Perioperative and oncological outcomes of distal ureter management during nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and meta-analysis.

INTRODUCTION: The best approach of the bladder cuff (i.e., transvesical, extravesical, endoscopic) during radical nephroureterectomy (RNU) remains an unsolved question. The aim of this review is to compare the oncological and perioperative outcomes among three different approaches of the distal ureter during RNU. EVIDENCE ACQUISITION: A literature search was conducted through June 2022 using PubMed/Medline, Embase, and Web of Science databases. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify eligible studies. The primary outcome was bladder recurrence-free survival and secondary outcomes included: perioperative outcomes, metastasis-free survival, and cancer-specific survival. EVIDENCE SYNTHESIS: A total of 19 non-randomized studies comprising 6581 patients met our inclusion criteria. The risk of bladder recurrence, metastasis and cancer-related death did not differ significantly between each approach (all P>0.05). In subgroup analysis excluding patients with history of bladder cancer, the risk of bladder recurrence remained similar between each approach (all P>0.05). There was no significant difference in terms of operative time, estimated blood loss, length of hospital stay, and postoperative complications between each approach (all P>0.05). The main limitation is the retrospective design of 18/19 included studies. CONCLUSIONS: The present systematic review and meta-analysis highlights the lack of high-level evidence on distal ureter management during RNU. On the basis of the available data, the present review supports the equivalence of different techniques of bladder cuff excision during RNU. The extravesical approach seems non-inferior to the transvesical approach in terms of oncological and perioperative outcomes.

Radioisotope-guided Lymphadenectomy for Pelvic Lymph Node Staging in Patients With Intermediate- and High-risk Prostate Cancer (The Prospective SENTINELLE Study).

PURPOSE: Our aim was to prospectively evaluate the diagnostic accuracy of sentinel lymph node biopsy-guided lymph node dissection compared to extended pelvic lymph node dissection in patients with intermediate- or high-risk prostate cancer. MATERIALS AND METHODS: We conducted a prospective, single-arm, multicenter study at 3 tertiary centers in France between February 2012 and May 2019. Eligible patients had clinically localized intermediate- or high-risk prostate cancer. After intraprostatic injection of (99m)Tc-nanocolloid, the locations of the sentinel lymph nodes were defined by preoperative lymphoscintigraphy. Surgical excision of the sentinel lymph nodes was performed using intraoperative gamma probe guidance. After resection of the sentinel lymph nodes, extended pelvic lymph node dissection was performed in all patients. We assessed the diagnostic accuracy of the sentinel lymph node biopsy method using extended pelvic lymph node dissection as the reference standard. This trial was registered in ClinicalTrials.gov (NCT02732392). RESULTS: A total of 162 men cN0M0 (CT scan and bone scan) were enrolled: 106 (65.4%) and 56 (34.6%) patients had intermediate- and high-risk prostate cancer, respectively. The median number of nodes retrieved was 14 (mean 16, IQR 10-21) per patient. At final pathological analysis, 22 patients (13.6%) were pN+. Sensitivity, specificity, negative predictive value, and positive predictive value of sentinel lymph node biopsy method in detecting patients with at least 1 lymph node metastasis were 95.4% (95% CI, 75.1-99.7), 100% (95% CI, 96.6-100), 99.2% (95% CI, 95.5-99.9), and 100% (95% CI, 80.7-100), respectively. CONCLUSIONS: Our multicenter prospective study supports that sentinel lymph node biopsy is a very effective and sensitive method for pelvic lymph node staging in patients with intermediate- or high-risk localized prostate cancer.

Predictive factors of non-operative management failure in 494 blunt liver injuries: a multicenter retrospective study.

Non-operative management (NOM) has become the major treatment of blunt liver trauma (BLT) with a NOM failure rate of 3-15% due to liver-related complications. The aim of the study was to determine the predictive factors and a risk-stratified score of NOM failure. From 2013 to 2021, all patients with BLT in three trauma centers were included; clinical, biological, radiological and outcome data were retrospectively analyzed. Predictive factors and a risk-stratified score associated with NOM failure were identified. Four hundred and ninety-four patients with BLT were included. Among them, 80 (16.2%) had isolated BLT. Fifty-nine patients (11.9%) underwent emergent operative management (OM) on the day of admission and 435 (88.1%) had a NOM. NOM failure rate was 11.5%. Patients with a NOM failure more frequently had a hemoperitoneum (p < 0.001), liver bleeding (p < 0.001), blood transfusion (p < 0.001) and angioembolization (p < 0.001) compared to patient with a successful NOM. In multivariate analysis, the presence of hemoperitoneum (OR = 5.71; 95 CI [1.29-25.45]), angioembolization (OR = 8.73; 95 CI [2.04-38.44] and severe liver injury (AAST IV or V) (OR = 8.97; 95 CI [3.36-23.99]) were independent predictive factors of NOM failure. When these three factors were associated, NOM failure rate was 83.3%. The AAST grade, the presence of hemoperitoneum and the realization of liver angioembolization on the day of admission are three independent predictive factors of NOM failure. Our risk-score based on these three factors stratify the risk of NOM failure in BLT and could be used for a more appropriate level of medical survey adapted to each patient. Level of evidence: prospective observational cohort study, Level III.

