Warm ischemia time length during on-clamp partial nephrectomy: does it really matter?

BACKGROUND: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN). METHODS: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m2. Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages. RESULTS: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study. CONCLUSIONS: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m2.

Retzius-sparing robot-assisted radical prostatectomy versus open retropubic radical prostatectomy: a prospective comparative study with 19-month follow-up.

BACKGROUND: The aim of the present study was to compare the surgical outcomes of retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and open retropubic radical prostatectomy (ORP). METHODS: We included patients with clinically localized prostate cancer who underwent RS-RARP or ORP and met our inclusion criteria. We compared the perioperative, oncological, and continence outcomes between both surgical approaches. Continence function was assessed using the validated International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Continence was defined as using 0-1 safety pad per day. Biochemical recurrence (BCR) was defined as two consecutive rises in serum PSA more than 0.2 ng/mL. Events of local recurrence, distant metastasis, and cancer death were reported and compared using Kaplan-Meier survival analysis. RESULTS: Between 1 June 2013 and 1 October 1 2016, 184 men were enrolled, of whom 125 underwent RS-RARP and 59 underwent ORP. Baseline demographic and pathological characteristics were similar between both groups (P>0.05). Patients in RS-RARP group had significantly lower blood loss, fewer transfusion rates, lower VAS score, and shorter hospital stay than patients in ORP group (P<0.05). Major complications (≥grade 3b) did not differ between both groups (P=0.121). Positive surgical margins were 28.8% and 24.8% in ORP and RS-RARP, respectively (P=0.494). The BCR free-survival rates in ORP and RS-RARP at 1-year was 87.3% and 92.3%, respectively (Log-rank, P=0.740). At 1-, 6-, and 12-month after surgery, 42.4%, 79.7%, and 84.7% of men undergoing ORP were continent, compared with 72.8%, 90.4%, and 92% undergoing RS-RARP, respectively. Men in RS-RARP group achieved faster recovery of urinary continence compared to men in ORP group (Log-rank, P=0.001). CONCLUSIONS: RS-RARP had better perioperative outcomes and faster recovery of urinary continence compared with ORP. Short-term oncological outcomes were comparable between both surgical approaches.

Monopolar vs. bipolar transurethral resection for non-muscle invasive bladder carcinoma: A post-hoc analysis from a randomized controlled trial.

PURPOSE: Traditionally, transurethral resection of bladder tumors (TURB) is performed using monopolar technique. Bipolar resection has been postulated to reduce complications. In this study we compare safety and efficacy between monopolar TURB (mTURB) and bipolar TURB (bTURB) for patients with primary non-muscle invasive bladder cancer (NMIBC). MATERIALS AND METHODS: Data were obtained from an international multicenter randomized clinical trial that compared the use of white light cystoscopy with narrow band imaging-assisted TURB using the Olympus system between 2010 and 2014. Main outcomes of interest were operative time, perioperative, and postoperative complications, and 12-month recurrence-free survival. RESULTS: In total, 716 patients were treated for primary NMIBC with mTURB (310 patients) or bTURB (406 patients). The use of white light cystoscopy or narrow band imaging was equally distributed between the 2 resection techniques. Multilevel logistic and linear regression corrected for possible confounders showed no significant difference between mTURB and bTURB for postoperative complications (OR = 1.76, P = 0.180), postoperative bleeding (OR = 1.27, P = 0.722), and the combination of intra + postoperative bleeding (OR = 1.992, P = 0.108). Additionally, no significant difference was found between mTURB and bTURB concerning operative time (1.05min. longer for bTURB, P = 0.536), intraoperative bleeding requiring intervention (OR:1.38, P=0.809), incidence of obturator reflex (OR = 0.93, P = 0.854), and bladder perforation (OR = 3.05, P = 0.195). In total, 185 patients (25.8%) developed a recurrence (mTURB = 88, bTURB = 97). Recurrence-free survival at 12 months in the mTURB and bTURB group was 70% and 74% (P = 0.410), respectively. CONCLUSION: Based on these results, bTURB is as safe and effective as mTURB in treatment of primary NMIBC. bTURB seems to have no evident advantages over mTURB with respect to operation time, perioperative and postoperative complication rates, and recurrence rates at 12 months.

Impact of preoperative calculation of nephron volume loss on future of partial nephrectomy techniques; planning a strategic roadmap for improving functional preservation and securing oncological safety.

