Durable biochemical response following adrenal metastasectomy for oligometastatic castrate-resistant prostate cancer.

A 77 year-old man was referred to Urology with an enlarging left adrenal mass after treatment with androgen deprivation therapy for metastatic castrate-resistant prostate cancer. He underwent a robotic-assisted left radical adrenalectomy, with pathology revealing metastatic adenocarcinoma consistent with a primary prostate adenocarcinoma. The patient had a durable oncological response to metastasectomy with no evidence of biochemical or radiological recurrence after 5 years of follow-up. Adrenal metastases from prostate cancer are extremely rare, representing only 1% of metastatic cases. Surgical resection of oligometastatic prostate cancer recurrences may be considered in select patients and may improve progression-free survival.

Robotic Renal Artery Aneurysm Repair.

BACKGROUND: Renal artery aneurysm (RAA) is a rare condition, traditionally managed with endovascular or open surgical techniques. OBJECTIVE: To report our experience with robotic RAA repair. DESIGN, SETTING, AND PARTICIPANTS: Nine consecutive patients underwent intracorporeal robotic surgery for 10 RAAs. SURGICAL PROCEDURE: Two patients underwent concomitant robotic partial nephrectomy. One patient had RAA in a solitary kidney. Median RAA diameter was 2.2 (1.8-3)cm. Intracorporeal transarterial hypothermic renal perfusion was performed in five patients. Robotic techniques included tailored aneurysmectomy and repair (n=5), excision with end-to-end anastomosis (n=2), aneurysmectomy with branch reimplantation (n=1), prosthetic interposition graft repair (n=1), and simple nephrectomy (n=1; this patient's data were excluded from analysis). MEASUREMENTS: Demographics, RAA characteristics, intraoperative techniques, perioperative outcomes, and follow up data were analyzed. Aneurysms were diagnosed by computed tomography, angiography, or incidentally during the performance of a partial nephrectomy. RESULTS AND LIMITATIONS: All cases were performed robotically, without conversion to open surgery. Median (range) operative time was 3.8 (3-6)h, warm ischemia time 26 (19-32)min, hypothermic renal perfusion time 34 (29-69)min, and estimated blood loss 100 (25-400)ml. No intraoperative blood transfusion was required. Median hospital stay was 3 (2-6)d. One patient had a Clavien-Dindo grade II complication. At median follow-up of 16 (2-67)mo, all patients had preserved renal function. Follow-up imaging confirmed normal caliber reconstructed renal arteries with globally perfused kidneys, except for two kidneys with small segmental infarcts due to an intentionally ligated small polar vessel. Limitations include the small number of patients and the retrospective nature of the study. CONCLUSIONS: Robotic repair of complex RAAs is feasible. Surgical expertise, patient selection, and RAA-specific vascular reconstruction are critical for success. Greater experience is needed to evaluate the proper place of robotic repair of RAAs. PATIENT SUMMARY: We report intracorporeal robotic repair for complex renal artery aneurysms. This robotic operation is feasible and safe, and replicates open principles. However, it requires considerable experience and expertise.

Use of indocyanine green to minimise uretero-enteric strictures after robotic radical cystectomy.

OBJECTIVE: To evaluate the impact of indocyanine green (ICG) for assessing ureteric vascularity on the rate of uretero-enteric stricture formation after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD). PATIENTS AND METHODS: We identified 179 patients undergoing RARC and ICUD between January 2014 and May 2017, and divided the patients into two groups based on the utilisation of ICG for the assessment of ureteric vascularity (non-ICG group and ICG group). We retrospectively reviewed the medical records to identify the length of ureter excised. Demographic, perioperative outcomes (including 90-day complications and readmissions), and the rate of uretero-enteric stricture were compared between the two groups. The two groups were compared using the t-test for continuous variables and the chi-squared test for categorical variables. A P < 0.05 was considered statistically significant. RESULTS: A total of 132 and 47 patients were in the non-ICG group and the ICG group, respectively. There were no differences in baseline characteristics and perioperative outcomes including operating time, estimated blood loss, and length of stay. The ICG group was associated with a greater length of ureter being excised during the uretero-enteric anastomosis and a greater proportion of patients having long segment (>5 cm) ureteric resection. The median follow-up was 14 and 12 months in the non-ICG and ICG groups, respectively. The ICG group was associated with no uretero-enteric strictures compared to a per-patient stricture rate of 10.6% and a per-ureter stricture rate of 6.6% in the non-ICG group (P = 0.020 and P = 0.013, respectively). CONCLUSION: The use of ICG fluorescence to assess distal ureteric vascularity during RARC and ICUD may reduce the risk of ischaemic uretero-enteric strictures. The technique is simple, safe, and reproducible. Larger studies with longer follow-up are needed to confirm our findings.

Robotic salvage retroperitoneal and pelvic lymph node dissection for 'node-only' recurrent prostate cancer: technique and initial series.

OBJECTIVES: To describe the technique of robot-assisted high-extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for 'node-only' recurrent prostate cancer. PATIENTS AND METHODS: In all, 10 patients underwent robot-assisted sRPLND+PLND (09/2015-03/2016) for 'node-only' recurrent prostate cancer, as identified by 11 C-acetate positron emission tomography/computed tomography imaging. Our anatomical template extends from bilateral renal artery/vein cranially up to Cloquet's node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees; RPLND precedes PLND. Meticulous node-mapping assessed nodes at four prospectively assigned anatomical zones. RESULTS: The median operative time was 4.8 h, estimated blood loss 100 mL and hospital stay 1 day. No patient had an intraoperative complication, open conversion or blood transfusion. Three patients had spontaneously resolving Clavien-Dindo grade II postoperative complications. The mean (range) number of nodes excised per patient was 83 (41-132) and mean (range) number of positive nodes per patient was 23 (0-109). Seven patients (70%) had positive nodes on final pathology. Node-positive rates per anatomical level I, II, III and IV were 28%, 32%, 33% and 33%, respectively. In patients with positive nodes, the median PSA level had decreased by 83% at the 2-month follow-up. CONCLUSION: The initial series of robot-assisted sRPLND+PLND is presented, wherein we duplicate open surgery with superior nodal counts and decreased morbidity. Robot-assisted technical details for an anatomical LND template up to the renal vessels are presented. Longer follow-up is necessary to assess oncological outcomes.

Active Surveillance for Small Renal Masses in Young Patients.

We certainly agree with active surveillance for small renal masses 9SRMs). However, it must be in appropriate patients, the elderly and the infirm, in whom the comorbidity risks outweigh the oncologic risks. Evidence to support active surveillance for SRMs in the young is lacking.

Importance of heart rate analysis in exercise tolerance test

After many years away from the limelights, at the beginning of this century, exercise tolerance testing has earned back an important position in international medical journals. The different sorts of information derived from a variety of studies based on it have shown us that this propedeutic method has a highly valuable prognostic impact. Because of its low cost and easy applicability, the exercise testing reinforces its position in the clinical practice of the cardiologist. In the early 70's, research relating the influence of the autonomic nervous system in heart rate behavior in all phases of an exercise tolerance testing began. Ever since, a number of hypotheses tried to clarify which would be the mechanisms related to the chronotropic response during effort and its performance in the recovery period. In this updating article the authors deal with an important data referring to the chronotropic deficit and the abnormal heart rate recovery, commenting on the prognostic implication of keeping the focus on the potential of its clinical impact. In other words, approaches that can be used whenever there is someone performing a monitored exercise tolerance testing