The aim of the study is to report surgical and early functional outcomes of first 100 patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD) ...in a single center. The main surgeon (A.P.) attended a modular training program at a referring center mentored by a worldwide-recognized robotic surgeon (P.W.). The program consisted of: (a) 10 h of theoretical lessons; (b) video session (c) step-by-step in vivo modular training. Each procedure was performed as taught, without any technique variation. Demographics, intra-operative data and post-operative complications, along with early functional outcomes, were recorded for each patient. We retrospectively evaluated the first consecutive 100 patients submitted to RARC with totally ICUD from July 2015 to December 2018. Median age at surgery was 69 years (IQR 60–74). 52 (52%), 32 (32%), and 17 (17%) patients received orthotopic neobladder, ileal conduit and uretero-cutaneostomy, respectively. Median operative time was 410 min. A median number of lymph nodes retrieved were 27 and median estimated blood loss was 240 mL with median hospitalization time of 7 days. All procedures were completed successfully without open conversion. A statistically significant improvement was found in the late (30–90 post-operative days) post-operative complications (
p
= 0.02) and operative time for urinary derivation. At multivariate logistic regression model ASA score ≥ 3 (OR = 4.2,
p
= 0.002) and number of lymph nodes retrieved (OR = 1.16,
p
= 0.02) were found to be predictors of 90-day complications. An adequate modular training is paramount to obtain successful results and reduce the learning curve of RARC, as demonstrated by our experience.
Abstract Introduction Nephron-sparing surgery (NSS) has become the standard of care for the surgical management of small and clinically localized renal cell carcinoma (RCC). The conservative ...management of those RCCs is increasing over time. Aim of this study was to report a snapshot of the clinical, perioperative and oncological results after NSS for RCC in Italy. Material and methods We evaluated all patients who underwent conservative surgical treatment for renal tumours between January 2009 and December 2012 at 19 urological Italian Centers (RECORd project). Perioperative, radiological and histopathological data were recorded. Surgical eras (2009 vs 2012 and year periods 2009–2010 vs 2011–2012) were compared. Results Globally, 983 patients were evaluated. More recently, patients undergoing NSS were found to be significantly younger (p = 0.05) than those surgically treated in the first study period, with a significantly higher rate of NSS with relative and imperative indication (p < 0.001). More recently, a higher percentage of procedures for cT1b or cT2 renal tumours was observed (p = 0.02). Utilization rate of open partial nephrectomy (OPN) constantly decreased during years, laparoscopic partial nephrectomy (LPN) remained almost constant while robot-assisted partial nephrectomy (RAPN) increased. The rate of clampless NSS constantly increased over time. The use of at least one haemostatic agent has been significantly more adopted in the most recent surgical era (p < 0.001). Conclusions The utilization rate of NSS in Italy is increasing, even in elective and more complex cases. RAPN has been progressively adopted, as well as the intraoperative utilization of haemostatic agents and the rate of clampless procedures.
To assess whether the addition of clinical Gleason score (Gs) 3+4 to the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria affects pathologic results in patients who are ...potentially suitable for active surveillance (AS) and to identify possible clinical predictors of unfavourable outcome.
Three hundred and twenty-nine men who underwent radical prostatectomy with complete clinical and follow-up data and who would have fulfilled the inclusion criteria of the PRIAS protocol at the time of biopsy except for the addition of biopsy Gs=3+4 and with at least 10 cores taken have been evaluated. One experienced genitourinary pathologist selected those with real Gs=3+3 and 3+4 in only one core according to the 2005 International Society of Urological Pathology criteria. The primary end point was the proportion of unfavourable outcome (nonorgan confined disease or Gs⩾4+3). Logistic regressions explored the association between preoperative characteristics and the primary end point.
Two hundred and four patients were evaluated and 46 (22.5%) patients harboured unfavourable disease at final pathology. After a median follow-up of 73.5 months, there was no cancer-specific death, and 4 (2.0%) patients had biochemical relapse. There were no significant differences in terms of high Gs, locally advanced disease, unfavourable disease and biochemical relapse-free survival among patients with clinical Gs=3+3 vs Gs=3+4. At multivariable analysis, the presence of atypical small acinar proliferation (ASAP) and lower number of core taken were independently associated with a higher risk of unfavourable disease.
The inclusion of Gs=3+4 in patients suitable to AS does not enhance the risk of unfavourable disease after radical prostatectomy. Additional factors such as number of cores taken and the presence of ASAP should be considered in patients suitable for AS.
