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BACKGROUND: Insulin-like growth factor (IGF)-1 and its binding proteins are important in cancer growth, especially in prostate cancer. Observational studies suggest that protein restriction can lower IGF-1 levels. However, it is unclear whether an isocaloric protein-restricted diet affects IGF-1 and IGFBPs in men with prostate cancer. METHODS: In this academic, single-center, parallel-group, prospective, randomized, open-label, blinded end-point trial, 38 consenting overweight (BMI 30.5 ± 5.5 kg/m2) men with localized prostate cancer, aged 43-72 years, were randomized (1:1) with permuted blocks to 4-6 weeks of customized isocaloric PR diets (0.8 g protein/kg lean body mass) or their usual diet. Biomarkers influencing cancer biology, including serum IGF-1 and its binding proteins were measured longitudinally. RESULTS: Contrary to our hypothesis, feeding individuals an isocaloric protein-restricted diet did not result in a significant reduction in serum IGF-1. Moreover, there was no observed increase in serum IGFBP-1 or IGFBP-3 concentration. CONCLUSION: These findings demonstrate that protein restriction without calorie restriction does not reduce serum IGF-1 concentration or increase IGFBP-1 and IGFBP-3 in men with localized prostate cancer. Further research is needed to identify dietary interventions for safely and effectively reducing IGF-1 in this patient group.
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Our objective was to assess the diagnostic accuracy of 99mTc-sestamibi SPECT/CT for characterizing solid renal masses. Methods: Imaging and clinical records of patients who underwent 99mTc-sestamibi SPECT/CT for clinical work-up of their solid renal masses from September 2018 to October 2021 were retrospectively reviewed. Histopathology formed the reference standard, and the diagnoses were categorized as malignant/concerning (renal cell carcinomas [RCCs] other than chromophobe histology) and benign/nonconcerning (oncocytic tumors including chromophobe RCC, other benign diagnoses) to calculate the sensitivity and specificity of 99mTc-sestamibi SPECT/CT and contrast-enhanced CT (ceCT). The clinical reads of the SPECT/CT images were used for visual classification of the lesions. Additionally, the SPECT images were manually segmented to obtain the maximum and mean counts of the lesion and adjacent renal cortex and maximum and mean lesion Hounsfield units. Results: 99mTc-sestamibi SPECT/CT was performed on 42 patients with 62 renal masses. A histopathologic diagnosis was available for 27 patients (18 male, 9 female) with 36 solid renal masses. ceCT findings were available for 20 of these patients. The most commonly identified single histologic type was clear cell RCC (13/36; 36.1%). Oncocytic tumors were the most common group of nonconcerning lesions (15/36), with oncocytoma as the predominant histologic type (n = 6). The sensitivity and specificity of SPECT/CT for diagnosing a nonconcerning lesion were 66.7% and 89.5%, respectively, compared with 10% and 75%, respectively, for ceCT. The lesion-to-kidney ratios for maximum and mean counts and maximum lesion Hounsfield units showed significant differences between the 2 groups (P < 0.05). The lesion-to-kidney mean count ratio at a cutoff of 0.46 showed a sensitivity and specificity of 87.5% and 86.67%, respectively, for detecting nonconcerning lesions, which was significantly higher than that of ceCT. Conclusion: The current literature on the utility of 99mTc-sestamibi SPECT/CT for characterization of solid renal masses is limited. We offer additional evidence of the incremental value of 99mTc-sestamibi SPECT/CT over ceCT for differentiating malignant or aggressive renal tumors from benign or indolent ones, thereby potentially avoiding overtreatment and its associated complications. Quantitative assessment can further increase the diagnostic accuracy of SPECT/CT and may be used in conjunction with visual interpretation.
