Best practices in near-infrared fluorescence imaging with indocyanine green (NIRF/ICG)-guided robotic urologic surgery: a systematic review-based expert consensus.

PURPOSE: The aim of the present study is to investigate the impact of the near-infrared (NIRF) technology with indocyanine green (ICG) in robotic urologic surgery by performing a systematic literature review and to provide evidence-based expert recommendations on best practices in this field. METHODS: All English language publications on NIRF/ICG-guided robotic urologic procedures were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed®, Scopus® and Web of Science™ databases (up to April 2019). Experts in the field provided detailed pictures and intraoperative video-clips of different NIRF/ICG-guided robotic surgeries with recommendations for each procedure. A unique QRcode was generated and linked to each underlying video-clip. This new exclusive feature makes the present the first "dynamic paper" that merges text and figure description with their own video providing readers an innovative, immersive, high-quality and user-friendly experience. RESULTS: Our electronic search identified a total of 576 papers. Of these, 36 studies included in the present systematic review reporting the use of NIRF/ICG in robotic partial nephrectomy (n = 13), robotic radical prostatectomy and lymphadenectomy (n = 7), robotic ureteral re-implantation and reconstruction (n = 5), robotic adrenalectomy (n = 4), robotic radical cystectomy (n = 3), penectomy and robotic inguinal lymphadenectomy (n = 2), robotic simple prostatectomy (n = 1), robotic kidney transplantation (n = 1) and robotic sacrocolpopexy (n = 1). CONCLUSION: NIRF/ICG technology has now emerged as a safe, feasible and useful tool that may facilitate urologic robotic surgery. It has been shown to improve the identification of key anatomical landmarks and pathological structures for oncological and non-oncological procedures. Level of evidence is predominantly low. Larger series with longer follow-up are needed, especially in assessing the quality of the nodal dissection and the feasibility of the identification of sentinel nodes and the impact of these novel technologies on long-term oncological and functional outcomes.

Robotic uterine-sparing vesicovaginal fistula repair.

INTRODUCTION AND HYPOTHESIS: The objective was to describe a technique for the robotic repair of complex vesicovaginal fistula (VVF) with uterine preservation. METHODS: From 2015 to 2017, two patients underwent the procedure. Following placement of the patient in the lithotomy position, catheterization of the fistulous tract and laparoscopic omental harvesting is performed. Then, the robotic system is docked. A transverse incision was made in the peritoneum above the uterus was made to provide access to the bladder, the uterus is mobilized, and a cystotomy is performed to identify the structures. Subsequently, the cystotomy is extended toward the fistulous tract, the plane between the organs is dissected to proceed with the vaginal closure, the vagina is closed, the omental flap is interposed, and the bladder is closed. RESULTS: Mean operative time (OT) was 219 min. Mean estimated blood loss (EBL) was 75 ml. One of the patients had an intraoperative cervix canal injury that was identified and repaired. The postoperative course was uneventful, and the mean length of hospital stay (LOS) was 1 day. A mean follow-up of 17 (±9.89) months showed no recurrence at cystoscopy or imaging evaluation. CONCLUSIONS: Uterine-sparing VVF repair is feasible and safe. More studies are needed to assess equivalence compared with other procedures.

Treatment of Acute Myeloid Leukemia with the FLT3 Gene Mutation.

In acute myeloid leukemia (AML), mutations of the Fms-like tyrosine kinase 3 receptor (FLT3) and its overexpression are related with hyperleukocytosis, higher risk of relapse, and decrease of both disease-free survival and overall survival. It has been suggested that this phenomenon confers proliferative and survival advantages to the malignant blast cells. As a consequence, it is an attractive therapeutic target. As the best treatment strategy for mutated FLT3 AML remains to be defined, the addition of FLT3 inhibitor drugs to chemotherapy or to the bone marrow transplant approach has become a growing strategy. With encouraging results, this combination seems to be an attractive option. Relevant data regarding the current treatment trends on mutated FLT3 AML is reviewed here.

Robotic-assisted laparoscopic repair of rectovesical fistula after Hartmann's reversal procedure.

The case is of a 59-year-old male with history of severe ischemic colitis following emergent intervention for a ruptured infrarenal aortic aneurysm who subsequently underwent left hemicolectomy, partial proctectomy, and Hartmann colostomy. The patient later underwent reversal of the Hartmann colostomy with diverting ileostomy. The surgery was complicated by a right ureteral and posterior bladder injury that resulted in a large rectovesical fistula involving the right hemitrigone and right ureteral orifice. An attempt to repair the rectovesical fistula at an outside facility was unsuccessful. Then, he underwent a robotic-assisted laparoscopic repair of rectovesical fistula, including simple prostatectomy, excision of rectovesical fistulous tract, rectal closure, peritoneal and omental flap interposition, bladder neck reconstruction, vesicourethral anastomosis and right ureteral reimplantation. There were no intraoperative or postoperative complications, and the patient was discharged at postoperative day 4; cystoscopy at 6-week follow-up demonstrated a successful closure of the fistula, at which time the ureteral stents were removed.

