Single-port vs multi-port robot-assisted renal surgery: analysis of perioperative outcomes for excision of high and low complexity renal masses.

There is emerging but limited data assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. We compared perioperative outcomes between SP and MP robot-assisted approaches for excision of high and low complexity renal masses. Retrospective chart review was performed for patients undergoing robot-assisted partial or radical nephrectomy using the SP surgical system (n = 23) at our institution between November 2019 and November 2021. Renal masses were categorized as high complexity (7+) or low complexity (4-6) using the R.E.N.A.L. nephrometry scoring system. Adjusting for baseline characteristics, patients were matched using a prospectively maintained MP database in a 2:1 (MP:SP) ratio. For high complexity tumors (n = 12), SP surgery was associated with a significantly longer operative time compared to MP (248.4 vs 188.1 min, p = 0.02) but a significantly shorter length of stay (1.9 vs 2.8 days, p = 0.02). For low complexity tumors (n = 11), operative time (177.7 vs 161.4 min, p = 0.53), estimated blood loss (69.6.0 vs 142.0 mL, p = 0.62), and length of stay (1.6 vs 1.8 days, p = 0.528) were comparable between SP and MP approaches. Increasing nephrometry score was associated with a greater relative increase in operative time for SP compared to MP renal surgery (p = 0.07) using best of fit linear modeling. SP robot-assisted partial and radical nephrectomy is safe and feasible for low complexity renal masses. For high complexity renal masses, the SP system is associated with a significantly longer operative time compared to the MP technique. Careful consideration should be given when selecting patients for SP robot-assisted kidney surgery.

Factors Associated with Ureteral Stent Failure in Patients with Malignant Ureteral Obstruction.

Introduction: Management of malignant ureteral obstruction (MUO) with ureteral stents remains a clinical challenge, often involving frequent stent exchanges attributable to stent failure or other urological complications. We report our institutional experience with ureteral stents for management of MUO, including analysis of clinical factors associated with stent failure. Methods: We performed a retrospective review of patients treated with indwelling ureteral stents for MUO in nonurothelial malignancies at our tertiary-care institution between 2008 and 2019. Univariate Cox proportional hazards analysis was performed to identify clinical variables associated with stent failure and stent-related complications. Stent failure was defined as need for unplanned stent exchange, placement of percutaneous nephrostomy (PCN), or tandem stents. Results: In our cohort of 78 patients, the median (range) number of stent exchanges was 2 (0-17) during a total stent dwell time of 4.3 (0.1-40.3) months. Thirty-four patients (43.6%) developed a culture-proven urinary tract infection (UTI) during stent dwell time. Thirty-five patients (44.8%) had stent failure. Twenty-two patients (28.2%) underwent unplanned stent exchanges, 23 (29.5%) required PCN after initial stent placement, and 6 (7.7%) required tandem stents. Ten (28.6%) patients with stent failure were treated with upsized stents, which led to resolution in seven patients. Stent failure occurred with 20/44 (45.4%) Percuflex™, 15/27 (55.6%) polyurethane, and 2/3 (66.7%) metal stents. In patients with ≥2 exchanges (N = 45), median time between exchanges was 4.1 (2.0-14.8) months. Bilateral stenting and history of radiation predicted UTI development. Median overall patient survival after initial stent placement was 19.9 months (95% CI 16.5-37.9 months). Conclusions: Ureteral stent failure poses a significant medical burden to patients with MUO. Better methods to minimize stent-related issues and improve patient quality of life are needed. Using a shared decision-making approach, clinicians and patients should consider PCN or tandem stents early in the management of MUO.

Post-chemotherapy Laparoscopic Retroperitoneal Lymph Node Dissection for Mixed Malignant Germ Cell Testicular Tumors.

INTRODUCTION: Retroperitoneal lymph node dissection (RPLND) is performed to treat residual disease following chemotherapy for stage II and III testicular cancer. Significant morbidity can be associated with open RPLND. As such, laparoscopic techniques have been demonstrated to be safe and effective in select cases. Outcomes following post-chemotherapy laparoscopic RPLND for mixed malignant germ cell testicular tumors (MMGCT) are limited in the literature. PATIENTS AND METHODS: We performed a retrospective chart review for patients who underwent laparoscopic RPLND at our institution for MMGCT from May 2006 to October 2016. Patient clinical data and perioperative and oncologic outcomes were recorded. RESULTS: Twenty-three patients underwent post-chemotherapy laparoscopic RPLND. Thirty-five percent (8/23) underwent bilateral template dissection, whereas 65% (15/23) underwent a modified unilateral template dissection. Robotic assistance was utilized in 22% (5/23) of cases. Bilateral template was inferior to unilateral template RPLND in operative time, estimated blood loss, open conversion rate, length of hospital stay, and complication rate. The mean follow-up was 35.1 months and 43.3 months for the bilateral and unilateral template groups, respectively. The mean lymph node yield and recurrence rate were similar between the 2 cohorts. One recurrence of mature teratoma was noted 67 months after unilateral laparoscopic RPLND. CONCLUSIONS: In select patients, laparoscopic RPLND for stage II and III MMGCT is safe and effective in the post-chemotherapy setting. Bilateral template laparoscopic RPLND was associated with inferior perioperative outcomes, but similar oncologic outcomes compared with unilateral template. Patients requiring bilateral template RPLND should be considered for an open approach.

