Publications by authors named "Nicolette K Janzen"

22 Publications

  • Page 1 of 1

Effect of Caudal vs. Penile Block on the Incidence of Hypospadias Complications Following Primary Repairs; A Retrospective Cohort Study.

J Urol 2020 Dec 21:101097JU0000000000001448. Epub 2020 Dec 21.

Baylor College of Medicine, Houston, Texas.

Purpose: Primary repair of hypospadias is associated with risk of complications, specifically urethra-cutaneous fistula and glanular dehiscence. Caudal block may potentially increase the risk of these complications. Therefore, we studied the incidence of hypospadias complications in children that underwent correction at our institution having received either penile or caudal block.

Methods: We analyzed all primary hypospadias repair cases from December 2011 through December 2018 at Texas Children's Hospital with a minimum of 1-year follow-up for the presence of complications: urethra-cutaneous fistula and glanular dehiscence. Surgical (surgeon, operative time, block type, local anesthetic, meatal position) and patient (age at correction, prematurity) factors were additionally analyzed.

Results: For the primary aim, 983 patients underwent primary hypospadias correction with a minimum of one year of postoperative follow-up data. There were 897 patients (91.3%) in which no complications were identified and 86 (8.7%) with either urocutaneous fistula (n=81) or glanular dehiscence (n=5). Of the 86 identified complications, (45/812 (5.5%) were distal, 41/171 (24%) were proximal; p=<0.001) with a complication, Rate of complications was not associated with caudal block (OR: 0.67, 95% CI: 0.41-1.09; p=0.11). On univariable analysis, age (OR 1.12, 95% CI 1.04-1.20; p=0.04), surgical duration (OR 1.02; 95% CI 1.01-1.02; p=<0.001), prematurity <32 weeks (OR 4.38, 95% CI 1.54-4.11 p=<0.001) and position of meatus as proximal (OR 5.38 95% CI 3.39-8.53; p=<0.001) were associated with an increased rate of complications. However, on multivariable analysis, associations of age (OR: 1.13, 95% CI: 1.05-1.22; p=0.001), surgery duration (OR: 1.01, 95% CI: 1.01-1.02; p=<0.001) and meatal position (OR: 3.85, 95% CI: 2.32-6.39; p=<0.001) were associated with increased rate of complications.

Conclusion: Our data suggests that meatal location, older age, extreme prematurity and surgical duration are associated with increased incidence of complications (urethra-cutaneous fistula and glanular dehiscence) following hypospadias correction. Analgesic block was not associated with increased hypospadias complication risk.
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http://dx.doi.org/10.1097/JU.0000000000001448DOI Listing
December 2020

Antireflux Surgery at National Surgical Quality Improvement Program-Pediatric Hospitals.

J Urol 2020 Nov 18:101097JU0000000000001439. Epub 2020 Nov 18.

Morristown Medical Center, Morristown, New Jersey.

Purpose: This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data.

Materials And Methods: Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures).

Results: In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections.

Conclusions: Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.
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http://dx.doi.org/10.1097/JU.0000000000001439DOI Listing
November 2020

Analysis of 1478 Cases of Hypospadias Repair: The Incidence of Requiring Repeated Anesthetic Exposure as Well as Exploration of the Involvement of Trainees on Case Duration.

Anesth Analg 2020 11;131(5):1551-1556

From the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

Background: Recently, there has been significant focus on the effects of anesthesia on the developing brain. Concern is heightened in children <3 years of age requiring lengthy and/or multiple anesthetics. Hypospadias correction is common in otherwise healthy children and may require both lengthy and repeated anesthetics. At academic centers, many of these cases are performed with the assistance of anesthesia and surgical trainees. We sought to identify both the incidence of these children undergoing additional anesthetics before age 3 as well as to understand the effect of trainees on duration of surgery and anesthesia and thus anesthetic exposure (AE), specifically focusing on those cases >3 hours.

Methods: We analyzed all cases of hypospadias repair from December 2011 through December 2018 at Texas Children's Hospital. In all, 1326 patients undergoing isolated hypospadias repair were analyzed for anesthesia time, surgical time, provider types involved, AE, caudal block, and additional AE related/unrelated to hypospadias.

