Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes

ABSTRACT Objectives The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). Materials and methods From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. Results All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). Conclusions The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes.

OBJECTIVES: The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). MATERIALS AND METHODS: From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. RESULTS: All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). CONCLUSIONS: The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Size of bladder cancers: correlation among different types of measurement.

OBJECTIVE: It was the aim of this study to evaluate the accuracy of the measurement of tumor size comparing the objective size with that measured by preoperative cystoscopy, by preoperative ultrasound (US) and with the diameter described by the operator before the transurethral resection. PATIENTS AND METHODS: This study included 100 patients with bladder papillary endoscopic features of single or multiple neoplasms who were candidates for transurethral resection. The sizes of the same neoplasms measured during preoperative cystoscopy, preoperative US and described by the operator before the transurethral resection were evaluated. A statistical analysis of the errors of measurement was performed if compared with an objective measurement done with an ureteral catheter. RESULTS: The statistical analysis of the data shows that there are no substantial differences between the objective and subjective measurement, and therefore, the measurements reported by individual operators are reliable. On the contrary, the diameters given by preoperative cystoscopy and US differ significantly from the objective measurement. CONCLUSIONS: This study shows that the most reliable measurement is the subjective measurement made directly by the urologist in the operating room.

Mitomycin C for the treatment of bladder cancer.

Bladder cancer is a heterogeneous disease: approximately 75% of its forms are non muscle invasive neoplasms. Standard treatment for non muscle invasive bladder cancer (NMIBC) consists of complete transurethral resection (TURB) of all visible lesions. Recurrence rates following TURB and intravesical chemoprophylaxis seem to decrease to 25-50% in 2 years of follow-up. The aim of the present paper is to review findings from the most relevant studies and evaluate the potentials of mitomycin C (MMC) in the treatment of non muscle invasive bladder cancer. Studies were identified by searching MEDLINE(R) and Pubmed(R) databases up to 2010 using both medical subject heading (Mesh) and a free text strategy with the name of known individual chemotherapeutic drug and the following key words: "non muscle-invasive bladder cancer", "intravesical therapy", "Mitomycin C", "Device Therapy". At the end of our research in literature we selected 66 articles. From literature is clear that in case of low or intermediate risk superficial bladder cancer, MMC is one of the most used agents with limited side effects. In fact MMC has a high molecular weight and is relatively hydrophobic, resulting in less sistemic absorption. Regimens are based on weekly instillations but despite many studies there is not universal consensus on timing and duration of therapy. MMC early istillation seems effective in preventing tumour recurrence in low risk non muscle invasive neoplasms. MMC maintenance chemotherapy continue to be considered effective in reducing tumour recurrence rate in low and intermediate risk tumours. It is known in literature that the lack of response to intravesical chemotherapy in patients with non muscle invasive bladder cancer is due to two factors: lack of sensitivity of the neoplasm to intravesical chemotherapy and inadequate drug delivery to the tumour. In order to resolve these limitations in the last years MMC, in many centers, is used with device assisted therapies or with new administration scheme.

Bayesian analysis of selection for greater weaning weight while maintaining birth weight in beef cattle.

An experimental Hereford herd established in 1960 was used from 1986 to 2006 to select for increased weaning weight (W) without increasing birth weight (B). Data were B and W collected over the 47 yr from 2,124 calves. Including ancestors, the pedigree file had 2,369 animals. Selection was practiced only in males. In the first stage (1986 to 1993), mass-selected bulls were chosen with the index I = B + 9374.76 RDG (relative daily gain). From 1994 to 2006, the selection criterion for bull i was I(i) = BLUP(i)(WD) - 2.33 BLUP(i)(BD), where the BLUP were for the direct BV of B (BD) and W (WD), respectively. Predictions were obtained from a 2-trait animal model with B having only BD, and W with WD and WM (maternal additive effects). Selection response was estimated using a Bayesian approach by means of the Gibbs sampler for a 2-trait animal model including BD, BM (maternal BV for B), WD, and WM. Estimated heritabilities for BD, BM, WD, and WM were 0.40, 0.23, 0.05, and 0.23, respectively. The correlation between BD and BM was close to zero (0.01), and between WD and WM was positive (0.37). The correlation between BD and WD was 0.07, and between BM and WM was 0.58. The 2 methods used to estimate selection response gave similar results. In both periods BD decreased, whereas BM increased. The reduction of BD due to selection was slightly larger in the second period than in the first one. The regression of BV for W increased due to selection in both stages, but selection response was 21.6% larger from 1986 to 1992 than from 1993 to 2006. The maternal effect, WM increased more than 3 times compared with WD in the first period, but ended up being almost the same value as WD in period 2. The Bulmer effect was manifested by the decrease in magnitude of all (co)variance components during selection. It is concluded that selection to increase BW at weaning in beef cattle, although not increasing BW at birth, was moderately effective.

[Integrated treatment with hyperthermia and chemotherapy for non-muscle invasive bladder cancer].

