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Jeffrey A Cadeddu

Publications and source records attributed to Jeffrey A Cadeddu.

At least 19 recordsLinked to original sources
PubMed2006

Large-volume laparoscopic partial nephrectomy using the potassium-titanyl-phosphate (KTP) laser in a survival porcine model.

OBJECTIVES: Laparoscopic partial nephrectomy (LPN) remains a technically challenging procedure primarily because of difficulties with hemostasis. In an attempt to develop a hemostatic cutting instrument for laparoscopic partial nephrectomy, we evaluated the potassium-titanyl-phosphate (KTP) laser for use during large-volume laparoscopic partial nephrectomy in a porcine model. METHODS: Transperitoneal lower pole laparoscopic partial nephrectomy was performed in six pigs. Two nonsurvival animals were used initially to develop the laser technique. Four animals underwent a right-sided laparoscopic laser partial nephrectomy followed by an identical left-sided procedure 2 weeks later. Renal hilar occlusion was used in all cases. A novel 365-mum end-firing laser fibre and 80-W KTP laser were used for resection and hemostasis. All renal remnants underwent retrograde pyelography and histologic examination. RESULTS: Laser resection and hemostasis was successfully completed in all cases, and no perioperative complications occurred. Mean estimated blood loss was 80 ml (25-250 ml). Mean laser and warm ischemia times were 35 and 34 minutes, respectively. Resection speed was limited by smoke formation but not by cutting or hemostatic efficiency of the laser. Mean resected kidney mass was 30 g or 25% of total kidney mass. There were no urinomas, but, on retrograde pyelogram, extravasation was noted in seven of eight kidneys (87.5%). CONCLUSIONS: The KTP laser provides hemostasis during large-volume resection in the porcine kidney. This technique appears promising for laparoscopic partial nephrectomy in humans.

Animals↗
PubMed2006

Efficacy of ablative high-dose-per-fraction radiation for implanted human renal cell cancer in a nude mouse model.

OBJECTIVES: Stereotactic body radiation therapy (SBRT) is a new therapeutic paradigm that uses a very large dose per fraction treatments (ablative hypofractionation). We investigated the use of ablative hypofractionation in treating human renal cell carcinoma using a nude mouse model. METHODS: Nude mice were injected subcutaneously with A498 human renal carcinoma cells. Tumour-bearing animals were radiated with three fractions (one per week) for a total dose of 48 Gy (n = 12), while untreated animals served as controls (n = 7). The mice were weighed, and tumour volumes were measured at baseline and weekly until 7 weeks post-treatment. RESULTS: Control animals demonstrated progressive tumour growth and were sacrificed because of either tumour size or ulceration. Tumours in the treatment group grew to three times their initial size over the 3 weeks of treatment but subsequently decreased progressively to less than 30% of their initial volume. All treated tumours exhibited marked cytologic changes. Tumours from mice sacrificed before post-treatment week 4 had a mitotic count of 1-4/10 hpf. Tumours from mice sacrificed more than 4 weeks post-treatment (n = 4) demonstrated no mitoses. CONCLUSIONS: Treatment with high-dose-per-fraction radiation to 48 Gy resulted in a sustained decrease in tumour volume and marked cytologic changes. These results are preliminary--but promising--and encourage further research into this application of ablative hypofractionated radiation for kidney cancer.

Animals↗
PubMed2006

Magnetic resonance imaging characteristics of renal tumors after radiofrequency ablation.

OBJECTIVES: The interpretation of radiographic findings in renal tumors treated with minimally invasive modalities, such as radiofrequency ablation (RFA), is critical for assessing treatment adequacy. Magnetic resonance imaging (MRI) is commonly used for patients with renal insufficiency or contrast allergy. Because the MRI experience with renal RFA is limited, we reviewed our experience and report the unique MRI characteristics of RFA-treated renal tumors. METHODS: A single-institution database of renal RFA was reviewed to identify patients followed up with MRI. A radiologist and urologist retrospectively reviewed all MRI scans to identify the characteristic lesion findings after RFA. RESULTS: Eleven patients (12 tumors) treated by RFA were followed up with MRI examinations. The mean follow-up was 10 months. The mean tumor size at ablation was 2.4 cm, with minimal reduction over time. Ablated lesions were characterized by high signal intensity on T1-weighted images, low signal intensity on T2-weighted images, and an absence of contrast enhancement. Of the patients treated by percutaneous RFA, 71% developed a characteristic peritumor halo, seen as a rim of low signal intensity on T1-weighted and T2-weighted images, surrounding a zone of perinephric fat just external to the ablated area. Two lesions demonstrated enhancement on the initial postablation MRI scan, indicating incomplete ablation. CONCLUSIONS: The MRI characteristics of successfully ablated renal tumors include the absence of enhancement, minimal size reduction over time, and high and low signal intensity on T1-weighted and T2-weighted imaging, respectively. Knowledge of these findings can aid radiologists and urologists in correctly assessing the success of RFA for kidney lesions.

