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1.
Eur Urol Open Sci ; 67: 69-76, 2024 Sep.
Article de Anglais | MEDLINE | ID: mdl-39229365

RÉSUMÉ

Background and objective: The role of pelvic lymph node dissection (PLND) for prostate cancer is still controversial. This study aims to compare the outcomes of PLND between extraperitoneal single-port (SP eRARP) and transperitoneal multiport (MP tRARP) robotic-assisted radical prostatectomy. Methods: This was a retrospective analysis from our single-center database for patients who underwent SP eRARP or MP tRARP with PLND between 2015 and 2023. The primary endpoint was to analyze and compare specific data related to PLND between the two populations by the detection of pN+ patients, the total number of lymph nodes removed, and the number of positive lymph nodes removed. The secondary endpoints included comparing major complications, lymphoceles, and biochemical recurrence between the two cohorts of the study. Key findings and limitations: A total of 293 patients were included, with 85 (29%) undergoing SP eRARP and 208 (71%) undergoing MP tRARP. SP eRARP showed significant differences in PLND extension from MP tRARP, while MP tRARP yielded more lymph nodes (p < 0.001). There were no differences in pN+ patient detection (p = 0.7) or the number of positive lymph nodes retrieved (p = 0.6). The rates of major complications (p = 0.6), lymphoceles (p = 0.2), and biochemical recurrence (p = 0.9) were similar between the two groups. Additionally, SP eRARP had shorter operative time (p = 0.045), hospital stay (p < 0.001), and less postoperative pain at discharge (p = 0.03). Limitations include a retrospective, single-center analysis. Conclusions and clinical implications: Despite the SP approach in RARP resulting in fewer retrieved lymph nodes, outcomes were comparable with the MP approach regarding the detection of patients with positive lymph nodes and the number of positive nodes. Additionally, the SP approach led to lower pain levels and shorter hospital stays. Patient summary: With this study, we demonstrate that pelvic lymph node dissection performed via the extraperitoneal approach during robotic-assisted radical prostatectomy with a single-port system provides comparable outcomes with the standard transperitoneal multiport approach in detecting patients with positive lymph nodes and retrieving positive nodes. In addition, it offers significantly reduced pain levels and shorter hospital stays.

2.
Int. braz. j. urol ; 50(4): 502-503, July-Aug. 2024.
Article de Anglais | LILACS-Express | LILACS | ID: biblio-1569216

RÉSUMÉ

ABSTRACT Introduction Vesicovaginal fistula (VVF) is the most common urogenital fistula due to iatrogenic cause, primarily associated with gynecologic surgery (1). Although both conservative and surgical management may be considered, the optimal treatment is still uncertain and several studies were published using different techniques (open, laparoscopic or robotic) and approaches (extravesical, transvesical or transvaginal) (2-5). In this context, we aim to report our initial experience repairing VVF with Single-Port (SP) Transvesical (TV) access. Materials and Methods Four patients with a diagnosis of VVF underwent SP-TV VVF repair between May 2022 and December 2023. Diagnosis was confirmed by cystoscopy, cystogram and in two cases by CT Urogram. Under general anesthesia, before robotic time, patients were placed in lithotomy position and a preliminary cystoscopy was performed. Fistula was noted and a 5fr stent was placed through the fistulous tract. Two ureteral stents were placed. Then, with patient supine, a transverse suprapubic 3cm incision and 2cm cystotomy were made for SP access. First step was to mark and remove fistula tract to the vagina. The edges of the vagina and bladder were dissected in order to have a closure free of tension and to create three different layers to close: vagina, muscularis layer of the bladder and mucosal layer of the bladder. A bladder catheter was placed, and the two ureteral stents were removed at the end of procedure. Results Mean age was 53 years old and three out of 4 patients developed VVF after gynecologic surgery. Two patients underwent VVF repair 6 and 8 months after total hysterectomy. One patient developed VVF after total hysterectomy and oophorectomy followed by radiation therapy. Last patient developed VVF after previous urological procedure. Fistula diameter was between 11 and 15mm. Operative time was 211 min, including preliminary cystoscopy, stents placement and SP-access. All patients were discharged on the same day with a bladder catheter, successfully removed between post-operative day 14-18 after negative cystogram. Only in one case a ureteral stent was left because the fistula was closed to the ureteral orifice and we reported one case of UTI twelve days after surgery, treated with outpatient antibiotics. Mean follow-up was 8 months, patients were scheduled for regular follow-up visits and no recurrence was reported. All patients have at least 3 months of post-operative follow-up. Conclusions Our experience suggests that SP Transvesical VVF repair may be considered as a safe and feasible minimally invasive treatment for small/medium fistulae (10-15mm).

