External validation of yonsei nomogram predicting chronic kidney disease development after partial nephrectomy: An international, multicenter study.

OBJECTIVE: To externally validate Yonsei nomogram. METHODS: From 2000 through 2018, 3526 consecutive patients underwent on-clamp PN for cT1 renal masses at 23 centers were included. All patients had two kidneys, preoperative eGFR ≥60 ml/min/1.73 m2, and a minimum follow-up of 12 months. New-onset CKD was defined as upgrading from CKD stage I or II into CKD stage ≥III. We obtained the CKD-free progression probabilities at 1, 3, 5, and 10 years for all patients by applying the nomogram found at https://eservices.ksmc.med.sa/ckd/. Thereafter, external validation of Yonsei nomogram for estimating new-onset CKD stage ≥III was assessed by calibration and discrimination analysis. RESULTS AND LIMITATION: Median values of patients' age, tumor size, eGFR and follow-up period were 47 years (IQR: 47-62), 3.3 cm (IQR: 2.5-4.2), 90.5 ml/min/1.73 m2 (IQR: 82.8-98), and 47 months (IQR: 27-65), respectively. A total of 683 patients (19.4%) developed new-onset CKD. The 5-year CKD-free progression rate was 77.9%. Yonsei nomogram demonstrated an AUC of 0.69, 0.72, 0.77, and 0.78 for the prediction of CKD stage ≥III at 1, 3, 5, and 10 years, respectively. The calibration plots at 1, 3, 5, and 10 years showed that the model was well calibrated with calibration slope values of 0.77, 0.83, 0.76, and 0.75, respectively. Retrospective database collection is a limitation of our study. CONCLUSIONS: The largest external validation of Yonsei nomogram showed good calibration properties. The nomogram can provide an accurate estimate of the individual risk of CKD-free progression on long-term follow-up.

Cytological and histopathological correlation of thyroid lesions.

OBJECTIVE: To determine accuracy of cytological diagnosis in comparison with the corresponding histopathological diagnosis of thyroid lesions. METHODS: The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan, and comprised data from January to December 2017 of all in-patient cases of thyroid cytology with their histopathological diagnosis. Both Haematoxylin and Eosin stain slides and cytological smears were reviewed. True negative, true positive, false negative and false positive cases were marked using the criteria defined in Table-1. RESULTS: Of the total 36 cases, 5(13.9%) were non-diagnostic or unsatisfactory for cytological assessment. Cytological diagnosis achieved sensitivity of 82.3%, specificity 64.3%, positive predictive value 73.6%, negative predictive value 75%, false positive rate 35.7% and false negative rate 17.6%. The diagnostic accuracy of cytological diagnosis was 63.9%. CONCLUSIONS: There was significant cytological and histopathological concordance of thyroid lesions.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy.

OBJECTIVE: To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. RESULTS: All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677). CONCLUSION: This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

Aquablation versus transurethral resection of the prostate: 1 year United States - cohort outcomes.

INTRODUCTION: The purpose of this analysis was to compare Aquablation to transurethral resection of the prostate (TURP) with respect to efficacy and safety at 1 year for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia (BPH) in the United States (U.S.) cohort from the Waterjet Ablation Therapy for Endoscopic Resection of prostate tissue (WATER) study. MATERIALS AND METHODS: WATER is a double-blinded, multicenter prospective randomized controlled trial for patients with moderate-to-severe lower urinary tract symptoms related to BPH. Men were randomized to TURP or Aquablation. The efficacy and safety outcomes at 1 year were evaluated for the U.S. cohort. The efficacy objective was reduction in International Prostate Symptom Score (IPSS). The safety objective was the occurrence of Clavien-Dindo persistent grade 1 or grade 2 or higher operative complications. RESULTS: Ninety patients were randomized and treated between December 2015 and December 2016. Change in IPSS at 1 year between Aquablation and TURP was similar (14.5 versus 13.8, respectively, p = 0.7117). The number of subjects experiencing persistent Clavien-Dindo grade 1 or Clavien-Dindo grade 2 or higher adverse events was lower in the Aquablation group compared to the TURP group (20% versus 47% respectively, p = 0.0132). Amongst sexually active subjects, the rate of anejaculation was lower in patients treated with Aquablation than TURP (9% versus 45%, respectively, p = .0006). CONCLUSIONS: Surgical prostate resection using Aquablation showed improvement in lower urinary tract symptoms at 1 year comparable to TURP, but with a lower risk of adverse events and ejaculatory dysfunction.

