Abstract Context On-clamp partial nephrectomy (PN) has been considered the standard approach to minimize intraoperative bleeding and thus achieve adequate control of tumor margins. The potential ...negative impact of ischemia on renal function (RF) led to the development of techniques to minimize or avoid renal ischemia, such as off-clamp PN and minimally ischemic PN techniques. Objective To review current evidence on the indications and techniques for and outcomes of minimally ischemic and off-clamp PN. Evidence acquisition A systematic review of English-language publications on PN without a main renal artery clamp from January 2005 to July 2014 was performed using the Medline, Embase, and Web of Science databases. Evidence synthesis The searches retrieved 52 papers. Off-clamp PN has been more commonly applied to small and peripheral renal tumors, while minimally ischemic PN is best suited for hilar and medially located renal tumors. These approaches are associated with increased intraoperative blood loss and perioperative transfusion rates compared to on-clamp PN. Minimally ischemic and off-clamp PN have potential functional benefits when longer ischemia time is anticipated, particularly for patients with lower baseline RF. Limitations include the lack of prospective randomized trials comparing minimally ischemic and off-clamp to on-clamp techniques, and the small sample size and short follow-up of most published series. The impact of different resection and renorrhaphy techniques on postoperative RF and its assessment via renal scintigraphy requires further investigations. Conclusions Minimally ischemic and off-clamp PN are established procedures that may be particularly applicable for patients with decreased baseline RF. However, these techniques are technically demanding, with potential for increased blood loss, and require considerable experience with PN surgery. The role of ischemia in patients with a contralateral healthy kidney and consequently an indication for elective minimally ischemic or off-clamp PN remains a debatable issue. Patient summary In this review we analyzed available evidence on minimally ischemic and off-clamp partial nephrectomy. These techniques, although technically demanding, may be particularly applicable for patients with decreased baseline renal function.
With the increasing adoption of novel technologies and anatomical techniques, surgical management of benign prostatic hyperplasia (BPH) provides significant benefits in terms of obstruction relief, ...early urethral catheter removal, and faster return to daily activities. However, the main pitfall of BPH surgery in sexually active men remains ejaculatory dysfunction (EjD), which permanently affects quality of life.
To detail a novel technique for marking the intraprostatic urethra through a retrograde injection of indocyanine green to enhance selective dissection of prostatic lobes during urethra-sparing robot-assisted simple prostatectomy (US-RASP) with the use of near-infrared fluorescence imaging (NIFI).
Between January and September 2017, 12 consecutive male patients, who had BPH, were sexually active, and were motivated to preserve ejaculatory function, underwent US-RASP.
US-RASP with NIFI to enhance the identification and preservation of the prostatic urethra.
Clinical data were prospectively collected in our institutional RASP dataset. Perioperative and functional outcomes of US-RASP were both graded, and assessed according to Clavien grading system and validated questionnaires postoperatively (International Prostate Symptom Score IPSS; Male Sexual Health Questionnaire on EjD MSHQ-EjD Short Form) at 3 and 12mo.
Median preoperative prostate size was 102cc (interquartile range IQR 88–115). Median operative time was 150min (IQR 145–170). Median estimated blood loss was 250 (IQR 200–350). Continuous bladder irrigation was avoided in 83.4% of patients. Median time to catheter removal was 7d (IQR 7–7) with a median hospital stay of 3d (IQR 2–3). At 1-yr follow-up, median IPSS score, International Index of Erectile Function score, and MSHQ-EjD Short Form score were 5 (IQR 4–8), 26 (IQR 26–28), and 12 (IQR 1–14), respectively. Satisfactory anterograde ejaculation was reported in eight patients (66%).
We described a novel NIFI-guided technique to perform US-RASP. This technique showed promising early functional results, suggesting a significant role of intraprostatic urethral integrity for the preservation of ejaculatory function.
We developed a novel robotic technique to perform simple prostatectomy with integral preservation of the prostatic urethra. This technique provided a high rate of ejaculatory function preservation.
