Contrast-enhanced ultrasound (CEUS) imaging for active surveillance of small renal masses.

PURPOSE: To assess the safety and efficacy of contrast-enhanced ultrasound (CEUS) imaging for monitoring small (< 4 cm) renal masses (SRM) in patients undergoing active surveillance (AS). METHODS: We retrospectively selected all consecutive patients with SRMs who underwent AS for at least 6 months at our Institution between January 2014 and December 2018. CEUS imaging was performed by two experienced genitourinary radiologists at established time points. The accuracy of CEUS for monitoring SRM size was compared with that of CT scan. For solid SRMs, four enhancement patterns (EP) were recorded. Radiological progression was defined as SRM growth rate ≥ 5 mm/year. RESULTS: Overall, 158/1049 (15.1%) patients with SRMs underwent AS. At a median follow-up of 25 months (IQR 13-39), no patient died due to renal cell carcinoma (RCC). No patients experienced CEUS-related adverse events. There was a large variability in the pattern of growth of SRMs (overall median growth rate: 0.40 mm/year), with 9.5% of SRMs showing radiological progression. The median SRM size was comparable between CEUS and CT scan examinations at all time points. The vast majority (92.7%) of SRMs did not show a change in their EP over time; and there was no association between the SRM's EP and radiological progression or SRM size. Overall, 43 (27.2%) patients underwent delayed intervention (DI); median SRM size, and median growth rate were significantly higher in these patients as compared to those continuing AS. CONCLUSION: In experienced hands, CEUS is a safe and effective strategy for active monitoring of SRMs in well-selected patients undergoing AS.

Surgical margin follow-up after nephron-sparing surgery: the possible role of CEUS.

PURPOSE: To evaluate the possible role of CEUS in the management of patients who underwent nephron-sparing surgery (NSS) and presented questionable findings on the surgical margins at the CECT follow-up exam. METHODS: In our retro-prospective study, we included 952 patients with small renal masses (SRMs) treated with NSS between 2012 and 2015 and followed with CECT for at least 3 years at Careggi University Hospital. Twenty-two of them presented solid masses on the site of surgery with questionable enhancement at CECT and were further studied with CEUS. This examination was followed by a quantitative analysis of the enhancement pattern. RESULTS: Out of the 22 masses, 18 were considered possible granulomas, presenting slow wash-in and low enhancement peaks compared to the surrounding parenchyma and persistent delayed wash-out at CEUS. Four lesions presented a suspicious malignant enhancement pattern, with rapid wash-in, high peak and rapid wash-out. In accordance with instructions from the urologist, the first group of 18 patients was strictly monitored, revealing that the mass dimensions and enhancement pattern were stable for at least 3 years of follow-up, while the other 4 patients underwent a second intervention and their masses were confirmed as tumor recurrence at the histopathological evaluation. CONCLUSIONS: CEUS can play a key role in the surgical margin follow-up after NSS when a suspicious enhancing mass is detected by CECT, giving an accurate depiction of the enhancement pattern and thus helping the clinician in the management of the patient.

Robot-Assisted Nephron-Sparing Surgery for Cystic Nephroma in a Pediatric Patient: A Case Report.

Cystic nephroma is a benign kidney tumor, which presents as a unilateral cystic mass without solid elements. We presented the first case of cystic nephroma treated with robotic nephron-sparing surgery in a pediatric patient. The procedure adopted was the robot-assisted simple enucleation of the lesion, without arterial clamping.

Intraoperative assessment of ureteral and graft reperfusion during robotic kidney transplantation with indocyanine green fluorescence videography.

BACKGROUND: The aim of this paper is to report the first preliminary experience with intraoperative indocyanine green (ICG) fluorescence videography (IFV) to assess graft and ureteral reperfusion during robot-assisted kidney transplantation (RAKT). METHODS: We prospectively collected data from consecutive patients undergoing RAKT and IFV from living-donors at our Institution between January 2017 and April 2018. RAKT was performed following the principles of the Vattikuti-Medanta technique. ICG was injected intravenously after vascular anastomoses to quantitate graft and ureteral fluorescence signal. The signal intensity within selected intraoperative snapshots was evaluated for renal parenchyma, ureter and vascular anastomoses. A systematic review of the English-language literature about the topic was performed according to the PRISMA statement recommendations. RESULTS: Six patients were included. Neither conversions to open surgery nor major intra- or postoperative complications were recorded. At a median follow-up of 12 months (IQR 8-13), median estimated glomerular filtration rate was 64.2 mL/min/1.73 m2 (IQR 45.3-98.4). Intraoperative quantitative assessment of ICG fluorescence was successful in all patients. Of the five studies selected by our review, mostly prospective studies, all including open KT series. Yet, most studies were limited by lack of quantitative measures of IFV fluorescence. CONCLUSIONS: IFV during RAKT is feasible and safe and provides a reliable assessment of graft reperfusion. Larger studies are needed to standardize the technique and to evaluate the association between fluorescence signal, ultrasound parameters and postoperative kidney function.

Robotic Kidney Transplantation from a Brain-Dead Deceased Donor in a Patient with Autosomal Dominant Polycystic Kidney Disease: First Case Report.

Background: Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end-stage renal disease (ESRD) and may pose significant technical challenges for kidney transplantation. Recently, robot-assisted kidney transplantation (RAKT) has been shown to achieve excellent patient and graft outcomes while reducing surgical morbidity. However, the vast majority of RAKT performed so far were from living donors and no studies reported the outcomes of RAKT in patients with ADPKD. Case Presentation: Herein, we describe the first successful case of RAKT from a brain-dead deceased donor in a 37-year-old patient with ESRD due to ADPKD. Conclusion: Our case highlights that RAKT can be safely performed by experienced robotic surgeons even in selected complex recipients such as patients with ADPKD and using grafts from deceased donors.

Standardized Duplex Ultrasound-Based Protocol for Early Diagnosis of Transplant Renal Artery Stenosis: Results of a Single-Institution Retrospective Cohort Study.

Transplant renal artery stenosis (TRAS) is the most frequent vascular complication after kidney transplantation (KT) and has been associated with potentially reversible refractory hypertension, graft dysfunction, and reduced patient survival. The aim of the study is to describe the outcomes of a standardized Duplex Ultrasound- (DU-) based screening protocol for early diagnosis of TRAS and for selection of patients potentially requiring endovascular intervention. We retrospectively reviewed our prospectively collected database of KT from January 1998 to select patients diagnosed with TRAS. The follow-up protocol was based on a risk-adapted, dynamic subdivision of eligible KT patients in different risk categories (RC) with different protocol strategies (PS). Of 598 patients included in the study, 52 (9%) patients had hemodynamically significant TRAS and underwent percutaneous angioplasty (PTA) and stent placement. Technical and clinical success rates were 97% and 90%, respectively. 7 cases of restenosis were recorded at follow-up and treated with re-PTA plus stenting. Both DU imaging and clinical parameters improved after stent placement. Prospective high-quality studies are needed to test the efficacy and safety of our protocol in larger series. Accurate trial design and standardized reporting of patient outcomes will be key to address the current clinical needs.