Label-Free SERS of Urine Components: A Powerful Tool for Discriminating Renal Cell Carcinoma through Multivariate Analysis and Machine Learning Techniques.

The advent of Surface-Enhanced Raman Scattering (SERS) has enabled the exploration and detection of small molecules, particularly in biological fluids such as serum, blood plasma, urine, saliva, and tears. SERS has been proposed as a simple diagnostic technique for various diseases, including cancer. Renal cell carcinoma (RCC) ranks as the sixth most commonly diagnosed cancer in men and is often asymptomatic, with detection occurring incidentally. The onset of symptoms typically aligns with advanced disease, aggressive histology, and unfavorable prognosis, and therefore new methods for an early diagnosis are needed. In this study, we investigated the utility of label-free SERS in urine, coupled with two multivariate analysis approaches: Principal Component Analysis combined with Linear Discriminant Analysis (PCA-LDA) and Support Vector Machine (SVM), to discriminate between 50 RCC patients and 44 healthy donors. Employing LDA-PCA, we achieved a discrimination accuracy of 100% using 13 principal components, and an 88% accuracy in discriminating between different RCC stages. The SVM approach yielded a training accuracy of 100%, a validation accuracy of 99% for discriminating between RCC and controls, and an 80% accuracy for discriminating between stages. The comparative analysis of raw and normalized SERS spectral data shows that while raw data disclose relative concentration variations in urine metabolites between the two classes, the normalization of spectral data significantly improves the accuracy of discrimination. Moreover, the selection of principal components with markedly distinct scores between the two classes serves to alleviate overfitting risks and reduces the number of components employed for discrimination. We obtained the accuracy of the discrimination between the RCC patients cases and healthy donors of 90% for three PCs and a linear discrimination function, and a 88% accuracy of discrimination between stages using six PCs, mitigating practically the risk of overfitting and increasing the robustness of our analysis. Our findings underscore the potential of label-free SERS of urine in conjunction with chemometrics for non-invasive and early RCC detection.

Systematic review of techniques and devices used to avoid warm ischemia time injury during kidney transplantation.

PURPOSE: The lack of a reliable and reproducible technique to ensure a constantly low temperature of the graft during kidney transplantation (KT) may be a cause of renal nonfunction. The aim of this review was to assess all the methods and devices available to ensure hypothermia during vascular anastomosis in KT. METHODS: A literature search was conducted through May 2022 using PubMed/Medline, Cochrane Library, Embase and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The review protocol was registered on PROSPERO (CRD42022326550). RESULTS: A total of 20 studies reporting on four hypothermia techniques met our inclusion criteria. Simple instillation of cold serum is not sufficient, the graft reaching up to 33 ℃ at the end of warm ischemia time (WIT). Plastic bags filled with ice slush have questionable efficiency. The use of a gauze jacket filled with ice-slush was reported in 12/20 studies. It ensures a graft temperature up to 20.3 ℃ at the end of WIT. Some concerns have been linked to potentially inhomogeneous parenchymal cooling and secondary ileus. Novel devices with continuous flow of ice-cold solution around the graft might overcome these limitations, showing a renal temperature below 20 ℃ at all times during KT. CONCLUSION: The gauze filled with ice slush is the most common technique, but several aspects can be improved. Novel devices in the form of cold-ischemia jackets can ensure a lower and more stable temperature of the graft during KT, leading to higher efficiency and reproducibility.

Integration of Virtual Reality in the Control System of an Innovative Medical Robot for Single-Incision Laparoscopic Surgery.

In recent years, there has been an expansion in the development of simulators that use virtual reality (VR) as a learning tool. In surgery where robots are used, VR serves as a revolutionary technology to help medical doctors train in using these robotic systems and accumulate knowledge without risk. This article presents a study in which VR is used to create a simulator designed for robotically assisted single-uniport surgery. The control of the surgical robotic system is achieved using voice commands for laparoscopic camera positioning and via a user interface developed using the Visual Studio program that connects a wristband equipped with sensors attached to the user's hand for the manipulation of the active instruments. The software consists of the user interface and the VR application via the TCP/IP communication protocol. To study the evolution of the performance of this virtual system, 15 people were involved in the experimental evaluation of the VR simulator built for the robotic surgical system, having to complete a medically relevant task. The experimental data validated the initial solution, which will be further developed.