Results: For the primary aim, a total of 1573 anesthetics were performed in children <3 years of age, including 1241 hypospadias repairs of which 1104 (89%) were completed with <3 hours of AE. For patients with <3 hours of AE, 86.1% had a single surgical intervention for hypospadias. Of patients <3 years of age, 17.3% required additional nonrelated surgeries. There was no difference in anesthesia time in cases performed solely by anesthesia attendings versus those performed with trainees/assistance (16.8 vs 16.8 minutes; P = .98). With regard to surgery, cases performed with surgical trainees were of longer duration than those performed solely by surgical attendings (83.5 vs 98.3 minutes; P < .001). Performance of surgery solely by attending surgeon resulted in a reduced total AE in minimal alveolar concentration (MAC) hours when compared to procedures done with trainees (1.92 vs 2.18; P < .001). Finally, comparison of patients undergoing initial correction of hypospadias with subsequent revisions revealed a longer time (117.7 vs 132.2 minutes; P < .001) and AE during the primary stage.

Conclusions: The majority of children with hypospadias were repaired within a single AE. In general, most children did not require repeated AE before age 3. While presence of nonattending surgeons was associated with an increase in AE, this might at least partially be due to differences in case complexity. Moreover, the increase is likely not clinically significant. While it is critical to maintain a training environment, attempts to minimize AE are crucial. This information facilitates parental consent, particularly with regard to anesthesia duration and the need for additional anesthetics in hypospadias and nonhypospadias surgeries.
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http://dx.doi.org/10.1213/ANE.0000000000004596DOI Listing
November 2020

Analysis of 1478 Cases of Hypospadias Repair: The Incidence of Requiring Repeated Anesthetic Exposure as Well as Exploration of the Involvement of Trainees on Case Duration.

Anesth Analg 2019 Dec 9. Epub 2019 Dec 9.

From the Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

Background: Recently, there has been significant focus on the effects of anesthesia on the developing brain. Concern is heightened in children <3 years of age requiring lengthy and/or multiple anesthetics. Hypospadias correction is common in otherwise healthy children and may require both lengthy and repeated anesthetics. At academic centers, many of these cases are performed with the assistance of anesthesia and surgical trainees. We sought to identify both the incidence of these children undergoing additional anesthetics before age 3 as well as to understand the effect of trainees on duration of surgery and anesthesia and thus anesthetic exposure (AE), specifically focusing on those cases >3 hours.

Methods: We analyzed all cases of hypospadias repair from December 2011 through December 2018 at Texas Children's Hospital. In all, 1326 patients undergoing isolated hypospadias repair were analyzed for anesthesia time, surgical time, provider types involved, AE, caudal block, and additional AE related/unrelated to hypospadias.

Results: For the primary aim, a total of 1573 anesthetics were performed in children <3 years of age, including 1241 hypospadias repairs of which 1104 (89%) were completed with <3 hours of AE. For patients with <3 hours of AE, 86.1% had a single surgical intervention for hypospadias. Of patients <3 years of age, 17.3% required additional nonrelated surgeries. There was no difference in anesthesia time in cases performed solely by anesthesia attendings versus those performed with trainees/assistance (16.8 vs 16.8 minutes; P = .98). With regard to surgery, cases performed with surgical trainees were of longer duration than those performed solely by surgical attendings (83.5 vs 98.3 minutes; P < .001). Performance of surgery solely by attending surgeon resulted in a reduced total AE in minimal alveolar concentration (MAC) hours when compared to procedures done with trainees (1.92 vs 2.18; P < .001). Finally, comparison of patients undergoing initial correction of hypospadias with subsequent revisions revealed a longer time (117.7 vs 132.2 minutes; P < .001) and AE during the primary stage.

Conclusions: The majority of children with hypospadias were repaired within a single AE. In general, most children did not require repeated AE before age 3. While presence of nonattending surgeons was associated with an increase in AE, this might at least partially be due to differences in case complexity. Moreover, the increase is likely not clinically significant. While it is critical to maintain a training environment, attempts to minimize AE are crucial. This information facilitates parental consent, particularly with regard to anesthesia duration and the need for additional anesthetics in hypospadias and nonhypospadias surgeries.
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http://dx.doi.org/10.1213/ANE.0000000000004596DOI Listing
December 2019

Evaluating Natural History and Follow Up Strategies for Non-obstructive Urolithiasis in Pediatric Population.

Front Pediatr 2018 16;6:353. Epub 2018 Nov 16.

Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.