Ten-Year Experience with Percutaneous Cryoablation of Renal Tumors: Tumor Size Predicts Disease Progression.

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.

Hunner Lesion Phenotype in Interstitial Cystitis/Bladder Pain Syndrome: A Systematic Review and Meta-Analysis.

PURPOSE: We compared demographics, clinical presentation, comorbidities, urinary profiles, and treatment responses between patients with interstitial cystitis/bladder pain syndrome with and without Hunner lesions. MATERIALS AND METHODS: We performed a systematic review of the literature in PubMed® in February 2019. Publications were included if they compared data between patients with interstitial cystitis/bladder pain syndrome with and without Hunner lesions, yielding 59 articles. Meta-analysis was performed on a subset of clinical characteristics. RESULTS: Meta-analysis showed that patients with interstitial cystitis/bladder pain syndrome with Hunner lesions were significantly older (MD 6.7 years, 95% CI 2.0-11.3, p=0.005), reported higher urinary frequency (MD 3.2 per day, 95% CI 1.1-5.4, p=0.003), nocturia (MD 1.0 per night, 95% CI 0.1-2.0, p=0.034) and Interstitial Cystitis Symptom Index (MD 2.2, 95% CI 1.4-3.0, p <0.001), but lower cystometric bladder capacity (MD -113 ml, 95% CI -164 to -61 ml, p <0.001) compared to those with interstitial cystitis/bladder pain syndrome without Hunner lesions. There were no differences in pain scores (p=0.105), symptom duration (p=0.2) or sex (p=0.83) between the 2 groups. While some studies reported higher rates of comorbid pain syndromes (eg fibromyalgia) among patients without Hunner lesions, overall results were conflicting. Patients with Hunner lesions had higher urinary levels of pro-inflammatory cytokines/chemokines (CXCL10, NGF, IL-6, IL-8, MIF), luminal nitric oxide and responded well to endoscopic treatment of the Hunner lesions (eg fulguration or triamcinolone injection). In comparative studies patients with interstitial cystitis/bladder pain syndrome with Hunner lesions responded better to oral cyclosporine A than those without Hunner lesions. CONCLUSIONS: Systematic review and meta-analysis demonstrated significant differences in demographics, clinical presentation, urinary marker profiles, and treatment responses between patients with and without Hunner lesions, suggesting that they may represent 2 distinct clinical phenotypes. Studies are needed to investigate their mechanistic differences.

Accuracy and Variability of Prostate Multiparametric Magnetic Resonance Imaging Interpretation Using the Prostate Imaging Reporting and Data System: A Blinded Comparison of Radiologists.

BACKGROUND: Multiparametric (mp) magnetic resonance imaging (MRI) has become an important tool for the detection of clinically significant prostate cancer. However, diagnostic accuracy is affected by variability between radiologists. OBJECTIVE: To determine the accuracy and variability in prostate mpMRI interpretation among radiologists, both individually and in teams, in a blinded fashion. DESIGN, SETTING, AND PARTICIPANTS: A study cohort (n=32) was created from our prospective registry of patients who received prostate mpMRI with subsequent biopsy. The cohort was then independently reviewed by four radiologists of varying levels of experience, who assigned a Prostate Imaging Reporting and Data System (PI-RADS) classification, blinded to all clinical information. Consensus interpretation by teams of two radiologists was evaluated after a 12-wk wash-out period. Interpretive accuracy was calculated with various cutoffs for PI-RADS classification and Gleason score. Variability among individual radiologists and teams was calculated using the Fleiss kappa and intraclass correlation coefficient (ICC). RESULTS AND LIMITATIONS: Using PI-RADS 3+/Gleason 7+ (p<0.01) and PI-RADS 4+/Gleason 6+ (p=0.02) as cutoffs, significant differences in accuracy among the four radiologists were noted. At no cutoff for PI-RADS classification or Gleason score did a team read achieve higher accuracy than the most accurate radiologist. The kappa and ICC ranged from 0.22 to 0.29 for the individuals and from 0.16 to 0.21 for the teams (poor agreement). A larger sample size may be needed to adequately power differences in accuracy among individual radiologists. CONCLUSIONS: At various cutoffs for PI-RADS classification and Gleason score, we find significant differences in individual radiologist accuracy, as well as a poor agreement among individual radiologists. Consensus interpretations-as teams of two radiologists-did not improve accuracy or reduce variability. PATIENT SUMMARY: This study investigated radiologist variability and differences in accuracy using multiparametric magnetic resonance imaging for the diagnosis of prostate cancer. Despite attempts to standardize interpretation within the field, we found substantial variability and significant differences in accuracy among individual radiologists.

Ureteropelvic junction obstruction caused by metastatic cholangiocarcinoma.

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.

Ureteropelvic junction obstruction caused by metastatic cholangiocarcinoma

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.

