Minimally invasive robotic versus conventional open living donor kidney transplantation.

PURPOSE: First robotic-assisted kidney transplants (RAKT) were performed in Germany in 2016. To introduce and establish this method as a routine procedure for patients in transplantation medicine, our 2-year experiences are presented. METHODS: Non-randomized open-label cohort study to compare functional and operative results as well as complication rates between RAKT and standard open transplantation. Collected data are part of ERUS RAKT Group Registry. RESULTS: Since initiation of the RAKT program 21/27 transplantations after living kidney donations have been performed as RAKT. This represents the largest series of RAKT in Germany. Patient survival, transplant survival, and primary function rate are 100% (mean follow-up 12.9 ± 8.6 month). Mean incision to closure time was 306.1 ± 45.5, mean handling time 70.8 ± 13.1 min compared to 212.1 ± 40.6 min and 51.7 ± 9.9 min, respectively, in the standard group. Despite extended operating times using the robotic approach, comparable complication rates and graft function with significant reduction in median length of hospital stay (14 vs. 20 days) were observed. CONCLUSIONS: RAKT extends the options for recipients towards minimally invasive techniques. Compared to classic open surgery, RAKT appears to be safe in selected patients without influencing graft outcome or higher complication rates. However, RAKT till today is not suitable for all patients but seems to be one of the upcoming new standard techniques in kidney transplantation.

Ureter Complications: A Rare Complication but which Requires the Highest Degree of Management Expertise.

INTRODUCTION: 0% of all urinary tract injuries are iatrogenic lesions. Although they only occur in < 5%, they can lead to severe ipsilateral renal dysfunctions. These lesions can be treated with extensive knowledge on the genesis of the lesion, the anatomy, the individual patient's history and high operative expertise in diverse surgical methods. MATERIAL AND METHODS: In this article, we show which reconstruction options are possible, depending on the lesion's severity according to the AAST and EAU Guidelines from 2009 on the classification of ureter injuries, as well as the localisation. A special focus is on the anatomy. It is important to adhere to surgical ground principles, such as making sure all pathological tissue is removed, the ureter ends are spatulated and a tension-free and watertight anastomosis is maintained. RESULTS: Iatrogenic ureter lesions are rare complications, but being able to deal with these frequently requires a urologist's expertise. Whenever surgeons operate close to the ureters, there is always a risk of an iatrogenic ureter lesion, which in turn requires that all available reconstructive measures are used dynamically. CONCLUSION: Ureter complications are rare but require surgeons' excellent management expertise.

Five-year experience with the adjustable transobturator male system for the treatment of male stress urinary incontinence: a single-center evaluation.

BACKGROUND: We report on our 5-year experience with the adjustable transobturator male system (ATOMS®, A.M.I., Feldkirch, Austria). METHODS: Between 10-2009 and 10-2014, 54 patients received an ATOMS. The mean follow-up of this retrospective observational trial was 27.5 ± 18.4 (2.3-59) months. Within each follow-up, the following were evaluated: micturition protocol, 24-h pad count, uroflowmetry and residual volume. Statistical analysis was performed with SigmaPlot® 11.0, p < 0.05 considered as significant. RESULTS: Stress urinary incontinence (SUI) I°, II° and III° was seen in 1 (1.9 %), 16 (29.6 %) and 37 patients (68.5 %), respectively. In summary, 48.1 % of the patients became "dry" (0-"safty pad"/day), while 29.6 % achieved at least an "improvement" of about more than 50 % (1-2 pads/day), which corresponds to an overall success rate of 77.7 %. The mean number of pads/day decreased from 7.7 to 1.6. Regarding the initial degree of SUI, patients with mild or moderate incontinence had a significantly better outcome (p = 0.002, 95 % CI 0.9066 to 2.760). Postoperative complications were scaled according to the Clavien classification, in which we have seen 4 grade I-, 1 grade IIIa- and 9 grade IIIb-complications (overall 25.9 %). The evaluation of quality of life by ICIQ-SF showed a significant improvement (p = 0.0001, 95 % CI -14.56 to -11.75). CONCLUSION: The treatment of male SUI using the ATOMS incontinence system achieved the best results in patients with mild and moderate incontinence. For severe incontinent patients, the system represents an efficient alternative.

