Nefrectomía parcial laparoscópica off-clamp tras la embolización del tumor en sala híbrida frente a nefrectomía parcial convencional: un análisis de pares emparejados por puntuación de propensión / Off-clamp laparoscopic partial nephrectomy in a hybrid room after tumor embolization versus conventional partial nephrectomy: A propensity score matched pair analysis

Objetivo: La nefrectomía parcial laparoscópica off-clamp tras la embolización arterial superselectiva (NPLh) en un quirófano híbrido es un abordaje mínimamente invasivo prometedor. En este estudio comparamos los resultados quirúrgicos perioperatorios de esta técnica innovadora con los de la técnica estándar de nefrectomía parcial laparoscópica convencional (NPLc).Pacientes y métodos: En total se incluyeron 86 y 127 pacientes tratados con NPLh y NPLc, respectivamente. Las dos técnicas se compararon en términos de complicaciones quirúrgicas, pérdida de sangre estimada (PSE), tiempo quirúrgico, duración de la estancia hospitalaria (DEH), márgenes quirúrgicos y tasa de consecución de la Trifecta (definida como duración de isquemia caliente <25min, márgenes quirúrgicos negativos y ausencia de complicaciones). Se utilizó una puntuación de propensión basada en la edad, el sexo, el índice de masa corporal (IMC), la tasa de filtración glomerular estimada (TFGe) preoperatoria y el tamaño tumoral para un emparejamiento 1:1 de los pacientes de cada grupo. Tras el emparejamiento, se obtuvieron dos grupos de 67 pacientes con características similares.Resultados: La tasa de conversión a cirugía abierta, las complicaciones y la PSE fueron similares entre ambos grupos. Por el contrario, el tiempo quirúrgico, la DEH y las tasas de Trifecta favorecieron la NPLh. El análisis multivariante demostró que la NPLh tenía un 70% más de probabilidades de lograr la Trifecta que la NPLc en todos los grupos de edad y para cualquier tamaño tumoral en toda la población del estudio.Conclusión: En comparación con el abordaje convencional, la nefrectomía parcial laparoscópica sin clampado después de la embolización arterial superselectiva en una sala híbrida mostró resultados quirúrgicos satisfactorios inmediatos y alcanzó una mayor tasa de consecución de la Trifecta. Se necesitan resultados funcionales y oncológicos a medio y a largo plazo para establecer esta

Objective: Off-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique.Patients and methods: Overall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration <25min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, two groups of 67 patients with similar characteristics were obtained.Results: Conversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population.Conclusion: Compared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative (AU)

Off-clamp laparoscopic partial nephrectomy in a hybrid room after tumor embolization versus conventional partial nephrectomy: A propensity score matched pair analysis.

OBJECTIVE: Off-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique. PATIENTS AND METHODS: Overall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration <25 min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, 2 groups of 67 patients with similar characteristics were obtained. RESULTS: Conversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population. CONCLUSION: Compared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative.

European temporal trends in the use of lymph node dissection in patients with renal cancer.

BACKGROUND: The role of lymph node dissection (LND) in renal cell carcinoma (RCC) is still under debate. We aimed to assess the utilization rates of LND over time in Europe. METHODS: A multi-institutional database of 13,581 RCC patients who underwent radical nephrectomy (RN) or nephron sparing surgery (NSS) between 1988 and 2014 was created within an European consortium. We analysed temporal trends in the frequency of LND by using Joinpoint regression. Logistic regression models were used to identify predictors of LND. RESULTS: Overall, 5114 patients (42.7%) underwent LND. Lymph node invasion was recorded in 566 cases (11% of LND patients) which represents 4.7% of the whole study cohort. A gradual decline in the use of LND started in the 1990s. After 2008 LND decreased significantly by 21.5% per year (95%CI -33.3 to -7.5, p < 0.01) until 2011 and stabilized thereafter (Annual Percentage Change 4.9%, 95%CI -3.4 to 13.8, p = 0.2). At multivariable analyses, patient age (OR 0.98, p < 0.0001), type of surgery (RN vs. NSS: OR 5.46, p < 0.0001), surgical approach (open vs. minimally invasive: OR 1.75, p < 0.0001), T stage (T2 vs. T1: OR 1.57; T3-4 vs. T1: OR 1.44, p < 0.0001), clinical tumour size (OR 1.14, p < 0.0001), and year of surgery (OR 0.95, p < 0.0001) were associated with higher probability of LND at nephrectomy. CONCLUSIONS: A trend towards lower LND was observed over time for RCC patients who underwent RN or NSS. LND is more frequently performed in younger patients, locally advanced diseases and in case of open surgery.

