Publications by authors named "Patricia J Zondervan"

27 Publications

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Multidisciplinary integrated care pathway for von Hippel-Lindau disease.

Cancer 2022 May 17. Epub 2022 May 17.

Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, the Netherlands.

Background: Clinical pathways are care plans established to describe essential steps in the care of patients with a specific clinical problem. They translate (inter)national guidelines into local applicable protocols and clinical practice. The purpose of this article is to establish a multidisciplinary integrated care pathway for specialists and allied health care professionals in caring for individuals with von Hippel-Lindau (VHL) disease.

Methods: Using a modified Delphi consensus-making process, a multidisciplinary panel from 5 Dutch University Medical Centers produced an integrated care pathway relating to the provision of care for patients with VHL by medical specialists, specialized nurses, and associated health care professionals. Patient representatives cocreated the pathway and contributed quality criteria from the patients' perspective.

Results: The panel agreed on recommendations for the optimal quality of care for individuals with a VHL gene mutation. These items were the starting point for the development of a patient care pathway. With international medical guidelines addressing the different VHL-related disorders, this article presents a patient care pathway as a flowchart that can be incorporated into VHL expertise clinics or nonacademic treatment clinics.

Conclusions: Medical specialists (internists, urologists, neurosurgeons, ophthalmologists, geneticists, medical oncologists, neurologists, gastroenterologists, pediatricians, and ear-nose-throat specialists) together with specialized nurses play a vital role alongside health care professionals in providing care to people affected by VHL and their families. This article presents a set of consensus recommendations, supported by organ-specific guidelines, for the roles of these practitioners in order to provide optimal VHL care. This care pathway can form the basis for the development of comprehensive, integrated pathways for multiple neoplasia syndromes.
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http://dx.doi.org/10.1002/cncr.34265DOI Listing
May 2022

Surgical margins after partial nephrectomy as prognostic factor for the risk of local recurrence in pT1 RCC: a systematic review and narrative synthesis.

World J Urol 2022 May 3. Epub 2022 May 3.

Department of Urology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.

Purpose: To systematically review the published literature on surgical margins as a risk factor for local recurrence (LR) in patients undergoing partial nephrectomy (PN) for pT1 renal cell carcinomas (RCC).

Evidence Acquisition: A systematic literature search of relevant databases (MEDLINE, Embase and the Cochrane Library) was performed according to the PRISMA criteria up to February 2022. The hypothesis was developed using the PPO method (Patients = patients with pT1 RCC undergoing PN, Prognostic factor = positive surgical margins (PSM) detected on final pathology versus negative surgical margins (NSM) and Outcome = LR diagnosed on follow-up imaging). The primary outcome was the rate of PSM and LR. The risk of bias was assessed by the QUIPS tool.

Evidence Synthesis: After assessing 1525 abstracts and 409 full-text articles, eight studies met the inclusion criteria. The percentage of PSM ranged between 0 and 34.3%. In these patients with PSM, LR varied between 0 and 9.1%, whereas only 0-1.5% of LR were found in the NSM-group. The calculated odds ratio (95% confident intervals) varied between 0.04 [0.00-0.79] and 0.27 [0.01-4.76] and was statistically significant in two studies (0.14 [0.02-0.80] and 0.04 [0.00-0.79]). The quality analysis of the included studies resulted in an overall intermediate to high risk of bias and the level of evidence was overall very low. A meta-analysis was considered unsuitable due to the high heterogeneity between the included studies.

Conclusion: PSM after PN in patients with pT1 RCC is associated with a higher risk of LR. However, the evidence has significant limitations and caution should be taken with the interpretation of this data.
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http://dx.doi.org/10.1007/s00345-022-04016-0DOI Listing
May 2022

MRI and CT in the follow-up after irreversible electroporation of small renal masses.

Diagn Interv Radiol 2021 09;27(5):654-663

Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.

Purpose: Ablation plays a growing role in the treatment of small renal masses (SRMs) due to its nephron sparing properties and low invasiveness. Irreversible electroporation (IRE) has the potential, although still experimental, to overcome current limitations of thermal ablation. No prospective imaging studies exist of the ablation zone in the follow up after renal IRE in humans. Objectives are to assess computed tomography (CT) and magnetic resonance imaging (MRI) on the ablation zone volume (AZV), enhancement and imaging characteristics after renal IRE.

Methods: Prospective phase 2 study of IRE in nine patients with ten SRMs. MRI imaging was performed pre-IRE, 1 week, 3 months, 6 months and 12 months after IRE. CT was performed pre-IRE, perioperatively (direct after ablation), 3 months, 6 months and 12 months after IRE. AZVs were assessed by two independent observers. Observer variation was analyzed. Evolution of AZVs, and relation between the needle configuration volume (NCV; planned AZV) and CT- and MRI volumes were evaluated.

Results: Eight SRMs were clear cell renal cell carcinomas, one SRM was a papillary renal cell carcinoma and one patient had a non-diagnostic biopsy. On CT, median AZV increased perioperatively until 3 months post-IRE (respectively, 16.8 cm3 and 6.2 cm3) compared to the NCV (4.8 cm3). On MRI, median AZV increased 1-week post-IRE until 3 months post-IRE (respectively, 14.5 cm3 and 4.6 cm3) compared to the NCV (4.8 cm3). At 6 months the AZV starts decreasing (CT 4.8 cm3; MRI 3.0 cm3), continuing at 12 months (CT 4.2 cm3, MRI 1.1 cm3). Strong correlation was demonstrated between the planning and the post-treatment volumes. Inter-observer agreement between observers was excellent (CT 95% CI 0.82-0.95, MRI 95% CI 0.86-0.96). All SRMs appeared non-enhanced immediately after ablation, except for one residual tumour. Subtraction images confirmed non-enhancement on MRI in unclear enhancement cases (3/9). Directly after IRE, gas bubbles, perinephric stranding and edema were observed in all cases.

Conclusion: The AZV increases immediately on CT until 3 months after IRE. On MRI, the AZV increases at 1 week until 3 months post-IRE. At 6 months the AZV starts decreasing until 12 months post-IRE on both CT and MRI. Enhancement was absent post-IRE, except for one residual tumour. Gas bubbles, perinephric stranding and edema are normal findings directly post-IRE.
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http://dx.doi.org/10.5152/dir.2021.19575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8480958PMC
September 2021

Laparoscopic cryoablation for small renal masses: Oncological outcomes at 5-year follow-up.

