Robotic partial nephrectomy for large renal Leiomyoma: first case report

ABSTRACT Aim: Renal leiomyoma is a rare benign mesenchymal tumor arising from the smooth muscle cells of the kidney. Renal capsule is its most common location (1). Large tumor may require surgical excision which can be challenging in case of proximity to major vessels (2). Indications of robotic partial nephrectomy (RPN) have exponentially expanded over the past few years (3). We aim to report a case of large renal leiomyoma successfully managed with RPN. Methods: A 59-year-old female patient with BMI 51 presented with chief complaint of abdominal discomfort. The patient underwent a CT scan that revealed a massive circumscribed exophytic complex solid cystic mass of 4.5 × 7.7 × 6.2 cm, arising from the lower pole of right kidney and abutting the inferior vena cava. RENAL score was 11ah (high complexity). Past surgical history included mid-urethral sling, breast reduction, and hysterectomy with salpingectomy. Preoperative creatinine and eGFR were 0.9 (mg/dL) and 77 (mL/min), respectively. A robotic excision of this mass was successfully performed by using Da Vinci Xi platform. Main steps of the procedure are illustrated in the present video. Results: Dissection and isolation of the tumor were carefully performed after identifying key anatomical structures such as the ureter, the IVC and the renal hilum. Intraoperative ultrasound was used to confirm the margins of the mass. The renal artery was clamped and then the tumor was resected/enucleated. Renal parenchyma was re-approximated with a single layer of interrupted CT-1 Vicryl 0 with sliding clip technique. Warm ischemia time was 19 min. Estimated blood loss (EBL) was 250 ml. Operative time was 165 min. No intraoperative complications occurred. No drain was placed. Patient was discharged on postoperative day 2. Post-operative hypotension was managed with fluid bolus. Postoperative creatinine and eGFR were 1,0 (mg/dL) and 69 (mL/min/1.72m2), respectively. Pathology revealed a leiomyoma of genital stromal origin with hyalinization and calcification. Conclusions: To the best of our knowledge, this is the first description of RPN for the management of a large (about 8 cm) renal leiomyoma. Robotic assisted surgery allows to expand the indications of minimally invasive conservative renal surgery whose feasibility becomes even more clinically significant in case of benign masses which can be managed without sacrificing healthy renal parenchyma.

Oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma: a literature review.

Background and Objective: Radical nephroureterectomy (RNU) represents the gold standard treatment for non-metastatic upper tract urothelial cancer. We sought to provide a comprehensive review of reported oncologic outcomes of the RNU procedure and of factors that might impact these outcomes. Methods: A non-systematic review of the literature was conducted by performing an electronic literature search using PubMed with "radical nephroureterectomy" and "oncologic outcomes" as free text search terms. Both original articles and systematic reviews were considered. Search was limited to articles in English that were published in the last 20 years. Key Content and Findings: Open and laparoscopic RNU offer comparable oncologic outcomes. In more recent years, the discussion has de facto shifted towards the "oncological safety" of robotic RNU, which also seems to offer comparable oncologic outcomes. Several studies have looked at the impact of different treatment-, patient- and tumor-related factors. Among treatment-related factors, attention has been given to diagnostic ureteroscopy and the risk of intravesical recurrence. Surgical wait time and perioperative blood transfusion have also been studied. Perioperative chemotherapy, specifically adjuvant therapy, was shown to improve survival. Among patient-related factors, baseline chronic kidney disease, diabetes mellitus, body mass index, and systemic inflammation have gained recent attention. Some tumor related factors, such as stage, grade, location, and multifocality may negatively impact survival outcomes. Lymphovascular invasion and histologic variants are clinically significant pathological findings. Conclusions: RNU is a procedure with measured long-term oncologic outcomes. Minimally invasive techniques have gained an established role as they seem to offer comparable oncologic "safety", although special attention is needed in relation to the method of bladder cuff excision. Robotic RNU is gaining popularity, and while evidence remains limited, the current literature supports the oncologic safety of this procedure. Several factors, which can be categorized as treatment-related, patient-related, and tumor-related, might impact the oncologic outcomes of UTUC patients undergoing RNU. These factors can provide crucial information to stratify patients based on their relative risk of disease recurrence and mortality which may guide clinical decision-making.

The use of low-intensity extracorporeal shockwave therapy in management of erectile dysfunction following prostate cancer treatment: a review of the current literature.