Advances in Cancer Therapy from Research to Clinical Practice-Surgical, Molecular or Systemic Management of Cancer.

Cancer represents one of the most important general health problems of our day [...].

Robotic Radical Cystectomy with Intracorporeal Urinary Diversion - Tips and Tricks.

Radical cystectomy represents the standard surgical treatment in case of muscle invasive bladder cancer. During the last two decades a change in the surgical approach of the MIBC has been observed, from open surgery to minimal invasive surgery. Nowadays, in the majority of tertiary urologic centers, robotic radical cystectomy with intracorporeal urinary diversion represents the standard surgical approach. The aim of the current study is to describe in detail the surgical steps of the robotic radical cystectomy and the reconstruction of the urinary diversion and to present our experience. From the surgical point of view, the most important principles which should guide the surgeon when performing this procedure are: 1. Good working place and access both to the pelvis and abdomen and use of the "technique of spaces" 2. Respect the oncological principles of the surgery with attention to the margin resection and limitation of the risk of tumour spillage; 3. Attention to both the ureter and bowel manipulation in order to avoid grasping lesions; 4. High care in realisation of the uretero-ileal anastomosis so that good long term functional results are achieved. We analyzed our database of 213 patients diagnosed with muscle invasive bladder cancer who underwent minimally invasive radical cystectomy (laparoscopic and robotic approaches) between January 2010 and December 2022. We identified 25 patients for whom the robotic approach was used to perform the surgery. Despite being one of the most challenging urologic surgical procedures, with careful preparation and training, the surgeon is able to achieve the maximum oncological and functional results by performing robotic radical cystectomy with intracorporeal urinary.

Adrenal Gland Primary Neuroblastoma in an Adult Patient: A Case Report and Literature Review.

Neuroblastoma (NB) is an undifferentiated malignant tumor of the sympathetic ganglia, occurring in children under 5 years of age. However, it is a rare histology in adult patients, occurring once per every 10 million patients per year. We present the case of a 68-year-old male patient presented to our department for right lumbar pain, asthenia, loss of weight and altered general status. The contrast-enhanced abdominal computer tomography revealed bilateral adrenal tumoral masses of 149 mm and 82 mm on the right and left sides, respectively, with invasion of the surrounding organs. The patient underwent right 3D laparoscopic adrenalectomy and right radical nephrectomy. The pathological result concluded that the excised tumor was a neuroblastoma of the adrenal gland. The patient followed adjuvant oncological treatment; however, due to disease progression, he passed away 22 months after the surgery. To our knowledge, less than 100 cases of adrenal NB in adult patients have been published, the eldest case being diagnosed at 75 years of age; meanwhile, the largest reported tumor measured 200 mm, and was excised through open surgery. Minimally invasive techniques have been limited so far to smaller, organ-confined diseases, thus making the present case the largest adrenal NB removed entirely laparoscopically. Neuroblastoma in the adult population is a rare finding, with worse prognosis compared to pediatric patients. The available literature does not provide enough data for standardized, multimodal management, as the patients are treated following adapted pediatric protocols, thus reinforcing the need for international, multidisciplinary boards for rare tumors.

A risk-group classification model in patients with bladder cancer under neoadjuvant cisplatin-based combination chemotherapy.

The objective of the current research was to explore the potential prognostic value of readily available clinical and pathologic variables in bladder cancer. The novel association found between cholesterol levels and prognosis may provide the rationale for exploring novel treatments. Patients included had histologically confirmed urothelial bladder cancer and were treated with at least 3 cycles of cisplatin-based neoadjuvant chemotherapy before radical cystectomy with lymphadenectomy. A total of 245 patients at low, intermediate and high risk, presenting with 0-1, 2 or 3-4 risk factors, including positive lymph nodes, Hb <12.8, NLR ≥2.7 and cholesterol levels ≥199, were included. Five-year cancer-specific survival rate was 0.67, 0.78 and 0.94 at high, intermediate and low risk, respectively. Total cholesterol levels at the time of cystectomy may represent a commonly assessable prognostic factor and may be incorporated in a clinically meaningful risk-group classification model.

Lay abstract This present study assessed a large group of patients with urothelial bladder cancer treated with chemotherapy followed by radical cystectomy, to capture the predictive power of commonly collected clinical, pathological and biochemical factors. The design of the study highlighted that higher cholesterol levels at the time of cystectomy were associated with shorter cancer-specific survival. This finding suggests that high blood-cholesterol levels truly have a negative influence on surviving cancer. In conclusion, total cholesterol levels at the time of cystectomy may represent a commonly assessable prognostic factor and could be incorporated into a clinically meaningful and valuable risk-group classification model.