Arab J Urol 2020 Dec 17;19(2):159-165. Epub 2020 Dec 17.

Department of Urology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands.

: To evaluate the oncological outcome at 5-year follow-up after laparoscopic cryoablation (LCA) for small renal masses (SRMs), as there is an increasing interest in ablative therapy for cT1a renal tumours due to the rising incidence of SRMs, the trend towards minimally invasive nephron-sparing treatments, and the ageing population. : Between 2004 and 2015, 233 consecutive LCA were performed in 219 patients for SRMs at two referral centres. We only included those patients with ≥5 years of follow-up ( = 165) in a prospectively maintained database. A descriptive analysis was conducted for pre-, peri- and postoperative characteristics. A Kaplan-Meier analysis assessed overall (OS), disease-specific (DSS), and recurrence-free survival (RFS). : The median (interquartile range [IQR]) age of our patient cohort was 68 (60.5-76) years. The median (IQR) body mass index was 26.2 (23.8-29) kg/m, and the median (IQR) Charlson Comorbidity Index score corrected for age was 4 (2.5-6). The median (IQR) tumour diameter was 28 (21-33) mm. In all, 15% developed a complication in the first 30 days after LCA, of which 1% had a major complication (Clavien-Dindo Grade ≥III). The median (IQR) preoperative estimated glomerular filtration rate (eGFR) was 82.5 (65-93.75) mL/min/1.73 m. The median eGFR decreased by 16.4% and 15.2% at the 3-month and 5-year follow-up, respectively. Persistence was found in 1%, local recurrence in 2%, and systemic progression in 4%. The OS, DSS, and RFS were 74%, 96.9% and 95.4%, respectively. : LCA is a safe and effective treatment for SRMs in selected cases and shows good oncological outcomes after 5 years of follow-up, with only 1% developing a major complication.
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http://dx.doi.org/10.1080/2090598X.2020.1863308DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158258PMC
December 2020

Identification of Meaningful Data for Providing Real-Time Intraoperative Feedback in Laparoscopic Surgery Using Delphi Analysis.

Surg Innov 2021 Feb 24;28(1):110-122. Epub 2020 Sep 24.

Department of Surgery, Amsterdam Gastroenterology and Metabolism, 26066Amsterdam UMC, University of Amsterdam, the Netherlands.

Surgeons are at risk of being overwhelmed with information while performing surgery. Initiatives focusing on the use of medical data in the operating room are on the rise. Currently, these initiatives require postprocessing of data. Although highly informative, data cannot be used to influence preventable error in real time. Ideally, feedback is provided preemptive. . First, to identify which information is considered to be relevant for real-time feedback during laparoscopic surgery according to surgeons. Second, to identify the optimal routing for providing such feedback, and third, to decide on optimal timing for feedback to alarm users during laparoscopic surgery. . A Delphi study of 3 iterations was conducted within the Amsterdam UMC, location AMC. A total of 25 surgeons and surgical residents performing laparoscopy were surveyed using 5-point Likert scales. Consensus was obtained when 80% of answers fitted the same answering category. . Delphi round 1 resulted in 198 unique ideas within 5 scenarios. After round 3, consensus was obtained on 102 items. Feedback most relevant during laparoscopic surgery refers to equipment like the gas insufflator, diathermy, and suction device. Feedback should be delivered via an additional monitor. Surgeons want to be instantly alarmed about aberrations in patients' vital parameters or combinations of vital parameters, preferably via a designated section on a monitor in their field of vision. Surgeons performing laparoscopy are uniform in their opinion that they need to be alarmed immediately when patients' vital parameters are becoming aberrant. Surgeons state that information regarding supporting equipment is best displayed on an additional monitor.
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http://dx.doi.org/10.1177/1553350620957783DOI Listing
February 2021

Renal biopsies performed before versus during ablation of T1 renal tumors: implications for prevention of overtreatment and follow-up.

Abdom Radiol (NY) 2021 01 20;46(1):373-379. Epub 2020 Jun 20.

Department of Urology, OLVG, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands.

Purpose: To assess the difference between renal mass biopsy (RMB) performed either before or during the ablation procedure.

Methods: A retrospective multicenter study was performed in patients with a cT1 renal mass treated with ablation between January 2007 and July 2019, including a search in the national pathology database for patients with a RMB planned for ablation. Patient and tumor characteristics and information on malignant, benign, and non-diagnostic biopsy results were collected to establish rates of overtreatment and number of ablations avoided in case of benign or non-diagnostic histology.

Results: RMB was performed in 714 patients, of which 231 patients received biopsy before planned ablation, and 483 patients at the time of ablation. Pathology results before ablation were malignant in 63% (145/231), benign in 20% (46/231) and non-diagnostic in 17% (40/231). Pathology results at the time of ablation were malignant in 67.5% (326/483), benign in 16.8% (81/483) and non-diagnostic in 15.7% (76/483), leading to a total of 32.5% of ablation of benign or non-diagnostic lesions. Of the patients with a benign biopsy obtained before ablation, 80.4% (37/46) chose not to undergo ablation. Patients with inconclusive biopsy before planned ablation chose an informed individualized approach including ablation, repeated biopsy, or no intervention in 56%, 34% and 10%.

Conclusion: This study emphasizes the importance of obtaining a biopsy prior to the ablation procedure in a separate session to lower the rate of potentially unnecessary ablations.
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http://dx.doi.org/10.1007/s00261-020-02613-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864836PMC
January 2021

The Successful Return-To-Work Questionnaire for Cancer Survivors (I-RTW_CS): Development, Validity and Reproducibility.

Patient 2020 10;13(5):567-582

Coronel Institute of Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.

Background: Cancer survivors' perspectives on a successful return to work (RTW) may not be captured in the common measure of RTW, namely time until RTW.

Objective: The purpose of this study was therefore to develop an RTW outcome measure that reflects employed cancer survivors' perspectives, with items that could be influenced by an employer, i.e. the Successful Return-To-Work questionnaire for Cancer Survivors (I-RTW_CS), and to assess its construct validity and reproducibility.

