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Biomedical subjects

A C Novick

Publications and source records attributed to A C Novick.

At least 73 records · Page 4Linked to original sources
PubMed1999

Comparison of direct hospital costs and length of stay for radical nephrectomy versus nephron-sparing surgery in the management of localized renal cell carcinoma.

OBJECTIVES: Recent work has demonstrated comparable surgical results and 5-year cancer-specific survival rates between radical nephrectomy and nephron-sparing surgery (NSS) in the treatment of patients with small (4 cm or smaller) solitary renal cell carcinomas (RCCs). However, differences exist in the intraoperative management and postoperative care of patients undergoing NSS versus radical nephrectomy, and we sought to compare direct hospital costs and length of stay (LOS) between these two groups to determine whether either treatment imparts a specific cost advantage. METHODS: Data were retrieved from medical records and administrative data sets containing billing encounters for all costs incurred during hospitalization at the Cleveland Clinic Foundation. Individual costs were grouped together using nine cost center categories encompassing every aspect of direct hospital care, including anesthesiology, laboratory, radiology, nursing, pharmaceutical, and emergency services, and medical care, surgical care, and miscellaneous costs. Each cost center was further subdivided, and a total of 52 cost subcategories were assessed. The total direct costs of hospitalization were compared using a multivariate regression model in which patient demographics and tumor characteristics, type and year of surgery, LOS, and cost center categories were assessed as single and interactive factors. Postoperative complication and cancer-specific survival rates were also compared to identify any potential therapeutic differences between the two groups. RESULTS: Between 1991 and 1995, 80 patients underwent surgery at the Cleveland Clinic Foundation for solitary RCCs 4 cm or smaller, including 52 partial and 28 radical nephrectomies. We found no difference in the postoperative complication rate or cancer-specific survival rate between the two surgical groups. Total direct hospital costs and LOS were not statistically different between the NSS and radical nephrectomy groups (P >0.05). This was further supported by our multivariate model, which accounted for 61% of the observed variance in the total costs (F = 12.11, P = 0.0001). The type of surgery was not associated with total cost when controlling for all other factors, including age, sex, year of surgery, tumor size, grade, and stage, and postoperative complications (P = 0.7). There was no significant interaction between the type of surgery and the LOS (P = 0.5). CONCLUSIONS: This study demonstrated that elective NSS can be performed with equivalent direct hospital costs and LOS when compared with patients undergoing radical nephrectomy for small solitary RCCs. These data have significant economic implications for the comparison of competing surgical treatment strategies for localized RCC.

Aged↗
PubMed1999

Laparoscopic renal and adrenal surgery in obese patients: comparison to open surgery.

PURPOSE: The efficacy and morbidity of laparoscopic renal and adrenal surgery in comparison to open surgery in obese patients are unknown. This retrospective study was performed to compare the outcome of laparoscopic versus open renal and adrenal surgery in the markedly and morbidly obese patient (body mass index 30 or greater). MATERIALS AND METHODS: The study group comprised all obese patients undergoing laparoscopic renal and adrenal surgery (laparoscopic group) from August 1997 to February 1998 at our institution. The majority of procedures were performed using a retroperitoneoscopic approach via the flank. These patients were compared with all obese patients undergoing open renal and adrenal surgery (open group) from 1994 to 1998. Open group patients with factors precluding laparoscopic surgery were excluded from the study (mass greater than 10 cm., renal vein and/or inferior vena caval thrombus and extension outside Gerota's fascia). RESULTS: There were 21 obese patients in each group and baseline parameters were comparable between groups. Median body mass index in the laparoscopic and open groups was 34 and 31, respectively. Median surgical time between the laparoscopic (210 minutes) and open (185) groups was comparable (p = 0.16). However, the laparoscopic group had decreased blood loss (100 versus 350 ml., p<0.001), quicker resumption of oral intake and ambulation (less than 1 versus 5 days, p<0.001), decreased narcotic analgesic requirements (12 versus 279 mg., p<0.001), shorter median hospital stay (less than 1 versus 5 days, p<0.001) and quicker convalescence (3 versus 9 weeks, p<0.001). There were 6 complications in 4 laparoscopic cases and 14 in 9 open surgery cases (p = 0.16). CONCLUSIONS: Markedly obese patients have an increased risk of complications from surgery, regardless of the approach. Our data suggest that laparoscopic renal and adrenal surgery is technically feasible in the markedly and morbidly obese patient, and compared with open surgery results in significantly decreased blood loss, quicker return of bowel function, less analgesic requirement, shorter convalescence and reduced hospital stay.

