Publications by authors named "Ronald Hrebinko"

30 Publications

  • Page 1 of 1

Novel Creation of a Noneverted Stoma During Ileal Conduit Urinary Diversion: Technique and Short-term Outcomes.

Urology 2020 Dec 10;146:260-264. Epub 2020 Aug 10.

Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.

Objective: To report our experience with a noneverted stoma technique used in ileal conduit urinary diversion. We successfully utilize this technique in patients when traditional everted stoma maturation is difficult due to a thick abdominal wall, bulky mesentery, and poor bowel compliance.

Methods: We retrospectively reviewed all patients who underwent surgical creation of ileal conduit using a noneverted stoma technique between 2009 and 2018. We recorded demographic and perioperative information, including 30-day postoperative complications, and stoma appearance at last follow-up visit. Using R software, chi-square testing of the distribution of stoma outcomes for obese and nonobese patients was performed.

Results: There were a total of 42 patients who underwent noneverted stoma maturation technique by a single surgeon. Our cohort meets obese criteria with a mean body mass index (BMI) of 30.2. Mean length of follow-up was 16.6 months (1-62). On follow-up, 35 (83.3%) of stomas were pink and everted appearing, 4 (9.5%) were flush, small, or noneverted, 1 (2.3%) had an eschar or area of granulation tissue around the stoma, and 2 (4.7%) did not have a stoma description documented. There were 9 (21%) stoma-related complications in our cohort. There was no statistical difference in stoma outcomes between obese (BMI > 30) and nonobese (BMI < 30) patients (P= .65).

Conclusion: Ileal conduit creation with a noneverted stoma provides good stoma protuberance in patients with a thick abdominal wall, bulky mesentery, and poor bowel compliance. This technique is safe and should be considered in patients in whom stoma maturation is difficult.
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http://dx.doi.org/10.1016/j.urology.2020.07.057DOI Listing
December 2020

E-cadherin is downregulated in benign prostatic hyperplasia and required for tight junction formation and permeability barrier in the prostatic epithelial cell monolayer.

Prostate 2019 08 18;79(11):1226-1237. Epub 2019 Jun 18.

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Background: We previously reported the presence of prostate-specific antigen (PSA) in the stromal compartment of benign prostatic hyperplasia (BPH). Since PSA is expressed exclusively by prostatic luminal epithelial cells, PSA in the BPH stroma suggests increased tissue permeability and the compromise of epithelial barrier integrity. E-cadherin, an important adherens junction component and tight junction regulator, is known to exhibit downregulation in BPH. These observations suggest that the prostate epithelial barrier is disrupted in BPH and E-cadherin downregulation may increase epithelial barrier permeability.

Methods: The ultra-structure of cellular junctions in BPH specimens was observed using transmission electron microscopy (TEM) and E-cadherin immunostaining analysis was performed on BPH and normal adjacent specimens from BPH patients. In vitro cell line studies using benign prostatic epithelial cell lines were performed to determine the impact of small interfering RNA knockdown of E-cadherin on transepithelial electrical resistance and diffusion of fluorescein isothiocyanate (FITC)-dextran in transwell assays.

Results: The number of kiss points in tight junctions was reduced in BPH epithelial cells as compared with the normal adjacent prostate. Immunostaining confirmed E-cadherin downregulation and revealed a discontinuous E-cadherin staining pattern in BPH specimens. E-cadherin knockdown increased monolayer permeability and disrupted tight junction formation without affecting cell density.

Conclusions: Our results indicate that tight junctions are compromised in BPH and loss of E-cadherin is potentially an important underlying mechanism, suggesting targeting E-cadherin loss could be a potential approach to prevent or treat BPH.
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http://dx.doi.org/10.1002/pros.23806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599563PMC
August 2019

Small cell bladder cancer: should we consider prophylactic cranial irradiation?

Int Braz J Urol 2019 Mar-Apr;45(2):299-305

Department of Urology, University of Pittsburgh, Pennsylvania, U.S.A.

Purpose: To describe the clinical characteristics, treatment patterns, and outcomes in patients with small cell bladder cancer at our institution, including those who received prophylactic cranial irradiation (PCI) for the prevention of intracranial recurrence.

Materials And Methods: Patients with small cell bladder cancer treated at a single institution between January 1990 and August 2015 were identified and analyzed retrospectively for demographics, tumor stage, treatment, and overall survival.

Results: Of 44 patients diagnosed with small cell bladder cancer, 11 (25%) had metastatic disease at the time of presentation. Treatment included systemic chemotherapy (70%), radical surgery (59%), and local radiation (39%). Six patients (14%) received PCI. Median overall survival was 10 months (IQR 4 - 41). Patients with extensive disease had worse overall survival than those with organ confined disease (8 months vs. 36 months, respectively, p = 0.04). Among those who received PCI, 33% achieved 5 - year survival.

Conclusion: Outcomes for patients with small cell bladder cancer remain poor. Further research is indicated to determine if PCI increases overall survival in small call bladder cancer patients, especially those with extensive disease who respond to chemotherapy.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541124PMC
July 2019

The comparative effectiveness of quadratus lumborum blocks and paravertebral blocks in radical cystectomy patients.

Can J Urol 2018 04;25(2):9255-9261.

School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

Introduction: Multimodal analgesia is an effective way to control pain and limit opioid use after surgery. The quadratus lumborum block and paravertebral block are two regional anesthesia techniques that leverage multimodal analgesia to improve postoperative pain control. We sought to compare the efficacy of these blocks for pain management following radical cystectomy.

