RESUMEN
BACKGROUND: Accurate primary staging of renal cancer with conventional imaging is challenging. Prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) may serve to improve the accuracy of renal cancer staging. OBJECTIVE: To determine clinicopathological and management differences for primary renal cancer staged with PSMA PET/CT in comparison to conventional imaging. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective cohort study of PSMA PET/CT scans performed for primary staging of renal cancer and incidental renal lesions at three sites in Brisbane, Australia between June 2015 and June 2020. Clinical characteristics, imaging, and histopathology were reviewed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Clinicopathological and management differences according to staging modality (PSMA PET/CT, conventional imaging) were assessed. Descriptive statistics were used to report demographics and clinical parameters. Nonparametric methods were used for statistical analysis. Fisher's exact test was used for comparison of small-cell size categorical variables. RESULTS AND LIMITATIONS: From a total of 120 PSMA PET/CT scans, 61 were included (52 staging, 9 incidental) for predominantly males (74%) with a mean age of 65.1 yr (standard deviation 12.0). Most primary lesions (40/51) were clear-cell renal cell carcinoma (ccRCC; 98% PSMA-avid), eight were non-ccRCC (75% PSMA-avid), and three were non-RCC (oncocytoma; 67% PSMA-avid). PSMA PET identified a greater number of presumed metastatic lesions than conventional imaging (195 vs 160). A management change was observed for 32% of patients (20% major, 12% minor). Limitations include the retrospective design and selection bias, lack of blinding to PSMA reporting, and the use of different PSMA radiotracers. CONCLUSIONS: PSMA PET/CT detected more metastases than conventional imaging and most renal cancers were PSMA-avid, resulting in a management change for one-third of the patients. PATIENT SUMMARY: We looked at a newer type of scan called PSMA PET/CT for first staging of kidney cancer. We found that this detects more metastasis and helps in decisions on changes in treatment for some patients. This type of imaging is a useful addition to conventional scans in tricky cases and may help in better selection of suitable treatments, but more studies are required.
RESUMEN
Objectives: There has been growing interest in intracorporeal techniques to urinary diversion during cystectomy in the modern area. There is little high-quality evidence that this technique is superior to extracorporeal diversion in patients who are obtaining an orthotopic intracorporeal neobladder urinary diversion. This study describes the proposed advantages and disadvantages of intracorporeal orthotopic neobladder urinary diversion and expert opinion on preference. Methods: We reviewed the literature for all studies discussing the outcomes and advantages of intracorporeal orthotopic neobladder urinary diversion, including those comparing the intracorporeal and extracorporeal approach. The studies were reviewed and these findings were summarized based on categories of the proposed advantages and disadvantages of the intracorporeal approach. We provided an assessment of the claims made in favor of the intracorporeal approach and discussed advantages of the extracorporeal approach that may persuade even the most experienced robotic surgeons to lean away from the former. Results and conclusions: Herein we review the studies that propose advantages of the intracorporeal diversion, as well as the studies that do not demonstrate any advantage to this approach. Some of the proposed advantages addressed include decreased stricture rate, lower complications and shorter hospitalization. Furthermore, we address the issues of the steep learning curve and the impact on resident education. We conclude that the proposed benefits of an intracorporeal approach to urinary diversion are not substantiated and it is the preference of the authors to primarily perform extracorporeal urinary diversions
Objetivos: Ha habido un interés creciente en la era moderna por las técnicas intracorpóreas de derivación urinaria durante la cistectomía. Hay poca evidencia de alta calidad que muestre que esta técnica es superior a la derivación extracorpórea en pacientes a los que se les hace una derivación con neovejiga ortotópica intracorpórea. Este estudio describe las ventajas y desventajas propuestas de la derivación urinaria con neovejiga ortotópica intracorpórea y la opinión de expertos sobre preferencias. Métodos: Revisamos todos los estudios de la literatura que discuten los resultados y ventajas de la derivación urinaria con neovejiga ortotópica intracorpórea, incluyendo los que comparan los abordajes intra y extracorpóreo. Se revisaron los estudios y estos hallazgos fueron resumidos en base a las categorías de las ventajas e inconvenientes propuestos del abordaje intracorpóreo. Hicimos una evaluación de las reivindicaciones a favor del abordaje intracorpóreo y discutimos las ventajas del abordaje extracorporeo que pueden persuadir incluso a los cirujanos robóticos más experimentados para no inclinarse por el primero. Resultados y conclusiones: Revisamos los estudios que proponen ventajas de la derivación intracorpórea, así como los estudios que no demuestran ninguna ventaja de este abordaje. Entre las ventajas tratadas se incluyen: disminución de la tasa de estenosis, menores complicaciones y estancias hospitalarias menores. Además, tratamos los aspectos de dificultad de la curva de aprendizaje e impacto sobre la educación del residente. Concluimos que los beneficios propuestos de un abordaje intracorpóreo de la derivación urinaria no están probados y que la preferencia de los autores es realizar las derivaciones urinarias extracorpóreas