Michael Blute - Academia.edu (original) (raw)

Papers by Michael Blute

European Urology, 2014

Although the purpose of the study by Hu et al. [1] in this issue of European Urology was not to s... more Although the purpose of the study by Hu et al. [1] in this issue of European Urology was not to sell the da Vinci robot, the study will probably be used by some to market it. We believe caution should be exercised when interpreting this study and its implications about whether this tool can lead to better prostate cancer (PCa) control outcomes. We should not readily believe the data being ‘‘sold’’ in this paper. Those who do not use or own the robot should not rush out to buy it. The tool does not make the carpenter. This study comes from an esteemed group of investigators in population-based urologic research and is not being published as a selling tool but rather as data reported. Conclusions are only as strong as the data, and this is where we feel this paper falls short. The US Surveillance Epidemiology and End Results (SEER)–Medicare data used in this study included men undergoing radical prostatectomy (RP) between 2004 and 2009. In the latter period of these data, robot-assisted RP (RARP) became the predominant form of RP in the United States. After close to 9000 exclusions (more than one-third), primarily for missing data (stage, grade, prostate-specific antigen [PSA]), an initial study group was developed of 5524 RARPs and 7878 open RPs (ORPs). After 1:1 propensity-based matching, an equal number of ORPs were created (n = 5524). With RARPs, there were lower PSA values, lower clinical stages, and lower grades of disease. In our opinion, this is suggestive of selection bias, and hence propensity-based matching was used. It is not known what the data were regarding positive surgical margins (PSMs) or secondary treatments (androgen-deprivation therapy [ADT] and/or radiation therapy [RT]) for the entire ORP cohort. Exclusions also included >1200 men with pT3b, arguably one of the most important unfavorable pathologic variables. This represents many data excluded.

European Urology Oncology, Jul 1, 2019

Context: The current role of cytoreductive nephrectomy (CN) is controversial. Objective: Review o... more Context: The current role of cytoreductive nephrectomy (CN) is controversial. Objective: Review of the available evidence about criteria defining CN optimal candidates. Evidence acquisition: Collaborative critical narrative review of the literature focusing on CN oncological outcomes, perioperative morbidity, eligibility criteria, presurgical systemic therapy, and surgical factors. Evidence synthesis: In contrast to observational studies, the Clinical Trial to Assess the Importance of Nephrectomy (CARMENA) trial demonstrated noninferiority of targeted therapy alone relative to CN with targeted therapy. CN is associated with a significant risk of perioperative mortality (0-13%) and major complications (3-36%). Metastatic burden, haematological parameters, performance status, sarcopenia, and genetic mutations have been proposed as CN eligibility criteria. Comprehensive models including local and systemic factors are recommended. The Immediate Surgery or Surgery after sunitinib Malate In Treating Patients with Kidney Cancer (SURTIME) trial reported similar progression-free rate after immediate or deferred CN, and suggests that presurgical systemic therapy can identify candidates for CN, avoiding unnecessary surgery in nonresponders without increasing the risk of perioperative complications. Minimally invasive and nephron-sparing CNs are established surgical strategies in selected patients.

European Urology, Dec 1, 2011

Context: Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most... more Context: Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most accurate and reliable staging procedure for the detection of lymph node invasion (LNI), its therapeutic benefit in renal cell carcinoma (RCC) still remains controversial. Objective: Review the available literature concerning the role of LND in RCC staging and outcome. Evidence acquisition: A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in RCC. Keywords included kidney neoplasms, renal cell cancer, renal cell carcinoma, kidney cancer, lymphadenectomy, lymph node excision, lymphatic metastases, nephrectomy, imaging, and complications. The articles with the highest level of evidence were identified with the consensus of all of the collaborative authors and were critically reviewed. This review is the result of an interactive peer-reviewing process by an expert panel of co-authors. Evidence synthesis: Renal lymphatic drainage is unpredictable. The newer available imaging techniques are still immature in detecting small lymph node metastases. Results from the European Organization for Research and Treatment of Cancer trial 30881 showed no benefit in performing LND during surgery for clinically node-negative RCC, but the results are limited to patients with the lowest risk of developing LNI. Numerous retrospective series support the hypothesis that LND may be beneficial in high-risk patients (clinical T3-T4, high Fuhrman grade, presence of sarcomatoid features, or coagulative tumor necrosis). If enlarged nodes are evident at imaging or palpable during surgery, LND seems justified at any stage. However, the extent of the LND remains a matter of controversy. Conclusions: To date, the available evidence suggests that an extended LND may be beneficial when technically feasible in patients with locally advanced disease (T3-T4) and/or unfavorable clinical and pathologic characteristics (high Fuhrman grade, larger tumors, presence of sarcomatoid features, and/or coagulative tumor necrosis). Although node-positive patients often harbor distant metastases as well, the majority of retrospective nonrandomized trials seem to suggest a possible benefit of regional LND even for this group of patients. In patients with T1-T2, clinically negative lymph nodes and absence of unfavorable clinical and pathologic characteristics, regional LND offers limited staging information and no benefit in terms of decreasing disease recurrence or improving survival.

