Port Site Metastasis and Tumor Seeding in Oncologic Laparoscopic Urology

Real World Analysis of Peritoneal Metastasis From Renal Cell Carcinoma. Meet-Uro27

BACKGROUND

Peritoneal metastases (PM) have been reported in approximately 1% of patients with metastatic Renal Cell Carcinoma (mRCC). Outcome data are limited due to the rarity of this metastatic site. Therefore, the aim of our study is to describe renal cell carcinoma (RCC) patients with PM treated as per clinical practice.

MATERIALS AND METHODS

Baseline characteristics and outcome data of patients with PM from RCC were retrospectively collected from 18 Italian oncological referral centers adhering to the Meet-Uro group, from January 2016 to January 2023.

RESULTS

We collect 81 RCC patients with PM. 78/81 received systemic treatment, 3/81 only best supportive care. First line treatment included tyrosine-kinase inhibitors (TKI) (46/78), ImmuneOncology (IO)-TKI (26/78) and IO-IO (6/78), with different Objective Response Rate (ORR) (43.4% in TKI monotherapy group vs 50% in IO-TKI group, respectively) and Disease Control Rate (DCR) (60.8% in TKI treated patients vs. 76.9% in IO-TKI treated patients). Median PFS was 6.4 months (95%CI 4.18-14.8) in patients treated with TKI monotherapy vs 23.7 months (95%CI 11.1-NR) in patients treated with IO-TKI (p < 0.015). The median OS (mOS) was 22.7 months (95%CI 13.32 - 64.7) in the TKI monotherapy group vs 34.5 mo (95%CI NR-NR) in the IO-TKI group with 53.8% of patients alive at 1 years in the latter group, (p < 0.16). Primary refractory patients were 36.9% for TKI and 15.3% for IO-TKI. According to International Metastatic renal cell carcinoma Database Consortium (IMDC) score, mPFS and mOS were consistent among risk categories. Median PFS was 36.6 months (95%CI 10.9-NR) for good risk patients compared to 10 months (95%CI 7.5-29.8) for intermediate risk and 2.96 months (95%CI 2.43-11.28) for poor risk population (p < 0.0005) whereas mOS was NR (95%CI 28.65-NR) for good risk patients compared to 35.3 months (95%CI 24.6-NA) and 12.4 months (95%CI 3.52-NR) for intermediate and poor risk population, respectively, (p < 0.0002). Only 34/78 (43.5%) received a second line treatment that was TKI (ORR 8.3% and DCR 41.6%) or IO (ORR 18.1% and DCR 40.9%).

CONCLUSION

We report one of the largest case series regarding PM from RCC. Characteristics of patients suggest a more aggressive behavior of PM from mRCC. Outcome data suggest that TKI-IO as first line treatment, and TKI as second line, confirm their activity for these patients with dismal prognosis.

Single omental metastasis of renal cell carcinoma after radical nephrectomy: A case report

BACKGROUND

Renal cell carcinoma (RCC) is the third most common malignancy in the genitourinary tract. The lungs, bone, lymph nodes, liver, and brain are common metastatic sites of RCC. However, there is limited literature on single omental metastasis of RCC.

CASE SUMMARY

We present the case of a 44-year-old man with single omental metastasis of RCC after laparoscopic radical nephrectomy. Pathological diagnosis of the resected left kidney revealed pT3a clear cell RCC (Fuhrman grade III). At 6 mo postoperatively, abdominal computed tomography revealed a 12-mm enhancing nodule in the left lower peritoneum. At 7 mo after initial operation, laparoscopic removal of the left omental nodule was performed. The pathological results indicated metastatic clear cell RCC. Currently, the patient is being treated with adjuvant pembrolizumab.

CONCLUSION

Omental metastasis of RCC owing to laparoscopic radical nephrectomy is rare. Urologists should be aware of the diverse nature of RCC.

Retroperitoneal drop metastases following robotic partial nephrectomy for renal cell carcinoma

Rare retroperitoneal recurrence of clear cell renal cell carcinoma highlights the risk of tumor violation during surgery. A 61-year-old female with recurrent RCC in the retroperitoneum is presented six years after partial nephrectomy. Initial surveillance CT revealed a renal cyst and subsequent imaging confirmed clear cell RCC. Multiple small lesions indicated retroperitoneal recurrence. Surgical excision confirmed metastatic clear cell RCC. The proximity of the recurrence to the lower pole of the primary tumor suggests tumor violation as the cause. Respecting tumor boundaries during surgery is crucial to prevent metastasis and improve patient survival.

Sclerosing encapsulating peritonitis in a dog with pancreatic ductal adenocarcinoma

BACKGROUND

Sclerosing encapsulating peritonitis (SEP) is a rare clinical syndrome characterised by fibrosis and thickening of the peritoneum with massive adhesions of the abdominal organs. In humans, abdominal tumours, such as pancreatic adenocarcinoma, can be underlying diseases of SEP. This report describes a case of SEP in a dog with pancreatic ductal adenocarcinoma.