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.

Long-term survival of patients aged 80 years or older treated with radical prostatectomy for prostate cancer.

BACKGROUND: Radical prostatectomy (RP) is the gold standard for clinically localized prostate cancer (PCa) patients with life expectancy (LE) of at least 10 years. We examined long-term survival of men aged 80 years or older treated with RP and we attempted to identify criteria based on age and comorbidities that could predict survival of at least 10 years after RP, to identify those that might be considered for RP. PATIENTS AND METHODS: In Surveillance Epidemiology and End Results (SEER)-Medicare-linked database, we identified 234 octo- and nonagenarians with clinical T1, T2 or T3 PCa treated with RP between 1991 and 2009. Kaplan-Meier analyses examined 10-year survival patterns. Multivariable Cox regression analyses focused on the combined effect of age and/or Charlson Comorbidity Index (CCI) after adjusting for different confounders. RESULTS: The 10-year overall survival (OS) and cancer specific mortality (CSM) rates in the overall population were 51 and 9.9%. In individuals aged 80-81 years old, the 10-year OS was 62.4 vs. 39.6% in older patients (p = 0.001). Moreover, combination of age 80-81 with CCI = 0 yielded 10-year OS of 67.9 vs. 28.5% in older and sicker patients (p < 0.001). Age 80-81, absence of comorbidities and the combination of age 80-81 with CCI = 0, represented independent predictors of lower overall mortality (all p ≤ 0.01). CONCLUSIONS: Two out of three individuals selected for RP aged 80-81 years and without comorbidities, fulfill the criterion of LE of 10 years or more. Therefore, elderly PCa individuals can be suitable for surgical management, if appropriately selected, based on LE criterion.

Sexual functioning mirrors overall men's health status, even irrespective of cardiovascular risk factors.

Erectile dysfunction has been described as a sentinel marker of co-existing and undetected cardiovascular disease. Beside cardiovascular diseases, a correlation between erectile dysfunction and other major comorbidities has been also reported. The study was aimed to analyze the association between sexual functioning and overall men's health in sexually active, Caucasian-European men with new-onset sexual dysfunction. Data from the last 881 consecutive patients seeking first medical help for sexual dysfunction were cross-sectionally analyzed. The International Classification of Diseases, 9th revision, Clinical Modification was used to classify health-significant comorbidities, which were scored with the Charlson Comorbidity Index (CCI). A modified CCI score from which all potential cardiovascular risk factors (CCI-CV) were subtracted was then calculated for every patient. Patients were requested to complete the International Index of Erectile Function (IIEF). The main outcome of the study was the association between the IIEF domain scores and CCI, which scored health-significant comorbidities even irrespective of cardiovascular risk factors (CCI-CV). The final sample included 757 patients (85.9%) (Median age: 48 years; IQ range: 37-59). Overall, erectile dysfunction was found in 540 (71.4%) patients. Of these, 164 (21.6%) had a CCI ≥ 1 and 138 (18.2%) had a CCI-CV ≥ 1, respectively. At the analysis of variance, IIEF-Erectile Function (EF) scores significantly decreased as a function of incremental CCI and CCI-CV scores (all p < 0.01). At multivariable logistic regression analysis, both IIEF-EF and IIEF-total score achieved independent predictor status for either CCI ≥ 1 or CCI-CV ≥ 1, after accounting for potential confounders (p < 0.01). We report novel findings of a significant association between erectile dysfunction severity and overall men's health, even irrespective of cardiovascular risk factors. Thereof, erectile dysfunction severity could serve as a proxy for general men's health, thus encouraging physicians to comprehensively assess patients complaining of sexual dysfunction in the real-life everyday clinical practice.