Materials And Methods: We performed a retrospective review of radical cystectomy patients who received bilateral continuous paravertebral blocks (n = 125) or bilateral single shot quadratus lumborum blocks (n = 50) between 2014-2016. The primary outcome was postoperative opiate consumption on day 0. Secondary outcomes included self-reported pain scores and hospital length of stay.

Results: Quadratus lumborum block patients had similar opioid use on postoperative day 0 compared with paravertebral block patients (29 mg versus 30 mg, p = 0.90). Pain scores on postoperative day 0 were similar between quadratus lumborum block and paravertebral block groups (4.0 versus 3.8, p = 0.72); however, the paravertebral block group had lower pain scores on days 1-3 compared with the quadratus lumborum block group (all p < 0.05). Hospital length of stay was similar between groups (6.6 days versus 6.2 days, p = 0.41).

Conclusions: There were no differences in opioid consumption among patients receiving bilateral single shot quadratus lumborum blocks and bilateral continuous paravertebral blocks after radical cystectomy. These data suggest that the quadratus lumborum block is a viable alternative for delivering multimodal analgesia in cystectomy patients.
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April 2018

Small Renal Masses in Close Proximity to the Collecting System and Renal Sinus Are Enriched for Malignancy and High Fuhrman Grade and Should Be Considered for Early Intervention.

Clin Genitourin Cancer 2018 08 5;16(4):e729-e733. Epub 2018 Feb 5.

Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.

Introduction: Recent reports show a correlation between renal tumor radiographic characteristics and pathologic features. We hypothesize that a more central location within the relatively hypoxic renal medulla might confer a more aggressive tumor phenotype. To test this, radiographic tumor characteristics were compared with tumor grade and histology.

Materials And Methods: We retrospectively reviewed renal masses <4 cm in diameter that underwent resection between 2008 and 2013. Tumor location was recorded using standard R.E.N.A.L. Nephrometry Score. Multivariate logistic regression was performed to compare independent anatomic features with incidence of malignancy and high nuclear grade.

Results: A total of 334 renal tumors had information available for analysis. Univariate analysis showed that increasing endophycity and proximity to the collecting system (<4 mm) were predictors of malignancy and high-grade features. In multivariate analysis, proximity to the collecting system <4 mm remained the as the only anatomical variable predictive of malignancy (odds ratio [OR], 3.58; 95% confidence interval [CI], 1.06-12.05; P = .04) and high nuclear grade (OR, 2.81; 95% CI, 1.44-5.51; P = .003).

Conclusion: Malignancy and high tumor grade occur with much greater frequency when tumors are located deep in the kidney, in close proximity to the collecting system and renal sinus. Ninety-six percent of small renal masses in this region were cancers and nearly half were Fuhrman Grade 3 or 4, suggesting that these small centrally located tumors should be targeted for early intervention.
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http://dx.doi.org/10.1016/j.clgc.2018.01.017DOI Listing
August 2018

Epidermoid cyst of the renal pelvis masquerading as malignancy.

Indian J Pathol Microbiol 2017 Oct-Dec;60(4):571-573

Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH, USA.

Epidermoid cyst of the renal pelvis is exceptionally rare. The histogenetic mechanism has not been well characterized. Herein, we report a case of intrarenal epidermoid cyst in a 62-year-old woman who had undergone left nephrolithotomy for a staghorn calculus. She was being followed up for bilateral renal cysts when a complex mass was noted arising from the lower pole of the left kidney. Renal ultrasound showed a small left kidney with a solid vascular echogenic mass. A laparoscopic radical nephrectomy was performed. Gross examination revealed a well-circumscribed cystic mass with friable tan-yellow contents. Microscopically, a cystic structure lined by mature epidermis without atypia indicating epidermoid cyst was noted. The lesion appeared to be in continuity with the pelvicalyceal urothelium which displayed extensive squamous metaplasia. The patient is disease free and is doing well. Better clinical awareness of this benign entity and a preoperative biopsy may help preserve a kidney.
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http://dx.doi.org/10.4103/IJPM.IJPM_618_16DOI Listing
July 2018

Preoperative immunonutrition prior to radical cystectomy: a pilot study.

Can J Urol 2017 Aug;24(4):8895-8901

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Introduction: To investigate the use of a high-arginine immunonutrient supplement prior to radical cystectomy for bladder cancer.

Materials And Methods: We recruited 40 patients to consume a total of four high-arginine immunonutrient shakes per day for 5 days prior to radical cystectomy. The primary outcome measures were safety, tolerability and adherence to the supplementation regimen. Ninety-day postoperative outcomes were also compared between supplemented patients and a cohort of 104 prospectively identified non-supplemented radical cystectomy patients. Multivariable logistic regression models were used to compare overall complications, infectious complications, and readmission rates between groups.

Results: There were no serious adverse events during supplementation. Four patients (10%) stopped supplementation due to nausea (n = 2) and bloating (n = 2). Thirty-three patients (83%) consumed all prescribed shakes. Immunonutrient supplementation was not significantly associated with overall complications (adjusted odds ratio [OR] 1.08; 95% confidence interval [CI] 0.50-2.33), infectious complications (OR 1.23; 95% CI 0.49-3.07), or readmissions (OR 1.48; 95% CI 0.62-3.51) on multivariable analyses.

