Horseshoe kidney is a rare renal fusion anomaly, and because of limited mobilization of the kidney and its multiple arterial blood supplies, minimally invasive surgery for renal tumors can be ...challenging. We describe a case of a right-side oncocytoma in a horseshoe kidney managed robotically and review the literature of robotic-assisted laparoscopic surgical resection of kidney tumors in renal fusion anomalies. Robotic-assisted laparoscopic partial nephrectomy in a horseshoe kidney is feasible. Fusion-related limited mobility during the procedure, as well as an extremely variable blood supply, require meticulous planning. Multi-phase computed tomography and interactive 3D anatomical models are helpful tools to prepare for surgery.
IntroductionStereotactic body radiotherapy (SBRT) is a non-invasive alternative to surgery for the treatment of non-metastatic prostate cancer (PC). The objectives of the Novel Integration of New ...prostate radiation schedules with adJuvant Androgen deprivation (NINJA) clinical trial are to compare two emerging SBRT regimens for efficacy with technical substudies focussing on MRI only planning and the use of knowledge-based planning (KBP) to assess radiotherapy plan quality.Methods and analysisEligible patients must have biopsy-proven unfavourable intermediate or favourable high-risk PC, have an Eastern Collaborative Oncology Group (ECOG) performance status 0-1 and provide written informed consent. All patients will receive 6 months in total of androgen deprivation therapy. Patients will be randomised to one of two SBRT regimens. The first will be 40 Gy in five fractions given on alternating days (SBRT monotherapy). The second will be 20 Gy in two fractions given 1 week apart followed 2 weeks later by 36 Gy in 12 fractions given five times per week (virtual high-dose rate boost (HDRB)). The primary efficacy outcome will be biochemical clinical control at 5 years. Secondary endpoints for the initial portion of NINJA look at the transition of centres towards MRI only planning and the impact of KBP on real-time (RT) plan assessment. The first 150 men will demonstrate accrual feasibility as well as addressing the KBP and MRI planning aims, prior to proceeding with total accrual to 472 patients as a phase III randomised controlled trial.Ethics and disseminationNINJA is a multicentre cooperative clinical trial comparing two SBRT regimens for men with PC. It builds on promising results from several single-armed studies, and explores radiation dose escalation in the Virtual HDRB arm. The initial component includes novel technical elements, and will form an important platform set for a definitive phase III study.Trial registration numberANZCTN 12615000223538.
Background:
A 76-year-old male presenting with macroscopic haematuria was found to have a lobulated mass infiltrating along the urothelium at the site of insertion of the upper moiety of a complete ...duplex right kidney. Suspected of being upper tract urothelial carcinoma, cystoscopy, bilateral retrograde pyelograms and transurethral resection of bladder tumour were attempted. Intra-operative findings revealed no tumour burden in the bladder or left ureter. The insertion of the upper pole moiety of the right ureter was not identified intra-operatively. Pelvic MRI demonstrated a markedly dilated upper pole moiety of the right ureter with a soft tissue mass in its distal aspect. Interestingly, the distal portion of the ectopic upper pole moiety was found to insert into the bladder neck.
Objective and Methods:
We report on an unusual case of upper tract urothelial carcinoma arising from the upper moiety of a complete duplex kidney. Our aim was to demonstrate the importance of thorough investigation of suspected urothelial carcinomas occurring in association with variant upper tract anatomy.
Results and Conclusion:
This case demonstrates the importance of thorough radiological and endourological investigation of suspected upper tract urothelial carcinoma and the various congenital abnormalities that may complicate the surgical management of this common malignancy.
Level of evidence:
4 (case report)
A 24-year-old male presented in 2014 with left sided abdominal pain and a palpable abdominal mass. After appropriate investigation a diagnosis of an extra-gonadal germ cell tumour was made and he was ...treated with platinum based chemotherapy. He then underwent retroperitoneal lymph node dissection due to residual disease identified on imaging with no specific tissue type identified on the histological sample. In early 2019 he presented to his General Practitioner with a left sided testicular lump and was diagnosed with non-seminomatous germ cell tumour of the testis, an uncommon condition; metachronous testicular tumour.
Level of Evidence: 5
Stereotactic ablative body radiotherapy (SABR) is a novel non-invasive alternative for patients with primary renal cell cancer who do not undergo surgical resection. The FASTRACK II clinical trial ...investigated the efficacy of SABR for primary renal cell cancer in a phase 2 trial.