CASE PRESENTATION

An 11-year-old male neutered French Bulldog presented with chronic vomiting. Ultrasonography revealed a mass in the centre of the abdomen. A small amount of ascites, interpreted as modified transudate, was present in the abdominal cavity. Computed tomography (CT) revealed peritoneal effusion with a thickened peritonium. Laparoscopy revealed a large nodular lesion occupying the central portion of the abdomen, continuous with the falciform ligament. Histological examination of the biopsy specimens of the mass, abdominal wall, and gastric peritoneum revealed marked fibroplasia with mild lymphoplasmacytic infiltrates. Based on these results, a tentative diagnosis of early stage sclerosing encapsulating peritonitis (SEP) was made. Prednisolone and tamoxifen were administered with the expectation of ameliorating SEP, however, the dog died 61 days post diagnosis. At autopsy, the intestinal loop and mesentery were encased in the fibrous membrane, which is a typical finding in SEP. Histopathology and immunohistochemistry of the samples obtained at autopsy supported the diagnosis of pancreatic ductal adenocarcinoma with peritoneal dissemination and distant metastasis with desmoplasia. The unexpectedly hardened skin, where previously laparoscopic ports were inserted, histologically contained the same carcinoma cells with desmoplasia.

CONCLUSIONS

To the best of our knowledge, this is the first report of canine SEP with pancreatic ductal adenocarcinoma that also caused metastasis to port insertion sites as well as distant organs.

Outcomes for Atypical Tumor Recurrences Following Minimally Invasive Kidney Cancer Operations

Background

We managed a cohort of patients treated with minimally invasive surgery (MIS) for a kidney tumor presenting with atypical tumor recurrence (ATR) involving port sites, intraperitoneal carcinomatosis, and nephrectomy bed/perinephric tumor implants.

Objective

To determine the clinical characteristics, management, and oncologic outcomes for patients with localized renal cell carcinoma (RCC) who develop ATR following curative-intent MIS for partial or radical nephrectomy.

Design, setting, and participants

The study cohort comprised patients from 1999 to 2021 with localized RCC managed at Memorial Sloan Kettering Cancer Center (New York, NY, USA) after MIS for partial or radical nephrectomy who developed ATR. Outcome measurements and statistical analysis: We collected data on clinicopathologic characteristics, treatments, time to ATR, and overall survival.

Results and limitations

The median age of the 58 RCC patients was 61 yr. Forty-one patients (71%) were male, 26 (45%) had robot-assisted operations, and 39 (67%) had clear cell RCC. Twenty-nine patients had stage pT1 disease (50%) and ten (17%) had positive surgical margins. The most common ATR site was perinephric/nephrectomy bed implants (n = 28, 48%). Management included: surgical resection alone (n = 11, 19%), systemic therapy alone (n = 12, 21%), surgical resection and systemic therapy (n = 17, 29%), and palliative care (n = 8, 14%). At median follow-up of 59 mo (interquartile range [IQR] 28–92), the median time to ATR was 12 mo (IQR 5–28). Overall survival at 5 yr was 69.0% (95% confidence interval 57.4–83.1%) with only nine patients alive with no evidence of disease. Limitations include the potential for referral, detection, and selection biases, as well as uncertainty regarding the true incidence of ATR.

Conclusions

ATR following MIS for partial or radical nephrectomy is an understudied, poor prognostic event which leads to a heavy treatment burden. Further investigation into its etiology and means of prevention is warranted.

Patient summary

Patients experiencing recurrence of kidney cancer in an atypical site require a heavy treatment burden and have a guarded overall prognosis. Continued research is needed to determine the precise incidence of these recurrences and identify methods for mitigating them.

Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors

Background

The Children's Oncology Group recommends upfront resection of Wilms tumor (WT), however, unique scenarios warrant neoadjuvant chemotherapy and delayed resection. We hypothesized that in the context of neoadjuvant chemotherapy, minimally invasive surgery (MIS) to resect WT achieves equivalent oncologic fidelity and better maintains therapy schedules.

Methods

A retrospective analysis of WT treated between 2010-2021 at a free-standing children's hospital was performed. Patient and disease specific characteristics were collected, and pre-resection tumor volumes (TV) were calculated. Impact of MIS or open resection on oncologic fidelity and time to resume chemotherapy was analyzed.

Results

For the study period, 62 patients were treated for 65 WT, and 14 patients (22.6%) received neoadjuvant chemotherapy to treat 17 WT (26.2%): 7 Stage I (all predisposition syndromes), 2 stage III, 7 stage IV, and 1 stage V (bilateral). MIS was utilized to resect 6 WT from 5 patients. For partial nephrectomy, pre-resection TV was 0.38 ml if MIS and 10.38 ml if open ( P = .025). For radical nephrectomy, pre-resection TV was 31.58 ml if MIS and 175.00 ml if open ( P = .101). No significant differences between surgical approach were detected regarding pathologic variables or survival. Epidural use was significantly greater with open procedures ( P = .001). Length of stay was 2.00 days after MIS compared to 6.00 for open resection ( P = .004). Time to resume chemotherapy was 7.00 days after MIS versus 27.00 for open ( P = .004).