Conclusions: Preoperative supplementation with a high-arginine immunonutrient shake was safe and well tolerated prior to radical cystectomy. Contrary to prior reports, immunonutrient supplementation was not associated with lower postoperative infectious complications in this cohort, perhaps owing to the 5 day supplementation period. Further study is needed to identify the optimal immunonutrient supplement regimen for radical cystectomy patients.
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August 2017

Management of Recurrent Venous Tumor Thrombus Following Inferior Vena Cava Thrombectomy: Is Surgery the Right Answer?

Eur Urol Focus 2016 Dec 16;2(6):631-632. Epub 2016 Jun 16.

Division of Urologic Oncology, Department of Surgical Oncology Fox Chase Cancer Center-Temple University Health System, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.euf.2016.06.003DOI Listing
December 2016

Molecular Cytogenetics as a Diagnostic Aid for Primary Liposarcoma of the Spermatic Cord.

Clin Genitourin Cancer 2017 02 10;15(1):e83-e89. Epub 2016 Aug 10.

Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA.

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http://dx.doi.org/10.1016/j.clgc.2016.08.008DOI Listing
February 2017

Total Psoas Area Predicts Complications following Radical Cystectomy.

Adv Urol 2015 21;2015:901851. Epub 2015 Dec 21.

Department of Urology, University of Pittsburgh, Pittsburgh, PA, USA.

Purpose. To determine whether total psoas area (TPA), a simple estimate of muscle mass, is associated with complications after radical cystectomy. Materials and Methods. Patients who underwent radical cystectomy at our institution from 2011 to 2012 were retrospectively identified. Total psoas area was measured on preoperative CT scans and normalized for patient height. Multivariable logistic regression was used to determine whether TPA was a predictor of 90-day postoperative complications. Overall survival was compared between TPA quartiles. Results. 135 patients were identified for analysis. Median follow-up was 24 months (IQR: 6-37 months). Overall 90-day complication rate was 56% (75/135). TPA was significantly lower for patients who experienced any complication (7.8 cm(2)/m(2) versus 8.8 cm(2)/m(2), P = 0.023) and an infectious complication (7.0 cm(2)/m(2) versus 8.7 cm(2)/m(2), P = 0.032) than those who did not. On multivariable analysis, TPA (adjusted OR 0.70 (95% CI 0.56-0.89), P = 0.003) and Charlson comorbidity index (adjusted OR 1.34 (95% CI 1.01-1.79), P = 0.045) were independently associated with 90-day complications. TPA was not a predictor of overall survival. Conclusions. Low TPA is associated with infectious complications and is an independent predictor of experiencing a postoperative complication following radical cystectomy.
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http://dx.doi.org/10.1155/2015/901851DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698521PMC
January 2016

The Role of Interferon in the Management of BCG Refractory Nonmuscle Invasive Bladder Cancer.

Adv Urol 2015 13;2015:656918. Epub 2015 Oct 13.

Department of Urology, University of Pittsburgh Medical Center, 3471 5th Avenue, Suite 700 Kaufmann Building, Pittsburgh, PA 15213, USA.

Background. Thirty to forty percent of patients with high grade nonmuscle invasive bladder cancer (NMIBC) fail to respond to intravesical therapy with bacillus Calmette-Guerin (BCG). Interferon-α2B plus BCG has been shown to be effective in a subset of patients with NMIBC BCG refractory disease. Here we present a contemporary series on the effectiveness and safety of intravesical BCG plus interferon-α2B therapy in patients with BCG refractory NMIBC. Methods. From January of 2005 to April of 2014 we retrospectively found 44 patients who underwent induction with combination IFN/BCG for the management of BCG refractory NMIBC. A chart review was performed to assess initial pathological stage/grade, pathological stage/grade at the time of induction, time to IFN/BCG failure, pathological stage/grade at failure, postfailure therapy, and current disease state. Results. Of the 44 patients who met criteria for the analysis. High risk disease was found in 88.6% of patients at induction. The 12-month and 24-month recurrence-free survival were 38.6% and 18.2%, respectively. 25 (56.8%) ultimately had disease recurrence. Radical cystectomy was performed in 16 (36.4%) patients. Conclusion. Combination BCG plus interferon-α2B remains a reasonably safe alternative treatment for select patients with BCG refractory disease prior to proceeding to radical cystectomy.
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http://dx.doi.org/10.1155/2015/656918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621325PMC
November 2015

Comprehensive Molecular Characterization of Papillary Renal-Cell Carcinoma.

N Engl J Med 2016 Jan 4;374(2):135-45. Epub 2015 Nov 4.

Background: Papillary renal-cell carcinoma, which accounts for 15 to 20% of renal-cell carcinomas, is a heterogeneous disease that consists of various types of renal cancer, including tumors with indolent, multifocal presentation and solitary tumors with an aggressive, highly lethal phenotype. Little is known about the genetic basis of sporadic papillary renal-cell carcinoma, and no effective forms of therapy for advanced disease exist.

Methods: We performed comprehensive molecular characterization of 161 primary papillary renal-cell carcinomas, using whole-exome sequencing, copy-number analysis, messenger RNA and microRNA sequencing, DNA-methylation analysis, and proteomic analysis.