Background
Incidental Prostate cancer (iPCa) is a relatively common finding during histopathological evaluation of radical cystectomy (RC) specimens. To reduce the high impact of RC on erectile ...function, several sexual-preserving techniques have been proposed. The aim of this study was to evaluate and compare the oncologic outcomes of patients with iPCa who underwent nerve spring and no-nerve sparing robot-assisted radical cystectomy (RARC).
Methods
The clinicopathologic data of male patients who underwent RARC at our institution between 2006 and 2016 were retrospectively analysed. Patients with iPCa at definitive pathological examinations were stratified in two groups, according to the preservation of the neurovascular bundles (nerve sparing vs no nerve sparing). Significant PCa was defined as any Gleason score ≥ 3 + 4. Biochemical recurrence (BR) was defined as a sustained PSA level > 0.2 ng/mL on two or more consecutive appraisals. BR rate was assessed only in patients with incidental prostate cancer and at least 2 years of follow-up. Differences in categorical and continuous variables were analysed using the chi-squared test and the Mann–Withney
U
test, respectively. Biochemical recurrence curves were generated using the Kaplan–Meier method and compared with the Log-rank test.
Results
Overall, 343 male patients underwent RARC for bladder cancer within the study period. Nerve-sparing surgery was performed in 143 patients (41%), of these 110 had at least 2 years of follow up after surgery. Patients who underwent nerve-sparing surgery were significantly younger (
p
< 0.001). Clinically significant PCa was found in 24% of patients. No significant differences regarding preoperative PSA value (
p
= 0.3), PCa pathological stage (
p
= 0.5), Gleason score (
p
= 0.3) and positive surgical margin rates (
p
= 0.3) were found between the two groups. After a median follow-up of 51 months only one patient, in the no-nerve-sparing group had developed a biochemical recurrence (
p
= 0.4).
Conclusions
In our series most of the iPca detected in RC specimens can be considered as insignificant with a low rate of BR (0.9%). Nerve-sparing RARC is a safe procedure which did not affect oncological outcomes of patients with iPCa.
Only few patients with PSA relapse after radical treatment will show clinically detectable disease. Although the natural history of recurrent prostate cancer is often one of the slowly progressing ...diseases, in some men it can be rapid and may need a salvage treatment. In general, time to PSA relapse, PSA velocity and PSA doubling time are useful in patient assesment. In patients with PCa disease relapse after primary therapy, salvage treatment for a local recurrence should only be offered to patients with little risk of already having metastases. In these patients a systemic imaging negative for metastases is mandatory, a positive biopsy is not always necessary before radiotherapy, but is mandatory before salvage prostatectomy. In patients with a high risk of distant metastases and suitable for systemic salvage therapy, a positive lesion must be obviously visualized with one of the currently available imaging techniques. Transrectal ultrasound has low accuracy in the detection of the recurrence. Multiparametric Magnetic Resonance Imaging may have a role in the early phase of PSA relapse. Conventional imaging, such as bone scan and CT, are not suggested in the initial phase of BCR. Today, it has been reported that PET/CT allows changing the therapeutic strategy (from palliative to curative treatment and vice-versa) in about 20% of cases. In recent years, the new radiotracer 18F-FACBC has been proposed as a possible alternative radiopharmaceutical to detect PCa relapse. The aim of the present paper is to evaluate the management of patients with BCR after radical treatment of PCa from the urologist point of view.
Abstract One of the main problems in transplant surgery is the preservation of the organ during the cold ischemic time. The interrupted blood supply triggers a cascade of biological modifications ...resulting in cell death, which predisposes to discharge of a large quantity of toxic metabolites at the moment of organ reperfusion. Many approaches have been studied to prevent the toxic processes. Immediately after procurement, kidneys are flushed with these solutions. Two main: techniques of organ preservation are cold static storage and hypothermic machine perfusion (HMP). Based on age and comorbidities, individuals can be generally divided into 2 groups: ideal and marginal donors. Characteristics of organs from marginal donors are associated with an increased rate of delayed graft function and primary graft nonfunction (PNF), which reduce transplant survival and increase the acute rejection risk. In the last 20 years, the United Network of Organ Sharing has reported a 170% increase in deceased donors older than 50 years of age. Techniques of perfusion have been demonstrated to play a pivotal role in graft function after transplantation. Some studies suggest that HMP may improve outcomes after transplantation.
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