Miami Pouch: A Simple Technique for Efficient Continent Cutaneous Urinary Diversion.

OBJECTIVE: To report a contemporary series of Miami pouch (MP) enriched with a full technical description and step-by-step video to contribute to wider use. PATIENTS AND METHODS: A retrospective charts review of all patients who had a MP at our center between January 2016 and December 2017 was performed. The MP technique uses the terminal 15cm of ileum and the right colon to build an intestinal heterotopic pouch located in the right iliac fossa and connected to the skin by an efferent catheterizable tube. Primary outcome was continence defined as the absence of leakage between clean intermittent self-catheterization (CISC) with a maximal interval of 4 hours between each CISC. RESULTS: Fifteen patients had MP during the study period. Thirty-day postoperative Clavien III complications were observed in 2 (13.3%) patients. At 39 months of median follow-up, continence was obtained for all patients except for 2 patients whom reported intermittent night-time leakages due to long intervals (5 to 7 hours) between 2 CISC. No significant alteration of renal function was reported and no stenosis of the efferent tube neither difficulty to perform CISC was observed. CONCLUSIONS: For patients who are candidates for radical cystectomy and not eligible for orthotopic neobladder, intestinal heterotopic pouch with a cutaneous continent urinary diversions as MP may be a reliable alternative. Patients should be informed of the existence of a valid alternative to ileal conduit since it may fit their expectations of a preserved body image without urine collecting appliances.

Robot-assisted implantation of an artificial urinary sphincter, the AMS-800, via a posterior approach to the bladder neck in women with intrinsic sphincter deficiency.

OBJECTIVES: To describe a new technique for robot-assisted AMS-800 artificial urinary sphincter (AUS) bladder neck implantation in women. PATIENTS AND METHODS: We reviewed the medical files of patients who underwent robot-assisted AUS implantation between March 2017 and November 2018 at our centre. All of the implantations were performed using a posterior approach to the bladder neck in order to avoid blind dissection and the risk of vaginal and/or bladder injury. This strategy was viewed as an alternative to the anterior robot-assisted implantation recently described. The AUSs were activated 5 weeks after implantation. Patients were followed up at 3, 6 and 12 months, then annually. RESULTS: Eight patients, with a median age of 64 years, underwent robot-assisted AUS implantation via a posterior approach to the bladder neck. The median preoperative pad weight was 300 g/24 h. The median operating time was 244 min. No peri-operative vaginal and or bladder injuries were observed. At a median of 12 months of follow-up, all the AUSs were functional. Five patients required no protection (62.5%), three had day protection (37.5%), and all said they were satisfied except for one patient (12.5%) who requested treatment for persistent urge incontinence. CONCLUSION: Robot-assisted AUS implantation in women via a posterior approach to the bladder neck is a procedure that is simple, reproducible and safe. The short-term functional results are satisfactory and comparable to those obtained via an open approach. A more long-term comparison of the efficacy and longevity of AUSs implanted using this posterior approach is needed to confirm its benefit compared with the anterior robot-assisted approach and the classic open technique.

Drainage of the right liver using EUS guidance.

Hepaticogastrostomy (HGS) has been reported for the management of palliative malignant hilar stricture and involves draining the left liver as rescue therapy. For the management of this complex stenosis, another new option for draining the right liver under EUS guidance was introduced. Ten publications involving 38 patients have been reported in the literature, in which the following two main techniques have been described: direct puncture of the right liver from the bulbus and the bridge technique allowing the drainage of the right liver across the left liver through HGS. In this review, we describe the techniques used and the potential advantages and complications of these procedures. Although this kind of drainage is demanding and probably limited to specific patients, EUS-biliary drainage of the right liver seems feasible with acceptable complications.