Aged↗
PubMed2006

Assessment of basic human performance resources predicts performance of ureteroscopy.

BACKGROUND: Our objective was to predict endoscopic performance in a cadaver model using basic performance resources (BPRs) measurements. METHODS: Medical students (n = 16) underwent intense ureteroscopic training on a virtual reality ureteroscopy trainer and were rated on performing ureteroscopy on a cadaver. The medical students also underwent 13 validated BPR measurements. Urology residents also performed cadaveric ureteroscopy and BPRs. A predictive model built from urology residents' (n = 16) BPRs and performance assessment was used to predict medical student cadaveric ureteroscopy performance based on their BPRs alone. RESULTS: The predictive model built with urology residents predicted the ureteroscopic performance of 10 of 16 medical students within 15% of their rated ureteroscopic performance on the cadaver. CONCLUSIONS: A predictive model built with urology residents can moderately predict the ureteroscopic performance of medical students from BPRs. Additional in vivo evaluation is required.

Adult↗
PubMed2006

The influence of clinical and pathological stage discrepancy on cancer specific survival in patients treated for renal cell carcinoma.

PURPOSE: We compared clinical and pathological staging in a contemporary, consecutive series of patients treated with partial or radical nephrectomy for renal cell carcinoma and we determined the effect of clinical and pathological stage discrepancy on outcomes. MATERIALS AND METHODS: We collected retrospective clinical, pathological and survival data on 264 consecutive patients with clinical T1-3 renal cell carcinoma who were treated with laparoscopic or open partial or radical nephrectomy at a single institution from 1994 to 2003. RESULTS: Pathological up staging occurred in 44 of 264 patients (17%) patients. Of 135 clinical T1 tumors 25 (18.5%) and 18 of 85 (21.2%) clinical T2 tumors were pathologically up staged. Patients with clinical T1 and T2 tumors were stratified into 2 groups, including those with the same clinical and pathological stage, and those with pathological up staging. Mean 5-year recurrence-free survival +/- SD for same stage vs pathologically up staged clinical T1 (84.3% +/- 4.4% vs 47.4% +/- 11.5%) and clinical T2 (80.0% +/- 6.8% vs 40.7% +/- 13.4%) tumors was significantly different (p < 0.0002). Five-year cancer specific survival for same stage vs pathologically up staged clinical T1 tumors was significantly different (98.5% +/- 1.5% vs 69.7% +/- 11.3%, p = 0.0005), while that for clinical T2 tumors approached clinical significance (90.9% +/- 5.0% vs 72.7% +/- 13.4%, p = 0.0501). CONCLUSIONS: Stage discrepancy is common in surgically treated patients diagnosed with renal masses and it has a significant impact on clinical outcome. Implications of such clinical and pathological stage discrepancy should be considered when counseling patients and determining therapeutic approaches.

Adult↗
PubMed2006

Laparoscopic decision making: impact of preoperative reading and laparoscopic experience.

