Abstract Context Recent advances in technology have led to the implementation of mini– and micro–percutaneous nephrolithotomy (PCNL) as well as retrograde intrarenal surgery (RIRS) in the management ...of kidney stones. Objective To provide a systematic review and meta-analysis of studies comparing RIRS with PCNL techniques for the treatment of kidney stones. Evidence acquisition A systematic literature review was performed in March 2014 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. A subgroup analysis was performed comparing standard PCNL and minimally invasive percutaneous procedures (MIPPs) including mini-PCNL and micro-PCNL with RIRS, separately. Evidence synthesis Two randomised and eight nonrandomised studies were analysed. PCNL techniques provided a significantly higher stone-free rate (weighted mean difference WMD: 2.19; 95% confidence interval CI, 1.53–3.13; p < 0.00001) but also higher complication rates (odds ratio OR: 1.61; 95% CI, 1.11–2.35; p < 0.01) and a larger postoperative decrease in haemoglobin levels (WMD: 0.87; 95% CI, 0.51–1.22; p < 0.00001). In contrast, RIRS led to a shorter hospital stay (WMD: 1.28; 95% CI, 0.79–1.77; p < 0.0001). At subgroup analysis, RIRS provided a significantly higher stone-free rate than MIPPs (WMD: 1.70; 95% CI, 1.07–2.70; p = 0.03) but less than standard PCNL (OR: 4.32; 95% CI, 1.99–9.37; p = 0.0002). Hospital stay was shorter for RIRS compared with both MIPPs (WMD: 1.11; 95% CI, 0.39–1.83; p = 0.003) and standard PCNL (WMD: 1.84 d; 95% CI, 0.64–3.04; p = 0.003). Conclusions PCNL is associated with higher stone-free rates at the expense of higher complication rates, blood loss, and admission times. Standard PCNL offers stone-free rates superior to those of RIRS, whereas RIRS provides higher stone free rates than MIPPs. Given the added morbidity and lower efficacy of MIPPs, RIRS should be considered standard therapy for stones <2 cm until appropriate randomised studies are performed. When flexible instruments are not available, standard PCNL should be considered due to the lower efficacy of MIPPs. Patient summary We searched the literature for studies comparing new minimally invasive techniques for the treatment of kidney stones. The analysis of 10 available studies shows that treatment can be tailored to the patient by balancing the advantages and disadvantages of each technique.
A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one ...sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management.
Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview.
Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery.
The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
A 70-year-old male with prior total colectomy for ulcerative colitis was referred for elevated prostate specific antigen (PSA) (8.01) with PIRADS 4 lesion on magnetic resonance imaging (MRI). ...Described is a novel technique using pre-operative multi-parametric prostate MRI and intraoperative computed tomography (CT) 3D/3D fusion for systematic and targeted prostate biopsy in a patient lacking a rectum.
Under general anesthesia, an ultra-low-dose (ULD) cone beam CT was performed in supine position using a robotic-armed fluoroscopy system (Artis Zeego Care+Clear, Siemens). 3D/3D auto-registration of the femoral heads and prostate from the MRI and ULD CT was performed. The prostate edges and two areas of concern were marked. Then, reduced-dose fluoroscopy-guided prostate biopsy was performed transperineally using triangulation technique. 27 prostate biopsy cores were obtained. Grade group 5 (Gleason 4+5=9) prostate cancer was identified in two cores from the targeted lesion and one core from the prostate base. The remaining twenty-four biopsies were negative for malignancy. Surgical time was 81 minutes. PSMA scan demonstrated no metastasis or lymphadenopathy. Robotic-assisted laparoscopic radical prostatectomy was performed without complications. Final pathology demonstrated T3a, grade group 5 prostate adenocarcinoma involving 10% of the prostate volume with negative surgical margins.
This is the initial report of fluoroscopy-guided prostate biopsy using imaging fusion techniques in a patient without a rectum. This technique allowed precise identification of localized, very high-risk prostate cancer with over three times the number of cores, and much lower radiation dose, than typical CT-guided biopsies. Our technique could provide a new paradigm in targeted prostate biopsy.
To compare outcomes of robot-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses.