Journal of Urology, 2009

For other articles on a related topic see pages 1582, 1588 and 1594.

Journal of Urology, 2009

Purpose-Recent observations suggest that partial nephrectomy for small renal tumors may be associ... more Purpose-Recent observations suggest that partial nephrectomy for small renal tumors may be associated with improved survival compared with radical nephrectomy. We evaluated survival in patients with renal tumors 4-7cm using a bi-institutional collaboration. Methods-Combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering, we identified 1,159 patients with sporadic, unilateral, solitary and localized renal masses 4.1-7.0 cm who underwent radical or partial nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models. Results-Among the 1,159 patients, 873 (75%) and 286 (25%) were treated with radical and partial nephrectomy, respectively. Patients treated with partial (vs radical) nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%, p<0.001) and chronic kidney disease (15% vs 7%, p<0.001). Median duration of follow-up for survivors was 4.8 years (range 0-19). There was not a significant difference in overall survival when comparing patients treated with radical and partial nephrectomy (p=0.8). Interestingly, in a subset of 943 patients with RCC, those treated with radical nephrectomy were significantly more likely to die from RCC compared with those treated with partial nephrectomy (hazard ratio 2.16; 95% CI 1.04-4.50; p=0.039) although this association only approached statistical significance in a multivariable analysis (hazard ratio 1.97; 95% CI 0.92-4.20; p=0.079). Conclusions-Our results suggest that overall and cancer-specific survival is not compromised when partial nephrectomy is utilized for patients with 4-7cm renal cortical tumors. With the

European Urology, 2003

Urology has continuously embraced novel technologies like laparoscopy that reduce patient morbidi... more Urology has continuously embraced novel technologies like laparoscopy that reduce patient morbidity yet maintain an excellent standard of care. Because of limitations on maneuverability, operative vision, manual dexterity, and tactile sense, laparoscopy can be more dif®cult to perform than corresponding tasks in open surgery. To potentially increase clinical applicability of laparoscopy, robots that enhance operative performance have recently been introduced for a variety of laparoscopic procedures such as laparoscopic radical prostatectomy, pyeloplasty, and even laparoscopic cystectomy and neobladder construction. While these robots have generated excitement and many robotic applications have been described, the bene®t of the advanced technology in expanded series of patients remains largely unknown. In addition, the ability of telerobotics to be used by surgeons inexperienced in conventional laparoscopy is also poorly understood. This review compares current features of available robots, advantages and limitations of robots, the emerging clinical applications, and the future potential of robotics in urology.

BJU International, 2010

Study Type – Prognosis (case series) Level of Evidence 4OBJECTIVETo investigate the impact of fam... more Study Type – Prognosis (case series) Level of Evidence 4OBJECTIVETo investigate the impact of family history on pathological and clinical outcomes after surgery for clear‐cell renal cell carcinoma (ccRCC) in patients with non‐syndromic disease.PATIENTS AND METHODSWe reviewed 2677 patients treated with radical nephrectomy or nephron‐sparing surgery for non‐cystic ccRCC between 1970 and 2004 to identify patients with a family history of ccRCC. Patients with von Hippel–Lindau, tuberous sclerosis, or Birt–Hogg–Dube syndrome were excluded from analysis. Demographics and clinico‐pathological outcomes were compared to patients with ccRCC without a family history of kidney cancer using chi‐squared and Fisher’s exact tests. Postoperative cancer‐specific survival was estimated using the Kaplan–Meier method.RESULTSWe identified 42 patients (1.6%) with a family history of ccRCC who were treated for non‐cystic ccRCC, with a median follow‐up of 4.7 years (range 1–34). Demographics and tumour char...