Results: Type 1 and type 2 papillary renal-cell carcinomas were shown to be different types of renal cancer characterized by specific genetic alterations, with type 2 further classified into three individual subgroups on the basis of molecular differences associated with patient survival. Type 1 tumors were associated with MET alterations, whereas type 2 tumors were characterized by CDKN2A silencing, SETD2 mutations, TFE3 fusions, and increased expression of the NRF2-antioxidant response element (ARE) pathway. A CpG island methylator phenotype (CIMP) was observed in a distinct subgroup of type 2 papillary renal-cell carcinomas that was characterized by poor survival and mutation of the gene encoding fumarate hydratase (FH).

Conclusions: Type 1 and type 2 papillary renal-cell carcinomas were shown to be clinically and biologically distinct. Alterations in the MET pathway were associated with type 1, and activation of the NRF2-ARE pathway was associated with type 2; CDKN2A loss and CIMP in type 2 conveyed a poor prognosis. Furthermore, type 2 papillary renal-cell carcinoma consisted of at least three subtypes based on molecular and phenotypic features. (Funded by the National Institutes of Health.).
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http://dx.doi.org/10.1056/NEJMoa1505917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775252PMC
January 2016

Dorsal Lumbotomy Incision for Partial Nephrectomy in Patients With Small Posterior Renal Masses.

Urology 2016 Jan 1;87:120-4. Epub 2015 Oct 1.

Department of Urology, University of Pittsburgh, Pittsburgh, PA.

Objective: To describe our single-surgeon experience with dorsal lumbotomy, an uncommonly utilized muscle-sparing incision, for open partial nephrectomy.

Materials And Methods: We retrospectively identified patients who underwent partial nephrectomy through dorsal lumbotomy incision by a single surgeon from September 2012 through April 2014. Clinicopathologic characteristics were recorded along with early postoperative outcomes including hospital length of stay and narcotic requirement.

Results: Twenty-four patients were identified for analysis. Median operative time was 71 minutes (interquartile range [IQR]: 63-91 minutes), and median estimated blood loss was 250 mL (IQR: 100-438 mL). Median length of stay was 1.2 days (IQR: 0.94-2.0 days) and median narcotic requirement was 17 mg of oral morphine equivalents (IQR: 4.9-43 mg). Overall perioperative complication rate was 25% including 1 major (Clavien III-V) complication.

Conclusion: Partial nephrectomy via dorsal lumbotomy incision is a safe and feasible option for small posterior renal masses when performed by an experienced surgeon. The drawbacks of this approach are limited access to the renal hilum and risk of injury to the iliohypogastric or subcostal nerves. Dorsal lumbotomy is associated with postoperative outcomes equivalent to or better than standard operative approaches and should be considered a viable surgical approach in selected cases.
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http://dx.doi.org/10.1016/j.urology.2015.09.023DOI Listing
January 2016

Comparative hospital cost-analysis of open and robotic-assisted radical prostatectomy.

Urology 2012 Jul 16;80(1):126-9. Epub 2012 May 16.

Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213-3232, USA.

Objective: To perform a contemporary comparative cost-analysis of robotic-assisted laparoscopic radical prostatectomy (RARP) and open radical retropubic prostatectomy (RRP).

Methods: All patients undergoing RARP (n = 115) or RRP (n = 358) by 1 of 4 surgeons at a single institution during a 15-month period were retrospectively reviewed. The hospital length of stay (LOS), operative time, hospital charges, reimbursement, and direct and indirect hospital costs were analyzed and compared.

Results: The mean LOS between patients undergoing RARP (1.2 ± 0.6 days) and RRP (1.4 ± 0.8 days) was not significantly different. The operating room supply costs per case were almost 7 times greater for RARP ($2852 ± $528) than for RRP ($417 ± $59; P < .05). The ancillary, cardiology, imaging, administrative, laboratory, and pharmacy costs were not significantly different between the 2 approaches. The mean total costs per case for RARP exceeded the total costs for RRP by 62% ($14 006 ± $1641 vs $8686 ± $1989; P < .05). Payment to the hospital from all sources was nearly equivalent: $10 011 for RRP and $9993 for RARP. Therefore, the average profit for each RRP was $1325 and each RARP lost $4013.

Conclusion: In the present single-institution analysis, the total actual costs associated with RARP were significantly greater than those for RRP and were attributable to the robotic equipment and supplies.
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http://dx.doi.org/10.1016/j.urology.2012.03.020DOI Listing
July 2012

Prostatic adenocarcinoma metastatic to pleomorphic liposarcoma, a "collision phenomenon": report of a case with review of pelvic collision tumors.

Patholog Res Int 2011 22;2011:173541. Epub 2011 Aug 22.

Department of Pathology, University of Pittsburgh Medical Center, A615, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.

"Collision tumor" is an uncommon phenomenon characterized by coexistence of two completely distinct and independent tumors at the same site. Collision tumors have been reported in different sites in the body; however, these are particularly uncommon in the pelvic cavity. A 70-year-old man, with prior history of urothelial and prostate cancer, presented with a large pelvic mass detected on imaging studies. Pathological examination revealed a large liposarcoma with prostatic carcinoma embedded in it. Immunohistochemistry and florescence in situ hybridization studies were performed to reach to a conclusive diagnosis. To the best of our knowledge, this is the second case reported till date. We present the challenges encountered in the diagnosis of this case and review of pelvic collision tumors.
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http://dx.doi.org/10.4061/2011/173541DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3166762PMC
November 2011

Adrenal insufficiency as presenting feature of non-Hodgkin lymphoma.

Can J Urol 2010 Oct;17(5):5411-4

Department of Urology, University of Pittsburgh School of Medicine, Pennsylvania 15213-3232, USA.