Combined Systematic and MRI-US Fusion Prostate Biopsy Has the Highest Grading Accuracy When Compared to Final Pathology.

Background and objectives: Systematic prostate biopsy (SB) has a low Gleason group (GG) accuracy when compared to final pathology. This may negatively impact the inclusion of patients into specific risk groups and treatment choice. The aim of our study was to assess the GG accuracy of magnetic resonance imaging-ultrasound (MRI-US) fusion prostate biopsy. Materials and Methods: Of a cohort of minimally invasive radical prostatectomy (RP), we selected all patients who were diagnosed with prostate cancer (PCa) via MRI-US fusion biopsy (n = 115). Results: Combined biopsy had the highest rate for GG concordance (61.7% vs. 60.4% for SB vs. 45.3% for MRI-US fusion biopsy) and the lowest for upgrading (20.9% vs. 24.5% for SB vs. 34.9% for MRI-US fusion biopsy), p < 0.0001. No clinical data were predictive for upgrading or downgrading at final pathology. Locally advanced PCa was associated with a high Prostate Imaging-Reporting and Data System (PIRADS) score (p = 0.0014) and higher percentages of positive biopsy cores (PBC)/targeted (p = 0.0002) and PBC/total (p = 0.01). Positive surgical margins were correlated with higher percentages of PBC/systematic (p = 0.003) and PBC/total (p = 0.009). Conclusions: Pre-biopsy prostate MRI improves GG concordance between biopsy and RP. Combined biopsy provides the highest grading accuracy when compared to final pathology. Targeted and systematic biopsy data are predictive for adverse pathologic outcomes.

Artificial intelligence and robotics: a combination that is changing the operating room.

PURPOSE: The aim of the current narrative review was to summarize the available evidence in the literature on artificial intelligence (AI) methods that have been applied during robotic surgery. METHODS: A narrative review of the literature was performed on MEDLINE/Pubmed and Scopus database on the topics of artificial intelligence, autonomous surgery, machine learning, robotic surgery, and surgical navigation, focusing on articles published between January 2015 and June 2019. All available evidences were analyzed and summarized herein after an interactive peer-review process of the panel. LITERATURE REVIEW: The preliminary results of the implementation of AI in clinical setting are encouraging. By providing a readout of the full telemetry and a sophisticated viewing console, robot-assisted surgery can be used to study and refine the application of AI in surgical practice. Machine learning approaches strengthen the feedback regarding surgical skills acquisition, efficiency of the surgical process, surgical guidance and prediction of postoperative outcomes. Tension-sensors on the robotic arms and the integration of augmented reality methods can help enhance the surgical experience and monitor organ movements. CONCLUSIONS: The use of AI in robotic surgery is expected to have a significant impact on future surgical training as well as enhance the surgical experience during a procedure. Both aim to realize precision surgery and thus to increase the quality of the surgical care. Implementation of AI in master-slave robotic surgery may allow for the careful, step-by-step consideration of autonomous robotic surgery.

Differentiation of Clear Cell Renal Cell Carcinoma from other Renal Cell Carcinoma Subtypes and Benign Oncocytoma Using Quantitative MDCT Enhancement Parameters.

Background and objectives: The use of non-invasive techniques to predict the histological type of renal masses can avoid a renal mass biopsy, thus being of great clinical interest. The aim of our study was to assess if quantitative multiphasic multidetector computed tomography (MDCT) enhancement patterns of renal masses (malignant and benign) may be useful to enable lesion differentiation by their enhancement characteristics. Materials and Methods: A total of 154 renal tumors were retrospectively analyzed with a four-phase MDCT protocol. We studied attenuation values using the values within the most avidly enhancing portion of the tumor (2D analysis) and within the whole tumor volume (3D analysis). A region of interest (ROI) was also placed in the adjacent uninvolved renal cortex to calculate the relative tumor enhancement ratio. Results: Significant differences were noted in enhancement and de-enhancement (diminution of attenuation measurements between the postcontrast phases) values by histology. The highest areas under the receiver operating characteristic curves (AUCs) of 0.976 (95% CI: 0.924-0.995) and 0.827 (95% CI: 0.752-0.887), respectively, were demonstrated between clear cell renal cell carcinoma (ccRCC) and papillary RCC (pRCC)/oncocytoma. The 3D analysis allowed the differentiation of ccRCC from chromophobe RCC (chrRCC) with a AUC of 0.643 (95% CI: 0.555-0.724). Wash-out values proved useful only for discrimination between ccRCC and oncocytoma (43.34 vs 64.10, p < 0.001). However, the relative tumor enhancement ratio (corticomedullary (CM) and nephrographic phases) proved useful for discrimination between ccRCC, pRCC, and chrRCC, with the values from the CM phase having higher AUCs of 0.973 (95% CI: 0.929-0.993) and 0.799 (95% CI: 0.721-0.864), respectively. Conclusions: Our observations point out that imaging features may contribute to providing prognostic information helpful in the management strategy of renal masses.