Annual Review of Medicine, 2002

▪ Nephron-sparing surgery (NSS) provides effective curative therapy for patients with localized... more ▪ Nephron-sparing surgery (NSS) provides effective curative therapy for patients with localized renal cell carcinoma. In patients with imperative indications, it represents an alternative to renal replacement therapy. For selected patients with systemic comorbidities that threaten global renal function, NSS preserves unaffected nephrons with excellent cancer-specific survival. Elective partial nephrectomy for patients with a small (≤4 cm), unifocal tumor and a normal contralateral kidney is associated with a low risk (0%–3%) of local recurrence and cancer-specific survival rates of 90%–100%. Comparisons between radical and partial nephrectomy demonstrate equivalent cancer control over five years. Minimally invasive techniques of NSS are feasible but await improved technologies and long-term outcome data before they become fully acceptable treatment options.

European Urology, 2011

Background-Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with ... more Background-Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with salvage radical prostatectomy (SRP) are poorly defined. Objective-To identify predictors of biochemical recurrence (BCR), metastasis, and death following SRP to help select patients who may benefit from SRP.

Journal of Urology, 2005

Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidi... more Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidity, including urinary fistulas. If conservative measures fail, urinary and/or fecal diversion is often required. In this study we examined a series of patients with fistulas that developed after pelvic radiation therapy and explored potential predisposing factors and treatment recommendations for refractory fistulas. Patients were identified who received radiation therapy for PCa between 1977 and 2002, and subsequently had a fistula to the urinary tract. Patients were excluded who had diverticulitis, inflammatory bowel disease, a history of recent radical retropubic prostatectomy (possible iatrogenic etiology) or cancer in the excised fistula. Data were extracted from patient charts, mailed questionnaires and outside records. A total of 51 patients were identified with a history of radiation for PCa who subsequently had a urinary fistula. Of 20 patients meeting inclusion criteria 30% received external beam RT alone, 30% received brachytherapy and 40% received combined external beam RT/brachytherapy. Most fistulas (80%) were from the rectum to the urinary tract with an average diameter of 3.2 cm. Of patients with rectal fistulas 81% had a history of rectal stricture, urethral stricture, rectal biopsy, rectal argon beam therapy or transurethral prostate resection after radiation. All patients with rectourethral fistulas who achieved symptomatic resolution required urinary and fecal diversion. Conservative treatment is generally ineffective in the management of large urinary fistulas. Surgical intervention offers symptomatic relief and improved quality of life in most patients.

European Urology, 2007

Objectives: This study compared the complications and the cancer control of elective nephron-spar... more Objectives: This study compared the complications and the cancer control of elective nephron-sparing surgery (NSS) and radical nephrectomy (RN) in patients with a small (5 cm), solitary, low-stage N0 M0 tumour suspicious for renal cell carcinoma (RCC) and a normal contralateral kidney. Methods: 541 patients were randomised in a prospective, multicentre, phase 3 trial to undergo NSS (n = 268) or RN (n = 273) together with a limited lymph node dissection. Results: This publication reports only on the complications reported for both surgical methods. The rate of perioperative blood loss <0.5 l was slightly higher after RN (96.0% vs. 87.2%) and the rate of severe haemorrhage was slightly higher after NSS (3.1% vs. 1.2%). Ten patients (4.4%), all of whom were treated with NSS, developed urinary fistulas. Pleural damage (11.5% for NSS vs. 9.3% for RN) and spleen damage (0.4% for NSS and 0.4% for RN) were observed with similar rates in both groups. Postoperative computed tomography scanning abnormalities were seen in 5.8% of NSS and 2.0% of RN patients. Reoperation for complications was necessary in 4.4% of NSS and 2.4% of RN patients. Conclusions: NSS for small, easily resectable, incidentally discovered RCC in the presence of a normal contralateral kidney can be performed safely with slightly higher complication rates than after RN. The oncologic results are eagerly awaited to confirm that NSS is an acceptable approach for small asymptomatic RCC.