Mortality, morbidity and healthcare expenditures after local tumour ablation or partial nephrectomy for T1A kidney cancer.

BACKGROUND: Local tumour ablation (LTA) may yield better perioperative outcomes than partial nephrectomy (PN), however the impact of each treatment on perioperative mortality and health care expenditures is unknown. The aim of the study was to compare mortality, morbidity and health care expenditures between LTA and PN. PATIENTS AND METHODS: A population-based assessment of 2471 patients with cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009, in the SEER-Medicare database was performed. After propensity score matching, 30-day mortality, overall and specific complication rates, length of stay, readmission rates and health care expenditures according to LTA or PN were estimated. Multivariable logistic and linear models addressed the effect of each specific LTA approach on overall complication rates, length of stay, readmission rates and health care expenditures. RESULTS: The 30-day mortality was <2% after either LTA or PN (OR 2.27, p = 0.2). The overall complication rate was 21% after LTA and 40% after PN (OR 0.38, p < 0.001). Blood transfusions, infection/sepsis, wound infections, respiratory complications, gastrointestinal complications, acute kidney injury, and accidental puncture or laceration/foreign body left during procedure rates resulted lower after LTA relative to PN (all p < 0.05). Similarly, length of stay and health care expenditures resulted lower after LTA relative to PN (all p < 0.05). Conversely, readmission rate was not significantly different in LTA relative to PN (p = 0.1). CONCLUSIONS: Despite similar perioperative mortality, LTA is associated with lower complications rate, shorter length of stay and lower health care expenditure relative to PN.

Long-term sexual outcomes after holmium laser enucleation of the prostate: which patients could benefit the most?

Assess rate and predictors of erectile function (EF) outcomes at long-term follow-up (FU) after holmium laser enucleation of the prostate (HoLEP). Cross-sectional analyses were performed on 135 patients with a mean FU of 12 years post HoLEP. Patients completed both a baseline and a FU International Index of Erectile Function (IIEF)-EF domain and the International Prostatic Symptoms Score (IPSS). Postoperative EF outcomes, including rate and predictors of EF improvement considering minimal clinically important differences (MCIDs) criteria, were assessed. Logistic regression models tested the association between predictors and EF. At a mean (median) FU of 152.1 (163) months, patients showed a significant decrease in the IIEF-EF score P<0.01) and significant IPSS improvement (P<0.01). Overall, 50 (37%) patients worsened by at least one IIEF-EF category. Conversel, 23 (17%) patients reported an improvement in postoperative IIEF-EF score; 75 (55.6%) and 10 (7.4%) patients maintained and eventually improved their IIEF-EF category, respectively. Patients reporting a decrease in the postoperative IIEF-EF score were significantly older (P=0.03) and showed a significantly longer mean FU (P<0.01) than those reporting postoperative improvements of IIEF-EF. Nine (6.7%) patients showed significant EF improvement according to MCIDs criteria. Both higher IPSS scores (odds ratio (OR): 1.12; P=0.02) and lower IIEF-EF (OR: 0.88; P<0.01) at baseline, emerged as independent predictors of postoperative EF improvement. HoLEP was associated with a decrease in EF and a persistent amelioration of BPH-related urinary symptoms at long-term FU. Almost one third of patients worsened by at least one IIEF-EF category. However, a clinically meaningful EF improvement was observed in roughly 7% of the individuals. Patients with more severe preoperative urinary symptoms and ED benefited more from HoLEP in terms of EF.

Can side-specific biopsy findings predict the side of nodal metastasis in clinically localized prostate cancer? Results from a multicenter prospective survey.