While small non-obstructive stones in the adult population are usually observed with minimal follow-up, the same guidelines for management in the pediatric population have not been well-studied. We evaluate the clinical outcomes of small non-obstructing kidney stones in the pediatric population to better define the natural history of the disease. In this IRB-approved retrospective study, patients with a diagnosis of kidney stones from January 2011 to March 2017 were identified using ICD9 and ICD10 codes. Patients with ureteral stones, obstruction, or stones >5 mm in size were excluded. Patients with no follow-up after initial imaging were also excluded. Patients with a history of stones or prior stone interventions were included in our population. Frequency of follow-up ultrasounds while on observation were noted and any ER visits, stone passage episodes, infections, and surgical interventions were documented. Over the 6-year study period, 106 patients with non-obstructing kidney stones were identified. The average age at diagnosis was 12.5 years and the average stone size was 3.6 mm. Average follow-up was 17 months. About half of the patients had spontaneous passage of stones (54/106) at an average time of 13 months after diagnosis. Stone location did not correlate with spontaneous passage rates. Only 6/106 (5.7%) patients required stone surgery with ureteroscopy and/or PCNL at an average time of 12 months after initial diagnosis. The indication for surgery in all 6 cases was pain. 17/106 (16%) patients developed febrile UTIs and a total of 43 ER visits for stone-related issues were noted, but no patients required urgent intervention for an infected obstructing stone. Median interval for follow-up was every 6 months with renal ultrasounds, which then was prolonged to annual follow up in most cases. The observation of pediatric patients with small non-obstructing stones is safe with no episodes of acute obstructive pyelonephritis occurring in these patients. The sole indication for intervention in our patient population was pain, which suggests that routine follow-up ultrasounds may not be necessary for the follow-up of pediatric non-obstructive renal stones ≤5 mm in size.
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http://dx.doi.org/10.3389/fped.2018.00353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6250749PMC
November 2018

Vesicoamniotic Shunting Improves Outcomes in a Subset of Prune Belly Syndrome Patients at a Single Tertiary Center.

Front Pediatr 2018 3;6:180. Epub 2018 Jul 3.

Scott Department of Urology, Baylor College of Medicine, Houston, TX, United States.

Review outcomes of Prune Belly Syndrome (PBS) with the hypothesis that contemporary management improves mortality. A retrospective chart review of inpatient and outpatient PBS patients referred between 2000 and 2018 was conducted to assess outcomes at our institution. Data collected included age at diagnosis, concomitant medical conditions, imaging, operative management, length of follow-up, and renal function. Forty-five PBS patients presented during these 18 years. Prenatal diagnoses were made in 17 (39%); 65% of these patients underwent prenatal intervention. The remaining patients were diagnosed in the infant period (20, 44%) or after 1 year of age (8, 18%). Twelve patients died from cardiopulmonary complications in the neonatal period; the neonatal mortality rate was 27%. The mean follow-up among patients surviving the neonatal period was 84 months. Forty-two patients had at least one renal ultrasound (RUS); of the 30 patients with NICU RUSs, 26 (89%) had hydronephrosis and/or ureterectasis. Of the 39 patients who underwent voiding cystourethrogram (VCUG), 28 (62%) demonstrated VUR. Fifty-nine percent had respiratory distress. Nine patients (20%) were oxygen-dependent by completion of follow up. Thirty-eight patients (84%) had other congenital malformations including genitourinary (GU) 67%, gastrointestinal (GI) 52%, and cardiac 48%. Sixteen patients (36%) had chronic kidney disease (CKD) of at least stage 3; three patients (7%) had received renal transplants. Eighty-four percent of patients had at least one surgery (mean 3.4, range 0-6). The most common was orchiopexy (71%). The next most common surgeries were vesicostomy (39%), ureteral reimplants (32%), abdominoplasty (29%), nephrectomy (25%), and appendicovesicostomy (21%). After stratifying patients according to Woodard classification, a trend for 12% improvement in mortality after VAS was noted in the Woodard Classification 1 cohort. PBS patients frequently have multiple congenital anomalies. Pulmonary complications are prevalent in the neonate while CKD (36%) is prevalent during late childhood. The risk of CKD increased significantly with the presence of other congenital anomalies in our cohort. Mortality in childhood is most common in infancy and may be as low as 27%. Contemporary management of PBS, including prenatal interventions, reduced the neonatal mortality rate in a subset of our cohort.
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http://dx.doi.org/10.3389/fped.2018.00180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038357PMC
July 2018

Does the use of 5 mm instruments affect the outcomes of robot-assisted laparoscopic pyeloplasty in smaller working spaces? A comparative analysis of infants and older children.

J Pediatr Urol 2018 12 6;14(6):537.e1-537.e6. Epub 2018 Jul 6.

Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital, and the Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA. Electronic address:

Introduction: Pediatric robot-assisted laparoscopic (RAL) pyeloplasty has become a viable minimally invasive surgical option for ureteropelvic junction obstruction (UPJO) based on its efficacy and safety. However, RAL pyeloplasty in infants can be a challenging procedure because of the smaller working spaces. The use of the larger 8 mm instruments for these patients instead of the 5 mm instruments is common because of the shorter wrist lengths.

Objective: We hypothesized that the use of 5 mm instruments for RAL pyeloplasty in infants with smaller working spaces will have comparable perioperative parameters and surgical outcomes in comparison with older children with larger working spaces.

Study Design: We compared the perioperative parameters and surgical outcomes of RAL pyeloplasties performed by a single surgeon in infants and non-infant pediatric patients over a 2 year period. All of the procedures were performed using an 8.5 mm camera and 5 mm robotic instruments. Patient demographics, operative times, perioperative complications, hospital pain medication usage, hospital length of stay, and treatment success rates were compared between the two groups.

Results: A total of 65 pediatric RAL pyeloplasties were included in the study (16 infants and 49 non-infants, Table). There were no significant differences in gender, laterality, proportion of re-do pyeloplasty, or preoperative hydronephrosis grade between the two groups. All procedures were performed without conversion to open surgery or significant perioperative complications. There were no differences in segmental operative times (total operative time, console time, port placement time, time for dissection to UPJO, and anastomosis time), hospital pain medication usage, and hospital length of stay between the two groups (p > 0.05 for all comparisons). The treatment success rates were 93.8% (15/16) and 100% (49/49), respectively (p = 0.08).

Discussion: We present the first comparative study of infant and non-infant pediatric RAL pyeloplasty using 5 mm robotic instruments. An advantage of the current study is the use of a single surgeon's experience to compare RAL pyeloplasty outcomes in infants with those of older children, a group in which RAL pyeloplasty has already been shown to be efficacious and safe. Operative tips for infant RAL pyeloplasty are also provided.

Conclusions: RAL pyeloplasty is a safe and effective surgical modality even in infants, with comparable perioperative parameters and outcomes as those in older children. The use of 5 mm instruments in infants does not affect outcomes and offers the potential for improved cosmesis.
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http://dx.doi.org/10.1016/j.jpurol.2018.06.010DOI Listing
December 2018

Quantifying the Additional Difficulty of Pediatric Robot-Assisted Laparoscopic Re-Do Pyeloplasty: A Comparison of Primary and Re-Do Procedures.

J Laparoendosc Adv Surg Tech A 2018 May 6;28(5):610-616. Epub 2018 Feb 6.

1 Division of Pediatric Urology, Department of Surgery, Texas Children's Hospital , Houston, Texas.

Background: Re-do pyeloplasty after failed open or laparoscopic ureteropelvic junction (UPJ) obstruction correction can be a challenging procedure because of scar formation at the previous anastomosis site and decreased vascularity of the ureter. This study compared the perioperative parameters for pediatric robot-assisted laparoscopic (RAL) primary and re-do pyeloplasties with an emphasis on the intra-operative parameters.

Materials And Methods: We compared the perioperative parameters of pediatric RAL procedures performed by a single surgeon at a tertiary care children's hospital for both primary ureteropelvic junction obstruction (UPJO) and recurrent UPJO after a previous open or laparoscopic procedure over 2013-2015. The operative time was subdivided as total operative time, console time, port placement time, dissection time to UPJ, and anastomosis time.

Results: A total of 65 pediatric RAL pyeloplasty procedures for UPJO were performed (55 primary and 10 re-do pyeloplasties) during the study period. The console times were 43.3% longer for re-do pyeloplasties than for primary pyeloplasties (133.0 ± 30.7 versus 92.8 ± 24.0 minutes, respectively, P < .01). The re-do cases had longer operative times, especially for UPJ exposure (52.2 ± 21.0 versus 28.0 ± 14.0 minutes, P < .01). There were no conversions to open surgery or significant perioperative complications. There was no difference in hospital pain medication usage and hospital length of stay between the 2 groups. The treatment success rates were 98.2% (54/55) and 100% (10/10), respectively.

Conclusions: RAL re-do pyeloplasty is associated with significantly longer operative times as compared with primary pyeloplasties, especially during the exposure of the UPJ, but it is overall a safe and effective surgical modality for persistent/recurrent UPJO in children. As surgeons are increasingly asked for more accurate predictions of operative time lengths when scheduling cases, this information can be helpful for surgeons when scheduling these cases and with counseling families.
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http://dx.doi.org/10.1089/lap.2016.0691DOI Listing
May 2018

Pediatric Prostatic Abscess Caused by Methicillin-susceptible Staphylococcus aureus.

