Zero ischemia robotic partial nephrectomy: Oncological and functional outcomes of a multicenter study.

BACKGROUND: The functional and oncological outcomes of zero ischemia robotic partial nephrectomy (RPN) procedures were evaluated. METHODS: A total of 56 patients underwent zero ischemia RPN transperitoneally, and their data were collected prospectively. Radius, exo/endophytic, nearness, anterior/posterior, location (R.E.N.A.L.) nephrometry, and PADUA scores were calculated. Patient and tumor characteristics were evaluated. Intra- and perioperative (0-30 days) complications were evaluated by Clavien classification. The change in serum creatinine, and estimated glomerular filtration rates (eGFR) were evaluated during preoperative, immediate postoperative periods, and at postoperative 6th months. RESULTS: The mean age of the patients was 52.2 ± 8.1 (27-75) years. R.E.N.A.L. nephrometry and PADUA scores were 6.1 ± 1.3 and 7.3 ± 1.0, respectively. The duration of surgery was 108.4 ± 18.2 min and estimated blood loss was 166.2 ± 124.7 mL. There were no intraoperative complications in any of the patients. Clavien Grade 1 and 3 complications were seen in 2 patients in the perioperative period. In the perioperative period (1-30 days), one patient required blood transfusion and angiographic intervention due to postoperative bleeding (Clavien Grade 3), and one patient required hospitalisation due to prolonged subileus (Clavien Grade 1) that resolved conservatively. The radiological and pathological tumor sizes were 3.1 ± 1.1 cm and 2.8 ± 1.4 cm, respectively. The surgical margins were positive in two patients with tumour sizes of 1.5 and 4 cm. Neither local recurrence nor distant metastasis was detected, during 33.6 ± 12.3 (3-76) months. There were no statistically significant differences between preoperative eGFR and serum creatinine levels, compared with those of immediate postoperative and postoperative 6th month periods. DISCUSSION: Zero ischemia RPN is a safe and applicable method with acceptable oncological and functional outcomes in small renal tumors and even in selected larger renal tumors.

A Retrospective Analysis of 83 Patients with Testicular Mass Who Underwent Testis-Sparing Surgery: The Eurasian Uro-oncology Association Multicenter Study.

INTRODUCTION: Herein, we analyzed the histopathological, oncological and functional outcomes of testis-sparing surgery (TSS) in patients with distinct risk for testicular cancer. METHODS: This is a multicenter retrospective study on consecutive patients who underwent TSS. Patients were categorized in high- or low-risk testicular germ cell tumor (TGCT) according to the presence/absence of features compatible with testicular dysgenesis syndrome. Histology was categorized per size and risk groups. RESULTS: TSS was performed in 83 patients (86 tumors) of them, 27 in the high-risk group. Fifty-nine patients had a non-tumoral contralateral testis present. Sixty masses and 26 masses were benign and TGCTs, respectively. No statistical differences were observed in mean age (30.9 ± 10.32 years), pathological tumor size (14.67 ± 6.7 mm) between risk groups or between benign and malignant tumors (p = 0.608). When categorized per risk groups, 22 (73.3%) and 4 (7.1%) of the TSS specimens were malignant in the high- and low-risk patient groups, respectively. Univariate analysis showed that the only independent variable significantly related to malignant outcome was previous history of TGCT. During a mean follow-up of 25.5 ± 22.7 months, no patient developed systemic disease. Local recurrence was detected in 5 patients and received radical orchiectomy. Postoperative testosterone levels remained normal in 88% of those patients with normal preoperative level. No erectile dysfunction was reported in patients with benign lesions. CONCLUSION: TSS is a safe and feasible approach with adequate cancer control, and preservation of sexual function is possible in 2/3 of patients harboring malignancy. Incidence of TGCT varies extremely between patients at high and low risk for TGCT requiring a careful consideration and counseling.

Comparison of Tumor Enucleation and Standard Partial Nephrectomy According to Trifecta Outcomes: A Multicenter Study by the Turkish Academy of Urology, Uro-Oncology Working Group.