Adrenal Gland Neoplasms↗
PubMed1999

Renal cell carcinoma-derived gangliosides suppress nuclear factor-kappaB activation in T cells.

Activation of the transcription factor nuclear factor-kappaB (NFkappaB) is impaired in T cells from patients with renal cell carcinomas (RCCs). In circulating T cells from a subset of patients with RCCs, the suppression of NFkappaB binding activity is downstream from the stimulus-induced degradation of the cytoplasmic factor IkappaBalpha. Tumor-derived soluble products from cultured RCC explants inhibit NFkappaB activity in T cells from healthy volunteers, despite a normal level of stimulus-induced IkappaBalpha degradation in these cells. The inhibitory agent has several features characteristic of a ganglioside, including sensitivity to neuraminidase but not protease treatment; hydrophobicity; and molecular weight less than 3 kDa. Indeed, we detected gangliosides in supernatants from RCC explants and not from adjacent normal kidney tissue. Gangliosides prepared from RCC supernatants, as well as the purified bovine gangliosides G(m1) and G(d1a), suppressed NFkappaB binding activity in T cells and reduced expression of the cytokines IL-2 and IFN-gamma. Taken together, our findings suggest that tumor-derived gangliosides may blunt antitumor immune responses in patients with RCCs.

Carcinoma, Renal Cell↗
PubMed1999

Multicenter, randomized, phase III trial of CD8(+) tumor-infiltrating lymphocytes in combination with recombinant interleukin-2 in metastatic renal cell carcinoma.

PURPOSE: To prospectively evaluate in a multicenter randomized trial the antitumor activity of CD8(+) tumor-infiltrating lymphocytes (TILs) in combination with low-dose recombinant interleukin-2 (rIL-2), compared with rIL-2 alone, after radical nephrectomy in metastatic renal cell carcinoma patients. PATIENTS AND METHODS: Between December 1994 and March 1997, 178 patients with resectable primary tumors were enrolled at 29 centers in the United States and Europe. Patients underwent total nephrectomy, recovered, and were randomized to receive either CD8(+) TILs (5 x 10(7) to 3 x 10(10) cells intravenously, day 1) plus rIL-2 (one to four cycles: 5 x 10(6) IU/m(2) by continuous infusion daily for 4 days per week for 4 weeks) (TIL/rIL-2 group) or placebo cell infusion plus rIL-2 (identical regimen) (rIL-2 control group). Primary tumor specimens were cultured at a central cell-processing center in serum-free medium containing rIL-2 to generate TILs. RESULTS: Of 178 enrolled patients, 160 were randomized (TIL/rIL-2 group, n = 81; rIL-2 control group, n = 79). Twenty randomized patients received no treatment after nephrectomy because of surgical complications (four patients), operative mortality (two patients), or ineligibility for rIL-2 therapy (14 patients). Among 72 patients eligible for TIL/rIL-2 therapy, 33 (41%) received no TIL therapy because of an insufficient number of viable cells. Intent-to-treat analysis demonstrated objective response rates of 9.9% v 11.4% and 1-year survival rates of 55% v 47% in the TIL/rIL-2 and rIL-2 control groups, respectively. The study was terminated early for lack of efficacy as determined by the Data Safety Monitoring Board. CONCLUSION: Treatment with CD8(+) TILs did not improve response rate or survival in patients treated with low-dose rIL-2 after nephrectomy.

Adolescent↗
PubMed1999

Triphasic helical CT of the kidneys: contribution of vascular phase scanning in patients before urologic surgery.