Methods: First, three focus groups with cancer survivors (n = 14) were organized to generate issues that may constitute successful RTW. Second, a two-round Delphi study among 108 cancer survivors was conducted to select the most important issues. Construct validity of the I-RTW_CS was assessed using correlations with a single-item measure of successful RTW and the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ-CS; n = 57). Reproducibility (test-retest reliability) was assessed using the intraclass correlation coefficient (ICC; n = 50).

Results: Forty-eight issues were generated, of which seven were included: 'enjoyment in work'; 'work without affecting health'; 'confidence of employer without assumptions about work ability'; 'open communication with employer'; 'feeling welcome at work'; 'good work-life balance'; and 'joint satisfaction with the situation (employer and cancer survivor)'. Correlations with single-item successful RTW and QWLQ-CS were 0.58 and 0.85, respectively. The reproducibility showed an ICC of 0.72.

Conclusions: The I-RTW_CS provides an RTW outcome measure that includes cancer survivors' perspectives and weights its items on an individual basis, allowing a more meaningful evaluation of cancer survivors' RTW. This study provides preliminary evidence for its construct validity and reproducibility.
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http://dx.doi.org/10.1007/s40271-020-00427-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478947PMC
October 2020

Feasibility and safety of irreversible electroporation (IRE) in patients with small renal masses: Results of a prospective study.

Urol Oncol 2019 03 30;37(3):183.e1-183.e8. Epub 2018 Nov 30.

Department of Radiology, Academic Medical Center, Amsterdam, the Netherlands.

Background: Irreversible electroporation (IRE) has the potential to overcome limitations of thermal ablation, enabling small renal mass (SRM) ablation near vital structures.

Purpose: To assess feasibility and safety of percutaneous IRE for the treatment of SRMs.

Materials And Methods: This prospective study is a phase 2 trial (NCT02828709) of IRE for patients with SRMs. Primary endpoints are feasibility and safety. Device- and procedural-adverse events were assessed by Clavien-Dindo and Common Terminology Criteria for Adverse Events version 4.0 grading systems. Technical feasibility was assessed by recording the technical success of the procedures. Technical success was evaluated by performing a CT immediately after ablation where complete tumor coverage and nonenhancement were evaluated. Tumor charcateristics and patient characteristics, procedural and anesthesia details, postprocedural events, and perioperative complications were recorded.

Results: Ten SRMs were included with a mean tumor size of 2.2 cm (range 1.1-3.9 cm) were treated with IRE. Renal mass biopsies revealed 7 clear cell and 1 papillary renal cell carcinoma. Two renal mass biopsies were nondiagnostic. The median follow-up was 6 months (range 3-12 months). Technical success was achieved in 9 out of 10 cases. One patient had a grade 3 Clavien-Dindo complication (1/10, 95% Confidence interval (CI) 0.0179-0.4041). Mean anesthesia time was 3.7 hours (range 3-5 hours), mean procedural time was 2.1 hours (range 1 hour 45 minutes-2 hours 30 minutes) and mean ablation time was 50 minutes (range 20 minutes-1 hour 45 minutes). The creatinine preoperative and postoperative (1 week, 3 months, 6 months, and 12 months) did not significantly differ. In total, 8 out of 10 cases did not experience postoperative pain.

Conclusion: IRE in SRMs is safe and feasible. Renal function is not affected by IRE and postoperative pain is rare. Anesthesia time and procedural time are a potential concern.
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http://dx.doi.org/10.1016/j.urolonc.2018.11.008DOI Listing
March 2019

study in nephroureterectomy specimens defining the role of 3-D upper urinary tract visualization using optical coherence tomography and endoluminal ultrasound.

J Med Imaging (Bellingham) 2018 Jan 12;5(1):017001. Epub 2018 Feb 12.

University of Amsterdam, Academic Medical Center, Department of Biomedical Engineering and Physics, Amsterdam, The Netherlands.

Minimal invasive endoscopic treatment for upper urinary tract urothelial carcinoma (UUT-UC) is advocated in patients with low-risk disease and limited tumor volume. Diagnostic ureterorenoscopy combined with biopsy is the diagnostic standard. This study aims to evaluate two alternative diagnostic techniques for UUT-UC: optical coherence tomography (OCT) and endoluminal ultrasound (ELUS). Following nephroureterectomy, OCT, ELUS, and computed tomography (CT) were performed of the complete nephroureterectomy specimen. Visualization software (AMIRA) was used for reconstruction and coregistration of CT, OCT, and ELUS. Finally, CT was used to obtain exact probe localization. Coregistered OCT and ELUS datasets were compared with histology. Coregistration with three-dimensional CT makes exact data matching possible in this setting to compare histology with OCT and ELUS. In OCT images of normal-appearing renal pelvis and ureter, urothelium, lamina propria, and muscularis were visible. With ELUS, all anatomical layers of the ureter could be distinguished, besides the urothelial layer. ELUS identified suspect lesions, although exact staging and differentiation between noninvasive and invasive lesions were not possible. OCT provides high-resolution imaging of normal ureter and ureter lesions. ELUS, however, is of limited value as it cannot differentiate between noninvasive and invasive tumors.
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http://dx.doi.org/10.1117/1.JMI.5.1.017001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5808355PMC
January 2018

Histopathology: ditch the slides, because digital and 3D are on show.

World J Urol 2018 Apr 2;36(4):549-555. Epub 2018 Feb 2.

Department of Urology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Due to the growing field of digital pathology, more and more digital histology slides are becoming available. This improves the accessibility, allows teleconsultations from specialized pathologists, improves education, and might give urologist the possibility to review the slides in patient management systems. Moreover, by stacking multiple two-dimensional (2D) digital slides, three-dimensional volumes can be created, allowing improved insight in the growth pattern of a tumor. With the addition of computer-aided diagnosis systems, pathologist can be guided to regions of interest, potentially reducing the workload and interobserver variation. Digital (3D) pathology has the potential to improve dialog between the pathologist and urologist, and, therefore, results in a better treatment selection for urologic patients.
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http://dx.doi.org/10.1007/s00345-018-2202-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871638PMC
April 2018

An In-vivo Prospective Study of the Diagnostic Yield and Accuracy of Optical Biopsy Compared with Conventional Renal Mass Biopsy for the Diagnosis of Renal Cell Carcinoma: The Interim Analysis.

Eur Urol Focus 2018 12 24;4(6):978-985. Epub 2017 Oct 24.

Department of Urology, AMC University Hospital, Amsterdam, The Netherlands.