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Carcinoma de Células Renales , Neoplasias Renales , Humanos , Masculino , Femenino , Carcinoma de Células Renales/diagnóstico por imagen , Estudios Retrospectivos , Tecnecio Tc 99m Sestamibi , Tomografía Computarizada de Emisión de Fotón Único/métodos , Neoplasias Renales/diagnóstico por imagen , Neoplasias Renales/patología , Tomografía Computarizada por Rayos X/métodos , RadiofármacosRESUMEN
Introduction: The proportion of robotic procedures continues to rise. The literature reinforces that robotic procedures take longer and are often more costly. We compared cost and perioperative outcomes of laparoscopic radical nephrectomy (LRN) and robot-assisted radical nephrectomy (RARN) at our high-volume center. Materials and Methods: We retrospectively reviewed our 2012-2015 data repository for patients undergoing RARN and LRN for a renal mass. Perioperative and oncologic outcomes were compared. We performed a multivariate analysis of operative time, estimated blood loss, length of stay (LOS), and overall and major 90-day complication rates while controlling for demographic data, Charlson comorbidity index (CCI), tumor size, and surgeon factors. We compared fixed, variable, and distinct procedural costs. Results: We identified 99 LRN and 95 RARN cases. There was no difference in demographic data, tumor size, preoperative renal function, and malignant histology. LRN patients had more comorbidities (49.5% vs 27.3% CCI 2+, p = 0.018). The mean preoperative glomerular filtration rate was higher in the robotic cohort (84.8 vs 75.1, p = 0.48). Mean operative time was 32.7 minutes longer (p = 0.002) and estimated blood loss 145 mL higher (p = 0.007) for the RARN cohort. There was no difference in mean LOS. Major and all 90-day complication rates were no different. The mean procedural cost for RARN was higher by $464 when controlling for operative time (p < 0.001). Fixed costs were not statistically different. Variable costs for RARN were estimated to be $2,310 higher (p = 0.045). Conclusions: Even with cost-conscious, experienced renal surgeons, RARN is associated with a longer procedure, higher supply costs, and higher hospitalization costs. There was no difference in positive surgical margin and complications. There were fewer 30-day readmissions for the RARN cohort, which may represent under-recognized cost savings. With fewer LRN cases in the United States each year, discussion to address cost is warranted. Without better outcomes for robotic surgery, a change in reimbursement to cover costs is unlikely to happen.
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Neoplasias Renales , Laparoscopía , Robótica , Humanos , Neoplasias Renales/cirugía , Nefrectomía , Estudios Retrospectivos , Estados UnidosRESUMEN
Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.
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Hernia Incisional , Procedimientos Quirúrgicos Robotizados , Humanos , Hernia Incisional/etiología , Hernia Incisional/cirugía , Nefrectomía/efectos adversos , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Centros de Atención TerciariaRESUMEN
Background: The surgical techniques and devices used to perform radical cystectomy have evolved significantly with the advent of laparoscopic and robotic methods. The da Vinci® Single-Port (SP) platform (Intuitive Surgical, Inc., Sunnyvale, CA) is an innovation that allows a surgeon to perform robot-assisted radical cystectomy (RARC) through a single incision. To determine if this new tool is comparable to its multiport (MP) predecessors, we reviewed a single-surgeon experience of SP RARC. Materials and Methods: We identified patients at our institution who underwent RARC between August 2017 and June 2020 by one surgeon at our institution (n = 64). Using propensity scoring analysis, patients whose procedure were performed with the SP platform (n = 12) were matched 1:2 to patients whose procedure was performed with the MP platform (n = 24). Univariable analysis was performed to identify differences in any perioperative outcome, including operative time, estimated blood loss (EBL), lymph node yield, 90-day complication/readmission rates, and positive surgical margin (PSM) rates. Results: Patients who had an SP RARC on average had a lower lymph node yield than those who had an MP RARC (11.9 vs 17.1, p = 0.0347). All other perioperative outcomes, including operative time, EBL, 90-day complication rates, 90-day readmission rates, and PSM rates, were not significantly different between the SP and MP RARC groups. Conclusions: Based on their perioperative outcomes, the SP platform is a feasible alternative to the MP platform when performing RARC. The SP's perioperative outcomes should continue to be evaluated as more SP RARCs are performed.
