Robotic-assisted kidney transplantation in obese recipients compared to non-obese recipients: the European experience.

PURPOSE: The main objective was to compare minor (Clavien I-II) and major (Clavien ≥ III) intra- and postoperative complications of living donor robotic assisted kidney transplantation (RAKT) in obese (≥ 30 kg/m2 BMI), overweight (< 30/ ≥ 25 kg/m2 BMI) and non-overweight recipients (< 25 kg/m2 BMI). METHODS: For the present retrospective study, we reviewed the multi-institutional ERUS-RAKT database to select consecutive living donor RAKT recipients. Functional outcomes, intra- and postoperative complications were compared between obese, overweight and non-overweight recipients. RESULTS: 169 living donor RAKTs were performed, by 10 surgeons, from July 2015 to September 2018 in the 8 European centers. 32 (18.9%) recipients were obese, 66 (39.1%) were overweight and 71 (42.0%) were non-overweight. Mean follow-up was 1.2 years. There were no major intra-operative complications in either study group. Conversion to open surgery occurred in 1 obese recipient, in 2 overweight recipients and no conversion occurred in non-overweight recipients (p = 0.3). Minor and major postoperative complications rates were similar in the 3 groups. At one-year of follow-up, median eGFR was similar in all groups [54 (45-60) versus 57 (46-70) versus 63 (49-78) ml/min/1.73 m2 in obese, overweight and non-overweight recipient groups, respectively, p = 0.5]. Delayed graft function rate was similar in the 3 groups. Only the number of arteries was an independent predictive factor of suboptimal renal function at post-operative day 30 in the multivariate analysis. CONCLUSION: RAKT in obese recipients is safe, compared to non-overweight recipients and yields very good function, when it performed at high-volume referral centers by highly trained transplant teams.

Invasive bladder cancer in the eighties: transurethral resection or cystectomy?

PURPOSE: Describe morbidity and survival in patients older than 80 years with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) or transurethral resection (TUR) in our institution. MATERIALS AND METHODS: We reviewed our database of all patients older than 80 years treated with RC and TUR for MIBC between 1993 and 2005 in our institution. Twenty-seven patients were submitted to RC, with mean age of 82 years and mean follow-up of 16.4 months. RC was carried out following diagnosis of previous MIBC in 14 cases (51.9%). The American Society of Anesthesiology (ASA) score was III or IV in 23 patients (85.1%). Seventy-two patients with a mean age of 84 years and mean follow-up of 33 months, diagnosed with MIBC, were managed by means of TUR. The ASA score was III-IV in 64 (88.8%) patients. RESULTS: Pathological stage of the RC specimen was pT3 in 18 cases (66.7%). Mean hospital stay was 16 days. Early complications were assessed in 8 patients (29.6%), with an overall survival (OS) of 42.94%, and cancer-specific survival (CSS) of 60.54%. In patients submitted to TUR, clinical stage was T2 in 36 cases (50%). The mean hospital stay was 7 days, with a readmission rate (RR) of 87.5%. OS and CSS was less than 20%. CONCLUSIONS: RC in octogenarian patients is a safe procedure, with complication and survival rates comparable to RC series in general population. Transurethral resection (TUR) for patients with MIBC within this age range is a much less morbid procedure, but disease specific survival is lower.

Bladder preservation strategy based on combined therapy in patients with muscle-invasive bladder cancer: management and results at long-term follow-up.

OBJECTIVE: To evaluate a bladder preservation strategy in patients with either muscle-invasive bladder cancer (MIBC) or development of MIBC cancer due to progression of non-muscle-invasive bladder cancer (NMIBC). METHODS: Between October 1982 and March 1998, 48 patients (mean age 61 years, range 45-75) with MIBC (T2a-b and T3a) were treated using transurethral resection followed by three cycles of systemic chemotherapy. 42 patients (87.5%) had primary MIBC and 6 (12.5%) had MIBC subsequent to NMIBC. After chemotherapy, 39 patients (81.25%) achieved complete remission and 4 (8.3%) partial remission. RESULTS: With a median follow-up of 98.5 months (13-246), the overall survival of the 48 patients was 62.6%. The cancer-specific survival (CSS) of the 39 patients with complete remission was 80.8%. Among the 39 patients with complete remission, 19 had invasive recurrence during follow-up with a CSS of 53.2%; by comparison, among patients with preserved bladders, CSS was 72.1% (p = 0.046). Predictive factors analysed were age, sex, tumour size >3 cm, grade, associated carcinoma in situ (CIS), number of tumours and number of previous recurrences. In multivariate analysis only tumour size and CIS were significant predictive factors for progression after preservation. Of the 6 patients with MIBC after NMIBC, 3 (50%) had no remission and underwent cystectomy and 15 patients (38.6%) had NMIBC recurrences during follow-up. CIS and high-grade tumours were treated with bacillus Calmette-Guérin. A bladder preservation rate of 81% and a CSS rate of 89% were obtained in the group with NMIBC recurrences. CONCLUSIONS: Conservative management of MIBC cancer is a feasible alternative to cystectomy in selected cases. Patients with MIBC after progression of primary NMIBC are not good candidates for a bladder preservation approach. NMIBC recurrences after bladder preservation in patients with MIBC respond to transurethral resection and bacillus Calmette-Guérin instillations.

