of progression to muscle-invasive disease, although the low number of progression events limited the power of this comparison. As such, a low threshold for radical cystectomy should be maintained in transurethrally resected HGT1 disease, regardless of the visualization technique used. Importantly, fluorescence cystoscopy represents a more costly and time-consuming procedure than does white-light cystoscopy. Larger clinical trials, as well as research at the molecular level, are needed to define the potential role of fluorescence cystoscopy in the treatment of HGT1 disease.

PURPOSE/OBJECTIVE:We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer. PATIENTS AND METHODS/METHODS:A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively. RESULTS:Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS <or=7. Overall positive surgical margin (PSM) rate was found to be 24.2%. pT(2)- and pT(3)-PSM rate was 6% and 42.3%, respectively. In multivariate logistic regression analysis, PSA <or=10 ng/mL (P = 0.04) and %MCB <or=30% (P = 0.001) were found to be statistically significant predictors of pT(2)N0 disease. CONCLUSION/CONCLUSIONS:Preoperative biopsy GS 8 to 10 predicts a significant likelihood of finding non-organ-confined prostate cancer on the final pathology report. Preoperative PSA <or=10 ng/mL and %MCB <or=30% may be used to predict favorable pathologic outcome for these patients during surgical counseling.

INTRODUCTION/BACKGROUND:The argon beam coagulator (ABC) is used in combination with other hemostatic agents and suture renorrhaphy to obtain hemostasis after laparoscopic partial nephrectomy. We performed a pilot study evaluating the efficacy of the ABC-alone in obtaining hemostasis during laparoscopic heminephrectomy (LHN) in a porcine model. METHODS:Eight pigs (4 small (30 kg-40 kg) and 4 large (70 kg-80 kg)), underwent bilateral LHN. Hemostasis then was obtained by using the ABC at 120W as a single modality. The collecting system was not repaired. The hilum was unclamped and the renal defect observed for 20 minutes with pneumoperitoneum pressure of 4 mmHg. The animals were survived for 24 hours at which time they were sacrificed and necropsy performed. RESULTS:All small pigs underwent LHN successfully. Mean pre- and post-op Hgb were 11.2 g/dl and 9.8 g/dl, respectively (p=0.12). In one of the animals, ABC at 150W was required to obtain hemostasis. All but one of the large pigs underwent LHN successfully. One of the animals had continuous bleeding despite ABC after right LHN and a completion nephrectomy was performed. Pre and postoperative Hgb for the large pigs were 9.9 g/dl and 9.3 g/dl, respectively (p=0.24). CONCLUSIONS:The ABC-alone was successful in obtaining hemostasis in all but two of the renal units in both small and large pigs. The two hemostatic failures were noticeable immediately after hilar unclamping. Our data suggest that ABC-alone provides adequate hemostasis when applied to small-caliber vessels. Further long term studies are needed to fully evaluate the efficacy of the ABC.

OBJECTIVES/OBJECTIVE:UroVysion (Abbott Molecular Inc., Des Plaines, IL) is a multi-target fluorescent in-situ hybridization (FISH) assay that detects aneuploidy of chromosomes 3, 7, and 17, and loss of the 9p21 locus in exfoliated cells in urine. In this study, we evaluated if UroVysion can predict tumor recurrence in patients with negative cystoscopy and urinary cytology at the time of (FISH) assay. METHODS:The study population included patients with history of non-muscle invasive bladder cancer treated by transurethral resection. Follow-up included cystoscopy, barbotage, urinary cytology, and UroVysion testing. Patients were followed for at least 6 months after their initial UroVysion testing. RESULTS:A total of 64 patients (37 males) were enrolled into the study. Mean patient age was 62 years (S.D. 13.2 years). Initial highest tumor stage was Ta in 42 patients (65.6%), T1 in 21 patients (33%), and isolated Tis in a single patient. Abnormal UroVysion results were observed in 40 patients (62.5%). After a median follow-up of 13.5 months, 21 patients (33%) developed tumor recurrence (Ta in 13 patients, T1 in 5, and Tis in 3). Recurrent tumors developed in 45% of the patients with abnormal UroVysion test compared with 12.5% of the patients with normal assay (P = 0.01). An abnormal UroVysion result preceded the diagnosis of tumor recurrence in 18/21 cases (86%), including all high-grade recurrences. CONCLUSIONS:This data suggest that UroVysion may be a useful tool for predicting tumor recurrence. Cystoscopy may be spared and surveillance intervals widened in patients with history of low grade tumors and a normal UroVysion test.

PURPOSE/OBJECTIVE:Partial nephrectomy has been established as a standard of care for T(1a) renal tumors. Laparoscopic partial nephrectomy (LPN) has been described as more difficult to perform than open partial nephrectomy (OPN). We compare our series of LPN and OPN. PATIENTS AND METHODS/METHODS:From October 2002 to January 2006, 76 LPNs were performed for patients with clinical T(1a) tumors. These patients were matched with a cohort of patients who underwent OPN for solitary tumors of 4 cm or smaller in diameter. The cohorts were compared with regard to demographics, perioperative data, and outcomes. RESULTS:The patient populations were demographically similar. Although mean tumor size was smaller in the laparoscopic cohort (2.5 v 2.9 cm, P=0.002), the OPN cohort demonstrated shorter operative (193 v 225 min, P=0.004) and ischemia times (20.5 v 32.8 min). LPN was associated with less blood loss (212 v 385 mL, P<0.001) and shorter hospital stay (2.5 v 5.6 days, P<0.001), however. One positive margin occurred in each of the LPN and OPN cohorts. Intraoperative complications were similar, although LPN was associated with fewer postoperative complications. Of note, two LPN (2.6%) patients had emergent reoperation and complete nephrectomy because of postoperative hemorrhage. CONCLUSIONS:Despite increased operative and ischemia times, LPN patients demonstrated quicker recovery and fewer postoperative complications. Two patients in the LPN group, however, had emergent complete nephrectomy because of hemorrhage. We conclude that LPN is still an evolving alternative to OPN in patients with small renal tumors.