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PURPOSE: Robot-assisted laparoscopic pyeloplasty (RALP) use in children has increased, though many centers still favor open pyeloplasty (OP) in infants. This study aims to compare safety and efficacy of RALP and OP in infants. MATERIALS AND METHODS: A single-institution, retrospective cohort study of infants <1 year of age who underwent primary RALP or OP between January 2009 and June 2020 was performed. Primary outcomes were intraoperative and 30-day complications, postoperative radiographic improvement at last clinic visit, and operative failure leading to redo pyeloplasty. Multivariable logistic regression was performed for 30-day complications to adjust for demographic variation between groups. Survival analysis was performed to compare time to diagnosis of operative failure leading to redo pyeloplasty. RESULTS: Among 204 patients, 121 underwent OP and 83 underwent RALP (74.5% male). RALP patients were older (median 7.2 vs 2.9 months, p <0.001) and larger (median 8.2 vs 5.9 kg, p <0.001) than OP patients. Radiographic improvement was seen in 91.1% of RALP patients and 88.8% of OP patients at last visit. Median (interquartile range) followup in months was 24.4 (10.8-50.3) for the full cohort. In adjusted analysis, the odds of a 30-day complication (OR 0.40, 95% CI 0.08-2.00) was lower for RALP compared to OP, though not statistically significant. In survival analysis, there was no difference in time to diagnosis of operative failure and redo pyeloplasty between groups (p=0.65). CONCLUSIONS: RALP is a safe and effective alternative to OP for infants, with comparable intraoperative and 30-day complications, radiographic improvement at last followup, and risk of pyeloplasty failure.
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Pelve Renal/cirurgia , Laparoscopia/efeitos adversos , Procedimentos de Cirurgia Plástica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Obstrução Ureteral/cirurgia , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Pelve Renal/diagnóstico por imagem , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Procedimentos de Cirurgia Plástica/métodos , Procedimentos de Cirurgia Plástica/estatística & dados numéricos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Análise de Sobrevida , Resultado do Tratamento , Ureter/diagnóstico por imagem , Ureter/cirurgia , Obstrução Ureteral/congênito , Obstrução Ureteral/mortalidadeRESUMO
BACKGROUND: A significant proportion of boys present to surgical specialists later in infancy/early childhood for elective operative circumcision despite the higher procedural risks. This study aims to assess physician perspectives on access to neonatal circumcision across the United States and identify potential reasons contributing to disparities in access. METHODS: A cross-sectional survey was electronically distributed to physician members of the Societies for Pediatric Urology and the American Academy of Pediatrics Section on Hospital Medicine. Hospital characteristics and circumcision practices were assessed. Associations between NC availability and institutional characteristics were evaluated using chi-squared testing and multivariable logistic regression. Qualitative analyses of free-text comments were performed. RESULTS: A total of 367 physicians responded (129 urologists [41%], 188 pediatric hospitalists [59%]). Neonatal circumcision was available at 86% of hospitals represented. On univariate and multivariate analysis, the 50 hospitals that did not offer neonatal circumcision were more likely to be located in the Western region (odds ratio [OR] = 8.33; 95% confidence interval [CI] 3.1-25 vs. Midwest) and in an urban area (OR = 4.2; 95% CI 1.6-10 vs. suburban/rural) compared with hospitals that offered neonatal circumcision. Most common reasons for lack of availability included not a birth hospital (N = 22, 47%), lack of insurance coverage (N = 8, 17%), and low insurance reimbursement (N = 7, 15%). Institutional, regional, or provider availability (68%), insurance/payment (12.4%), and ethics (12.4%) were common themes in the qualitative comments. CONCLUSIONS: Overall availability of neonatal circumcision varied based on hospital characteristics, including geography. Information from this survey will inform development of interventions designed to offer neonatal circumcision equitably and comprehensively.