INTRODUCTION: We aimed to evaluate the impact of the resection technique (tumor enucleation (TE) or standard partial nephrectomy (SPN)) on trifecta outcomes in patients having undergone partial nephrectomy (PN). MATERIALS AND METHODS: We retrospectively analyzed the clinical and pathologic parameters in patients with localized renal cell carcinoma (pT1-2N0M0) who had undergone PN between January 2001-December 2018 at one of 15 different tertiary referral centers. Multivariable logistic regression analysis was applied to investigate independent predictors of trifecta failure, decreased postoperative renal functions (decreased estimated glomerular filtration rate (eGFR) > 10%), perioperative complications (Clavien-Dindo > 1), and positive surgical margins. RESULTS: A total of 1070 patients with a mean age 56.11 ± 11.88 years were included in our study. PN was performed with TE in 848 (79.25%) and SPN in 222 (20.75%) patients. Trifecta failure rate was 56.2% for TE and 64.4% for SPN (p = 0.028). On multivariable analysis, TE was associated with less trifecta failure (p = 0.025) and eGFR decrease >10% rates (p = 0.024). On the other hand, there was no statistically significant difference between TE and SPN according to positive surgical margins (p = 0.450) and complication > Clavien-Dindo grade 1 (p = 0.888) rates. The only independent predictive factor for complications > Clavien-Dindo 1 was the Charlson comorbidity index (CCI) (p = 0.001). CONCLUSION: TE is associated with less trifecta failure than SPN. This result is mainly due to better preservation of renal function with TE.

A risk grouping algorithm for predicting factors of persistently elevated prostate-specific antigen in patients following robot-assisted radical prostatectomy.

OBJECTIVE: After radical prostatectomy, prostate-specific antigen(PSA) value measuring ≥0.1 ng/mL is defined as persistent PSA(pPSA) and in many studies, it was found to be associated with aggressive disease and poor prognosis. Our aim in this study is to point out the pathological and clinical factors affecting pPSA among the patients who underwent robot-assisted radical prostatectomy(RARP) in an experienced academic centre and to make a useful risk grouping algorithm that can predict pPSA value based on operative data. METHODS: We examined records of 1273 patients who underwent RARP retrospectively. Preoperative, operative and postoperative data were collected. Based on the PSA values (ng/mL) measured after 4-to-8 weeks of RARP, patients were divided into two groups as pPSA group (Group1)(n = 97) with PSA values ≥0.1 ng/mL and undetectable PSA group (Group2)(n = 778) with PSA values <0.1 ng/mL. Later on, Group1 was further divided into Group1a (PSA:0.1-0.2 ng/mL) and Group 1b (PSA≥0.2 ng/mL) to evaluate biochemical recurrence(BCR). RESULTS: Multivariate logistic regression analyses of the collected data revealed that preoperative PSA≥20 ng/mL, operation time, a postoperative international society of urological pathology (ISUP) grade of ≥4, pT 3-4 and pN were independently associated with pPSA. Based on these results, a risk grouping algorithm predicting pPSA was developed. By looking at the risk grouping algorithm pPSA was found in 98.9% of the cases with a preoperative PSA value of ≥20 ng/mL, an operation time of 150 min, a postoperative ISUP grade of 4-5, a positive lymphovascular invasion (LVI) status, pT3-T4, and pN+; while pPSA was found in 25.5% of the cases with a preoperative PSA value of <20 ng/mL, an operation time of 100 min, a postoperative ISUP grade of <4-5, a negative LVI status, pT<3-4 and pN-. The estimated BCR-free survival time was 16.3 months in Group 1a and 57.0 months in Group2 (P < .001). Adjuvant treatment ratio was 64.9% in Group1 and 7.1% in Group2 (P < .001). CONCLUSION: For the patients who underwent RARP, factors associated with aggressive disease can predict the PSA persistence. To plan our treatment modalities accurately, an applicable risk grouping algorithm in daily practice would be useful.

Outcomes and complications of radical cystectomy with ileal conduit urinary diversion: A comparison between open, semi-robotic and totally robotic surgery.

BACKGROUND: It was aimed to compare open versus robotic-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (ICIC), versus RARC with extracorporeal ileal conduit (ECIC) formation for bladder cancer. MATERIALS AND METHODS: Open, RARC-ECIC and RARC-ICIC groups were compared in terms of patient demographics, operative and postoperative parameters, pathological parameters, complications and functional outcomes. RESULTS: Mean operative times were lower in the RARC-ECIC group (p = 0.004). Mean estimated blood loss was significantly lower (p < 0.01) in the robotic groups. The blood transfusion was lower in RARC-ICIC groups (p < 0.001). Rates of stage pT3-4 disease were the highest in the RARC-ICIC group (p = 0.004). LOS was significantly shorter in the RARC-ICIC group (p = 0.01). Numbers of Clavien 3-5 complications were lower in the robotic groups (p = 0.012). CONCLUSIONS: RARC and ICIC is a complex procedure involving an increased operation time but with the advantages of lower estimated blood loss, transfusion rates, complications and hospital stays compared with open surgery.

