Surgical metastasectomy for metastatic renal cell carcinoma in the era of targeted and immune therapy: a narrative review.

PURPOSE: Metastatic renal cell carcinoma (mRCC) still harbours a big propensity for future metastasis. Combinations of immune and targeted therapies are currently the cornerstone of management with a less clear role for surgical metastasectomy (SM). METHODS: We performed a narrative review of literature searching for the available evidence on the yield of surgical metastasectomy in the era of targeted and immune therapies. The review consisted of a PubMed search of relevant articles using the Mesh terms:" renal cell carcinoma", "surgery¼, «resection", "metastasectomy", "molecular targeted therapies", "immune checkpoint inhibitors" alone or in combination. RESULTS: In this review, we exposed the place of surgical metastasectomy within a multimodal treatment algorithm for mRCC Also, we detailed the patient selection criteria that yielded the best results when SM was performed. Finally, we discussed the feasibility and advantages of SM per organ site. CONCLUSION: Our work was able to show that SM could be proposed as a consolidation treatment to excise residual lesions that were deemed unresectable prior to a combination of systemic therapies. Contrastingly, it can be proposed as an upfront treatment, leaving systemic therapies as an alternative in case of future relapse. However, patient selection regarding their performance status, metastatic sites, number of lesions and tumorous characteristics is of paramount importance.

Long term follow-up after minimally invasive sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a benign condition that can adversely affect women's quality of life. Minimally invasive mesh sacrocolpopexy is an effective surgical treatment for POP. This study aims to assess the perioperative, postoperative, and long term (10 years) outcome of a single institution cohort undergoing minimally invasive sacrocolpopexy. METHODS: This retrospective study included all cases of laparoscopic sacrocolpopexy performed between 2003 and 2016. Patients were contacted by phone in 2022 for long term follow-up. Data on operative time, length of hospital stay, conversion rate, perioperative injuries, early and late postoperative complications and subjective success rates were collected. RESULTS: Ninety-five patients were included aged 60±12 years. Most patients (72%) presented grade 3 POP. Grade of prolapse (3±0.4 vs 3±0.5, p<0.01) and hospital stay (3±1.1 vs 3.1±1.7; p<0.01) were significantly higher in patients who developed early postoperative complications (1st year). At long term follow-up (12±3 years), 48 patients responded. Nine subjects (19%) presented a subjective recurrence with bulge symptoms. Surgery satisfaction was of 79%. The most frequent de novo reported symptom was urge urinary incontinence followed by stress urinary incontinence. Three cases (3%) of mesh erosion were described, all occurred after the 5th postoperative year. CONCLUSIONS: Laparoscopic mesh sacrocolpopexy is a safe surgical technique that shows satisfying and consistent long-term results despite the occasional onset of new urinary symptoms.

Quality of life after laparoscopic sleeve gastrectomy: Pre-operative, 1-year and 5-year results.

Introduction: The negative impact of obesity on the quality of life (QoL) and its association with multiple comorbidities is unquestionable. The primary objective of this study was to compare the QoL of patients before, 1 year and 5 years after laparoscopic sleeve gastrectomy (LSG). Secondary objectives were to evaluate the resolution of obesity-related comorbidities and weight loss success. Materials and Methods: We included patients who underwent LSG for body mass index (BMI) ≥30 kg/m2 between August 2016 and April 2017 and completed the Moorehead-Ardelt QoL Questionnaire II (MA II). Statistical analysis was conducted using SPSS IBM Statistics for Windows version 21. Results: In total, 64 patients participated with a female majority (73.44%) and a mean age of 36.09 with an average BMI at 40.47. Percentage of excess BMI loss and excess weight loss (% EWL) at one and 5 years after surgery went from 90.18% to 85.05% and 72.17% to 67.09%, respectively. The total MA II score before LSG was - 0.39 ± 0.94. Postoperatively, it increased to 1.73 ± 0.60 at 1 year and 1.95 ± 0.67 at 5 years. The positive impact of LSG on QoL was more significant in patients presenting ≥30% of weight loss and in females. At 5 years, a significant improvement in many comorbidities was noted except for arterial hypertension, coxalgia, gastro-oesophageal reflux disease and lower extremities' varices. Conclusion: LSG maintains a long-term QoL improvement, a significant EWL and a resolution of the most common obesity-associated comorbidities such as diabetes, dyslipidaemia and symptoms related to sleep apnoea.

Urothelial carcinoma in COVID-19: lessons from a pandemic and their impact on clinical practice.