Modified transurethral resection of the prostate (TURP) for men with moderate lower urinary tract symptoms (LUTS) before brachytherapy is safe and feasible.

OBJECTIVE: To report the urinary toxicity outcomes for patients at greater risk of voiding symptoms and retention who received a modified limited transurethral resection of the prostate (TURP) before low-dose rate (LDR) brachytherapy. PATIENTS AND METHOD: Data were analysed from patients receiving the above procedures between 2006 to present, taken from the prospective brachytherapy database of 2000 patients at the St. Luke's Cancer Centre. The limited TURP (TURP(BXT) ) was performed at a median (range) of 64 (25-205) days before seed implantation with a median resection weight of 1.15 g. Selection criteria were based on patients with moderate lower urinary tract symptoms, poor flow or post-void residual urine volume (PVR), or a prominent middle lobe or high bladder neck on transrectal ultrasonography. Baseline prostate cancer characteristics, uroflowmetry, International Prostate Symptom Score (IPSS) and quality-of-life QoL scores were collected and compared with follow-up IPSS and QoL scores. RESULTS: Data for 112 patients was gathered from the database. The TURP(BXT) resulted in statistically significant improvements before LDR brachytherapy in maximum urinary flow rate (Qmax ) and PVR, IPSS and QoL scores (the mean Qmax before vs after the TURP(BXT) was 11.3 vs 16.7 mL/s). The IPSS and QoL scores at 6 months after seed implantation were increased compared with baseline values before the TURP(BXT) (mean IPSS at 6 months 11.7 vs 9.2 before TURP(BXT) ), but no difference at 1 year (mean IPSS 9), and improved scores at 2, 3, 4 and 5 years follow-up (mean IPSS of 7.9, 5.6, 5.3 and 7.4, respectively). CONCLUSION: The present study suggests patients at increased risk of deteriorating voiding symptoms, including urinary retention, are no longer contraindicated against LDR brachytherapy if they receive a modified TURP before seed implantation. This procedure does not appear to carry the risk of urinary incontinence thought to be associated with a conventional TURP before LDR brachytherapy.

Retroperitoneal Robotic-Assisted Laparoscopic Pyeloplasty: A 10 Year Experience in a Single Institution.

Introduction: Pelvi-ureteric junction (PUJ) obstruction was traditionally treated with open pyeloplasty. In recent decades, the development of minimally invasive techniques, including laparoscopic and later robotic surgery, has transformed treatment. The transperitoneal approach has most commonly been undertaken, with a few institutions reporting outcomes of the retroperitoneal approach. We report our 10-year experience of retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP). Methods: A prospective database of 160 patients undergoing RALP between February 2010 and November 2019 was analyzed. Data were recorded on demographics, operative details, complications, and success rate. Success was determined as symptomatic improvement and/or an unobstructed renogram. Results: One hundred fifty-two cases (95.0%) were performed by using a retroperitoneal approach, and 8 (5.0%) were performed by using a transperitoneal approach. Mean age was 45.3 ± 17.4 years. Mean operating time was 139.4 ± 45.6 minutes. A surgical drain was placed in 57 (71.3%) of the first 80 cases and 15 (18.8%) of the second 80 cases. Median hospital stay was one night (range 1-27). One case was converted to open pyeloplasty due to dense inflammatory tissue and one to robotic-assisted nephrectomy due to severe adhesions around the PUJ. There were no blood transfusions. There were six major (>grade 2 Clavien-Dindo) postoperative complications in four patients (2.5%). Two (1.3%) grade 3a complications, urine leak and pain after stent removal, required nephrostomy. There were three (1.9%) grade 3b complications: migrated stent requiring ureteroscopy, perirenal hematoma requiring open evacuation, and stent re-insertion. One (0.6%) grade 4 complication required ventilatory support on intensive care. Eighteen patients received follow-up at an alternative hospital, and 13 were lost to follow-up. Of the remaining cases, 94.5% were successful. Conclusions: R-RALP is a safe and effective treatment for PUJ obstruction allowing predictably rapid discharge from hospital without the need for a routine surgical drain. To our knowledge, our study represents the largest single institution experience on RALP using a retroperitoneal approach.