Thrombin is present in the lungs of patients with primary extremity osteosarcoma and pulmonary metastases.

Osteosarcoma is a rare cancer, which metastasizes to the lung in up to 80% of cases. Thrombin is involved in metastasis and is present in the lungs of patients with pulmonary metastases (PM). To identify its role in PM and osteosarcoma, we measured thrombin levels in the bronchoalveolar lavage fluid (BALF) of 15 patients. BALF was collected at different stages of the disease and correlated with the diagnosis of PM. We also assessed fibrinogen overexpression in the tumors. We found that 11/15 (73%) patients with high thrombin levels in the lungs developed PM within the first 12 months from primary surgery. The median thrombin concentration in the BALF of these patients increased up to 8x10(-9) M (range, 3x10(-9)M-15x10(-9)M), which represents a more than 100-fold increase compared to patients without PM (p<0.0001). Eight of 15 (53%) primary and 11/15 (73%) metastatic samples showed fibrinogen overexpression. A significant difference between high thrombin levels, fibrinogen overexpression and PM was found compared to patients without PM (p=0.00073 and p=0.025). These results show that thrombin levels are increased in the lungs of patients with primary osteosarcoma and a high risk of developing PM. They suggest that thrombin may be involved in the development of PM.

[Hybrid-NOTES transvaginal hemi-nephrectomy for duplicated renal collecting system in the adult patient]. / Heminefrectomía NOTES-híbrido transvaginal por duplicidad del sistema colector renal en el paciente adulto.

INTRODUCTION: Duplication of the ureter and renal pelvis is the most common anomaly of the upper urinary tract. Upper pole heminephrectomy is a treatment option when duplication anomalies are associated with ureteral ectopia or ureterocele with an associated nonfunctioning or infected upper pole moiety. MATERIAL AND METHOD: We describe a NOTES hybrid transvaginal upper pole heminephrectomy in a 24 year old with recurrent infections in a poorly functioning right upper pole moiety. The procedure was performed with a bariatric trocar in the vagina, and a multichannel single-port device (Triport, Olympus Surgical) in the umbilicus. An ultrasonic scalpel was used for the heminephrectomy. The specimen was retrieved through the vagina. RESULTS: Operative time was 150 minutes and blood loss 50 cc. One week later the patient developed urinoma at the surgical site and was re-explored laparoscopically. The cut edge of the heminephrectomy defect was fulgurated and a drain placed. The patient recovered uneventfully following re-exploration. CONCLUSIONS: We describe the technique for transvaginal Hybrid-NOTES heminephrectomy. This approach requires further development with respect to instrumentation, and surgical expertise. The combined umbilical and vaginal approached restored triangulation and facilitates dissection, but more experience is required to determine safety, efficacy and reproducibility.

[A novel technique for distal ureterectomy and bladder cuff excision]. / Nueva técnica para la ureterectomía distal y excisión de manguito vesical.

INTRODUCTION: We describe a novel endoscopic approach and provide a literature review for the "en bloc" dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum. MATERIALS AND METHODS: The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen. RESULTS: The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3. CONCLUSION: The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy.

Heminefrectomía NOTES-híbrido transvaginal por duplicidad del sistema colector renal en el paciente adulto / Hybrid-NOTES transvaginal hemi-nephrectomy for duplicated renal collecting system in the adult patient

Introducción: La duplicación del uréter y la pelvis renal es la anomalía más común del tracto urinario superior. La heminefrectomía polar superior es el tratamiento de elección cuando la anomalía se asocia con ectopia ureteral o ureterocele en un sistema no funcionante o infección crónica del riñón. Material y método: Se describe la heminefrectomía del polo renal superior por NOTES-híbrido en una mujer de 24 años de edad con infecciones urinarias recurrentes en un sistema superior con escasa función. El procedimiento se realizó con un trócar bariátrico a través de la vagina, y un trócar multicanal (Triport, Olympus Surgical) a través del ombligo. Se utiliza bisturí ultrasónico para la heminefrectomía. El espécimen se retira por la vagina. Resultados: El tiempo operatorio fue 150 minutos y el sangrado 50 cc. Después de una semana la paciente desarrolló un urinoma en el lecho quirúrgico, que precisó exploración por vía laparoscópica. El lecho de la heminefrectomía fue fulgurado y se colocó un drenaje. La paciente se recuperó sin eventualidad tras la reintervención. Conclusiones: Se describe la técnica de heminefrectomía transvaginal con técnica NOTES híbrido. Este abordaje requiere mayor desarrollo, tanto de la instrumentación como de la técnica. La combinación de los abordajes umbilical y transvaginal restablece la triangulación y facilita la disección, pero se requiere más experiencia para determinar su seguridad, eficacia y reproducibilidad (AU)