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Procedimientos Quirúrgicos Robotizados , Robótica , Neoplasias de la Vejiga Urinaria , Cistectomía , Humanos , Complicaciones Posoperatorias , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/cirugíaRESUMEN
Introduction and Objective: African American (AA) race has been identified to have a higher incidence of chronic kidney disease (CKD) and worse renal cancer survival compared with Caucasian Americans (CA), irrespective of tumor size, pathologic type, and surgical procedure. We aimed to compare the outcomes between CA and AA patients undergoing minimally invasive partial nephrectomy (PN) at our high-volume center. Materials and Methods: We queried our PN data repository from 2007 to 2017. We identified 981 cases of PN (robotic n = 943 and laparoscopic n = 38), of which there were 852 CA and 129 AA patients. We compared age, sex, body mass index (BMI), operative time, estimated blood loss (EBL), nephrometry score, tumor size, pre- and postoperative estimated glomerular filtration rate (eGFR), length of stay, Charlson Comorbidity Index (CCI), tumor characteristics, and 30-day complication rate. We then estimated the overall survival and disease-specific survival. Results: Age, BMI, operative time, EBL, nephrometry score, tumor size, CCI, length of stay, and sex were not statistically different. The mean preoperative eGFR was higher in the AA cohort (91.4 mL/min/1.73 m2 vs 86.1 mL/min/1.73 m2, p = 0.007); however, at 1 year, there was no mean difference (76.8 mL/min/1.73 m2 vs 74.5 mL/min/1.73 m2, p = 0.428). There was a higher percentage of Fuhrman Grade 3/4 in the AA cohort (33.3% vs 22.5%, p = 0.044). The AA cohort had a 2.66 × higher incidence of papillary renal cell carcinoma (RCC) (34.9% vs 13.1%, p < 0.001) and unclassified RCC (3.9% vs 0.4%, p = 0.001). There was no difference in tumor stage (p = 0.260) or incidence of benign histology (15.3% vs 11.6%, p = 0.278). There were no differences in 30-day complications (p = 0.330). The median follow-up was 43.2 months. By using Kaplan-Meier curves, there was no observed difference in overall survival (p = 0.752) or disease-free survival (p = 0.403). Conclusions: Our cohort of AA and CA patients with intermediate follow-up showed no worse outcomes for CKD or survival when undergoing laparoscopic or robotic PN. For low-stage renal cancer, there was no difference in overall survival and disease-free survival at a median follow-up of 43.2 months among AA patients, despite having higher grade tumors and a higher percentage of unclassified RCC. Our cohort of AA patients did have a higher incidence of papillary RCC. The equivalent overall survival and disease-free survival could be due to the earlier discovery of lower stage renal masses incidentally identified on imaging studies performed equally for other reasons in both AA and CA patients.