An increased body mass index is associated with a worse prognosis in patients administered BCG immunotherapy for T1 bladder cancer.

PURPOSE: The body mass index (BMI) may be associated with an increased incidence and aggressiveness of urological cancers. In this study, we aimed to evaluate the impact of the BMI on survival in patients with T1G3 non-muscle-invasive bladder cancer (NMIBC). METHODS: A total of 1155 T1G3 NMIBC patients from 13 academic institutions were retrospectively reviewed and patients administered adjuvant intravesical Bacillus Calmette-Guérin (BCG) immunotherapy with maintenance were included. Multivariable Cox regression analysis was performed to identify factors predictive of recurrence and progression. RESULTS: After re-TURBT, 288 patients (27.53%) showed residual high-grade NMIBC, while 867 (82.89%) were negative. During follow-up, 678 (64.82%) suffered recurrence, and 303 (30%) progression, 150 (14.34%) died of all causes, and 77 (7.36%) died of bladder cancer. At multivariate analysis, tumor size (hazard ratio [HR]:1.3; p = 0.001), and multifocality (HR:1.24; p = 0.004) were significantly associated with recurrence (c-index for the model:55.98). Overweight (HR: 4; p < 0.001) and obesity (HR:5.33 p < 0.001) were significantly associated with an increased risk of recurrence. Addition of the BMI to a model that included standard clinicopathological factors increased the C-index by 9.9. For progression, we found that tumor size (HR:1.63; p < 0.001), multifocality (HR:1.31; p = 0.01) and concomitant CIS (HR: 2.07; p < 0.001) were significant prognostic factors at multivariate analysis (C-index 63.8). Overweight (HR: 2.52; p < 0.001) and obesity (HR: 2.521 p < 0.001) were significantly associated with an increased risk of progression. Addition of the BMI to a model that included standard clinicopathological factors increased the C-index by 1.9. CONCLUSIONS: The BMI could have a relevant role in the clinical management of T1G3 NMIBC, if associated with bladder cancer recurrence and progression. In particular, this anthropometric factor should be taken into account at initial diagnosis and in therapeutic strategy decision making.

High-Grade T1 on Re-Transurethral Resection after Initial High-Grade T1 Confers Worse Oncological Outcomes: Results of a Multi-Institutional Study.

INTRODUCTION: The aim of this multicenter study was to investigate the prognostic impact of residual T1 high-grade (HG)/G3 tumors at re-transurethral resection (TUR of bladder tumor) in a large multi-institutional cohort of patients with primary T1 HG/G3 bladder cancer (BC). PATIENTS AND METHODS: The study period was from January 2002 to -December 2012. A total of 1,046 patients with primary T1 HG/G3 and who had non-muscle invasive BC (NMIBC) on re-TUR followed by adjuvant intravesical Bacillus Calmette-Guerin (BCG) therapy with maintenance were included. Endpoints were time to disease recurrence, progression, and overall and cancer-specific death. RESULTS: A total of 257 (24.6%) patients had residual T1 HG/G3 tumors. The presence of concomitant carcinoma in situ, multiple and large tumors (> 3 cm) at first TUR were associated with residual T1 HG/G3. Five-year recurrence-free survival (RFS), progression-free survival (PFS), overall survival (OS), and cancer-specific survival (CSS) were 17% (CI 11.8-23); 58.2% (CI 50.7-65); 73.7% (CI 66.3-79.7); and 84.5% (CI 77.8-89.3), respectively, in patients with residual T1 HG/G3, compared to 36.7% (CI 32.8-40.6); 71.4% (CI 67.3-75.2); 89.8% (CI 86.6-92.3); and 95.7% (CI 93.4-97.3), respectively, in patients with NMIBC other than T1 HG/G3 or T0 tumors. Residual T1 HG/G3 was independently associated with RFS, PFS, OS, and CSS in multivariable analyses. CONCLUSIONS: Residual T1 HG/G3 tumor at re-TUR confers worse prognosis in patients with primary T1 HG/G3 treated with maintenance BCG. Patients with residual T1 HG/G3 for primary T1 HG/G3 are very likely to fail BCG therapy alone.