European Urology, 2010

Background: The safe duration of warm ischemia during partial nephrectomy remains controversial. ... more Background: The safe duration of warm ischemia during partial nephrectomy remains controversial. Objective: Our aim was to evaluate the short-and long-term renal effects of warm ischemia in patients with a solitary kidney. Design, setting, and participants: Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open (n = 319) or laparoscopic (n = 43) partial nephrectomy using warm ischemia with hilar clamping. Measurements: Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments. Results and limitations: Median tumor size was 3.4 cm (range: 0.7-18.0 cm), and median ischemia time was 21 min (range: 4-55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (19%) including 58 (16%) who had a glomerular filtration rate (GFR) <15 ml/min per 1.73 m 2 within 30 d of surgery. Among the 226 patients with a preoperative GFR 30 ml/min per 1.73 m 2 and followed 30 d, 38 (17%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: 1.05 for each 1-min increase; p < 0.001) and a GFR < 15 (odds ratio: 1.06; p < 0.001) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: 1.06; p < 0.001) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study. Conclusions: Longer warm ischemia time is associated with short-and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped.

European urology, Jan 19, 2015

Partial nephrectomy (PN) is the current gold standard treatment for small localized renal tumors.... more Partial nephrectomy (PN) is the current gold standard treatment for small localized renal tumors.; however, the impact of duration and type of intraoperative ischemia on renal function (RF) after PN is a subject of significant debate. To review the current evidence on the relationship of intraoperative ischemia and RF after PN. A review of English-language publications on renal ischemia and RF after PN was performed from 2005 to 2014 using the Medline, Embase, and Web of Science databases. Ninety-one articles were selected with the consensus of all authors and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The vast majority of reviewed studies were retrospective, nonrandomized observations. Based on the current literature, RF recovery after PN is strongly associated with preoperative RF and the amount of healthy kidney parenchyma preserved. Warm ischemia time (WIT) is modifiable and prolonged warm ischemia is significantly asso...

The Journal of …, 2008

At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. ... more At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical nephrectomy was not significantly associated with ...

The Journal of …, 2004

We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperati... more We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperative indications for renal preservation and radical nephrectomy (RN) for 4 to 7 cm renal cell carcinoma (RCC). We identified 91 patients treated with NSS and 841 patients treated with RN for 4 to 7 cm RCC between 1970 and 2000. Cancer specific, distant metastases-free and recurrence-free survivals were estimated using the Kaplan-Meier method. Cancer specific survival rates at 5 years for patients treated with NSS and RN for 4 to 7 cm RCC were 98% and 86%, respectively. On univariate analysis patients treated with RN for 4 to 7 cm RCC were more likely to die of RCC compared to patients treated with NSS. However, after adjusting for features associated with death from RCC including stage, grade, histological tumor necrosis and histological subtype, this difference was no longer statistically significant (risk ratio 1.60, 95% CI 0.50-5.12, p = 0.430). Distant metastases-free survival rates at 5 years for patients treated with NSS and RN were 94% and 83%, respectively. On univariate analysis patients treated with RN were more likely to have tumors that metastasized compared to patients treated with NSS, although this difference was no longer significant after adjusting for the features listed previously (risk ratio 1.76, 95% CI 0.64-4.83, p = 0.273). Recurrence-free survival rates at 5 years for patients treated with NSS and RN were 94% and 98%, respectively. On univariate analysis patients treated with RN were less likely to have recurrence compared to patients treated with NSS (risk ratio 0.32, 95% CI 0.12-0.85, p = 0.022). There were no statistically significant differences in cancer specific survival and distant metastases-free survival between patients treated with NSS and RN for 4 to 7 cm RCC after adjusting for important pathological features. NSS for 4 to 7 cm RCC results in excellent outcome in appropriately selected patients.