Introduction: Duplication of the ureter and renal pelvis is the most common anomaly of the upper urinary tract. Upper pole heminephrectomy is a treatment option when duplication anomalies are associated with ureteral ectopia or ureterocele with an associated nonfunctioning or infected upper pole moiety. Material and method: We describe a NOTES hybrid transvaginal upper pole heminephrectomy in a 24 year old with recurrent infections in a poorly functioning right upper pole moiety. The procedure was performed with a bariatric trocar in the vagina, and a multichannel single-port device (Triport, Olympus Surgical) in the umbilicus. An ultrasonic scalpel was used for the heminephrectomy. The specimen was retrieved through the vagina. Results: Operative time was 150 minutes and blood loss 50 cc. One week later the patient developed urinoma at the surgical site and was re-explored laparoscopically. The cut edge of the heminephrectomy defect was fulgurated and a drain placed. The patient recovered uneventfully following re-exploration. Conclusions: We describe the technique for transvaginal Hybrid-NOTES heminephrectomy. This approach requires further development with respect to instrumentation, and surgical expertise. The combined umbilical and vaginal approached restored triangulation and facilitates dissection, but more experience is required to determine safety, efficacy and reproducibility (AU)

Nueva técnica para la ureterectomía distal y excisión de manguito vesical / A Novel Technique for Distal Ureterectomy and Bladder Cuff Excision

Introducción: Se describe un novedoso abordaje endoscópico y se hace una revisión de la literatura para la disección «en bloque» del uréter distal y el manguito vesical durante la nefroureterectomía radical laparoscópica, usando un puerto único multicanal transvesical con pneumovejiga (pneumovesicum). Materiales y método: El procedimiento se llevó a cabo en un hombre de 80 años de edad, con historia de hematuria macroscópica debida a carcinoma de células transicionales (CCT) en la pelvis renal izquierda, sin historia previa de CCT en vejiga. Se realizó una nefroureterectomía radical laparoscópica y el uréter fue disecado hasta la inserción en la vejiga y fue clipado. Un dispositivo de puerto único multicanal (single-port) fue insertado transvesicalmente y se estableció la pneumovejiga. Se practica una incisión de la vejiga en todo su grosor alrededor del uréter, y se va realizando una movilización intravesical del uréter distal. Subsecuentemente, se realiza un cierre hermético del defecto vesical. El uréter distal, junto con el manguito vesical, se liberan laparoscópicamente y se extraen en bloque con el espécimen. Resultados: El tiempo operatorio (nefroureterectomía radical laparoscópica, LDRP y escisión del manguito vesical por puerto único) fue de 6 horas y 15 minutos. El tiempo del manguito vesical fue de 45 minutos. No hubo complicaciones intra o postoperatorias y la sonda fue retirada al sexto día de la cirugía. El análisis histopatológico mostró CCT comprometiendo el riñón, pT3G3 pN0 (0/7). Conclusión: La técnica de abordaje del uréter distal y el manguito vesical aún no ha sido estandarizada. El manejo del manguito vesical con un puerto único multicanal es factible. Estudios adicionales son necesarios para identificar cuál es el mejor abordaje para el manejo del uréter distal durante una nefroureterectomía laparoscópica (AU)

Introduction: We describe a novel endoscopic approach and provide a literature review for the “en bloc” dissection of the distal ureter and bladder cuff during laparoscopic radical nephroureterectomy using a transvesical single port approach under pneumovesicum. Materials and methods: The procedure was performed in an 80-year old male with a history of gross hematuria due to left renal pelvic TCC and no history of prior bladder TCC. Laparoscopic radical nephroureterectomy was performed and the ureter was dissected down to the bladder and clipped. A single-port device was inserted transvesically and pneumovesicum established. A full thickness incision of the bladder around the ureter was performed with progressive intravesical mobilization of the distal ureter. Subsequently, a water-tight closure of the bladder defect was achieved. The distal ureter, together with the bladder cuff, was then delivered en bloc laparoscopically with the specimen. Results: The operating time (LESS radical nephroureterectomy, RPLND, and bladder cuff excision) was 6 hours and 15minutes. The bladder cuff time was 45minutes. There were no intra or postoperative complications and the catheter was removed after 6 days. Histopathological analysis showed kidney-invasive papillary urothelial cancer, pT3 pN0 (0/7) G3. Conclusion: The distal ureter and bladder cuff techniques have not yet been standardized. Management of the bladder cuff with a single port is feasible. Additional studies are needed to identify the best approach for management of the distal ureter at the time of laparoscopic nephroureterectomy (AU)

Ki-67: a proliferative marker that may predict pulmonary metastases and mortality of primary osteosarcoma.

