Outcome of Mini-PCNL Under Loco-Regional Anesthesia: Outcomes of a Systematic Review.

PURPOSE OF REVIEW: Miniaturized PCNL (mi-PCNL) for stone disease is performed under a general anesthesia. However, the role of loco-regional anesthesia in mi-PCNL and its outcomes are not well defined yet. Here, we review the outcomes and complications of loco-regional anesthesia for mi-PCNL. A Cochrane-style review was performed in accordance with the preferred reporting items for systematic reviews to evaluate the outcomes of loco-reginal anesthesia for URS in stone disease, including all English language articles from January 1980 and October 2021. RECENT FINDINGS: Ten studies with a total of 1663 patients underwent mi-PCNL under loco-regional anesthesia. The stone-free rate (SFR) for mi-PCNL under neuro-axial anesthesia ranged between 88.3 and 93.6%, while it ranged between 85.7 and 93.3% for mi-PCNL under local anesthesia (LA). The conversion rate to another anesthesia modality was 0.5%. The complications ranged widely between 3.3 and 85.7%. The majority were Grade I-II complications and none of the patients had grade V complications. Our review shows that mi-PCNL under loco-regional anesthesia is feasible with good SFR and a low risk of major complications. The conversion to general anesthesia is needed in a small minority, with the procedure itself being well tolerated and a big step towards establishing an ambulatory pathway for these patients.

Regional versus general anaesthesia in percutaneous nephrolithotomy: a systematic review and meta-analysis.

Introduction: Several studies have compared the safety and effectiveness of general and regional anaesthesia in percutaneous nephrolithotomy (PCNL). This study aimed to compare the perioperative and postoperative outcomes of general anaesthesia and regional anaesthesia for patients undergoing PCNL. Material and methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until March 2023. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. The risk ratio (RR) and mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI). Results: The final cohort analysis, comprised 3871 cases of PCNL, (2154 regional anaesthesia and 1717 general anaesthesia). Compared to general anaesthesia, the regional anaesthesia group had a significantly shorter length of stay (MD = -0.34 days, 95% CI -0.56 to -0.12, p = 0.002), lower postoperative nausea and vomiting rates (RR = 0.16, 95% CI 0.03 to 0.80, p = 0.026), lower complications grade III-V rates (RR = 0.68, 95% CI 0.53 to 0.88, p = 0.004), and lower postoperative visual analogue pain score (VAS) at 1 hour (MD = -3.5, 95% CI -4.1 to -2.9, p <0.001). There were no significant differences in other outcomes between the two groups. Conclusions: Our results show that PCNL under regional anaesthesia is safe and feasible, with comparable results to those done under general anaesthesia. While patient selection is important, counselling and decision-making for these procedures must go hand in hand to achieve the best clinical outcome.

Outcomes of Percutaneous Nephrolithotomy Under Local Anesthesia: Outcomes of a Systematic Review of Literature.

Background: Several studies have reported on the safety and feasibility of percutaneous nephrolithotomy (PCNL) under local anesthesia (LA). The aim of this systematic review is to assess the perioperative outcomes of PCNL under LA. Methods: Three electronic databases, including MEDLINE, EMBASE, and Web of Science, were searched for relevant English-language studies published from January 1980 to March 2023. The systematic review has been performed according to the Cochrane style and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. The primary outcomes include stone-free rate (SFR) and conversion to general anesthesia (GA). Secondary outcomes include postoperative complications. Results: Of 301 articles that were extracted, 42 full-text articles were selected, of which 36 were excluded, yielding a total of 6 articles in our results. A total of 3646 patients were included in this review. The SFR of PCNL under LA ranged between 69.9% and 93.3%. PCNL under LA was not tolerated by 19 (0.5%) patients: 6 patients had conversion to general anesthesia, 2 had conversion to epidural anesthesia, and 11 had their procedure terminated. The overall complication rates varied from 4.8% to 21% across studies. Grade I-II complications were reported in 2.4%-16.7% of cases, while grade III-IV complications were encountered in 0.5%-5% of patients. Conclusions: In this review, we found a few studies that examined the outcomes of PCNL under LA, which highlight the feasibility and safety of PCNL under LA and the low conversion rate to GA.

Oncological and Functional Outcomes of Robot-Assisted Radical Prostatectomy in Kidney Transplant Recipients.