Does the renal parenchymal thickness affect the efficacy of the retrograde intrarenal surgery? A prospective cohort study.

Retrograde intrarenal surgery (RIRS) is one of the minimally invasive main treatment modalities in renal stone disease. There are many factors which affect stone-free rate (SFR). Our study was based on the hypothesis that higher renal parenchymal thickness (RPT) which may include higher average number of nephrons provides better diuresis. We investigated the efficacy of RPT on success of RIRS. This study is a single-centered prospective surgical cohort study. A total of 383 patients were analyzed. Regularly followed 304 patients with unilateral kidney stone at single pole or renal pelvis and who underwent single-session RIRS were included in the final analysis, and the patients' preoperative and postoperative 1st and 3rd months' data were evaluated. RPT was measured on the non-contrast computed tomography (CT) images. ROC analysis was performed to estimate the cutoff value of RPT for SFR. Univariate and multivariate logistic regression analyses were used to model the relationship between RPT and SFR after RIRS. ROC analysis revealed the best cutoff value of the RPT for predicting residual stone as 19 mm for both the 1st and 3rd month visits with Youden indexes of 0.397 and 0.406, respectively. To the best of our knowledge, this is the first study which evaluated the effect of RPT on the efficacy of RIRS. RPT measurement is a cost-effective method that can be easily performed on routinely applied non-contrast CT and may have predictive value for the surgical success in patients with nephrolithiasis.

Robot Assisted Radical Cystectomy Outcomes in Micropapillary and Plasmacytoid Variants.

PURPOSE: To compare the patients who underwent robot assisted radical cystectomy (RARC) and extended pelvic lymph node dissection (EPLND) and whose pathology result was reported as micropapillary variant (MV), plasmacytoid variant (PV) and pure urothelial carcinoma (PUC). MATERIALS AND METHODS: The data of 133 patients who underwent RARC and EPLND with the postoperative pathology results reported as MV, PV and PUC were analyzed. According to the postoperative pathology results, patients were divided into two groups in initial analyses as variant pathologies group (n=14) and PUC group (n=119). In secondary analyses, patients were divided into three groups as MV group (n=7), PV group (n=7) and PUC group (n=119). The operative data, oncologic outcomes and complications were compared between the groups. RESULTS: Median operation time and estimated blood loss were significantly increased in variant pathologies group (P <0.001 and P = .001, respectively). The postoperative pathological T stage, positive surgical margin rate and lymph node involvement were also significantly increased in variant pathologies (P = .001, P = 0.004, P <0.001, respectively). Kaplan-Meier analysis revealed significant decrease in OS and CSS times in PV group compared to PUC group (P = .048 and P = .016, respectively). CONCLUSION: MV and PV are rarely seen variant pathologies with higher pathological T stages. RARC is a minimally invasive surgical technique that can be performed successfully by an experienced surgical team with low morbidity rates and similar oncological results, even in challenging cases.

Which is the best radiological imaging method for predicting actual prostate weight?

In this study, we compared the weight of the prostate specimen removed after robotic radical prostatectomy with the prostate weight measured pre-operatively by four different imaging modalities. Pre-operative prostate weight before robotic radical prostatectomy was measured by Transabdominal Ultrasonography (TAUS), Transrectal Ultrasonography (TRUS), Abdominal Tomography (CT) and MultiparametricProstate Magnetic Resonance imaging (mpMRI). Of the 170 patients enrolled in the study, the mean age was 65.2 ± 7.08 (46-84) years and mean prostate-specific antigen (PSA) 9.6 ± 7.7 (1.8-50). The mean post-operative actual prostate weight was 63.1 ± 30 gr. The mean pre-operative prostate volumes measured by TAUS, TRUS, CT and MPMRI were 64.5 ± 28.5, 49.1 ± 30.6, 54.5 ± 30.5 and 68.7 ± 31.7 ml, respectively (p < .001). Post-operative actual prostate weight correlated with prostate weight measured by TAUS, TRUS, CT and mpMRI (r coefficient 0.776, 0.802, 0.768 and 0.825 respectively). The best of these was mpMRI. Although prostate weight measured by different imaging methods has a high correlation to predict actual prostate weight, actual prostate weight is best predicted by measurements with mpMRI. However, errors and deviations that may occur with these imaging methods should be taken into consideration.