Laparoendoscopic single-site versus conventional laparoscopic radical nephrectomy for renal cell cancer in patients with increased comorbidities and previous abdominal surgery: preliminary results of a single-centre retrospective study.

OBJECTIVE: Laparoendoscopic single-site surgery (LESS) represents an evolution of laparoscopy for the treatment for urologic diseases. The aim of this study is to investigate the feasibility of LESS in patients with increased comorbidities and previous abdominal surgery undergoing radical nephrectomy (LESS-RN) for renal cell carcinoma. MATERIALS AND METHODS: A total of 25 patients with increased comorbidities and previous abdominal surgery who underwent LESS-RN were compared to 31 patients with the same characteristics after conventional laparoscopic radical nephrectomy (LRN). LRN was performed between January 2009 and May 2010, and LESS-RNs were performed between June 2010 and November 2011. Demographic data and perioperative and postoperative variables were recorded and analysed. RESULTS: The mean ASA score in the LESS-RN and LRN groups was 3.2 ± 0.4, and the mean BMI was 32.7 ± 2.1 and 34.2 ± 0.8 kg/m(2), respectively. The mean operative time in the LESS-RN and LRN groups was 143.7 ± 24.3 and 130.6 ± 26.5 min, (p = 0.11), and the mean hospital stay was 3.8 ± 0.8 versus 4.2 ± 1.4 days in the two groups (p = 0.06), respectively. Three and four complications were recorded in the LESS-RN and in the LRN groups, for a mean complication rate of 12 and 12.9 % (p = 0.12), respectively All tumours were organ-confined with negative surgical margins, and the mean R.E.N.A.L nephrometry score for LESS-RN and LRN was 9.78 ± 1.7 and 9.82 ± 1.3 (p = 0.14), respectively. CONCLUSIONS: LESS-RN in patients with increased comorbidities and previous abdominal surgery is equally effective as LRN without compromising on surgical, oncologic short-term and postoperative outcomes.

Role of Nivolumab in the Modulation of PD-1 and PD-L1 Expression in Papillary and Clear Cell Renal Carcinoma (RCC).

The expression and cellular mechanisms of programmed cell death-1 protein (PD-1) and its ligands (PD-L1 and PD-L2) in renal cancer cells are not well known. Here, we aimed to investigate the response of renal carcinoma subtypes to the immune checkpoint inhibitor nivolumab and its impact on related signaling pathways. All cell lines analyzed (clear cell (cc)RCC (Caki-1, RCC31) and papillary (p)RCC (ACHN, RCC30)) expressed PD-1 and both ccRCC cell lines, and RCC30 expressed PD-L1. Nivolumab treatment at increasing doses led to increased PD-1 levels in analyzed cells and resulted in aggressive behavior of pRCC but diminished this behavior in ccRCC. The analysis of PD-1/PD-L1-associated signaling pathways demonstrated increased AKT activity in Caki-1 and RCC30 cells but decreased activity in ACHN and RCC31 cells, while ribosomal protein S6 remained largely unchanged. Androgen receptors are related to RCC and were predominantly increased in RCC30 cells, which were the only cells that formed nivolumab-dependent spheroids. Finally, all cell lines exhibited a complex response to nivolumab treatment. Since the pRCC cells responded with increased tumorigenicity and PD-1/PD-L1 levels while ccRCC tumorigenicity was diminished, further studies are needed to improve nivolumab-based therapy for renal carcinoma subtypes, especially the identification of response-involved molecular pathways.

Potential Use of CTCs as Biomarkers in Renal Cancer Patients.

We demonstrated that the CellCollector is an appropriate tool for detecting CTCs in RCC patients. We examined EpCAM and MUC1 expression levels in RCC tissues and cell lines and analyzed the detection rate of CTCs in blood samples ex vivo using an anti-EpCAM antibody-covered straight or spiraled CellCollector. Eight matched samples were examined for affinity to the anti-EpCAM vs. anti-EpCAM/anti-MUC1 antibody-covered wire. The use of this combination of antibodies allowed us to classify patients with lung metastasis. Finally, four patients were analyzed in vivo. In conclusion, both straight (ex vivo, in vivo) and spiraled (ex vivo) wires detected CTCs.

Laparoscopic adrenalectomy in urological centres - the experience of the German Laparoscopic Working Group.