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Carcinoma de Células Renales , Neoplasias Renales , Carcinoma de Células Renales/cirugía , Tasa de Filtración Glomerular , Humanos , Neoplasias Renales/cirugía , Nefrectomía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: The decision to perform a partial nephrectomy (PN) relies largely upon the complexity of the renal mass and its surrounding anatomy. The presence of adherent perinephric fat (APF) can increase surgical complexity and extend operative times. The accurate prediction of APF may improve surgical planning and aid in decision making for the surgical approach. OBJECTIVE: We sought to develop and externally validate a score that predicts APF based on preoperative clinical and radiological prognostic factors. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively analyzed 495 consecutive patients who underwent open or minimally invasive PN. APF was defined as the presence of "dense," "adherent," or "sticky" perinephric fat at the time of dissection by the surgeon, and this did not require subcapsular dissection. Additionally, we analyzed an independent cohort of 285 patients for external validation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: A score model was developed using multivariate logistic regression analysis. Calibration of the fitted model was assessed graphically with a plot of the predicted versus the actual probability of APF, and discrimination was assessed by calculating the area under the receiver operating characteristic curve. RESULTS AND LIMITATIONS: Of the 495 patients, 95 (19%) had APF. Patients with APF had longer operative (p=0.02) and arterial clamp (p=0.01) times than non-APF patients. On multivariate analyses, diabetes mellitus (p=0.009), posterior perinephric fat thickness (p<0.001), and perinephric stranding (p<0.001) were predictors of encountering APF in PN. A risk score ranging from 0 to 4 was developed based on these three variables to predict APF. The scoring system demonstrated good discrimination of 0.82 and 0.84 for the development and external validation cohorts, respectively. CONCLUSIONS: The APF score can accurately predict the presence of APF in patients with a small renal mass who are planning to undergo PN. This score could aid in pre- and intraoperative planning and impact the surgical approach. PATIENT SUMMARY: The presence of "sticky" fat surrounding the kidney in patients undergoing partial nephrectomy has previously been linked to longer operative times, intraoperative complications, and surgical conversion. In our study, we found that this feature is more often presented in patients with diabetes mellitus, and thicker and more inflammatory fat on renal imaging. Based on these findings, we developed a risk score that can accurately predict this feature before surgery, in order to improve surgical planning and better counsel the patients.
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Tejido Adiposo/patología , Riñón/cirugía , Nefrectomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Diabetes Mellitus , Femenino , Humanos , Riñón/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Carcinoma de Células Renales , Neoplasias Renales , Carcinoma de Células Renales/tratamiento farmacológico , Carcinoma de Células Renales/cirugía , Procedimientos Quirúrgicos de Citorreducción , Humanos , Inmunoterapia , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/cirugía , NefrectomíaRESUMEN
Introduction: Percutaneous cryoablation (PCA) has emerged as an alternative to extirpative management of small renal masses (SRMs) in select patients, with a reduced risk of perioperative complications. Although disease recurrence is thought to occur in the early postoperative period, limited data on long-term oncologic outcomes have been published. We reviewed our 10-year experience with PCA for SRMs and assessed predictors of disease progression. Materials and Methods: We reviewed our prospectively maintained database of patients who underwent renal PCA from March 2005 to December 2015 (n = 308). Baseline patient and tumor variables were recorded, and postoperative cross-sectional imaging was examined for evidence of disease recurrence. Disease progression was defined as the presence of local recurrence or new lymphadenopathy/metastasis. Results: Mean patient age was 67.2 ± 11 years, mean tumor size was 2.7 ± 1.3 cm, and mean nephrometry score was 6.8 ± 1.7. At mean follow-up of 38 months, local recurrence and new lymphadenopathy/metastasis occurred in 10.1% (31/308) and 6.2% (19/308) of patients, respectively. Excluding patients with a solitary kidney and/or von Hippel-Lindau, local recurrence and new lymphadenopathy/metastasis occurred in 8.6% (23/268) and 1.9% (5/268) of cases, respectively. Kaplan-Meier estimated disease-free survival was 92.5% at 1 year, 89.3% at 2 years, and 86.7% at 3 years post-PCA. Increasing tumor size was a significant predictor of disease progression (hazard ratio 1.32 per 1-cm increase in size, p = 0.001). Conclusions: PCA is a viable treatment option for patients with SRMs. Increasing tumor size is a significant predictor of disease progression following PCA.