Diagnosis and Conservative Management of Ureteral Orifice Injury During Robotic Prostatectomy for a Large Prostate with a Prominent Median Lobe.

Introduction: Robot-assisted laparoscopic radical prostatectomy (RALRP) is now considered the standard treatment for localized prostate cancer. However, challenges may arise when dealing with large prostates with a prominent median lobe because the ureteral orifices may not always be visible during dissection and maybe injured in the process. We describe our experience on the diagnosis and conservative management of ureteral orifice injury in this situation. Case: A Gleason score 3 + 3 prostatic adenocarcinoma was detected during 12-quadrant prostate biopsy performed after measurement of a serum prostate specific antigen value of 8.1 ng/mL in a 65-year-old man presenting with lower urinary tract symptoms. The left ureter orifice was observed to have been injured by scissors at dissection of the neck of the bladder and enlarged median lobe at RALRP. An online video call was made to more experienced robotic surgeons for advice. Diagnosis and management of the ureteral injury are presented. Conclusion: Ureteral orifice injury during an RALRP may be managed conservatively with intraoperative ureteral stenting without the need for reimplantation nor conversion to open surgical techniques. Online video call with experienced robotic surgeons is helpful in the decision process.

Robotic Radical Cystectomy with Intracorporeal Studer Pouch Formation for Bladder Cancer: Experience in Ninety-Eight Cases.

Aim: To report the outcomes of robot-assisted radical cystectomy (RARC) with bilateral extended pelvic lymph node dissection (BEPLND) and intracorporeal Studer pouch formation for bladder cancer. Materials and Methods: Overall 98 patients (92 males, 6 females) were included. Patient demographics, operative and postoperative variables, pathological parameters, complications, and functional outcomes were evaluated. Results: Mean age and American Society of Anesthesiologists score and body mass index were 60.9 years, 1.7 and 26 kg/m2, respectively. Neoadjuvant chemotherapy was given to 18 patients. Mean operation time, intraoperative estimated blood loss, and mean lymph node (LN) yield were 8.22 hours, 314.6 mL, and 28.3, respectively. Mean hospitalization time was 13.6 days. There were one perioperative and one postoperative deaths, both due to cardiac arrest on postoperative 21st and 60th days. Drains were removed at a mean of 10 days. Surgical margins were positive in two patients. Postoperative pathological stages were reported as pT0 (n = 21), pTis (n = 7), pT1 (n = 7), pT2a (n = 14), pT2b (n = 14), pT3a (n = 15), pT3b (n = 11), and pT4a (n = 9). Positive LNs were found in 21 patients. Prostate cancer was incidentally detected in 23 patients. Twenty-five patients received adjuvant chemotherapy. At a mean follow-up period of 25.1 months, 13 patients died from metastatic disease and 7 from cardiac disease. According to the modified Clavien-Dindo system, 30 minor and 20 major complications were identified in the perioperative (0-30 days) period, and 6 minor and 7 major complications were detected in the postoperative (31-90 days) period. According to the available data of the 60 patients, 37 were fully continent, 14 had mild, 6 had moderate, and 4 had severe daytime incontinence. Conclusions: Due to our experience, RARC with BEPLND and intracorporeal Studer pouch reconstruction procedures are complex procedures with acceptable morbidity, excellent surgical and pathological outcomes, and satisfactory oncologic and functional results.

Robotic radical prostatectomy in 93 cases: Outcomes of the first ERUS robotic urology curriculum trained surgeon in Turkey.