The COVID-19 pandemic has modified the management of urothelial carcinoma (UC). Eighteen months after the onset of the pandemic, a scoping narrative review was able to state that radical cystectomy for UC should not be delayed beyond 10 weeks when neoadjuvant chemotherapy (NAC) was administered and 12 weeks when it was not. NAC should be considered when imminent chemotherapy cannot be performed. Early cystectomy should not be delayed when indicated for patients with high-risk non-MIBC. Patients with non-MIBC should still receive their induction doses of intravesical instillations. Diagnostic cystoscopy should not be deferred in symptomatic patients. Surgical management of upper tract urothelial carcinoma (UTUC) allows for a wider deferral interval.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis.

BACKGROUND: Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic. OBJECTIVE: To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis. METHODS: Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture. RESULTS: Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes (p = 0.03), elevated CRP (p = 0.01), stone size (>5 mm) (p = 0.03), dilatation of renal pelvis (p = 0.01), peri-renal fat stranding (p = 0.02), and positive nitrites on urinalysis (p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm3), hypertension, and were not associated with the onset of obstructive pyelonephritis. CONCLUSION: This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

Hormone Treatment of Prostate Cancer:: Evidence for Usage and Safety.

Androgen deprivation therapy, used alone or in combination, inhibits androgen activity either upstream at the level of the pituitary gland or downstream by disrupting the androgenesis pathway in the adrenal or androgen activity in prostate cells. Its appropriate utilization varies depending on disease stage, aggressivity, and resistance. Special consideration should be given to side effects, as it can affect patients' quality of life and their treatment of other conditions.

Is pudendal nerve entrapment a potential cause for weak ejaculation?

Ejaculatory dysfunction is one of the most common complaints of patients with sexual disorders. While it encompasses several ejaculatory disorders, weak ejaculation is seldom described in the literature. Since the pudendal nerve is the main nerve of ejaculation, we aim to hypothesize that pudendal nerve entrapment could be a cause of weak ejaculation, and that pudendal nerve release could contribute to the improvement of the ejaculatory stream. We presented two cases suffering from a weak ejaculatory stream and sensation of incomplete semen emptying, accompanied with clinical features of pudendal nerve entrapment. Both cases improved after pudendal nerve block and then laparoscopic transperitoneal pudendal release, with a sustained amelioration of the ejaculatory stream after 3 weeks of surgery. Pudendal canal entrapment is therefore a potentially curable cause for weak ejaculation.

Pure Laparoscopic Donor Nephrectomy: A Single Institution Experience From a Middle Eastern Country.

BACKGROUND: Laparoscopic live donor nephrectomy (LLDN) is the most adopted technique for kidney transplantation. Several obstacles preclude brain-dead organ transplantation in the Middle East, going from social and cultural barriers to economical and structural difficulties. To our knowledge, this is the first study to report Lebanese experience with pure LLDN, and kidney transplantation. METHODS: We included 120 cases of pure LLDN performed at our center. Demographic, perioperative, and immediate postoperative data were analyzed. Surgical particularities of the technique are described. RESULTS: The reported laparoscopic technique allowed for minimal perioperative morbidity, with an overall complication rate of 3%. Operative time averaged 146 minutes and warm ischemia time averaged 4 minutes. Mean hospital stay was 3 ± 1 days. Postoperative hemoglobin and creatinine showed a mean absolute variation of 0.09 ± 0.06 g/dL for hemoglobin and 0.51 ± 015 µmoles/L increase for creatinine. No Clavien-Dindo III-V complications were recorded. CONCLUSIONS: Strict adherence to the reproducible pure LLDN technique allowed for the performance of almost 45 cases per year with minimal morbidity and results comparable to similar series.

Multiparametric MRI with in-bore targeted biopsy in the diagnostic pathway of prostate cancer: Data from a single institution experience.