PURPOSE: A competent laparoscopic surgeon requires good technical skills and good surgical judgment. The assessment of technical skills using bench models and simulators has been well studied. However, there has been a paucity of studies examining the cognitive aspects of surgery. We developed a novel tool to assess the procedural knowledge and higher level decision making required for successful laparoscopic nephrectomy. We assessed the effect of laparoscopic experience and the effect of self-preparation or preoperative reading on surgical decision making abilities using a novel assessment tool and methodology. MATERIALS AND METHODS: A total of 17 novice and advanced urology residents were randomized to preoperative reading or no preoperative reading. Subjects viewed laparoscopic nephrectomy clips and verbalized their thought processes. Their performance was transcribed and blindly rated using a new surgical decision making rating scale. RESULTS: The correlation with overall surgical decision making rating scale score was good for years of training and moderate for the number of laparoscopic cases performed (r = 0.7 and 0.54, respectively, p < 0.05). Preoperative reading did not have a significant impact on the overall surgical decision making rating scale score (p > 0.05). However, when stratified by laparoscopic experience level (fewer than 10 cases), preoperative reading had a significant impact on the performance of novices with respect to the knowledge components of the procedure but not the judgment domain (each p > 0.05). CONCLUSIONS: Overall preoperative reading did not improve the surgical decision making rating scale. Novice procedural knowledge benefited from preoperative reading but not surgical judgment. The surgical decision making rating scale appears promising and it may have future implications for assessing surgical competency.

Clinical Competence↗
PubMed2006

A randomized, controlled, prospective study validating the acquisition of percutaneous renal collecting system access skills using a computer based hybrid virtual reality surgical simulator: phase I.

PURPOSE: The need to develop new methods of surgical training combined with advances in computing has led to the development of sophisticated virtual reality surgical simulators. The PERC Mentortrade mark is designed to train the user in percutaneous renal collecting system access puncture. We evaluated and established face, content and construct validation of the simulator in this task. MATERIALS AND METHODS: A total of 63 trainees underwent baseline testing on the simulator, consisting of percutaneous renal puncture followed by the introduction of a guidewire into the collecting system. Subjects were then randomized to an intervention arm, in which they underwent 2, 30-minute training sessions on the simulator, and a control arm, in which no further training was given, followed by repeat testing. Performance was assessed using a global rating scale and by virtual reality derived parameters. RESULTS: There were no significant differences between the 2 groups with respect to baseline measures. Subjects who underwent training with the simulator demonstrated significant improvement in objective and subjective parameters compared to their baseline performance and compared to the untrained control group. Spearman rank correlations demonstrated a significant relationship between multiple parameters of the objective and subjective data. CONCLUSIONS: Training on the simulator improves virtual reality skills. It may allow trainees to develop the basic skills necessary to perform percutaneous renal collecting system access. Face and content validity were demonstrated and construct validity was supported by establishing convergent validity.

Computer Simulation↗
PubMed2006

Residual and recurrent disease following renal energy ablative therapy: a multi-institutional study.

PURPOSE: In this study we detail the incidence and pattern of residual and recurrent disease after radio frequency ablation or cryoablation of a renal mass and, using this information, determine reasonable minimum recommendations for when to perform surveillance imaging during year 1 after treatment. To our knowledge no evidence based guidelines exist for determining how or when followup abdominal imaging should be performed after renal energy ablative therapy. MATERIALS AND METHODS: We reviewed treatment and followup information of patients who underwent radio frequency ablation or cryoablation for a renal mass at 7 institutions. Postoperative monitoring was performed using a variety of surveillance schedules. RESULTS: Of 616 patients 63 were found to have residual or recurrent disease after primary radio frequency ablation (13.4%) or cryoablation (3.9%) for a median of 8.7% in 7 institutions. Most incomplete treatments (70%) were detected within the first 3 months. After salvage ablative therapy was rendered, therapy failed in only 4.2%. At a mean followup of 2 years patients with residual or recurrent disease had an overall survival rate of 82.5% and a 2-year metastasis-free survival rate of 97.4% for those with localized, unilateral renal tumors. CONCLUSIONS: In most cases initial treatment failure was detected within the first 3 months after treatment. Our findings support a minimum of 3 to 4 imaging studies in year 1 after ablative therapy, and at months 1, 3, 6 (optional) and 12.

Catheter Ablation↗
PubMed2006

Nicotinamide adenine dinucleotide staining immediately following radio frequency ablation of renal tumors-is a positive stain synonymous with ablative failure?