Lymphomatous involvement of an adrenal gland during the course of a lymphoma is common, but a primary presentation of adrenal insufficiency in a patient with lymphoma involving both adrenal glands is rare. We describe a 36-year-old man with non-Hodgkin lymphoma (NHL) who presented with adrenal insufficiency. His evaluation consisted of several imaging modalities, including positron emission tomography-computed tomography (PET-CT) scans, which were helpful in defining the extent of disease prior to treatment and in monitoring the patient's response to treatment. Our case illustrates the importance of preoperative evaluation to exclude a lymphoma, particularly in patients with bilateral renal and/or adrenal masses.
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October 2010

Resection of a staggering 36-cm angiomyolipoma.

Can Urol Assoc J 2010 Aug;4(4):E97-9

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Angiomyolipomas (AMLs) are benign tumours characterized by fat, smooth muscle and vascular components. Epithelioid AML is a recognized variant of AML that is comprised of epithelioid smooth muscle cells. We present a case of a 41-year-old male who presented with light-headedness, dizziness, right-sided abdominal pain and, on subsequent computed tomography, was found to have an enormous right kidney mass characteristic of an AML. The patient underwent preoperative selective arterial embolization followed by a right radical nephrectomy. The pathology revealed a 36-cm AML with focal epithelioid features. Although uncommon, AMLs can present as enormous retroperitoneal masses.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911987PMC
http://dx.doi.org/10.5489/cuaj.889DOI Listing
August 2010

Changes in renal function following nephroureterectomy may affect the use of perioperative chemotherapy.

Eur Urol 2010 Oct 25;58(4):581-7. Epub 2010 Jun 25.

Memorial Sloan-Kettering Cancer Center, New York, NY, USA.

Background: Nephroureterectomy alone fails to adequately treat many patients with advanced upper tract urothelial carcinoma (UTUC). Perioperative platinum-based chemotherapy has been proposed but requires adequate renal function.

Objective: Our aim was to determine whether the ability to deliver platinum-based chemotherapy following nephroureterectomy is affected by postoperative changes in renal function.

Design, Settings, And Participants: We retrospectively reviewed data on 388 patients undergoing nephroureterectomy for UTUC between 1991 and 2009. Four institutions were included.

Intervention: All patients underwent nephroureterectomy.

Measurements: All patients had serum creatinine measured before and after surgery. The value closest to 3 mo after surgery was taken as the postoperative value (range: 2-52 wk). Estimated glomerular filtration rate (eGFR) was calculated using the abbreviated Modification of Diet in Renal Disease study equation. eGFR values before and after surgery were compared using the paired t test. We chose an eGFR of 45 and 60 ml/min per 1.73 m(2) as possible cut-offs for chemotherapy eligibility and compared eligibility before and after surgery using the chi-square test.

Results And Limitations: Our cohort of 388 patients included 233 men (60%) with a median age of 70 yr. Mean eGFR decreased by 24% after surgery. Using a cut-off of 60 ml/min per 1.73 m(2), 49% of patients were eligible for chemotherapy before surgery, but only 19% of patients remained eligible postoperatively. Using a cut-off of 45 ml/min per 1.73 m(2), 80% of patients were eligible preoperatively, but only 55% remained eligible after surgery. This distribution persisted when we limited the analysis to patients with advanced pathologic stage (T3 or higher). Patients older than the median age of 70 yr were more likely to be ineligible for chemotherapy both pre- and postoperatively by either definition, and they were significantly more likely to have an eGFR <45 ml/min per 1.73 m(2) postoperatively, regardless of their starting eGFR. This study is limited by its retrospective nature, and there was some variability in the timing of postoperative serum creatinine measurements.

Conclusions: eGFR is significantly diminished after nephroureterectomy, particularly in elderly patients. These changes in renal function likely affect eligibility for adjuvant cisplatin-based therapy. Accordingly, we suggest strong consideration of neoadjuvant regimens.
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http://dx.doi.org/10.1016/j.eururo.2010.06.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3677959PMC
October 2010

Estimating postoperative mortality and morbidity risk of radical cystectomy with continent diversion using predictor equations.

J Urol 2009 Dec;182(6):2619-24

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15232, USA.

Purpose: The POSSUM (Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity) and Portsmouth POSSUM predictor equations are scoring systems validated in the general surgery literature that estimate postoperative morbidity and mortality risk. We tested the validity of POSSUM and Portsmouth POSSUM in patients undergoing radical cystectomy with continent diversion.

Materials And Methods: We retrospectively reviewed physiological parameters, operative parameters, and 30-day morbidity and mortality in 102 patients who underwent radical cystectomy with continent orthotopic diversion, as done by a single surgeon. Predicted morbidity and mortality were calculated using the POSSUM and Portsmouth POSSUM equations. Patients were stratified into risk groups, and observed and predicted outcomes were compared. The accuracy of predictions was assessed using binomial and chi-square analysis.

Results: Observed mortality and morbidity rates were 2.9% and 34.3%, respectively. Predicted morbidity using POSSUM analysis was 46 compared to the 35 observed in our series (p = 0.01). Compared to 3 observed deaths predicted mortality using POSSUM and Portsmouth POSSUM analysis was 13 and 5 (p = 0.002 and 0.30, respectively). There was a significant lack of fit for the POSSUM model to predict morbidity and mortality (p <0.05). However, the mortality risk estimated by Portsmouth POSSUM was not significantly different from the observed mortality rate in our cohort.