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Carcinoma de Células Renales , Criocirugía , Neoplasias Renales , Laparoscopía , Anciano , Carcinoma de Células Renales/cirugía , Progresión de la Enfermedad , Humanos , Neoplasias Renales/cirugía , Persona de Mediana Edad , Recurrencia Local de Neoplasia/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
We describe the rare case of a 61-year-old female with right ureteropelvic junction (UPJ) obstruction caused by metastatic cholangiocarcinoma. Her past medical history was notable for cholangiocarcinoma treated with neoadjuvant chemoradiation and two orthotopic liver transplants six years earlier. Urology was consulted when she presented with flank pain and urinary tract infection. Diagnostic workup demonstrated right UPJ obstruction. She was managed acutely with percutaneous nephrostomy. She subsequently underwent robotic pyeloplasty and intrinsic obstruction of the UPJ was discovered. Histological examination revealed adenocarcinoma, consistent with systemic recurrence of the patient's known cholangiocarcinoma.
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Colangiocarcinoma/complicaciones , Neoplasias Pélvicas/complicaciones , Neoplasias Ureterales/complicaciones , Obstrucción Ureteral/etiología , Neoplasias de los Conductos Biliares/patología , Colangiocarcinoma/secundario , Femenino , Humanos , Hidronefrosis/diagnóstico por imagen , Hidronefrosis/etiología , Persona de Mediana Edad , Neoplasias Pélvicas/secundario , Tomografía Computarizada por Rayos X , Neoplasias Ureterales/secundario , Obstrucción Ureteral/diagnóstico por imagen , Obstrucción Ureteral/patología , UrografíaRESUMEN
ABSTRACT We describe the rare case of a 61-year-old female with right ureteropelvic junction (UPJ) obstruction caused by metastatic cholangiocarcinoma. Her past medical history was notable for cholangiocarcinoma treated with neoadjuvant chemoradiation and two orthotopic liver transplants six years earlier. Urology was consulted when she presented with flank pain and urinary tract infection. Diagnostic workup demonstrated right UPJ obstruction. She was managed acutely with percutaneous nephrostomy. She subsequently underwent robotic pyeloplasty and intrinsic obstruction of the UPJ was discovered. Histological examination revealed adenocarcinoma, consistent with systemic recurrence of the patient's known cholangiocarcinoma.
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Humanos , Femenino , Neoplasias Pélvicas/complicaciones , Neoplasias Ureterales/complicaciones , Obstrucción Ureteral/etiología , Colangiocarcinoma/complicaciones , Neoplasias Pélvicas/secundario , Neoplasias Ureterales/secundario , Obstrucción Ureteral/patología , Obstrucción Ureteral/diagnóstico por imagen , Neoplasias de los Conductos Biliares/patología , Urografía , Tomografía Computarizada por Rayos X , Colangiocarcinoma/secundario , Hidronefrosis/etiología , Hidronefrosis/diagnóstico por imagen , Persona de Mediana EdadRESUMEN
BACKGROUND: Local-regional failure (LF) for locally advanced bladder cancer (LABC) after radical cystectomy (RC) is common even with chemotherapy and is associated with high morbidity/mortality. Postoperative radiotherapy (PORT) can reduce LF and may enhance overall survival (OS) but has no defined role. We hypothesized that the addition of PORT would improve OS in LABC in a large nationwide oncology database. METHODS: We identified ≥ pT3pN0-3M0 LABC patients in the National Cancer Database diagnosed 2004-2014 who underwent RC ± PORT. OS was calculated using Kaplan-Meier and Cox proportional hazards regression modeling was used to identify predictors of OS. Propensity matching was performed to match RC patients who received PORT vs those who did not. RESULTS: 15,124 RC patients were identified with 512 (3.3%) receiving PORT. Median OS was 20.0 months (95% CI, 18.2-21.8) for PORT vs 20.8 months (95% CI, 20.3-21.3) for no PORT (P = 0.178). In multivariable analysis, PORT was independently associated with improved OS: hazard ratio 0.87 (95% CI, 0.78-0.97); P = 0.008. A one-to-three propensity match yielded 1,858 patients (24.9% receiving PORT and 75.1% without). In the propensity-matched cohort, median OS was 19.8 months (95% CI, 18.0-21.6) for PORT vs 16.9 months (95% CI, 15.6-18.1) for no PORT (P = 0.030). In the propensity-matched cohort of urothelial carcinoma patients (N = 1,460), PORT was associated with improved OS for pT4, pN+, and positive margins (P < 0.01 all). CONCLUSION: In this observational cohort, PORT was associated with improved OS in LABC. While the data should be interpreted cautiously, these results lend support to the use of PORT in selected patients with LABC, regardless of histology. Prospective trials of PORT are warranted.