3.
World J Urol ; 42(1): 387, 2024 Jul 03.
Article de Anglais | MEDLINE | ID: mdl-38958744

RÉSUMÉ

PURPOSE: Single-Port Robot-Assisted Partial Nephrectomy (SP-RAPN) can be performed by transperitoneal and retroperitoneal approaches. However, there is a lack of surgical outcomes for novel Retroperitoneal Low Anterior Access (LAA) in SP-RAPN. The study compared outcomes of the standard approach (SA), considering transperitoneal (TP) and posterior retroperitoneal (RP) access vs LAA in SP-RAPN series. METHODS: 102 consecutive patients underwent SP-RAPN between 2019 and 2023 at a tertiary referral robotic center were identified. Baseline characteristics, peri- and post-operative outcomes were collected. Patients were stratified according to surgical approach into standard (RP or TP) vs LAA and, subsequently, RP vs LAA. Multivariable logistic regression analysis was used to test the probability of the same-day discharge adjusting for comorbidity indexes. RESULTS: Overall, 102 consecutive patients were included in this study (68 SA - 26 TP and 42 posterior RP vs 34 LAA). Median age was 60 (IQR 51.5-66) years and median BMI was 31 (IQR 26.3-37.6). No baseline differences were observed. LAA exhibited significantly shorter length of stay (LOS) (median 10 [IQR 8-12] vs 24 [IQR 12-30.2.] hours, p < .0001), reduced post-operative pain (p < .0001) and decreased narcotic use on 0-1 PO Day (p < .001) compared to SA and RP only. Multivariate analysis, adjusting for comorbidities, identified LAA as a strong predictor for Same-Day Discharge. CONCLUSION: LAA is an effective approach as well as RP and TP, regardless of the renal mass location, whether it is anterior or posterior, upper/mid or lower pole, yielding favorable outcomes in LOS, post-operative pain and decreased narcotics use compared to SA in SP-RAPN.


Sujet(s)
Néphrectomie , Interventions chirurgicales robotisées , Humains , Néphrectomie/méthodes , Adulte d'âge moyen , Mâle , Femelle , Interventions chirurgicales robotisées/méthodes , Sujet âgé , Espace rétropéritonéal , Résultat thérapeutique , Études rétrospectives , Péritoine/chirurgie , Tumeurs du rein/chirurgie
4.
World J Urol ; 42(1): 451, 2024 Jul 27.
Article de Anglais | MEDLINE | ID: mdl-39066794

RÉSUMÉ

PURPOSE: To evaluate the incidence of postoperative complications after cytoreductive nephrectomy (CN) following first-line treatment for metastatic renal cell carcinoma (mRCC), and to compare it with postoperative complications of upfront CN. METHODS: For this population-based retrospective study, the PearlDiver Mariner database (PearlDiver Technologies, Colorado Springs, CO), a database of insurance billing records was analyzed. Using relevant ICD-9/10 and CPT codes, patients diagnosed with mRCC between 2011 and 2021, who received first-line systemic molecular therapy (SMT), either tyrosine kinase inhibitors (TKI) or immune-checkpoint inhibitors (ICI), were identified. The selected population was stratified into two cohorts according to the timing of CN (deferred: after SMT vs. upfront: before SMT). Propensity-score matching (PSM) was performed as per baseline patients' characteristics to control for potential confounders between the two cohorts. The primary outcome was to compare 30-day postoperative complications rate between patients undergoing upfront vs. deferred CN. RESULTS: After PSM, 162 patients who received upfront CN were compared with 162 patients who underwent deferred CN. The overall rate of 30-day postoperative complications was statistically significantly higher in patients undergoing deferred CN (33.9%), compared to patients treated with upfront CN (21%, p < 0.01). In addition, the rate of both medical (26.5% vs. 14.2%, p < 0.01) and surgical (14.8 vs. 7.4%, p = 0.03) complication rate was statistically significantly higher in deferred vs. upfront CN. Multivariable logistic regression analysis revealed that none of the treatment regimens significantly predicted the occurrence of postoperative complications. CONCLUSION: Patients undergoing deferred CN experience a higher rates of overall, medical, and surgical 30-day postoperative complications compared to those receiving upfront surgery. Findings from this study should be interpreted within the limitations of this type of analysis.


