Laparoscopic Pyelolithotomy for treating urolithiasis in ectopic pelvic kidneys

ABSTRACT Introduction: The management of urolithiasis ectopic pelvic kidneys (EPK) can be challenging because of the aberrant anatomy (1-4). We demonstrate the step-by-step technique of the laparoscopic approach for treating urolithiasis in EPK. Patients and methods: Three men with EPK (2 left, 1 right) underwent laparoscopic pyelolithotomy through a transperitoneal approach. After establishing the pneumoperitoneum, the parietal peritoneum was opened at the parietal colic sulcus and the bowel displaced medially. The kidney was identified in the retroperitoneum and the renal pelvis exposed after removal of the perirenal adipose tissue. The renal pelvis was opened, and the stones were identified and retrieved with forceps in 2 cases and with a flexible nephroscope in 1 case. The renal pelvis was closed with a 3/0 running barbed suture. A DJ stent was placed in all patients. Results: For the first time, a laparoscopic technique for treating stones in the ectopic kidney is demonstrated in detail. Mean patient age was 52.6 years (44-58). The mean stone size was 22.3 mm (20-24 mm). Stones were in the renal pelvis in 2 cases and in the inferior calyx in 1 case. Mean operative time was 146 minutes (135-155 min). Mean estimated blood loss was 116 ml (60-140 ml). No complications were observed. The mean hospital stay was 3 days. The DJ stents were removed after 3 weeks. All patients were stone free at the postoperative CT scan with a mean follow-up of 3.3 months (1-6 months). Conclusions: Laparoscopic pyelolithotomy can be an effective and reproducible minimally invasive technique for treating urolithiasis in EPK.

Laparoscopic Pyelolithotomy for treating urolithiasis in ectopic pelvic kidneys.

INTRODUCTION: The management of urolithiasis ectopic pelvic kidneys (EPK) can be challenging because of the aberrant anatomy (1-4). We demonstrate the step-by-step technique of the laparoscopic approach for treating urolithiasis in EPK. PATIENTS AND METHODS: Three men with EPK (2 left, 1 right) underwent laparoscopic pyelolithotomy through a transperitoneal approach. After establishing the pneumoperitoneum, the parietal peritoneum was opened at the parietal colic sulcus and the bowel displaced medially. The kidney was identified in the retroperitoneum and the renal pelvis exposed after removal of the perirenal adipose tissue. The renal pelvis was opened, and the stones were identified and retrieved with forceps in 2 cases and with a flexible nephroscope in 1 case. The renal pelvis was closed with a 3/0 running barbed suture. A DJ stent was placed in all patients. RESULTS: For the first time, a laparoscopic technique for treating stones in the ectopic kidney is demonstrated in detail. Mean patient age was 52.6 years (44-58). The mean stone size was 22.3 mm (20-24 mm). Stones were in the renal pelvis in 2 cases and in the inferior calyx in 1 case. Mean operative time was 146 minutes (135-155 min). Mean estimated blood loss was 116 ml (60-140 ml). No complications were observed. The mean hospital stay was 3 days. The DJ stents were removed after 3 weeks. All patients were stone free at the postoperative CT scan with a mean follow-up of 3.3 months (1-6 months). CONCLUSIONS: Laparoscopic pyelolithotomy can be an effective and reproducible minimally invasive technique for treating urolithiasis in EPK.

Incidence, patterns of progression, and outcomes of preexisting and newly discovered brain metastases during treatment with anti-PD-1 in patients with metastatic melanoma.

BACKGROUND: Melanoma brain metastases (MBM) occur in up to 50% of patients with metastatic melanoma (MM) and represent a frequent site of systemic treatment failure for targeted therapies. However, to the authors' knowledge, little is known regarding the incidence, patterns of disease progression, and outcomes of MBM in patients treated with anti-PD-1 immunotherapy. METHODS: A total of 320 patients with MM who were treated with anti-PD-1 at The University of Texas MD Anderson Cancer Center in Houston were reviewed. Analyses were performed to identify factors associated with brain metastasis-free survival and overall survival (OS) using Cox regression models. RESULTS: The median age of the patients was 63.3 years. OS from the initiation of anti-PD-1 therapy was not significantly different between patients without MBM prior to anti-PD-1 compared with patients with prior MBM (P = .359). Among patients without prior MBM, 21 patients (8.6%) developed MBM during anti-PD-1 therapy, 12 of whom (4.9%) presented with disease progression in the central nervous system (CNS) only. Developing MBM during or after therapy with anti-PD-1 (hazard ratio, 4.70; 95% CI, 3.18-6.93) was associated with shorter OS. Among patients with MBM prior to anti-PD-1 treatment, 15 (20.0%) progressed in the CNS only and 19 (25.3%) progressed both intracranially and extracranially; at the time of the last data cutoff, 27 patients (36.0%) had not developed disease progression. Radiation necrosis occurred in 11.3% of patients (7 of 62 patients) in the group with a prior MBM who received stereotactic radiosurgery. CONCLUSIONS: Anti-PD-1 therapy may change the natural history of patients with preexisting MBM. However, CNS failure during treatment with anti-PD-1 is predictive of a worse prognosis compared with extracranial progression. The results of the current study support the activity of anti-PD-1 in patients with MBM, although routine CNS imaging during therapy is warranted.