Background: Lack of accuracy in preoperative imaging leads to overtreatment of benign renal masses (RMs) or indolent renal cell carcinomas (RCCs). Optical coherence tomography (OCT) is real time and high resolution, enabling quantitative analysis through attenuation coefficient (μ, mm).

Objective: To determine the accuracy and diagnostic yield of OCT and renal mass biopsy (RMB) for the differentiation of benign RMs versus RCC and oncocytoma versus RCC.

Design, Setting, And Participants: From October 2013 to June 2016, 95 patients with solid enhancing RMs on cross-sectional imaging were prospectively included. All patients underwent subsequent excision or ablation.

Intervention: Percutaneous, image-guided, needle-based OCT followed by RMB in an outpatient setting under local anaesthesia.

Outcome Measurements And Statistical Analysis: Accuracy and diagnostic yield, μ correlated to resection pathology or second biopsy during ablation. Tables (2×2) for RMB, receiver operating characteristic curve for OCT. Mann-Whitney test to differentiate μ of RMs.

Results And Limitations: RMB diagnostic yield was 79% with sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 100%, 89%, 99%, and 100%, respectively. Diagnostic yield and added value of OCT to differentiate RCC from benign was 99% and 15%, respectively. Significant difference was observed in median μ between benign RMs (3.2mm, interquartile range [IQR]: 2.65-4.35) and RCCs (4.3mm, IQR: 3.70-5.00), p=0.0171, and oncocytomas (3.38mm, IQR: 2.68-3.95) and RCCs (4.3mm, IQR: 3.70-5.00), p=0.0031. OCT showed sensitivity, specificity, positive predictive value. and NPV of 91%, 56%, 91%, and 56%, respectively, to differentiate benign RMs from RCCs and 92%, 67%, 95%, and 55%, respectively, to differentiate oncocytoma from RCC. Limitations include two reference standards and heterogeneity benign RMs.

Conclusions: Compared with RMB, OCT has a higher diagnostic yield. OCT accurately distinguishes benign RMs from RCCs, and oncocytoma from RCCs, although specificity and NPV are lower.

Patient Summary: Optical coherence tomography, a new optical scan, exhibits similar sensitivity and positive predictive value than renal mass biopsy, although lower specificity and negative predictive value. Optical coherence tomography has a higher diagnostic yield for diagnosing renal cell carcinoma.
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http://dx.doi.org/10.1016/j.euf.2017.10.002DOI Listing
December 2018

Irreversible Electroporation for the Ablation of Renal Cell Carcinoma: A Prospective, Human, In Vivo Study Protocol (IDEAL Phase 2b).

JMIR Res Protoc 2017 Feb 16;6(2):e21. Epub 2017 Feb 16.

Academic Medical Center, Department of Urology, University of Amsterdam, Amsterdam, Netherlands.

Background: Irreversible electroporation (IRE) is an emerging technique delivering electrical pulses to ablate tissue, with the theoretical advantage to overcome the main shortcomings of conventional thermal ablation. Recent short-term research showed that IRE for the ablation of renal masses is a safe and feasible treatment option. In an ablate and resect design, histopathological analysis 4 weeks after radical nephrectomy demonstrated that IRE-targeted renal tumors were completely covered by ablation zone. In order to develop a validated long-term IRE follow-up study, it is essential to obtain clinical confirmation of the efficacy of this novel technology. Additionally, follow-up after IRE ablation obliges verification of a suitable imaging modality.

Objective: The objectives of this study are the clinical efficacy and safety of IRE ablation of renal masses and to evaluate the use of cross-sectional imaging modalities in the follow-up after IRE in renal tumors. This study conforms to the recommendations of the IDEAL Collaboration and can be categorized as a phase 2B exploration trial.

Methods: In this prospective clinical trial, IRE will be performed in 20 patients aged 18 years and older presenting with a solid enhancing small renal mass (SRM) (≤4 cm) who are candidates for ablation. Magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) will be performed at 1 day pre-IRE, and 1 week post-IRE. Computed tomography (CT), CEUS, and MRI will be performed at 3 months, 6 months, and 12 months post-IRE.

Results: Presently, recruitment of patients has started and the first inclusions are completed. Preliminary results and outcomes are expected in 2018.

Conclusions: To establish the position of IRE ablation for treating renal tumors, a structured stepwise assessment in clinical practice is required. This study will offer fundamental knowledge on the clinical efficacy of IRE ablation for SRMs, potentially positioning IRE as ablative modality for renal tumors and accrediting future research with long-term follow-up.

Trial Registration: Clinicaltrials.gov registration number NCT02828709; https://clinicaltrials.gov/ct2/show/NCT02828709 (archived by WebCite at http://www.webcitation.org/6nmWK7Uu9). Dutch Central Committee on Research Involving Human Subjects NL56935.018.16.
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http://dx.doi.org/10.2196/resprot.6725DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5334515PMC
February 2017

Diagnostic dilemmas in patients with upper tract urothelial carcinoma.

Nat Rev Urol 2017 Mar 13;14(3):181-191. Epub 2016 Dec 13.

Department of Urology, AMC University Hospital, Meibergdreef 9, 1100 DE Amsterdam, Netherlands.

Upper tract urothelial carcinoma (UTUC) is a rare condition and recommendations based on a high level of evidence for diagnosis, treatment and follow-up monitoring are lacking. Current decision-making is often based on evidence from trials investigating urothelial carcinoma of the lower tract. Radical nephroureterectomy has been the standard of care for UTUC but kidney-sparing treatment using endoscopic approaches has been established for a select patient group with low-grade and low-stage disease. Optimal treatment choice requires correct tumour characterization. According to available recommendations, diagnostic work-up of UTUC includes evaluation by CT urography or MRI urography, cystoscopy and urine cytology. Ureterorenoscopy and lesion biopsy are grade C recommendations in patients with suspected UTUC. When kidney-sparing treatment is planned, ureterorenoscopy and biopsy should be considered and are the procedures of choice in most cases. These diagnostics have limitations and their accuracy varies in defining tumour characteristics and predicting grade and stage. Urinary tests have higher sensitivity than cytology for detection of lower tract urothelial carcinoma but evidence of their benefit in UTUCs is lacking. New optical and image enhancement techniques are being developed to facilitate real-time diagnostics with increased accuracy. A new diagnostic algorithm for patients with suspected UTUC that integrates the diagnosis, treatment and clinical risk stratification is required.
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http://dx.doi.org/10.1038/nrurol.2016.252DOI Listing
March 2017

Current position of diagnostics and surgical treatment for upper tract urothelial carcinoma.