Conclusions: In our series the POSSUM equation over predicted morbidity and mortality, and was unsuitable for a comparative audit of patients who underwent radical cystectomy with continent diversion. The Portsmouth POSSUM equation allowed satisfactory prediction of mortality in our cohort and should be evaluated further in larger series.
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http://dx.doi.org/10.1016/j.juro.2009.08.024DOI Listing
December 2009

Partial nephrectomy without hilar control or cooling: longitudinal data over 5 years.

Can J Urol 2009 Oct;16(5):4820-5

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.

Introduction: Partial nephrectomy for the management of small renal masses has become a well accepted technique. Contemporary series have shown its safety and efficacy in well selected patients. We present our experience of partial nephrectomies exclusively without hilar control or parenchymal cooling stratified into imperative and elective patients.

Methods: We retrospectively reviewed our experience in 124 patients who underwent partial nephrectomy between December 1995 and September 2003. Patients were followed with regular radiographic and laboratory studies at 6 months postsurgery and then annually. Renal function was followed by serum creatinine.

Results: Of the 124 patients, 105 were performed without hilar control or renal cooling and met our criteria for analysis. The operation was elective in 78 patients (74%) and imperative in 27 patients (26%). Mean specimen size was 2.8 cm for elective cases and 3.3 cm for imperative cases. The mean estimated blood loss was 606 533 cc and 950 656 cc in elective and imperative cases respectively. Surgical margins were positive in 6.6% with an overall recurrence rate of 3.8%. At a mean follow up time of 31 months and 23 months in the elective and imperative groups respectively, there were no statistically significant differences between baseline and follow up serum creatinine levels in either elective or imperative cases at time intervals of 0-12, 13-24, 25-48 and > 48 months. The intraoperative complication rate was 5.7% and the postoperative complication rate was 4.7% including three patients requiring blood transfusions.

Conclusion: Partial nephrectomy without hilar control or renal cooling is a safe and reliable method of removing small renal tumors. In this cohort, intraoperative blood loss is slightly higher than historical series. However, blood transfusion rates, complications, renal function and oncologic outcomes are comparable to historical series of patients in whom vascular control and renal cooling are used.
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October 2009

Case of a concurrent renal mass and extragonadal retroperitoneal teratoma.

Can J Urol 2009 Apr;16(2):4607-10

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

The presentation of a synchronous renal cell carcinoma (RCC) and germ cell tumor (GCT) is rare. We report the case of a 57 year-old male who presented with a right renal mass and retroperitoneal lymphadenopathy. He underwent a successful right partial nephrectomy and retroperitoneal lymph node dissection, and the subsequent pathology revealed a stage I clear cell RCC and a retroperitoneal teratoma with a component of benign prostatic tissue. We briefly discuss the rarity of this occurrence, the pathological features that helped support this diagnosis, and the likely etiologies of these synchronous lesions.
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April 2009

Management of bilateral synchronous renal cell carcinoma in a single versus staged procedure.

Can J Urol 2009 Feb;16(1):4507-11

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Objectives: The presentation of synchronous bilateral renal lesions is rare. We report our experience with the surgical management of these lesions in both a single and staged procedure.

Methods: We retrospectively reviewed the records of all patients with bilateral synchronous renal lesions who underwent surgical management by one surgeon between 2000-2007. We compared characteristics including pre and postoperative renal function, complication rates, and oncological outcomes between the single and staged cohorts. Data were analyzed using descriptive statistics, Student's t-test, and Fisher's exact test.

Results: A total of 26 patients (73% male, mean age 65.5 +/- 12.2 years) with bilateral synchronous lesions were identified with a mean follow-up of 25.9 +/- 19.7 months. Of these, 18 (69%) were performed as a single procedure, 5 (19%) were done as a staged procedure, and 3 (12%) had only the first part of the staged procedure performed. The single and staged cohorts were comparable in regards to preoperative creatinine (Cr) (1.1 +/- 0.4 mg/dl versus 1.1 +/- 0.2 mg/dl, p = 0.70), postoperative Cr (1.5 +/- 1.0 mg/dl versus 1.4 +/- 0.5 mg/dl, p = 0.73), and median hospital length of stay (HLOS) (5 days versus 4 days). The complication rate was 22% and 20% for the single and staged cohorts, respectively. One patient had a local recurrence and one patient developed metastatic disease in the single cohort versus no local recurrence or metastatic disease in the staged cohort.

Conclusion: In the appropriate setting, surgical management of synchronous bilateral renal lesions can be done safely in a single procedure with comparable outcomes to those done in a staged manner.
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February 2009

Glomus tumor of the kidney: case report and literature review.

Int J Surg Pathol 2011 Jun 22;19(3):393-7. Epub 2009 Jan 22.

Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Philadelphia 15232, USA.

Glomus tumor is a benign mesenchymal neoplasm of the subcutaneous tissue of the distal extremities and head and neck region. Glomus tumor rarely occurs in the visceral organs. This study reports the sixth case of a glomus tumor arising in the kidney in a 62-year-old man who presented with weight loss and an incidental kidney lesion detected by computed tomographic scan. Radiologically, the tumor was difficult to differentiate from a malignant lesion and was therefore excised by partial nephrectomy. The tumor was challenging to diagnose by routine hematoxylin and eosin microscopic examination, necessitating immunohistochemical analysis. Immunoreactivity was demonstrated for smooth muscle actin, vimentin, collagen IV, and CD57, with little to no expression of neuroendocrine, endothelial, or epithelial markers. To date, the tumor has followed a benign course without evidence of local recurrence or metastasis.
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http://dx.doi.org/10.1177/1066896908331233DOI Listing
June 2011

Long-term results of selective partial cystectomy for invasive urothelial bladder carcinoma.

