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International Journal of Urology (2015) 22, 131–138
Urological Notes Renal radiofrequency ablation with pyeloperfusion Jairam R Eswara M.D.,1 Debra A Gervais M.D.,2 Peter R Mueller M.D.,2 Ronald S Arellano M.D.,2 Colin P Cantwell M.D.2 and Francis J McGovern M.D.1 Abbreviations & Acronyms ASA = American Society of Anesthesiologists RFA = radiofrequency ablation 1
Department of Urology, Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA [email protected]
2
DOI: 10.1111/iju.12625
© 2014 The Japanese Urological Association
RFA is an effective means of renal tumor ablation. The ablation of masses adjacent to the ureter poses the risk of ureteral injury; however, retrograde pyeloperfusion through a ureteral catheter with dextrose 5% in water has been promoted to reduce ureteral injury. Although ureteral injury during RFA is rare, the consequences can be significant including long-term ureteral stenting or nephrostomy tube drainage. The ablation of tumors located near the ureter might cause injury by direct thermal damage, damage to the ureteral vasculature or perinephric scarring. Gervais showed that 25% (2/8) of tumors ablated within 1 cm of the ureter caused ureteral stricture, whereas RFA resulted in stricture in 10% of tumors (1/10) 1–2 cm from the ureter and 0% of tumors (0/82) 2 cm or further from the ureter.1 A subsequent study showed that pyeloperfusion with dextrose 5% in water might protect the ureter from injury during ablation of tumors within 1.5 cm.2 The proposed mechanism of ureteral preservation is through thermal conduction to the perfusate in a manner analogous to hypothermic renal preservation.3 Pyeloperfusion was carried out by insertion of a 5-Fr Flexitip ureteral catheter (Cook, Bloomington, IN, USA) through a rigid cystoscope.2 A 14-Fr foley catheter was inserted into the bladder with the ureteral catheter secured to it to prevent displacement. Dextrose 5% in water cooled to 2–6° was hung at 2 m above the floor (generally 110 cm above the patient) and infused by gravity into the renal pelvis through the ureteral catheter in a retrograde manner. Between 200–300 cc of fluid was typically used depending on the duration of the procedure. The ureteral catheter was removed at the end of the procedure. Patients were selected for pyeloperfusion during RFA if the tumor was located within 1.5 cm of the ureter. The risks and benefits of stent placement including possible decreased treatment efficacy were explained to patients, and consent was obtained before the procedure. Tumors were classified as central, exophytic or mixed according to the Gervais classification system. From 2005–2010, 45 patients (52 ablations) underwent pyeloperfusion to protect the ureter with median follow up of 43.3 months (1.3–79.5 months; Table 1). The primary technical success rate was 87% (39/45). Five patients required two ablations and one patient required three procedures. After their last ablations, all 45 patients had complete tumor ablation for a total effectiveness rate of 100%. This is in keeping with prior studies showing no decrease in efficacy.2 The median tumor diameter was 3.3 cm (1.5–6.2 cm). Interpolar tumors were found in 24 patients (46%), while 16 (31%) had tumors in the lower pole and 12 (23%) had tumors in the upper pole. Using the Gervais classification, 28 (54%) tumors were exophytic, 18 (35%) were central and six (12%) were mixed. Of the 45 masses ablated, 43 (96%) were renal cell carcinomas, one (2%) was a metastatic leiomyosarcoma and one (2%) had an inadequate biopsy sample. Of all the masses, clear cell renal cell carcinoma comprised 76% (34/45), chromophobe 7% (3/45), papillary 11% (5/45) and 2% (1/45) could not be differentiated. Major complications occurred in 14 of 45 (31%) patients (Table S1). Postprocedural complications included significant hematuria in five patients (11%), and urinoma, perinephric abscess, pseudoaneurysm, grounding pad burn and significant hematoma in one patient (2%) each. All five of the patients with hematuria were admitted for continuous bladder irrigation, and none required blood transfusion. Notably, two patients (4%) had a ureteral stricture, and both were patients who underwent a lower pole ablation. Two patients developed delayed abscesses, one after ablation of a 6 cm upper pole mass and the other after ablation of a 3 cm interpolar mass. Seven patients required follow-up procedures: two underwent serial ureteral stent placements for stricture, one underwent percutaneous drainage of urinoma, one underwent percutaneous drainage of a perinephric abscess and one underwent embolization of a pseudoaneurysm. One patient underwent percutaneous drainage of a delayed abscess. The fluid culture grew pan-sensitive Citrobacter koseri, and the patient was treated with ceftriaxone with no recurrence 131
UROLOGICAL NOTES
Table 1
Conflict of interest
Patient characteristics
Median age (years) Median follow up (months) ASA class 2 3 4 % Male % Left-sided ablation Median preoperative creatinine (mg/dL) Median postoperative creatinine (mg/dL) Median PT (s) Median PTT (s) Median platelets (1000/µL)
74.5 (55–88) 43.3 (1.3–79.5) 20% 76% 4% 60% 52% 1.20 (0.77–3.90) 1.28 (0.70–4.06) 12.6 (10.6–19.0) 25.7 (21.6–36.8) 212 (72–561)
None declared.