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Circuncisão Masculina/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Estudos Transversais , Médicos Hospitalares , Hospitais , Humanos , Recém-Nascido , Cobertura do Seguro , Reembolso de Seguro de Saúde , Masculino , Padrões de Prática Médica , Estados Unidos , UrologistasRESUMO
PURPOSE: We determined the effect of 5α-reductase inhibitors on disease reclassification in men with prostate cancer optimally selected for active surveillance. MATERIALS AND METHODS: In this retrospective review we identified 635 patients on active surveillance between 2002 and 2015. Patients with favorable cancer features on repeat biopsy, defined as absent Gleason upgrading, were included in the cohort. Patients were stratified by those who did or did not receive finasteride or dutasteride within 1 year of diagnosis. The primary end point was grade reclassification, defined as any increase in Gleason score or predominant Gleason pattern on subsequent biopsy. This was assessed by multivariable Cox proportional hazards regression analysis. RESULTS: At diagnosis 371 patients met study inclusion criteria, of whom 70 (19%) were started on 5α-reductase inhibitors within 12 months. Median time on active surveillance was 53 vs 35 months in men on vs not on 5α-reductase inhibitors (p <0.01). Men on 5α-reductase inhibitors received them for a median of 23 months (IQR 6-37). On actuarial analysis there was no significant difference in grade reclassification for 5α-reductase inhibitor use in patients overall or in the very low/low risk subset. The overall percent of patients who experienced grade reclassification was similar at 13% vs 14% (p = 0.75). After adjusting for baseline clinicopathological features 5α-reductase inhibitors were not significantly associated with grade reclassification (HR 0.80, 95% CI 0.31-1.80, p = 0.62). Furthermore, no difference in adverse features on radical prostatectomy specimens was observed in treated patients (p = 0.36). CONCLUSIONS: Among our cohort of men on active surveillance 5α-reductase inhibitor use was not associated with a significant difference in grade reclassification with time.
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Inibidores de 5-alfa Redutase/uso terapêutico , Antineoplásicos/uso terapêutico , Neoplasias da Próstata/tratamento farmacológico , Conduta Expectante , Adulto , Idoso , Esquema de Medicação , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Modelos de Riscos Proporcionais , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE: Currently no data exist to guide renal surgeons on the perioperative use of renin-angiotensin blockers despite potential cardiorenal benefits. We aimed to assess the impact of resuming renin-angiotensin blockers on postoperative renal function and adverse cardiac events following partial nephrectomy. MATERIALS AND METHODS: This is an observational analysis of patients who underwent robot-assisted laparoscopic partial nephrectomy from 2006 to 2014 at a single institution. The Wilcoxon rank sum and chi-square tests, and logistic regression were used to assess the risk of adverse renal and cardiac events stratified by history and pattern of renin-angiotensin blockade perioperatively. RESULTS: We identified 900 patients with a median followup of 16.3 months (IQR 1.4-39.1). There were no significant differences in severe renal dysfunction at last followup on univariate analysis or adverse cardiac events at 30 days on multivariate analysis in patients stratified by a history of renin-angiotensin blockade. Of the 338 patients 137 (41.9%) resumed renin-angiotensin blockade immediately after surgery, which did not result in any significant difference in the postoperative glomerular filtration rate (p >0.05). Resuming renin-angiotensin blockade at discharge home was associated with a decreased risk of heart failure within 30 days of surgery (0.3% vs 11.8% of cases) and stage IV/V chronic kidney disease at last followup (2.6% vs 25.5%, each p <0.001). CONCLUSIONS: Renin-angiotensin blockers appear safe to continue immediately after renal surgery. Discharge home with angiotensin converting enzyme inhibitors/angiotensin receptor blockers was associated with a decreased risk of heart failure and severe renal dysfunction. However, this risk may be overstated as a result of the small number of patients discharged without resuming the home medication.
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Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Síndrome Cardiorrenal/prevenção & controle , Laparoscopia/métodos , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Feminino , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
PURPOSE: We compare intermediate term clinical outcomes among men with favorable risk and intermediate/high risk prostate cancer managed by active surveillance. MATERIALS AND METHODS: A total of 635 men with localized prostate cancer have been on active surveillance since 2002 at a high volume academic hospital in the United States. Median followup is 50.5 months (IQR 31.1-80.3). Time to event analysis was performed for our clinical end points. RESULTS: Of the cohort 117 men (18.4%) had intermediate/high risk disease. Overall 5 and 10-year all cause survival was 98% and 94%, respectively. Cumulative metastasis-free survival at 5 and 10 years was 99% and 98%, respectively. To date no cancer specific deaths had been observed. Overall freedom from intervention was 61% and 49% at 5 and 10 years, respectively. Overall cumulative freedom from failure of active surveillance, defined as metastasis or biochemical failure after local therapy with curative intent, was 97% and 91% at 5 and 10 years, respectively. Of the men 21 (9.9%) experienced biochemical failure after deferred treatment and the 5-year progression-free probability was 92%. Compared to men with favorable risk disease those with intermediate/high risk cancer experienced no difference in metastases, surveillance failure or curative intervention. However, patients at higher risk were at significantly increased risk for all cause mortality, likely reflecting patient selection factors. These conclusions may be limited by the small number of events and the duration of our study. CONCLUSIONS: Patients with localized prostate cancer who are on active surveillance demonstrated a low rate of active surveillance failure, prostate cancer specific mortality and metastases regardless of baseline risk.