Data of patients who underwent RAPN or PTA for treatment ...of completely endophytic (three points for "E" domain of R.E.N.A.L. score) were collected from seven high-volume U.S. and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Meier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment "quality." Multivariable logistic regression model assessed predictors of trifecta failure.
One hundred fifty-two patients (RAPN,
= 60; PTA,
= 92) were included in the analysis. RAPN group was younger (
< 0.001), had lower American Society of Anesthesiologists score (
= 0.002), and higher baseline estimated glomerular filtration rate (
< 0.001). There was no difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (
< 0.001) and minor (
< 0.001) complications. ΔeGFR at 1 year was statistically higher for RAPN (-15.5 mL/min
-3.1 mL/min;
= 0.005), no difference in ΔeGFR at last follow-up (
= 0.22) was observed. No difference in recurrences (RAPN,
= 2; PTA,
= 6) and RFS was found (
= 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3%
58.8%;
= 0.477). R.E.N.A.L. Nephrometry Score resulted predictive of trifecta failure (odds ratio = 1.47; confidence interval = 1.13-1.90;
= 0.004).
PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications and good mid-term functional and oncologic outcomes. These outcomes compare favorably with those of RAPN, which seem to be the preferred option for younger and less comorbid patients.
Renal cell carcinoma (RCC) in solitary kidney (SK) represents a challenging scenario. We sought to compare outcomes of robot-assisted partial nephrectomy (RAPN) versus percutaneous thermal ablation ...(PTA) in SK patients with renal tumors cT1.
We performed a multicenter retrospective analysis of SK patients treated for RCC. The PTA group included cryoablation or radiofrequency ablation. We collected baseline characteristics, intraoperative, pathological, and post-operative data. We applied an arbitrary composite “trifecta” to assess surgical, functional, and oncological outcomes, only for malignant histology. RFS analysis was performed using the Kaplan-Meier method. Multivariable regression analysis was performed to determine independent predictors of “trifecta” achievement.
We included 198 SK patients (RAPN, n = 50; PTA n = 119). Mean clinical tumor size was not significantly different while R.E.N.A.L. score was higher for RAPN (p < 0.001). No differences in intra and major post-procedural complications. Recurrence rate was higher in PTA group but not statistically significant (p < 0.328). No difference in metastasis rate was found (p = 0.435). RFS was 96.1% in RAPN and 86.8% in PTA cohort (p = 0.003) while no difference in PFS was detected (p = 0.1). Trifecta was achieved in 72.5% of RAPN vs 77.3% of PTA (p = 0.481). Multivariable analysis has not detected predictors for Trifecta achievement.
PTA offers good outcomes in the management of SK patients with RCC. Compared with RAPN, it might carry a higher risk of recurrence; on the other hand, re-treatment is possible. Overall, PTA can be safely offered to treat SK patients presenting RCC. In general, it should be preferred in more frail patients to minimize the risk of complications.
Purpose
This study was designed to determine the role of laparoscopic adrenalectomy (LA) in the surgical management of adrenocortical carcinoma (ACC).
Methods
A systematic literature review was ...performed on January 2, 2015 using PubMed. Article selection proceeded according to PRISMA criteria. Studies comparing open adrenalectomy (OA) to LA for ACC and including at least 10 cases per each surgical approach were included. Odds ratio (OR) was used for all binary variables, and weight mean difference (WMD) was used for the continuous parameters. Pooled estimates were calculated with the fixed-effect model, if no significant heterogeneity was identified; alternatively, the random-effect model was used when significant heterogeneity was detected. Main demographics, surgical outcomes, and oncological outcomes were analyzed.
Results
Nine studies published between 2010 and 2014 were deemed eligible and included in the analysis, all of them being retrospective case–control studies. Overall, they included 240 LA and 557 OA cases. Tumors treated with laparoscopy were significantly smaller in size (WMD −3.41 cm; confidence interval CI −4.91, −1.91;
p
< 0.001), and a higher proportion of them (80.8 %) more at a localized (I–II) stage compared with open surgery (67.7 %) (odds ratio OR 2.8; CI 1.8, 4.2;
p
< 0.001). Hospitalization time was in favor of laparoscopy, with a WMD of −2.5 days (CI −3.3, −1.7;
p
< 0.001). There was no difference in the overall recurrence rate between LA and OA (relative risk RR 1.09; CI 0.83, 1.43;
p
= 0.53), whereas development of peritoneal carcinomatosis was higher for LA (RR 2.39; CI 1.41, 4.04;
p
= 0.001). No difference could be found for time to recurrence (WMD −8.2 months; CI −18.2, 1.7;
p
= 0.11), as well as for cancer specific mortality (OR 0.68; CI 0.44, 1.05;
p
= 0.08).