OBJECTIVE: To evaluate the safety and feasibility of laparoscopic adrenalectomy (LA) performed in several German centres with different laparoscopic experience, as LA has become the gold-standard approach for benign surgical adrenal disorders; however, for solitary metastasis or primary adrenal cancer its precise role is uncertain. PATIENTS AND METHODS: The data of 363 patients who underwent a LA were prospectively collected in 23 centres. All centres were stratified into three groups according to their experience: group A (<10 LAs/year), group B (10-20 LAs/year) and group C (>20 LAs/year). In all, 15 centres used a transperitoneal approach, four a retroperitoneal approach and four both approaches. Demographic data, perioperative and postoperative variables, including operating time, surgical approach, tumour size, estimated blood loss, complications, hospital stay and histological tumour staging, were collected and analysed. RESULTS: The transperitoneal approach was used in 281 cases (77.4%) and the retroperitoneal approach was used in 82 patients (22.6%). In all, 263 of 363 lesions (72.5%) were benign and 100 (27.5%) were malignant. The mean (sd) operating time was 127.22 (55.56) min and 130.16 (49.88) min after transperitoneal and retroperitoneal LA, respectively. The mean complication rates for transperitoneal and retroperitoneal LA were 5% and 10.9%, respectively. CONCLUSION: LAs performed by urologists experienced in laparoscopy is safe for the removal of benign and malignant adrenal masses. LA for malignant adrenal tumours should be performed only in high-volume centres by a surgeon performing at least >10 LAs/year.

Differential Expression of the Androgen Receptor, Splice Variants and Relaxin 2 in Renal Cancer.

BACKGROUND: The role of the androgen receptor (AR) in renal cell carcinoma (RCC) is unclear. We aimed to analyze the expression of AR and its splice variants (SVs) and their correlation with relaxin 2 (RLN2) and cytokines in RCC. METHODS: We investigated the expression of RLN2 and AR variants in 25 clear cell RCC (ccRCC) and 9 papillary (pRCC) tumor tissues and the corresponding controls using quantitative PCR and serum RLN2, testosterone and cytokine levels in matched samples using ELISA and chemiluminescent immunometric assay, respectively. RESULTS: ccRCC tissues but not pRCC tissues more frequently expressed AR and the SVs than did normal tissues. All pRCC samples expressed more AR than did ccRCC samples. The highest expression of all AR variants except AR-V12 was found in low-stage tumors, with dominant expression of AR-V7. In males in the ccRCC cohort, the expression of AR-FL, AR-V1 and AR-V3 was significantly correlated with that of RLN2. The secretion pattern of proinflammatory IL-6 was higher in ccRCC than in pRCC. CONCLUSIONS: The results highlight additional molecular differences between ccRCC and pRCC, suggesting the influence of external factors on the whole kidney or genetic predispositions to developing certain types of renal cancer, and may support further pathological analysis and studies of targeted hormone therapy.

In vivo isolation of circulating tumor cells in patients with different stages of prostate cancer.

Circulating tumor cells (CTCs) provide accurate information on the clinical stage of cancer progression. The present study examined the clinical validity and feasibility of a new medical device for the in vivo isolation of CTCs from the blood of patients with prostate cancer (PCa). The GILUPI CellCollector® (DC01) was applied in 188 cases. The CTC/prostate-specific antigen (PSA) profile of each patient was checked for therapeutic monitoring of patients with PCa. The CellCollector, which is a unique in vivo approach for the isolation of CTCs, was compared with the CellSearch® system, which is the current standard. Overall survival (OS) and diagnostic performance were evaluated. By in vivo isolation, 78.9% (56/71) of patients with metastatic disease (PCa-m) and 46.3% (24/53) of patients with localized disease (PCa-l) had ≥1 captured CTC. Kaplan-Meier analysis revealed that patients with PCa-m that had ≥5 CTCs had a significantly different OS compared with those with <5 CTCs (27.5 months vs. 37 months; HR 2.6; 95% CI 0.78-8.3). Patients with a higher number of CTCs at all time-points had the shortest median OS of 25 months (HR 1.9; 95% CI 0.4-11.6). The effectiveness of CTC isolation technologies demonstrated that in 65.7% of the applications, patients with cancer were positive for CTCs using the CellCollector. By contrast, the CellSearch system detected CTCs in 44.4% of applications. In vivo isolation of CTCs demonstrated the clinical viability of the CellCollector, related to the current standard for the isolation of CTCs from patients with PCa. The advantage of the in vivo device is that it overcomes the blood volume limitations of other CTC assays. Furthermore, the present study revealed that the CellCollector was well tolerated, and no adverse events (AEs) or serious AEs were reported.