OBJECTIVES: To assess the correlation of the resected and ischaemic volume (RAIV), which is a preoperatively calculated volume of nephron loss, with the amount of postoperative renal function (PRF) decline after minimally invasive partial nephrectomy (PN) in a multi-institutional dataset. PATIENTS AND METHODS: We identified 348 patients from March 2005 to December 2013 at six institutions. Data on all cases of laparoscopic (n = 85) and robot-assisted PN (n = 263) performed were retrospectively gathered. Univariable and multivariable linear regression analyses were used to identify the associations between various time points of PRF and the RAIV, as a continuous variable. RESULTS: The mean (sd) RAIV was 24.2 (29.2) cm3 . The mean preoperative estimated glomerular filtration rate (eGFR) and the eGFRs at postoperative day 1, 6 and 36 months after PN were 91.0 and 76.8, 80.2 and 87.7 mL/min/1.73 m2 , respectively. In multivariable linear regression analysis, the amount of decline in PRF at follow-up was significantly correlated with the RAIV (ß 0.261, 0.165, 0.260 at postoperative day 1, 6 and 36 months after PN, respectively). This study has the limitation of its retrospective nature. CONCLUSION: Preoperatively calculated RAIV significantly correlates with the amount of decline in PRF during long-term follow-up. The RAIV could lead our research to the level of prediction of the amount of PRF decline after PN and thus would be appropriate for assessing the technical advantages of emerging techniques.

Impact of a bladder cuff excision during radical nephroureterectomy on cancer specific survival in patients with upper tract urothelial cancer in Korea: a retrospective, multi-institutional study.

BACKGROUND: Radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is the surgical principle adopted for the treatment of upper tract urothelial cancers (UTUCs). However, not all RNUs are performed with BCE. We quantified the prognostic impact of RNU with BCE on cancer-specific survival (CSS) in a large patient population. METHODS: In total, 505 patients with UTUC were enrolled from four different institutions. The clinicopathological parameters of patients who underwent RNU with and without BCE were compared. The Kaplan-Meier and multivariate Cox regression analyses were performed to assess the influence of BCE on CSS. RESULTS: In total, 60 (11.9%) patients had not undergone BCE during RNU. Compared to patients who underwent BCE, these patients were older and had more comorbidities. Patients with UTUC who had not undergone BCE were more likely to be associated with ≥pT3, margin positivity, and renal pelvis localization compared to patients who underwent BCE. Median follow-up periods were 30.5 months (range, 6-144 months). The Kaplan-Meier estimates revealed that BCE during RNU was not significantly associated with CSS in all UTUC patients and in the subgroup with renal pelvis localization; however, patients who underwent RNU without BCE had significantly worse CSS rates compared to patients who underwent RNU with BCE in the subgroup analysis of patients with ureteral cancer. Multivariate analysis identified BCE as an independent prognostic factor of CSS in patients with ureteral cancer. CONCLUSIONS: In the present study, RNU without BCE resulted in significantly worse CSS in ureteral cancer patients, which indicated that BCE should be mandatory in patients with ureteral cancer.

Perioperative and short-term outcomes of Retzius-sparing robot-assisted laparoscopic radical prostatectomy stratified by gland size.

OBJECTIVE: To investigate the effect of preoperative prostate volume (PV) on the perioperative, continence and early oncological outcomes among patients treated with Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RS-RALP). PATIENTS AND METHODS: This is a retrospective analysis of 294 patients with organ-confined prostate cancer treated with RS-RALP in a high-volume centre from November 2012 to February 2015. Patients were divided into three groups based on their transrectal ultrasonography estimated PV as follows: group 1, <40 mL (231 patients); group 2, 40-60 mL (47); group 3, >60 mL (16). Perioperative, oncological, and continence outcomes were compared between the three groups. RESULTS: The median [interquartile range (IQR)] PV for each group was; 26.1 (22-31) mL, 45.9 (41-50) mL, and 70 (68-85) mL. Blood loss was higher in group 3 compared to groups 2 and 1; at a median (IQR) of 475 (312-575) mL, 200 (150-400) mL, and 250 (150-400) mL, respectively (P = 0.001). The intraoperative transfusion rate was higher in group 3 patients (P = 0.004), while the complication rate did not differ (P = 0.05). The console time was slightly higher but was not statistically significant in group 3 compared to groups 2 and 1; at a mean (sd) of 100 (35) min, 92 (34.4) min, and 93 (24.8) min, respectively (P = 0.70). Biochemical recurrence and the continence rate did not differ between the three groups (P = 0.89 and P = 0.25, respectively). CONCLUSION: RS-RALP is oncologically and functionally equivalent for all prostate sizes but technically demanding for larger prostates. We therefore recommend that surgeons initiate their RS-RALP technique with smaller prostates.