The Journal of Urology, 2010

European Urology, 2014

Although the purpose of the study by Hu et al. [1] in this issue of European Urology was not to s... more Although the purpose of the study by Hu et al. [1] in this issue of European Urology was not to sell the da Vinci robot, the study will probably be used by some to market it. We believe caution should be exercised when interpreting this study and its implications about whether this tool can lead to better prostate cancer (PCa) control outcomes. We should not readily believe the data being ‘‘sold’’ in this paper. Those who do not use or own the robot should not rush out to buy it. The tool does not make the carpenter. This study comes from an esteemed group of investigators in population-based urologic research and is not being published as a selling tool but rather as data reported. Conclusions are only as strong as the data, and this is where we feel this paper falls short. The US Surveillance Epidemiology and End Results (SEER)–Medicare data used in this study included men undergoing radical prostatectomy (RP) between 2004 and 2009. In the latter period of these data, robot-assisted RP (RARP) became the predominant form of RP in the United States. After close to 9000 exclusions (more than one-third), primarily for missing data (stage, grade, prostate-specific antigen [PSA]), an initial study group was developed of 5524 RARPs and 7878 open RPs (ORPs). After 1:1 propensity-based matching, an equal number of ORPs were created (n = 5524). With RARPs, there were lower PSA values, lower clinical stages, and lower grades of disease. In our opinion, this is suggestive of selection bias, and hence propensity-based matching was used. It is not known what the data were regarding positive surgical margins (PSMs) or secondary treatments (androgen-deprivation therapy [ADT] and/or radiation therapy [RT]) for the entire ORP cohort. Exclusions also included >1200 men with pT3b, arguably one of the most important unfavorable pathologic variables. This represents many data excluded.

European Urology Oncology, Jul 1, 2019

Context: The current role of cytoreductive nephrectomy (CN) is controversial. Objective: Review o... more Context: The current role of cytoreductive nephrectomy (CN) is controversial. Objective: Review of the available evidence about criteria defining CN optimal candidates. Evidence acquisition: Collaborative critical narrative review of the literature focusing on CN oncological outcomes, perioperative morbidity, eligibility criteria, presurgical systemic therapy, and surgical factors. Evidence synthesis: In contrast to observational studies, the Clinical Trial to Assess the Importance of Nephrectomy (CARMENA) trial demonstrated noninferiority of targeted therapy alone relative to CN with targeted therapy. CN is associated with a significant risk of perioperative mortality (0-13%) and major complications (3-36%). Metastatic burden, haematological parameters, performance status, sarcopenia, and genetic mutations have been proposed as CN eligibility criteria. Comprehensive models including local and systemic factors are recommended. The Immediate Surgery or Surgery after sunitinib Malate In Treating Patients with Kidney Cancer (SURTIME) trial reported similar progression-free rate after immediate or deferred CN, and suggests that presurgical systemic therapy can identify candidates for CN, avoiding unnecessary surgery in nonresponders without increasing the risk of perioperative complications. Minimally invasive and nephron-sparing CNs are established surgical strategies in selected patients.

European Urology, Dec 1, 2011

Context: Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most... more Context: Although lymphadenectomy (lymph node dissection [LND]) is currently accepted as the most accurate and reliable staging procedure for the detection of lymph node invasion (LNI), its therapeutic benefit in renal cell carcinoma (RCC) still remains controversial. Objective: Review the available literature concerning the role of LND in RCC staging and outcome. Evidence acquisition: A Medline search was conducted to identify original articles, review articles, and editorials addressing the role of LND in RCC. Keywords included kidney neoplasms, renal cell cancer, renal cell carcinoma, kidney cancer, lymphadenectomy, lymph node excision, lymphatic metastases, nephrectomy, imaging, and complications. The articles with the highest level of evidence were identified with the consensus of all of the collaborative authors and were critically reviewed. This review is the result of an interactive peer-reviewing process by an expert panel of co-authors. Evidence synthesis: Renal lymphatic drainage is unpredictable. The newer available imaging techniques are still immature in detecting small lymph node metastases. Results from the European Organization for Research and Treatment of Cancer trial 30881 showed no benefit in performing LND during surgery for clinically node-negative RCC, but the results are limited to patients with the lowest risk of developing LNI. Numerous retrospective series support the hypothesis that LND may be beneficial in high-risk patients (clinical T3-T4, high Fuhrman grade, presence of sarcomatoid features, or coagulative tumor necrosis). If enlarged nodes are evident at imaging or palpable during surgery, LND seems justified at any stage. However, the extent of the LND remains a matter of controversy. Conclusions: To date, the available evidence suggests that an extended LND may be beneficial when technically feasible in patients with locally advanced disease (T3-T4) and/or unfavorable clinical and pathologic characteristics (high Fuhrman grade, larger tumors, presence of sarcomatoid features, and/or coagulative tumor necrosis). Although node-positive patients often harbor distant metastases as well, the majority of retrospective nonrandomized trials seem to suggest a possible benefit of regional LND even for this group of patients. In patients with T1-T2, clinically negative lymph nodes and absence of unfavorable clinical and pathologic characteristics, regional LND offers limited staging information and no benefit in terms of decreasing disease recurrence or improving survival.