Urology 2008 Sep 13;72(3):613-6. Epub 2008 Jun 13.

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.

Objectives: We reviewed our experience with partial cystectomy to assess local control and survival rates, and to identify pathologic predictors for recurrence.

Methods: From 1995 to 2005, 25 patients with urothelial carcinoma underwent partial cystectomy with curative intent. As protocol, patients with primary solitary muscle-invasive bladder tumors underwent preoperative localized radiotherapy, administration of a single dose of intravesical chemotherapy at the time of partial cystectomy, and postoperative intravesical Bacillus Calmette-Guérin therapy. We reviewed clinical and pathologic data to identify variables associated with disease recurrence.

Results: We analyzed data from 25 patient records meeting review criteria (72% male, mean age 65.1 +/- 9.8 years). At time of transurethral resection of a bladder tumor (TURBT), all had a solitary primary T2 (68%) or T1HG (32%) lesion with no evidence of carcinoma in situ. At follow-up (mean 45.3 +/- 30.7 months), 5-year recurrence-free, disease-specific, and overall survival rates were 64%, 84%, and 70%, respectively. At a mean of 18.0 +/- 15.6 months, 8% of patients experienced intravesical non-muscle-invasive tumor recurrences and were treated with TURBT and intravesical chemotherapy. Twenty percent recurred with locally advanced tumors or visceral metastasis and were treated with systemic chemotherapy, local resection or cystectomy, or both. On univariate analysis, only tumor size at time of partial cystectomy (P = .03) was significantly associated with tumor recurrence.

Conclusions: Partial cystectomy offers adequate control of localized invasive urothelial carcinoma in carefully selected patients with solitary primary tumors. Lifelong follow-up with cystoscopy and abdominal imaging is recommended to detect recurrence.
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http://dx.doi.org/10.1016/j.urology.2008.04.052DOI Listing
September 2008

Renal cell carcinoma containing fat without associated calcifications: two case reports and review of literature.

Urology 2009 Feb 9;73(2):443.e5-7. Epub 2008 Apr 9.

Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.

With rare exceptions, angiomyolipomas can be distinguished from malignant renal masses by the presence of macroscopic fat within the mass. We report 2 cases in which preoperative imaging with computed tomography was interpreted as diagnostic for angiomyolipoma, but the final pathologic analysis revealed clear cell renal cell carcinoma.
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http://dx.doi.org/10.1016/j.urology.2008.02.047DOI Listing
February 2009

Resection of recurrent inferior vena cava tumor after radical nephrectomy for renal cell carcinoma.

Urology 2006 May;67(5):1084.e5-7

Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.

Management of recurrent tumor in the inferior vena cava (IVC) after radical nephrectomy is surgically challenging. We report 3 cases of recurrent renal cell carcinoma within the IVC managed by three different surgical techniques. One patient was treated with tumor thrombus removal and primary cavotomy closure. The second patient was treated with IVC ligation and removal without vascular reconstruction. A third patient was treated with IVC wall excision and placement of a bovine pericardium graft. Although technically difficult, repeat resection of IVC tumor recurrence after nephrectomy for renal cell carcinoma is an acceptable method of treatment.
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http://dx.doi.org/10.1016/j.urology.2005.10.058DOI Listing
May 2006

Hand-assisted laparoscopic nephroureterectomy with open cystotomy for removal of the distal ureter and bladder cuff.

J Endourol 2005 Oct;19(8):973-5

Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213-3232, USA.

Background And Purpose: While performing laparoscopic nephroureterectomy, different techniques are used for removal of the distal ureter and bladder cuff. We present a series of patients with urothelial carcinoma of the renal pelvis or ureter who underwent hand-assisted laparoscopic nephroureterectomy (HALNU) with open cystotomy for removal of the distal ureter and bladder cuff.

Patients And Methods: From January 2000 to August 2004, 34 patients underwent HALNU. The hand-port device was placed in a lower-midline infraumbilical incision in all cases. After laparoscopic removal of the kidney and ureter down to the bladder, the hand port incision was extended caudally to allow open cystotomy. Intravesical dissection was performed at the ureteral orifice, and the bladder cuff and distal ureter were removed in a traditional open fashion.

Results: The mean operative time was 317 +/- 150 (SD) minutes, but the median operative time was 247 minutes. The mean estimated blood loss was 252 +/- 146 mL. The mean length of stay was 7.6 +/- 6.0 days, but the median stay was 5 days postoperatively (range 3-25). The mean morphine equivalent required postoperatively was 33 +/- 22 mg. The time of Foley catheter removal ranged from 3 to 15 days (mean 6.1 +/- 3.8 days), with no cases of extravasation by cystography at removal. Within a mean follow-up of 13.9 months, no recurrence of urothelial carcinoma was seen at the site of the excised ureteral orifice.

Conclusion: A HALNU utilizing an open cystotomy for removal of the entire distal ureter with a bladder cuff provides excellent oncologic control while not adding significantly to the operative time or the morbidity of the procedure.
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http://dx.doi.org/10.1089/end.2005.19.973DOI Listing
October 2005

15-year experience with the management of extrinsic ureteral obstruction with indwelling ureteral stents.