PURPOSE: Nicotinamide adenine dinucleotide diaphorase staining is arguably the standard for assessing tissue viability following radio frequency ablation, yet the accuracy of this test is questionable. Thus, it is imperative to examine the reliability of nicotinamide adenine dinucleotide to predict ablation success. To evaluate the observation that immediate nicotinamide adenine dinucleotide staining may not be clinically reliable, we compared results from immediate post-ablation biopsies of renal tumors to radiological and clinical followup. MATERIALS AND METHODS: Laparoscopic radio frequency ablation was performed in 9 patients and 10 tumors using a temperature modulated radio frequency system. Cold cup biopsies were taken immediately following ablation, and processed for nicotinamide adenine dinucleotide and hematoxylin and eosin staining. Patients were then followed using contrast enhanced computerized tomography at regular intervals. RESULTS: Median tumor size was 2.3 cm. Hematoxylin and eosin stain diagnosed 8 renal cell carcinomas and 2 angiomyolipomas. A quarter of the renal cell carcinomas and both angiomyolipomas stained positive for scattered nicotinamide adenine dinucleotide diaphorase activity immediately after RFA. Mean followup for the nicotinamide adenine dinucleotide positive tumors was 28.5 months (range 24 to 30) and for the nicotinamide adenine dinucleotide negative tumors was 25 months (range 18 to 30). There was no evidence of local tumor recurrence in any patient. CONCLUSIONS: Four lesions had nicotinamide adenine dinucleotide diaphorase activity on post-ablation biopsy suggesting retained viable tissue, yet there has been no recurrence during an average 2-year followup. While negative nicotinamide adenine dinucleotide staining is consistent with nonviability, these results suggest that false-positive staining can occur immediately following RFA, making the predictive value of positive nicotinamide adenine dinucleotide diaphorase staining unclear.

Adult↗
PubMed2006

Imaging associated with percutaneous and intraoperative management of renal tumors.

As new minimally invasive treatment options for small renal tumors such as laparoscopic partial nephrectomy (LPN), radiofrequency ablation (RFA), and cryoablation(CA) have been developed, the reliance upon imaging technologies, both intraoperatively and postoperatively, has expanded greatly. CT, MRI, and ultrasonography (US)have proven themselves extremely useful in this regard, but their utility requires a thorough understanding of each modality's limitations, proper intraoperative use, and expected postoperative findings. This article discusses intraoperative use of US for LPN,RFA, and CA. The expected postoperative MRI and CT findings after CA and RFA also are covered, highlighting the different radiographic evolutionary patterns encountered after use of these technologies. Because the success of these new treatments for small re-nal tumors (especially RFA and CA) depends not only on the technology itself but also on the advantages and limitations of the associated radiographic techniques, urologists of the 21st century must be facile at interpreting and manipulating these imaging modalities to appropriately care for their renal tumor patients.

Catheter Ablation↗
PubMed2006

Resorbable clip migration in the collecting system after laparoscopic partial nephrectomy.

A complication is reported in which Lapra-Ty absorbable suture clips (Ethicon EndoSurgery) migrated from a laparoscopic partial nephrectomy bed into the collecting system, causing renal colic. During surgery performed with hilar occlusion, visual inspection did not reveal collecting system entry. Transected vessels were oversewn with absorbable suture secured with Lapra-Tys. Absorbable bolsters were placed in the parenchymal bed, and compression sutures secured with Lapra-Tys were placed through the renal capsule. Six weeks postoperatively, the patient developed ipsilateral renal colic, and computed tomography demonstrated several 3-mm opacities within the ureter. After 2 weeks of conservative management, he spontaneously passed several Lapra-Ty clips.

Foreign-Body Migration↗
PubMed2006

No evidence of disease after radiofrequency ablation in delayed nephrectomy specimens.

OBJECTIVES: Computed tomography and magnetic resonance imaging are routinely used during follow-up of radiofrequency ablation (RFA) of renal masses. Widespread acceptance of needle ablation is limited by the need to rely on radiographic criteria to confirm effective ablation. In this report, we correlated the long-term radiographic appearance of RFA with the histologic findings in three delayed nephrectomy specimens. This should enhance our understanding of the histopathologic features of successful RFA and highlight potential shortcomings of modern imaging after ablation. METHODS: Radiographic and histologic data were analyzed in 3 patients who underwent delayed partial or total nephrectomy after RFA, performed for complications or misinterpretation of postablation surveillance imaging findings. RESULTS: Two delayed nephrectomies were performed for new enhancement at the periphery of the ablation zone margin and one for RFA-related ureteropelvic junction obstruction. At the initial ablation, all 3 patients had biopsy-proven renal cell carcinoma, and the mean time to delayed nephrectomy was 18 months. Histologically, all three demonstrated absence of residual cancer within the ablation zone. In the patients with enhancement at the periphery of the ablation zone, a granulomatous foreign body giant cell reaction was found. CONCLUSIONS: RFA is an effective technology for eradicating small renal cell carcinomas. However, proper image interpretation after ablation is a crucial component of patient care. New enhancement at the peripheral margin of the tumor ablation zone does not invariably suggest malignant recurrence, but a benign granulomatous reaction. Additional experience with interpretation of cross-sectional imaging is required to better understand the radiographic evolution of radiofrequency-ablated renal tumors.