OBJECTIVE: This study presents the surgical, oncological, and functional outcomes of the first 93 robotic radical prostatectomy (RARP) procedures performed in Erzurum, Turkey. These procedures were performed by a single surgeon who had completed the European Association of Urology Robotic Urology Section (ERUS) RARP curriculum in an ERUS-certified training center in Ankara. MATERIAL AND METHODS: The study present the results of 93 RARP procedures performed by a single surgeon. The surgeon performing the operations completed an ERUS training program structured for RARP by two robotic surgeons holding ERUS training certificates in an ERUS-approved academic robotic surgery training center in Ankara. The RARP cases performed by the surgeon after completion of the training between April 2016 and August 2018 were retrospectively evaluated. RESULTS: The mean patient age was 63.62±7.04 years, and the mean preoperative serum prostate-specific antigen level was 8.34±4.96 ng/mL. Preoperatively, 82 and 4 patients had prostate biopsy Gleason scores of 3+3 and 4+3, respectively. Bilateral neurovascular bundle (NVB) sparing, unilateral NVB-sparing, and non-NVB-sparing surgery were performed in 21, 13, and 59 cases, respectively. The mean prostate weight was 85.34±47.57 g. Posterior rhabdosphincter reconstruction was performed in 60 (64.5%) cases. Mean console time, intraoperative blood loss, duration of hospital stay, and urethral catheter removal time were 170.49±36.50 min, 100.70±34.08 cc, 6.84±2.28 days, and 7.40±3.11 days, respectively. During the perioperative period (0-30 days), five minor (prolonged drain output, n=3; rectocele, n=1; gout arthritis, n=1) and six major (inguinal hernia, n=1; incisional hernia, n=2; anastomotic urinary leakage, n=2; myocardial infarction, n=1) complications were identified. No complication was detected during postoperative days 31-90. Postoperative pathological stages included pT2a, pT2b, and pT2c disease in 77 (82.8%), 9 (9.7%), and 7 (7.5%) patients, respectively. The positive surgical margin (SM) rate was 10.7% (n=10), including patients with pT2a (n=6) and pT2c (n=2) diseases. Eleven (11.8%) patients underwent pelvic lymph node (LN) dissection. The mean LN yield was 16.45±4.29. The mean length of follow-up was 11.17±8.01 months. Biochemical recurrence was observed in two patients, one of whom received maximal androgen blockage (MAB), and the other one received pelvic radiotherapy+MAB. All the patients with at least one-year follow-up (n=48, 51.6%) were fully continent (0 pads/day). Of the 40 (43%) patients with no preoperative erectile dysfunction (ED) and with at least three-month follow-up, 18 (45%) had no ED, with or without any additional medication including phosphodiesterase-5 (PDE5) inhibitors. CONCLUSION: RARP is a safe minimally invasive procedure with acceptable morbidity, excellent operative, pathological and oncological outcomes, and satisfactory functional results. The ERUS RARP curriculum provides effective and sufficient training.

Does Type 2 Diabetes Mellitus Have an Impact on Postoperative Early, Mid-Term and Late-Term Urinary Continence After Robot-Assisted Radical Prostatectomy?

OBJECTIVE: We evaluated the effect of diabetes mellitus (DM) on urinary continence after robotic radical prostatectomy (RARP). PATIENTS AND METHODS: Overall, 99 patients with DM and 213 patients without DM who underwent RARP with at least 2-year follow-up were included. The preoperative prostate biopsy Gleason scores and clinical stages of the groups were similar. The patients who were dry or used one safety pad per day were regarded as continent. Early (0-3 months), mid-term (4-12 months), and late-term (>12 months) continence rates were evaluated. RESULTS: In diabetic and nondiabetic groups, mean age was 63.3 ± 6.5 and 61.3 ± 6.8 years, respectively (p = 0.015). On the day of the removal of the urethral catheter, 61.6% (n = 61) of the diabetic patients and 99.1% (n = 211) of the nondiabetic patients were continent (p = 0.000). At third-month follow-up, 80.8% (n = 80) of the diabetic patients and 99.1% (n = 211) of the nondiabetic patients were continent (p = 0.000). At sixth-month follow-up, 89.9% (n = 89) of the diabetic patients and 99.1% (n = 211) of the nondiabetic patients were continent (p = 0.000). At first-year follow-up, 93.9% (n = 93) of the diabetic patients and 100% (n = 213) of the nondiabetic patients were continent (p = 0.001). At 18th-month follow-up, 96.0% (n = 95) of the diabetic patients and 100% (n = 213) of the nondiabetic patients were continent (p = 0.013). At second-year follow-up, 98.0% (n = 97) of the diabetic patients and 100% (n = 213) of the nondiabetic patients were continent (p = 0.115). Multivariate analysis showed that age and body mass index had no impact on urinary continence (p > 0.05). Presence of diabetes (p = 0.008) and duration (≥5 years) of diabetes (p = 0.004) were independent factors that had a significant negative impact on urinary continence. CONCLUSIONS: Diabetes seems to be a significant disadvantage in gaining urinary continence compared with nondiabetic patients particularly in the first 18 months after RARP. Diabetic patients should be informed about possible late recovery of postoperative urinary continence compared with nondiabetic patients after RARP.