Background and Objective: Erectile dysfunction (ED) is a prevalent and impactful complication post definitive management of prostate cancer. The mechanism of ED is thought to be secondary to vascular and neural injury as well as corporal smooth muscle damage with resultant fibrosis. The use of penile rehabilitation in ED following treatment for prostate cancer has been studied. Low-intensity extracorporeal shockwave therapy (Li-ESWT) is a novel treatment for ED thought to stimulate neovascularization and nerve regeneration, and as such, has gained interest in treatment of ED related to radical prostatectomy or radiation therapy. Herein, we performed a narrative review on the use of Li-ESWT in management of ED following treatment for prostate cancer. Methods: A literature review was performed using PubMed and Google Scholar. Studies evaluating Li-ESWT following prostate cancer treatment were included. Key Content and Findings: We identified three randomized controlled trials and two observational studies that assessed use of Li-ESWT for ED after prostate surgery. Use of Li-ESWT across most studies showed improvements in the International Index of Erectile Function-erectile function (IIEF-EF) domain scores, but this improvement was not statistically significant. Additionally, use of Li-ESWT in an early versus delayed fashion does not appear to affect changes in long-term sexual function scores. No data on use of Li-ESWT after radiotherapy were identified. Conclusions: There is a paucity of data regarding use of Li-ESWT for penile rehabilitation in treatment of ED post-prostate cancer therapy. Current protocols for Li-ESWT are not standardized and have a limited number of participants with short duration of follow-up. Additional evaluation is needed to determine optimal Li-ESWT protocols. Ideally, studies should have longer follow-up to truly evaluate the clinical significance of Li-ESWT in the treatment of post-prostatectomy ED. Furthermore, the role of Li-ESWT after radiotherapy remains elusive.

Robotic partial nephrectomy for large renal Leiomyoma: first case report.

AIM: Renal leiomyoma is a rare benign mesenchymal tumor arising from the smooth muscle cells of the kidney. Renal capsule is its most common location (1). Large tumor may require surgical excision which can be challenging in case of proximity to major vessels (2). Indications of robotic partial nephrectomy (RPN) have exponentially expanded over the past few years (3). We aim to report a case of large renal leiomyoma successfully managed with RPN. METHODS: A 59-year-old female patient with BMI 51 presented with chief complaint of abdominal discomfort. The patient underwent a CT scan that revealed a massive circumscribed exophytic complex solid cystic mass of 4.5 x 7.7 x 6.2 cm, arising from the lower pole of right kidney and abutting the inferior vena cava. RENAL score was 11ah (high complexity). Past surgical history included mid-urethral sling, breast reduction, and hysterectomy with salpingectomy. Preoperative creatinine and eGFR were 0.9 (mg/dL) and 77 (mL/min), respectively. A robotic excision of this mass was successfully performed by using Da Vinci Xi platform. Main steps of the procedure are illustrated in the present video. RESULTS: Dissection and isolation of the tumor were carefully performed after identifying key anatomical structures such as the ureter, the IVC and the renal hilum. Intraoperative ultrasound was used to confirm the margins of the mass. The renal artery was clamped and then the tumor was resected/enucleated. Renal parenchyma was re-approximated with a single layer of interrupted CT-1 Vicryl 0 with sliding clip technique. Warm ischemia time was 19 min. Estimated blood loss (EBL) was 250 ml. Operative time was 165 min. No intraoperative complications occurred. No drain was placed. Patient was discharged on postoperative day 2. Post-operative hypotension was managed with fluid bolus. Postoperative creatinine and eGFR were 1,0 (mg/dL) and 69 (mL/min/1.72m2), respectively. Pathology revealed a leiomyoma of genital stromal origin with hyalinization and calcification. CONCLUSIONS: To the best of our knowledge, this is the first description of RPN for the management of a large (about 8 cm) renal leiomyoma. Robotic assisted surgery allows to expand the indications of minimally invasive conservative renal surgery whose feasibility becomes even more clinically significant in case of benign masses which can be managed without sacrificing healthy renal parenchyma.

Outcomes of Initial Transcorporal Versus Standard Placement of Artificial Urinary Sphincter in Patients With Prior Radiation.

OBJECTIVE: This study aimed to evaluate both device and functional outcomes of men who underwent initial artificial urinary sphincter (AUS) placement after pelvic radiation using the transcorporal versus the standard approach. METHODS: A retrospective review of patients who underwent first-time AUS placement after pelvic irradiation for prostate cancer was conducted between January 2008 and June 2020. Patients were grouped by transcorporal versus standard device placement. The primary outcomes of interest included major complications (revision or explant surgery) and functional outcomes (pads per day, International Prostate Symptom Score {IPSS}, quality of life {QOL} score). RESULTS: We identified 45 patients who underwent first-time AUS with a history of prior pelvic irradiation for prostate cancer, 27 underwent transcorporal placement and 18 underwent standard placement. Transcorporal AUS placement resulted in a significantly lower number of major complications (p=0.01), explants (p=0.02), and revisions (p=0.04) The transcorporal artificial urinary sphincter group had better postoperative pads per day (p=0.04), IPSS (p<0.01), and IPSS QOL score (p<0.01). CONCLUSIONS: Initial transcorporal artificial urinary sphincter placement is a promising technique with lower rates of major complications in patients with a history of prior pelvic radiation and had better functional urinary outcomes.

Novel Insights into Autophagy and Prostate Cancer: A Comprehensive Review.

