Safety and quality of cystectomy and pelvic lymph node dissection after neoadjuvant durvalumab and cisplatin/gemcitabine.

OBJECTIVE: To report on the surgical safety and quality of pelvic lymph node dissection (PLND) in patients treated with radical cystectomy (RC) and PLND for muscle-invasive bladder cancer (MIBC) after neoadjuvant chemo-immunotherapy. PATIENTS AND METHODS: The Swiss Group for Clinical Cancer Research (SAKK) 06/17 was an open-label single-arm phase II trial including 61 cisplatin-fit patients with clinical stage (c)T2-T4a cN0-1 operable urothelial MIBC or upper urinary tract cancer. Patients received neoadjuvant cisplatin/gemcitabine and durvalumab followed by surgery. Prospective quality assessment of surgeries was performed via central review of intraoperative photographs. Postoperative complications were assessed using the Clavien-Dindo Classification. Data were analysed descriptively. RESULTS: A total of 50 patients received RC and PLND. All patients received neoadjuvant chemo-immunotherapy. The median (interquartile range) number of lymph nodes removed was 29 (23-38). No intraoperative complications were registered. Grade ≥III postoperative complications were reported in 12 patients (24%). Complete nodal dissection (100%) was performed at the level of the obturator fossa (bilaterally) and of the left external iliac region; in 49 patients (98%) at the internal iliac region and at the right external iliac region; in 39 (78%) and 38 (76%) patients at the right and left presacral level, respectively. CONCLUSION: This study supports the surgical safety of RC and PLND following neoadjuvant chemo-immunotherapy in patients with MIBC. The extent and completeness of protocol-defined PLND varies between patients, highlighting the need to communicate and monitor the surgical template.

The Transabdominal Lumbar Approach (TALA) for Robotic Renal Surgery-A Retrospective Single-Center Comparative Study and Step-by-Step Description of a Novel Approach.

The transperitoneal approach (TP) and the retroperitoneal approach (RP) are two common methods for performing nephrectomy or partial nephrectomy. However, both approaches face difficulties, such as trocar placement and limited working space (RP). TP is impaired in the case of dorsal tumors and dissection of the renal artery can be challenging due to the anatomic localization dorsally to the renal vein. A hybrid approach that combines both methods has been previously reported in a case series, but not evaluated systematically. This study proposes a modified hybrid approach, which we call the transabdominal lumbar approach (TALA), involving late robotic docking after elaborating the retroperitoneum using conventional laparoscopy. The study compares the last 20 consecutive patients who underwent RP and the last 20 patients who underwent TALA at our institution. The investigated variables include operative time and amount of blood loss, hospitalization duration, postoperative analgesia requirement, and postoperative complications. The study found no significant difference in operative time, blood loss, ischemia time, or hospital stay between the two groups. The TALA group had fewer complications regarding Clavien-Dindo category 3, but one complication of category 4. In Conclusion, TALA is a safe and promising approach that combines the advantages of RP and TP.

Quantifying and Statistically Modeling Residual Pneumoperitoneum after Robotic-Assisted Laparoscopic Prostatectomy: A Prospective, Single-Center, Observational Study.

BACKGROUND: Laparoscopic surgery (LS) requires CO2 insufflation to establish the operative field. Patients with worsening pain post-operatively often undergo computed tomography (CT). CT is highly sensitive in detecting free air-the hallmark sign of a bowel injury. Yet, the clinical significance of free air is often confounded by residual CO2 and is not usually due to a visceral injury. The aim of this study was to attempt to quantify the residual pneumoperitoneum (RPP) after a robotic-assisted laparoscopic prostatectomy (RALP). METHODS: We prospectively enrolled patients who underwent RALP between August 2018 and January 2020. CT scans were performed on postoperative days (POD) 3, 5, and 7. To investigate potential factors influencing the quantity of RPP, correlation plots were made against common variables. RESULTS: In total, 31 patients with a mean age of 66 years (median 67, IQR 62-70.5) and mean BMI 26.59 (median 25.99, IQR: 24.06-29.24) underwent RALP during the study period. All patients had a relatively unremarkable post-operative course (30/31 with Clavien-Dindo class 0; 1/31 with class 2). After 3, 5, and 7 days, 3.2%, 6.4%, and 32.3% were completely without RPP, respectively. The mean RPP at 3 days was 37.6 mL (median 9.58 mL, max 247 mL, IQR 3.92-31.82 mL), whereas the mean RPP at 5 days was 19.85 mL (median 1.36 mL, max 220.77 mL, IQR 0.19-5.61 mL), and 7 days was 10.08 mL (median 0.09 mL, max 112.42 mL, IQR 0-1.5 mL). There was a significant correlation between RPP and obesity (p = 0.04665), in which higher BMIs resulted in lower initial insufflation volumes and lower RPP. CONCLUSIONS: This is the first study to systematically assess RPP after a standardized laparoscopic procedure using CT. Larger patients tend to have smaller residuals. Our data may help surgeons interpreting post-operative CTs in similar patient populations.