Journal of Urology, 2009

For other articles on a related topic see pages 1582, 1588 and 1594.

Journal of Urology, 2009

Purpose-Recent observations suggest that partial nephrectomy for small renal tumors may be associ... more Purpose-Recent observations suggest that partial nephrectomy for small renal tumors may be associated with improved survival compared with radical nephrectomy. We evaluated survival in patients with renal tumors 4-7cm using a bi-institutional collaboration. Methods-Combining institutional databases from Mayo Clinic and Memorial Sloan-Kettering, we identified 1,159 patients with sporadic, unilateral, solitary and localized renal masses 4.1-7.0 cm who underwent radical or partial nephrectomy between 1989 and 2006. Patient outcome was compared using Cox proportional hazards regression models. Results-Among the 1,159 patients, 873 (75%) and 286 (25%) were treated with radical and partial nephrectomy, respectively. Patients treated with partial (vs radical) nephrectomy were significantly more likely to have a solitary kidney (10% vs 0.2%, p<0.001) and chronic kidney disease (15% vs 7%, p<0.001). Median duration of follow-up for survivors was 4.8 years (range 0-19). There was not a significant difference in overall survival when comparing patients treated with radical and partial nephrectomy (p=0.8). Interestingly, in a subset of 943 patients with RCC, those treated with radical nephrectomy were significantly more likely to die from RCC compared with those treated with partial nephrectomy (hazard ratio 2.16; 95% CI 1.04-4.50; p=0.039) although this association only approached statistical significance in a multivariable analysis (hazard ratio 1.97; 95% CI 0.92-4.20; p=0.079). Conclusions-Our results suggest that overall and cancer-specific survival is not compromised when partial nephrectomy is utilized for patients with 4-7cm renal cortical tumors. With the

European Urology, 2003

Urology has continuously embraced novel technologies like laparoscopy that reduce patient morbidi... more Urology has continuously embraced novel technologies like laparoscopy that reduce patient morbidity yet maintain an excellent standard of care. Because of limitations on maneuverability, operative vision, manual dexterity, and tactile sense, laparoscopy can be more dif®cult to perform than corresponding tasks in open surgery. To potentially increase clinical applicability of laparoscopy, robots that enhance operative performance have recently been introduced for a variety of laparoscopic procedures such as laparoscopic radical prostatectomy, pyeloplasty, and even laparoscopic cystectomy and neobladder construction. While these robots have generated excitement and many robotic applications have been described, the bene®t of the advanced technology in expanded series of patients remains largely unknown. In addition, the ability of telerobotics to be used by surgeons inexperienced in conventional laparoscopy is also poorly understood. This review compares current features of available robots, advantages and limitations of robots, the emerging clinical applications, and the future potential of robotics in urology.

BJU International, 2010

Study Type – Prognosis (case series) Level of Evidence 4OBJECTIVETo investigate the impact of fam... more Study Type – Prognosis (case series) Level of Evidence 4OBJECTIVETo investigate the impact of family history on pathological and clinical outcomes after surgery for clear‐cell renal cell carcinoma (ccRCC) in patients with non‐syndromic disease.PATIENTS AND METHODSWe reviewed 2677 patients treated with radical nephrectomy or nephron‐sparing surgery for non‐cystic ccRCC between 1970 and 2004 to identify patients with a family history of ccRCC. Patients with von Hippel–Lindau, tuberous sclerosis, or Birt–Hogg–Dube syndrome were excluded from analysis. Demographics and clinico‐pathological outcomes were compared to patients with ccRCC without a family history of kidney cancer using chi‐squared and Fisher’s exact tests. Postoperative cancer‐specific survival was estimated using the Kaplan–Meier method.RESULTSWe identified 42 patients (1.6%) with a family history of ccRCC who were treated for non‐cystic ccRCC, with a median follow‐up of 4.7 years (range 1–34). Demographics and tumour char...