Conclusion

After neoadjuvant chemotherapy for WT, MIS partial and radical nephrectomies achieved equivalent oncologic fidelity, reduced epidural use and post-operative stays, and better maintained adjuvant therapy timelines when compared to open resections.

Complications of renal interventions: a pictorial review of CT findings

A number of potential vascular and non-vascular complications can arise from surgical, extracorporeal shock wave lithotripsy, radiotherapy and radiological renal interventions, including percutaneous image-guided biopsy and drainage. Computed tomography scan is usually one of the first and most important diagnostic imaging examinations requested when a potential complication is suspected. There are a wide range of common and uncommon potential complications from renal interventions. An understanding of underlying risk factors is important to reduce potential complications from renal intervention. Radiologists play a crucial role in recognising and diagnosing post-renal intervention complications on computed tomography scans, which could significantly improve the patient’s prognosis.

[Retrovesical recurrence of renal cell carcinoma 14 years after laparoscopic nephrectomy: a case report]

Local recurrence or metachronous distant metastasis of renal cell carcinoma mostly occurs in the first five years after radical or partial nephrectomy. Nevertheless, late local recurrences or metachronous metastases are regularly observed. The most common metastatic sites are lung and bones, although unusual metastatic sites are also possible. We present the case of a 70-year-old patient with a solitary recurrence of a clear renal cell carcinoma in retrovesical location after a relapse-free survival of 14 years. We performed cystoprostatectomy with an ileal conduit, resecting the tumour completely (in sano). The long-term prognosis of the patient cannot be estimated as yet.Despite the fact that a solitary and very late recurrence of a renal cell carcinoma in retrovesical location is extremely rare, late recurrence is a specific characteristic of renal cell carcinoma. Therefore, long-term follow-up for at least 15 years is required. Curative surgical resection is the treatment of choice for such late solitary recurrences.

Trocar site recurrence after robotic partial nephrectomy to treat of renal cell carcinoma

Introduction:

Wound seeding during surgical excision of malignant tumor is known problem in the oncologic surgery. Trocar site recurrence (TSR) is well described in laparoscopic oncologic surgery. Little has been reported about TSR after robotic partial nephrectomy (RPN) performed for renal cell carcinoma (RCC). Here, we report on the incidence of TSR and demonstrate the presentation of this type of RCC recurrence.

Patients and Methods:

We reviewed prospectively collected data about patient who underwent RPN at our institute from September 2009 to March 2018. We reviewed the medical record of the patients who had the diagnosis of RCC on the final pathology. We identified the patient with TSR and demonstrated their presentation and treatment along with the outcome.

Results:

A total of 335 patients underwent RPN during the study period for renal mass. Two hundred and sixty-nine (80.3%) patients were found to have RCC on the final pathologic evaluation of their mass. We identified two patients (0.7% of all the RCC in the study) who developed TSR during an average follow-up period of 31 months (ranging from 18 to 72 months). The first recurrence appeared 18 months after the surgery. The second recurrence presented 72 months after RPN. Both cases underwent open surgical excision of the trocar site, in which the recurrence appeared.

Conclusion:

TSR is potential type of RCC recurrence after RPN, though it is rare and underreported. Special attention should be given to examine the trocar site during the surveillance follow-up of RCC treated with RPN. It can develop up to 72 months after the surgery.

Efficacy of povidone-iodine against accidental tumor incision during nephron-sparing surgery: experimental study in patients with renal cell carcinoma

Purpose

Accidental tumor incision (ATI) can occur during nephron-sparing surgery (NSS) and correlates with recurrence and metastasis. This study investigated risk factors of intraoperative ATI in renal cell carcinoma (RCC) patients after NSS and the efficacy of povidone-iodine for ATI.

Methods

A retrospective analysis was performed on 150 consecutive stage I (pT1N0M0) RCC patients who underwent NSS at The Second Hospital of Tianjin Medical University between May 2010 and October 2015 for the causes of ATI. Furthermore, in vitro experiments investigated whether tumor cells remained on the surface of scissors and the effect of treatment with povidone-iodine on the number of remaining 786-O cells.

Results

Among the 150 cases, 15 showed ATI, of which three suffered local recurrence during a median follow-up of 56 months. Pseudocapsules, satellite nodules, and renal cystic tumors were observed in ATI cases. In vitro experiments showed that tumor cells remained on the surface of scissors after ATI during NSS and that 0.5% povidone-iodine effectively killed tumor cells in 30 minutes.

Conclusions

The probability of ATI is high in patients with complex-type RCC during NSS. ATI potentially increases the chance of metastasis and local recurrence, and 0.5% povidone-iodine kills tumor cells more effectively than distilled water.

Laparoscopic port-site metastasis as the manifestation of neuroendocrine prostate cancer: Case report and literature review

Introduction

The neuroendocrine differentiation in prostate cancer is a rare entity that may occur as de novo, or as a result of treatment with androgen deprivation. It is characterized by its rapid progression and poor prognosis, without elevation of the prostate specific antigen (PSA), which is why it is often diagnosed by biopsy of a site of metastasis; there are no established treatment regimens. In this case, metastasis was presented as implantation to a laparoscopic port. These implantations subsequent to laparoscopic procedures in prostate cancer are very rare, with an incidence between 0.09 and 0.7%. The exact pathogenesis of the tumor implantation at the insertion site is not clear, there are several theories.