The Role of New Technologies in the Diagnosis and Surveillance of Non-Muscle Invasive Bladder Carcinoma: A Prospective, Double-Blinded, Monocentric Study of the XPERT© Bladder Cancer Monitor and Narrow Band Imaging© Cystoscopy.

Follow-up is essential for the early detection of recurrent non-muscle invasive bladder cancers (NMIBC). This study investigates the clinical relevance of new diagnostic tools such as an mRNA-based urine test (XPERT© Bladder Cancer Monitor, XBCM) and Narrow Band Imaging© (NBI) and compares them with the established follow-up diagnostics (white-light cystoscopy (WLC) and urine cytology). This was a prospective, double-blind, single-center study that involved patients undergoing NMIBC screening at a tertiary care center. Enrollment occurred between January 2018 and March 2020. In addition to standard care (WLC, cytology, and ultrasound), patients underwent XBCM urine testing and NBI cystoscopy. In total, 301 WLCs were performed; through this, 49 patients demonstrated NMIBC recurrence. NBI cystoscopy was congruent with WLC in all patients. Cytology showed a sensitivity (SE) and specificity (SP) of 27% and 97% (PPV: 65%; NPV 87%), respectively, whereas XBCM showed SE and SP of 58% and 89%, respectively (PPV: 51%; NPV: 92%; AUC: 0.79 (0.716-0.871)). Subgroup analysis showed improved SE and similar SP (PPV, NPV) for high grade (HG) recurrence, with a SE of 74% and SP of 89% (39%, 97%). NBI cystoscopy does not necessarily provide additional benefit over standard WLC. However, the XBCM may provide better SE and a diagnostic advantage in instances of HG disease recurrence.

Success of arterial revascularization determined by contrast ultrasound muscle perfusion imaging.

BACKGROUND: In the early postoperative evaluation of the success of arterial revascularization, ankle-brachial index (ABI) and other noninvasive tests lack reliability, especially in patients with incompressible arteries or local edema. Contrast-enhanced ultrasound (CEUS) imaging of limb muscle perfusion may be an alternative to standard tests if it detects treatment success reliably. METHODS: We compared a simplified CEUS method with clinical staging, pulse volume recording (PVR), and ABI in patients with lifestyle-limiting peripheral arterial disease undergoing revascularization by percutaneous transluminal angioplasty (PTA) or bypass surgery. Patients underwent staging, PVR, ABI, and CEUS before, directly after, and 3 to 5 months after successful PTA (n = 20) or successful bypass grafting (n = 14). For CEUS, contrast agent was injected into an antecubital vein, and the time from beginning to peak intensity of contrast enhancement (TTP) in the calf muscle was measured. RESULTS: Successful revascularization by both PTA and bypass was associated with a significant improvement in staging, PVR, ABI, and TTP directly after intervention and at follow-up. Median ABI increased from 0.60 to 0.85 (P = .001) after PTA and from 0.36 to 0.76 (P = .003) after bypass surgery. Median TTP decreased from 45 seconds to 24 seconds (P = .015) and from 30 seconds to 27 seconds (P = .041), respectively. McNemar analysis revealed unidirectional changes in both ABI and TTP (P = .625 after PTA and P = 1.000 after bypass surgery), and equivalence analysis showed 95% confidence intervals within clinical indifference, indicating that TTP was equivalent to standard tests in detecting successful revascularization. CONCLUSIONS: Contrast ultrasound perfusion imaging of calf muscle after arterial revascularization may be a valuable alternative to standard noninvasive tests such as ABI or PVR to determine the success of an arterial revascularization.

Late seed migration after prostate brachytherapy with Iod-125 permanent implants.

BACKGROUND: Seed migration is a common finding after low dose rate brachytherapy of the prostate. It has often been assessed soon after implantation, but little is known about late seed migration. We evaluated the incidence, site, symptoms, and therapeutic consequences of late seed migration more than 3 years postoperatively. MATERIALS AND METHODS: We retrospectively examined the data of 63 unselected patients with transrectal ultrasound-guided, transperineal low dose rate brachytherapy of the prostate with stranded seeds between 2001 and 2010. A pelvic X-ray was taken the day after implantation and after 6 weeks in combination with a pelvic computed tomography/magnetic resonance imaging scan (image fusion) for dosimetry. Late radiological follow-up with a further pelvic and chest X-ray was conducted 3 or more years postoperatively. We differed between seed loss without anatomical detection and seed migration into another anatomical region. RESULTS: We found seed loss up to 3 years and more after brachytherapy in 36 of 63 patients (57%). Between one and nine seeds had been lost. Late seed migration after 3 or more years occurred in two of 36 patients (6%), with pelvic migration of one seed and extrapelvic migration of one seed to the lung and two seeds to the liver, respectively. All late seed migrations were asymptomatic and had no therapeutic consequences. CONCLUSION: Beside a frequent number of seed losses, seed migration 3 or more years after implantation was as well a frequent finding but seems to be asymptomatic. Long-term follow-up with complementary radiological controls could be helpful in detecting any rare complications.