First Comparison of Retroperitoneal Versus Transperitoneal Robot-Assisted Nephroureterectomy with Bladder Cuff: A Single Center Study.

INTRODUCTION: After recent presentation of the first complete robot-assisted retroperitoneal nephroureterectomy with bladder cuff (RRNU) for patients with upper tract urothelial cancer (UTUC), we aimed to compare this new surgical technique with robot-assisted transperitoneal nephroureterectomy (TRNU) representing the current standard of care. METHODS: Robot-assisted nephroureterectomies (NUs) were retrospectively analyzed and compared based on two groups: transperitoneal versus retroperitoneal approach. Baseline data were collected for patient demographics, tumor characteristics, intra- (EAUiaiC) and postoperative (Clavien-Dindo) complications, and perioperative variables. Tumor characteristics included grade of malignancy, clinical stage, and surgical margin status. Short-term follow-up data including 30-day readmission rates were collected. Statistical analyses were performed assuming a significant p-value of < 0.05. RESULTS: The analysis includes perioperative patient data after proven UTUC of 24 TRNU versus 12 RRNU (mean age: 70 versus 71 years; BMI: 25.9 versus 26.1 kg/m2; CCI score ≥ 4: 83% versus 75%; ASA score ≥ 3: 37% vs 33%). Intraoperative (16.4% vs 0%, p = 0.35) and postoperative (25% vs 12.5%, p = 0.64) complications demonstrated no significant discrepancy. Notably, RRNU demonstrated significantly shorter surgery time (p < 0.05) and length of stay (p < 0.05). There was no significant difference in histopathological tumor characteristics, whereas significantly more lymph nodes were removed through RRNU (11.0±3.3 vs. 6.4±5.1, p < 0.05). Finally, no statistical difference was shown in short-term follow-up. CONCLUSION: We report the first head-to-head comparison between RRNU and TRNU. RRNU proves to be a safe and feasible approach which appears to be non-inferior to TRNU. RRNU expands the spectrum of minimally invasive treatment options, particularly for patients with major previous abdominal surgery.

Contemporary role of palliative cystoprostatectomy or pelvic exenteration in advanced symptomatic prostate cancer.

OBJECTIVE: To access the feasibility of palliative cystoprostatectomy/pelvic exenteration in patients with bladder/rectal invasion due to prostate cancer (PC). PATIENTS AND METHODS: Twenty-five men with cT4 PC were retrospectively identified in the institutional databases of six tertiary referral centers in the last decade. Local invasion was documented by CT or MRI scans and was confirmed by urethrocystoscopy. Oncological therapies, local symptoms, previous local treatments, time from diagnosis to intervention and type of surgical procedure were recorded. Patients were divided into groups: ADT group (12 pts) and 13 pts without any history of previous local/systemic treatments for PCa (nonADT groups). Perioperative complications were classified using the Clavien-Dindo system. Overall survival (OS) was defined as the time from surgery to death from any cause. A Cox regression analysis, stratified for ISUP score and previous hormonal treatment (ADT) was also performed for survival analysis. RESULTS: Ileal conduit was the main urinary diversion in both cohorts. For the entire cohort, complication rate was 44%. No significant differences regarding perioperative complications and complication severity between both subgroups were observed (p = 0.2). Median follow-up was 15 months (range 3-41) for the entire cohort with a median survival of 15 months (95% CI 10.1-19.9). In Cox regression analysis stratified for ISUP score, no statistically significant differences in OS in patients with and without previous ADT before cystectomy or exenteration were observed (HR 3.26, 95% CI 0.62-17.23, p = 0.164). CONCLUSION: Palliative cystoprostatectomy and pelvic exenteration represent viable treatment options associated with acceptable morbidity and good short-term survival outcome.

Prognostic significance of Fuhrman grade and age for cancer-specific and overall survival in patients with papillary renal cell carcinoma: results of an international multi-institutional study on 2189 patients.