Testis-sparing surgery: Experience in 13 patients with oncological and functional outcomes.

INTRODUCTION: We present oncological and functional outcomes of patients who underwent testis-sparing surgery (TSS). METHODS: Overall, 13 patients were included. Mean patient age was 29.9±12.5 years. In five patients, TSS was performed for sequential bilateral testicular tumours. One patient underwent concurrent left radical orchiectomy and right TSS. In eight patients with normal contralateral testis, seven underwent left and one underwent right TSS. RESULTS: Mean pathological tumour size was 14.6±12.5 mm. Intraoperative frozen section evaluation of the mass was performed in eight patients that revealed benign lesions. No intraoperative tumour bed biopsies were taken in this patient group. Regarding the remaining five patients, intraoperative tumour bed biopsies were taken and testicular intraepithelial neoplasia (TIN) was reported in two (40%) patients; no local testicular radiotherapy was given postoperatively. Tumour pathology was malignant in all but one lesion, including Leydig cell tumour (n=1), seminoma(n=2), embryonal carcinoma (n=1), and adenomatoid tumour (n=1). During 47.2±22.5 months of followup, local recurrence was detected in one patient who underwent radical orchiectomy. No additional local recurrence or systemic metastasis was identified in other patients with malignant lesions. For patients with malignant tumours, of the three patients with a normal preoperative testosterone levels, testosterone level was normal in one patient (with no erectile dysfunction [ED]) and was decreased in two patients (with ED) following TSS. No ED was reported in the nine patients with benign lesions. CONCLUSIONS: In carefully selected cases, TSS appears to be a safe, feasible procedure with adequate cancer control that could preserve sexual function.

Does extent of prostate-specific antigen fluctuation can predict Gleason score upgrading in low-risk prostate cancer patients?

OBJECTIVE: To evaluate the effect of prostate-specific antigen (PSA) fluctuation on Gleason score (GS) upgrading, disease upstaging, oncological outcomes in low-risk prostate cancer (PCa) patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP) and met the inclusion criteria for active surveillance (AS). MATERIAL AND METHODS: Data of 354 low-risk PCa patients who underwent RARP were retrospectively evaluated. Patients were divided into two groups: PSA fluctuation rate<9.5%/month (Group 1, n=192) and >9.5%/month (Group 2, n=162). Mainly compared parameters were GS upgrading, disease upstaging, biochemical recurrence (BCR) and surgical margin positivity (SMP) rates. RESULTS: GS upgrading, disease upstaging and SMP were detected in 128 (36.2%), 56 (15.8%) and 42 (11.9%) patients, respectively. After a median follow-up of 46 months, BCR was observed in 40 (11.3%) patients. GS upgrading (41.1% vs. 30.2%, p=0.033), disease upstaging (19.8% vs. 11.1%, p=0.028), SMP (15.1% vs. 8%, p=0.035) and BCR development (15.6% vs. 6.2%, p=0.005) rates were statistically significantly higher in Group 1 than Group 2. In multivariate analysis, digital rectal examination positivity, the presence of two positive cores and low PSA fluctuation rate were found to be significant predictors of GS upgrading. CONCLUSION: Low PSA fluctuation rate is associated with higher GS upgrading.

Is there a difference in the number of interstitial cells, neurons, presence of fibrosis and inflammation in ureteropelvic junction tissues of patients with ureteropelvic junction obstruction with and without crossing vessels?