OBJECTIVE: The purpose of this study was to evaluate the potential benefits of performing vascular phase scanning of the kidneys in addition to unenhanced and parenchymal phase contrast-enhanced CT in patients being examined for urologic surgery. MATERIALS AND METHODS: Parenchymal and vascular phase images from triphasic renal helical CT of 50 patients were sequentially evaluated in a randomized, retrospective fashion by two independent observers. The number of renal arteries and veins and the presence of vein or collecting system anomalies were recorded for each scan phase along with a subjective 10-point-scale score of the visibility of the vasculature and collecting system. Correlation of these findings was made with surgical or angiographic findings in 67 of the 87 kidneys and was made by consensus review in the remaining 20 kidneys. RESULTS: Accessory renal arteries were seen significantly more often (p < .05, chi-square test) on the vascular phase scans. The subjective scores for the visibility of the renal arteries and renal veins were significantly higher on the vascular phase scans (p < .0001, Wilcoxon's rank sum test). The subjective scores for the visibility of the filling of the collecting system and renal pelvis were significantly higher for the parenchymal phase scans, despite the use of a small contrast bolus before each scan (p < .0001, Wilcoxon's rank sum test). CONCLUSION; Triphasic renal CT better reveals the artery and vein anatomy of the kidney than does parenchymal phase imaging only. Triphasic helical CT is indicated in patients undergoing planning for urologic surgery when vascular anatomy is clinically important.

Adult↗
PubMed1999

Successful outcomes in pheochromocytoma surgery in the modern era.

PURPOSE: We describe our experience with surgical management, complications and treatment outcome of histologically confirmed pheochromocytoma. MATERIALS AND METHODS: The records of 113 patients who underwent surgical excision of pheochromocytoma were reviewed and assessed for preoperative medical treatment, intraoperative findings, postoperative hospitalization and complications. RESULTS: There were no surgical mortalities. Average length of stay in the intensive care unit was 1.2 days. There were only 6 major cardiovascular complications all of which occurred in patients who received preoperative medications, including 5 with alpha blockade. Patients receiving no preoperative alpha blockade required an average of 956 cc less in total intraoperative fluids, which approached statistical significance, and 479 cc less fluids on postoperative day 1, which was statistically significant. CONCLUSIONS: Preoperative alpha-adrenergic blockade is not essential in pheochromocytoma patients. Calcium channel blockers are just as effective and safer when used as the primary mode of antihypertensive therapy. Surgery for pheochromocytoma is safe in the modern era.

Adolescent↗
PubMed1999

Impact of diagnostic ureteroscopy on long-term survival in patients with upper tract transitional cell carcinoma.

PURPOSE: We determine whether diagnostic retrograde ureteroscopy for evaluation of upper tract transitional cell carcinoma adversely affects survival outcomes in terms of urothelial and metastatic tumor recurrence, and tumor-free and overall survival. MATERIALS AND METHODS: A total of 96 patients underwent total nephroureterectomy or resection of the distal ureter with a bladder cuff for upper tract transitional cell carcinoma. Of the patients 48 (study group) had undergone preoperative diagnostic ureteroscopy while 48 (control group) had not. Grade and stage of disease were compared, and time to recurrence, and disease-free and overall survival were analyzed. RESULTS: Grade and stage of disease were equivalent in both groups. There were no significant differences in recurrence rates, time to recurrence or mortality between the groups. Metastases developed in 9 patients (18.8%) in the control group and 6 (12.5%) in the study group (p = 0.58), while 5 (10.4%) in each group died of metastases of upper tract carcinoma (p = 1.00). Kaplan-Meier estimates were 0.67 and 0.71 for metastasis-free survival at 5 years (p = 0.25, not significant) and 0.87 and 0.76 for overall 5-year survival (p = 0.75, not significant) for the study and control groups, respectively. CONCLUSIONS: Diagnostic ureteroscopy has no clinically apparent adverse effect on long-term or disease specific survival of patients with upper tract transitional cell carcinoma who subsequently undergo standard definitive surgical management.

Aged↗
PubMed1999

3-dimensional volume rendered computerized tomography for preoperative evaluation and intraoperative treatment of patients undergoing nephron sparing surgery.