The impact of minimal invasive surgery on early complications and mortality after radical cystectomy for muscle-invasive urothelial bladder cancer.

PURPOSE: to evaluate the 30-day death rate and the factors associated with short-term complications after radical cystectomy for muscle-invasive urothelial bladder cancer. METHODS: The study included 123 patients (age 64.1±7.9 years; 111 (90.2%) males and 12 (9.8%) females) previously diagnosed with urothelial bladder cancer, admitted for radical cystectomy in a tertiary center. The following data were noted: age, gender, perioperative chemotherapy and radiotherapy, pre- and postoperative hemoglobin and creatinine levels, tumor stage, type of surgery, type of diversion and Clavien classification. Patients were followed for 30 days and several complications were noted: cardiovascular, gastrointestinal, local, or infectious complications, anemia. Death rate was also recorded. RESULTS: Open cystectomy was performed in 81 (65.9%) patients, and laparoscopic approach was used in 43 (34.1%) patients. An ileal neobladder was created for 11 (8.9%) patients and noncontinent diversion for 112 (91.1%). There were 2 (1.6%) deaths following surgery. The following complication rates were noted: 27 local (22%), 16 infectious (13%), 54 cases of postoperative anemia (43.9%). Postoperative anemia was independently associated with open cystectomy (OR, 5.7; p=0.001), ileal neobladder (Odds ratio/OR, 14.6, p=0.002) and male gender (OR, 0.15, p=0.01). The Clavien classification did not differ between open and laparoscopic cystectomy (p=0.3), even though the complication grade was higher in the former. CONCLUSIONS: The 30-day death rate after radical cystectomy for muscle-invasive urothelial bladder cancer was low. Open cystectomy was associated with more severe short-term complications as compared with the laparoscopic approach. Postoperative anemia was associated with the type of surgery, diversion type and male gender.

Serum metabolomics can predict the outcome of first systematic transrectal prostate biopsy in patients with PSA <10 ng/ml.

AIM: To assess the predictive value of metabolomic analysis for the presence of prostate cancer (PCa) at first systematic biopsy. PATIENTS & METHODS: Ninety serum samples from patients with suspicion for PCa were included. Targeted and nontargeted metabolomic analysis was performed. RESULTS: Six metabolites were combined into a predictive score. A cutoff value of 0.528 for the metabolomic score showed a good accuracy for the prediction of PCa at biopsy (Area under the curve (AUC): 0.779; p < 0.001). These results were validated in a subgroup of patients, showing similar accuracy (p = 0.1). For patients with prostate specific antigen (PSA) less than 10 ng/ml, the score showed a Se 80.95%, Sp 64.52% for the detection of PCa at biopsy. CONCLUSION: Metabolomic analysis can predict the outcome of the first systematic biopsy.

Robot-Assisted Vesico-Vaginal Fistula Repair: Our Technique and Review of the Literature.