Materials and methods

We describe the case of a 53-year-old patient with a diagnosis of prostate adenocarcinoma who underwent laparoscopic radical prostatectomy plus lymphadenectomy, staged as PT3BN0 (0/6) M0R1 Gleason 4 + 5. The patient never had negative PSA levels after the treatment, and presented elevation of the same, so radiotherapy was performed at a dose of 66 Gy plus antiandrogen deprivation therapy with leuprolide acetate for 30 months, with a decrease in PSA to 0.011 ng/ml, which remained stable. After 3 months of hormonal therapy, he presented with an umbilical mass on the scar of the laparoscopic port; ultrasound and computed tomography were performed, showing a solid mass dependent of the umbilical upper edge with a defect in the abdominal wall of 3 cm, as well as hepatic nodules suggestive of metastatic lesions and peritoneal implantations.

Results

A biopsy of the abdominal wall lesion was performed, documenting poorly differentiated carcinoma with an immune-profile consistent with neuroendocrine carcinoma; immunohistochemistry showed strong and diffuse positivity with cytokeratin cocktail and chromogranin. In conjunction with oncology, treatment with chemotherapy was decided. He received six cycles of cisplatin and etoposide, with progression of his disease and death seven months after diagnosis.

Conclusions

Prostate cancer with neuroendocrine differentiation is a rare entity, usually occurring in the castration resistance stage, with poor prognosis and survival of less than 1 year. It presents as clinical and radiological progression without elevation of the PSA. Although it is very rare, the possible causes include tumor implantation in laparoscopic ports and/or open surgery scars, so caution and certain precautions must be taken when performing radical prostatectomy. In case of suspecting a tumor with neuroendocrine differentiation, biopsy and immunohistochemistry studies should be performed in order to clarify the diagnosis and provide a multimodal treatment based on surgery, radiotherapy and chemotherapy.

Port-Site Metastasis of Undiagnosed Pancreatic Adenocarcinoma After Laparoscopic Radical Prostatectomy: Case Report and Literature Review

Background: Laparoscopic port-site metastases remain rare for urologic tumors, despite the increasing use of laparoscopic techniques on the approach of urologic malignancy. Herein, we report a case of port-site mass after laparoscopic radical prostatectomy whose immunohistochemistry demonstrated metastasis from a pancreatic lesion.

Case Presentation: A 62-year-old man presented to our ambulatory clinic with an elevated prostate-specific antigen (PSA) of 7.7 ng/mL. Transrectal biopsies revealed prostate cancer Gleason 6 (3 + 3) on the right side. He was subjected to a transperitoneal laparoscopic radical prostatectomy at our institution. The PSA on postoperative week 6 was 0.04 ng/mL. Three months after the surgery, he comes back to the emergency department complaining of an abdominal pain especially on the right flank. Our examination of the abdomen revealed a small palpable mass at the right upper port-site scar. Computed tomography of the abdomen and pelvis, with contrast, revealed a hypodense nodular lesion located on the abdominal wall near the upper port site and adjacent to the pancreatic tail. An excisional biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. Immunohistochemistry demonstrated metastasis from a pancreatic lesion.

Conclusion: Port-site mass after laparoscopic radical prostatectomy is uncommon especially in quite different tumors like this one with Gleason score 6 (3 + 3). Generally, port-site recurrences after a urologic laparoscopic surgery are uncommon and are not associated with diffused peritoneal carcinomatosis. Therefore, in this situation, another tumor site should be investigated as the primary source.

Images: Port site recurrence on followup imaging after adrenalectomy for adrenocortical carcinoma - first indicator of carcinomatosis

Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy of the adrenal cortex. Complete surgical resection is essential for localized tumours because ACC is highly resistant to chemotherapy and radiotherapy.1 Use of a laparoscopic approach for adrenalectomy in the setting of a confirmed or suspected ACC is controversial because it is unknown if laparoscopy provides equivalent oncological outcomes compared to an open approach.

Viability of Airborne Tumor Cells during Excision by Ultrasonic Device

Background. Laparoscopic surgery has become more widely used, but peritoneal dissemination and port-site metastasis have been reported to occur in these surgeries. One reason for these problems is the ultrasonically activated scalpel (UAS) used for laparoscopic surgery. This study aimed to investigate the viability of airborne cells released during cancer dissection using a UAS. Methods. Flank tumors measuring about 2 cm were induced in male NOD-Cg-Rag1^tm1MomIL2rg^tm1wjl/SzJ mice by subcutaneous injection of 1 × 10⁶ HepG2 cells. Dissection was performed with UAS (in high or low power modes) and PowerStar bipolar scissors. The mist of released tissue was collected in cell culture medium. The viability of the cellular material was assessed with trypan blue exclusion cell counting, counting after immunofluorescence staining, and flow cytometric analysis. Results. Large quantities of cellular debris were trapped in the tissue dispersed by both devices. In all experiments, there were significantly more viable cells produced by the UAS in high power mode. By using suction at the excision site, the number of viable cancer cells was reduced. Conclusions. This study demonstrates that viable cancer cells can be released into the nearby environment during tumor ablation with a UAS.