Aged↗
PubMed2006

Serum laboratory values following uncomplicated laparoscopic urological surgery.

PURPOSE: Presentation of complications following laparoscopic surgery can be different from corresponding open surgical complications. While leukopenia has been identified as a common finding in patients with unrecognized bowel injury following laparoscopy, to our knowledge no study has determined if leukopenia or other serum abnormalities are unique to patients with laparoscopic complications. We present an analysis of postoperative laboratory values from patients after uncomplicated urological laparoscopic surgery. MATERIALS AND METHODS: A retrospective review of 50 adult patients who had previously undergone uncomplicated laparoscopic urological procedures was performed. Exclusion criteria were preexisting hematological, immune, liver or pancreatic disorders. Common serum laboratory values were measured on postoperative day 1. RESULTS: All values for bilirubin were within normal limits. Of patients undergoing a right side renal procedure, 10 of 16 (63%) had a postoperative increase in liver function tests. Amylase or lipase was increased in a total of 12 (24%) patients. Patients undergoing laparoscopic prostatectomy accounted for the majority of this group with 9 of 21 (43%) patients having increased amylase or lipase. Finally, there were no patients with immediate postoperative leukopenia. CONCLUSIONS: Following uncomplicated laparoscopic procedures, bilirubin levels are rarely affected, amylase and lipase may be acutely increased following laparoscopic prostatectomy, and white blood count is commonly increased. While 16 (36%) patients had postoperative leukocytosis, leukopenia was not detected after uncomplicated laparoscopic urological surgery and should alert the surgeon to the possibility of an undiagnosed complication.

Adult↗
PubMed2006

Comparison of basic elements of human performance scores between urologists with various extents of experience.

BACKGROUND AND PURPOSE: An objective evaluation of innate ability and its ability to predict potential success as a surgical trainee is an appealing concept for the selection process of residency applications. The objective of this study was to evaluate whether basic elements of performance (BEP) could discriminate among resident applicants and urologists with various extents of surgical experience. SUBJECTS AND METHODS: One hundred forty-five participants were divided into four study groups: group A, 57 urology residency applicants to the 2002 and 2003 interview process; group B, 8 post-internship urology residents; group C, 19 urologists tested with BEP within 10 years of graduation from their residency training program; and group D, 61 urologists who had graduated from their residency training program more than 10 years prior to testing. The BEP measures consisted of 13 basic performance resources (BPR) including visual-information processing speed, visual-spatial immediate-recall capacity, and neuromotor channel capacity. RESULTS: The four study groups differed significantly in their mean age: group A=27.6 years, group B=29.1 years, group C=37.1 years, and group D=48.9 years (P<0.0005). There was essentially no significant difference between the groups with regard to immediate-recall memory, reaction time simple, or reaction time complicated. The younger participants (groups A and B) were faster than the older surgeons (groups C and D) (P<0.02). However, the older surgeons (groups C and D) were significantly more accurate than the younger groups (A and B) (P<0.0005). The only sex differences noted were in hand-grip strength and shoulder-strength scores, which were all higher in the men. CONCLUSIONS: There generally appears to be a lack of direct correlation between innate abilities and surgical experience. Urology resident applicants with no surgical experience and urology residents with limited surgical experience are faster but less accurate in innate skills testing than experienced practicing urologists.

Adult↗
PubMed2006

Effect of multisite radiofrequency ablation on porcine renal function.