Autophagy is a complex process involved in several cell activities, including tissue growth, differentiation, metabolic modulation, and cancer development. In prostate cancer, autophagy has a pivotal role in the regulation of apoptosis and disease progression. Several molecular pathways are involved, including PI3K/AKT/mTOR. However, depending on the cellular context, autophagy may play either a detrimental or a protective role in prostate cancer. For this purpose, current evidence has investigated how autophagy interacts within these complex interactions. In this article, we discuss novel findings about autophagic machinery in order to better understand the therapeutic response and the chemotherapy resistance of prostate cancer. Autophagic-modulation drugs have been employed in clinical trials to regulate autophagy, aiming to improve the response to chemotherapy or to anti-cancer treatments. Furthermore, the genetic signature of autophagy has been found to have a potential means to stratify prostate cancer aggressiveness. Unfortunately, stronger evidence is needed to better understand this field, and the application of these findings in clinical practice still remains poorly feasible.

Large reduction in opioid prescribing by a multipronged behavioral intervention after major urologic surgery.

BACKGROUND: Surgeons play a pivotal role in combating the opioid crisis that currently grips the United States. Changing surgeon behavior is difficult, and the degree to which behavioral science can steer surgeons toward decreased opioid prescribing is unclear. METHODS: This was a single-institution, single-arm, pre- and postintervention study examining the prescribing of opioids by urologists for adult patients undergoing prostatectomy or nephrectomy. The primary outcome was the quantity of opioids prescribed in oral morphine equivalents (OMEs) after hospital discharge. The primary exposure was a multipronged behavioral intervention designed to decrease opioid prescribing. The intervention had 3 components: 1) formal education, 2) individual audit feedback, and 3) peer comparison performance feedback. There were 3 phases to the study: a pre-intervention phase, an intervention phase, and a washout phase. RESULTS: Three hundred eighty-two patients underwent prostatectomy, and 306 patients underwent nephrectomy. The median OMEs decreased from 195 to 19 in the prostatectomy patients and from 200 to 0 in the nephrectomy patients (P < .05 for both). The median OMEs prescribed did not increase during the washout phase. Prostatectomy patients discharged with opioids had higher levels of anxiety than patients discharged without opioids (P < .05). Otherwise, prostatectomy and nephrectomy patients discharged with and without opioids did not differ in their perception of postoperative pain management, activity levels, psychiatric symptoms, or somatic symptoms (P > .05 for all). CONCLUSIONS: Implementing a multipronged behavioral intervention significantly reduced opioid prescribing for patients undergoing prostatectomy or nephrectomy without compromising patient-reported outcomes.

The Prevalence of Penile Cancer in Patients With Adult Acquired Buried Penis.

OBJECTIVE: To determine the prevalence of penile cancer in patients with adult acquired buried penis (AABP). Penile cancer is a rare but aggressive cancer. Several case reports have recently been published that indicate that AABP may increase the risk of penile cancer. MATERIALS AND METHODS: A retrospective review was conducted of adults diagnosed with AABP and penile cancer between January, 2008 and December, 2018 seen at a tertiary referral center. Demographics including age, BMI, comorbidities, etiology of AABP, smoking history, circumcision status, and premalignant lesions (condyloma, lichen sclerosus [LS] carcinoma in situ [CIS]) were recorded. For patients with penile cancer, AJCC staging, grade, TNM staging and treatments were recorded. Basic descriptive statistics were performed for the overall cohort. We used Chi-square tests and Fisher exact tests to compare differences between patients with benign pathology and patients with malignant or pre-malignant pathology. RESULTS: We identified 150 patients with the diagnosis of AABP. The prevalence of penile squamous cell carcinoma was 7%. There was a 35% rate of premalignant lesions. This study is limited by its retrospective and single-institution nature. CONCLUSION: AABP is a condition that incorporates multiple risk factors for penile cancer. The prevalence of penile cancer appears to be higher in patients with AABP; however, more data are needed to confirm these initial findings. Patients with AABP should be counseled on these risks and should be considered for buried penis repair if a physical examination cannot be performed.

Robotic Inguinal Hernia Repair: A Large Health System's Experience With the First 300 Cases and Review of the Literature.

BACKGROUND: Over the past 5 y, robotic surgery has expanded within general surgery, especially in regard to hernia repairs. We aimed to evaluate the outcomes of the early experience of over 300 consecutive robotic inguinal hernia repairs performed in an academic multihospital system. METHODS: Consecutive robotic inguinal hernia repairs performed between December 2015 and June 2017 were analyzed. Retrospective chart review was performed, and hospital records were queried. Descriptive statistics were performed. A surgical learning curve case study is presented, breakdown of operative time is delineated, and review of the literature performed. RESULTS: Over a period of 19 mo, 335 robotic inguinal hernia repairs were performed across seven hospitals by 18 surgeons. The mean patient age was 59 y (standard deviation [SD] 14), 93% were male, and the mean body mass index was 27 (SD 4.6). Bilateral hernia repairs were performed on 131 patients (39%). The mean operative time was 102 min (SD 38) and a resident or fellow trainee was present in the operating room for 119 cases (36%). Minor postoperative complications occurred in 54 patients (16%), including 14 with urinary retention (4.2%) and 13 with scrotal swelling (3.9%). The learning curve of the first adopted surgeon was 11-12 cases. CONCLUSIONS: In the largest case series of robotic inguinal hernia repairs to date reporting short-term outcomes, early experience in an academic multihospital system produced safe outcomes including no open conversions, reoperations, and one readmission. In addition, the learning curve is manageable showing improvement in operating time with experience.