Minerva Urol Nefrol 2017 Apr 21;69(2):159-165. Epub 2016 Oct 21.

Department of Urology, Academic Medical Center, Amsterdam, The Netherlands.

Background: The applicability of urinary biomarkers and optical diagnostics in upper urinary tract carcinoma (UUT-UC) are increasingly debated. To receive insight in the opinion of the urological community involved in this field, a survey was sent out to identify the most promising techniques and understand the need for new diagnostics. Primary objective of this study was to provide an overview of current diagnostics in upper urinary tract urothelial carcinoma. Secondary objectives of this study was to assess the need for additional diagnostic techniques in the current diagnostic work-up for UUT-UC and to assess knowledge of novel techniques.

Methods: An electronic survey was distributed to all participants of the upper urinary tract tumor registration study by the Clinical Research Office of the Endourological Society. Additionally, based on publications, experts in the field were contacted. Analysis was performed on the results overviewed by the survey monkey website.

Results: In total 81 of the 112 invited individuals responded resulting in a response rate of 72.3%. Most urologists involved in the treatment of upper urinary tract tumors follow the guidelines in their diagnostic work-up of patients suspected for UUT-UC. 61.4% of all responders consider current available diagnostic methods insufficient to select patient candidates for conservative renal sparing surgery. According to the responders, digital endoscopes for retrograde intrarenal surgery (RIRS) including narrow-band imaging (NBI) are best known and most likely to be beneficial compared to all evaluated diagnostic tools currently available.

Conclusions: Urologists consider current diagnostic techniques for upper urinary tract tumors insufficient for optimal patient selection for conservative renal sparing surgery. Among the new techniques, NBI and digital RIRS are best known and considered to be beneficial in the diagnostic work-up.
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http://dx.doi.org/10.23736/S0393-2249.16.02720-XDOI Listing
April 2017

Irreversible electroporation: state of the art.

Onco Targets Ther 2016 22;9:2437-46. Epub 2016 Apr 22.

Department of Urology, Academic Medical Center, Amsterdam, the Netherlands.

The field of focal ablative therapy for the treatment of cancer is characterized by abundance of thermal ablative techniques that provide a minimally invasive treatment option in selected tumors. However, the unselective destruction inflicted by thermal ablation modalities can result in damage to vital structures in the vicinity of the tumor. Furthermore, the efficacy of thermal ablation intensity can be impaired due to thermal sink caused by large blood vessels in the proximity of the tumor. Irreversible electroporation (IRE) is a novel ablation modality based on the principle of electroporation or electropermeabilization, in which electric pulses are used to create nanoscale defects in the cell membrane. In theory, IRE has the potential of overcoming the aforementioned limitations of thermal ablation techniques. This review provides a description of the principle of IRE, combined with an overview of in vivo research performed to date in the liver, pancreas, kidney, and prostate.
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http://dx.doi.org/10.2147/OTT.S88086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853139PMC
May 2016

Prostate cancer diagnosis by optical coherence tomography: First results from a needle based optical platform for tissue sampling.

J Biophotonics 2016 05 9;9(5):490-8. Epub 2016 Feb 9.

Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, The Netherlands.

The diagnostic accuracy of Optical Coherence Tomography (OCT) based optical attenuation coefficient analysis is assessed for the detection of prostate cancer. Needle-based OCT-measurements were performed on the prostate specimens. Attenuation coefficients were determined by an earlier described in-house developed software package. The mean attenuation coefficients (benign OCT data; malignant OCT data; p-value Mann-Whitney U test) were: (3.56 mm(-1) ; 3.85 mm(-1) ; p < 0.0001) for all patients combined. The area under the ROC curve was 0.64. In order to circumvent the effect of histopathology mismatching, we performed a sub-analysis on only OCT data in which tumor was visible in two subsequent histopathological prostate slices. This analysis could be performed in 3 patients. The mean attenuation coefficients (benign OCT data; malignant OCT data; p-value Mann-Whitney U test) were: (3.23 mm(-1) ; 4.11 mm(-1) ; p < 0.0001) for all patients grouped together. The area under the ROC curve was 0.89. Functional OCT of the prostate has shown to differentiate between cancer and healthy prostate tissue. The optical attenuation coefficient in malignant tissue was significantly higher in malignant tissue compared to benign prostate tissue. Further studies are required to validate these initial results in a larger group of patients with a more tailored histopathology matching protocol.
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http://dx.doi.org/10.1002/jbio.201500252DOI Listing
May 2016

Percutaneous Needle Based Optical Coherence Tomography for the Differentiation of Renal Masses: a Pilot Cohort.

J Urol 2016 May 21;195(5):1578-1585. Epub 2015 Dec 21.

Department of Urology, AMC University Hospital, Amsterdam, The Netherlands.

Purpose: We determine the ability of percutaneous needle based optical coherence tomography to differentiate renal masses by using the attenuation coefficient (μOCT, mm(-1)) as a quantitative measure.

Materials And Methods: Percutaneous needle based optical coherence tomography of the kidney was performed in patients presenting with a solid renal mass. A pathology specimen was acquired in the form of biopsies and/or a resection specimen. Optical coherence tomography results of 40 patients were correlated to pathology results of the resected specimens in order to derive μOCT values corresponding with oncocytoma and renal cell carcinoma, and with the 3 main subgroups of renal cell carcinoma. The sensitivity and specificity of optical coherence tomography in differentiating between oncocytoma and renal cell carcinoma were assessed through ROC analysis.

Results: The median μOCT of oncocytoma (3.38 mm(-1)) was significantly lower (p=0.043) than the median μOCT of renal cell carcinoma (4.37 mm(-1)). ROC analysis showed a μOCT cutoff value of greater than 3.8 mm(-1) to yield a sensitivity, specificity, positive predictive value and negative predictive value of 86%, 75%, 97% and 37%, respectively, to differentiate between oncocytoma and renal cell carcinoma. The area under the ROC curve was 0.81. Median μOCT was significantly lower for oncocytoma vs clear cell renal cell carcinoma (3.38 vs 4.36 mm(-1), p=0.049) and for oncocytoma vs papillary renal cell carcinoma (3.38 vs 4.79 mm(-1), p=0.027).