J Urol 2004 Aug;172(2):592-5

Department of Urology, University of Pittsburgh Medical Center, Pennsylvania, USA.

Purpose: We assessed the success of retrograde placement of indwelling ureteral stents in the management of ureteral obstruction due to extrinsic compression.

Materials And Methods: Between July 1987 and December 2002 adequate followup was available for 101 patients who underwent primary retrograde ureteral stenting for extrinsic ureteral obstruction. Mean age at presentation was 61.4 years (range 33 to 90). Chart review was performed on all patients for primary diagnosis, symptomatology, degree of hydronephrosis, creatinine levels (baseline, treatment and posttreatment), location of compression, size and number of stents used, progression to percutaneous nephrostomy tube (PNT), stent failure, days to stent failure, post-stent therapy and status at last followup.

Results: Mean length of followup was 11 months (range 1 to 127). In 101 patients 138 ureteral units (UU) were stented. Total stent failure occurred in 41 (40.6%) patients and 58 (42.0%) UU. A total of 40 (29.0%) UU required PNTs at a mean of 40.3 days (range 0 to 330) with 18 PNTs placed in less than 1 week. Cases of stent failure that did not undergo PNT placement included 18 (13.0%) UU at a mean of 52.4 days (range 3 to 128). A total of 90 (89.1%) patients had metastatic cancer at stenting with 32.2% dead at 5.8 months (range 1 to 32). Univariate and multivariate analyses identified cancer diagnosis, baseline creatinine greater than 1.3 mg/dl and post-stent systemic treatment as predictors of stent failure. Proximal location of compression and treatment creatinine greater than 3.11 mg/dl were marginal predictors of failure on univariate analysis, while proximal location of obstruction was also marginally significant on multivariate analysis. No predictors were identified for early stent failure (less than 1 week).

Conclusions: At almost 1 year followup stent failure due to extrinsic compression occurred in nearly half of treated patients. Analysis of data revealed a diagnosis of cancer, baseline mild renal insufficiency and metastatic disease requiring chemotherapy or radiation as predictors of stent failure. Managing extrinsic compression by retrograde stenting continues to be a practical but guarded decision and should be tailored to each patient.
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http://dx.doi.org/10.1097/01.ju.0000130510.28768.f5DOI Listing
August 2004

Surgical enucleation for the treatment of renal tumors.

Urol Int 2003 ;71(2):184-9

Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Introduction: We analyzed our institutional experience with surgical enucleation for the primary treatment of small renal tumors.

Materials And Methods: Patient demographics, histological features, effect of different types of vascular control and outcome from surgery were analyzed in 45 patients. A majority of the tumors (67%) were diagnosed incidentally.

Results: All were stage T(1), 77% were low grade (I-II) and 23% were high grade (III-IV). Complication occurred in 12% of patients. At a mean follow-up of 34 months (range 7-97), 28 of 33 patients (84%) with malignant tumors were alive without evidence of disease. One patient with a solitary kidney developed recurrent tumor after enucleation that required nephrectomy. Mean operative time was significantly lower with the compression technique versus direct vascular control (164 +/- 12 min vs. 233 +/- 15 min, p = 0.002). There were no differences in outcome between the two techniques.

Conclusions: Surgical enucleation is a safe and viable procedure for the treatment of small renal tumors. Manual compression of the kidney appears to be at least as effective as clamping of the renal vessels in obtaining vascular control during the procedure and is more expeditious.
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http://dx.doi.org/10.1159/000071844DOI Listing
November 2003

Cadaveric renal transplantation using kidneys from donors greater than 60 years old.

Clin Transplant 1992 Jan;6:77-80

Division of Urologic Surgery/Renal Transplantation Department of Surgery, University of Pittsburgh, Presbyterian University Hospital, Pittsburgh, PA.

Transplantation of kidneys from donors over the age of 60 yr is controversial. However, as the demand for cadaveric kidneys far exceeds the supply, exploration of the usefulness of kidneys outside the currently accepted donor pool is necessary. Between January 1987 and July 1989, 31 (5.5%) of the 558 cadaveric renal transplants performed at the University of Pittsburgh utilized organs from donors older than 60 yr. Median recipient age was 41 yr (range 24-71 yr); 4 recipients were diabetic and 6 had panel-reactive antibody levels greater than 20% at the time of transplant. All recipients were treated with cyclosporine, prednisone and azathioprine. The 1-yr allograft survival was 65% which was less than but not statistically different from the graft survival of 80% in a retrospective selected control group who received grafts from younger donors aged 11 to 50 yr. However, the 1-yr graft survival of older donor kidneys with cold ischemia time greater than 48 hours was 38%, which was significantly poorer than the 78% 1-yr graft survival seen with cold ischemia times less than 48 h (p=0.04 Breslow). The mean serum creatinine was significantly higher in the older donor kidneys at 1, 3, and 12 months post-transplant than in the control kidneys even when kidneys with greater than 48 h of cold ischemia time were excluded. In summary, transplantation of cadaver kidneys from donors older than 60 yr results in acceptable graft survival rates. These kidneys are more susceptible to cold ischemic injury and function with a higher serum creatinine than kidneys from younger donors. Expansion of the donor pool by the use of older donor kidneys in selected recipients could have an impact on alleviating the chronic national cadaver kidney shortage.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035838PMC
January 1992