PURPOSE: Computerized tomography (CT) is the diagnostic and staging modality of choice for renal neoplasms. Existing imaging modalities are limited by a 2-dimensional (D) format. Recent advances in computer technology now allow the production of high quality 3-D images from helical CT. Nephron sparing surgery requires a detailed understanding of renal anatomy. Preoperative evaluation must delineate the relationship of the tumor to adjacent normal structures and demonstrate the vascular supply to the tumor for the surgeon to conserve as much normal parenchyma as possible. We propose that helical CT combined with 3-D volume rendering provides all of the information required for preoperative evaluation and intraoperative management of nephron sparing surgery cases. We prospectively evaluated the role of 3-D volume rendering CT in 60 patients undergoing nephron sparing surgery for renal cell carcinoma at the Cleveland Clinic Foundation. MATERIALS AND METHODS: Triphasic spiral CT was performed preoperatively in 60 consecutive patients undergoing nephron sparing surgery for renal neoplasms. A 3 to 5-minute videotape was prepared using volume rendering software which demonstrated the position of the kidney, location and depth of extension of the tumor(s), renal artery(ies) and vein(s), and relationship of the tumor to the collecting system. These videotapes were viewed by a radiologist and urologist in the operating room at surgery, and immediately correlated with surgical findings. Corresponding renal arteriograms of 19 patients were retrospectively compared to 3-D volume rendering CT and operative findings. RESULTS: A total of 97 renal masses were identified in 60 cases evaluated with 3-D volume rendering CT before nephron sparing surgery. There were no complications related to the 3-D protocol and 3-D rendering was successful in all patients. The number and location of lesions identified by 3-D volume rendering CT were accurate in all cases, while enhancement and diagnostic characteristics were consistent with pathological findings in 95 of 97 tumors (98%). Of 77 renal arteries identified at surgery 74 were detected by 3-D volume rendering CT (96%). Helical CT missed 3 small accessory arteries, including 1 in a cross fused ectopic kidney. All major venous branches and anomalies were identified, including 3 circumaortic left renal veins. Of 69 renal veins identified at surgery 64 were detected by 3-D volume rendering CT (93%). All 5 renal veins missed by CT were small, short, duplicated right branches of the main renal vein. Renal fusion and malrotation anomalies were correctly identified in all 4 patients. CONCLUSIONS: The 3-D volume rendering CT accurately depicts the renal parenchymal and vascular anatomy in a format familiar to most surgeons. The data integrate essential information from angiography, venography, excretory urography and conventional 2-D CT into a single imaging modality, and can obviate the need for more invasive imaging. Additionally, the use of videotape in an intraoperative setting provides concise, accurate and immediate 3-D information to the surgeon, and it has become the preferred means of data display for these procedures at our center.

Adult↗
PubMed1999

Mechanisms of apoptosis in T cells from patients with renal cell carcinoma.

Tumors may escape immune recognition and destruction through the induction of apoptosis in activated T lymphocytes. Results from several laboratories suggest that FasL (L/CD95L) expression in tumors may be responsible for this process. In this study of patients with renal cell carcinoma (RCC), we provide evidence for two mechanisms of T-cell apoptosis. One mechanism involves the induction of apoptosis via FasL expression in tumor cells. This is supported by several observations, including the fact that tumor cells in situ as well as cultured cell lines expressed FasL mRNA and protein by a variety of techniques. The FasL in RCC is functional because in coculture experiments, FasL+ tumors induced apoptosis in Fas-sensitive Jurkat T cells and in activated peripheral blood T cells but not in resting peripheral blood T cells. Most importantly, antibody to FasL partially blocked apoptosis of the activated T cells. Moreover, Fas was expressed by T cells derived from the peripheral blood (53% median) and tumor (44.3% median) of RCC patients. Finally, in situ staining for DNA breaks demonstrated apoptosis in a subset of T cells infiltrating renal tumors. These studies also identified a second mechanism of apoptosis in RCC patient peripheral T cells. Whereas these cells did not display DNA breaks when freshly isolated or after culture for 24 h in medium, peripheral blood T cells from RCC patients underwent activation-induced cell death after stimulation with either phorbol 12-myristate 13-acetate/ionomycin or anti-CD3/CD28 antibodies. Apoptosis mediated by exposure to FasL in tumor cells or through T-cell activation may contribute to the failure of RCC patients to develop an effective T-cell-mediated antitumor response.

Apoptosis↗
PubMed1998

A randomized prospective controlled trial of oral acyclovir versus oral ganciclovir for cytomegalovirus prophylaxis in high-risk kidney transplant recipients.