Conclusions
OA should still be considered the standard surgical management of ACC. LA can offer a shorter hospital stay and possibly a faster recovery. Therefore, this minimally invasive approach can certainly play a role in this setting, but it should be only offered in carefully selected cases to avoid jeopardizing the oncological outcome.
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal).
This article is being retracted following ...correspondence from an Investigation Committee at the University of Colorado Denver.
An internal investigation into this manuscript by the University of Colorado Denver, found evidence that there was image manipulation and that these actions warrant retraction to correct the scientific record.
Bands on blot obscured or removed, apparent when the images are enhanced (Fig 4A p21 band “C” at 24hr, Fig 4B p21 band “C” at 24hr, and Fig 4B Cyclin A band “10” at 48 hr).
Abstract Background Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. Objective To report a large ...multi-institutional series of minimally invasive SP (MISP). Design, setting, and participants Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. Intervention Laparoscopic or robotic SP. Outcome measurements and statistical analysis Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score <8, maximum flow rate >15 ml/s, and no perioperative complications. Results and limitations Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100 ml (range: 89–128). Median estimated blood loss was 200 ml (range: 150–300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3–5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p = 0.136; odds ratio OR: 1.6; 95% confidence interval CI, 0.8–2.9), whereas operative time ( p = 0.01; OR: 0.9; 95% CI, 0.9–1.0) and estimated blood loss ( p = 0.03; OR: 0.9; 95% CI, 0.9–1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. Conclusions This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. Patient summary Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.
We established an ex vivo model to evaluate the temperature profile of the ureter during laser lithotripsy, the influence of irrigation on temperature, and thermal spread during lithotripsy with the ...holmium:yttrium-aluminum-garnet (Ho:YAG) laser.
Two ex vivo models of Ovis aries urinary tract and human calcium oxalate calculi were used. The Open Ureteral Model was opened longitudinally to measure the thermal profile of the urothelium. On the Clinical Model, anterograde ureteroscopy was performed in an intact urinary system. Temperatures were measured on the external portion of the ureter and the urothelium during lithotripsy and intentional perforation. The lithotripsy group (n=20) was divided into irrigated (n=10) and nonirrigated (n=10), which were compared for thermal spread length and values during laser activation. The intentional perforation group (n=10) was evaluated under saline flow. The Ho:YAG laser with a 365 μm laser fiber and power at 10W was used (1J/Pulse at 10 Hz). Infrared Fluke Ti55 Thermal Imager was used for evaluation. Maximum temperature values were recorded and compared.
On the Clinical Model, the external ureteral wall obtained a temperature of 37.4°C±2.5° and 49.5°C±2.3° (P=0.003) and in the Open Ureteral Model, 49.7°C and 112.4°C with and without irrigation, respectively (P<0.05). The thermal spread along the external ureter wall was not statically significant with or without irrigation (P=0.065). During intentional perforation, differences in temperatures were found between groups (opened with and without irrigation): 81.8°±8.8° and 145.0°±15.0°, respectively (P<0.005).
There is an increase in the external ureteral temperature during laser activation, but ureteral thermal values decreased when saline flow was applied. Ureter thermal spread showed no difference between irrigated and nonirrigated subgroups. This is the first laser lithotripsy thermography study establishing the framework to evaluate the temperature profile in the future.
Abstract Background Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. Objective To report a large multi-institutional worldwide series of LESS in ...urology. Design, setting, and participants Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. Intervention Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. Measurements Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. Results and limitations Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160 ± 93 min and estimated blood loss was 148 ± 234 ml. Skin incision length at closure was 3.5 ± 1.5 cm. Mean hospital stay was 3.6 ± 2.7 d with a visual analog pain score at discharge of 1.5 ± 1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. Conclusions This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.
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