We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.

BACKGROUND: The authors evaluated the incidence of pathologic downstaging and complete remission (CR) in patients with high‐grade ureteral and renal pelvic transitional cell carcinoma (TCC) (upper tract TCC) who received neoadjuvant chemotherapy followed by surgery.METHODS: The study group comprised patients with biopsy‐demonstrated, high‐grade disease who received neoadjuvant chemotherapy followed by nephrouterectomy from 2004 to 2008, during which time patients uniformly were considered for neoadjuvant chemotherapy. The control group comprised patients with biopsy‐demonstrated, high‐grade disease who underwent initial nephroureterectomy from 1993 to 2004, when patients uniformly underwent initial surgery. Multiple clinical and pathologic features were evaluated, and the primary endpoint was pathologic tumor classification.RESULTS: One hundred seven patients in the control group underwent initial surgery, and 43 patients in the study group received neoadjuvant chemotherapy. Baseline demographics were similar between the groups except for a higher rate of sessile tumor architecture in the study group (72.1% vs 49.5%; P = .018). There was significant downstaging in study group patients compared with the historic control group (P = .004). The incidence of tumors classified as pathologic T2 (pT2) or as pT3 or higher was significantly lower in the study group (pT2, 65.4% vs 48.8%; P = .043; pT3 or higher, 47.7% vs 27.9%; P = .029). Fourteen percent of patients who received neoadjuvant chemotherapy had a pathologic CR.CONCLUSIONS: Neoadjuvant chemotherapy was associated with a 14% CR rate and a significant rate of downstaging. While longer follow‐up is awaited for survival data to mature, the current data provide justification for the sustained support of trials using this strategy. Cancer 2010. © 2010 American Cancer Society.

In this study we detail the incidence and pattern of residual and recurrent disease after radio frequency ablation or cryoablation of a renal mass and, using this information, determine reasonable minimum recommendations for when to perform surveillance imaging during year 1 after treatment. To our knowledge no evidence based guidelines exist for determining how or when followup abdominal imaging should be performed after renal energy ablative therapy. We reviewed treatment and followup information of patients who underwent radio frequency ablation or cryoablation for a renal mass at 7 institutions. Postoperative monitoring was performed using a variety of surveillance schedules. Of 616 patients 63 were found to have residual or recurrent disease after primary radio frequency ablation (13.4%) or cryoablation (3.9%) for a median of 8.7% in 7 institutions. Most incomplete treatments (70%) were detected within the first 3 months. After salvage ablative therapy was rendered, therapy failed in only 4.2%. At a mean followup of 2 years patients with residual or recurrent disease had an overall survival rate of 82.5% and a 2-year metastasis-free survival rate of 97.4% for those with localized, unilateral renal tumors. In most cases initial treatment failure was detected within the first 3 months after treatment. Our findings support a minimum of 3 to 4 imaging studies in year 1 after ablative therapy, and at months 1, 3, 6 (optional) and 12.

BACKGROUND: High‐grade upper tract urothelial carcinoma (UTUC) is frequently upstaged after surgery and is associated with uniformly poor survival. Neoadjuvant chemotherapy may offer a way to improve clinical outcomes. The authors compared the survival rates of patients with UTUC who received neoadjuvant chemotherapy before surgery with the rates among patients who did not.METHODS: A retrospective review was conducted of patients with high‐risk UTUC who received neoadjuvant chemotherapy followed by surgery from 2004 to 2008 (study group) compared with a matched cohort who underwent initial surgery from 1993 to 2003 (control group). Fisher exact tests, Wilcoxon rank‐sum tests, and Kaplan‐Meier methods were used. The log‐rank test and Cox proportional‐hazards models were used to evaluate the association of the 2 outcomes with patient, treatment, and tumor characteristics in univariate and multivariate models.RESULTS: Of 112 patients, there were 31 in the study group and 81 in the control group. Patients who received neoadjuvant chemotherapy had improved overall survival (OS) and disease‐specific survival (DSS) with a 5‐year DSS rate of 90.1% and a 5‐year OS rate of 80.2% versus DSS and OS rates of 57.6% for those who underwent initial surgery (P = .0204 and P = .0015, respectively). In multivariate analyses, the neoadjuvant group had a lower risk of mortality (OS: hazard ratio, 0.42 [P = .035]; DSS: hazard ratio, 0.19 [P = .006]).CONCLUSIONS: Neoadjuvant chemotherapy improved the survival of patients with UTUC compared with a matched historic cohort of patients who underwent initial surgery. Patients with high‐risk UTUC should be considered for neoadjuvant chemotherapy in view of the limited opportunity to administer effective cisplatin‐based chemotherapy after nephroureterectomy. Cancer 2014;120:1794–1799. © 2014 American Cancer Society.

OBJECTIVE: To evaluate factors associated with disease recurrence and survival in patients undergoing nephroureterectomy for upper urinary tract transitional cell carcinoma (UUT‐TCC) in one centre over an 18‐year period. PATIENTS AND METHODS: The records of patients who had a nephroureterectomy for UUT‐TCC at our institution from 1986 to 2004 were reviewed for clinical, pathological and treatment period data. Cox’s proportional hazards regression model was used to test the statistical significance of several potential prognostic factors for recurrence and survival. RESULTS: The median overall duration of follow‐up was 2.5 years for 184 patients. Significant prognosticators for disease‐specific survival (DSS) by univariate analysis were tumour stage ( P < 0.01), tumour grade ( P < 0.01), node‐positive disease ( P < 0.01), multifocality ( P = 0.03), previous cystectomy ( P < 0.01) and synchronous bilateral UUT‐TCC ( P = 0.02). On multivariate analysis, only tumour stage ( P = 0.03) and grade ( P = 0.01) correlated with DSS. The median recurrence‐free survival duration was 2.4 years. In 44 patients, the disease recurred outside the bladder; 15 (8.2%) had local recurrence, 20 (10.9%) distant metastasis, and nine (4.9%) both local and distant recurrence. Bladder tumours occurred in 40 (26.1%) patients with no previous cystectomy. The evaluation of treatment outcome during three periods of the study showed no significant effect on DSS. CONCLUSION: Tumour stage and grade correlated with DSS in this cohort, with no improvement in outcome over the 18‐year period assessed. Patients with high‐stage and high‐grade disease continue to fare poorly, suggesting a need for changing the treatment protocol. Judiciously applying a multimodal approach to the management of high‐risk patients by incorporating neoadjuvant chemotherapy and surgical resection might provide, for the first time, the opportunity to improve patient outcome.