Pediatr Infect Dis J 2017 04;36(4):426-427

From the *Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, and †Scott Department of Urology, Baylor College of Medicine and the Urology Division, Texas Children's Hospital, Houston, Texas.

Prostatic abscesses are infrequently encountered in adults and are exceedingly rare in the pediatric population. We present the case of an 11-year-old boy with a methicillin-susceptible Staphylococcus aureus prostatic abscess and bacteremia.
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http://dx.doi.org/10.1097/INF.0000000000001458DOI Listing
April 2017

Whole-exome sequencing in the molecular diagnosis of individuals with congenital anomalies of the kidney and urinary tract and identification of a new causative gene.

Genet Med 2017 04 22;19(4):412-420. Epub 2016 Sep 22.

Center for Reproductive Medicine, Baylor College of Medicine, Houston, Texas, USA.

Purpose: To investigate the utility of whole-exome sequencing (WES) to define a molecular diagnosis for patients clinically diagnosed with congenital anomalies of kidney and urinary tract (CAKUT).

Methods: WES was performed in 62 families with CAKUT. WES data were analyzed for single-nucleotide variants (SNVs) in 35 known CAKUT genes, putatively deleterious sequence changes in new candidate genes, and potentially disease-associated copy-number variants (CNVs).

Results: In approximately 5% of families, pathogenic SNVs were identified in PAX2, HNF1B, and EYA1. Observed phenotypes in these families expand the current understanding about the role of these genes in CAKUT. Four pathogenic CNVs were also identified using two CNV detection tools. In addition, we found one deleterious de novo SNV in FOXP1 among the 62 families with CAKUT. The clinical database of the Baylor Miraca Genetics laboratory was queried and seven additional unrelated individuals with novel de novo SNVs in FOXP1 were identified. Six of these eight individuals with FOXP1 SNVs have syndromic urinary tract defects, implicating this gene in urinary tract development.

Conclusion: We conclude that WES can be used to identify molecular etiology (SNVs, CNVs) in a subset of individuals with CAKUT. WES can also help identify novel CAKUT genes.Genet Med 19 4, 412-420.
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http://dx.doi.org/10.1038/gim.2016.131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5362362PMC
April 2017

A Case of Obstructed Hemivagina with Ectopic Ureter Leading to Severe Hydrocolpos and Contralateral Renal Outflow Tract Obstruction in a Neonate.

J Pediatr Adolesc Gynecol 2015 Oct 23;28(5):e131-3. Epub 2014 Oct 23.

Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas.

Background: Renal and Müllerian anomalies are frequently associated. Young age at presentation can present challenges in diagnosis and management. We report a case with an unusual presentation and management of this association in the neonatal period.

Case: A 2-day-old girl had hydronephrosis with a large pelvic fluid collection. Magnetic resonance imaging of the pelvis demonstrated right hydronephrosis and uterine didelphys with an obstructed left hemivagina with hydrocolpos. A tube vaginostomy was used to decompress the vagina. Fluid was consistent with urine from an ectopic ureteral implantation from a dysgenetic left kidney, which was removed.

Summary And Conclusion: For obstructed hemivagina in a newborn, expanding fluid collections may be addressed with a drain to avoid mass effect and to aid in the diagnosis. Resection of the vaginal obstruction is performed when the patient is older. A nonfunctional kidney can be removed to eliminate fluid accumulation in the obstructed space.
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http://dx.doi.org/10.1016/j.jpag.2014.10.008DOI Listing
October 2015

Feasibility of nerve-sparing prostate cryosurgery: applications and limitations in a canine model.

J Endourol 2005 May;19(4):520-5

Department of Urology, University of California Los Angeles School of Medicine, 90095, USA.

Background And Purpose: In a canine model, we evaluated the feasibility of nerve-sparing cryosurgery by active warming of the neurovascular bundle (NVB). Furthermore, our aim was to determine if NVB warming increases the risk of acinar gland and stromal-tissue preservation in adjacent areas of the prostate. The effects of a single versus double freeze-thaw cycle on prostate tissue were also assessed.

Materials And Methods: Ten prostate lobes from five dogs were evaluated. Nine lobes from five dogs were treated with cryoablation using 17-gauge gas-driven cryoneedles. Seven lobes wre treated with active warming of the NVB using helium gas, and two lobes were treated without active warming. A single or double freeze-thaw cycle was utilized. Prostate tissue ablation and NVB preservation were evaluated in histologic sections.