Warm ischemia time length during on-clamp partial nephrectomy: does it really matter?

BACKGROUND: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN). METHODS: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m2. Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages. RESULTS: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study. CONCLUSIONS: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m2.

Preclinical Evaluation of the Versius Surgical System, a New Robot-assisted Surgical Device for Use in Minimal Access Renal and Prostate Surgery.

BACKGROUND: Minimal access surgery (MAS) is well-established in urological surgery. However, MAS is technically demanding and associated with a prolonged learning curve. Robot-assisted laparoscopy has made progress in overcoming these challenges. OBJECTIVE: The aim of this study was to evaluate the feasibility of a new robot-assisted surgical system (the Versius Surgical System; CMR Surgical, Cambridge, UK) for renal and prostate procedures in a preclinical setting, at the IDEAL-D phase 0. DESIGN, SETTING, AND PARTICIPANTS: Cadaveric sessions were conducted to evaluate the ability of the system to complete all surgical steps required for a radical nephrectomy, prostatectomy, and pelvic lymph node dissection. A live animal (porcine) model was also used to assess the surgical device in performing radical nephrectomy safely and effectively. Procedures were performed by experienced renal and prostate surgeons, supported by a full operating room team. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Surgical access and reach were evaluated by the lead surgeon using a visual analogue scale. The precise surgical steps conducted to make the assessment that the procedures could be completed fully were recorded, as well as instruments used (including manual laparoscopic instruments) and endoscope angle. RESULTS AND LIMITATIONS: In total, all 24 procedures were completed successfully in cadavers by eight different lead surgeons. Positioning of the ports and bedside units reflected the lead surgeon's preferred laparoscopic set-up and enabled good surgical access and reach, as quantified by a median visual analogue score of ≥6.5. Radical nephrectomies performed in pigs were all completed successfully, with no device- or non-device-related intraoperative complications recorded. Testing in human cadavers and pig models balances the bias introduced by each model; however, it is impossible to completely replicate the experience and performance of the robot for surgery in live humans. CONCLUSIONS: This is the first preclinical assessment of the Versius Surgical System for renal and prostate procedures. The safety and effectiveness of the system have been demonstrated and warrant progressive assessment in a clinical setting utilising the IDEAL-D framework. PATIENT SUMMARY: In this report, we looked at the usability of a new robot-assisted surgical device for renal and prostate surgery by testing the system in cadavers and pigs. We found that a number of different surgeons and operating team personnel were able to use the system to successfully complete the procedures under evaluation. We conclude that the system is ready to be tested in live human studies.

Retroperitoneal Robot-Assisted Partial Nephrectomy in Obese Patients.

Objectives: To report our experience with retroperitoneal robotic-assisted partial nephrectomy (RAPN) in obese patients. Patients and Methods: From April 2012 to December 2018, 127 patients with body mass index (BMI) ≥30 kg/m2 underwent RAPN, of whom 110 patients had retroperitoneal RAPN. We reviewed the patients' demographic, operative data, perioperative and postoperative complications, and postoperative histology. Results: The median BMI was 33.1 kg/m2 (interquartile range [IQR] 31.5-36.6). The median age of the patients was 59 years. The mean histological size of tumor was 32.2 mm (IQR 23.8-40). The median total surgical time was 130 minutes (IQR 110-176) with a median warm ischemia time of 22.0 minutes. The tumor was located anteriorly in 25% of the cases. The median R.E.N.A.L.* nephrometry score was 6. The median estimated blood loss was 30 mL (IQR 10-80). Three cases were converted to open partial nephrectomy because of bleeding (2.7%). Four patients and one patient returned within 30 days with postoperative complications Clavien-Dindo classification grade 2 and 3a, respectively. Two patients needed perioperative blood transfusion because of bleeding. The median length of stay was 1 day (IQR 1-2). Conclusion: Retroperitoneal RAPN is feasible in patients with high BMI and provides good surgical access to treat nonanterior renal masses. Retroperitoneal RAPN is associated with less blood loss, shorter surgical time, and warm ischemia time when compared with transperitoneal RAPN studies.