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Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Conduta Expectante , Idoso , Estudos de Coortes , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Intervalo Livre de Progressão , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Medição de Risco , Taxa de SobrevidaRESUMO
Seminomas account for approximately 50% of all cases of testicular cancer. Testicular cancer is a highly curable disease that can be broadly classified as either seminomatous or nonseminomatous; the management and treatment of the 2 forms vary widely. Although surgery plays a large role in the management of nonseminoma, its role in the management of seminoma is much more limited. Most clinicians in the United States choose orchiectomy followed by surveillance for patients with stage I seminomatous disease, and chemotherapy or radiation-followed by surgery for the management of residual masses-for patients with disease that is stage II and higher. Recently, clinicians have proposed a larger role for surgery in stage II seminoma to avoid the long-term toxic effects of chemotherapy and radiation therapy. In this review, we discuss the oncologic rationale for the treatment of seminoma, the role of surgery, and the use of minimally invasive operative techniques for retroperitoneal lymph node dissection.
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Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Orquiectomia/métodos , Seminoma/cirurgia , Neoplasias Testiculares/cirurgia , Humanos , Masculino , Estadiamento de Neoplasias , Seminoma/patologia , Neoplasias Testiculares/patologiaRESUMO
INTRODUCTION: Prior research conducted on treatment of erectile dysfunction (ED) has been derived from surveys involving relatively small populations of men. There are needs for large population-based studies in this area. Our study addresses that need. AIM: The aim of this study was to characterize ED treatment among a large population of men. METHODS: Patients ≥30 years in commercial insurance dataset with diagnosis code for ED during 12-month period ending June 2011 were identified. Men were considered "treated" if prescription was filled for phosphodiesterase type 5 inhibitor (PDE5i), injection or urethral prostaglandins, or androgen replacement (ART) during study period. "Untreated" patients received the diagnosis but did not fill prescription. Statistical analyses were used to compare prescription frequency with clinical characteristics, including age and comorbidities. MAIN OUTCOME MEASURES: ED treatment rates among large population of insured men, treatment types employed, patient demographics, associated medical comorbidities of this population, and prescriber details were the main outcome measures. RESULTS: Only 25.4% of 6,228,509 men with ED were treated during study period. While PDE5is were the most commonly prescribed medical therapy (75.2%), ART was utilized as monotherapy or in combination therapy in 30.6% of men. ART was significantly (P < 0.0001) more frequently used in men <40 and >65 years. Although ED frequency was associated with increased age and number of comorbidities, men >60 years were significantly (P < 0.0001) less likely to be treated compared with men aged 40-59 years. Additionally, treatment frequency did not vary as a function of number of comorbidities. However, compared with men with prostate cancer, men with comorbid hypogonadism, sleep disorders, benign prostatic hyperplasia, or components of metabolic syndrome were (P < 0.0001) more likely to be treated. CONCLUSIONS: Despite high prevalence of ED with age and comorbidities, most men continue receiving no treatment. Although benefits of medical intervention for ED are well-recognized, many barriers to treatment continually exist including physician, patient and partner preference and knowledge.