OBJECTIVE: Management of prostate cancer in kidney transplant recipients presents a unique surgical challenge due to the risk of direct or indirect injury to the transplanted kidney. Herein, we report the largest single center study of Robot-assisted Radical prostatectomy (RARP) in kidney transplant recipients. METHODS: Between Jan 2014-2019, 14 kidney transplant recipients with prostate cancer underwent RARP. Clinical and pathological features, perioperative and postoperative complications were retrospectively evaluated. Continence was defined as by patient utilization of zero urinary pads postoperatively. RESULTS: The median (IQR) age at RARP was 60.2 (57.8-61.3) years, the interval between kidney transplant and RARP was 8.1 ± 7.5 years. The median (IQR) PSA was 6.9 (4-8.6); 10 of 14 patients had intermediate or high-risk prostate cancer. The median ASA score was 3, the mean (SD) operative time was 129.7 (26.3) minutes, and mean (SD) blood loss was 110 (44.6) ml. All cases were completed robotically, there was no graft loss or injury to transplanted ureter, and the mean length of stay was 1 (0.26) day.Final pathology demonstrated that 42.8% (6/14) of the patients had nonorgan confined disease (pT3a/T3b). 50% (7/14) of the patients were upgraded to higher risk Gleason disease on final surgical pathology. Post-RARP continence rate at 3 months, and 12 months were 45.5% (5/11) and 87.5% (7/8), respectively. CONCLUSION: RARP following kidney transplantation represents a safe and feasible operation which does not appear to compromise oncological or transplant outcomes.

Robotic ureterocalicostomy in the pediatric population.

PURPOSE: Ureterocalicostomy is a potential option in patients with ureteropelvic junction obstruction and significant lower pole calicectasis. It is often reserved for patients with a failed pyeloplasty and a minimal pelvis, or patients with an exaggerated intrarenal pelvis. We present our technique of robotic ureterocalicostomy in the pediatric population as a primary modality for an exaggerated intrarenal collecting system not amenable to standard dismembered pyeloplasty, and for secondary ureteropelvic junction obstruction. MATERIALS AND METHODS: Nine patients 3 to 15 years old (mean age 6.5) underwent transperitoneal robotic ureterocalicostomy for ureteropelvic junction obstruction. Six of the patients had recurrent ureteropelvic junction obstruction after primary pyeloplasty performed elsewhere. The remaining 3 patients had an exaggerated intrarenal collecting system with minimal or no appreciable renal pelvis for reconstruction. Outcome measures included operative time, length of hospital stay and postoperative ultrasound at 3 months, as well as resolution of obstruction by diuretic radionuclide imaging at 6 and 12 months of followup. RESULTS: Mean operative time was 168 minutes (range 102 to 204) for the ureterocalicostomy portion. Two patients underwent concomitant pyelolithotomy, with 14 and 21 minutes added to the operative time. Mean hospital stay was 21 hours (range 17 to 26). Diuretic radionuclide imaging, which was performed in all patients at 6 and 12 months postoperatively, revealed no evidence of obstruction in any patient. CONCLUSIONS: Robotic ureterocalicostomy is a viable and technically feasible treatment option for patients with recurrent ureteropelvic junction obstruction, or patients with difficult intrarenal ureteropelvic junctions.

Multiple repeat prostate biopsies and the detection of clinically insignificant cancer in men with large prostates.

OBJECTIVE: To determine the impact of repeating prostate biopsies on the risk of detecting clinically insignificant prostate cancer (PCa) in larger prostate glands. METHODS: We performed a retrospective cohort study using patients enrolled in our institutional PCa registry from 1991 to 2008 to assess the association of prostate volume and clinically insignificant PCa in men undergoing multiple prostate biopsies. Patients were stratified by prostate volume into 2 cohorts (<50 cm(3) or ≥50 cm(3)). Additionally, patients were stratified by prostate biopsy on which PCa was identified (1 biopsy or ≥3 biopsies). RESULTS: Within the subgroup of patients with prostate volume ≥50 cm(3) requiring ≥3 biopsies before cancer diagnosis, 72.6% (45/62) had pathologic Gleason scores ≤6 and 81.6% (49/60) had an estimated tumor volume of ≤10% at the time of radical prostatectomy. This was significantly different from patients with prostate volume <50 cm(3) diagnosed on their first biopsy, in which only 48.5% (656/1349) were found to have Gleason scores ≤6 and 54.2% (705/1300) had estimated tumor volume ≤10% (P <.01). There was no significant difference in the rate of Gleason score upgrading at time of prostatectomy between any of the subgroups. CONCLUSION: PCas detected in men with prostatic enlargement requiring multiple biopsies are more likely to be low-grade, low-volume tumors at final pathology than men without prostate enlargement. Men with larger prostates who have already had prior negative biopsies should be counseled regarding the increased risk of detecting clinically insignificant PCa with additional biopsies.