Alterations in Ki-67 activity have been associated with tumor progression and poor outcome in cancer patients. This study was undertaken to identify the potential of this proliferative marker as a predictor of pulmonary metastases (PM) and mortality in osteosarcoma patients. In 38 patients with tissue available for immunohistochemical analysis, overexpression of Ki-67 was assessed. Chi-square and log rank tests were used to determine differences between proportions of the marker with PM and mortality and survival distributions respectively. P values equal or less than .05 were considered statistically significant. The median follow up of this case series was 28 months. Eighteen (47.4%) of 38 patients developed PM, and 17 (44%) overexpressed Ki-67. We found a high frequency of PM (15 of 17) among those cases that overexpressed Ki-67. This relationship was significant (P = .000006) when compared to the rest of the group. We also found a statistically significant correlation between patients with positive and negative Ki-67 scores and higher and lower mortality (P = .000962). These findings suggest that Ki-67 overexpression could be used as a prognostic molecular marker for the development of PM in osteosarcoma patients.

Changes in the quality of rabbit semen in 14 consecutive ejaculates obtained every 15 minutes.

Modifications of semen quality related to ejaculation frequency is one of the most important and neglected factors from the standpoint of artificial insemination or sperm competition. New Zealand white rabbits (Oryctolagus cuniculus) offer an advantageous experimental model because they have characteristic sexual behavior, they present rapid ejaculation after a single intromission, they have a very short interval between successive ejaculations, and semen can be easily collected. The authors studied the modifications on sperm quality (semen volume, sperm concentration, sperm motility) produced by 14 consecutive ejaculations recovered every 15 min using stimulus females and an artificial vagina. Bucks were exposed every 15 min to a sexually receptive female. After each ejaculation the female was removed and reintroduced 15 min later. Sperm concentration showed a clear biphasic conduct. The amount of spermatozoa per milliliter decreased rapidly until ejaculate number 6, showed a highly significant increase in ejaculates 7-9, and decreased to nil in the last 2 ejaculates. Total number of ejaculated spermatozoa was 557 x 10(6), 76% of which were recovered from the first 4 ejaculates. Ejaculate volume also showed a biphasic conduct. In the first ejaculates the volume decreased linearly until ejaculate number 6, showed a significant increase in ejaculates 7-10, and then decreased. The total semen volume recovered during the experiment was 2.44 mL, 40% of which (0.98 mL) was recovered from the first 2 ejaculates. Individual motility in the first 6 ejaculates was preferentially progressive (60% of the sperms) and turned to random or in situ from the seventh ejaculate up. The proportion of spermatozoa with cytoplasmic droplets increased from ejaculates 6 and 7 up. The results seem to reflect an acceleration of semen transport through the epididymis when the demands for spermatozoa increase.

High prevalence of oncogenic human papillomavirus in the genital tract of women with human immunodeficiency virus.

OBJECTIVE: The goal of this study was to determine the prevalence of human papillomavirus (HPV) and squamous intraepithelial lesions (SILs) in women infected with human immunodeficiency virus (HIV) in Mexico. METHODS: Cases included women who were positive for human immunodeficiency virus (HIV) and accepted to participate. There were two control groups in this study: group A, heterosexual partners of HIV+ men; group B, commercial sex workers. Gynecologic examination was performed in all participants. Also, a cervical smear with colposcopy and a sample for detection of HPV DNA by polymerase chain reaction (PCR) were obtained in all subjects, as were CD4+ counts. Relative risks (RR) and 95% confidence interval were calculated. RESULTS: Eighty-five HIV+ women agreed to participate in this study; the route of HIV infection was heterosexual in 78.8%; transfusion in 8.2%; paid donors in 3.5%; and 9.4% unknown. A total of 9 controls were included: 4 from group A and 5 from group B. HPV DNA was detected by PCR in 57 (69%) cases and in 26 (29%) controls from both groups (P < 0.0001). The RR of HPV infection was 5.5 (2.7-11.5). Also, a significant difference in the prevalence of high-risk HPV types was observed between cases and controls, RR = 12.8 (4.07-42.9). These associations were independent of CD4+ counts and antiretroviral therapy. No association was observed between HIV infection and the risk for high-grade SIL. CONCLUSIONS: We observed a high prevalence of oncogenic HPV types in HIV-positive women. These women should be screened regularly for early diagnosis of premalignant lesions and prevention of cervical cancer.