Post- chemotherapy retroperitoneal lymph node dissection is a technically complex surgery due to significant fibrosis causing dense adherence of nodal tissue and any residual masses to the major ...vessels. While open- retroperitoneal lymph node dissection (O-RPLND) remains the standard of care in stage I non-seminomatous germ cell tumor and patients with post-chemotherapy masses greater than 1 cm, minimally invasive approaches such as laparoscopic and robotic have become more wide-spread in high volume centers over the past decade. Early research confirms the safety and early oncologic efficacy of post-chemotherapy robotic retroperitoneal lymph node dissection (R-RLPND), demonstrating comparable nodal yield, shorter operative times, lower estimated blood loss, shorter length of stay, and fewer overall post- operative complications.
At City of Hope, we are performing both primary and post-chemotherapy XI R- RPNLD on select patients. For post-chemotherapy RPLNDs, a bilateral retroperitoneal lymph node dissection is performed according to standard templates. Patient preparation, positioning, and port position is demonstrated. The steps of the operation, including gonadal vein dissection, bowel mobilization and suspension with Keith needles, paracaval, inter-aortic, and para-aortic dissections are showed. Post-operative care is discussed.
Post-Chemotherapy R-RPLND is feasible and safe. Patients are commonly able to discharge either same day or on post-operative day one.
Background:
Ischemia is thought to contribute to benign ureteroenteric stricture (UES) after radical cystectomy with urinary diversion (RCUD). Our institution adopted the use of ureteral perfusion ...assessment during all RCUDs using real-time indocyanine green angiography using the SPY fluorescence imaging platform (Stryker Corp., Kalamazoo, MI, USA). This guides the location of ureteral transection prior to ureteroenteric anastomosis. We sought to compare UES rates before and after adoption of SPY.
Methods:
A retrospective chart review was undertaken for the first 47 consecutive cases of RCUD using SPY as well as the previous 47 consecutive cases, which were performed without SPY. Fisher’s exact and Wilcoxon rank-sum tests were used to compare benign UES rates and the length of ureter excised during anastomosis. A p < 0.05 indicated statistical significance.
Results:
Median follow up was 12.0 months for SPY cases and 24.3 months for non-SPY cases. The UES rate for SPY RCUDs was 0% (0/93 ureters) compared with 7.5% (7/93 ureters) for non-SPY RCUDs (p = 0.01). Amongst SPY RCUDs, 86 ureters had no hydronephrosis and 7 had mild hydronephrosis with reflux on loopogram. A total of 34.4% of ureters (32/93) had poor distal perfusion, requiring a more proximal anastomosis. The median length excised for ureters with poor distal perfusion was 3.8 cm, compared with 2.2 cm for ureters with good distal perfusion (p < 0.0001). No complications attributable to the use of SPY were noted.
Conclusion:
Use of SPY to assess ureteral perfusion was associated with a decrease in the UES rate after RCUD. A total of 34.4% of ureters demonstrated poor distal perfusion, requiring a significantly more proximal ureteroenteric anastomosis.
Heated intraperitoneal chemotherapy (HIPEC) is commonly performed at the time of tumor resection for metastatic intraabdominal tumors. Post operative complications, such as superficial wound ...infections or bowel leaks are common. They are largely thought to be secondary to poor wound healing due to chemotherapy-associated neutropenia. Scrotal eschars resulting in full-thickness skin necrosis have rarely been reported as a delayed complication after HIPEC. Here, we present the first case report of penile full-thickness skin necrosis after abdominal cytoreduction with HIPEC combined with ventral hernia repair and mesh placement.
Objective
To report our experience with ureteroenteric anastomotic revision as initial treatment of stricture after urinary diversion.
Methods
An institutional review board‐approved retrospective ...study was carried out. A total of 41 patients who underwent primary ureteroenteric anastamotic revision were identified between 2007 and 2015. Data analyzed included patient characteristics, type of diversion, estimated blood loss, operative time, change in renal function, length of stay, postoperative complications and time with nephrostomy/stent. Success of revision was defined as an improvement in hydronephrosis on radiographic imaging and/or reflux during pouchogram. Predictors of length of stay and complications were analyzed using analysis of covariance.
Results
A total of 50 renal units were revised with a success rate of 100%. The median length of stay was 6 days (2–16 days). There were a total of 15 complications (one major, 14 minor) in 14 patients (33% 30‐day complication rate). The most common were wound infection (n = 4) and arrhythmia (n = 4). Robotic revision (n = 5) had a median length of stay of 3 days (2–4) with no complications.
Conclusions
Primary ureteroenteric anastomotic revisions have an excellent success rate at an experienced center and might obviate the need for multiple interventions. Open revision is associated with mostly minor complications. Robotic revision might reduce the morbidity of open revision in select cases.