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Disfunção Erétil/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Adulto , Idoso , Comorbidade , Disfunção Erétil/epidemiologia , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Prevalência , Hiperplasia Prostática/tratamento farmacológico , Hiperplasia Prostática/epidemiologia , Neoplasias da Próstata/tratamento farmacológico , Neoplasias da Próstata/epidemiologiaRESUMO
To date, there are no efficacious translational solutions for end-stage urinary bladder dysfunction. Current surgical strategies, including urinary diversion and bladder augmentation enterocystoplasty (BAE), utilize autologous intestinal segments (e.g. ileum) to increase bladder capacity to protect renal function. Considered the standard of care, BAE is fraught with numerous short- and long-term clinical complications. Previous clinical trials employing tissue engineering approaches for bladder tissue regeneration have also been unable to translate bench-top findings into clinical practice. Major obstacles still persist that need to be overcome in order to advance tissue-engineered products into the clinical arena. These include scaffold/bladder incongruencies, the acquisition and utility of appropriate cells for anatomic and physiologic tissue recapitulation, and the choice of an appropriate animal model for testing. In this study, we demonstrate that the elastomeric, bladder biomechanocompatible poly(1,8-octamethylene-citrate-co-octanol) (PRS; synthetic) scaffold coseeded with autologous bone marrow-derived mesenchymal stem cells and CD34+ hematopoietic stem/progenitor cells support robust long-term, functional bladder tissue regeneration within the context of a clinically relevant baboon bladder augmentation model simulating bladder trauma. Partially cystectomized baboons were independently augmented with either autologous ileum or stem-cell-seeded small-intestinal submucosa (SIS; a commercially available biological scaffold) or PRS grafts. Stem-cell synergism promoted functional trilayer bladder tissue regeneration, including whole-graft neurovascularization, in both cell-seeded grafts. However, PRS-augmented animals demonstrated fewer clinical complications and more advantageous tissue characterization metrics compared to ileum and SIS-augmented animals. Two-year study data demonstrate that PRS/stem-cell-seeded grafts drive bladder tissue regeneration and are a suitable alternative to BAE.
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OBJECTIVE: To characterize elective, post-neonatal operative circumcision at US children's hospitals, in the context of established sociodemographic disparities in access to neonatal circumcision. METHODS: A retrospective cohort study was performed of boys undergoing elective, operative circumcision at the 23 Pediatric Health Information System (PHIS) hospitals who contributed data from 2004-2018. Boys > = 36 months' and those with congenital anomalies of the penis were excluded. Bivariate statistics were used to compare the circumcision cohort to a referent cohort of boys undergoing other ambulatory surgery or having an observational hospital stay. RESULTS: The annual median number of operative circumcisions per hospital increased during the study (72 [IQR 54-162] to 136 [IQR 88-266], P = .003). Boys undergoing circumcision were mostly non-Hispanic White (46.7%) or non-Hispanic Black (30.9%), in the lowest income quartile (26.6%), from the Southern US (51.5%), and publicly-insured (60.5%). When compared to the reference cohort, boys undergoing circumcision were more likely to be non-Hispanic Black (30.9 vs 15.7%, P = .001) and publicly-insured (60.5 vs 45.9%, P = . 001). CONCLUSION: The number of post-neonatal operative circumcisions performed at US children's hospitals nearly doubled from 2004 to 2018. Study findings suggest an emerging healthcare disparity, with non-Hispanic Black boys of lower socioeconomic status undergoing more post-neonatal operative circumcisions that are more expensive and higher risk.
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Circuncisão Masculina , Pré-Escolar , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Masculino , Estudos RetrospectivosRESUMO
INTRODUCTION: Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital. MATERIAL AND METHODS: Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new "Groin-Penis Tray" (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared. RESULTS: A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figure compares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5 min (p < 0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p = 0.34). The new GPT is 2.7 kg lighter than the prior tray. Median OR time remained stable (baseline: 91 min; post-implementation: 102 min, p = 0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later. DISCUSSION: This systematic, iterative QI process spanned the course of â¼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives. CONCLUSIONS: Streamlining surgical trays for common pediatric urologic procedures at a large freestanding children's hospital using established QI methodology reduced OR cost by >$51,000/year and Mayo stand set-up times without compromising balancing measures.