Is It Safe to Use the Same Scissors After Accidental Tumor Incision During Partial Nephrectomy? Results of In Vitro and In Vivo Experiments

PURPOSE

When accidental tumor incision (ATI) has occurred during open partial nephrectomy (PN), scissors can be changed easily. In contrast, during laparoscopic partial nephrectomy (LPN) or robotic partial nephrectomy (RPN), it is time consuming and expensive especially during RPN to change scissors. This study investigates whether tumor cells remain on the surface of scissors after ATI during PN and investigates an alternative way to avoid changing scissors during LPN and RPN.

MATERIALS AND METHODS

We subcutaneously injected 786-O renal-cell carcinoma (RCC) cells containing enhanced green fluorescent protein (786-O/EGFP) into six mice. We incised the subsequent tumor with straight or Microline scissors. The scissor surfaces were then examined by microscopy for detection of EGFP immunofluorescence. In addition, the scissor surfaces were treated in three ways: no electrical treatment, electrical treatment of 20 W for 5 seconds, and electrical treatment of 40 W for 5 seconds.

RESULTS

Strings or dots of EGFP were detected on every scissor surface, and 786-O/EGFP cells were alive and able to proliferate in medium in 33% of the nonelectrically treated samples. However, no 786-O/EGFP cells treated with monopolar electricity survived. In another experiment, we also found that 100 786-O cells placed on scissor surfaces could not survive after the same electrical treatment.

CONCLUSIONS

RCC cells remained on scissors after ATI; however, electrical treatment eliminated tumor cells, possibly preventing recurrence or metastasis after surgery.

Port-site metastasis as a primary complication following retroperitoneal laparoscopic radical resection of renal pelvis carcinoma or nephron-sparing surgery: A report of three cases and review of the literature

The present study reports the clinical data of two patients with renal pelvis carcinoma and one patient with renal carcinoma who developed port-site metastasis following retroperitoneal laparoscopic surgery. The current study aimed to identify the cause and prognosis of the occurrence of port-site metastasis subsequent to laparoscopic radical resection of renal pelvis carcinoma and nephron-sparing surgery. Post-operative pathology confirmed the presence of high-grade urothelial cell carcinoma in two patients and Fuhrman grade 3 renal clear cell carcinoma in one patient. Port-site metastasis was initially detected 1–7 months post-surgery. The two patients with renal pelvis carcinoma succumbed to the disease 2 and 4 months following the identification of the port-site metastasis, respectively, whereas the patient with renal carcinoma survived with no disease progression during the targeted therapy period. The occurrence of port-site metastasis may be attributed to systemic and local factors. Measures to reduce the development of this complication include strict compliance with the operating guidelines for tumor surgery, avoidance of air leakage at the port-site, complete removal of the specimen with an impermeable bag, irrigation of the laparoscopic instruments and incisional wound with povidone-iodine when necessary, and enhancement of the body's immunity. Close post-operative follow-up observation for signs of recurrence or metastasis is essential, and systemic chemotherapy may be required in patients with high-grade renal pelvis carcinoma and renal carcinoma in order to prolong life expectancy.

Isolated port-site metastasis after surgical staging for low-risk endometrioid endometrial cancer: A case report

Port-site metastases (PSMs) are well-known potential complications of laparoscopic surgery for gynaecologic malignancies. The present case study reports PSM following laparoscopic surgery for Stage IA Grade 1 endometrioid endometrial cancer (EEC). The recurrence developed within 7 months following primary surgery and required surgical excision followed by adjuvant chemo-radio therapy. After 9 months, the patient remains disease-free. PSMs are rare complications following laparoscopic surgery. Amongst the 23 cases of endometrial cancer PSMs reported so far, only 4 followed EEC Stage IA Grade 1-2. The present study reports a rare case of PSM after Stage IA Grade 1 EEC. The clinical and prognostic relevance of PSMs has not been identified so far; and it is not known whether PSMs represent a local recurrence or a systemic recurrence. Surgeons should be aware that even low-risk EEC may be followed by PSMs and should take steps to prevent these rare recurrences.

Impact of Accidental Tumor Incision During Laparoscopic Partial Nephrectomy on the Oncologic and Clinical Outcomes

BACKGROUND

To investigate the impact of accidental tumor incision (ATI) during laparoscopic partial nephrectomy (LPN) on the treatment outcome of LPN and to determine the predictive factors for ATI.

PATIENTS AND METHODS

Consecutive 156 patients with renal tumors suspicious of renal cell carcinoma cT1N0M0 undergoing laparoscopic partial nephrectomy at Yokohama City University between May 2003 and November 2014 were retrospectively evaluated. The analyzed clinical factors included maximum tumor diameter, the R.E.N.A.L. Nephrometry Score, occurrence of ATI during surgery, and the postoperative pathological findings including the presence of a pseudocapsule. Port site metastasis, tumor seeding, and local recurrence were investigated by routine follow-up computed tomography during the postoperative period.