OBJECTIVE: Our first objective was to report our experience on robot-assisted vesico-vaginal fistula (VVF) repair after radical surgery for gynecologic malignancies without omental flap interposition using a da Vinci robotic system. The second objective was to critically review the literature in order to analyze surgical solutions used to avoid repair failure. MATERIALS AND METHODS: Five patients with VVF diagnosed after previous open surgery for gynecologic malignancies referred to our tertiary institutions were selected. After an adequate oncologic follow-up, based on the fistula diameter and conservative management failure, robotic surgery repair was proposed. A bivalve 2-layer suturing technique was carried out without tissue interpositions; omentum was not available secondary to previous surgery including hysterectomy, ovaryectomy, and omentectomy and citoreductive peritoneomectomy. A systematic review of the literature was performed in December 2016 using the PubMed database with the following keywords: robotic, robot-assisted, vesico-vaginal, fistula repair. RESULTS: Median age was 62 years (range 55-71) bearing long-lasting VVF were referred to our divisions. Median fistula diameter was 5 mm (range 3-8 mm). Fistula site was the trigone and identified during cystoscopy near the mid-line, left, and right urether meatus, respectively. The median overall and console operatory time were 250 and 120 min, respectively. Blood loss was insignificant (median 40 mL) and the median length of stay was 7 days without any complication. Ten papers were found fulfilling the mentioned criteria, from which 6 were case reports, single or multiple, accounting for the overall 41 robotic-approach-operated patients. CONCLUSION: The quality of the dissection and suture associated with efficient urine drainage are in our opinion the key elements of the success of our technique, which can be performed even without omentum or other tissue flap or graft interposition.

Every setback is a setup for a comeback: 3D laparoscopic radical prostatectomy after robotic radical prostatectomy.

PURPOSE: To assess whether previous experience in robotic surgery has a role in the transition to 3D laparoscopy and influences the perioperative results and short term oncological and functional outcomes of the first patients that undergo laparoscopic radical prostatectomy (LRP). METHODS: We analyzed 248 patients that underwent robotic radical prostatectomy (RALP) between 2009-2015 and 98 patients that underwent 3D HD LRP from 2015-present in our department. The procedures were performed by the same two surgeons, who crossed from open to robotic surgery, and afterwards to 3D laparoscopy. RESULTS: The patients in the study groups were comparable in terms of age, pre-operative PSA levels, clinical staging and D'Amico risk groups. The operative time was significantly shorter in favor of the laparoscopic approach (a difference of 110 min, p<0.0001). The overall rate of positive surgical margins was similar, with the biggest difference from 40.8% to 25% in pT3 patients in favor of the laparoscopic approach. The mean time to catheter removal was 7 days for RALP and 8 days for LRP. We did not identify any significant difference between the two groups in terms of biochemical recurrence, continence or potency at 3 and 6 months after the procedure. CONCLUSIONS: Previous experience in robotic surgery ensured a fast transition to 3D laparoscopic approach for radical prostatectomy, with comparable oncologic and functional outcomes, but with a shorter operative time and reduced costs.

Salvage radical prostatectomy after external beam radiation therapy: a systematic review of current approaches.

BACKGROUND: Radical external beam radiotherapy (EBRT) is a standard treatment for prostate cancer patients. Despite this, the rate of intraprostatic relapses after primary EBRT is still not negligible. There is no consensus on the most appropriate management of these patients after EBRT failure. For these patients, local salvage therapy such as radical prostatectomy, cryotherapy, and brachytherapy may be indicated. OBJECTIVE: The objectives of this review were to analyze the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. METHODS: A review of the literature was performed to identify studies of local salvage therapy for patients who had failed primary EBRT for localized prostate cancer. RESULTS: Most studies demonstrated that local salvage therapy after EBRT may provide long-term local control in appropriately selected patients, although toxicity is often significant. CONCLUSIONS: Our results suggest that for localized prostate cancer recurrence after EBRT, the selection of a local treatment modality should be made on a patient-by-patient basis. An improvement in selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological outcome and least comorbidity.

Robotic-assisted radical prostatectomy - the 5-year Romanian experience.

PURPOSE: Radical prostatectomy is the standard therapeutic approach for localized prostate cancer. After the implementation of robotic surgery in Romania, the indication extended progressively to locally advanced prostate cancer. Our objective was to evaluate the oncological and functional outcomes in patients undergoing robotic-assisted radical prostatectomy (RARP), 5 years after the first intervention in Romania. METHODS: Between November 2009 and July 2014, 207 RARPs were performed using the da Vinci SI Surgical System. Perioperative data were prospectively collected. The oncological and functional follow-up was up to 55 months (range 3-55). RESULTS: Patient stratification according to D'Amico risk categories was 16% low risk, 56.7% intermediate risk and 27.3% high risk. Median console time was 210 min (range 160-360). Median blood loss was 300 ml (range 50-1300), transfusion being required in 2.9% of the cases. Histopathological examinations showed pT3 in 40.8% of the cases, with a positive surgical margin rate of 21.1%, 13.6% for pT2, and 32.1% for pT3. Continence rate (0-1 daily safety pad) at 6, 12, 24 and 55 months was 88.3, 88.8, 90.1, and 93.7% respectively. Overall sexual function restoration rate at 6, 12, 24 and 55 months was 41.1, 44.4, 47.4 and 53%, respectively. Biochemical recurrence rate during follow-up was 6.9%. CONCLUSIONS: RARP is a minimally invasive therapeutic approach for prostate cancer, with acceptable outcomes, even in countries such as Romania, where the detection rate for localized prostate cancer is lower compared to other European countries due to lack of national screening programs.