BACKGROUND AND PURPOSE: The acute and long-term effects of radiofrequency ablation (RFA) on kidney function have not been well studied. The functional change when RFA is used in combination with renal ischemia is likewise unknown. Our goal was to determine the change in renal function caused by various volumes of RFA on a porcine kidney model and the effect cold ischemia had on the results. MATERIALS AND METHODS: Twenty-two female pigs with solitary kidneys underwent various volumes of RFA both with and without cold ischemia. Animals were divided into control, 10%, 15%, and 20% ablation of the total kidney volume. Measurements of creatinine were obtained for 2 weeks. RESULTS: In the nonischemic group, the mean acute (day 1-3) creatinine changes in control, 10%, 15%, and 20% ablations were 0.6, 2.4, 1.7, and 2.6 mg/dL, respectively. In the cold-ischemia group, the mean acute creatinine changes were 0.85, 2.33, 3.3, and 3.75 mg/dL, respectively. Regression line analysis demonstrated a positive linear relationship in both groups. Fourteen-day mean creatinine changes for the nonischemic group were similar to those in the control animals and did not show a correlation with ablation volume. The mean creatinine changes at 14 days in the cold-ischemia group showed a positive linear correlation with ablation volume. CONCLUSIONS: The volume of RFA correlates with an acute change in renal function in the porcine model for both nonischemic and cold-ischemia groups. This study may help predict the extent of acute renal dysfunction in patients undergoing RFA for large or multiple renal masses. These results also suggest renal function may recover after nonischemic RFA.

Acute Disease↗
PubMed2006

Radiofrequency ablation of renal tumors: intermediate-term results.

BACKGROUND AND PURPOSE: Needle ablative therapies are being offered to patients presenting with small renal masses, but long-term outcomes are currently unavailable. We report our intermediate-term results (1-4 years) after radiofrequency ablation (RFA) of small (<4-cm) renal masses. PATIENTS AND METHODS: At our institution, all renal tumors treated using RFA since May 2001 have been recorded in a prospective database. During this time, 94 tumors (mean size 2.4 cm; range 1-4.2 cm) in 78 patients were treated using a temperature-based RFA generator by either a percutaneous (59%) or a laparoscopic approach. The patients followed with imaging at 6 weeks, 3 and 6 months, and every 6 months thereafter. Only patients with at least 12 months of follow-up were eligible for this analysis; the mean follow-up was 25 months. RESULTS: Of the 89% of masses that were biopsied, 77% were renal-cell carcinomas (RCC), of which 66% were Fuhrman grade 1, 31% were grade 2, and 3% were grade 3. Three recurrences were noted, for an overall recurrence-free rate of 96.8%. In this patient population with numerous comorbid conditions, there were six deaths but only one related to renal cancer, for a cancer-specific survival rate of 98.5% and an overall survival rate of 92.3%. CONCLUSION: In the intermediate term (1-4 years), the oncologic effectiveness of RFA appears comparable to that of traditional treatments offered for small renal masses. Further studies of larger numbers of patients with longer follow-up are needed.

Adult↗
PubMed2006

Laparoscopic and open retroperitoneal lymph-node dissection for clinical stage I nonseminomatous germ-cell testis tumors.

BACKGROUND AND PURPOSE: Laparoscopic retroperitoneal lymph node dissection (L-RPLND) has been reported as efficacious for staging of the retroperitoneum in patients with stage I nonseminomatous germ-cell testis tumors (NSGCT). However, reports are limited to a few centers, and this procedure has yet to be widely accepted as an alternative to open retroperitoneal lymph node dissection (O-RPLND). Thus, we compared our contemporary open and laparoscopic experience with RPLND. PATIENTS AND METHODS: A retrospective chart review identified 28 patients who underwent either open (N = 6) or laparoscopic (N = 22) RPLND for clinical stage I NSGCT since 2000. Each patient received the appropriate modified template dissection. Perioperative demographic data, histologic nodal status, and recurrence data were evaluated. The mean follow-up was similar in the two groups. RESULTS: The mean operative time was not significantly different (313 minutes for L-RPLND v 284 minutes for O-RPLND). However, L-RPLND did have a significantly shorter hospitalization (1.2 v 8.5 days). Significantly more lymph nodes were removed with O-LPLND than with L-RPLND (mean 33 v 17). There was a single recurrence outside the modified template after both L-RPLND and O-RPLND and one within-the-template recurrence in the O-RPLND group. CONCLUSIONS: The L-RPLND is associated with less blood loss and a shorter hospital stay than O-RPLND, whereas the lymph-node yield of O-RPLND is greater. However, during the critical early follow-up period, the oncologic effectiveness and morbidity of L-RPLND for clinical stage I NSGCT appears similar to that of O-RPLND.

Adolescent↗