RESULTS

Among enrolled 156 procedures, 12 (7.7%) showed ATI during surgery. Positive surgical margin and local tumor recurrence were observed in 5 and 1 cases in the non-ATI group, respectively, as compared with in no cases in the ATI group. Port site metastasis or tumor seeding was not observed in either group. Multivariate analysis indicated that pseudocapsule formation significantly correlated with ATI (P = .022) and that maximum tumor diameter was a possible predictor of ATI (P = .054).

CONCLUSION

To our knowledge, there are no previous studies to evaluate the impact of ATI, and we here, for the first time, report that the risk of ATI is influenced by the presence of a pseudocapsule, and, to some degree, by the tumor size. Moreover, we also show that ATI during laparoscopic partial nephrectomy is not necessarily associated with poor outcomes such as local tumor recurrence.

Port site and peritoneal metastases after robot-assisted radical prostatectomy

INTRODUCTION

Port site metastasis after minimally invasive urologic surgery is a rare event despite the widespread utility of laparoscopic techniques in the management of urologic malignancies. Herein, we report a case of port site metastasis after robot-assisted radical prostatectomy.

PRESENTATION OF CASE

A currently 77-year-old male patient, who was diagnosed with cT2c, Gleason 7 (4+3) prostate adenocarcinoma in our clinic back in 2009, had undergone robot-assisted radical prostatectomy elsewhere. Histopathological examination revealed pT3a, Gleason 9 (4+5) disease. Lymph nodes were negative, however surgical margins were positive on the right side. PSA recurred after 9 months and maximal androgen blockade was initiated. Despite antiandrogenic manipulations, PSA reached 0.83ng/ml, 33 months postoperatively. Concurrently, we noticed a palpable anterior abdominal mass which demonstrated metabolic hyperactivity on PET scanning. Percutaneous biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. PSA did not normalize after the complete excision of the metastatic focus. Repeated PET scan revealed multiple implants on the peritoneal surfaces of various organs.

DISCUSSION

Port site and peritoneal metastasis of prostate cancer after robot-assisted radical prostatectomy has not been reported so far. This peculiar dissemination pattern is most probably the result of tumor biology and perioperative factors.

CONCLUSION

Although encountered extremely rarely, surgeons should be aware of the possibility of port site and/or peritoneal metastases after minimally invasive radical prostatectomy.

Specimen processing during laparoscopic renal surgery: a review of techniques and technologies

Laparoscopic surgery has well-defined benefits for patients and has become accepted over time as a standard access strategy for the management of benign and malignant urologic diseases. Unlike in open surgery, the surgeon is often faced with the additional challenges of specimen retrieval and extraction at the end of laparoscopic extirpative procedures. This final step often requires significant laparoscopic skill to entrap and safely extract the laparoscopic specimens. Failure to apply safe exit steps at the end of a laparoscopic procedure may lead to significant morbidity. The aim of this review is to explore the different techniques and technologies available for laparoscopic kidney retrieval, entrapment and safe extraction.

Tumor seeding incidentally found two years after robotic-Assisted radical nephrectomy for papillary renal cell carcinoma. A case report and review of the literature

INTRODUCTION

Port-site metastasis or peritoneal spread after laparoscopic surgery for urological malignancies is a rare phenomenon accounting for 0.09% and 0.03% of the cases respectively.

PRESENTATION OF CASE

We present a case of tumor seeding in the omentum found in a female patient after previous transperitoneal robotic-assisted radical nephrectomy (RARN) for papillary renal cell carcinoma (RCC). Two years after the robotic operation, the patient was diagnosed with cervical clear cell carcinoma and underwent radical hysterectomy with lymphadenectomy and omentectomy. A neoplastic omental nodule was incidentally identified intraoperatively. Pathological characteristics and immunohistochemistry revealed features of papillary RCC. Two years after the hysterectomy, the patient is clinically cancer free, without any adjuvant therapy for her cervical cancer.

DISCUSSION

To the best of our knowledge, we report the first case of tumor seeding in the omentum following RARN for organ confined low grade papillary (T2aN0M0) RCC. No risk factors that could explain the tumor seeding were identified. The neoplastic cells had a low proliferative index (Ki-67<5%) and a decreased capability to metastasize.

CONCLUSION

Tumor seeding as a result of robotic assisted laparoscopic nephrectomy, although rare, might represent a novel way of tumor inoculation deprived of or with low malignant potential.

Camera-port site metastasis of a renal-cell carcinoma after robot-assisted partial nephrectomy

BACKGROUND AND PURPOSE

Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN.

PATIENT AND METHODS

A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed.

RESULTS

Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction.

CONCLUSION

PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.

Is port site metastasis a result of systemic involvement?

Aims:

Port site metastasis (PSM) is an unwelcome consequence of laparoscopy for oncological procedures with uncertain etiology. We present the clinical evidence to prove that PSM is likely to be due to the hematogenous spread of tumor cells.