Conclusions: We demonstrated that the μOCT is significantly higher in renal cell carcinoma vs oncocytoma, with ROC analysis showing promising results for their differentiation. This demonstrates the potential of percutaneous needle based optical coherence tomography to help in the differentiation of renal masses, thus warranting ongoing research.
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http://dx.doi.org/10.1016/j.juro.2015.12.072DOI Listing
May 2016

Preoperative Decision Making for Nephron-Sparing Procedure in the Renal Mass: Time for Using Standard Tools?

J Endourol 2016 Jan 20;30(1):128-34. Epub 2015 Oct 20.

1 Department of Urology, AMC University Hospital , Amsterdam, The Netherlands .

Objective: To determine if the application of using standard tools on tumor complexity and comorbidity indexes may replace the traditional choice of nephron-sparing procedure (NSP) based on clinical maximal tumor diameter (cMTD), age, and comorbidity.

Patients And Methods: Anatomic complexity scores (PADUA and RENAL) and Charlson comorbidity index (CCI) and CCI age-adjusted (CACI) were applied to 261 cases of either nephron-sparing surgery (NSS) or cryoablation (CA). Patient- and tumor-related preoperative variables, PADUA, RENAL, CCI, and CACI, were evaluated for their association and as treatment predictors in uni- and multivariate regression analysis. Discriminative ability of each of the models generated was compared for their receiver operating curve area under the curve (AUC). Survival analysis was performed using log rank tests.

Results: In total, 124 cases underwent partial nephrectomy and 137 cases CA. cMTD, RENAL, PADUA, age, and CACI were independently associated with the choice of NSS. Five models integrating a combination of age, cMTD, CACI, PADUA, and RENAL (scores and complexity groups) showed an AUC >0.72 to predict the odds of receiving NSS. The discriminative ability of these five models was not statistically significantly different.

Conclusions: cMTD, RENAL, PADUA, age, and CACI are preoperative variables independently associated with the choice of NSP. Models incorporating tools on tumor anatomic complexity and CACI may replace the decision-making in the type of NSP based on cMTD and age. The use of these models can be of value for future standardization and comparison.
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http://dx.doi.org/10.1089/end.2015.0472DOI Listing
January 2016

Prostate cancer diagnosis: the feasibility of needle-based optical coherence tomography.

J Med Imaging (Bellingham) 2015 Jul 9;2(3):037501. Epub 2015 Jul 9.

University of Amsterdam , Academic Medical Center, Department of Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.

The objective of this study is to demonstrate the feasibility of needle-based optical coherence tomography (OCT) and functional analysis of OCT data along the full pullback trajectory of the OCT measurement in the prostate, correlated with pathology. OCT images were recorded using a commercially available C7-XR™ OCT Intravascular Imaging System interfaced to a C7 Dragonfly™ intravascular 0.9-mm-diameter imaging probe. A computer program was constructed for automated image attenuation analysis. First, calibration of the OCT system for both the point spread function and the system roll-off was achieved by measurement of the OCT signal attenuation from an extremely weakly scattering medium (Intralipid® 0.0005 volume%). Second, the data were arranged in 31 radial wedges (pie slices) per circular segments consisting of 16 A-scans per wedge and 5 axial B-scans, resulting in an average A-scan per wedge. Third, the decay of the OCT signal is analyzed over 50 pixels ([Formula: see text]) in depth, starting from the first found maximum data point. Fourth, for visualization, the data were grouped with a corresponding color representing a specific [Formula: see text] range according to their attenuation coefficient. Finally, the analyses were compared to histopathology. To ensure that each single use sterile imaging probe is comparable to the measurements of the other imaging probes, the probe-to-probe variations were analyzed by measuring attenuation coefficients of 0.03, 6.5, 11.4, 17, and 22.7 volume% Intralipid®. Experiments were repeated five times per probe for four probes. Inter- and intraprobe variation in the measured attenuation of Intralipid samples with scattering properties similar to that of the prostate was [Formula: see text] of the mean values. Mean attenuation coefficients in the prostate were [Formula: see text] for parts of the tissue that were classified as benign (SD: [Formula: see text], minimum: [Formula: see text], maximum: [Formula: see text]) and [Formula: see text] for parts of tissue that were classified as malignant (SD: [Formula: see text], minimum: [Formula: see text], maximum: [Formula: see text]). In benign areas, the tissue looked homogeneous, whereas in malignant areas, small glandular structures were seen. However, not all areas in which a high attenuation coefficient became apparent corresponded to areas of prostate cancer. This paper describes the first in-tissue needle-based OCT imaging and three-dimensional optical attenuation analysis of prostate tissue that indicates a correlation with pathology. Fully automated attenuation coefficient analysis was performed at 1300 nm over the full pullback. Correlation with pathology was achieved by coregistration of three-dimensional (3-D) OCT attenuation maps with 3-D pathology of the prostate. This may contribute to the current challenge of prostate imaging and the rising interest in focal therapy for reduction of side effects occurring with current therapies.
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http://dx.doi.org/10.1117/1.JMI.2.3.037501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498002PMC
July 2015

The efficacy and safety of irreversible electroporation for the ablation of renal masses: a prospective, human, in-vivo study protocol.

BMC Cancer 2015 Mar 22;15:165. Epub 2015 Mar 22.

Department of Urology, Academic Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, Netherlands.

Background: Electroporation is a novel treatment technique utilizing electric pulses, traveling between two or more electrodes, to ablate targeted tissue. The first in human studies have proven the safety of IRE for the ablation of renal masses. However the efficacy of IRE through histopathological examination of an ablated renal tumour has not yet been studied. Before progressing to a long-term IRE follow-up study it is vital to have pathological confirmation of the efficacy of the technique. Furthermore, follow-up after IRE ablation requires a validated imaging modality. The primary objectives of this study are the safety and the efficacy of IRE ablation of renal masses. The secondary objectives are the efficacy of MRI and CEUS in the imaging of ablation result.

Methods/design: 10 patients, age ≥ 18 years, presenting with a solid enhancing mass, who are candidates for radical nephrectomy will undergo IRE ablation 4 weeks prior to radical nephrectomy. MRI and CEUS imaging will be performed at baseline, one week and four weeks post IRE. After radical nephrectomy, pathological examination will be performed to evaluate IRE ablation success.