Sujet(s)
Néphrocarcinome , Interventions chirurgicales de cytoréduction , Immunothérapie , Tumeurs du rein , Néphrectomie , Complications postopératoires , Score de propension , Humains , Tumeurs du rein/chirurgie , Tumeurs du rein/traitement médicamenteux , Néphrectomie/méthodes , Mâle , Femelle , Néphrocarcinome/chirurgie , Néphrocarcinome/traitement médicamenteux , Néphrocarcinome/thérapie , Adulte d'âge moyen , Études rétrospectives , Complications postopératoires/épidémiologie , Sujet âgé , Thérapie moléculaire ciblée , Incidence
5.
Urol Case Rep ; 54: 102720, 2024 May.
Article de Anglais | MEDLINE | ID: mdl-38827533

RÉSUMÉ

Chyluria, an abnormal lymphatic disorder, results in excessive abdominal lymph drainage into the urinary system, causing protein loss, nutritional deficiencies, and immune issues. Mainly linked to parasitic infections in developed countries, non-parasitic causes like trauma or tumors are rare. Typically appearing in adults with bilateral involvement, management options include conservative or surgical approaches. We present the case of a 13-year-old with congenital chyluria, treated with robot-assisted staged reno-lymphatic disconnection after failed interventional radiology. Bilateral scleroangiography followed, leading to persistently milky urine for a month. Finally, urine clarity improved, correlating with better urinalysis, emphasizing the need for a comprehensive, multi-disciplinary approach.

6.
Int Braz J Urol ; 50(4): 502-503, 2024.
Article de Anglais | MEDLINE | ID: mdl-38743067

RÉSUMÉ

INTRODUCTION: Vesicovaginal fistula (VVF) is the most common urogenital fistula due to iatrogenic cause, primarily associated with gynecologic surgery (1). Although both conservative and surgical management may be considered, the optimal treatment is still uncertain and several studies were published using different techniques (open, laparoscopic or robotic) and approaches (extravesical, transvesical or transvaginal) (2-5). In this context, we aim to report our initial experience repairing VVF with Single-Port (SP) Transvesical (TV) access. MATERIALS AND METHODS: Four patients with a diagnosis of VVF underwent SP-TV VVF repair between May 2022 and December 2023. Diagnosis was confirmed by cystoscopy, cystogram and in two cases by CT Urogram. Under general anesthesia, before robotic time, patients were placed in lithotomy position and a preliminary cystoscopy was performed. Fistula was noted and a 5fr stent was placed through the fistulous tract. Two ureteral stents were placed. Then, with patient supine, a transverse suprapubic 3cm incision and 2cm cystotomy were made for SP access. First step was to mark and remove fistula tract to the vagina. The edges of the vagina and bladder were dissected in order to have a closure free of tension and to create three different layers to close: vagina, muscularis layer of the bladder and mucosal layer of the bladder. A bladder catheter was placed, and the two ureteral stents were removed at the end of procedure. RESULTS: Mean age was 53 years old and three out of 4 patients developed VVF after gynecologic surgery. Two patients underwent VVF repair 6 and 8 months after total hysterectomy. One patient developed VVF after total hysterectomy and oophorectomy followed by radiation therapy. Last patient developed VVF after previous urological procedure. Fistula diameter was between 11 and 15mm. Operative time was 211 min, including preliminary cystoscopy, stents placement and SP-access. All patients were discharged on the same day with a bladder catheter, successfully removed between post-operative day 14-18 after negative cystogram. Only in one case a ureteral stent was left because the fistula was closed to the ureteral orifice and we reported one case of UTI twelve days after surgery, treated with outpatient antibiotics. Mean follow-up was 8 months, patients were scheduled for regular follow-up visits and no recurrence was reported. All patients have at least 3 months of post-operative follow-up. CONCLUSIONS: Our experience suggests that SP Transvesical VVF repair may be considered as a safe and feasible minimally invasive treatment for small/medium fistulae (10-15mm).