The Accuracy of Prostate Magnetic Resonance Imaging Interpretation: Impact of the Individual Radiologist and Clinical Factors.

OBJECTIVE: To compare test performance of multiparametric magnetic resonance imaging (mpMRI) for detection of prostate cancer between individual radiologists using the Prostate Imaging Reporting and Data System (PI-RADS) and to identify clinical factors that may predict test performance. MATERIALS AND METHODS: We examined our database of consecutive men who received prostate mpMRI prior to biopsy between September 2014 and December 2016 (n = 459). Test performance (eg, sensitivity, specificity, positive predictive value [PPV] and negative predictive value) were defined with PI-RADS classification 4 or 5 considered test positive and Gleason score ≥7 on biopsy from any targeted core considered outcome positive. Multivariate logistic regression was performed to identify clinical variables that affect test performance. RESULTS: No significant differences in test performance were found among individual radiologists. Prior biopsy (odds ratio [OR] 0.10, P = .01), radiologist experience >500 prostate mpMRI (OR 0.18, P = .04), transition zone location (OR 0.10, P = .04), and posterior location (OR 0.04, P = .03) were predictors of diminished sensitivity. Location of the mpMRI lesion in the TZ was a predictor of improved specificity (OR 2.53, P = .04). Increasing age (OR 1.07, P <.01) and prostate-specific antigen (OR 1.10, P <.01) predicted increased PPV, while prior biopsy predicted decreased PPV (OR 0.50, P <.01). CONCLUSION: Although variation exists in test performance among individual radiologists using PI-RADS, significant differences were not observed. Additional prostate mpMRI experience was not beneficial in improving accuracy of interpretation. Nonmodifiable patient variables-including prostate lesion location, prior biopsy history, prostate-specific antigen, and age-are predictive of prostate mpMRI test performance.

Regression of cephalic index following endoscopic repair of sagittal synostosis.

OBJECTIVEMetrics used to quantify preoperative severity and postoperative outcomes for patients with sagittal synostosis include cephalic index (CI), the well-known standard, and the recently described adjusted cephalic index (aCI), which accounts for altered euryon location. This study tracks the time course of these measures following endoscopic repair with orthotic helmet therapy. The authors hypothesize that CI and aCI show significant regression following endoscope-assisted repair.METHODSCT scans or 3D photographs of patients with nonsyndromic sagittal synostosis treated before 6 months of age by endoscope-assisted strip craniectomy and postoperative helmet therapy (n = 41) were reviewed retrospectively at three time points (preoperatively, 0-2 months after helmeting, and > 24 months postoperatively). The CI and aCI were measured at each time point.RESULTSMean CI and aCI increased from 71.8 to 78.2 and 62.7 to 72.4, respectively, during helmet treatment (p < 0.001). At final follow-up, mean CI and aCI had regressed significantly from 78.2 to 76.5 and 72.4 to 69.7, respectively (p < 0.001). The CI regressed in 33 of 41 cases (80%) and aCI in 39 of 41 cases (95%). The authors observed a mean loss of 31% of improvement in aCI achieved through treatment. A strong, positive correlation existed between CI and aCI (R = 0.88).CONCLUSIONSRegression following endoscope-assisted strip craniectomy with postoperative helmet therapy commonly occurs in patients with sagittal synostosis. Future studies are required to determine whether duration of helmet therapy or modifications in helmet design affect regression.

Sex-Specific Differences in an ApoE(-/-):Ins2(+/Akita) Mouse Model of Accelerated Atherosclerosis.

Diabetic patients have a twofold to fourfold increased risk of cardiovascular disease. Despite a vast amount of research, the underlying mechanisms that predispose individuals with diabetes to the development of cardiovascular disease are unclear. To further our understanding of how diabetes promotes atherosclerosis, we have established, characterized, and manipulated a new model of hyperglycemia-induced atherosclerosis: the apolipoprotein E-deficient (ApoE(-/-)):Ins2(+/Akita) mouse. All mice were fed a standard chow diet. Male ApoE(-/-):Ins2(+/Akita) mice developed chronic hyperglycemia, which significantly accelerated atherosclerosis. Female ApoE(-/-):Ins2(+/Akita) mice presented hyperglycemia that normalized by 15 weeks of age. Despite the transient hyperglycemia, advanced atherosclerosis was observed at 15 weeks of age compared with ApoE(-/-) females. To better understand these differences, subsets of mice were castrated or ovariectomized at 5 weeks of age. Castrated ApoE(-/-):Ins2(+/Akita) mice showed a reduction in blood glucose levels that correlated with the amelioration of atherosclerosis. Interestingly, castrated normoglycemic ApoE(-/-) mice developed larger atherosclerotic lesions than sham-operated on controls. Ovariectomized ApoE(-/-):Ins2(+/Akita) mice presented chronic hyperglycemia, and atherosclerosis appeared to be advanced. We have characterized the distinctive sex-specific phenotypes exhibited by the ApoE(-/-):Ins2(+/Akita) mouse model and present evidence for the action of sex hormones on pancreatic ß-cell function and the vasculature that affect the regulation of blood glucose levels and the development of atherosclerosis. This model will provide a test bed to further delineate these effects.