Novel robot-assisted laparoscopic total extra-peritoneal repair with primary fascial closure plus pre-peritonea mesh for large groin defects.

BACKGROUND: Since the introduction of robot-assisted laparoscopic surgery, a variety of conventional laparoscopic procedures have been explored via this approach. In the robotic era, most of the reported robot-assisted laparoscopic hernia repairs were performed with the trans-abdominal pre-peritoneal approach. According to the evidence extrapolated from laparoscopic ventral hernia repair, simultaneous fascial defect closure and mesh repair can significantly decrease the risk of seroma formation and recurrence over those without fascial closure. Therefore, we describe our novel technique of robot-assisted total extra-peritoneal (TEP) repair with primary fascial closure and pre-peritoneal mesh and its preliminary clinical outcomes. METHODS: We retrospectively reviewed our prospectively collected hernia database from October 2017 to July 2019, which included 26 consecutive patients with primary or recurrent groin hernias. Patients' baseline characteristics and perioperative outcomes were compared and analyzed. Perioperative factors included operative time, visual analog scale (VAS) score (0-100), hospital stay, perioperative complications, time to return to normal activity, and the modified Medical Outcome Study (MOS; item 3-12/36 items) score. RESULTS: All procedures were completed successfully without conversion to open or conventional laparoscopic surgery. The patients' age ranged from 28 to 74 years (median 57.5). The mean operative time was 115 minutes (range 95-172 min). There were no major procedure-related complications. Only four cases experienced asymptomatic seromas, which were detected by ultrasonography; and all resolved spontaneously within 6 weeks after the operation. The VAS and modified MOSs revealed quick recovery after robot-assisted endoscopic TEP repair. CONCLUSIONS: Robot-assisted endoscopic TEP repair combined with primary fascial closure and pre-peritoneal mesh is a safe and feasible technique for groin hernia repair.

A comprehensive study comparing tack and glue mesh fixation in laparoscopic total extraperitoneal repair for adult groin hernias.

BACKGROUND: Glue mesh fixation is thought to cause less pain compared to tack mesh fixation during laparoscopic total extraperitoneal inguinal hernia repair (TEP). However, the clinical benefits of glue mesh fixation are still controversial. This study aimed to evaluate the acute pain, chronic pain, and recurrence rate between these two fixation methods. METHODS: After reviewing all patients in our prospective hernia repair database from February 2008 to December 2017, we identified 583 patients who underwent TEP with tack mesh fixation and 70 patients with glue fixation by a single surgeon. Acute post-operative pain and activity level were evaluated using a Visual Analog Score (VAS) and the modified Medical Outcome Study (MOS) score. The primary endpoint was chronic pain 6 months after TEP. The secondary endpoints were acute pain, activity level, complications, and recurrence. RESULTS: After adjustment for potential confounding factors, the glue mesh fixation had significant lower VAS at 2 h post operation during rest and coughing and on the first day after surgery during coughing (p = 0.005, p < 0.001, and p = 0.011). The modified MOS on the first day was higher in the glue group (p < 0.001). There were no reduced risk of chronic pain or increased risk of recurrence for the glue group compared to the tack group [Odds ratio (OR) = 0.237, p = 0.169; OR = 2.498, p = 0.299]. In the sub-group analysis for recurrent hernia repair, glue fixation is associated with better modified MOS (p = 0.031) on first day and lower VAS on the operative day and first day at rest (p = 0.003 and p = 0.024) after surgery. CONCLUSIONS: Glue fixation method was superior to tack fixation method in acute post-operative pain and early post-operative activity level after laparoscopic TEP repair. However, both fixation methods had similar incidence of chronic pain-, recurrence-, and procedure-related complications after laparoscopic TEP repair.

Risk of severe erectile dysfunction in primary hyperaldosteronism: A population-based propensity score matching cohort study.