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Melhoria de Qualidade , Urologia , Masculino , Humanos , Criança , Instrumentos Cirúrgicos , Salas Cirúrgicas , Redução de CustosRESUMO
Nanotechnology has introduced many exciting new tools for the treatment of human diseases. One of the obstacles in its application to that end is the lack of a fundamental understanding of the interaction that occurs between nanoparticles and living cells. This report describes the quantitative analysis of the kinetics and endocytic pathways involved in the uptake of anatase titanium dioxide (TiO(2)) nanoparticles into prostate cancer PC-3M cells. The experiments were performed with TiO(2) nanoconjugates: 6-nm nanoparticles with surface-conjugated fluorescent Alizarin Red S. Results obtained by flow cytometry, fluorescence microscopy, and inductively coupled plasma-mass spectrometry confirmed a complex nanoparticle-cell interaction involving a variety of endocytic mechanisms. The results demonstrated that a temperature, concentration, and time-dependent internalization of the TiO(2) nanoparticles and nanoconjugates occurred via clathrin-mediated endocytosis, caveolin-mediated endocytosis, and macropinocytosis. FROM THE CLINICAL EDITOR: The interaction and uptake of TiO(2) nanoparticles (6-nm) with prostate PC-3M cells was investigated and found to undergo temperature, time, and concentration dependent intracellular transport that was mediated through clathrin pits, caveolae, and macropinocytosis. These results suggest that nanoparticles may widely permeate through tissues and enter almost any active cell through a variety of biological mechanisms, posing both interesting opportunity and possible challenges for systemic use.
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Endocitose/fisiologia , Nanopartículas Metálicas , Neoplasias da Próstata/metabolismo , Titânio/metabolismo , Cavéolas/metabolismo , Linhagem Celular Tumoral , Clatrina/metabolismo , Humanos , Masculino , Nanotecnologia , Tamanho da PartículaRESUMO
While few publications have documented the uptake of nanoparticles in plants, this is the first study describing uptake and distribution of the ultrasmall anatase TiO(2) in the plant model system Arabidopsis. We modified the nanoparticle surface with Alizarin red S and sucrose and demonstrated that nanoconjugates traversed cell walls, entered into plant cells, and accumulated in specific subcellular locations. Optical and X-ray fluorescence microscopy coregistered the nanoconjugates in cell vacuoles and nuclei.
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Antraquinonas/metabolismo , Arabidopsis/ultraestrutura , Nanopartículas , Titânio/metabolismo , Antraquinonas/química , Arabidopsis/metabolismo , Transporte Biológico , Microscopia de Fluorescência , Nanopartículas/química , Titânio/química , Raios XRESUMO
OBJECTIVE: To address information overload for trainees, a concise electronic case-based urology learning program (CBULP) was developed. Previous qualitative assessments suggested CBULP's potential efficacy/utility. Herein we assess CBULP more stringently by evaluating test performance before/after reviewing a CBULP curriculum covering core concepts in testicular cancer. METHODS: Eleven of 33 CBULP testicular cancer cases were strategically selected for this curriculum. A 26 question multiple-choice test was developed to assess fundamental knowledge about testis cancer tumor biology and evaluation/management. Pretest was administered to PGY4/PGY1 residents at 2 pilot urology-training programs, and medical students interested in Urology. Participants were given 4 weeks to review the curriculum and the test was then repeated. A control group (4 PGY1s) was administered the pretest and repeat test in an analogous manner without provision of the CBULP curriculum. RESULTS: Twenty individuals took the pretest (7 medical students, 8 PGY1s, and 5 PGY4s), and 17 (85%) took the post-test (5 medical students, 8 PGY1s, and 4 PGY4s,). As expected, PGY4s performed significantly better than the other 2 groups on the pre- and post-test. However, significant improvement in test performance was seen across all groups that utilized the CBULP curriculum (P <.02), with highest increase demonstrated by PGY1 residents (4.75 more questions correct, Pâ¯=â¯.002). The control arm did not demonstrate significant improvement (Pâ¯=â¯.20). CONCLUSION: Significant improvement in test performance was observed after completion of the CBULP testicular series. This study suggests that CBULP can be an efficacious and clinically useful educational resource for urologic residents and students interested in the field.