References 1 Gervais DA, McGovern FJ, Arellano RS, McDougal WS, Mueller PR. Radiofrequency ablation of renal cell carcinoma: part 1, Indications, results, and role in patient management over a 6-year period and ablation of 100 tumors. AJR Am. J. Roentgenol. 2005; 185: 64–71. 2 Cantwell CP, Wah TM, Gervais DA et al. Protecting the ureter during radiofrequency ablation of renal cell cancer: a pilot study of retrograde pyeloperfusion with cooled dextrose 5% in water. J. Vasc. Interv. Radiol. 2008; 19: 1034–40. 3 Landman J, Venkatesh R, Lee D et al. Renal hypothermia achieved by retrograde endoscopic cold saline perfusion: technique and initial clinical application. Urology 2003; 61: 1023–5.
n = 45.
Supporting Information of the abscess or tumor. Another patient underwent nephrectomy for what was thought to be recurrent tumor, but was found on pathology to be a Proteus mirabilis abscess with no evidence of malignancy. RFA with pyeloperfusion for renal masses is generally welltolerated. Pyeloperfusion for ablations adjacent to the ureter led to just two ureteral strictures, but also two delayed abscesses.
Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Table S1 Postprocedural complications.
Do testosterone levels have prognostic significance in patients with metastatic prostate cancer treated with combined androgen blockade? Yosuke Yasuda M.D.,1 Yasuhisa Fujii M.D., Ph.D.,2 Takeshi Yuasa M.D., Ph.D.,1 Shinya Yamamoto M.D., Ph.D.,1 Junji Yonese M.D., Ph.D.1 and Iwao Fukui M.D., Ph.D.1 Abbreviations & Acronyms ADT = androgen deprivation therapy CAB = combined androgen blockade CSS = cancer-specific survival DHT = 5-α-dihydrotestosterone GnRH = gonadotropin-releasing hormone mPCa = metastatic prostate cancer OS = overall survival PSA = prostate-specific antigen TTP = time to prostate-specific antigen progression
1
Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 2 Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan [email protected] DOI: 10.1111/iju.12623
132
Introduction In 1941, Huggins and Hodges reported the hormone dependence of prostate cancer, and ADT has since become the standard systemic therapy for patients with mPCa.1 Historically, the castration level was considered to be
International Journal of Urology (2015) 22, 131–138
Urological Notes Renal radiofrequency ablation with pyeloperfusion Jairam R Eswara M.D.,1 Debra A Gervais M.D.,2 Peter R Mueller M.D.,2 Ronald S Arellano M.D.,2 Colin P Cantwell M.D.2 and Francis J McGovern M.D.1 Abbreviations & Acronyms ASA = American Society of Anesthesiologists RFA = radiofrequency ablation 1
Department of Urology, Division of Abdominal Imaging and Interventional Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA [email protected]
2
DOI: 10.1111/iju.12625
© 2014 The Japanese Urological Association
RFA is an effective means of renal tumor ablation. The ablation of masses adjacent to the ureter poses the risk of ureteral injury; however, retrograde pyeloperfusion through a ureteral catheter with dextrose 5% in water has been promoted to reduce ureteral injury. Although ureteral injury during RFA is rare, the consequences can be significant including long-term ureteral stenting or nephrostomy tube drainage. The ablation of tumors located near the ureter might cause injury by direct thermal damage, damage to the ureteral vasculature or perinephric scarring. Gervais showed that 25% (2/8) of tumors ablated within 1 cm of the ureter caused ureteral stricture, whereas RFA resulted in stricture in 10% of tumors (1/10) 1–2 cm from the ureter and 0% of tumors (0/82) 2 cm or further from the ureter.1 A subsequent study showed that pyeloperfusion with dextrose 5% in water might protect the ureter from injury during ablation of tumors within 1.5 cm.2 The proposed mechanism of ureteral preservation is through thermal conduction to the perfusate in a manner analogous to hypothermic renal preservation.3 Pyeloperfusion was carried out by insertion of a 5-Fr Flexitip ureteral catheter (Cook, Bloomington, IN, USA) through a rigid cystoscope.2 A 14-Fr foley catheter was inserted into the bladder with the ureteral catheter secured to it to prevent displacement. Dextrose 5% in water cooled to 2–6° was hung at 2 m above the floor (generally 110 cm above the patient) and infused by gravity into the renal pelvis through the ureteral catheter in a retrograde manner. Between 200–300 cc of fluid was typically used depending on the duration of the procedure. The ureteral catheter was removed at the end of the procedure. Patients were selected for pyeloperfusion during RFA if the tumor was located within 1.5 cm of the ureter. The risks and benefits of stent placement including possible decreased treatment efficacy were explained to patients, and consent was obtained before the procedure. Tumors were classified as central, exophytic or mixed according to the Gervais classification