BACKGROUND: Accuracy of multiparametric MRI (mpMRI) for the detection of significant prostate cancer (CaP) varies in the literature as only few studies use radical prostatectomy specimens as their gold standard. On another hand, MRI-targeted prostate biopsy is emerging as an alternative to the traditional randomized biopsy, with a higher detection rate of high-grade cancers. However, data on MRI guided in bore biopsy is lacking. MATERIAL AND METHODS: We reviewed every patient that had his mpMRI, MRI guided in bore biopsy and radical prostatectomy performed in our hospital between November 2015 and December 2020. The diagnostic performances of both mpMRI and MRI targeted biopsy in sampling PIRADS index lesions were studied, using radical prostatectomy specimens as the gold standard. Sensitivity, specificity, positive predictive value and negative predictive value of mpMRI for detecting T3 stage, extra-capsular extension, seminal vesicles involvement and lymph node disease were also evaluated. RESULTS: Sixty-two met our inclusion criteria. For PIRADS≥3 lesions, sensitivity and positive predictive value for detecting clinically significant CaP were of 83.5% and 94.7%. A total of 32.2% prostate cancers on targeted biopsy were upgraded on final pathology, with an upgrading to ISUP≥2 in 3.2% and to ISUP≥3 in 14.5%. A total of 20.9% of cancers were downgraded but without any downgrading to ISUP 1. When final pathology is taken as a gold standard, sensitivity of mpMRI was 31.8% for T3 staging prediction, 30.0% for extra-capsular extension, 28.7% for seminal vesicles involvement and 66.7% for lymph node disease prediction. Specificity was 89.3%, 93.1%, 95.3%, and 92.7%, respectively. CONCLUSION: mpMRI has an acceptable accuracy for the prediction of significant CaP and index lesion detection but is unreliable for CaP staging. Comparison between pathology and biopsy results revealed that the in-bore biopsy technique has an upgrading and downgrading rate comparable in the literature to fusion biopsy, but higher than the combined biopsy approach.

Sexual dysfunction due to pudendal neuralgia: a systematic review.

BACKGROUND: The pudendal nerve is considered as the main nerve of sexuality. Pudendal neuralgia is an underdiagnosed disease in clinical practice. The aim of this systematic review is to highlight the role of pudendal neuralgia on sexual dysfunction in both sexes. METHODS: A PubMed search was performed using the following keywords: "Pudendal" AND "Sexual dysfunction" or "Erectile dysfunction" or "Ejaculation" or "Persistent sexual arousal" or "Dyspareunia" or "Vulvodynia". The search involved patients having sexual dysfunction due to pudendal neuralgia. Treatment received was also reported. RESULTS: Five case series, seven cohort studies, two pilot studies, and three randomized clinical trials were included in this systematic review. Pudendal nerve and/or artery entrapment, or pudendal neuralgia, is a reversible cause of multiple sexual dysfunctions. Interventions such as anesthetic injections, neurolysis, and decompression are reported as potential treatment modalities. There are no studies describing the role of pudendal canal syndrome in the pathophysiology or treatment of delayed ejaculation or penile shortening. DISCUSSION: Pudendal neuralgia is an underestimated yet important cause of persistent genital arousal, erectile dysfunction (ED), premature ejaculation (PE), ejaculation pain, and vulvodynia. Physicians should be aware of this entity and examine the pudendal canal in such patients before concluding an idiopathic cause of sexual dysfunction.

Bladder stone following intravesical migration of surgical clip five years after radical prostatectomy.

Bladder stone formation on iatrogenic foreign bodies following radical prostatectomy is an uncommon postoperative complication. We present the case of a bladder lithiasis that developed around a metallic clip five years after radical retropubic prostatectomy.

Quality of Life before and after Sleeve Gastrectomy in Lebanese Population.

Introduction: Obesity is increasing worldwide and in Lebanon with a negative impact on the quality of life. The primary objective of this study is to measure the quality of life in obese subjects before and after bariatric surgery, depending on age, sex, and degree of weight loss. A secondary objective is to determine the impact of bariatric surgery on comorbidities associated with obesity. Materials and methods: Patients undergoing laparoscopic sleeve gastrectomy for BMI ≥ 30 kg/m2 between August 2016 and April 2017 were included. Participants completed the Moorehead-Ardelt Quality of Life Questionnaire II (MA II) prior to operation and one year after. Statistical analysis was carried out using SPSS statistics version 20.0. Results: 75 patients participated in the study. The majority were women (75%), and the mean age was 36.3 years. The mean weight loss was 36.57 kg (16-76). Initially, the total MA II score was -0.33 ± 0.93. Postoperatively, it increased to 1.68 ± 0.62 (p ≤ 0.001). All MA II parameters improved after surgery (p ≤ 0.001), but this improvement was independent of age and sex. Improvement in self-esteem, physical activity, work performance, and sexual pleasure was influenced by the degree of weight loss (p ≤ 0.001). All comorbidities associated with obesity regressed significantly after sleeve gastrectomy (p < 0.05) with the exception of gastroesophageal reflux and varicose veins of the lower limbs. Conclusion: Sleeve gastrectomy improves quality of life and allows reduction of comorbidities.