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Cuidados Posoperatorios , Neoplasias de la Vejiga Urinaria/patología , Neoplasias de la Vejiga Urinaria/radioterapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Comorbilidad , Cistectomía , Bases de Datos Factuales , Femenino , Humanos , Seguro de Salud , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Modelos de Riesgos Proporcionales , Radioterapia Adyuvante , Resultado del Tratamiento , Neoplasias de la Vejiga Urinaria/epidemiología , Adulto JovenRESUMEN
INTRODUCTION: Squamous cell carcinoma (SqCC) is the second most common histology of primary bladder cancer, but still very limited information is known about its treatment outcomes. Most bladder cancer trials have excluded SqCC, and the current treatment paradigm for localized SqCC is extrapolated from results in urothelial carcinoma (UC). In particular, there is limited data on the efficacy of definitive chemo-radiotherapy (CRT). In this study, we compare overall survival outcomes between SqCC and UC patients treated with definitive CRT. MATERIALS/METHODS: We queried the National Cancer Database (NCDB) for muscle-invasive (cT2-T4 N0 M0) bladder cancer patients diagnosed from 2004 to 2013 who underwent concurrent CRT. Propensity matching was performed to match patients with SqCC to those with UC. OS was analyzed using the Kaplan-Meier survival method, and the log-rank test and Cox regression were used for analyses. RESULTS: 3332 patients met inclusion criteria of which 79 (2.3%) had SqCC. 73.4% of SqCC patients had clinical T2 disease compared to 82.5% of UC patients. Unadjusted median OS for SqCC patients was 15.6â¯months (95% CI, 11.7-19.6) versus 29.1â¯months (95% CI, 27.5-30.7) for those with UC (Pâ¯<â¯0.0001). On multivariable analysis, factors associated with worse OS included: SqCC histology [HR: 1.53 (95% CI, 1.19-1.97); Pâ¯=â¯0.001], increasing age [HR: 1.02 (95% CI, 1.02-1.03); Pâ¯<â¯0.0001], increasing clinical T-stage [HR: 1.21 (95% CI, 1.13-1.29); Pâ¯<â¯0.0001], and Charlson-Deyo comorbidity index [HR: 1.26 (95% CI, 1.18-1.33); Pâ¯<â¯0.0001]. Seventy-seven SqCC patients were included in the propensity-matched analysis (154 total patients) with a median OS for SqCC patients of 15.1â¯months (95% CI, 11.1-18.9) vs. 30.4â¯months (95% CI, 19.4-41.4) for patients with UC (Pâ¯=â¯0.013). CONCLUSIONS: This is the largest study to-date assessing survival outcomes for SqCC of the bladder treated with CRT. In this study, SqCC had worse overall survival compared to UC patients. Histology had a greater impact on survival than increasing T-stage, suggesting that histology should be an important factor when determining a patient's treatment strategy and that treatment intensification in this subgroup may be warranted.