We describe a novel robotic technique to perform simple prostatectomy with the preservation of the prostatic urethra and ejaculatory ducts. This procedure provided complete preservation of antegrade ejaculation in two-thirds of patients at 1-yr assessment.
Objectives
Our goal is to determine the ability of multi-parametric magnetic resonance imaging (mpMRI) to differentiate muscle invasive bladder cancer (MIBC) from non-muscle invasive bladder cancer ...(NMIBC).
Methods
Patients underwent mpMRI before tumour resection. Four MRI sets, i.e. T2-weighted (T2W) + perfusion-weighted imaging (PWI), T2W plus diffusion-weighted imaging (DWI), T2W + DWI + PWI, and T2W + DWI + PWI + dif-fusion tensor imaging (DTI) were interpreted qualitatively by two radiologists, blinded to histology results. PWI, DWI and DTI were also analysed quantitatively. Accuracy was determined using histopathology as the reference standard.
Results
A total of 82 tumours were analysed. Ninety-six percent of T1-labeled tumours by the T2W + DWI + PWI image set were confirmed to be NMIBC at histopathology. Overall accuracy of the complete mpMRI protocol was 94% in differentiating NMIBC from MIBC. PWI, DWI and DTI quantitative parameters were shown to be significantly different in cancerous versus non-cancerous areas within the bladder wall in T2-labelled lesions.
Conclusions
MpMRI with DWI and DTI appears a reliable staging tool for bladder cancer. If our data are validated, then mpMRI could precede cystoscopic resection to allow a faster recognition of MIBC and accelerated treatment pathways.
Key Points
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A critical step in BCa staging is to differentiate NMIBC from MIBC
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Morphological and functional sequences are reliable techniques in differentiating NMIBC from MIBC
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Diffusion tensor imaging could be an additional tool in BCa staging
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While partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented ...worldwide.
To analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors.
Retrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass).
Robotic-assisted PN.
Patients’ demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival.
A total of 298 patients were analyzed. Median tumor size was 7.6 (7–8.5) cm. Median RENAL score was 9 (8–10). Median ischemia time was 25 (20–32) min. Median estimated blood loss was 150 (100–300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio OR 0.46, 95% confidence interval CI 0.21–0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12–0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5–35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design.
RAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication.
This report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.
This large multicenter experience suggests that robot-assisted partial nephrectomy for clinical T2 renal masses is feasible, it offers good surgical outcomes, and it allows preservation of renal function. Overall, the outcomes of a robotic approach compare favorably with those reported for open nephron-sparing surgery for this challenging indication.
Objectives
To report surgical technique, perioperative, oncological, and mid‐term functional outcomes in a single‐center purely off‐clamp robotic partial nephrectomy series for totally endophytic ...masses.
Methods
A retrospective analysis of a prospectively collected, institutional review board‐approved renal cancer database was carried out to include patients with a totally endophytic renal tumor treated with off‐clamp robotic partial nephrectomy between January 2013 and December 2020 at our center. Our database was queried to identify cases that had been assigned 3 points for the “E” domain of the R.E.N.A.L. nephrometry score and 3 points for the “exophytic rate” domain of the PADUA (Preoperative Aspects and Dimensions Used for an Anatomical) nephrometry score. Preoperative indocyanine green renal mass marking was performed in 33 patients, in whom the tumor was vascularized by a specific feeding artery. Surgical steps, perioperative, oncological and functional data were reported.
Results
Fifty‐six consecutive patients with totally endophytic renal masses were treated. The median tumor diameter was 3 cm, and median PADUA and R.E.N.A.L. scores were both 10. The median operative time was 82 min. Low‐grade Clavien complications occurred in two patients (3.6%) and high‐grade Clavien complications were observed in four patients (7.1%). Positive surgical margins were detected in one patient; 2‐year recurrence‐free, cancer‐specific, and overall survival rates were 100%, 100%, and 98.2%, respectively. At a median follow‐up of 24 months, new onset of chronic kidney disease stage 3b occurred in one patient. At last follow‐up, the median estimated glomerular filtration rate was 77 mL/min, with a median estimated glomerular filtration rate percent decrease of 5.5%. Trifecta was achieved in 91% of patients.