Discussion: The only way to truly assess short-term (4 weeks) ablation success is by histopathology of a resection specimen. In our opinion this trial will provide essential knowledge on the safety and efficacy of IRE of renal masses, guiding future research of this promising ablative technique.

Trial Registration: Clinicaltrials.gov registration number NCT02298608 . Dutch Central Committee on Research Involving Human Subjects registration number NL44785.018.13.
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http://dx.doi.org/10.1186/s12885-015-1189-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4376341PMC
March 2015

In vivo, percutaneous, needle based, optical coherence tomography of renal masses.

J Vis Exp 2015 Mar 30(97). Epub 2015 Mar 30.

Department of Urology, Academic Medical Center.

Optical coherence tomography (OCT) is the optical equivalent of ultrasound imaging, based on the backscattering of near infrared light. OCT provides real time images with a 15 µm axial resolution at an effective tissue penetration of 2-3 mm. Within the OCT images the loss of signal intensity per millimeter of tissue penetration, the attenuation coefficient, is calculated. The attenuation coefficient is a tissue specific property, providing a quantitative parameter for tissue differentiation. Until now, renal mass treatment decisions have been made primarily on the basis of MRI and CT imaging characteristics, age and comorbidity. However these parameters and diagnostic methods lack the finesse to truly detect the malignant potential of a renal mass. A successful core biopsy or fine needle aspiration provides objective tumor differentiation with both sensitivity and specificity in the range of 95-100%. However, a non-diagnostic rate of 10-20% overall, and even up to 30% in SRMs, is to be expected, delaying the diagnostic process due to the frequent necessity for additional biopsy procedures. We aim to develop OCT into an optical biopsy, providing real-time imaging combined with on-the-spot tumor differentiation. This publication provides a detailed step-by-step approach for percutaneous, needle based, OCT of renal masses.
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http://dx.doi.org/10.3791/52574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4401379PMC
March 2015

Irreversible electroporation of the porcine kidney: Temperature development and distribution.

Urol Oncol 2015 Apr 31;33(4):168.e1-7. Epub 2014 Dec 31.

Department of Urology, Academic Medical Center, Amsterdam, The Netherlands.

Objective: Although tissue ablation by irreversible electroporation (IRE) has been characterized as nonthermal, the application of frequent repetitive high-intensity electric pulses has the potential of substantially heating the targeted tissue and causing thermal damage. This study evaluates the risk of possible thermal damage by measuring temperature development and distribution during IRE of porcine kidney tissue.

Methods: The animal procedures were conducted following an approved Institutional Animal Ethics Committee protocol. IRE ablation was performed in 8 porcine kidneys. Of them, 4 kidneys were treated with a 3-needle configuration and the remaining 4 with a 4-needle configuration. All IRE ablations consisted of 70 pulses with a length 90 µs. The pulse frequency was set at 90 pulses/min, and the pulse intensity at 1,500 V/cm with a spacing of 15 mm between the needles. The temperature was measured internally using 4 fiber-optic temperature probes and at the surface using a thermal camera.

Results: For the 3-needle configuration, a peak temperature of 57°C (mean = 49 ± 10°C, n = 3) was measured in the core of the ablation zone and 40°C (mean = 36 ± 3°C, n = 3) at 1cm outside of the ablation zone, from a baseline temperature of 33 ± 1°C. For the 4-needle configuration, a peak temperature of 79°C (mean = 62 ± 16°C, n = 3) was measured in the core of the ablation zone and 42°C (mean = 39 ± 3°C, n = 3) at 1cm outside of the ablation zone, from a baseline of 35 ± 1°C. The thermal camera recorded the peak surface temperatures in the center of the ablation zone, reaching 31°C and 35°C for the 3- and 4-needle configuration IRE (baseline 22°C).

Conclusions: The application of repetitive high-intensity electric pulses during IRE ablation in porcine kidney causes a lethal rise in temperature within the ablation zone. Temperature monitoring should be considered when performing IRE ablation near vital structures.
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http://dx.doi.org/10.1016/j.urolonc.2014.11.019DOI Listing
April 2015

[Urothelial carcinoma in the upper urinary tract: developments in diagnostics, treatment and follow-up].

Ned Tijdschr Geneeskd 2014 ;158:A7347

Academisch Medisch Centrum, afd. Urologie, Amsterdam.

Ninety-five percent of all urothelial carcinomas are located in the bladder and 5% in the upper urinary tract. Therefore, upper urinary tract urothelial carcinoma is relatively rare, with an incidence of 2.1-2.4 per 100,000 persons per year. Diagnosis is based on imaging, endoscopy, urine cytology and histology. Histopathological diagnosis of upper urinary tract tumours is essential for choice of therapy and follow-up, as both tumour grade and stage are important prognostic factors. Radical nephroureterectomy is the standard treatment, but has a direct effect on kidney function. For this reason, an increasing number of patients with low-risk tumours undergo kidney-sparing surgery to maintain kidney function. After kidney-sparing surgery intensive follow-up of the ipsilateral upper urinary tract is mandatory because of a five-year recurrence-free survival rate of 17-63%, depending on tumour grade. Current diagnostics all have their limitations. Nowadays, research focuses on improving diagnosis in order to be able to offer better individual treatment.
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March 2015

Optical diagnostics for upper urinary tract urothelial cancer: technology, thresholds, and clinical applications.

J Endourol 2015 Feb 16;29(2):113-23. Epub 2014 Oct 16.

1 Department of Urology, Academic Medical Center , Amsterdam, The Netherlands .

Purpose: Developments in optical diagnostics have potential for less invasive diagnosis of upper urinary tract urothelial carcinoma (UUT-UC). This systematic review provides an overview of technology, applications, and limitations of recently developed optical diagnostics in the upper urinary tract and outlines their potential for future clinical applications. In addition, current evidence was evaluated.

Literature Search: A PubMed literature search was performed and articles on narrow band imaging (NBI), photodynamic diagnosis (PDD), Storz professional imaging enhancement system (SPIES), optical coherence tomography (OCT), and confocal laser endomicroscopy (CLE) regarding UUT-UC were reviewed for data extraction. Study quality was reviewed according to Quality Assessment of Diagnostic Accuracy Studies and Innovation, Development, Exploration, Assessment, and Long-term follow-up (IDEAL) standards.