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Hypertriglyceridemia is an independent risk factor for cardiovascular disease. Dietary interventions based on protein restriction (PR) reduce circulating triglycerides (TGs), but underlying mechanisms and clinical relevance remain unclear. Here, we show that 1 week of a protein-free diet without enforced calorie restriction significantly lowered circulating TGs in both lean and diet-induced obese mice. Mechanistically, the TG-lowering effect of PR was due, in part, to changes in very low-density lipoprotein (VLDL) metabolism both in liver and peripheral tissues. In the periphery, PR stimulated VLDL-TG consumption by increasing VLDL-bound APOA5 expression and promoting VLDL-TG hydrolysis and clearance from circulation. The PR-mediated increase in Apoa5 expression was controlled by the transcription factor CREBH, which coordinately regulated hepatic expression of fatty acid oxidation-related genes, including Fgf21 and Ppara. The CREBH-APOA5 axis activation upon PR was intact in mice lacking the GCN2-dependent amino acid-sensing arm of the integrated stress response. However, constitutive hepatic activation of the amino acid-responsive kinase mTORC1 compromised CREBH activation, leading to blunted APOA5 expression and PR-recalcitrant hypertriglyceridemia. PR also contributed to hypotriglyceridemia by reducing the rate of VLDL-TG secretion, independently of activation of the CREBH-APOA5 axis. Finally, a randomized controlled clinical trial revealed that 4-6 weeks of reduced protein intake (7%-9% of calories) decreased VLDL particle number, increased VLDL-bound APOA5 expression, and lowered plasma TGs, consistent with mechanistic conservation of PR-mediated hypotriglyceridemia in humans with translational potential as a nutraceutical intervention for dyslipidemia.
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Dieta con Restricción de Proteínas/efectos adversos , Lipoproteínas VLDL/sangre , Diana Mecanicista del Complejo 1 de la Rapamicina/metabolismo , Proteínas Serina-Treonina Quinasas/metabolismo , Triglicéridos/sangre , Animales , Apolipoproteína A-V , Apolipoproteínas/metabolismo , Proteína de Unión a Elemento de Respuesta al AMP Cíclico , Dieta con Restricción de Proteínas/métodos , Femenino , Humanos , Hidrólisis , Hipertrigliceridemia/complicaciones , Hipertrigliceridemia/epidemiología , Metabolismo de los Lípidos , Lipoproteínas VLDL/metabolismo , Hígado/metabolismo , Hígado/patología , Masculino , Ratones , Proteínas Serina-Treonina Quinasas/deficiencia , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo , Triglicéridos/metabolismoRESUMEN
OBJECTIVE: To identify avoidable predictors of postureteroscopy (URS) unplanned encounters and to minimize 30-day encounters. MATERIALS AND METHODS: We performed retrospective chart review and telephone surveys on patients who underwent URS for urolithiasis between January and June 2016. Univariate and multivariable analyses evaluated for potential predictors of unplanned encounters. RESULTS: Of 157 patients, there were 44 (28.0%) unplanned patient-initiated clinical phone calls, 23 (14.6%) emergency department (ED) visits, and 8 (5.1%) readmissions, with pain being the most common complaint during the encounters. Factors associated with a higher rate of phone calls include first-time stone procedure (36.6% vs 20.9%, p = 0.029), outpatient status (30.3% vs 0%, p = 0.021), intraoperative stent placement (31.2% vs 0%, p = 0.006), and stent removal at home (58.8% vs 28.8%, p = 0.014). Factors associated with increased rate of ED visits were first-time stone procedure (22.5% vs 8.1%, p = 0.011) and ureteral access sheath (UAS) usage (29.6% vs 11.8%, p = 0.018). Factors associated with a higher rate of readmissions were lower body mass index (23.9 vs 29.7, p = 0.013), bilateral procedure (20.0% vs 2.9%, p = 0.010), and UAS usage (14.8% vs 3.1%, p = 0.032). Stone burden, operative time, Charlson comorbidity index, and preoperative urinary tract infection were not significantly associated with postoperative encounters. CONCLUSIONS: Pain, first-time stone treatment, presence of a ureteral stent, outpatient status, bilateral procedures, and UAS usage were common reasons for postoperative encounters after URS. Appropriate perioperative patient education and counseling and adequate pain management may minimize these encounters and improve treatment quality and patient satisfaction.