Conclusions
Purely off‐clamp robotic partial nephrectomy is a feasible and safe surgical approach, even in totally endophytic renal tumors, providing a favorable perioperative complications rate, excellent oncological outcomes, and negligible impact on renal function at mid‐term follow‐up. Indocyanine green preoperative marking of endophytic renal tumors represents a useful tool for rapid intraoperative identification of the mass, real‐time control of resection margins, and a more precise dissection.
The pressure towards innovation and creation of new model systems in regenerative medicine and cancer research has fostered the development of novel potential therapeutic applications. Kidney ...injuries provoke a high request of organ transplants making it the most demanding system in the field of regenerative medicine. Furthermore, renal cancer frequently threaten patients' life and aggressive forms still remain difficult to treat. Ethical issues related to the use of embryonic stem cells, has fueled research on adult, patient-specific pluripotent stem cells as a model for discovery and therapeutic development, but to date, normal and cancerous renal experimental models are lacking. Several research groups are focusing on the development of organoid cultures. Since organoids mimic the original tissue architecture in vitro, they represent an excellent model for tissue engineering studies and cancer therapy testing. We established normal and tumor renal cell carcinoma organoids previously maintained in a heterogeneous multi-clone stem cell-like enriching medium. Starting from adult normal kidney specimens, we were able to isolate and propagate organoid 3D-structures composed of both differentiated and undifferentiated cells while expressing nephron specific markers. Furthermore, we were capable to establish organoids derived from cancer tissues although with a success rate inferior to that of their normal counterpart. Cancer cultures displayed epithelial and mesenchymal phenotype while retaining tumor specific markers. Of note, tumor organoids recapitulated neoplastic masses when orthotopically injected into immunocompromised mice. Our data suggest an innovative approach of long-term establishment of normal- and cancer-derived renal organoids obtained from cultures of fleshly dissociated adult tissues. Our results pave the way to organ replacement pioneering strategies as well as to new models for studying drug-induced nephrotoxicity and renal diseases. Along similar lines, deriving organoids from renal cancer patients opens unprecedented opportunities for generation of preclinical models aimed at improving therapeutic treatments.
Sensors are tools for detecting, recognizing, and recording signals from the surrounding environment. They provide measurable information on chemical or physical changes, and thus are widely used in ...diagnosis, environment monitoring, food quality checks, or process control. Polymers are versatile materials that find a broad range of applications in sensory devices for the biomedical sector and beyond. Sensory materials are expected to exhibit a measurable change of properties in the presence of an analyte or a stimulus, characterized by high sensitivity and selectivity of the signal. Signal parameters can be tuned by material features connected with the restriction of macromolecule shape by crosslinking or folding. Gels are crosslinked, three-dimensional networks that can form cavities of different sizes and forms, which can be adapted to trap particular analytes. A higher level of structural control can be achieved by foldamers, which are macromolecules that can attain well-defined conformation in solution. By increasing control over the three-dimensional structure, we can improve the selectivity of polymer materials, which is one of the crucial requirements for sensors. Here, we discuss various examples of polymer gels and foldamer-based sensor systems. We have classified and described applied polymer materials and used sensing techniques. Finally, we deliberated the necessity and potential of further exploration of the field towards the increased selectivity of sensory devices.
Active surveillance has emerged as a valid therapeutic option in patients with low-risk prostate cancer, allowing for the deferral of definitive treatment until the time of possible disease ...progression. Although it is known that physical activity plays a protective role in the onset and progression of this tumor, its impact on patients with low-risk disease who are managed with active surveillance remains unclear. Our scoping review aims to summarize the existing evidence on this subject.