PURPOSE: Because the prognostic impact of the clinical and pathological features on cancer-specific survival (CSS) and overall survival (OS) in patients with papillary renal cell carcinoma (papRCC) is still controversial, we want to assess the impact of clinicopathological features, including Fuhrman grade and age, on survival in surgically treated papRCC patients in a large multi-institutional series. METHODS: We established a comprehensive multi-institutional database of surgically treated papRCC patients. Histopathological data collected from 2189 patients with papRCC after radical nephrectomy or nephron-sparing surgery were pooled from 18 centres in Europe and North America. OS and CSS probabilities were estimated using the Kaplan-Meier method. Multivariable competing risks analyses were used to assess the impact of Fuhrman grade (FG1-FG4) and age groups (<50 years, 50-75 years, >75 years) on cancer-specific mortality (CSM). RESULTS: CSS and OS rates for patients were 89 and 81% at 3 years, 86 and 75% at 5 years and 78 and 41% at 10 years after surgery, respectively. CSM differed significantly between FG 3 (hazard ratio [HR] 4.22, 95% confidence interval [CI] 2.17-8.22; p < 0.001) and FG 4 (HR 8.93, 95% CI 4.25-18.79; p < 0.001) in comparison to FG 1. CSM was significantly worse in patients aged >75 (HR 2.85, 95% CI 2.06-3.95; p < 0.001) compared to <50 years. CONCLUSIONS: FG is a strong prognostic factor for CSS in papRCC patients. In addition, patients older than 75 have worse CSM than patients younger than 50 years. These findings should be considered for clinical decision making.

Cytotoxic antibodies monitoring in kidney transplantation--their clinical relevance and challenges.

INTRODUCTION: The key of the successful renal transplantation is the ability to identify the best immunological match between donor and recipient considering the possibility of rejection phenomenon. The aim was to identify class I and/or class II cytotoxic antibodies in renal-transplanted patients in order to assess the immunological potential for prevention of subclinical or acute rejection episodes. PATIENTS AND METHODS: We have evaluated ninety-two patients who had kidney transplantation in 2010 in Fundeni Clinical Institute, Bucharest, Romania, concerning HLA matching and anti-HLA immunization status. For HLA genotyping were used molecular biology methods--PCR-SSP (Invitrogen, USA). For cytotoxic antibodies, the methods used were ELISA (GTI Diagnostics, USA) and Luminex (One Lambda, USA). Crossmatch tests between donor cells and recipient serum were performed by ELISA (GTI Diagnostics, USA). Rejection diagnosis was supported by renal biopsy. RESULTS: In the 20 presensitized cases, the rate of acute rejection was 30% while in the 72 unsensitized cases the rejection was 19.4%. The incidence of acute rejection was higher in anti-HLA class I presensitized patients compared with anti-HLA class II (20% and 14.3%, respectively) but there was no significant difference compared to pre-transplant unsensitized patients (19.4%). Sequential post-transplantation monitoring of anti-HLA antibodies has shown in pre-transplant sensitized patients group a constantly increasing of PRA value, while in the pre-transplant unsensitized patients group, 32% developed de novo cytotoxic antibodies. CONCLUSIONS: More sensitive and specific methods to detect anti-HLA antibodies before transplantation and sequential post-transplantation monitoring of these antibodies would be useful to identify patients who are at higher risk for allograft failure.

Comparative analysis of different surgical procedures for female stress urinary incontinence. Is stem cell implantation the future?

RATIONALE: Stress urinary incontinence (SUI) represents a major public health problem and although there are many treatments available, only a few can restore the anatomical background of this disorder. Injections of stem cells into the middle urethra have the possibility of restoring the contractility of the striated muscles and rhabdosphincters. The aim of stem cell therapy is to replace, repair or enhance the biological function of damaged tissue or organs. OBJECTIVE: Assessing the latest minimally invasive procedures of intra and perisphincterian injection of autologous stem cells and to compare the urodynamic results at one year after different surgical procedures for genuine stress urinary incontinence by measuring their impact on urinary flow rate (Qmax) and bladder pressure at Qmax during micturition. METHODS AND RESULTS: On October 18, 2010, in "Fundeni" Clinic of Urology and Renal Transplantation we performed for the first time in Romania, stem cell implantation in the urethral sphincter in four patients with stress urinary incontinence and compared the results of the urodynamic investigations of female patients operated with pure SUI with other surgical techniques. The analyzed procedures were: Burch colposuspension (11 cases), TVT-like (IVS sling in 26 cases), TOT-like (CYSTO-SWING sling in 41 cases). Followed variables were: Qmax, Pves at Qmax, postvoiding residual (PVR). Clinical examination and voiding diary in six weeks after the surgery revealed a decrease of urine loss with an improvement of the patient' quality of life according to visual analogue scale. For female patients with myoblasts implant, changes in Qmax and Pves at Qmax were minimal and statistically insignificant in the context of inclusion criteria, but we noticed a trend of minimal change in these urodynamic characteristics, namely, an average decrease of Qmax with 2.1 mL/s and an average increase of Pves at Qmax with 0.6 cmH(2)O. CONCLUSIONS: The development of myoblasts implant (if they will pass the time-proof test) could represent a breakthrough in treating this condition. As the pathogenesis of SUI is better understood and the development of tissue engineering technology advances, tissue engineering will play a more important role in the treatment of patients with SUI.