Outcomes of high-complexity renal tumours with a Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of ≥10 after robot-assisted partial nephrectomy with a median 46.5-month follow-up: a tertiary centre experience.

OBJECTIVES: To compare perioperative trifecta achievement and long-term oncological and functional outcomes between patients with renal tumours of low [Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score 6-7], intermediate (PADUA score 8-9) and high (PADUA score ≥10) complexity undergoing robot-assisted partial nephrectomy (RAPN), and to determine predictors for trifecta achievement. PATIENTS AND METHODS: Data were retrospectively analysed from 295 patients, who underwent RAPN, between 2006 and 2015, at a high-volume tertiary centre. Trifecta achievement was the primary outcome measurement. The perioperative parameters and long-term oncological and functional outcomes were the secondary outcome measures. Groups were compared using the Kruskal-Wallis H test or chi-square test. Univariable and multivariable binary logistic regression analyses were used to determine the most important determinant variables associated with trifecta accomplishment. The Kaplan-Meier method was used to estimate overall survival (OS), cancer-specific survival (CSS) and cancer-free survival (CFS). RESULTS: Of the 295 patients, 121 (41%) had a PADUA score of ≥10. Patients in the high-complexity PADUA group had larger tumours (P ≤ 0.001), higher clinical stages ≥T1b (P < 0.001), an increased risk of malignancy (P = 0.02), longer warm ischaemia time (P = 0.0030), and higher estimated blood loss (P = 0.001) compared with those in the intermediate- and low-complexity groups. Seven of eight patients who were converted to radical nephrectomy had high-complexity tumours (P = 0.02). Trifecta achievement was less in the high-complexity PADUA group (P < 0.001). Renal functional outcomes did not differ among the groups at follow-up (P > 0.05). There were no significant differences between the groups for OS (P = 0.314), CSS (P = 0.228) and CFS (P = 0.532). In multivariable analysis, the American Society of Anesthesiologists classification, operative time and tumour size were independent predictors of trifecta achievement (P = 0.001, P = 0.03, and P = 0.006, respectively). CONCLUSION: High-complexity PADUA tumours are associated with a lower rate of trifecta achievement; however, long-term oncological and functional outcomes seem to be equivalent among high-, intermediate-, and low-complexity tumours. Despite the perioperative outcomes; high-complexity tumours can be handled successfully via the robotic approach and the improved long-term oncological and functional outcomes might be considered useful for patients counselling.

Number of positive preoperative biopsy cores is a predictor of positive surgical margins (PSM) in small prostates after robot-assisted radical prostatectomy (RARP).

OBJECTIVE: To determine the impact of prostate size on positive surgical margin (PSM) rates after robot-assisted radical prostatectomy (RARP) and the preoperative factors associated with PSM. PATIENTS AND METHODS: In all, 1229 men underwent RARP by a single surgeon, from 2005 to August of 2013. Excluded were patients who had transurethral resection of the prostate, neoadjuvant therapy, clinically advanced cancer, and the first 200 performed cases (to reduce the effect of learning curve). Included were 815 patients who were then divided into three prostate size groups: <31 g (group 1), 31-45 g (group 2), >45 g (group 3). Multivariate analysis determined predictors of PSM and biochemical recurrence (BCR). RESULTS: Console time and blood loss increased with increasing prostate size. There were more high-grade tumours in group 1 (group 1 vs group 2 and group 3, 33.9% vs 25.1% and 25.6%, P = 0.003 and P = 0.005). PSM rates were higher in prostates of <45 g with preoperative PSA levels of >20 ng/dL, Gleason score ≥7, T3 tumour, and ≥3 positive biopsy cores. In group 1, preoperative stage T3 [odds ratio (OR) 3.94, P = 0.020] and ≥3 positive biopsy cores (OR 2.52, P = 0.043) were predictive of PSM, while a PSA level of >20 ng/dL predicted the occurrence of BCR (OR 5.34, P = 0.021). No preoperative factors predicted PSM or BCR for groups 2 and 3. CONCLUSION: A preoperative biopsy with ≥3 positive cores in men with small prostates predicts PSM after RARP. In small prostates with PSM, a PSA level of >20 ng/dL is a predictor of BCR. These factors should guide the choice of therapy and indicate the need for closer postoperative follow-up.