Hinrichsenhanna3036

Penile cancer is a rare malignancy with a reported incidence of 0.66-1.44 per 100,000 men, and a reported mortality of 0.15-0.37 per 10,000 men. Expert clinical examination and histological diagnosis from biopsy is required to determine the extent and invasion of disease, which is paramount in planning of appropriate treatment. Management of loco-regional penile cancer can be divided into management of primary tumour and management of regional lymph nodes. This review article will focus on the management of the primary penile tumour with particular focus on penile sparing therapies. The aim of primary penile tumour management is to completely remove the tumour whilst preserving as much organ function as possible. Preservation of the penis is important as it allows patients to maintain urinary and sexual function, as well as quality of life. With the majority of penile cancer confined to the glans and foreskin, most penile cancers can be managed with organ-preserving therapy. A wide variety of treatment options are available, and this review aims to describe each of the options including the reported oncological and functional outcome for the different therapies for penile cancer.Penile cancer is a rare cancer, with the majority treated with penile preserving methods. There remains a role for partial and totally penectomy for advanced and more proximal penile cancers. Significant functional and psychological morbidity can ensue for patients undergoing surgical management. Recent studies and guidelines are changing the way Urologists approach surgical management of penile malignancies. Reductions in safe surgical margin recommendations from 2 cm to 3-5 mm provide surgeons with the ability to perform penile preserving techniques to maximise patient functionality. These guidelines are reflected by recent studies showing that smaller surgical margins; although heralding higher rates of local recurrence, have no detriment on cancer specific or overall survival rate. Although oncological clearance remains the primary outcome for surgical management of penile cancer, the ability to perform radical salvage surgery at a later date means patients are more likely to experience a longer period of functionality without sacrificing oncologic outcomes. The importance of patient education on regular self-examination as well as clinic follow up are key in identifying local recurrence and planning salvage surgery if needed to maintain oncologic control. Ongoing studies into the functional and psychological outcomes of patients undergoing partial penectomy show encouraging results however further studies are needed to elucidate long-term outcomes. The evolving paradigm of surgical management in penile malignancy is shifting to favour organ preserving techniques in order to maximise functional, psychological and aesthetic outcomes without compromising patients' oncologic outcomes-however a role still exists for radical surgery in advanced penile malignancy.The nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.Upper tract urothelial carcinoma (UTUC) often occurs in elderly patients with multiple co-morbidities including renal impairment. As such, nephron sparing surgery (NSS) often needs to be considered. This article reviews the available NSS techniques for UTUC, including ureteroscopy, percutaneous approaches and segmental ureterectomy. PubMed and OvidMEDLINE reviews of available case series from the last 10 years demonstrated that recurrence was highly variable between studies and occurred in 19-90.5% of ureteroscopic cases, 29-98% of percutaneous resections and in 10.2-31.4% of patients who underwent segmental ureterectomy. The small number of included studies and variable follow up periods made comparison between techniques difficult. Galunisertib ic50 NSS is a necessary alternative for patients with significant comorbidities or renal impairment who cannot undergo radical nephro-ureterectomy. However, there is significant variation in oncological outcomes, with an increased risk of progression or death from cancer-salvage by radical surgery may sometimes be required.Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.Partial nephrectomy is recommended for surgical management of small renal masses (SRM), or lesions ≤7 cm. The decision for surgical intervention involves a balanced patient assessment. Minimally invasive approach, which includes laparoscopic and robotic techniques, has shown to have improved blood loss, length of hospitalization, and post-operative pain while maintaining oncologic efficacy when compared to an open approach. Transperitoneal approach is preferred at most centers; however, retroperitoneoscopic minimally invasive surgery (MIS) partial nephrectomy expertise is essential for comprehensive kidney cancer care. With advances in surgical technology and deep penetration of robotics into surgical training and practice, robotic partial nephrectomy has become the modality of choice in modern clinical practice. This review discusses the indications and outcomes for various minimally invasive approaches of partial nephrectomy.Radical nephrectomy (RN) remains a cornerstone of the management of localised renal cell carcinoma (RCC). RN involves the en bloc removal of the kidney along with perinephric fat enclosed within Gerota's fascia. Key principles of open RN include appropriate incision for adequate exposure, dissection and visualisation of the renal hilum, and early ligation of the renal artery and subsequently renal vein. Regional lymph node dissection (LND) facilitates local staging but its therapeutic role remains controversial. LND is recommended in patients with high risk clinically localised disease, but its benefit in low risk node-negative and clinically node-positive patients is unclear. Concomitant adrenalectomy should be reserved for patients with large tumours with radiographic evidence of adrenal involvement. Despite a recent downtrend in utilisation of open RN due to nephron-sparing and minimally invasive alternatives, there remains a vital role for open RN in the management of RCC in three domains. Firstly, open RN is important to the management of large, complex tumours which would be at high risk of complications if treated with partial nephrectomy (PN). Secondly, open RN plays a crucial role in cytoreductive nephrectomy (CN) for metastatic RCC, in which the laparoscopic approach achieves similar results but is associated with a high reoperation rate. Finally, open RN is the current standard of care in the management of inferior vena caval (IVC) tumour thrombus. Management of tumour thrombus requires a multidisciplinary approach and varies with cranial extent of thrombus. Higher level thrombus may require hepatic mobilisation and circulatory support, whilst the presence of bland thrombus may warrant post-operative filter insertion or ligation of the IVC.Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.Retroperitoneal lymph node dissection (RPLND) is an infrequently used, but important part of the management of men with metastatic germ cell tumours. The surgery aims to remove the lymph nodes from the primary retroperitoneal landing site from testicular tumours, usually accomplished by removing tissue surrounding the great vessels using a split-and-roll technique. RPLND may be carried out as a primary surgical procedure for staging or treatment of metastases. More frequently it is undertaken as a follow-up after chemotherapy for a residual mass that may contain viable tumour or teratoma. RPLND is recognised as a major surgery with significant risks of morbidity and complications, particularly loss of ejaculation secondary to damage to hypogastric nerves. In select cases, especially during primary RPLND, nerve-sparing surgery may help preserve ejaculation, which maybe of importance to the young men usually treated for germ cell tumours. In recent years, the development of minimally invasive approaches have also offered a means for potential improvement in the pain and post-operative recovery from RPLND. We conducted a narrative review of the literature to assess indications for RPLND, along with operative approaches and techniques and related outcomes. The majority of available literature is in the form of relatively small retrospective case series, hence additional research in this area is desirable.