Sujet(s)
Fistule vésicovaginale , Humains , Femelle , Fistule vésicovaginale/chirurgie , Adulte d'âge moyen , Résultat thérapeutique , Adulte , Interventions chirurgicales robotisées/méthodes , Cystoscopie/méthodes , Reproductibilité des résultats , Durée opératoire
7.
Urology ; 189: 55-63, 2024 Jul.
Article de Anglais | MEDLINE | ID: mdl-38723951

RÉSUMÉ

OBJECTIVE: To explore the safety and feasibility of the Da Vinci single-port (SP) platform in robotic-assisted radical prostatectomy (SP-RARP), aiming to provide a viable option for patients with surgical and medical complexities that might otherwise limit their access to common minimally invasive technique. METHODS: Data from 60 medically and surgically highly complex patients undergoing SP-RARP between December 2018 and December 2023 were analyzed. Variables included patient characteristics, surgical history, intraoperative and postoperative outcomes. Statistical analysis was conducted using Stata 17.0. RESULTS: Fifty-three percent of cases had a hostile abdomen (HA) (≥1 major abdominal surgery), and 47% were medically highly complex (American Society of Anesthesiologists score ≥3, Charlson Comorbidity Index ≥5, and a body mass index ≥30). The extraperitoneal approach was used in 56% of HA cases and 68% of MHC cases. Intraoperative complications occurred in 12%, exclusively with the transperitoneal approach in HA cases. Postoperative complications (Clavien-Dindo ≥3) were 6% and 14%, respectively, with no significant difference between approaches. Same-day discharge was possible in 44% of HA cases and 54% of MHC cases, with significant statistical differences favoring the extraperitoneal approach in both groups. CONCLUSION: SP-RARP, particularly the extraperitoneal approach, is a viable option for highly complex and challenging cases, providing acceptable oncological and functional outcomes. Prospective studies are crucial for further validating the safety and feasibility of SP-RARP in this patient population.


Sujet(s)
Études de faisabilité , Prostatectomie , Tumeurs de la prostate , Interventions chirurgicales robotisées , Humains , Prostatectomie/méthodes , Mâle , Interventions chirurgicales robotisées/méthodes , Interventions chirurgicales robotisées/effets indésirables , Adulte d'âge moyen , Tumeurs de la prostate/chirurgie , Sujet âgé , Complications postopératoires/épidémiologie , Complications postopératoires/étiologie , Études rétrospectives , Complications peropératoires/épidémiologie , Complications peropératoires/étiologie , Résultat thérapeutique
8.
BJU Int ; 2024 Apr 15.
Article de Anglais | MEDLINE | ID: mdl-38622957

RÉSUMÉ

OBJECTIVE: To perform a systematic review and meta-analysis of trials comparing trimodal therapy (TMT) and radical cystectomy (RC), evaluating differences in terms of oncological outcomes, quality of life, and costs. MATERIALS AND METHODS: In July 2023, a literature search of multiple databases was conducted to identify studies analysing patients with cT2-4 N any M0 muscle-invasive bladder cancer (MIBC; Patients) receiving TMT (Intervention) compared to RC (Comparison), to evaluate survival outcomes, recurrence rates, costs, and quality of life (Outcomes). The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS) and metastasis-free survival (MFS). Hazard ratios (HRs) were used to analyse survival outcomes according to different treatment modalities and odds ratios were used to evaluate the likelihood of receiving each type of treatment according to T stage. RESULTS: No significant difference in terms of OS was observed between RC and TMT (HR 1.07, 95% confidence interval [CI] 0.81-1.4; P = 0.6), even when analysing radiation therapy regimens ≥60 Gy (HR 1.02, 95% CI 0.69-1.52; P = 0.9). No significant difference was observed in CSS (HR 1.12, 95% CI 0.79-1.57, P = 0.5) or MFS (HR 0.88, 95% CI 0.66-1.16; P = 0.3). The mean cost of TMT was significantly higher than that of RC ($289 142 vs $148 757; P < 0.001), with greater effectiveness in terms of cost per quality-adjusted life-year. TMT ensured significantly higher general quality-of-life scores. CONCLUSION: Trimodal therapy appeared to yield comparable oncological outcomes to RC concerning OS, CSS and MFS, while providing superior patient quality of life and cost effectiveness.

