Journal of Clinical Urology

Significant study has been made of the role of tumor volume contributing to outcome in prostate cancer: almost two dozen studies have been published on the subject, without clear results either for or against a relationship.

An extensive MEDLINE and PUBMED search yielded fourteen articles involving >10,600 patients describing analyses of institutional prostate cancer experiences including tumor volume after radical prostatectomy (RP). Studies were included if multivariate analysis (MVA) was performed including a variable related to tumor volume. All studies had a common outcome of biochemical disease-free (bNED) survival.

The more rigorous the MVA performed, the more likely tumor volume was to be independently predictive. When the analysis included only tumor volume and Gleason score, studies agreed on outcome half the time. As more variables were added to the analysis, the degree of concordance increased. The two studies with most complete MVAs concur in a volume effect on outcome in over 1470 patients.

While no meta-analysis on the subject is possible without knowing particulars of each reported case, tumor volume as a predictive variable is likely to be less important than more frequently analyzed factors such as Gleason score and PSA. However, the studies that most completely address the complex and competing variables impacting bNED survival in prostate cancer are those that describe a relationship of tumor volume on outcome.

Stented PCNL is an increasingly practiced technique in which PCNL is performed without leaving a post-operative nephrostomy tube. We present our results from one of the biggest UK series to assess the impact of this technique on the safety, efficacy, length of hospital stay and analgesic requirement, to guide our future practice in terms of patient selection.

Case notes of 56 stented PCNLs between October 2005 and 2007 were reviewed retrospectively and compared to a similar group of 50 conventional PCNLs (only a nephrostomy post-operatively) in terms of co-morbidities (ASA grade), stone burden, intra-operative details, complications, length of stay (LOS) and analgesic requirement. The stented technique was employed in complex stones and in anatomical abnormalities (e.g. horseshoe, solitary, and duplex systems). The use of a stent rather than a nephrostomy was decided at the time of surgery when satisfactory haemostasis and stone clearance were achieved at the end of the procedure.

Co-morbidities, anatomical abnormalities, stone burden, operative time, number of punctures, access and infection rates were comparable. The stented technique was employed in complex stones (staghorn n = 13, multiple stones n = 11) and in patients with anatomical abnormalities (n = 9). Overall stone free rate was 92.8% and 82% for the stented and the conventional groups, respectively. No haemorrhage or ureteric obstruction was reported in the stented group. All stent removals were uneventful. Mean LOS and analgesic requirement of diclofenac were markedly less in stented group. The number of stented procedures tripled from year 1 (n = 14) to year 2 (n = 42). Mean LOS dropped steadily from 68.6h in the first 6 months (n = 5) to 47.4h in the last 6 months (n = 22) with increased experience. Twenty-four patients (42%) were fit for discharge within 35h.

In our experience, the stented technique was well tolerated and has reduced the length of hospital stay with no evidence of loss of efficacy or increased morbidity even in complex stones or patients with anatomical abnormalities.