OBJECTIVE: We compared the number of interstitial cells (ICs), nerves, presence of fibrosis and inflammation at the level of full-thickness human ureteropelvic junction (UPJ) tissues obtained from normal subjects, and patients with UPJ obstruction with and without crossing vessels. MATERIAL AND METHODS: Normal UPJ tissues (n=12) histopathologically confirmed to be without tumor involvement were obtained from subjects who underwent radical nephrectomy for kidney mass. Additional UPJ tissues were obtained from patients who underwent pyeloplasty due to UPJ obstruction. Crossing vessel was identified in 17 patients. In 57 patients, no crossing-vessel was noted. ICs were stained immunohistochemically with anti-human CD117 (c-kit) antibody. Neural tissue was stained with S-100. The numbers of ICs and neurons were compared between the groups: controls with normal UPJ (Group I), Ureteropelvic junction obtruction (UPJO) with crossing vessel (Group II) and UPJ obstruction without crossing vessel (Group III). Groups were also compared in terms of the presence of fibrosis and inflammation. RESULTS: The mean age of total population included in the study was 30.5±18.5 years. No significant differences were detected between the three groups regarding mean and median numbers of ICs at the level of UPJ (lamina propria and muscle layer) and mean and median numbers of neurons at the level of lamina propria (p>0.05). Likewise, no significant differences were detected between the three groups regarding the presence of fibrosis and inflammation (p>0.05). CONCLUSION: Number of ICs, neurons, presence of fibrosis and inflammation seem to be similar in the intact UPJ and UPJ with obstruction with and without crossing vessel. Cellular function rather than the number ICs might play a role that warrants further research.

Does Presence of a Median Lobe Affect Perioperative Complications, Oncological Outcomes and Urinary Continence Following Robotic-assisted Radical Prostatectomy?

PURPOSE: To evaluate of the presence of a median lobe(ML) affect perioperative complications, positive surgical margins(PSM), biochemical recurrence(BCR) and urinary continence(UC) following robotic-assisted radical prostatectomy(RARP). MATERIALS AND METHODS: Data of 924 consecutive patients who underwent RARP for prostate cancer (PCa) and who have at least 1-year follow-up were evaluated retrospectively. All patients were divided into two groups: Group 1(n=252) included patients with ML and Group 2 (n=672) included patients without ML. The primary endpoint of this study was to compare complication rates between two groups. The secondary endpoints were to compare PSM, BCR and UC rates. RESULTS: Both groups were statistically similar in terms of demographics and variables about PCa. Mean prostate volume was higher in Group 1 vs. Group 2 (69± 31 vs. 56±23 mL, p<.001). Total operative time was longer in Group 1 vs. Group 2 (144±38 vs. 136±44 min, p=.01). Biochemical recurrence, PSM, perioperative and postoperative complication rates of our population were 13.6%, 14.9%, 1.7% and 8.7%, respectively. There were no statistical differences in terms of perioperative complication, PSM and BCR rates between the groups(p>0.05). At the first month after RARP, total continence rate was statistically significant lower in Group 1 vs. Group 2 (49.2% and 56.5%, p=.03), respectively. However, there were no significant differences in terms of continence rates at 3rd month, 6th month and 1st-year follow-up. CONCLUSIONS: Due to our experience, the presence of ML does not seem to affect perioperative complication, intraoperative blood loss, PSM and BCR following RARP. However, the presence of ML seems to be a disadvantage in gaining early UC following RARP.

Prognostic significance of the programmed death ligand 1 expression in clear cell renal cell carcinoma and correlation with the tumor microenvironment and hypoxia-inducible factor expression.

BACKGROUND: Clear cell renal cell carcinoma (ccRCC) is the most common renal malignancy. Hypoxia-inducible factors, HIF-1α and HIF-2α, are expressed in the majority of ccRCC. Targeting immune checkpoints with the blockade of PD-1 and its ligand PD-L1 reorganizes T-cell activity in tumor microenvironment and provides important antitumor responses. PD-L1 upregulation has been found to be hypoxia-inducible factor (HIF) dependent. Our aim is to demonstrate the association between PD-L1 and HIF expression and to reveal the role of PD-L1 in prognosis and its association with tumor microenvironment. METHODS: Surgical specimens from 145 patients diagnosed with ccRCC, who had undergone radical or partial nephrectomy, were retrospectively analyzed. Immunohistochemistry on tissue microarrays (TMA) was performed to demonstrate expressions of PD-L1, HIF-1α, and HIF-2α in tumor cells and PD-1, CD4, and CD8 in lymphocytes to assess lymphocyte density in tumor microenvironment. RESULTS: PD-L1 tumor cell expression was detected in 20/125 (13.8%) cases, which correlated with higher levels of PD-1, CD4, CD8 and HIF-2α expression. Low or high expression of HIF-1α was similar in PD-L1-positive cases. When PD-L1-positive cases were compared with negative ones, there was no significant difference in terms of prognostic factors. However, the number of WHO/ISUP grade 3-4 tumors was significantly higher in PD-L1-positive cases than in negative ones. CONCLUSION: PD-L1 tumor cell expression is strongly associated with increased HIF-2α expression and presence of dense lymphocytic infiltration in ccRCCs. Our findings confirm that PD-L1 positivity is associated with high ISUP nucleolar grade. The association between PD-L1, HIF, and lymphocyte density in tumor microenvironment must be clarified and especially taken into account in combination treatment.