9.
Eur Urol Open Sci ; 63: 104-112, 2024 May.
Article de Anglais | MEDLINE | ID: mdl-38591096

RÉSUMÉ

Background and objective: The Hugo RAS and DaVinci Xi systems are used for performing robot-assisted radical prostatectomy (RARP). This study aims to compare these two platforms providing granular and comprehensive data on their intraoperative performance. Methods: The Comparison of Outcomes of Multiple Platforms for Assisted Robotic surgery-Prostate (COMPAR-P) trial is a prospective post-market study (clinicaltrials.org NCT05766163). Enrollment began in March 2023, allocating patients to DaVinci or Hugo RAS for RARP, without selection criteria, for up to 50 consecutive cases. Two experienced console surgeons performed the procedures, following the same technique. Evaluation focused on timing, learning curves, malfunctioning events, complications, and users' satisfaction, using standard statistical methods, including the cumulative summation analysis (CUSUM) for the learning curve assessment. Key findings and limitations: Fifty patients each were enrolled for DaVinci (DV-RARP) and Hugo RAS (H-RARP) RARP. Baseline features were balanced. DV-RARP showed significantly shorter "setup" and "console" phase durations than H-RARP (37 vs 55 min and 97 vs 126 min, respectively, p < 0.001). A longitudinal timing analysis revealed DV-RARP's flat line, while H-RARP showed a modest decline with breakpoints at 22 and 17 procedures by CUSUM for the setup and console phases. The numbers of malfunctioning events were 4 (DV-RARP) and 20 (H-RARP). DV-RARP had high user satisfaction, while the user satisfaction of H-RARP varied. The comparison was between the first 50 H-RARP and the last 50 DV-RARP cases performed at our institution. This likely accounts for the observed differences in setup and console times between the cohorts. The specialized expertise of the surgeons involved could limit the generalizability of our findings. Conclusions and clinical implications: This prospective study compared unselected patients who underwent DV-RARP and H-RARP. More malfunctioning events occurred in case of Hugo RAS, but surgical outcomes were similar. Longer operative times for Hugo RAS were attributed to meticulous care with the novel platform. Improvement potential was evident within a few procedures, providing valuable insights for adopting this new platform. Patient summary: This study compared two advanced robotic systems, DaVinci and Hugo RAS, used to remove the prostate in patients diagnosed with prostate cancer. While both systems showed similar surgical outcomes, the newer Hugo RAS system required more meticulous movements, leading to slightly longer operation times. The findings suggest that, with further experience, both systems can provide effective treatment options for patients undergoing prostate surgery.

10.
J Endourol ; 38(7): 668-674, 2024 Jul.
Article de Anglais | MEDLINE | ID: mdl-38613809

RÉSUMÉ

Purpose: This study aimed to assess early outcomes of the single port (SP) robotic low anterior access (LAA) for all upper urinary tract surgeries. In addition, it aimed to explore the impact of clinical factors, notably Body Mass Index (BMI), on post-operative outcomes and length of hospital stay. Materials and Methods: Overall, 76 consecutive patients underwent SP robotic surgery with LAA involving all upper urinary tract pathologies, with data collected prospectively. Baseline characteristics, intra- and post-operative outcomes, pain levels, and opioid use were analyzed. Statistical methods, including logistic regression and locally weighted scatterplot smoothing analysis, were used to assess same-day discharge (SDD) predictors and the association between BMI and SDD probability. According to the Institutional Review Board (IRB) protocol, only data recorded in our electronic medical record system was included. Results: Ten different procedures were performed with LAA, with no need for conversion to open surgery and complication rates in line with the literature (30 days: 5%, 90 days: 6.6%). Notably, 77.6% of patients were discharged on the same day. A significant association was found between BMI and prolonged hospital stay, particularly in obese patients (BMI ≥30 kg/m2). Post-operative pain was generally low (median VAS: 4), with over 70% discharged without opioid prescriptions. Conclusions: The novel LAA is a versatile approach for various upper urinary tract surgeries, including in obese patients. While achieving satisfactory post-operative outcomes, increased BMI correlated with a reduced likelihood of SDD. Further studies, including larger cohorts and multicenter collaborations, are warranted to explore anesthesiologic management and validate these findings.