This international, non-randomised, phase 2 study was conducted in seven centres in Australia and one centre in the Netherlands. Eligible patients aged 18 years or older had biopsy-confirmed diagnosis of primary renal cell cancer, with only a single lesion; were medically inoperable, were at high risk of complications from surgery, or declined surgery; and had an Eastern Cooperative Oncology Group performance status of 0–2. A multidisciplinary decision that active treatment was warranted was required. Key exclusion criteria were a pre-treatment estimated glomerular filtration rate of less than 30 mL/min per 1·73 m2, previous systemic therapies for renal cell cancer, previous high-dose radiotherapy to an overlapping region, tumours larger than 10 cm, and direct contact of the renal cell cancer with the bowel. Patients received either a single fraction SABR of 26 Gy for tumours 4 cm or less in maximum diameter, or 42 Gy in three fractions for tumours more than 4 cm to 10 cm in maximum diameter. The primary endpoint was local control, defined as no progression of the primary renal cell cancer, as evaluated by the investigator per Response Evaluation Criteria in Solid Tumours (version 1.1). Assuming a 1-year local control of 90%, the null hypothesis of 80% or less was considered not to be worthy of proceeding to a future randomised controlled trial. All patients who commenced trial treatment were included in the primary outcome analysis. This trial is registered with ClinicalTrials.gov, NCT02613819, and has completed accrual.
Between July 28, 2016, and Feb 27, 2020, 70 patients were enrolled and initiated treatment. Median age was 77 years (IQR 70–82). Before enrolment, 49 (70%) of 70 patients had documented serial growth on initial surveillance imaging. 49 (70%) of 70 patients were male and 21 (30%) were female. Median tumour size was 4·6 cm (IQR 3·7–5·5). All patients enrolled had T1–T2a and N0–N1 disease. 23 patients received single-fraction SABR of 26 Gy and 47 received 42 Gy in three fractions. Median follow-up was 43 months (IQR 38–60). Local control at 12 months from treatment commencement was 100% (p<0·0001). Seven (10%) patients had grade 3 treatment-related adverse events, with no grade 4 adverse events observed. Grade 3 treatment-related adverse events were nausea and vomiting (three 4% patients), abdominal, flank, or tumour pain (four 6%), colonic obstruction (two 3%), and diarrhoea (one 1%). No treatment-related or cancer-related deaths occurred.
To our knowledge, this is the first multicentre prospective clinical trial of non-surgical definitive therapy in patients with primary renal cell cancer. In a cohort with predominantly T1b or larger disease, SABR was an effective treatment strategy with no observed local failures or cancer-related deaths. We observed an acceptable side-effect profile and renal function after SABR. These outcomes support the design of a future randomised trial of SABR versus surgery for primary renal cell cancer.
Cancer Australia Priority-driven Collaborative Cancer Research Scheme.
Renal ischaemia research has shown an increase in renal damage proportional to ischaemic time. Therefore, we assessed the importance of renal ischaemic times for warm and cold ischaemia approaches, ...and explored the different surgical techniques that can help to minimise renal ischaemia in robot-assisted partial nephrectomy (RAPN). Minimising renal ischaemia during nephron-sparing surgery (NSS) is a key factor in preserving postoperative renal function. Current data support a safe warm ischaemia time (WIT) of ≤25 min and cold ischaemic time of ≤35 min, resulting in no significant deterioration in renal function. In general, patients undergoing NSS have increased comorbidities, including chronic kidney disease, and in these patients it is difficult to predict their postoperative renal function recovery. With RAPN, efforts should be made to keep the WIT to <25 min, as minimising the ischaemic time is vital for preservation of overall renal function and remains a modifiable risk factor. Parenchymal or segmental artery clamping, early unclamping or off-clamp techniques can be adopted when ischaemic times are likely to be >25 min, but may not lead to superior functional outcome. Careful preoperative planning, tumour factors, and meticulous surgical technique are critical for optimum patient outcome.
Objective:
This study assesses whether fusion or cognitive magnetic resonance imaging (MRI)-guided prostate targeted and systematic transperineal biopsies (TPB) increase detection of clinically ...significant prostate cancer (csPCa).
Materials and Methods:
A retrospective analysis was completed of patients (2018–2020) undergoing 3-Tesla multiparametric prostate MRI informing targeted (either cognitive or MIM software fusion approach) and systematic TPB. ISUP (International Society of Urological Pathology) grade group ⩾ 2 was considered csPCa.
Results:
A total of 355 cases from 4 urologists were included; 131 were fusion and 224 were cognitive MRI-guided biopsies. Of all csPCa found, 86.8% ( n = 171) of cases were confirmed to be at the MRI-indicated location and 11.6% were found as part of active surveillance. In all, 45.0% of the fusion group were found to have csPCa, compared to 62.05% ( n = 139) in the cognitive group ( p = 0.002). csPCa detection rates varied between urologists (41% to 78%, p < 0.001), so a subgroup analysis was performed on Urologist A; 45.0% of fusion and 41.3% of cognitive biopsies had csPCa ( p = 0.644). Multinomial logistic regression analysis showed that biopsy type, being on active surveillance, number of biopsy cores, iPSA (initial Prostate Specific Antigen) value or PIRADS (Prostate Imaging-Reporting and Data System) score made no significant difference in whether csPCa was found.
Conclusion:
Cognitive and fusion targeting had similar csPCa detection rates. Further prospective studies would be beneficial to validate these findings.
Level of evidence:
2b (according to Oxford Centre for Evidence-Based Medicine)
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