Objective To study the natural history, prognosticators, and outcomes in patients with RCC with extension of tumor beyond Gerota’s fascia and/or invading contiguously into the adrenal gland (pT4). Patients and Methods From 1992 to 2012, we identified 61 patients who underwent radical nephrectomy and were found to have pT4 disease. Clinicopathological variables were queried using univariate analysis to identify relevant prognostic variables. Cox proportional hazards model was used for multivariate analysis of predictors of cancer-specific survival. Survival plots were estimated using Kaplan-Meier method and survival analysis using log-rank test. Results Median age was 56 years (IQR 49-64) and 49 (81.7%) had ECOG PS 0-1. At diagnosis, 22 (36.1%) patients were M0 and 39 (63.9%) were M1. Forty-nine(80.3%) patients had clear cell RCC. Twenty-four(39.3%) had sarcomatoid features. Thirty-nine(69.6%) patients had Fuhrman grade 3-4. There were twenty-six(42.6%) pN0 patients, 16(26.2%) pN1, and 19(31.1%) pNx. Median CSS was 37 months for M0 and 8 months for M1 patients. On multivariate analysis, preoperative LDH and alkaline phosphatase, M stage, pN stage, and sarcomatoid dedifferentiation were significantly associated with survival. Conclusions Survival in patients with pT4 remains poor. pT4 is associated with a locally and regionally invasive biology that requires specific attention and warrants careful study. Understanding the drivers of this unique phenotype will generate therapeutic interventions that can change the behavior of these uniquely aggressive tumors.

In the setting of an infected inflatable penile prosthesis (IPP), removal of the reservoir is a surgical challenge. We describe a novel technique for IPP reservoir removal at the time of IPP explantation utilizing laparoscopic instruments. We present two cases of infected IPPs requiring complete removal of all components of the implant. The corporal cylinders and scrotal pump were removed via a single penoscrotal incision. Through the same incision, a lighted, hand-held retractor was used for visibility, and laparoscopic instruments were utilized to dissect the tissue surrounding reservoir and the attached tubing until free. Then, a completely intact reservoir was easily removed. Infected IPP reservoirs were successfully removed in this fashion without any complication. This new technique not only facilitated the safe removal of the reservoir, but also enhanced surgical efficiency by eliminating the need for additional incisions. We performed a review of current literature concerning techniques and indications for removal of IPPs and the reservoir. In the setting of an infected penile prosthesis, all components of the implant should be removed. Removal of the reservoir has been surgically difficult due to its location, either deep in the space of Retzius or high in the abdomen between the muscular fascias. Our new technique provides an innovative solution for reservoir removal with the use of laparoscopic instruments via a single penoscrotal incision. We have found that this technique overcomes the challenge of a cumbersome blind dissection and the need for the second incision.

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