BACKGROUND: An elevated plasma aldosterone level has been reported as an independent risk factor for severe erectile dysfunction in men. The aim of this study was to explore whether primary hyperaldosteronism patients experience erectile dysfunction after targeted treatment. METHODS: We conducted a population-based cohort study of men with newly identified primary hyperaldosteronism/aldosterone-producing adenoma from January 1, 1997, to December 31, 2009. Men with essential hypertension and normotension were matched to the primary hyperaldosteronism group according to propensity score matching. RESULTS: We identified 1,067 men with primary hyperaldosteronism (mean age, 46.7 ± 12.8 years) and matched them with the same number of men with essential hypertension or normotension. During the mean follow-up interval of 5.4 years, the incident rates of total erectile dysfunction were 5.7, 3.9, and 3.1 per 1,000 person-years for the primary hyperaldosteronism, essential hypertension, and normotension groups, respectively. Men with primary hyperaldosteronism exhibited a higher risk of erectile dysfunction compared with men with normotension (competing risks hazard ratio, 1.83), and no difference was seen in comparison with men who have essential hypertension. After adrenalectomy, men who have primary hyperaldosteronism had a higher risk of exhibiting severe erectile dysfunction compared with men who have essential hypertension (competing risks hazard ratio, 2.44) or normotension (competing risks hazard ratio, 2.90). CONCLUSION: Men with primary hyperaldosteronism reported a higher incidence of severe erectile dysfunction than normotension controls despite targeted treatment. The risk of severe erectile dysfunction increased after men who have primary hyperaldosteronism underwent adrenalectomy. This result raises the possibility of severe erectile dysfunction after adrenalectomy and calls for a prospective large-scale study of men who have aldosterone-producing adenoma regarding their erectile function both before and after adrenalectomy.

Risk of new-onset diabetes mellitus in primary aldosteronism: a population study over 5 years.

OBJECTIVE: Abnormal glucose metabolism due to insulin resistance has been linked to aldosterone overproduction. However, the long-term incidence of new-onset diabetes mellitus (NODM) among patients with primary aldosteronism after targeted treatment has not been well documented. METHODS: The diagnosis of primary aldosteronism and essential hypertension were identified, and then the occurrence of NODM, all-cause mortality among these patients, was ascertained by a validated algorithm from a 23-million population insurance registry. RESULTS: From 1999 to 2007, 2367 primary aldosteronism patients without previously diabetes mellitus were identified and propensity score-matched with 9468 patients with essential hypertension. Among those primary aldosteronism patients, 754 aldosterone-producing adenomas patients were identified and matched with 3016 essential hypertension controls. After a mean 5.2 years of follow-up, primary aldosteronism patients who underwent adrenalectomy had an attenuated NODM incidence (hazard ratio = 0.60, P < 0.01, versus essential hypertension); whereas those treated with mineralocorticoid receptor antagonist had augmented risk of NODM (hazard ratio = 1.16, P < 0.001, versus essential hypertension). Among the aldosterone-producing adenoma patients, adrenalectomy is also protective from developing NODM (hazard ratio = 0.61, P < 0.001, versus essential hypertension), however, mineralocorticoid receptor antagonist treatment did not alter the risk of NODM (P = 0.10, versus essential hypertension). Adjusted hazard ratios for long-term risk of mortality from this analysis revealed that adrenalectomy is protective, but NODM and major cardiovascular disease are deleterious. CONCLUSION: The primary aldosteronism patients who underwent adrenalectomy had reduced risk for incident NODM and all-cause of mortality, compared with matched hypertensive controls. This observation adds more evidence on the association of primary aldosteronism with a higher risk of metabolic syndrome and long-term mortality.

Is Robotic Partial Nephrectomy Safe for T3a Renal Cell Carcinoma? Experience of a High-Volume Center.