Materials and Methods:

Six cases of port site metastasis, four following laparoscopic radical nephrectomy for localized renal cell carcinoma (RCC), one after laparoscopic radical prostatectomy done in two patients and one after laparoscopic partial cystectomy for tumor at bladder dome done in two were studied. One case of metastatic RCC with bilateral gluteal masses and two cases of open radical nephrectomy, with recurrence at the drain and incision site were also studied.

Results:

During the median follow up of 59 months (range 24–120), 4/136 patients with RCC (1.47%) developed port site metastasis between 7–36 months after surgery. All six cases of PSM had advanced disease and recurrences at other sites, that is, peritoneum, omentum, bones, and lungs. None of the patients had isolated PSM. One patient of metastatic RCC, who did not have any intervention but repeated intramuscular injections of analgesics-developed bilateral gluteal masses, confirmed to be RCC on fine needle aspiration cytology. Two patients had metastasis at the incision site (one at the drain site) with distance, including cutaneous metastases.

Conclusions:

Port site metastasis did not develop in isolation. There could be a likely existence of circulating tumor cells at the time of surgical trauma of penetrating nature, that is, port site or injection site, which manifest in some patients depending upon their immune response.

Transient variations in the serum concentrations of cell adhesion molecules following retroperitoneal laparoscopic and open radical nephrectomy for localized renal-cell carcinoma

PURPOSE

To evaluate differences in the serum concentrations of cell adhesion molecules (CAMs) after retroperitoneal laparoscopic and conventional open radical nephrectomies for localized renal-cell carcinoma (RCC).

PATIENTS AND METHODS

A total of 62 patients with stage T(1)N(0)M(0) RCC were randomized to either a retroperitoneal laparoscopic radical nephrectomy group (n=31) or an open group (n=31). Serum levels of soluble cluster of differentiation 44 splice variant 6 (sCD44v6), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), and soluble epithelial cadherin (sE-cadherin) were determined independently by enzyme linked immunosorbent assay (ELISA) preoperatively, and on postoperative days 1 and 5. In addition, follow-up results were compared.

RESULTS

On postoperative day 1, sCD44v6, sICAM-1, and sVCAM-1 levels increased significantly compared with preoperative levels in both groups (P<0.05). sE-cadherin levels decreased compared with preoperative levels in both groups without statistically significant differences (P>0.05). sCD44v6 levels in the retro-laparoscopy group were significantly higher than in the open group (P<0.05), while sICAM-1, sVCAM-1, and sE-cadherin levels showed no statistically significant differences between both groups (P>0.05). On postoperative day 5, all parameters in both groups were similar to preoperative values (P>0.05). Follow-up ranged from 7 to 18 months postoperatively in all 62 patients, with a 100% cancer-specific survival rate in each group.

CONCLUSION

Although postoperatively higher serum concentrations of CAMs in both groups and significantly elevated sCD44v6 in the retro-laparoscopy group may be facilitated, the differences in CAMs between both groups are small and transient. Together with the similar follow-up results, this further supports previous studies that failed to show a difference in the oncologic outcomes between open and laparoscopic radical nephrectomy and provides a probable molecular mechanism.

Upper tract urothelial carcinoma: current treatment and outcomes

The reference standard treatment of upper tract urothelial carcinoma is open radical nephroureterectomy. Many centers have advocated less-invasive treatment modalities. We reviewed contemporary treatments of upper tract urothelial carcinoma and their outcomes. A MEDLINE search was conducted for all relevant published data during the past 15 years. Endoscopic management is feasible for low-grade disease with strict surveillance protocols. Radical nephroureterectomy remains the reference standard for upper tract urothelial carcinoma. The intermediate-term oncologic outcomes are similar between the laparoscopic and open approaches. Controversies still exist regarding the optimal management of the distal ureter, the utility of topical therapy, and the role of lymphadenectomy.

Increased metastases are associated with inflammation and matrix metalloproteinase-9 activity at incision sites in a murine model of peritoneal dissemination of colorectal cancer

BACKGROUND

Pro-inflammatory processes associated with the early postoperative state are known to contribute to peritoneal metastases in patients with advanced diseases. This study aimed to determine whether the wound healing response after an abdominal incision leads to increased matrix metalloproteinase (MMP)-9 activity locally, contributing to peritoneal metastasis.

MATERIALS AND METHODS

Metastatic tumors were initiated in C57bl/6J male mice (8wk of age) using a peritoneal injection model with syngeneic MC38 murine colon cancer cells; appropriate control mice also were studied. Injections were performed into the peritoneum in the right lower quadrant. We then observed the occurrence and rate of peritoneal metastasis for each group.

RESULTS

By making an incision into the abdominal wall of mice, an inflammatory response was induced at the wound site. The inflammatory response initiated by the wound, in turn, increased the proliferation of mesothelial cells and increased inflammatory cell numbers locally, which contributed to an increase in parietal peritoneal metastases. In addition, the wound healing process increased the expression of pro-inflammatory cytokines and the number of inflammatory cells in the peritoneum. Moreover, MMP-9 in the modeled postoperative injury setting increased the number and severity of peritoneal metastases.

CONCLUSIONS

Thus, we conclude that wound-associated inflammation enhances pro-MMP-9 expression, which plays a key role in the growth and progression of cancer cells associated with peritoneal metastases.