Results: Four articles available for quality assessment, demonstrated high level of evidence, but low level of IDEAL stage. NBI and SPIES enhance contrast of mucosal surface and vascular structures, improving tumor detection rate. A first in vivo study showed promising results. PDD uses fluorescence to improve tumor detection rate. However, due to the acute angle of the ureterorenoscopes there is an increased risk of false positives. OCT produces cross-sectional high-resolution images, providing information on tumor grade and stage. A pilot study showed promising diagnostic accuracy. CLE allows ultrahigh-resolution microscopy of tissue resulting in images of the cellular structure. CLE cannot be applied in vivo in the upper urinary tract yet, due to technical limitations.

Conclusions: NBI, SPIES, and PDD aim at improving visualization of UUT-UC through contrast enhancement. OCT and CLE aim at providing real-time predictions of histopathological diagnosis. For all techniques, more research has to be conducted before these techniques can be implemented in the routine management of UUT-UC. All techniques might be of value in specific clinical scenarios and allow for integration, for example, OCT with NBI, and could therefore improve tumor detection and staging and help in selecting the optimal treatment for the individual patient.
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http://dx.doi.org/10.1089/end.2014.0551DOI Listing
February 2015

Prognostic models and factors for patients with renal-cell carcinoma: a survey on their use among urologists.

J Endourol 2013 Jun 3;27(6):790-9. Epub 2013 Apr 3.

Department of Urology, Academic Medical Center, Amsterdam, The Netherlands.

Purpose: To assess the use of prognostic factors and models in renal-cell carcinoma (RCC) and to gain insight in the motivations precluding prognosis estimation and the use of prognosticators.

Materials And Methods: A questionnaire was sent to 110 urologists involved in the Clinical Research Office of the Endourological Society (CROES) Global Renal Mass Study. Frequencies were gathered using descriptive statistics.

Results: The majority of the 86 responders worked in a university hospital in Europe. Most of the urologists (97.7%) used the tumor-node-metastasis (TNM) classification, and 44% performed prognosis estimations in all patients. The main reason not to estimate prognosis was lack of accuracy (20.9%) and of additional benefit (11.6%). In addition, clinical, laboratory, or pathologic factors were used by 89.5% of the urologists and biomarkers by 16.3%. Preoperative models were used by 20.9%, postoperative models by 38.4%, and metastatic models by 38.4%. The Raj and Motzer models were the most used in preoperative and metastatic settings, while no predominance among the different postoperative models was seen. The most important reasons to skip the use of models were "lack of additional value" and "lack of familiarity" reported by 30.2% and 27.9% of the responders, respectively.

Conclusions: The TNM is the mainstay for assessing prognosis in RCC. Our data indicate that penetration of prognostic systems is, at most, moderate, suggesting limited use outside original developmental settings. On the contrary, clinical, laboratory, and pathologic factors are used by almost all urologists for prognosis estimations. The most important reason not to use models is the lack of additional value.
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http://dx.doi.org/10.1089/end.2012.0654DOI Listing
June 2013

Partial nephrectomy: is there an advantage of the self-retaining barbed suture in the perioperative period? A matched case-control comparison.

World J Urol 2012 Oct 6;30(5):659-64. Epub 2012 Sep 6.

Department of Urology, Academic Medical Center (AMC), University of Amsterdam, Meibergdreef 9, 1100 DE Amsterdam, The Netherlands.

Objective: To evaluate the efficacy of the self-retaining barbed suture (SRBS) in renal defect repair during partial nephrectomy (PN), by assessing perioperative outcomes.

Methods: From June 2010 on we have been using the SRBS for superficial layer closure during open and laparoscopic PN in two European centers. These data were collected prospectively and matched with historical PN cases performed with conventional suture. Cases were matched for PADUA score, surgical approach (laparoscopic or open) and the center where surgery was performed. Comparisons were made in patient characteristics and perioperative outcomes including warm ischemia time (WIT), changes in hemoglobin (Hb), changes in estimated glomerular filtration rate (eGFR) and perioperative complications between the SRBS and non-SRBS groups. Statistical tests of significance were performed using Student's t test and chi-square test for continuous and categorical variables, respectively.

Results: Thirty-one consecutive cases of PN under WIT were performed with SRBS. These cases were matched with cases from the historical database of PN performed with conventional suture. The rate of perioperative complications was statistically significantly lower in the SRBS cohort (6.5 vs. 22.6 %, p = 0.038). Mean ischemia time was 19.6 min (SD, 7.5) in the SRBS group versus 21.8 min (SD, 9.5) in the conventional suture group (p = 0.312). There were no significant differences between groups for postoperative changes in creatinine, eGFR and Hb. Limitations of this study include the absence of randomization and the relative small sample size.

Conclusions: SRBS can be safely used during partial nephrectomy. SRBS reduces significantly the number of perioperative complications.
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http://dx.doi.org/10.1007/s00345-012-0933-yDOI Listing
October 2012

Focal therapy in the management of small renal masses.

Curr Opin Urol 2012 Sep;22(5):372-8

Department of Urology, AMC, University of Amsterdam, Amsterdam, The Netherlands.

Purpose Of Review: Focal therapy has gained attention in the treatment of small renal masses. However its use is encased by scarce data on long-term outcomes and low evidence regarding perioperative complications. Our purpose is to review the emerging data in the past 18 months.

Recent Findings: Population US-based studies show steady increase in the use of thermal ablation. Clinical series and comprehensive reviews support safety and mid/long-term efficacy. Comparative studies and meta-analysis outlined oncological inferiority against partial nephrectomy in local tumor control. There are profound demographic and tumor differences between patients treated by one or another. Complication rate is lower after ablation but the lack of standard reporting weakens conclusions on this point. Generalizable cost-benefit studies are yet missed. Clinical and basic research aims to diminish radiological associated burden, improving lesion targeting and developing new energy-based technologies.

Summary: Data confirm acceptable outcomes of focal therapy in the small renal masses treatment.Although these are inferior in terms of local control compared with partial nephrectomy, patients and tumor characteristics differ between treatments.Current data remain of low evidence but for some meta-analysis. Preliminary reports suggest the possibility to decrease radiation burden and bipolar radiofrequency and photodynamic therapy as focus of future interest.
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http://dx.doi.org/10.1097/MOU.0b013e328355a9a7DOI Listing
September 2012
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