PURPOSE: To compare the oncological and functional outcomes of robotic partial nephrectomy (RPN) with radical nephrectomy (RN) in renal-cell carcinoma (RCC) cases with pT3a staging. PATIENTS AND METHODS: A retrospective analysis of our IRB-approved nephrectomy database from 2005 to 2015 was performed. RPN and RN cases with confirmed RCC and pT3a staging were matched. Preoperative variables, functional, and oncological outcomes were compared between the groups, as well as Kaplan-Meier estimated overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). A multivariable Cox proportional hazards regression model for overall mortality rate was generated to evaluate hazard ratios (HRs) of potential risk factors. RESULTS: Seventy patients with pT3a tumors composed each group. Preoperative variables were comparable between groups. The median follow-up time for the cohort was 20 (9-38) months and the renal function preservation was higher in the RPN group (86% vs 70%; p < 0.001). The estimated 3 years of OS (90% vs 84%; p = 0.42), CSS (94% vs 95%; p = 0.78), and RFS (95% vs. 100%; p = 0.06) were similar between RPN and RN groups, respectively. On multivariable Cox regression model, the presence of ≥2 aggressive tumor features was the only factor associated with increased risk of overall mortality rate (HR 4.01 95% confidence interval [1.13, 14.27)]; p = 0.03). CONCLUSION: Patients with localized pT3a RCC treated with RPN had similar short-term oncological and better renal functional outcomes compared with similar cases treated by RN. In the minimally invasive robotic surgery era, renal masses suspicious for pathological T3a disease should not be a deterring factor for performing nephron-sparing surgery when technically feasible by skilled surgeons.

Is Extensive Parenchymal Resection During Robotic Partial Nephrectomy Justified? A Match-Paired Comparison of Two Extirpative Surgical Modalities for Treatment of a Complex Renal Neoplasm.

OBJECTIVE: To analyze the outcomes of robotic partial nephrectomy (RPN) in patients where nephron-sparing surgery would have mandated a large amount of renal volume resection. METHODS: Patients undergoing RPN with extensive volume resection (≥30%), from 2006 to 2014, were identified. Pre- and postoperative CT/MRI-based volumetric assessment of the operated kidney was performed. To address the possible benefits of RPN, we matched this cohort to patients undergoing laparoscopic radical nephrectomy (LRN). The groups were matched for tumor size, R.E.N.A.L. nephrometry score, age-adjusted Charlson comorbidity index (ACCI), and preoperative estimated glomerular filtration rate (eGFR). Demographics, perioperative, functional, and oncologic outcomes were compared between the groups. Multivariable analysis of factors predicting chronic kidney disease (CKD) upstaging (type of surgery, R.E.N.A.L. score, ACCI, and baseline eGFR) was performed. RESULTS: In total, 52 patients undergoing RPN were matched to 52 LRN patients. The median R.E.N.A.L. score (interquartile range) was 9 (9-10) for both groups. Demographic variables were comparable between the groups. The median renal volume preservation in the RPN group was 57.0% (47.2-67.2). The rates of overall and major complications were comparable between RPN and LRN. The RPN group had higher overall eGFR preservation (75.8% vs 68.5%; p = 0.01) and a lower rate of CKD upstaging (26.9% vs 50.6%; p = 0.001). On multivariable analysis, LRN and baseline eGFR were significant predictors of CKD upstaging (odds ratio [OR] 4.26; 95% CI [1.80-10.12]; p = 0.001 and OR 0.98; 95% CI [0.96-0.99]; p = 0.03, respectively). During the median follow-up time of 21 (9-36) months, local recurrence, metastasis, and cancer-specific and overall survival were comparable between RPN and LRN. CONCLUSION: RPN requiring extensive volume resection provides renal functional preservation without significant increase in surgical complications or compromising short-term oncologic outcomes.

Laparoendoscopic single-site (LESS) vs laparoscopic living-donor nephrectomy: a systematic review and meta-analysis.