Oncology-applied hyperthermia is a very old form of therapy. In recent years hyperthermia has been investigated with the aim of improving the treatment for non-muscle invasive bladder cancer to prevent relapse and disease progression, in association with mitomycin-C, a well-known chemotherapeutic agent, to enhance its effect. Target patients are those with non-muscle invasive transitional cell carcinoma, showing medium (Ta-T1, G1-2, multifocal, diameter >3 cm) or high (T1, G3, multifocal or rapidly relapsing, CIS) risk for recurrence or progression. The treatment may be prophylactic following tumor eradication, or ablative when tumor cannot be otherwise eradicated. Several studies have shown the benefits of thermochemotherapy with lower risk for relapse than other treatment options, and 66-80% complete responses following ablative treatment. This association of treatments has a synergic therapeutic effect, higher than administering hyperthermia and drug therapy as single treatment.

[Methodology of clinical trials for non-muscle infiltrating bladder cancer. Objective evaluation: standardization requirements].

The formulation of proper evaluation criteria after superficial bladder cancer therapy poses several methodological problems that are often peculiar to the disease. The Achilles' heel of many trials is possibly found in the criteria used for the evaluation of the trial outcomes. As a consequence of that, total agreement regarding the criteria for response and the evaluation of response is needed. The adoption of standard response criteria should be given high priority. Uniform response criteria should be chosen because they meet standards of reliability and statistical validity. Thus, the criteria must be reproducible, and they should correlate with some measures of patient's benefit, such as quantity and quality of survival. A proposal of standardization in superficial bladder cancer clinical trials is presented based upon current knowledge on the methodology for conducting clinical trials and upon the experience coming from major clinical research groups.

Bladder tumor markers: a review of the literature.

Bladder cancer is among the top eight most frequent cancers. Its natural history is related to a combination of factors that impact on its aggressiveness. Cystoscopy and urine cytology are the currently used techniques for the diagnosis and surveillance of non-invasive bladder tumors. The sensitivity of urine cytology for diagnosis is not high, particularly in low-grade tumors. The combination of voided urine cytology and new diagnostic urine tests would be ideal for the diagnosis and follow-up of bladder cancer. However, in order to have some clinical utility, new diagnostic and/or prognostic markers should achieve better predictive capacity that the currently used diagnostic tools. None of the markers evaluated over the last years showed remarkable sensitivity or specificity for the identification of any of the diverse types of bladder cancer in clinical practice. The limitations of the known prognostic markers have led to the research of new molecular markers for early detection of bladder cancer. This research focused in particular on the discovery of biomarkers capable of reducing the need for periodic cystoscopies or, ideally, offering a non-invasive examination instead. In this review, we will examine various new markers of bladder cancer and their value in the diagnosis and follow-up of non-muscleinvasive bladder cancer. When compared with urine cytology, which showed the highest specificity, most of these markers demonstrated an increased sensitivity.

On identifiability of (co)variance components in animal models with competition effects.

There is an increased interest in estimating the (co)variance components of additive animal models with direct and competition effects (AMC). However, some attempts to estimate the dispersion parameters in different animal species faced problems of convergence or inaccurate estimates when pen effects entered the model. We argue that the problem relates to lack of identifiability of the (co)variance components in some AMC. The check for identifiability of the dispersion parameters in mixed models with linear (co)variance structure requires that all the eigenvalues of the restricted maximum likelyhood information matrix (I(theta)) be positive. We show, by way of simple numerical examples, that the singularity of I(theta) is due to confounding between fixed pen effects and the additive competition effects (SBVs). It is also observed that setting pen effects as random does not always remedy the collinearity with SBVs. An alternative AMC is presented in which the incidence matrix of the SBVs can be written as a function of the 'intensity of competition' (IC) among animals in the same pen. Examples are presented in which the ICs are related to time. The distribution of families of full and half sibs across pens also plays a role in the identifiability and asymptotic variances of the (co)variance components.

[Innovations in superficial bladder cancer treatments].

Bladder cancer treatment is a challenge for both urologists and oncologists. Particularly during these last years many changes have been made in the management of superficial bladder cancer. In the case of superficial bladder cancer, intravesical instillation of chemo/immunotherapeutic agents after transurethral resection is the standard. The treatment goals include: complete removal of the initial tumor, prevention of recurrences and inhibition of disease progression. This work aims at reviewing the new developments in the therapeutic field of superficial bladder cancer. A growing trend involves the use of multimodality treatment to obtain the activation of the host immunity against the tumor, and to enhance the cytotoxic effects of chemotherapeutic agents. The new therapeutic modalities, which are under preclinical and clinical investigations, are showing promising results.

The 70-kDa heat-shock protein is a major antigenic determinant in human Trypanosoma cruzi/Leishmania braziliensis braziliensis mixed infection.

Five sera from Bolivian individuals chronically infected by Trypanosoma cruzi, and suffering an active Leishmania braziliensis braziliensis metastatic mucocutaneous lesion were characterized. They reacted with the T. cruzi recombinant antigens that are currently used as Chagas diagnostic reagents, and with several L. b. braziliensis proteins as assessed by Western blot. These sera showed an intense reaction with a T. cruzi and an L. b. braziliensis polypeptide of about 70 kDa. Expression cloning techniques demonstrated that the target of this immunologic reaction was a cross-reactive antigen, the 70-kDa heat-shock protein (HSP 70). High levels of anti-HSP 70 reactivity and positive reactions with all or some of the T. cruzi recombinant antigens JL7, JL8, and JL5, defined a serologic pattern that was characteristic of the T. cruzi/L. b. braziliensis mixed infection.