Results: All seven prostate lobes treated with active warming demonstrated complete or partial NVB preservation. Four of these lobes had adjacent gland preservation. All lobes treated with a double freeze-thaw cycle showed complete and uniform ablation of prostate tissue. One of the three lobes treated with a single freeze-thaw cycle demonstrated incomplete ablation of the tissue.

Conclusions: This is the first study investigating the feasibility of NVB preservation under controlled experimental conditions. In our canine model, NVB preservation with active warming was possible but not consistently reproducible. In some cases, NVB preservation with active warming may result in incomplete peripheral tissue ablation. A double, but not a single, freeze-thaw cycle induces complete and effective necrosis of prostatic tissue. These results have significant clinical applications when attempting nerve-sparing cryosurgical ablation of the prostate.
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http://dx.doi.org/10.1089/end.2005.19.520DOI Listing
May 2005

The effects of intentional cryoablation and radio frequency ablation of renal tissue involving the collecting system in a porcine model.

J Urol 2005 Apr;173(4):1368-74

Department of Urology, University of California-Los Angeles School of Medicine, 90095, USA.

Purpose: Ablative techniques for the treatment of urological malignancy are gaining acceptance and they are likely to become more widely used in clinical practice. Indications and limitations of the technologies are still evolving. In a porcine model we evaluated the safety and efficacy of cryotherapy and radio frequency ablation (RFA) of cortical and deep renal tissue.

Materials And Methods: In 11 swine argon gas based cryoablation or RFA of renal tissue adjacent to the collecting system was performed using a laparoscopic or percutaneous approach. Lesions created in renal units 30 days or 2 hours prior to harvest were termed chronic or acute. Using single or multiple 17 gauge cryoneedles or 3.0 mm cryoprobes and 2 freeze-thaw cycles (10-minute freeze and 5-minute thaw) 13 acute and 10 chronic cryolesions were made. Using a single 16 gauge umbrella-shaped RFA probe and 2 heating cycles to maximum impedance 13 acute and 4 chronic RFA lesions were made. Gross and microscopic tissue analysis was performed to assess lesion size and renal parenchymal, collecting system and arterial effects. Acute cryolesion size estimation by laparoscopic or transcutaneous ultrasound (US) was compared with pathological lesion size.

Results: Acute cryolesions on hematoxylin and eosin staining demonstrated uniform coagulative necrosis of renal parenchyma and chronic cryolesions demonstrated uniform necrosis with fibrous scar formation. Interlobar artery (adjacent to renal pyramid) preservation occurred in 7 of 13 acute and 5 of 9 chronic cryolesions. Urothelial architecture was preserved in 8 of 13 acute and 7 of 9 chronic cryolesions. Acute and chronic RFA lesions demonstrated indeterminate necrosis on hematoxylin and eosin staining, although triphenyl tetrazolium chloride staining of gross specimens confirmed necrosis most definitively in renal cortex. Interlobar artery preservation occurred in 6 of 13 acute and 3 of 4 chronic RFA lesions. Urothelial architecture was preserved in 1 of 13 acute and 2 of 4 chronic RFA lesions. Acute cryolesion dimensions measured by laparoscopic US equaled or underestimated lesion size measured grossly in all 6 cases. Lesion dimensions measured by transcutaneous US equaled or underestimated true lesion size in 3 of 6 cases. In 3 of 6 lesions transcutaneous US overestimated true lesion size by 20%, 76% and 260%, respectively.

Conclusions: Renal cortical tissue can be effectively destroyed by cryoablation or RFA. However, treatment of deep parenchymal lesions with either modality may result in incomplete ablation. Cryosurgery but not RFA spares the collecting system in an acute setting. However, healing or regrowth of the urothelium may occur with time after RFA. Laparoscopic US is more accurate for cryolesion monitoring than transcutaneous US.
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http://dx.doi.org/10.1097/01.ju.0000147014.69777.06DOI Listing
April 2005

Cystic renal cell carcinoma: biology and clinical behavior.

Urol Oncol 2004 Sep-Oct;22(5):410-4

UCLA Department of Urology, Los Angeles, CA, USA.