On 9 April 2023, a systematic search was conducted using the PubMed and Scopus databases. The search employed the combination of the following terms: ("prostate cancer" OR "prostate tumor") AND ("active surveillance") AND ("physical activity" OR "physical exercise" OR "physical intensive activity" OR "intensive exercise") AND ("lifestyle"). Out of the 506 identified articles, 9 were used for the present scoping review, and their results were reported according to the PRISMA-ScR statement.
We discovered a lack of uniformity in the assessment of PA and its stratification by intensity. There was no consensus regarding what constitutes cancer progression in patients choosing expectant management. In terms of the impact of PA on AS outcomes, conflicting results were reported: some authors found no correlation, while others (six of total studies included) revealed that active men experience smaller increases in PSA levels compared to their sedentary counterparts. Additionally, higher levels of exercise were associated with a significantly reduced risk of PCa reclassification.
Due to the heterogeneity of the methodologies used in the available studies and the conflicting results reported, it is not possible to draw definitive conclusions concerning the role physical activity may play in the risk of prostate cancer progression in men managed with active surveillance.
In the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a ...two-center robot-assisted partial adrenalectomy (RAPA) series.
To detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes.
Data of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported.
RAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration.
Baseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed.
All cases were completed robotically. Median nodule size was 18mm (interquartile range IQR 16–20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2–3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19–42), neither symptoms nor imaging recurrence was observed.
We demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community.
Robot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future.
Robot-assisted partial adrenalectomy is a feasible and safe surgical option for small, isolated unilateral aldosterone-producing adenoma. The role of partial adrenalectomy (PA) versus total adrenalectomy is still a matter of debate, and indications for PA should be discussed in a multidisciplinary setting.
The purpose of this study was to assess patient frailty as a risk factor for radical cystectomy (RC) complications.
We performed an analysis of prospectively collected data of consecutive patients 80 ...years of age or older who underwent RC and ureterocutaneostomy in 6 primary care European urology centers. Frailty was measured using a simplified frailty index (sFI) with a 5-item score including: (1) diabetes mellitus; (2) functional status; (3) chronic obstructive pulmonary disease; (4) congestive cardiac failure; and (5) hypertension, with a maximum 5-item score meaning high level of frailty. Within 90 days surgical complications were scored according to the Clavien Classification System (CCS). sFI ≥3 was considered as poor frailty status. Clinical and pathological variables were analyzed as predictors of severe complications (CCS ≥3).
One hundred seventeen patients were enrolled. Most patients reported an sFI score of 2 and 3, respectively, 31/117 (26.5%) and 45/117 patients (38.5%). CCS ≥3 occurred in 17/117 patients (14.5%). Patients with sFI ≥3 were significantly older than patients with sFI <3 (median age, 85 years interquartile range (IQR), 82-86 versus 82 years IQR, 80-84; P = .001). Most CCS ≥3 scores occurred in patients with sFI ≥3: 13 (11.1%) versus 4 (3.4%; P = .02). No significative differences were detected in terms of length of hospital stay, pathological stage, and postoperative bowel canalization when related to sFI. sFI ≥3 was an independent risk factor of CCS ≥3 in univariate and multivariate analysis (respectively, odds ratio OR, 3.81 95% confidence interval (CI), 1.16-12.5; P = .02 and OR, 3.1 95% CI, 0.7-13.7; P = .01). Body mass index, age, American Society of Anesthesiologists score ≥3, and pathological stage were not related to CCS ≥3.
RC appears feasible in elderly patients with an sFI <3. In cases of sFI ≥3, this choice should be carefully valued, discussed, and possibly avoided because of a higher risk of complications.
We used the Frailty index as a risk factor for radical cystectomy (RC) complications. We performed an analysis of data of consecutive patients 80 years of age or older who had undergone RC and ureterocutaneostomy (UCS) in 6 European centers. No differences were detected in terms of length of hospital stay, pathological stage, or postoperative bowel canalization as related to the Frailty index. RC and UCS seem to be a feasible option in frail elderly patients.
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