Atypical primary tuberculosis mimicking an advanced penile cancer. Can we rely on preoperative assessment?

Tuberculosis of penis is a very rare clinical entity. There are isolated reports of its presentation as a subcutaneous nodule with or without superficial ulcers and can be interpreted as advanced penile cancer. We present a case of penile tuberculosis that presented in our Center with a bulky penoscrotal formation treated in other center for the suspicion of Fournier gangrene.

Morphological aspects of the kidney: can normality be predicted?

PURPOSE: Our study aimed to assess the normal parameters of renal parenchyma and upper urinary tract from a contrast enhanced computed tomography assessment in order to create a mathematical model of normal kidney. PATIENTS AND METHODS: We conducted a retrospective observation study on 520 patients with a normal abdominal contrast enhanced CT scan in our Institute during November 2008-November 2010. All CT examinations were performed using 16 slices Siemens Emotion 2007 (Siemens Medical Solutions, Malvern, PA, USA). Two experienced radiologists evaluated all the evaluations and reformatted axial sections and after excluding patients with urinary tract pathology, the images were transferred to a separate workstation (eFilm Workstation(TM) 2.2.1, Merge Healthcare, Milwaukee, USA). Parameters measured were: the number of kidneys, craniocaudal diameter (CCD) in a coronar reconstruction, transverse diameter (TD) and anteroposterior diameter (APD) as the maximum diameter of the kidneys in the axial sections, parenchymal (PW) and cortical width (CW) in axial sections, kidney pyelon width (KPW), parenchymal index (PI), kidney rotation, measured in relation to the sagittal axial plane of reference (AR) and rotation of the kidney measured in the sagittal plane in relation to the coronary reference (SR). To identify factors that can influence the variables CCD, CW and PW, multivariate regression models were performed using SPSS software (SPSS 15, SPSS Inc., Chicago, Illinois, USA). We considered p<0.05 statistically significant. RESULTS: CCD remains high until the fifth decade of life (p=0.0053 on the right side, p=0.0012 on the left, ANOVA), PW values were found to be somewhat increased (p=0.0293 on the right side, p=0.2924 on the left, ANOVA). There are linear correlations between height and CCD, CW and PW, with statistical significance (p<0.05 each, Spearman ρ between 0.13 and 0.4). In multivariate analysis, only BMI, male gender and height had statistical significance. CONCLUSIONS: There is a wide range in size kidney. Among factors that strongly influence the values of CCD, CW, and PW in adults, BMI, male gender and height are most important. Also, cranial and caudal position of the kidney influences renal size. As for the size of the renal cortex, the factor most influencing these values is the absence of a contralateral kidney.

Management of small renal masses--update 2011.

RATIONALE: The management of renal parenchymal tumors has known many changes over time, a trend that continues today, as a result of technological advances, clinical research and improved diagnostic and therapeutic tools. Unfortunately, conventional cancer treatments--chemotherapy and radiotherapy have proven ineffective and modern approaches such as immunotherapy, angiogenesis inhibitors, though they enjoyed an initial enthusiasm, subsequent studies have shown limited and controversial effects. Thus, surgery remains the gold standard therapy for this type of cancer. The options for the treatment of RCC are numerous, with options that have advantages and disadvantages, with oncological results, in most cases, positive at five years and with different impact on cancer specific survival. It is difficult to compare the results, as these are different techniques with various instruments and intraoperative steps, with more questionable inclusion criteria, selection biases and prosecution, with a tendency for preferential enrollment, different reasons to why randomized prospective studies have not been performed until today. OBJECTIVE: This article is a review of the diagnosis and methods of treatment of small renal masses 2011. CONCLUSION: At the beginning of the new millennium, kidney cancer, with all the arsenal of techniques and methods of ablative surgery, remains a potentially fatal disease for a high percentage of patients, and the decision to choose a treatment or another should be taken with responsibility, depending on currently existing medical records, the degree of expertise and not based on subjective or other non-standard parameters.

Highlights in the minimally invasive treatment of SUI in women.