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Currículo , Educação de Graduação em Medicina/métodos , Internato e Residência/métodos , Neoplasias Testiculares/diagnóstico , Urologia/educação , Adulto , Competência Clínica , Instrução por Computador/métodos , Educação de Graduação em Medicina/estatística & dados numéricos , Avaliação Educacional/estatística & dados numéricos , Humanos , Internato e Residência/estatística & dados numéricos , Masculino , Avaliação de Programas e Projetos de Saúde , Estudantes de Medicina/estatística & dados numéricos , Neoplasias Testiculares/patologia , Neoplasias Testiculares/terapiaRESUMO
Germline PTEN mutations defining PTEN hamartoma tumor syndrome (PHTS) confer heritable predisposition to breast, endometrial, thyroid and other cancers with known age-related risks, but it remains impossible to predict if any individual will develop cancer. In the general population, gut microbial dysbiosis has been linked to cancer, yet is unclear whether these are associated in PHTS patients. In this pilot study, we aimed to characterize microbial composition of stool, urine, and oral wash from 32 PTEN mutation-positive individuals using 16S rRNA gene sequencing. PCoA revealed clustering of the fecal microbiome by cancer history (P = 0.03, R2 = 0.04). Fecal samples from PHTS cancer patients had relatively more abundant operational taxonomic units (OTUs) from family Rikenellaceae and unclassified members of Clostridia compared to those from non-cancer patients, whereas families Peptostreptococcaceae, Enterobacteriaceae, and Bifidobacteriaceae represented relatively more abundant OTUs among fecal samples from PHTS non-cancer patients. Functional metagenomic prediction revealed enrichment of the folate biosynthesis, genetic information processing and cell growth and death pathways among fecal samples from PHTS cancer patients compared to non-cancer patients. We found no major shifts in overall diversity and no clustering by cancer history among oral wash or urine samples. Our observations suggest the utility of an expanded study to interrogate gut dysbiosis as a potential cancer risk modifier in PHTS patients.
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Síndrome do Hamartoma Múltiplo/microbiologia , Microbiota/genética , PTEN Fosfo-Hidrolase/genética , Adolescente , Adulto , Idoso , DNA Bacteriano/genética , Disbiose , Fezes/microbiologia , Feminino , Mutação em Linhagem Germinativa , Humanos , Masculino , Pessoa de Meia-Idade , Boca/microbiologia , RNA Ribossômico 16S/genética , Fatores de Risco , Urina/microbiologia , Adulto JovemRESUMO
OBJECTIVE: With the evolution of robot-assisted surgery in the urology field, this technology is being applied to treat many genitourinary conditions.1 Although incidence of urolithiasis and renal neoplasm has increased, encountering both entities in a single kidney is noteworthy. Our video exhibits the concurrent management of a renal calculus and an ipsilateral renal neoplasm using a robotic platform. MATERIALS AND METHODS: A 53-year-old man was diagnosed with a 1.7-cm left renal pelvis calculus and a 4.7-cm enhancing ipsilateral upper pole renal mass (R.E.N.A.L score 8a) after an episode of flank pain. After reviewing preoperative imaging, a single-setting approach using a robotic platform was planned. Main steps of our robotic technique on the case included (1) kidney defatting and mobilization, (2) hilum and ureter dissection up to the renal pelvis, (3) intraoperative ultrasound for tumor demarcation and stone localization, (4) anterior robotic pyelolithotomy,2 (5) double J stent placement and pyelotomy closure, (6) excision of renal mass, and (7) renorrhaphy. Perioperative outcomes were recorded. RESULTS: The operative time was 180 minutes and the estimated blood loss was 100 mL. Warm ischemia time was 17 minutes. There were no intra- or postoperative complications. The patient was discharged home on postoperative day 3. Final pathology reported a 3.4-cm mass consistent with a clear cell renal carcinoma, with a tumor, nodes, metastases (TNM) staging pT1aNx and negative surgical margin. The double J stent was removed after 4 weeks, and the patient remained asymptomatic at 1 month postoperatively. CONCLUSION: Pyelolithotomy and robotic partial nephrectomy can be performed effectively when treating patients with concurrent kidney mass and renal stone using the same surgical access. This minimally invasive approach should be contemplated as an option when managing patients with both conditions in an ipsilateral kidney. Furthermore, it will diminish the necessity of various surgeries while preserving renal function and maintaining oncological outcomes. We underline that the association of both procedures increases the likelihood of technical complications and risk for clot-related or stone-related ureteral obstruction, infection, and urine leak.
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Cálculos Renais/cirurgia , Neoplasias Renais/cirurgia , Pelve Renal/cirurgia , Nefrectomia/métodos , Nefrotomia , Procedimentos Cirúrgicos Robóticos , Humanos , Cálculos Renais/complicações , Neoplasias Renais/complicações , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
Malignancies of the urinary tract (kidney, ureter, and bladder) are distinct clinical entities. Hematuria is a unifying common presenting symptom for these malignancies. Surgical management of localized disease continues to be the mainstay of treatment, and early detection is important in the prognosis of disease. Patients often require life-long follow-up and assessment for recurrence.