Management of renal extraskeletal mesenchymal chondrosarcoma.

BACKGROUND: Primary mesenchymal chondrosarcoma of the kidney is an extremely rare malignant tumor. To our best knowledge, only 9 such cases have been reported so far. CASE PRESENTATION: In the current paper, we present the case of a 67 year-old patient with recurrent left lumbar pain, increased fatigability and intermittent macroscopic hematuria. He underwent a surgical resection of the left kidney and left hemicolon.The pathological diagnosis was primary extraskeletal renal mesenchymal chondrosarcoma. Overall survival was 9 months, with pulmonary metastasis and local recurrence at 6 months. The management of the patient is described, from the initial differential diagnosis, after the first clinical examination to the surgical resection, with a special emphasis on the surgical procedures that were carried out. CONCLUSION: Extraskeletal chondrosarcoma of primary origin in the kidney are extremely rare tumors with a highly malignant potential and very poor prognosis. Because the role of chemotherapy or radiation therapy has not been evaluated properly yet, we underline the importance of surgery in the management of such cases as the main and best approach to achieve clinical remission and long-term survival, provided the patient is referred to a surgical consult in time.

Right Radical Nephrectomy With Level IV Thrombus by Combined 3D Laparoscopic and Mini-thoracotomy Approach.

OBJECTIVE: To report our step-by-step technique for 3D laparoscopic radical nephrectomy and thrombectomy for a right renal tumor with level IV venous thrombus. Worldwide experience in minimally-invasive approach for such complex cases is limited. MATERIALS AND METHODS: A 66-year-old male was incidentally diagnosed with a right renal tumor. He had a medical history of hypertension and benign prostatic hyperplasia. Blood test analysis showed a hemoglobin of 11.2 g/dL and creatinine of 0.92 mg/dL. Liver function and bilirubin were within normal limits. Contrast-enhanced abdominal CT scan showed an 90/77/85 mm right renal mass with a level IV inferior vena cava (IVC) tumor thrombus. Cardiac MRI showed that the tumor thrombus was extending into the right atrium, through the tricuspid valve and into the right ventricle. There was no evidence of distant metastases. After a multidisciplinary team reviewed the case, the patient was scheduled for 3D laparoscopic radical nephrectomy and thrombectomy by mini-thoracotomy approach RESULTS: Retroperitoneal laparoscopic approach was used to ensure rapid access on the renal artery, with minimal mobilization of the renal vein, and to better isolate the posterior wall of the IVC. Surgery continued with the transperitoneal approach and the isolation of the infrarenal and infrahepatic IVC and left renal vein. Meanwhile the right femoral artery and vein and right jugular vein were cannulated. Mini-thoracotomy was performed and cardiopulmonary by-pass was started. Blood flow through the IVC and left renal vein was stopped, and the right atrium was opened to control the thrombus. Cavotomy was performed at the level of right renal hilum and the tumor thrombus was identified and sectioned. There were no signs of thrombus adherence to the IVC wall. The thoracic segment of the thrombus was completely extracted by the cardiovascular surgeons. Pringle maneuver was not necessary, as there was no retrograde bleeding. No intraoperative adverse events occurred, according to the Intraoperative Complications Assessment and Reporting with Universal Standards Criteria. The operative time was 7 hours. Blood loss was minimal, with no need of intra- or postoperative transfusions. Hospital length of stay was 8 days. Pathology revealed renal cell carcinoma, International Society of Urological Pathology 3, with negative surgical margins. At 9-months follow-up, the patient is doing well, without signs of local or distant recurrence. CONCLUSION: 3D laparoscopy is a feasible alternative to open surgery for the most complex cases, enabling very precise dissection and suturing. We have shown a case of successful 3D laparoscopic radical nephrectomy with IVC thrombectomy combined with mini-thoracotomy achieving complete intracardiac thrombus removal.