BACKGROUND: Posttransplantation cytomegalovirus (CMV) infection remains a significant cause of morbidity in kidney transplant recipients. We performed a randomized prospective controlled trial of oral acyclovir versus oral ganciclovir for CMV prophylaxis in a group of renal allograft recipients considered at high risk for CMV disease due to the use of OKT3 induction therapy. METHODS: A total of 101 recipients of cadaveric (83) and zero haplotype-matched live donor (18) kidney transplants were entered into the trial. A total of 22 D-R- patients received no prophylaxis. Twenty-seven D+R-, 29 D+R+, and 23 D-R+ patients were randomized to receive 3 months of either oral acyclovir (800 mg q.i.d.) or oral ganciclovir (1000 mg t.i.d.). Doses were adjusted according to the level of renal function. The D+R- patients were also given CMV immune globulin biweekly for 16 weeks. Surveillance blood cultures were obtained at transplantation, at months 1, 2, 3, and 6, and when clinically indicated. The primary study end points were time to CMV infection and disease the first 6 months after transplantation. RESULTS: The mean follow up was 14.4 months. Both agents were well tolerated, and no drug interruptions for toxicity occurred. CMV was isolated in 14 of 39 (35.9%) acyclovir-treated and 1 of 40 (2.5%) ganciclovir-treated recipients by 6 months (P=0.0001). Symptomatic CMV disease occurred in 9 of 14 (64%) of the acyclovir patients, two with tissue-invasive disease. Infection rates for acyclovir vs. ganciclovir, respectively, stratified by CMV serology were: D+R-, 54 vs. 0%, P=0.0008; D+R+, 43 vs. 6.6%, P=0.01; D-R+, 8.3 vs. 0%, P=NS. No patient developed CMV infection while taking oral ganciclovir, however three delayed infections occurred 2-7 months after finishing therapy. Each patient had been previously treated for acute rejection. CONCLUSIONS: Oral acyclovir provides effective CMV prophylaxis only for recipients of seronegative donor kidneys. Oral ganciclovir is a superior agent providing effective CMV prophylaxis for recipients of seropositive donor kidneys. Recipients who are treated for acute rejection are at risk for delayed CMV infection during the first posttransplantation year.

Acute Disease↗
PubMed1998

Transplantation of pediatric en bloc cadaver kidneys into adult recipients.

BACKGROUND: To maximize the renal donor pool, cadaveric pediatric en bloc kidneys have been transplanted as a dual unit by some transplant centers. We compared the short- and long-term outcomes of adult recipients of cadaveric pediatric en bloc renal transplants versus those of matched recipients of cadaveric adult kidneys. METHODS: Thirty-three adults who received pediatric en bloc kidney transplants between April 1990 and September 1997 were retrospectively identified and were compared with 33 matched adults who received adult cadaveric kidney transplants. The groups were identical for transplantation era, immunosuppression, recipient sex, race, cause of renal failure, mean weight, and follow-up duration (37.8 vs. 37.5 months). The mean recipient age study versus control was lower (36.3 vs. 48.9 years, P=0.0003). Results. There was no difference between the en bloc and adult donor groups in the 3-year patient survival rates (95% vs. 87%, P=0.16) or the 3-year graft survival rates (87.3% vs. 84.2%, P=0.35). Further, there was no difference in en bloc patient or en bloc graft survival time stratified by recipient age (14-44 vs. >45 years, P=0.11), en bloc donor age (<24 vs. >24 months, P=0.39), or recipient weight (<60, 61-75, >75 kg; P=0.60). Differences in serum creatinine (mg/dl) for the en bloc versus the control group at the time of discharge (3.0 vs. 7.8 mg/dl, P=0.06), at 1 year (1.4 vs. 2.0 mg/dl, P=0.06), and at 2 years (1.1 vs. 1.6 mg/dl, P=0.14) had dissipated by the time of the 5-year follow-up examination (1.1 vs. 1.6 mg/dl, P=0.14). Vascular complications were more prevalent in the en bloc group: renal vein thrombosis (one case), thrombosis of donor aorta (two cases), arterial thrombosis of one renal moiety (two cases), and renal artery stenosis (two cases). There were no differences between groups in delayed graft function, acute or chronic rejection, posttransplant hypertension, posttransplant protein-uria, or long-term graft function. CONCLUSIONS: Collectively, these data indicate that transplanting pediatric en bloc kidneys into adult recipients results in equivalent patient and graft survival compared with adult cadaveric kidneys. Further, the data also suggest that pediatric en bloc kidneys need not be strictly allocated based on recipient weight or age criteria.

