Faculty Bibliography

Introduction & Objectives: The prognostic significance of venous involvement and tumour thrombus level in renal cell carcinoma (RCC) remains highly controversial. Patients with Level III (above hepatic veins below diaphragm) and Level IV (Above diaphragm-atrium) can be managed with or without using of by-pass. Investigations have suggested differences in morbidity between the two approaches but there is a lack of data regarding the potential impact on oncological outcomes. We aimed to evaluate the impact of cardiopulmonary by-pass in Level III-IV thrombus in Cancer- Specific Mortality (CSM). Materials & Methods: An International Consortium of 11 institutions was established to retrospectively review a combined cohort of 1215 patients undergoing radical nephrectomy and tumour thrombectomy for RCC, including 271 (22%) patients with Level III (170-62%) or IV (101-38%%) involvement. Predictive factors of survival including age, cardiopulmonary by-pass, nodal status, Fuhrman grade, node status, preoperative embolisation and presence of metastasis at time or surgery were analysed. The Chi-square tests was used to compare discrete factors, t-tests for continuous factors and actuarial methods for the survival endpoints. (Graph presented) Results: The mean follow-up for uncensored patients were 39.8 (0-258) months with a median survival of 30 months. Finally we analyzed 170 Level III (113 withby- pass and 57 without-by-pass) and 101 Level IV (98 with-by-pass and 3 withoutby- pass). The 5-yr CSM was 31% (Level III with by-pass), 31% (Level III-without by-pass), 28% (Level IV-with by-pass) and on the Level IV without by-pass did not reach the minimum time to calculate. On multivariate analysis, only Fuhrman grade ( p=0.022) and existence of metastasis at the time of surgery (p=0,012) correlated independently with survival; age (p=0.39), N+ (p=0.50), by-pass (0.11), embolisation (p=0.21) were not associated with CSM. Conclusions: Based on analysis of the largest known cohort of patients with RCC along with Level III and IV thrombus involvement, Fuhrman grade and existence of preoperative metastasis were independent predictors of survival. Our findings support that based on oncological outcomes both approaches (with or without bypass using) are safe

Traditionally, the patient with a new diagnosis of localized prostate cancer faces either radical therapy, in the form of surgery or radiation, or active surveillance. A growing subset of these men may not be willing to accept the psychological burden of active surveillance nor the side effects of extirpative or radiation therapy. Local ablative therapies including cryotherapy, high-intensity focused ultrasound, and vascular-targeted photodynamic therapy have emerged as a means for minimally invasive definitive treatment. These treatments are well tolerated with decreased morbidity in association with improvements in technology; however, long-term oncologic efficacy remains to be determined

We have fabricated a bandgap-guiding hollow-core photonic crystal fiber (PCF) capable of transmitting and compressing ultrashort pulses in the green spectral region around 532 nm. When propagating subpicosecond pulses through 1 m of this fiber, we have observed soliton-effect temporal compression by up to a factor of 3 to around 100 fs. This reduces the wavelength at which soliton effects have been observed in hollow-core PCF by over 200 nm. We have used the pulses delivered at the output of the fiber to machine micrometer-scale features in copper

PURPOSE: A novel equation, the Chronic Kidney Disease Epidemiology Collaboration, has been proposed to replace the Modification of Diet in Renal Disease for estimated glomerular filtration rate due to higher accuracy, particularly in the setting of normal renal function. We compared these equations in patients with 2 functioning kidneys undergoing partial nephrectomy. MATERIALS AND METHODS: We assembled a cohort of 1,158 patients from 5 institutions who underwent partial nephrectomy between 1991 and 2009. Only subjects with 2 functioning kidneys were included in the study. The end points were baseline estimated glomerular filtration rate, last followup estimated glomerular filtration rate (3 to 18 months), absolute and percent change estimated glomerular filtration rate ([absolute change/baseline] x 100%), and proportion of newly developed chronic kidney disease stage III. The agreement between the equations was evaluated using Bland-Altman plots and the McNemar test for paired observations. RESULTS: Mean baseline estimated glomerular filtration rate derived from the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations were 73 and 77 ml/minute/1.73 m(2), respectively, and following surgery were 63 and 67 ml/minute/1.73 m(2), respectively. Mean percent change estimated glomerular filtration rate was -12% for both equations (p = 0.2). The proportion of patients with newly developed chronic kidney disease stage III following surgery was 32% and 25%, according to the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations, respectively (p = 0.001). CONCLUSIONS: For patients with 2 functioning kidneys undergoing partial nephrectomy the Chronic Kidney Disease Epidemiology Collaboration equation provides slightly higher glomerular filtration rate estimates compared to the Modification of Diet in Renal Disease equation, with 7% fewer patients categorized as having chronic kidney disease stage III or worse