system. From 2005–2010, 45 patients (52 ablations) underwent pyeloperfusion to protect the ureter with median follow up of 43.3 months (1.3–79.5 months; Table 1). The primary technical success rate was 87% (39/45). Five patients required two ablations and one patient required three procedures. After their last ablations, all 45 patients had complete tumor ablation for a total effectiveness rate of 100%. This is in keeping with prior studies showing no decrease in efficacy.2 The median tumor diameter was 3.3 cm (1.5–6.2 cm). Interpolar tumors were found in 24 patients (46%), while 16 (31%) had tumors in the lower pole and 12 (23%) had tumors in the upper pole. Using the Gervais classification, 28 (54%) tumors were exophytic, 18 (35%) were central and six (12%) were mixed. Of the 45 masses ablated, 43 (96%) were renal cell carcinomas, one (2%) was a metastatic leiomyosarcoma and one (2%) had an inadequate biopsy sample. Of all the masses, clear cell renal cell carcinoma comprised 76% (34/45), chromophobe 7% (3/45), papillary 11% (5/45) and 2% (1/45) could not be differentiated. Major complications occurred in 14 of 45 (31%) patients (Table S1). Postprocedural complications included significant hematuria in five patients (11%), and urinoma, perinephric abscess, pseudoaneurysm, grounding pad burn and significant hematoma in one patient (2%) each. All five of the patients with hematuria were admitted for continuous bladder irrigation, and none required blood transfusion. Notably, two patients (4%) had a ureteral stricture, and both were patients who underwent a lower pole ablation. Two patients developed delayed abscesses, one after ablation of a 6 cm upper pole mass and the other after ablation of a 3 cm interpolar mass. Seven patients required follow-up procedures: two underwent serial ureteral stent placements for stricture, one underwent percutaneous drainage of urinoma, one underwent percutaneous drainage of a perinephric abscess and one underwent embolization of a pseudoaneurysm. One patient underwent percutaneous drainage of a delayed abscess. The fluid culture grew pan-sensitive Citrobacter koseri, and the patient was treated with ceftriaxone with no recurrence 131
UROLOGICAL NOTES
Table 1
Conflict of interest
Patient characteristics
Median age (years) Median follow up (months) ASA class 2 3 4 % Male % Left-sided ablation Median preoperative creatinine (mg/dL) Median postoperative creatinine (mg/dL) Median PT (s) Median PTT (s) Median platelets (1000/µL)
74.5 (55–88) 43.3 (1.3–79.5) 20% 76% 4% 60% 52% 1.20 (0.77–3.90) 1.28 (0.70–4.06) 12.6 (10.6–19.0) 25.7 (21.6–36.8) 212 (72–561)
None declared.
References 1 Gervais DA, McGovern FJ, Arellano RS, McDougal WS, Mueller PR. Radiofrequency ablation of renal cell carcinoma: part 1, Indications, results, and role in patient management over a 6-year period and ablation of 100 tumors. AJR Am. J. Roentgenol. 2005; 185: 64–71. 2 Cantwell CP, Wah TM, Gervais DA et al. Protecting the ureter during radiofrequency ablation of renal cell cancer: a pilot study of retrograde pyeloperfusion with cooled dextrose 5% in water. J. Vasc. Interv. Radiol. 2008; 19: 1034–40. 3 Landman J, Venkatesh R, Lee D et al. Renal hypothermia achieved by retrograde endoscopic cold saline perfusion: technique and initial clinical application. Urology 2003; 61: 1023–5.
n = 45.
Supporting Information of the abscess or tumor. Another patient underwent nephrectomy for what was thought to be recurrent tumor, but was found on pathology to be a Proteus mirabilis abscess with no evidence of malignancy. RFA with pyeloperfusion for renal masses is generally welltolerated. Pyeloperfusion for ablations adjacent to the ureter led to just two ureteral strictures, but also two delayed abscesses.
Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Table S1 Postprocedural complications.
Do testosterone levels have prognostic significance in patients with metastatic prostate cancer treated with combined androgen blockade? Yosuke Yasuda M.D.,1 Yasuhisa Fujii M.D., Ph.D.,2 Takeshi Yuasa M.D., Ph.D.,1 Shinya Yamamoto M.D., Ph.D.,1 Junji Yonese M.D., Ph.D.1 and Iwao Fukui M.D., Ph.D.1 Abbreviations & Acronyms ADT = androgen deprivation therapy CAB = combined androgen blockade CSS = cancer-specific survival DHT = 5-α-dihydrotestosterone GnRH = gonadotropin-releasing hormone mPCa = metastatic prostate cancer OS = overall survival PSA = prostate-specific antigen TTP = time to prostate-specific antigen progression
1
Department of Urology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 2 Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan [email protected] DOI: 10.1111/iju.12623
132
Introduction In 1941, Huggins and Hodges reported the hormone dependence of prostate cancer, and ADT has since become the standard systemic therapy for patients with mPCa.1 Historically, the castration level was considered to be