Annual Review of Medicine, 2002

▪ Nephron-sparing surgery (NSS) provides effective curative therapy for patients with localized... more ▪ Nephron-sparing surgery (NSS) provides effective curative therapy for patients with localized renal cell carcinoma. In patients with imperative indications, it represents an alternative to renal replacement therapy. For selected patients with systemic comorbidities that threaten global renal function, NSS preserves unaffected nephrons with excellent cancer-specific survival. Elective partial nephrectomy for patients with a small (≤4 cm), unifocal tumor and a normal contralateral kidney is associated with a low risk (0%–3%) of local recurrence and cancer-specific survival rates of 90%–100%. Comparisons between radical and partial nephrectomy demonstrate equivalent cancer control over five years. Minimally invasive techniques of NSS are feasible but await improved technologies and long-term outcome data before they become fully acceptable treatment options.

European Urology, 2011

Background-Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with ... more Background-Oncologic outcomes in men with radiation-recurrent prostate cancer (PCa) treated with salvage radical prostatectomy (SRP) are poorly defined. Objective-To identify predictors of biochemical recurrence (BCR), metastasis, and death following SRP to help select patients who may benefit from SRP.

Journal of Urology, 2005

Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidi... more Prostate cancer (PCa) radiotherapy (RT), including brachytherapy, may lead to significant morbidity, including urinary fistulas. If conservative measures fail, urinary and/or fecal diversion is often required. In this study we examined a series of patients with fistulas that developed after pelvic radiation therapy and explored potential predisposing factors and treatment recommendations for refractory fistulas. Patients were identified who received radiation therapy for PCa between 1977 and 2002, and subsequently had a fistula to the urinary tract. Patients were excluded who had diverticulitis, inflammatory bowel disease, a history of recent radical retropubic prostatectomy (possible iatrogenic etiology) or cancer in the excised fistula. Data were extracted from patient charts, mailed questionnaires and outside records. A total of 51 patients were identified with a history of radiation for PCa who subsequently had a urinary fistula. Of 20 patients meeting inclusion criteria 30% received external beam RT alone, 30% received brachytherapy and 40% received combined external beam RT/brachytherapy. Most fistulas (80%) were from the rectum to the urinary tract with an average diameter of 3.2 cm. Of patients with rectal fistulas 81% had a history of rectal stricture, urethral stricture, rectal biopsy, rectal argon beam therapy or transurethral prostate resection after radiation. All patients with rectourethral fistulas who achieved symptomatic resolution required urinary and fecal diversion. Conservative treatment is generally ineffective in the management of large urinary fistulas. Surgical intervention offers symptomatic relief and improved quality of life in most patients.

European Urology, 2007

Objectives: This study compared the complications and the cancer control of elective nephron-spar... more Objectives: This study compared the complications and the cancer control of elective nephron-sparing surgery (NSS) and radical nephrectomy (RN) in patients with a small (5 cm), solitary, low-stage N0 M0 tumour suspicious for renal cell carcinoma (RCC) and a normal contralateral kidney. Methods: 541 patients were randomised in a prospective, multicentre, phase 3 trial to undergo NSS (n = 268) or RN (n = 273) together with a limited lymph node dissection. Results: This publication reports only on the complications reported for both surgical methods. The rate of perioperative blood loss <0.5 l was slightly higher after RN (96.0% vs. 87.2%) and the rate of severe haemorrhage was slightly higher after NSS (3.1% vs. 1.2%). Ten patients (4.4%), all of whom were treated with NSS, developed urinary fistulas. Pleural damage (11.5% for NSS vs. 9.3% for RN) and spleen damage (0.4% for NSS and 0.4% for RN) were observed with similar rates in both groups. Postoperative computed tomography scanning abnormalities were seen in 5.8% of NSS and 2.0% of RN patients. Reoperation for complications was necessary in 4.4% of NSS and 2.4% of RN patients. Conclusions: NSS for small, easily resectable, incidentally discovered RCC in the presence of a normal contralateral kidney can be performed safely with slightly higher complication rates than after RN. The oncologic results are eagerly awaited to confirm that NSS is an acceptable approach for small asymptomatic RCC.