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Complicaciones Posoperatorias/etiología , Cálculos Ureterales/cirugía , Ureteroscopía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tempo Operativo , Dolor Postoperatorio/etiología , Estudios Retrospectivos , Factores de Riesgo , Infecciones Urinarias/etiologíaRESUMEN
OBJECTIVE: To provide a training tool to address the technical challenges of robot-assisted laparoscopic partial nephrectomy, we created silicone renal tumor models using 3-dimensional printed molds of a patient's kidney with a mass. In this study, we assessed the face, content, and construct validity of these models. MATERIALS AND METHODS: Surgeons of different training levels completed 4 simulations on silicone renal tumor models. Participants were surveyed on the usefulness and realism of the model as a training tool. Performance was measured using operation-specific metrics, self-reported operative demands (NASA Task Load Index [NASA TLX]), and blinded expert assessment (Global Evaluative Assessment of Robotic Surgeons [GEARS]). RESULTS: Twenty-four participants included attending urologists, endourology fellows, urology residents, and medical students. Post-training surveys of expert participants yielded mean results of 79.2 on the realism of the model's overall feel and 90.2 on the model's overall usefulness for training. Renal artery clamp times and GEARS scores were significantly better in surgeons further in training (P ≤.005 and P ≤.025). Renal artery clamp times, preserved renal parenchyma, positive margins, NASA TLX, and GEARS scores were all found to improve across trials (P <.001, P = .025, P = .024, P ≤.020, and P ≤.006, respectively). CONCLUSION: Face, content, and construct validity were demonstrated in the use of a silicone renal tumor model in a cohort of surgeons of different training levels. Expert participants deemed the model useful and realistic. Surgeons of higher training levels performed better than less experienced surgeons in various study metrics, and improvements within individuals were observed over sequential trials. Future studies should aim to assess model predictive validity, namely, the association between model performance improvements and improvements in live surgery.
Asunto(s)
Neoplasias Renales/cirugía , Modelos Anatómicos , Nefrectomía/educación , Procedimientos Quirúrgicos Robotizados/educación , Adulto , Competencia Clínica , Humanos , Laparoscopía/educación , Persona de Mediana Edad , Impresión Tridimensional , Siliconas , Entrenamiento Simulado , Análisis y Desempeño de TareasRESUMEN
Treatment modalities for small renal masses (SRMs) include open or minimally invasive radical or partial nephrectomy, and laparoscopic or percutaneous ablations. Members of the Endourological Society were surveyed to evaluate how practitioner and clinical practice characteristics may be associated with the management of SRMs over time. The survey assessed characteristics of urologists (recency of residency and fellowship training, clinical practice type and location, and treatment modalities available) and their management of SRMs over the past year and over the course of the year 5 years prior. Of the 1495 surveys e-mailed, there were 129 respondents (8.6%). Comparing the past year to 5 years prior, there was increasing utilization of robotic partial nephrectomy (p < 0.001) and robotic radial nephrectomy (p = 0.031). In contrast, there was decreasing utilization of open partial nephrectomy (p < 0.001), open radical nephrectomy (p = 0.039), laparoscopic partial nephrectomy (p = 0.002), and laparoscopic radical nephrectomy (p = 0.041). Employment of laparoscopic ablation decreased (p = 0.001), but that of percutaneous ablation did not change significantly. For masses treated with image-guided therapy, there was increasing utilization of microwave ablation (p = 0.008) and decreasing usage of radiofrequency ablation (p = 0.002). Future studies should focus on the most effective treatment modalities based on provider, patient, and tumor characteristics.
RESUMEN
Lymphoepithelioma-like carcinoma (LELC) is a rare finding in the upper urinary tract. The presenting clinical findings mimic those of other more common upper-tract tumors, such as urothelial carcinoma. Preoperative imaging has not been shown to reliably predict the diagnosis of LELC. This tumor can be misdiagnosed as a reactive inflammatory lesion or lymphoma if the proper immunohistochemical stains for cytokeratin are not used.