OBJECTIVE: Treatment of stress urinary incontinence consists of a wide range of options, from conservative therapies like lifestyle changes, medication, pelvic floor muscles exercises, electro-stimulation, to minimally invasive procedures--injection of collagen, suburethral slings TVT/TOT and last but not least, invasive surgical treatment reserved for recurrent and complex cases. Among the latest minimally invasive procedures reported in literature, the injection of intra-and perisphincterian of autologous stem cell (mioblasts and/or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscles). MATERIAL AND METHOD: On October 18, 2010, in 'Fundeni' Clinical Institute of Uronephrology and Renal Transplantation was performed the first stem cell implantation procedure in the urethral sphincter, in Romania. RESULTS: Assessment at 6 weeks, the quality of life questionnaires, micturition diary and clinical examination revealed a stunning decrease of urine loss from 6 pads/day at one per day, which significantly improved the patient's quality of life. CONCLUSIONS: Stem-cell-mioblasts therapy may represent in the future an every-day intervention in the urologist's armamentarium. The effectiveness of this treatment can change the course of therapy and last but not least, the accessibility to urological evaluation of patients with stress urinary incontinence. Clinical and urodynamic evaluations will continue and will be future scientific topics.

Minimally invasive treatment for female stress urinary incontinence - Romanian highlights.

RATIONALE: Stress urinary incontinence is still a "battlefield" for many minimally invasive therapies, but, unfortunately, few can restore the anatomical and functional background of this disorder. OBJECTIVE: Assessing the latest minimally invasive procedures of intra and perisphincterian injection of autologous stem cells. METHOD AND RESULT: The first stem cell implantation (myoblasts and /or mature fibroblasts grown and multiplied in the laboratory from biopsy samples taken from the pectoralis muscle) in the urethral sphincter was performed on October 18, 2010, in "Fundeni" Clinic of Urology and Renal Transplantation, in Romania. DISCUSSION: The follow-up at six weeks with the quality of life questionnaires, micturition diary and clinical examination revealed a decrease of urine loss from six pads/ day at one per day, which significantly improved the patient's quality of life according to visual analogue scale. Clinical and urodynamic evaluations will continue and will be future scientific topics.

Prognostic factors in retroperitoneal fibrosis.

UNLABELLED: The aim of this study is to evaluate effective prognostic factors in the evolution of patients with retroperitoneal fibrosis and to establish the validity of fractal analysis in determining the disease severity in these patients. MATERIAL AND METHODS: This study included 19 patients (M/F: 5/14) treated for idiopathic retroperitoneal fibrosis and bilateral obstructive renal failure between Jan 2004-Dec 2008. Patients were identified retrospectively, searching for patients diagnosed with IRF, after retroperitoneal biopsy or, in most cases the diagnosis rested on radiological findings, especially CT, with identification of a retroperitoneal mass, the absence of other demonstrable renal or ureteric disease or any other pathology that could explain the findings. CT was very useful in describing the retroperitoneal mass around the aorta and inferior vena cava, the extent of the lesion and for monitoring the response to surgical treatment during the follow-up. The data were evaluated about medical history, physical examination findings, laboratory tests (serum urea and creatinine, blood sugar, sodium, potassium, bicarbonate levels, serum pH, uric acid, haematocrit, white blood cell count), imaging methods (renal ultrasound, abdominal CT-scan, MRI). At admission all patients had active disease with obstructive renal failure and underwent bilateral ureteric stenting in order to normalize the BUN levels. After normalizing of BUN levels, ureterolysis and omental wrapping was performed. Postoperatively, ureteric stents were removed after 1 month and remission of renal disfunction was obtained in approximately 5 months (range 2-10 months). All patients were followed for at least 1 year. Patients were regularly checked every 3 months. RESULTS: Of the 19 patients, there were 5 men and 14 women. The median age at diagnosis of RF was 50 years (range 42-64 years). The most frequent presenting symptoms were back or abdominal pain, weakness, weight loss, oligoanuria, arterial hypertension and mild fever. The duration of symptoms before diagnosis ranged from 6 to 18 months. At presentation all patients had active disease, presenting renal dysfunction with a median serum creatinine of 5.18 mg/dl (range 1-15.4 mg/dl). Most of the patients had moderate bilateral hydronephrosis (2nd degree hydronephrosis). In our study, all patients had excellent prognosis, with full recovery of renal function in 78% of cases (15 patients). The fractal dimension of the fibrosis mass contour correlates with level of renal function impairment. Even more, the fractal dimension seems to slightly variate between CT evaluations (1.30 +/- 0.1), suggesting a non aggressive pattern of extension of the fibrotic mass characteristic for benign lesions. CONCLUSIONS: The imaging parameters did not predict the disease severity, except the increase in fractal dimension of fibrosis surface area. Efficacy of bilateral ureteric stenting in improving renal function is limited in most of the cases. Dispite the level of renal function impairment at admission, full recovery can be achieved after bilateral ureteric stenting/nephrostomy and ureterolisis.