The aim of this study was to provide a systematic review and meta-analysis of reports comparing laparoendoscopic single-site (LESS) living-donor nephrectomy (LDN) vs standard laparoscopic LDN (LLDN). A systematic review of the literature was performed in September 2013 using PubMed, Scopus, Ovid and The Cochrane library databases. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Weighted mean differences (WMDs) were used to measure continuous variables and odds ratios (ORs) to measure categorical ones. Nine publications meeting eligibility criteria were identified, including 461 LESS LDN and 1006 LLDN cases. There were more left-side cases in the LESS LDN group (96.5% vs 88.6%, P < 0.001). Meta-analysis of extractable data showed that LLDN had a shorter operative time (WMD 15.06 min, 95% confidence interval [CI] 4.9-25.1; P = 0.003), without a significant difference in warm ischaemia time (WMD 0.41 min, 95% CI -0.02 to 0.84; P = 0.06). Estimated blood loss was lower for LESS LDN (WMD -22.09 mL, 95% CI -29.5 to -14.6; P < 0.001); however, this difference was not clinically significant. There was a greater likelihood of conversion for LESS LDN (OR 13.21, 95% CI 4.65-37.53; P < 0.001). Hospital stay was similar (WMD -0.11 days, 95% CI -0.33 to 0.12; P = 0.35), as well as the visual analogue pain score at discharge (WMD -0.31, 95% CI -0.96 to 0.35; P = 0.36), but the analgesic requirement was lower for LESS LDN (WMD -2.58 mg, 95% CI -5.01 to -0.15; P = 0.04). Moreover, there was no difference in the postoperative complication rate (OR 1.00, 95% CI 0.65-1.54; P = 0.99). Renal function of the recipient, as based on creatinine levels at 1 month, showed similar outcomes between groups (WMD 0.10 mg/dL, -0.09 to 0.29; P = 0.29). In conclusion, LESS LDN represents an emerging option for living kidney donation. This procedure offers comparable surgical and early functional outcomes to the conventional LLDN, with a lower analgesic requirement. However, it is more technically challenging than LLDN, as shown by a greater likelihood of conversion. The role of LESS LDN remains to be defined.

Clinical application of sirolimus in renal transplantation: an update.

In addition to an analysis of the final results of phase I/II and phase III clinical trials of sirolimus (SRL), this review focuses on the recent results of several studies in renal transplantation, which include diverse combinations of SRL with other immunosuppressive agents. While SRL was initially introduced as an adjunctive agent to calcineurin inhibitors, it is now serving as the base for therapies that spare or avoid these nephrotoxic drugs. However, to optimize the use of SRL as base therapy, further work is necessary to determine target concentrations, requirement for concomitant steroids and/or nucleoside synthesis blockers, and countermeasure therapy to overcome the drug's adverse effects.

Dyslipidemia in renal transplant recipients treated with a sirolimus and cyclosporine-based immunosuppressive regimen: incidence, risk factors, progression, and prognosis.

BACKGROUND: This retrospective study compared the incidence, severity, and predisposing factors for dyslipidemia among renal transplant patients treated for up to 6 years with a cyclosporine +/- prednisone-based concentration-controlled regimen without (n=118) or with (n=280) ascending exposures to sirolimus. METHODS: The diagnosis of dyslipidemia was established when the serum cholesterol value (CHO) was more than 240 mg/dL or serum triglycerides (TG) were more than 200 mg/dL. Generalized estimating equations and mixed-modeling procedures were used for statistical analyses. RESULTS: Hypercholesterolemia was observed in 46% to 80% and hypertriglyceridemia in 43% to 78% of sirolimus-treated patients during the first 6 posttransplantation months. The mean peak serum lipid levels among patients in the sirolimus group (CHO=285.5 mg/dL; TG=322.4 mg/dL) were significantly higher than those in the nonsirolimus group (CHO=250.2 mg/dL and TG=267.6 mg/dL; both P<0.01). The lipid values, which were persistently elevated during the first posttransplantation year, decreased slowly thereafter but remained significantly higher than the pretransplantation levels beyond 4 years after transplantation. The two forms of hyperlipidemia tended to occur in parallel (Pearson's coefficient of correlation, r=0.5, P<0.001), showing a positive predictive value of 0.67 and a negative predictive value of 0.65. However, there was no significant difference in the incidence of cardiovascular events within 4 years after transplantation among patients treated with versus without sirolimus. CONCLUSION: The dyslipidemia associated with sirolimus therapy, albeit persistent, does not seem to represent a major risk factor for the early emergence of cardiovascular complications.