European Urology, 2010

Background: The safe duration of warm ischemia during partial nephrectomy remains controversial. ... more Background: The safe duration of warm ischemia during partial nephrectomy remains controversial. Objective: Our aim was to evaluate the short-and long-term renal effects of warm ischemia in patients with a solitary kidney. Design, setting, and participants: Using the Cleveland Clinic and Mayo Clinic databases, we identified 362 patients with a solitary kidney who underwent open (n = 319) or laparoscopic (n = 43) partial nephrectomy using warm ischemia with hilar clamping. Measurements: Associations of warm ischemia time with renal function were evaluated using logistic or Cox regression models first as a continuous variable and then in 5-min increments. Results and limitations: Median tumor size was 3.4 cm (range: 0.7-18.0 cm), and median ischemia time was 21 min (range: 4-55 min). Postoperative acute renal failure (ARF) occurred in 70 patients (19%) including 58 (16%) who had a glomerular filtration rate (GFR) <15 ml/min per 1.73 m 2 within 30 d of surgery. Among the 226 patients with a preoperative GFR 30 ml/min per 1.73 m 2 and followed 30 d, 38 (17%) developed new-onset stage IV chronic kidney disease during follow-up. As a continuous variable, longer warm ischemia time was associated with ARF (odds ratio: 1.05 for each 1-min increase; p < 0.001) and a GFR < 15 (odds ratio: 1.06; p < 0.001) in the postoperative period, and it was associated with new-onset stage IV chronic kidney disease (hazard ratio: 1.06; p < 0.001) during follow-up. Similar results were obtained adjusting for preoperative GFR, tumor size, and type of partial nephrectomy in a multivariable analysis. Evaluating warm ischemia in 5-min increments, a cut point of 25 min provided the best distinction between patients with and without all three of the previously mentioned end points. Limitations include the retrospective nature of the study. Conclusions: Longer warm ischemia time is associated with short-and long-term renal consequences. These results suggest that every minute counts when the renal hilum is clamped.

European urology, Jan 19, 2015

Partial nephrectomy (PN) is the current gold standard treatment for small localized renal tumors.... more Partial nephrectomy (PN) is the current gold standard treatment for small localized renal tumors.; however, the impact of duration and type of intraoperative ischemia on renal function (RF) after PN is a subject of significant debate. To review the current evidence on the relationship of intraoperative ischemia and RF after PN. A review of English-language publications on renal ischemia and RF after PN was performed from 2005 to 2014 using the Medline, Embase, and Web of Science databases. Ninety-one articles were selected with the consensus of all authors and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. The vast majority of reviewed studies were retrospective, nonrandomized observations. Based on the current literature, RF recovery after PN is strongly associated with preoperative RF and the amount of healthy kidney parenchyma preserved. Warm ischemia time (WIT) is modifiable and prolonged warm ischemia is significantly asso...

The Journal of …, 2008

At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. ... more At last followup 146 patients had died of any cause and 502 were alive at a median of 7.1 years. Radical and partial nephrectomy was performed in 290 and 358 patients, respectively. In all patients radical nephrectomy was not significantly associated with ...

The Journal of …, 2004

We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperati... more We compared outcomes between patients treated with nephron sparing surgery (NSS) without imperative indications for renal preservation and radical nephrectomy (RN) for 4 to 7 cm renal cell carcinoma (RCC). We identified 91 patients treated with NSS and 841 patients treated with RN for 4 to 7 cm RCC between 1970 and 2000. Cancer specific, distant metastases-free and recurrence-free survivals were estimated using the Kaplan-Meier method. Cancer specific survival rates at 5 years for patients treated with NSS and RN for 4 to 7 cm RCC were 98% and 86%, respectively. On univariate analysis patients treated with RN for 4 to 7 cm RCC were more likely to die of RCC compared to patients treated with NSS. However, after adjusting for features associated with death from RCC including stage, grade, histological tumor necrosis and histological subtype, this difference was no longer statistically significant (risk ratio 1.60, 95% CI 0.50-5.12, p = 0.430). Distant metastases-free survival rates at 5 years for patients treated with NSS and RN were 94% and 83%, respectively. On univariate analysis patients treated with RN were more likely to have tumors that metastasized compared to patients treated with NSS, although this difference was no longer significant after adjusting for the features listed previously (risk ratio 1.76, 95% CI 0.64-4.83, p = 0.273). Recurrence-free survival rates at 5 years for patients treated with NSS and RN were 94% and 98%, respectively. On univariate analysis patients treated with RN were less likely to have recurrence compared to patients treated with NSS (risk ratio 0.32, 95% CI 0.12-0.85, p = 0.022). There were no statistically significant differences in cancer specific survival and distant metastases-free survival between patients treated with NSS and RN for 4 to 7 cm RCC after adjusting for important pathological features. NSS for 4 to 7 cm RCC results in excellent outcome in appropriately selected patients.

The Journal of Urology, 2010