BACKGROUND: Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function. OBJECTIVE: Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function. DESIGN, SETTINGS, AND PARTICIPANTS: We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included. INTERVENTION: All patients underwent nephroureterectomy. MEASUREMENTS: All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test. RESULTS AND LIMITATIONS: Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements. CONCLUSIONS: eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens

The surgical management of kidney tumors has significantly evolved over the past decade. Partial nephrectomy and nephron sparing surgery have emerged as the treatments of choice for most newly diagnosed kidney tumors at tertiary care centers. The trend towards an organ sparing approach is largely due to an improved understanding of the global importance of kidney function as well as the impact that kidney surgery may have on non-oncologic morbidity and mortality. In addition to reviewing the methods of evaluating kidney function, this article discusses the effectiveness of various nephron sparing techniques in preserving kidney function and improving non-oncologic outcomes

BACKGROUND:: Most small renal tumors are amenable to partial nephrectomy (PN). Studies have documented the association of radical nephrectomy (RN) with an increased risk of comorbid conditions, such as chronic kidney disease. Despite evidence of equivalent oncologic outcomes, PN remains under used within the United States. In this study, the authors identified the most recent trends in kidney surgery for small renal tumors and determined which factors were associated with the use of PN versus RN within the United States. METHODS:: A population-based patient cohort was analyzed using the Surveillance, Epidemiology and End Results cancer registry (SEER 1999-2006). The authors identified 18,330 patients ages 40 to 90 years who underwent surgery for kidney tumors </=4 cm in the United States between 1999 and 2006. RESULTS:: In total, 11,870 patients (65%) underwent RN, and 6460 patients (35%) underwent PN. The ratio of PN to RN increased yearly (P < .001), representing 45% of kidney surgeries in 2006 for small tumors. There were significant differences in the cohort of patients who underwent PN versus RN, including age, sex, tumor location, marital status, year of treatment, and tumor size. When adjusting for these variables, being a man, age </=70 years, urban residence, smaller tumor size, and more recent treatment year were predictors of PN. CONCLUSIONS:: Although the total numbers of PN procedures increased in the United States between 1999 and 2006, there remains a significant under use of PN, particularly among women, the elderly, and those living in rural locations. Further investigation will be required to determine the reasons for these disparities, and strategies to optimize access to PN need to be developed. Cancer 2010. (c) 2010 American Cancer Society

BACKGROUND:: Procedures performed in the office offer potential cost savings. Recent analyses suggest, however, that a fee-for-service system may incentivize subscale operations and, thus, contribute to excessive spending. The authors of this report sought to characterize changes in the practice of office-based and hospital-based endoscopic bladder surgery after 2005 increases in Medicare reimbursement. METHODS:: All office and hospital-based endoscopic surgeries that were performed in a faculty practice from 2002 through 2007 were identified using billing codes for procedures, diagnoses, and procedure locations and then analyzed using the chi-square test and logistic regression. Costs were estimated based on published Medicare reimbursements for office and hospital-based surgeries. RESULTS:: In total, 1341 endoscopic bladder surgeries were performed, including 764 in the office and 577 in the hospital. After 2005, the odds ratio (OR) for office surgery occurring among all cystoscopies and for surgery occurring in the office versus the hospital was 2.01 (95% confidence interval [CI], 1.71-2.37) and 2.29 (95% CI, 1.83-2.87), respectively. Among all treated lesions that were associated with a diagnosis of bladder cancer and nonbladder cancer, the OR for a procedure occurring in the office versus the hospital was 1.36 (95% CI, 1.07-1.73) and 1.99 (95% CI, 1.52-2.60), respectively. The likelihood of repeat surgery on the same lesion increased after 2005 (OR, 2.86; 95% CI, 1.46-5.62), and the likelihood of an office surgery leading to a bladder cancer diagnosis at the next visit declined (OR, 0.29; 95% CI, 0.16-0.51). The overall estimated expenditure increased by 50%. CONCLUSIONS:: After 2005, more bladder lesions were identified and treated in the office. In a single group practice, office treatment of bladder cancer did not fully explain this new practice pattern, suggesting a lowered threshold for office intervention. Cancer 2010. (c) 2010 American Cancer Society