BACKGROUND: To evaluate the correlation between the side of positive biopsy (Bx) and the risk of lymph-node metastases (LNMs) on each side and to quantify the risk of contralateral LNMs in patients with unilateral positive biopsy. METHODS: We analyzed the outcomes of 1599 patients with complete data regarding the sides of positive Bx and LN (lymph-node). By dividing each prostate into two separate sides, we assessed the accuracy of the side-specific Bx details in determining the side of positive nodes; the area under the receiver-operating characteristic (ROC) (AUCs) was used. For patients with unilateral positive Bx, we assessed the risk of homolateral and contralateral LNMs according to the number of total Bx taken and the preoperative risk of LN invasion. RESULTS: Considering the 3198 prostate sides, there was a strict correlation between the side of positive Bx and the side of LNMs. The ratio of positive/total Bx was more informative than the number of positive core. The AUC for ipsilateral LNMs was significantly higher than that for contralateral LNMs (P = 0.039). In the 805 patients with unilateral positive Bx, the percentage of contralateral LNMs was >30% even considering a more meticulous biopsy scheme and increased in the patients at a higher clinical risk for LN invasion. CONCLUSION: PCa preferentially metastasizes to ipsilateral LNs but >30% of contralateral LNMs are present. A unilateral LN dissection that is limited to the tumor-bearing side of the gland should not be recommended because of the substantial risk of missing contralateral metastases.

Silodosin in the management of lower urinary tract symptoms as a result of benign prostatic hyperplasia: who are the best candidates.

BACKGROUND: As the clinical effects of the available α1-adrenoceptors (ARs) blockers are usually considered comparable for treatment in patients suffering from lower urinary tract symptoms (LUTS) secondary to prostatic enlargement, officially recognised guidelines do not make specific recommendations regarding the choice of which agent should be considered according to the patient's characteristics. AIM: To analyse data supporting the use of silodosin, a highly selective once-daily dosing α1-ARs blocker, in different daily clinical practice scenarios. MATERIALS AND METHODS: A structured literature review was performed using data retrieved from articles assessing the role of silodosin in the management of LUTS secondary to benign prostatic hyperplasia (BPH). A literature search of English language publications was performed using MEDLINE(®) and Web of Science from 2000 to 2012 using the terms LUTS; BPH; silodosin; α1-ARs blockers. The papers with the highest level of evidence were identified and represent the basis of the present review. RESULTS: Available data coming from basic research analyses, randomised trials and prospective studies showed that silodosin is efficacious for the initial management of patients with LUTS. Clinical developmental safety data from patients receiving silodosin with concomitant antihypertensive therapy do not indicate an increase in risk of orthostatic hypotension. In this context, a recent study demonstrated that silodosin can be safely administered to patients who are consensually assuming phosphodiesterase type 5 inhibitors. A recent randomised crossover study comparing the efficacy of silodosin and tamsulosin in patients with LUTS showed that further significant improvement was observed after switching to silodosin treatment, while worsening or little improvement was observed after switching to tamsulosin treatment. Preliminary results seem to demonstrate a potential role of silodosin in the treatment of chronic prostatitis/chronic pelvic pain syndrome and to facilitate ureteral stone passage, as well. DISCUSSION: When considering the above cited pharmacological and clinical characteristics of the drug, silodosin can be considered in the following clinical scenario: patients suffering from moderate-severe nocturia, patients with low normal blood pressure levels and patients concomitantly treated with antihypertensive medications, patients concomitantly treated with phosphodiesterase type 5 inhibitors, patients not satisfied (for efficacy or tolerability) with previous treatment with other α1-ARs blockers. CONCLUSION: Silodosin is efficacious for the initial management of patients with LUTS. Silodosin has a good cardiovascular safety profile and can be considered an option in patients with cardiovascular co-morbidities. It seems to be especially beneficial in patients with nocturia alone or presenting with the symptomatic trial nocturia-frequency-incomplete emptying. Patients on phosphodiesterase type 5 inhibitors treatment can be safely managed with silodosin.

Does diabetes mellitus increase the risk of high-grade prostate cancer in patients undergoing radical prostatectomy?