Long-Term Outcomes of Laparoscopic Nephroureterectomy with Transurethral Circumferential Excision of the Ureteral Orifice for Urothelial Carcinoma.

INTRODUCTION: When performing open or laparoscopic nephroureterectomy (LNU), the optimal way to excise the distal ureter remains controversial. There are concerns that primary endoscopic detachment of the intramural ureter is associated with adverse outcomes. Existing studies have limited number of patients and inadequate oncologic follow-up. We provide our institutions experience of this technique. MATERIALS AND METHODS: Data were collected prospectively on 59 patients (37 men) who underwent LNU for a 10-year period at a single center using a standardized technique: initial endoscopic circumferential release of the distal ureter and bladder cuff followed by retroperitoneal en bloc LNU. RESULTS: Patients had a mean age of 67 years and Charlson score of 2. One case was converted to open surgery. Mean operative time was 194 minutes with estimated blood loss of 125 mL. Three patients (5%) required a blood transfusion. Mean in-patient stay was 3 days. Forty-six patients had urothelial carcinoma. Seventy-one percent of patients had high-grade disease (n = 33) and 21% had distal ureteral disease (n = 10). One patient required open excision of recurrence at the site of the excised ureteral orifice and remains disease free 5 years later. Five-year cancer-specific survival was 100% for patients with stages pTa (n = 7) and pT1 (n = 14), 93% for stage pT2 (n = 7) disease, and 49% for patients with stage pT3 (n = 18) disease. CONCLUSIONS: Transurethral resection of the ureteral orifice during LNU achieves acceptable long-term oncologic outcomes while minimizing perioperative morbidity and in-patient stay. This represents the largest single-center study of this technique to date.

Redefining the limits of flexible ureterorenoscopy.

BACKGROUND AND PURPOSE: Flexible ureterorenoscopic holmium laser lithotripsy allows retrograde management of renal calculi that previously needed alternative strategies. This study assesses the influences of stone size, density, and location on treatment outcomes from a large series. PATIENTS AND METHODS: Data concerning patients who presented for ureterorenoscopic laser lithotripsy between May 2005 and September 2008 were retrospectively analyzed. Single-treatment success was defined as satisfactory visual clearance of stone bulk, radiopacities less than 2 mm on noncontrast CT, and no further treatment. RESULTS: One hundred and eighty-five patients had 236 treatments (median=51 years; range 18-83 years). Overall success rate was 90.7%. The mean ± standard deviation (SD) stone size was 13.1 ± 8.5 mm with significant differences between the successful (11.6 ± 6.7 mm) and nonsuccessful (27.8 ± 10.0 mm) outcome groups (P<0.0001, unpaired t test). Of treatments for stone size ≤ 20 mm, 96.5% were successful. Of 36 patients with stone size >20 mm, 21 (58.3%) were stone free after one treatment and 31 (86.1%) after two treatments. Hounsfield unit data did not differ significantly between the groups (mean ± SD 858 ± 388 vs 1115 ± 643, P=0.146, unpaired t test). Stone locations were: Renal pelvis, caliceal diverticula, and upper pole, midpolar, and lower pole in 61, 9, 24, 27, and 115 cases with success rates of 85%, 100%, 83%, 93%, and 94%, respectively (P=0.899, chi-square test). CONCLUSION: Clearance rates of >90% can be achieved for stones up to 20 mm with flexible ureterorenoscopy and holmium laser lithotripsy, but with larger stones, the stone-free rates reduce significantly. Therefore, 20 mm should be regarded as the upper limit of stone size that can be cleared in a single procedure. Stone density and location do not influence outcome.