Sujet(s)
Interventions chirurgicales robotisées , Humains , Mâle , Femelle , Adulte d'âge moyen , Interventions chirurgicales robotisées/méthodes , Résultat thérapeutique , Sujet âgé , Espace rétropéritonéal/chirurgie , Durée du séjour , Adulte , Indice de masse corporelle , Procédures de chirurgie urologique/méthodes , Douleur postopératoire/étiologie , Sujet âgé de 80 ans ou plus
11.
Minerva Urol Nephrol ; 76(2): 235-240, 2024 Apr.
Article de Anglais | MEDLINE | ID: mdl-38270908

RÉSUMÉ

Herein we report our first experience with Hugo RAS™ proposing a mirrored approach with different angles. Two experienced surgeons performed 10 prostatectomies (six with the standard approach and four with the mirrored one). The median docking time was 12.5 (IQR 12-15) vs. 13.5 (IQR 12-20) minutes. The median console time was 229 (174-245) vs. 172 (IQR 164-191) minutes. None of the procedures required conversion to open surgery. The study proves the versatility of the Hugo RAS™ to perform robot-assisted radical prostatectomy with two different docking angles and might be useful for novel users to adopt the preferred approach.


Sujet(s)
Prostatectomie , Tumeurs de la prostate , Interventions chirurgicales robotisées , Prostatectomie/méthodes , Humains , Mâle , Interventions chirurgicales robotisées/méthodes , Tumeurs de la prostate/chirurgie , Adulte d'âge moyen , Sujet âgé , Durée opératoire
13.
Clin Genitourin Cancer ; 21(6): e495-e501.e2, 2023 12.
Article de Anglais | MEDLINE | ID: mdl-37365053

RÉSUMÉ

INTRODUCTION: We tested the association between functional impairment in activities of daily living (ADL) assessed through the Barthel Index (BI), and oncological outcomes following radical cystectomy (RC) for bladder cancer (BCa). PATIENTS AND METHODS: We retrospectively analyzed data of 262 clinically nonmetastatic BCa patients, who underwent RC between 2015 and 2022, with available follow-up. According to preoperative BI, patients were divided in 2 groups: BI ≤90 (moderate/severe/total dependency in ADL) versus BI 95 to 100 (slight dependency/independency in ADL). Kaplan-Meier plots compared disease recurrence (DR)-, cancer-specific mortality (CSM)-, and overall mortality (OM)-free survival according to established categories. Multivariable Cox regression models tested the BI as an independent predictor of oncological outcomes. RESULTS: According to the BI, the patient cohort was distributed as follows: 19% (n = 50) BI ≤90 versus 81% (n = 212) BI 95-100. Compared to patients with BI 95 to 100, patients with BI ≤90 were less likely to receive intravesical immuno- or chemotherapy (18% vs. 34%, p = .028), and more frequently underwent less complex urinary diversion as ureterocutaneostomy (36% vs. 9%, p < .001), or harbored muscle-invasive BCa at final pathology (72% vs. 56%, p = .043). In multivariable Cox regression models adjusted for age, ASA physical status score, pathological T and N stage, and surgical margins status, BI ≤90 independently predicted higher DR (HR [hazard ratio]:2.00, 95%CI [confidence interval]:1.21-3.30, p = .007), CSM (HR:2.70, 95%CI:1.48-4.90, p = .001), and OM (HR:2.09, 95%CI:1.28-3.43, p = .003). CONCLUSION: Preoperative impairment in ADL was associated with adverse oncological outcomes following RC for BCa. The integration of the BI into clinical practice may improve the risk assessment of BCa patients candidates to RC.


Sujet(s)
Cystectomie , Tumeurs de la vessie urinaire , Humains , Activités de la vie quotidienne , Études rétrospectives , Récidive tumorale locale/anatomopathologie , Tumeurs de la vessie urinaire/anatomopathologie
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