The objective was to test the hypothesis that in patients with prostate cancer undergoing radical prostatectomy (RP), diabetic patients are at a higher risk of harboring a high-grade tumor than non-diabetic patients. We examined 2060 consecutive men who underwent RP between 2001 and 2009. Of them, 7.1% had type 2 diabetes mellitus (DM). A high-grade tumor was defined as having a Gleason score ≥ 8. Univariable and multivariable logistic regression analyses were used to test the relationship between type 2 DM and high-grade tumor. Mean patient age was 64 years (range: 45-85). Mean total PSA level was 9 ng ml(-1) (range: 1-89.5). A significantly higher percentage of diabetic patients had high-grade tumor on biopsy (16.3 vs 7.6%; P = 0.001) and on RP specimen (21.1 vs 11.7%; P = 0.001) in comparison with non-diabetic patients. In multivariable analyses, DM was an independent predictor of high-grade tumor on biopsy (odds ratio = 2.31, P = 0.001) and on final pathological specimen (odds ratio = 2.22, P = 0.002). In patients undergoing RP, those with type 2 DM had a higher risk of harboring a poorly differentiated tumor on final pathological examination.

The use of partial nephrectomy in European tertiary care centers.

PURPOSE: The objective was to define the trends of PN use over time at six tertiary care European centers. METHODS: Data were retrieved from institutional databases for patients treated with either PN or radical nephrectomy (RN) for stages T(1-2)N(0)M(0) renal cell carcinoma (RCC) between 1987 and 2007. For purpose of temporal trend analyses patients were divided into five equally sized groups according to the date of surgery. Categorical and multivariable logistic regression analyses assessed predictors of PN use. RESULTS: Overall 597 (31.7%) patients were treated with PN. Overall, a 4.5-fold increase of PN was recorded. The absolute increases were 41.7-86.3%, 14.9-69.3% and 8.1-35.3% for lesions < or = 2 cm, 2.1-4 cm and 4.1-7 cm (chi-square trend test p<0.001), respectively. In multivariable logistic regression models, decreasing tumor size, younger age, more contemporary date of surgery, male gender and institutional PN rate represented independent predictors of the individual probability of treatment with PN. Lack of data from community hospitals limits the generalizability of our findings. CONCLUSION: Based on data from six tertiary care centers, the contemporary rate of PN ranges from 86 to 35% for renal masses < or = 2 cm to 4.1-7 cm and is indicative of excellent quality of care.

Partin Tables cannot accurately predict the pathological stage at radical prostatectomy.

PURPOSE: The Partin Tables represent the most commonly used staging tool for radical prostatectomy (RP) candidates. The Partin Tables' predictions are used to guide the type (nerve preserving RP) and/or the extent (RP with wide resection) of RP. We examined the ability of the Partin Tables' predictions incorrectly assigning the stage at RP. METHODS: The testing of the Partin Tables (external validation) was based on 3105 patients treated with RP at a single European institution. Standard validation metrics were used (area under the receiver operating characteristics curve, AUC) to test the three endpoints predicted by the Partin Tables, namely the presence of extracapsular extension (ECE), seminal vesicle invasion (SVI), and lymph node invasion (LNI). RESULTS: Ideal predictions are denoted with 100% accuracy vs. 50% for entirely random predictions. For the 2001 version of the Tables the accuracy defined by the AUC was 79.7, 77.8, and 73.0 for ECE, SVI, and LNI, respectively. For the 2007 version of the Tables the corresponding accuracy estimates were 79.8, 80.5, and 76.2. The relationship between predicted probabilities and observed rates was poor. CONCLUSION: The Partin Tables are meant to guide clinicians about the safety of nerve bundle preservation at RP, about the need for seminal vesicle resection or for lymphadenectomy. Therefore, the use of the Partin Tables predictions may significantly affect the type and/or the extent of RP. In their present format the Partin Tables are not accurate enough to influence the pre-operative decision making regarding the type or extent of RP.