Laparoscopic vs open retropubic intrafascial nerve-sparing radical prostatectomy: surgical and functional outcomes in 300 patients.

OBJECTIVE: To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRP) and retropubic nsRP (nsRRP). PATIENTS AND METHODS: Between January 2005 and November 2007, 150 nsLRP and 150 nsRRP were performed at our clinic. Demographic data, variables before and after surgery, and outcomes, were compared. RESULTS: The operative duration was 165 min for nsLRP and 120 min for nsRRP. Although the nsLRP group had a lower frequency of positive margins, the difference was not statistically significant. At 1 year after surgery, complete continence was reported in 97% of patients who had nsLRP and in 91% who had nsRRP (P= 0.03). At that time, 66% of patients in the nsLRP and 51% in the nsRRP group reported being able to engage in sexual intercourse (P < 0.05). There were no statistical differences in surgical trauma in both groups. CONCLUSION: Our study showed that nsLRP performed by expert surgeons results in better functional outcomes for continence and potency than for nsRRP. There was no significant difference between the surgical techniques in surgical trauma.

Laparoscopic dismembered pyeloplasty: technique and results in 105 patients.

PURPOSE: To evaluate the postoperative and functional results of the laparoscopic dismembered pyeloplasty (LDP). PATIENTS AND METHODS: Between May 2000 and April 2008, we performed in our department 105 LDP. All patients presented an ureteropelvic junction obstruction with dilatation of renal calyx system with an enlarged renal pelvis. Demographic data (age, gender), perioperative and postoperative parameters, including operating time, estimated blood loss, complications, length of hospital stay, functional outcome were collected and evaluated. RESULTS: The mean operative time for LDP was 150 min (range 120-180 min) and the mean estimated blood loss was negligible in all patients. The mean hospital stay was 4 days (4-8). No conversion to open surgery occurred. In the follow-up, we noted a successful rate in 96.2% of the patients. CONCLUSION: Laparoscopic dismembered pyeloplasty, if performed by expert surgeons in high-volume centres, presents results that are comparable with open surgery, with a lower surgical trauma for the patients.

Robotic Donor Nephrectomy: Against.

The use of robotic techniques in laparoscopic donor nephrectomy currently tends to involve a longer ischemia time without clear advantages, and the cost of robotic surgery is significantly higher. If only one robot is available, then unnecessary prolongation of cold ischemia time also occurs, as the donor must first be undocked to dock the recipient. The combination of laparoscopic donor nephrectomy with parallel initiation of robot-assisted situs preparation and exposure of the renal vessels appears to be the best current approach to safe and cost-effective donor nephrectomy and subsequent robot-assisted kidney transplantation without wasting any time.

New Hybrid Mini-laparoendoscopic Single-site Partial Nephrectomy With Early Unclamped Technique for Renal Tumors With Intermediate PADUA Score (IDEAL Phase 2a).

OBJECTIVE: To evaluate a new hybrid technique, which we defined as mini-laparoendoscopic single-site partial nephrectomy (MILESS-PN), for renal masses presenting an intermediate PADUA score. MATERIALS AND METHODS: Forty consecutive cases of MILESS-PN performed between April 2013 and November 2015 were included in this study. Mini-laparoendoscopic single-site surgery consisted of the simultaneous use of two 3-mm pararectal trocars and an umbilical SILS trocar; the sequence of steps of MILESS-PN was comparable with standard laparoscopic partial nephrectomy. Demographic data and the main perioperative and oncological outcome parameters were gathered and analyzed. RESULTS: The median operative time was 134.6 (interquartile range [IQR] 110-180) minutes with a median warm ischemia time of 12.1 (IQR 9.5-15.5) minutes. Postoperatively, 4 early complications were recorded and the median hospital stay was 4.2 (IQR 3.5-6.0) days. The median renal tumor size was 3.6 (IQR 2.4-5.3) cm with a median PADUA score of 8.3 (IQR 8-9). The definitive pathologic results revealed a renal cell carcinoma in 32 cases (80%), an angiomyolipoma in 3 cases (7.5%), and an oncocytoma in 5 cases (12.5%). All tumors were removed with negative surgical margins, and at the median follow-up of 34.5 (IQR 24-48) months, all patients were alive without evidence of tumor recurrence or port-site metastasis. A statistically significant decrease in the estimated glomerular filtration rate (eGFR) was observed postoperatively (postoperative vs preoperative median eGFR: 87.6 [IQR 70.4-101.8] and 104.7 [IQR 82.7-123.3], P <.0001) and at 6 months (6 months vs preoperative eGFR 93.6 [IQR 79.1-110.2] and 104.7 [IQR 82.7-123.3], P <.0001). CONCLUSION: MILESS-PN for renal tumors with an intermediate PADUA score in well-selected patients is not associated with increased risks for the patients, presenting excellent oncological and functional results at the midterm follow-up. Mini-laparoendoscopic single-site surgery could represent a valid alternative to laparoendoscopic single-site surgery or minilaparoscopy because of its higher surgical reproducibility.

