Impact of mpMRI targeted biopsy on intraoperative nerve-sparing (NeuroSAFE) during robot-assisted laparoscopic radical prostatectomy.

BACKGROUND: The aim of our study was to evaluate the impact of prostate biopsy technique (transrectal ultrasound (US)-prostate biopsy (PBx) versus multiparametric magnetic resonance imaging (mpMRI) targeted prostate biopsy (MRI-PBx) on intraoperative nerve-sparing and the rate of secondary neurovascular-bundle resection (SNR) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP). A real-time investigation with a frozen-section examination (NeuroSAFE) microscopically excluded or confirmed prostate cancer invasion of the nerve structures resulting in preservation of the neurovascular bundle or SNR. Additionally, we analyzed risk factors related to SNR, such as longer operation time and postoperative complications. METHODS: The total study cohort was stratified according to non-nerve-sparing versus nerve-sparing RARP. Patients with nerve-sparing approach were then stratified according to biopsy technique (PBx vs. MRI-PBx). Further, we compared PBx versus MRI-PBx according to SNR rate. RESULTS: We included a total of 470 consecutive patients, who underwent RARP for PCa at our institution between January 2016 and December 2019. Patients with a preoperative MRI-PBx had a 2.12-fold higher chance of successful nerve-sparing (without SNR) compared to patients with PBx (p < 0.01). Patients with preoperative MRI-PBx required 73% less intraoperative SNR compared to patients with PBx (p < 0.0001). Prior MRI-PBx is thus a predictor for successful nerve-sparing RARP approach. CONCLUSION: Preoperative MRI-PBx led to better oncological outcomes and less SNR. Young patients with good erectile function could benefit from a preoperative MRI-PBx before nerve-sparing RARP.

Can remote ischemic preconditioning counteract the renal functional deterioration attributable to partial nephrectomy under warm ischemia? Results of an animal study.

BACKGROUND: To investigate if remote ischemic preconditioning (RIPC) can offer any renoprotective value by counteracting the deleterious effect of partial nephrectomy (PN) under warm ischemia on renal function. METHODS: Four groups, each with 5 Wistar albino rats, were constructed; RIPC + PN, PN, RIPC and sham. Right nephrectomy was performed to constitute a solitary kidney model. RIPC denoted sequential clamping/declamping of the femoral artery/vein complex. PN was performed under warm-ischemia following RIPC. Blood samples were collected on multiple occasions until euthanasia on day 7. Immunoassays were conducted to measure the serum and tissues levels of kidney injury markers. Kidneys were examined histologically and morphometric analyzes were performed using digital scanning. RESULTS: IL-33 levels did not differ significantly between the groups. Serum levels of KIM-1, NGAL, and aldose reductase in RIPC + PN, PN and RIPC groups were significantly lower than that of sham group. Tissue biomarker levels were similar across groups. The observed trend in mean necrosis area of PN group was higher than that of RIPC + PN group (p > 0.05). The transitional zone between necrosis and healthy tissue showed a trend towards increasing width in the rats subjected to RIPC before PN vs. those who underwent PN without RIPC (p > 0.05). CONCLUSION: RIPC failed to counteract the renal functional consequences of PN under warm ischemia in a solitary kidney animal model. The supportive but marginal histological findings in favor of RIPC's renoprotective potential were not supplemented with the changes in serum and tissue biomarker levels.

Do new generation flexible ureterorenoscopes offer a higher treatment success than their predecessors?

New generation flexible ureterorenoscopes offer an improved deflection mechanism and a stiffer sheath compared to their predecessors. We aimed to determine if these improvements in design lead to a higher efficacy in the treatment of nephrolithiasis. Ninety patients with upper urinary tract calculi were included into a retrospective analysis. Twenty-nine cases were treated with the conventional flexible ureterorenoscope (11274 AA, Karl Storz Endoscopy, Germany) and 61 cases were treated with the new generation device (Flex-X, Karl Storz Endoscopy). Patients' and stone characteristics, intraoperative data, treatment success and complications were retrieved from the charts and compared between the two groups. Preoperative data were comparable in both groups. Whereas stone access was also comparable (97 vs. 100%; n.s.), immediate treatment success was significantly higher for the new flexible scope (70 vs. 38%; p = 0.003). For the subgroup of lower pole stones, stone access was possible in 94 versus 100% (n.s.) and treatment success was 31 versus 69% (p = 0.0004) for the conventional and the new generation device, respectively. No major complications were observed, minor complications were comparable in both groups. Our study suggests an advantage of the new generation flexible ureterorenoscopes compared to their predecessors. They offer an increased stone free rate especially in the treatment of lower pole stones. It seems therefore advisable to switch to the latest generation flexible devices.

Intraoperative inspection of the ureteropelvic junction during pyeloplasty is not sufficient to distinguish between extrinsic and intrinsic causes of obstruction: Correlation with histological analysis.