Abstract Introduction and Objectives: To prospectively assess the ideal dosing and the value of fluorescent SLN detection with ICG for the detection of lymph node (LN) metastases in intermediate- and ...high-risk patients undergoing robotic prostatectomy and extended pelvic lymph node dissection (ePLND). Methods 20 patients received transperineal prostatic injections of ICG. Patients were cycled through five doses (1.25mg, 2.5mg, 3.75 mg, 5 mg, 7.5 mg) so optimal ICG dosing could be discovered early. Results ICG injection was able to identify fluorescent lymph node (FLN) packets in all 20 patients. Compared to the higher ICG doses, the 1.25 mg and 2.5 mg doses had fewer FLN packets and were abandoned after one dose each. The median number of FLN packets was 4.0, 6.0 and 4.5, for the respective doses of 3.75, 5.0 and 7.5 mg. The external iliac group was the most common site of fluorescence in 27.2% of patients, followed by the common iliac (21.3%), obturator (20.3%), internal iliac (18.5%), and node of Cloquet (7.7%). 7/20 (35%) patients had node positive disease. Out of the 5 patients that had fluorescent tissue outside of our ePLND template, one had a positive node present in the anterior bladder neck fat. Across all patients, ICG had 62% sensitivity, 50% specificity, 8% positive predictive value (PPV), and 95% negative predictive value (NPV) in detecting LN metastases. Conclusion The low sensitivity of ICG for the detection of LN metastases highlight why fluorescent SLN dissection with ICG does not represent an alternative to ePLND.
Primary neuroendocrine tumors of the bladder are rare and they include small and large cell variants. We reviewed our experience with treating these tumors with radical cystectomy to evaluate their ...histopathological characteristics and clinical outcomes.
From August 1971 to June 2004, 2,005 patients underwent radical cystectomy for primary bladder cancer at our institution, of whom 25 (1.2%) had neuroendocrine tumors of the bladder, including small cell carcinoma in 20 and large cell carcinoma in 5. Pure neuroendocrine-type histology was identified in 16 cases, including 1 with small and large cell features, while the remaining 9 had mixed histology, that is transitional cell carcinoma in 8 and adenocarcinoma in 1. Multi-agent chemotherapy was administered to 14 patients.
Median patient age was 68 years (range 40 to 82) and 19 patients were male (76%). A total of 19 patients (76%) had lymph node involvement, of whom 2 had small liver metastases found intraoperatively, while only 4 (16%) had organ confined tumors and 2 (8%) had extravesical, node negative disease. These tumors tended to have a flat, ulcerative gross appearance with lymphovascular invasion, carcinoma in situ and necrosis present microscopically. Median followup was 11.8 years (range 18 days to 15.1 years). Five-year overall and recurrence-free survival was 10% and 13%, respectively. There was no significant survival difference between small and large cell carcinoma. Mixed histologies tended to do better than pure neuroendocrine tumors, although this did not attain statistical significance (p = 0.064). Patients receiving multimodality therapy had significantly better overall (p = 0.051) and recurrence-free (p = 0.003) survival than those treated with cystectomy alone.
Neuroendocrine tumors of the bladder usually present with advanced pathological stage and portend a poor prognosis. Adjuvant chemotherapy protocols may provide improved survival compared with cystectomy alone.
As the US transitions from volume- to value-based cancer care, many cancer centers and community groups have joined to share resources to deliver measurable, high-quality cancer care and clinical ...research with the associated high patient satisfaction, provider satisfaction, and practice health at optimal costs that are the hallmarks of value-based care. Multidisciplinary oncology care pathways are essential components of value-based care and their payment metrics. Oncology pathways are evidence-based, standardized but personalizable care plans to guide cancer care. Pathways have been developed and studied for the major medical, surgical, radiation, and supportive oncology disciplines to support decision-making, streamline care, and optimize outcomes. Implementing multidisciplinary oncology pathways can facilitate comprehensive care plans for each cancer patient throughout their cancer journey and across large multisite delivery systems. Outcomes from the delivered pathway-based care can then be evaluated against individual and population benchmarks. The complexity of adoption, implementation, and assessment of multidisciplinary oncology pathways, however, presents many challenges. We review the development and components of value-based cancer care and detail City of Hope's (COH) academic and community-team-based approaches for implementing multidisciplinary pathways. We also describe supportive components with available results towards enterprise-wide value-based care delivery.
The field of regenerative medicine continues to make substantial advancements in therapeutic strategies addressing urologic diseases. Tissue engineering borrows principles from the fields of cell ...biology, materials science, transplantation and engineering in an effort to repair or replace damaged tissues. This review is intended to provide a current overview of the use of stem cells and tissue engineering technologies specifically in the treatment of genitourinary diseases. Current themes in the field include the use of adult stem cells seeded onto biocompatible resorbable matrices for implantation as tissue substitutes, which is conducive to host tissue in-growth. Injection therapy of adult stem cells for organ rehabilitation is also making strong headway toward the restoration of organ structure and function. With new data describing the molecular mechanisms for differentiation, work has begun on targeting tissues for regeneration by genetic modification methods. Promising laboratory discoveries portend the emergence of a new class of clinical therapies for regenerative medicine applications in the genitourinary tract.
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