Laparoendoscopic single-site radical nephrectomy for renal cancer: technique and surgical outcomes.

BACKGROUND: Laparoendoscopic single-site (LESS) surgery has been developed in attempt to further reduce the morbidity and scarring associated with surgical intervention. OBJECTIVE: To describe the technique and report the surgical outcomes of LESS radical nephrectomy (RN) in the treatment of renal cell carcinoma. DESIGN, SETTING, AND PARTICIPANTS: LESS-RN was performed in 33 patients with renal tumours. The indications to perform a LESS-RN were represented by renal tumours not greater than T2 and without evidence of lymphadenopathy or renal vein involvement. SURGICAL PROCEDURE: The Endocone (Karl Storz, Tuttlingen, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and bent grasper and scissors was used. The sequence of steps of LESS-RN was comparable to standard laparoscopic RN. MEASUREMENTS: Demographic data and perioperative and postoperative variables were recorded and analysed. RESULTS AND LIMITATIONS: The mean operative time was 143.7±24.3 min, with a mean estimated blood loss of 122.3±34.1 ml and a mean hospital stay of 3.8±0.8 d. The mean length of skin incision was 4.1±0.6 cm and all patients were discharged from hospital with minimal discomfort, as demonstrated by their pain assessment scores (visual analogue scale: 1.9±0.8). The definitive pathologic results revealed a renal cell carcinoma in all cases and a stage distribution of four T1a, 27 T1b, and 2 T2 tumours. All patients were very satisfied with the appearance of the scars, and at a median follow-up period of 13.2±3.9 mo, all patients were alive without evidence of tumour recurrence or port-site metastasis. CONCLUSIONS: LESS is a safe and feasible surgical procedure for RN in the treatment of renal cell carcinoma and has excellent cosmetic results.

Is intensive multimodality therapy the best treatment for fournier gangrene? Evaluation of clinical outcome and survival rate of 41 patients.

BACKGROUND: To evaluate the effect of surgical wound debridement, antibiotics, and hyperbaric oxygen (HBO) in the treatment of Fournier gangrene (FG). METHODS: Forty-one patients with a mean age of 54.3±14.6 years were referred to our department with a diagnosis of FG. To calculate a Fourier Gangrene Severity Index (FGSI), nine factors were assessed (temperature; heart rate; ventilatory rate; serum sodium, potassium, creatinine, and bicarbonate concentrations; hematocrit; and leukocyte count). After clinical stabilization, extensive debridement of the necrotic tissue was performed, and a surgical vacuum-assisted closure (V.A.C.®) device was applied. Hyperbaric oxygen was administered; medical therapy consisted of intravenous antibiotics, electrolyte replacement, and parenteral nutrition. RESULTS: Intraoperative cultures revealed Escherichia coli in 27 patients (66%), Pseudomonas aeruginosa in 28 (68%), gram-positive cocci in 24 (59%), and mixed flora (aerobic and anaerobic bacteria) in 39 (95%). One month after primary debridement, wound granulation was sufficient for plastic surgical reconstruction in all patients. CONCLUSION: Because of the rapid worsening of FG, early diagnosis and immediate, aggressive multi-modality therapy with surgical debridement and broad-spectrum empiric antibiotics is crucial. The utility of HBO remains unproved.