Concurrent Repair of Inguinal Hernias with Mesh Application During Transperitoneal Robotic-assisted Radical Prostatectomy: Is it Safe.

PURPOSE: To assessment the safety of concurrent repair of inguinal hernia (IH) with mesh application during transperitoneal robotic-assisted radical prostatectomy(RARP). MATERIALS AND METHODS: Data of 20 patients (totally 25 procedures) who performed concurrent IH repair with mesh application during RARP were retrospectively enrolled in this study. Preoperative patient characteristics, intra and postoperative parameters (pathological Gleason grade, prostate volume at surgical specimen, operative time, herniorrhaphy time, estimated blood loss, complications, time of hospitalization, catheterization, and drainage) were evaluated. Standard PSA control and postoperative complications of mesh application such as herniarecurrence, mesh infection, seroma formation and groin pain were evaluated at every follow-up visits (every three in the first year, then every 6 months in years 2 to 5 and annually thereafter. RESULT: The mean age was 66 ± 8 years in our population. Fifteen (60 %) patients had a unilateral hernia and 5 (40%) patients had bilateral hernias. The mean operative time was 139 ± 21minutes and estimated mean blood loss was 108 ± 76 mL. The mean duration of IH repair in patients which was 27 ± 5 (range: 17- 40) minutes. The mean time of drainage, hospitalization, and catheterization were 2.5 ± 0.8 days (range: 2-6), 4 ± 0.9 days (range: 2-7) and 8.2 ± 1.9 days (range: 7-14), respectively. We did not observe any intra-operative complication due to RARP orIH repair. Wound evisceration at camera port site developed in only a patient on postoperative day 20. Our median follow-up time was 13 months and we did not observe mesh infection or hernia recurrence during follow-up. CONCLUSION: Concurrent IH repair with RARP procedure seem to be easy to perform, effective and safe procedure.

The effect of corticosteroid on postoperative early pain, renal colic and total analgesic consumption after uncomplicated and unstented ureteroscopy: a matched-pair analysis.

PURPOSE: To evaluate the effect of corticosteroid (CS) on early postoperative pain, renal colic and total analgesic consumption after uncomplicated and unstented ureteroscopy (URS). METHODS: Data of 397 patients who underwent URS and stone fragmentation for symptomatic distal ureteral stone (≤ 15 mm) were retrospectively evaluated. After exclusion, 72 patients who received methylprednisolone (Group I) after non-stenting uncomplicated URS were matched with another 72 patients who did not receive CS (Group II). Cases were matched 1:1 ratio and the matched-pair criteria were age, stone diameter, and duration of surgery. RESULTS: Both groups were statistically similar in terms of mean age, operative time, stone size and preoperative pain score. However, the mean postoperative pain score was statistically significantly lower in group I than group II on the day of surgery (3.3 ± 1.7 vs. 3.9 ± 1.3, p = 0.012) and postoperative day 1 (2.8 ± 1.8 vs. 3.4 ± 1.3, p = 0.02), respectively. Renal colic episode development rate (4.2 vs. 13.2%, p = 0.036), parenteral analgesic requirement rate (18.1 vs. 33.3%, p = 0.001) and total parenteral analgesic consumption per patient (18 vs. 36mg, p = 0.009) were statistically lower in group I than group II on the day of surgery; however, there were no statistically significant differences on postoperative day 1. There were no statistically significant differences between groups in terms of ureteral stenting requirement and late unplanned urgent room visit rates. CONCLUSIONS: Corticosteroid after uncomplicated URS can be offered to reduce early postoperative pain, renal colic episode and total analgesic consumption.

A giant pararectal cyst successfully treated by robotic surgery.

A 50 year-old patient was referred to our department with severe obstructive lower urinary tract symptoms, suprapubic pain and rectal fullness that started after a perianal fistula operation performed one year ago. Radiologic evaluation showed a large pararectal cystic lesion with septa formation on the right side compressing the bladder and prostate. Aspiration of the cystic fluid attempted initially but was not successful. A robotic transperitoneal approach was applied and the cyst was excised completely. On 1-year follow-up, patient did not have any symptoms and cyst was completely disappeared on radiology.