Adolescent↗
PubMed1998

Laparoscopic adrenalectomy: the preferred choice? A comparison to open adrenalectomy.

PURPOSE: We compare the effectiveness and efficiency of laparoscopic adrenalectomy to open surgical management of adrenal disorders. MATERIALS AND METHODS: A retrospective comparison was undertaken of 21 patients who underwent transperitoneal laparoscopic adrenalectomy between April 1996 and May 1997 with 17 patients who underwent open adrenalectomy between October 1994 and January 1996. Any patient suspected of having primary adrenal carcinoma and/or an adrenal lesion larger than 6 cm. was excluded from the study. RESULTS: Patient demographics were matched well. Mean laparoscopic surgical time was 79 minutes longer than for open surgery. After overcoming the learning curve, the surgical time decreased by 59 minutes in the last 10 laparoscopic adrenalectomies. All laparoscopic intraoperative complications were managed without the need for open surgical conversion. Postoperative characteristics demonstrated significant benefits in the laparoscopic group (p=0.001) with respect to days to return to full diet (1.7 versus 4.6), analgesic pain requirements and days of hospitalization (2.7 versus 6.2). CONCLUSIONS: Laparoscopic adrenalectomy offers significant postoperative benefits to patients with benign adrenal disease requiring surgical intervention. The surgical time is longer than that for open adrenalectomy but there was an encouraging reduction in time after overcoming the laparoscopic learning curve. Laparoscopic adrenalectomy is an excellent choice for tumors smaller than 6 cm. Its role for larger lesions and/or primary adrenal carcinoma is currently under investigation.

Adrenal Gland Neoplasms↗
PubMed1998

Efficacy of multimodality therapy in advanced renal cell carcinoma.

OBJECTIVES: The integration of systemic biologic response modifier (BRM) therapy and surgery to treat metastatic renal cell carcinoma (RCC) is an evolving approach. The purpose of this study was to evaluate the efficacy of this form of multimodality therapy in patients with metastatic RCC. METHODS: Between 1988 and 1996, 14 patients at our institution underwent initial BRM therapy followed by surgical resection of primary and metastatic RCC lesions. Patient records were reviewed to determine the response to BRM therapy, progression-free survival rate, and overall survival rate. The mean follow-up for the entire group was 43.5 months. RESULTS: After BRM therapy, 9 patients manifested an objective response and 5 patients had stable disease. All patients were then rendered disease-free by surgical excision of residual or recurrent metastatic lesions and the primary tumor. The cancer-specific survival rate at 3 years was 81.5%. Currently, 7 patients are alive and disease-free (mean follow-up 41.4 months), 3 patients are alive with recurrent disease (mean survival 48.3 months), 3 patients died of metastatic disease (mean survival 27.9 months), and 1 patient died of an unrelated cause 54.4 months after therapy. CONCLUSIONS: The results of this study suggest that adjunctive surgery after BRM therapy can extend the survival of selected patients with metastatic RCC. Aggressive surgical resection of stable or responding lesions after BRM therapy should be considered in the management of these patients.

Adult↗
PubMed1998

P53, bcl-2, and Bax expression in renal cell carcinoma.

OBJECTIVES: Renal cell carcinomas often show a high degree of resistance to chemotherapy and radiation despite expressing normal function of the protein p53. The loss of control of apoptosis may also contribute to progression and resistance to treatment modalities and can be attributed to an interaction between p53 and the apoptotic regulators bcl-2 and Bax. To determine whether the expression of p53, bcl-2, or Bax could be correlated with outcome, we analyzed the expression pattern of these proteins in renal cell tumor samples. METHODS: We examined 28 patients with clear cell renal cell carcinomas along with 7 patients with papillary renal cell carcinomas and 4 with renal oncocytomas. All renal cell carcinomas were clinically localized Stage pT2 with tumor size ranging from 4.0 to 10.3 cm (mean 6.23). Immunohistochemistry was performed on all samples and correlated with markers of outcome, including tumor grade, metastasis, recurrence, and overall survival rate. RESULTS: In all clear cell tumors, the detection level of p53 expression was below the sensitivity of the assay, consistent with the reported infrequent incidence of p53 mutations in renal cell cancers. bcl-2 expression showed a significant correlation (P = 0.018) with higher tumor grade but could not be significantly correlated with other parameters examined including tumor recurrence, metastasis, or survival rate. The expression of Bax could similarly be correlated with higher tumor grade but with none of the other parameters. CONCLUSIONS: At the present time, the combination of both tumor grade and stage represents the best prognostic markers available. Adjunctive use of bcl-2 and Bax staining currently plays a minimal role in helping to further stratify patients at high risk for disease progression or recurrence.