INTRODUCTION: Based on current knowledge, it is possible to have an initial diagnosis of intrinsic or extrinsic ureteropelvic junction obstruction (UPJO) based solely on clinical and imaging findings. However, it may not be possible to strictly discriminate an intrinsic case with an additional extrinsic component from a primarily intrinsic stenosis because of lower pole aberrant vessels. These two disorders may coexist or trigger each other. Herein, we aimed to compare the histological changes observed in intrinsic and extrinsic types of UPJO. Our hypothesis is that inspecting the UPJ during pyeloplasty may not be a sufficient way to delineate the underlying cause of obstruction in every individual. MATERIAL AND METHODS: We retrospectively reviewed the data of 56 patients who had dismembered pyeloplasty. The intrinsic and extrinsic groups consisted of 38 and 18 patients, respectively. Masson's trichrome stain, CD117, and connexin 43 (Cx43) antibody were used in histopathology and immunochemistry. Statistical calculations were done with chi-square and Mann-Whitney U tests. DISCUSSION: Connexin 43 staining pattern, CD117 positive cell count, and the extent of fibrosis did not differ significantly between extrinsic and intrinsic cases. However, the difference with regard to the degree of muscular hypertrophy was close to statistical significance. The exact pathophysiological mechanism underlying UPJO has yet to be elucidated. A study directly comparing both groups histologically is indeed rare. Our study showed that there are no significant differences between the intrinsic and extrinsic groups in terms of the pacemaker activity, gap junctional communication, and extent of fibrosis. Muscular hypertrophy, which was marginally higher in our extrinsic group, may persist despite successful relocation of the obstructing vessel. The main drawbacks of our study are; the absence of a control group and the retrospective study design with its inherent selection biases. CONCLUSIONS: Immunohistochemical profiles of intrinsic and extrinsic UPJOs resemble each other. Intraoperative inspection of the UPJ may not be enough for accurate discrimination for a surgical procedure that can correct only the extrinsic cause.

Isolated omental metastasis of renal cell carcinoma after extraperitoneal open partial nephrectomy: A case report.

INTRODUCTION: Metachronous metastatic spread of clinically localized renal cell carcinoma (RCC) affects almost 1/3 of the patients. They occur most frequently in lung, liver, bone and brain. Isolated omental metastasis of RCC has not been reported so far. CASE PRESENTATION: A 62-year-old patient previously diagnosed and treated due to pulmonary sarcoidosis has developed an omental metastatic lesion 13 years after having undergone open extraperitoneal partial nephrectomy for T1 clear-cell RCC. Constitutional symptoms and imaging findings that were attributed to the presence of a sarcomatoid paraneoplastic syndrome triggered by the development this metastatic focus complicated the diagnostic work-up. Biopsy of the [18F]-fluorodeoxyglucose (+) lesions confirmed the diagnosis of metastatic RCC and the patient was managed by the resection of the omental mass via near-total omentectomy followed by targeted therapy with a tyrosine kinase inhibitor. DISCUSSION: Late recurrence of RCC has been reported to occur in 10-20% of the patients within 20 years. Therefore lifelong follow up of RCC has been advocated by some authors. Diffuse peritoneal metastases have been reported in certain RCC subtypes with adverse histopathological features. However, isolated omental metastasis without any sign of peritoneal involvement is an extremely rare condition. CONCLUSION: To our knowledge, this is the first reported case of metachronously developed, isolated omental metastasis of an initially T1 clear-cell RCC. Constitutional symptoms, despite a long interval since nephrectomy, should raise the possibility of a paraneoplastic syndrome being associated with metastatic RCC. Morphological and molecular imaging studies together with histopathological documentation will be diagnostic.

Erratum to: Comparison of the trifecta outcomes of robotic and open nephron-sparing surgeries performed in the robotic era of a single institution.

[This corrects the article DOI: 10.1186/s40064-015-1274-2.].

Comparison of the trifecta outcomes of robotic and open nephron-sparing surgeries performed in the robotic era of a single institution.

PURPOSE: In this study we aimed to report a comparative analysis between open and robotic nephron sparing surgeries (NSS) from a single institutional database. METHODS: Patients who have undergone NSS during the robotic era of our institution were included in this study. Open (n = 74) and robotic (n = 59) groups were compared regarding trifecta outcome. Trifecta was defined as; warm ischemia time (WIT) <25 min, negative surgical margins and the absence of perioperative complications. RESULTS: A total of 57 (77 %) and 45 (76 %) patients in the open and robotic groups, respectively achieved the trifecta outcome. Overall trifecta rate was 77 % (n = 102/133). The only statistically significant difference between trifecta positive and trifecta negative patients was the length of hospitalization (LOH). Except LOH; none of the tested parameters were shown to be predictive of trifecta outcome on univariate and multivariate analyses. Concerning trifecta positive patients; those in the open surgery group had larger tumors with a higher degree of morphometric complexity and were hospitalized for a longer period of time. Additionally, operative duration was significantly higher in the robotic group. CONCLUSIONS: In our cohort, no significant difference in achieving the trifecta outcome was reported after open and robotic NSS. Length of hospitalization was the only parameter that differed significantly between trifecta positive and trifecta negative patients. Surgical approach was not a significant predictor of simultaneous achievement of trifecta outcomes. Irrespective of the trifecta definition; larger and more complicated tumors were handled via open NSS.