Hemangioma of the prostatic urethra: holmium laser treatment.

Urethral hemangiomas are benign vascular tumors that are found in perimontanal prostatic localization and less frequently in the urethra. Although different urethral procedures have been postulated for its treatment, the best results are achieved using lasers. A patient who underwent endoscopic holmium laser treatment for such hemangiomas is presented. Total disappearance of the lesions without any complications was achieved.

Robot-assisted Kidney Transplantation: The European Experience.

BACKGROUND: Robot-assisted kidney transplantation (RAKT) has recently been introduced to reduce the morbidity of open kidney transplantation (KT). OBJECTIVE: To evaluate perioperative and early postoperative RAKT outcomes. DESIGN, SETTING AND PARTICIPANTS: This was a multicenter prospective observational study of 120 patients who underwent RAKT, predominantly with a living donor kidney, in eight European institutions between July 2015 and May 2017, with minimum follow-up of 1 mo. The robot-assisted surgical steps were transperitoneal dissection of the external iliac vessels, venous/arterial anastomosis, graft retroperitonealization, and ureterovesical anastomosis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive analysis of surgical data and their correlations with functional outcomes. RESULTS AND LIMITATIONS: The median operative and vascular suture time was 250 and 38min, respectively. The median estimated blood loss was 150ml. No major intraoperative complications occurred, although two patients needed open conversion. The median postoperative estimated glomerular filtration rate was 21.2, 45.0, 52.6, and 58.0ml/min on postoperative day 1, 3, 7, and 30, respectively. Both early and late graft function were not related to overall operating time or rewarming time. Five cases of delayed graft function (4.2%) were reported. One case (0.8%) of wound infection, three cases (2.5%) of ileus, and four cases of bleeding (3.3%; three of which required blood transfusion), managed conservatively, were observed. One case (0.8%) of deep venous thrombosis, one case (0.8%) of lymphocele, and three cases (2.5%) of transplantectomy due to massive arterial thrombosis were recorded. In five cases (4.2%), surgical exploration was performed for intraperitoneal hematoma. Limitations of the study include selection bias, the lack of an open control group, and failure to report on patient cosmetic satisfaction. CONCLUSIONS: When performed by surgeons with robotic and KT experience, RAKT is safe and reproducible in selected cases and yields excellent graft function. PATIENT SUMMARY: We present the largest reported series on robot-assisted kidney transplantation. Use of a robotic technique can yield low complication rates, rapid recovery, and excellent graft function. Further investigations need to confirm our promising data.

Robot-assisted Kidney Transplantation with Regional Hypothermia Using Grafts with Multiple Vessels After Extracorporeal Vascular Reconstruction: Results from the European Association of Urology Robotic Urology Section Working Group.

BACKGROUND: Kidney transplantation using grafts with multiple vessels (GMVs) is technically demanding and may be associated with increased risk of complications or suboptimal graft function. To date, no studies have reported on robot-assisted kidney transplantation (RAKT) using GMVs. OBJECTIVE: To report our experience with RAKT using GMVs from living donors, focusing on technical feasibility and early postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS: We reviewed the multi-institutional, prospectively collected European Association of Urology (EAU) Robotic Urology Section (ERUS)-RAKT database to select consecutive patients undergoing RAKT from living donors using GMVs between July 2015 and January 2018. Patients undergoing RAKT using grafts with single vessels (GSVs) served as controls. In case of GMVs, ex vivo vascular reconstruction techniques were performed during bench surgery according to the case-specific anatomy. INTERVENTION: RAKT with regional hypothermia. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Intraoperative outcomes and early (30 d) postoperative complications and functional results were the main study endpoints. Multivariable logistic regression analysis evaluated potential predictors of suboptimal renal function at 1 mo. RESULTS AND LIMITATIONS: Overall, 148 RAKTs were performed during the study period. Of these, 21/148 (14.2%) used GMVs; in all cases, single arterial and venous anastomoses could be performed after vascular reconstruction. Median anastomoses and rewarming times did not differ significantly between the GMV and GSV groups. Total and cold ischemia times were significantly higher in the GMV cohort (112 vs 88min, p=0.004 and 50 vs 34min, p=0.003, respectively). Overall complication rate and early functional outcomes were similar among the two groups. No major intra- or postoperative complications were recorded in the GMV cohort. At multivariable analysis, use of GMVs was not significantly associated with suboptimal renal function at 1 mo. Small sample size and short follow-up represent the main study limitations. CONCLUSIONS: RAKT using GMVs from living donors is technically feasible and achieved favorable perioperative and short-term functional outcomes. Larger studies with longer follow-up are needed to confirm our findings. PATIENT SUMMARY: In this study, we evaluated for the first time in literature the results of RAKT from living donors using kidneys with multiple arteries and veins. We found that, in experienced centers, RAKT using kidneys with multiple vessels is feasible and achieves optimal results in terms of postoperative kidney function with a low number of postoperative complications.

Laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope: initial experience at a tertiary center.

Laparoscopy has become the standard of care for kidney recovery during live donor nephrectomy (LDN) because of the well-documented better outcomes of minimally invasive surgery compared with the open approach. Especially in the donor population, the cosmetic results are of great importance; therefore, an effort to reduce the incision size should be attempted while maintaining the safe general principles of surgery. We present our initial experience with the use of 3-mm instruments for laparoscopic LDN.

Simplified technique for parastomal hernia repair after radical cystectomy and ileal conduit creation.

OBJECTIVE: To review the results of parastomal hernia repair with a simplified technique of translocation of the stoma with no need for a midline incision. METHODS: A total of 405 radical cystectomies with creation of an ileal conduit were reviewed at our institution. The primary goal of the review was to determine the incidence of parastomal hernias in a large series of cystectomies and their management at our institution. Surgical correction of parastomal hernia was indicated in case of pain, discomfort, risk of bowel obstruction, and/or distortion of the abdominal wall. The simplified technique includes an elliptical incision around the stoma and dissection of the hernia's sac down to the level of the fascia. The sac is incised and the peritoneum is entered. The ileal conduit is thereafter mobilized to guarantee sufficient length. This is crucial to be able to transpose the conduit 5-10 cm superiorly and to obtain a tension-free ileostomy. RESULTS: Sixty-three patients (16%) presented during the follow-up after ileal conduit a palpable defect or bulge adjacent to the stoma. The review highlighted 19 patients (4.69%) who developed a parastomal hernia and underwent surgical repair. Four cases (21%) recurred at a median follow-up of 55 months. Recurrence was not found to be related to gender, age, body mass index, protein level, radiotherapy, adjuvant chemotherapy, or previous abdominal surgery on univariate analysis. Postoperative complications included one wound infection (5.2%) and one stomal necrosis (5.2%). CONCLUSIONS: The technique herein proposed simplifies the management of parastomal hernia repair by avoiding a midline incision, which implies a reduction in surgical trauma with acceptable recurrence and postoperative complication rate.

Invasive bladder cancer in the eighties: transurethral resection or cystectomy?

PURPOSE: Describe morbidity and survival in patients older than 80 years with muscle invasive bladder cancer (MIBC) treated with radical cystectomy (RC) or transurethral resection (TUR) in our institution. MATERIALS AND METHODS: We reviewed our database of all patients older than 80 years treated with RC and TUR for MIBC between 1993 and 2005 in our institution. Twenty-seven patients were submitted to RC, with mean age of 82 years and mean follow-up of 16.4 months. RC was carried out following diagnosis of previous MIBC in 14 cases (51.9 percent). The American Society of Anesthesiology (ASA) score was III or IV in 23 patients (85.1 percent). Seventy-two patients with a mean age of 84 years and mean follow-up of 33 months, diagnosed with MIBC, were managed by means of TUR. The ASA score was III-IV in 64 (88.8 percent) patients. RESULTS: Pathological stage of the RC specimen was pT3 in 18 cases (66.7 percent). Mean hospital stay was 16 days. Early complications were assessed in 8 patients (29.6 percent), with an overall survival (OS) of 42.94 percent, and cancer-specific survival (CSS) of 60.54 percent. In patients submitted to TUR, clinical stage was T2 in 36 cases (50 percent). The mean hospital stay was 7 days, with a readmission rate (RR) of 87.5 percent. OS and CSS was less than 20 percent. CONCLUSIONS: RC in octogenarian patients is a safe procedure, with complication and survival rates comparable to RC series in general population. Transurethral resection (TUR) for patients with MIBC within this age range is a much less morbid procedure, but disease specific survival is lower.