Adenoma, Oxyphilic↗
PubMed1998

Renal cryosurgery: experimental evaluation of treatment parameters.

OBJECTIVES: Cryosurgery represents a minimally invasive alternative for the management of small or equivocal lesions of the kidney. We evaluated the relationship between ultrasonographic appearance and intrarenal temperatures and the effect of renal artery occlusion on the efficacy of the freezing process in a canine model. METHODS: Ten animals were treated with intraparenchymal cryoablative therapy with (n = 5) or without (n = 5) renal artery occlusion using a rapid freeze technique. Intrarenal temperatures were measured 1.0 cm away from the cryoprobe at various times during the freezing process. The distance from the cryoprobe to the ice ball as monitored by ultrasonography was also determined. The contralateral kidney was removed to facilitate studies of renal function and all animals were killed on day 28 for autopsy and histopathologic examination. RESULTS: A target temperature of less than -20 degrees C was achieved 3.1 mm behind the ice ball in all animals tested. The ice ball stabilized at a radius of 16 mm with prolonged treatment, suggesting that multiple probes will be required to treat renal lesions greater than 2.5 cm in diameter. Renal artery occlusion did not significantly alter the freezing process and provided no practical advantage. Renal function remained stable (final serum creatinine level 1.5 mg/dL or less) in all but 1 animal in which an obstructive stricture of the ureteropelvic junction developed. Effective tissue ablation was confirmed at the treatment site in all instances. CONCLUSIONS: Renal cryoablative therapy is a nephron-sparing modality that can be delivered in a safe, efficacious, and reproducible manner. The treatment parameters defined in this study should allow for intelligent patient selection and rational administration of renal cryotherapy.

Animals↗
PubMed1998

Needlescopic adrenalectomy--the initial series: comparison with conventional laparoscopic adrenalectomy.

OBJECTIVES: To report the initial series of needlescopic transperitoneal adrenalectomy and to compare the results with a contemporary series of conventional transperitoneal laparoscopic adrenalectomy performed at the same institution. METHODS: Fifteen patients underwent needlescopic adrenalectomy over a 4-month period. Outcome data were retrospectively compared with 21 conventional laparoscopic adrenalectomies performed over the preceding 12-month period at the same institution. The needlescopic technique included three subcostal ports (two, 2 mm; one, 5 mm) and one umbilical port for ultimate specimen extraction (10/12 mm). The laparoscopic technique included four subcostal ports (all 10/12 mm). Endoscopic transperitoneal adrenalectomy was completed by the standard technique in both groups. RESULTS: Baseline demographics were comparable between the needlescopic (n = 15) and laparoscopic (n = 21) groups. The needlescopic group had a shorter surgical time (169 versus 220 minutes, P = 0.05), less blood loss (61 versus 183 mL, P = 0.002), and shorter hospital stay (1.1 versus 2.7 days, P < 0.001). Convalescence averaged 2.1 weeks in the needlescopic group and 3.1 weeks in the laparoscopic group (P < 0.001). No significant complications occurred in either group. One patient in the needlescopic group was converted to conventional laparoscopy because of marked obesity; hospital stay in this patient was 2 days. CONCLUSIONS: Reported herein is the initial series of needlescopic adrenalectomy. Compared with conventional laparoscopy, needlescopic adrenalectomy results in an overnight hospital stay, rapid recovery, and excellent cosmesis. However, prior experience with conventional laparoscopy is essential before embarking on needlescopic surgery.

Adrenalectomy↗