The purpose of the study was to evaluate unilocular and multilocular cystic renal cell carcinoma (cRCC). These tumors are a rare entity, comprising approximately 1 to 2% of all renal tumors, and their true biologic behavior is not well-known. Initial review of renal cell carcinoma (RCC) cases treated at our institution between 1989 and 2001 identified 39 cases of cRCC. However, histopathologic review of these cases by 2 pathologists revealed that only 18 cases met the criteria that all tumors have a cystic component that constitutes at least 75% of the total lesion without evidence of necrosis. These cases were compared to 614 conventional clear cell RCC cases with regards to clinical outcomes. All 18 patients presented with localized (N0M0) disease. Thirteen (72%) of the tumors were Fuhrman Grade 1, while the remaining 5 (28%) were Fuhrman Grade 2. By comparison, only 60% of the clear cell RCC tumors were Grade 1 or 2. Similarly, 83% of cRCC were pT1 tumors compared to only 35% of conventional clear cell tumors. Mean tumor size for the cRCC tumors was 4.9 cm compared to 7.4 cm for conventional clear cell tumors. Cystic RCC patients had an 82% four-year disease-specific survival (DSS). Unilocular and multilocular cRCC is a distinct subtype of clear cell RCC. Its biology appears to be more favorable with regards to important prognostic factors such as metastatic presentation, Fuhrman grade, 1997 T stage, and tumor size. These findings suggest that cRCC patients may benefit from nephron sparing surgery.
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http://dx.doi.org/10.1016/S1078-1439(03)00173-XDOI Listing
January 2005

Generation of kidney cancer-specific antitumor immune responses using peripheral blood monocytes transduced with a recombinant adenovirus encoding carbonic anhydrase 9.

Clin Cancer Res 2004 Feb;10(4):1421-9

Departments of Urology and Medicine, University of California Los Angeles, Los Angeles, California 90095-1738, USA.

Purpose: Carbonic anhydrase 9 (CA9) is the most promising molecular marker described for renal cell carcinoma (RCC) to date. We investigated whether transduction of monocytes from peripheral blood with adenovirus encoding the CA9 gene (AdV-CA9) could stimulate a T-cell mediated immune response against cancer cells expressing CA9. The ability to consistently generate a T-cell response is an important step toward the development of a CA9-specific RCC vaccine.

Experimental Design: AdV-CA9 was generated using the AdEasy system. AdV-CA9-transduced peripheral blood mononuclear cell (PBMC)-derived monocytes were used to raise CTLs from autologous peripheral blood lymphocytes (PBLs). The ability of CTLs to lyse targets expressing CA9 was assessed by (51)Cr-release.

Results: Monocytes were efficiently transduced with AdV-CA9. In five of six experiments, AdV-CA9-transduced monocytes were able to induce a population of CTLs from bulk PBLs. CTLs were capable of lysing autologous, but not allogeneic monocytes expressing CA9. Furthermore, CTLs were able to lyse autologous RCC tumor cells expressing CA9. The ability of CTLs to lyse relevant targets was blocked by anti-CD3, anti-CD8, and anti-MHC class I antibodies demonstrating a MHC class I restricted response.

Conclusions: These results suggest that PBMC-derived monocytes transduced with AdV-CA9 can generate RCC-specific MHC class I restricted CTLs capable of lysing CA9-expressing cancer cells. Transduction of PBMC-derived monocytes with adenovirus provides a simple and effective alternative to the use of dendritic cells for the induction of antigen-specific CTL.
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http://dx.doi.org/10.1158/1078-0432.ccr-03-0067DOI Listing
February 2004

Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease.

Urol Clin North Am 2003 Nov;30(4):843-52

Department of Urology, University of California at Los Angeles School of Medicine, 10833 Le Conte Avenue, CHS 66-118, Los Angeles, CA 90095-1738, USA.

Surveillance after surgery for RCC is important because approximately 50% of these patients will develop a disease recurrence, two thirds of who will recur within the first year. Although the prognosis is generally poor in these patients, some may respond favorably to immunotherapy. The small subset of patients who develop solitary metastases has the greatest chance to achieve long-term survival. Aggressive surgical resection is an integral part of this success. Proposed surveillance protocols using a stage-based approach or an integrated approach combining stage with other important prognostic factors attempt to provide a rational approach to identifying treatable recurrences while minimizing unnecessary examinations and patient anxiety. However, strict adherence to follow-up guidelines may not be appropriate for all patients. Factors including patient comorbidities and patient willingness to pursue aggressive management in the event of recurrence may alter the follow-up for each individual.
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http://dx.doi.org/10.1016/s0094-0143(03)00056-9DOI Listing
November 2003

Emerging technologies in uroradiologic imaging.

Urol Oncol 2003 Sep-Oct;21(5):317-26

Department of Urology, UCLA School of Medicine, 10833 LeConte Avenue, Los Angeles, CA 90095, USA.

