Faculty Bibliography

OBJECTIVES/OBJECTIVE:In part because of concern regarding overtreatment in men with prostate cancer, watchful waiting with active surveillance (WWAS) has been increasingly used in men diagnosed with low-risk prostate cancer. The present study investigates the difference in costs between men with low-risk prostate cancer treated with up-front radical prostatectomy (RP) versus WWAS. METHODS:A cost model was constructed using data from centers that have published their results in men who were followed up with WWAS compared with the actual costs of up-front RP calculated from a high volume center. Two WWAS arms of 15-year duration were created in which the follow-up protocol and conversion rate to active treatment were varied. RESULTS:The cost of up-front RP including costs of surgery, complications, and follow up for 15 years was $15 235 per person. Costs of WWAS were estimated using annual conversion rates from WWAS to RP of both 5% and 7%. Costs per person in the WWAS arms ranged from $6558 to $11 992 in the scenarios created which represent a 43%-78.7% reduction in costs when compared with men undergoing up-front RP. CONCLUSIONS:Watchful waiting with active surveillance is being increasingly used in hopes of decreasing the potential overtreatment of prostate cancer in men with low-risk disease. The present study suggests that WWAS is likely to markedly decrease costs when compared with active treatment with RP.

Renal cell carcinoma with inferior vena cava (IVC) tumor thrombus is a well described clinical entity. We report a case of 64-year-old man that developed an aggressive renal pelvic squamous cell carcinoma (SCC) with extensive IVC and bilateral iliac vein tumor thrombus. To our knowledge this is the fifth reported case of renal pelvic SCC with IVC tumor thrombus and the first involving the iliac veins. We review the current therapeutic options for treatment of SCC with IVC involvement.

PURPOSE/OBJECTIVE:The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity) and Portsmouth POSSUM predictor equations are scoring systems validated in the general surgery literature that estimate postoperative morbidity and mortality risk. We tested the validity of POSSUM and Portsmouth POSSUM in patients undergoing radical cystectomy with continent diversion. MATERIALS AND METHODS/METHODS:We retrospectively reviewed physiological parameters, operative parameters, and 30-day morbidity and mortality in 102 patients who underwent radical cystectomy with continent orthotopic diversion, as done by a single surgeon. Predicted morbidity and mortality were calculated using the POSSUM and Portsmouth POSSUM equations. Patients were stratified into risk groups, and observed and predicted outcomes were compared. The accuracy of predictions was assessed using binomial and chi-square analysis. RESULTS:Observed mortality and morbidity rates were 2.9% and 34.3%, respectively. Predicted morbidity using POSSUM analysis was 46 compared to the 35 observed in our series (p = 0.01). Compared to 3 observed deaths predicted mortality using POSSUM and Portsmouth POSSUM analysis was 13 and 5 (p = 0.002 and 0.30, respectively). There was a significant lack of fit for the POSSUM model to predict morbidity and mortality (p <0.05). However, the mortality risk estimated by Portsmouth POSSUM was not significantly different from the observed mortality rate in our cohort. CONCLUSIONS:In our series the POSSUM equation over predicted morbidity and mortality, and was unsuitable for a comparative audit of patients who underwent radical cystectomy with continent diversion. The Portsmouth POSSUM equation allowed satisfactory prediction of mortality in our cohort and should be evaluated further in larger series.

BACKGROUND AND PURPOSE/OBJECTIVE:During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. PATIENTS AND METHODS/METHODS:We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. RESULTS:Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. CONCLUSIONS:Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

INTRODUCTION/BACKGROUND:Partial nephrectomy for the management of small renal masses has become a well accepted technique. Contemporary series have shown its safety and efficacy in well selected patients. We present our experience of partial nephrectomies exclusively without hilar control or parenchymal cooling stratified into imperative and elective patients. METHODS:We retrospectively reviewed our experience in 124 patients who underwent partial nephrectomy between December 1995 and September 2003. Patients were followed with regular radiographic and laboratory studies at 6 months postsurgery and then annually. Renal function was followed by serum creatinine. RESULTS:Of the 124 patients, 105 were performed without hilar control or renal cooling and met our criteria for analysis. The operation was elective in 78 patients (74%) and imperative in 27 patients (26%). Mean specimen size was 2.8 cm for elective cases and 3.3 cm for imperative cases. The mean estimated blood loss was 606 533 cc and 950 656 cc in elective and imperative cases respectively. Surgical margins were positive in 6.6% with an overall recurrence rate of 3.8%. At a mean follow up time of 31 months and 23 months in the elective and imperative groups respectively, there were no statistically significant differences between baseline and follow up serum creatinine levels in either elective or imperative cases at time intervals of 0-12, 13-24, 25-48 and > 48 months. The intraoperative complication rate was 5.7% and the postoperative complication rate was 4.7% including three patients requiring blood transfusions. CONCLUSION/CONCLUSIONS:Partial nephrectomy without hilar control or renal cooling is a safe and reliable method of removing small renal tumors. In this cohort, intraoperative blood loss is slightly higher than historical series. However, blood transfusion rates, complications, renal function and oncologic outcomes are comparable to historical series of patients in whom vascular control and renal cooling are used.

Prostate brachytherapy is a minimally invasive option in treating prostate cancer, usually with little risk of surgical morbidity. This reports a case of significant bleeding associated with the procedure of prostate brachytherapy.

PURPOSE/OBJECTIVE:The incidence of nephrolithiasis in the pediatric population has been steadily increasing. The miniaturization of endoscopic instruments and improvement in imaging modalities have facilitated safe and effective endourological treatment in this patient population. We reviewed the current status of pediatric stone disease management. MATERIALS AND METHODS/METHODS:A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the indications, techniques, complications and efficacy of endourological stone management in children. RESULTS:In the 1980s shock wave lithotripsy revolutionized stone management in children, becoming the procedure of choice for treating upper tract calculi less than 1.5 cm. Percutaneous nephrolithotomy has replaced open surgical techniques for the treatment of stone burdens greater than 1.5 cm with efficacy and complication rates mirroring those in the adult population. However, at an increasing number of centers ureteroscopy is now being performed in cases that previously would have been treated with shock wave lithotripsy or percutaneous nephrolithotomy. Results from recent retrospective series demonstrate that stone-free rates and complication rates with ureteroscopy are comparable to percutaneous nephrolithotomy and shock wave lithotripsy. Although concerns remain with all endoscopic techniques in children regarding damage to the urinary tract and renal development, neither short-term nor long-term adverse effects have been consistently reported. CONCLUSIONS:Shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopy are highly effective endourological techniques to treat stone disease in the pediatric population. A lack of prospective randomized trials comparing treatment modalities coupled with a vast disparity in the access to resources worldwide continues to individualize rather than standardize stone treatment in children.