Early immune outcome of retroperitoneal laparoscopic radical nephrectomy for localized renal cell carcinoma: a prospective, randomized study

OBJECTIVES

We evaluated differences in cytokine responses and T-lymphocyte subsets following retroperitoneal laparoscopic and conventional open radical nephrectomies for localized renal cell carcinoma (RCC).

METHODS

A total of 62 patients with T(1)N(0)M(0) staged RCC were randomized to either retro-laparoscopic (n = 31) or open (n = 31) radical nephrectomy. Plasma levels of interleukin-1β (IL-1β), IL-6, and tumour necrosis factor-alpha (TNF-α) were measured separately by enzyme linked immunosorbent assay (ELISA) preoperatively and on postoperative days 1 and 5. Levels of CD3(+), CD4(+) and CD8(+) as well as the CD4(+):CD8(+) ratio were acquired by flow cytometry at the same time points.

RESULTS

Levels of IL-1β, IL-6 and TNF-α increased significantly compared to preoperative values in both groups (p < 0.05) on postoperative day 1, and all the parameters in the open group were significantly higher than those in the retro-laparoscopy group (p < 0.05). On postoperative day 1, the levels of CD3(+) and CD4(+) and the CD4(+):CD8(+) ratio decreased markedly compared to preoperative values for both groups (p < 0.05). Elevations of the CD4(+):CD8(+) ratio in the retro-laparoscopy group (p < 0.05) and the CD8(+) level in the open group (p < 0.05) were observed when compared with the other group. On postoperative day 5, the levels of CD3(+) and CD4(+) and the CD4(+):CD8(+) ratio in the retro-laparoscopy group, as well as the level of CD8(+) in the open group, returned to about preoperative levels (p < 0.05). Follow-up ranged from 4 to 14 months postoperatively in all 62 patients with a 100% cancer-specific survival rate in both groups.

CONCLUSIONS

Retroperitoneal laparoscopic radical nephrectomy is associated with the milder cytokine responses caused by trauma and inflammation and the better preserved distribution of T-lymphocytes.

Electrochemical prevention of needle-tract seeding

Needle-tract seeding refers to the implantation of tumor cells by contamination when instruments, such as biopsy needles, are employed to examine, excise, or ablate a tumor. The incidence of this iatrogenic phenomenon is low but it entails serious consequences. Here, as a new method for preventing neoplasm seeding, it is proposed to cause electrochemical reactions at the instrument surface so that a toxic microenvironment is formed. In particular, the instrument shaft would act as the cathode, and the tissues would act as the electrolyte in an electrolysis cell. By employing numerical models and experimental observations reported by researchers on Electrochemical Treatment of tumors, it is numerically showed that a sufficiently toxic environment of supraphysiological pH can be created in a few seconds without excessive heating. Then, by employing an ex vivo model consisting of meat pieces, validity of the conclusions provided by the numerical model concerning pH evolution is confirmed. Furthermore, a simplified in vitro model based on bacteria, instead of tumor cells, is implemented for showing the plausibility of the method. Depending on the geometry of the instrument, suitable current densities will probably range from about 5 to 200 mA/cm(2), and the duration of DC current delivery will range from a few seconds to a few minutes.

Postchemotherapy laparoscopic retroperitoneal lymph node dissection in nonseminomatous germ-cell tumor

BACKGROUND AND PURPOSE

Postchemotherapy retroperitoneal lymph node dissection (RPLND) remains essential in the management of metastatic testicular carcinoma and represents a surgical challenge. We determined to assess the feasibility and complications of laparoscopic RPLND in patients who were treated with induction chemotherapy for testis cancer.

PATIENTS AND METHODS

We performed a retrospective analysis of data that was prospectively recorded from 26 patients who underwent laparoscopic RPLND postplatinum-based chemotherapy between 2000 and 2006. The surgical technique consisted of excision of the residual mass plus unilateral template dissection. A transperitoneal technique was used in 24 patients, and an extraperitoneal approach was used in 2 patients. Operative details, perioperative morbidity data, and histologic findings were assessed for the study.

RESULTS

Primary pathologic evaluation of the testis tumor revealed pure embryonal carcinoma in 4 patients, teratocarcinoma in 1 patient, and mixed nonseminomatous germ-cell tumors in 21 patients. All patients had residual disease in the retroperitoneum on a preoperative CT scan, with a median size of 3.4 cm (range 2-6 cm). Procedures in three (11.5%) patients were converted to open surgery. Median operative time was 183 minutes (range 120-260 min). Median estimated blood loss was 400 mL (range 100-600 mL), and blood transfusion was necessary in one patient. Median hospital stay was 5 days (range 2-6 d). Median number of lymph nodes obtained on final histologic examination was 7 (range 4-13). Perioperative complications included eight lymphovascular and one intestinal. At a mean follow-up of 27 months (range 14-36 mos), no recurrences have been observed and no patient was lost to follow-up.

CONCLUSIONS

Postchemotherapy laparoscopic RPLND is technically feasible. The most frequent complications and causes of conversion are lymphovascular.