Advances in imaging technologies have readily been incorporated into the practice of urology and have led to important advances in patient care and outcomes. In the area of oncology, advances in radiologic imaging are improving the ability of the urologist to diagnose and monitor urologic malignancies. Some of these technologies include positron emission tomography (PET), intraoperative ultrasound (IUS), 3-dimensional computerized tomography (3D-CT), and magnetic resonance spectroscopy (MRS). We provide an overview of these four emerging imaging modalities and their potential applications and limitations in the diagnosis and management of urologic malignancy.
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http://dx.doi.org/10.1016/s1078-1439(03)00061-9DOI Listing
August 2004

Laparoscopic radical nephrectomy and minimally invasive surgery for kidney cancer.

Cancer Treat Res 2003 ;116:99-117

University of California Los Angeles, Los Angeles, CA 90095, USA.

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http://dx.doi.org/10.1007/978-1-4615-0451-1_6DOI Listing
May 2004

Validation of an integrated staging system toward improved prognostication of patients with localized renal cell carcinoma in an international population.

J Urol 2003 Dec;170(6 Pt 1):2221-4

Department of Urology, School of Medicine, University of California Los Angeles, 90095-1738, USA.

Purpose: Outcome prediction for patients with renal cell carcinoma is based on a combination of factors. In this study a previously published clinical outcome algorithm based on 1997 T stage, Fuhrman grade and performance score is validated using an international database.

Materials And Methods: A total of 1,060 patients from Nijmegen, the Netherlands (NN), MD Anderson (MDA) and University of California, Los Angeles (UCLA) who had localized renal cell carcinoma were evaluated for outcome prediction using a clinical outcome algorithm previously shown to stratify patients into low, intermediate and high risk groups. Validation was performed by comparing the 3 risk groups separately within the 3 centers as well as by comparing hazard ratios and concordance indices among the 3 centers.

Results: Estimated disease specific survival rates at 5 years for the low risk groups were 94% (NN), 92% (MDA) and 93% (UCLA). The 5-year disease specific survival rates for the intermediate risk groups were 65% (NN), 73% (MDA) and 78% (UCLA), while the rates for the high risk groups were 40% (NN), 30% (MDA) and 48% (UCLA). The concordance indices for each of the databases were 79% (NN), 86% (MDA) and 84% (UCLA).

Conclusions: A clinical algorithm that uses only 3 prognostic variables (1997 T stage, Fuhrman grade and performance status) to stratify patients with localized renal cell carcinoma into 3 risk groups has been shown to be applicable to external databases. This algorithm may be useful for patient counseling, surveillance and identification of high risk patients for enrollment in clinical trials.
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http://dx.doi.org/10.1097/01.ju.0000096049.64863.a1DOI Listing
December 2003

TNM T3a renal cell carcinoma: adrenal gland involvement is not the same as renal fat invasion.

J Urol 2003 Mar;169(3):899-903; discussion 903-4

Deparment of Urology, University of California-Los Angeles School of Medicine, USA.

Purpose: Upper pole tumors with direct extension into the adrenal gland are currently staged as pT3a tumors in the 1997 TNM staging system. To determine whether the clinical behavior of pT3a adrenal tumors differs from that of tumors with perinephric fat invasion (also stage pT3a) a retrospective analysis was performed.

Materials And Methods: Of 1,087 patients who underwent nephrectomy 27 were identified with direct adrenal involvement and 187 were identified with perinephric fat or renal sinus involvement. Variables and outcomes analyzed in each group included the percent of patients with metastatic disease at presentation, lymph node involvement, Eastern Cooperative Oncology Group score, response to immunotherapy, and median and overall survival using Kaplan-Meier curves.

Results: Median survival for patients with pT3a disease and perinephric or renal sinus fat involvement was 36 months with a 36% 5-year cancer specific survival rate. In contrast, patients with adrenal gland invasion had significantly worse survival at a median of 12.5 months and a 0% 5-year cancer specific survival rate (p <0.001), which was similar to median survival of those with stage pT4 disease (11 months).

Conclusions: Upper pole tumors with direct extension into the adrenal gland predict significantly worse survival than similarly staged tumors with fat invasion and they have a prognosis similar to that of stage pT4 disease. While these data await external validation, consideration should be given to re-categorizing tumors with direct adrenal gland involvement as stage pT4 or in a subcategory such as pT4a.
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http://dx.doi.org/10.1097/01.ju.0000051480.62175.35DOI Listing
March 2003