Abstract Background Partial nephrectomy (PN) is the reference standard of management for a cT1a renal mass. However, its role in the management of larger tumors (cT1b and cT2) is still under ...scrutiny. Objective To conduct a meta-analysis assessing functional, oncologic, and perioperative outcomes of PN and radical nephrectomy (RN) in the specific case of larger renal tumors (≥ c T1b). The primary endpoint was an overall analysis of cT1b and cT2 masses. The secondary endpoint was a sensitivity analysis for cT2 only. Evidence acquisition A systematic literature review was performed up to December 2015 using multiple search engines to identify eligible comparative studies. A formal meta-analysis was performed for studies comparing PN to RN for both cT1b and cT2 tumors. In addition, a sensitivity analysis including the subgroup of studies comparing PN to RN for cT2 only was conducted. Pooled estimates were calculated using a fixed-effects model if no significant heterogeneity was identified; alternatively, a random-effects model was used when significant heterogeneity was detected. For continuous outcomes, the weighted mean difference (WMD) was used as summary measure. For binary variables, the odds ratio (OR) or risk ratio (RR) was calculated with 95% confidence interval (CI). Statistical analyses were performed using Review Manager 5 (Cochrane Collaboration, Oxford, UK). Evidence synthesis Overall, 21 case-control studies including 11 204 patients (RN 8620; PN 2584) were deemed eligible and included in the analysis. Patients undergoing PN were younger (WMD −2.3 yr; p < 0.001) and had smaller masses (WMD −0.65 cm; p < 0.001). Lower estimated blood loss was found for RN (WMD 102.6 ml; p < 0.001). There was a higher likelihood of postoperative complications for PN (RR 1.74, 95% CI 1.34–2.2; p < 0.001). Pathology revealed a higher rate of malignant histology for the RN group (RR 0.97; p = 0.02). PN was associated with better postoperative renal function, as shown by higher postoperative estimated glomerular filtration rate (eGFR; WMD 12.4 ml/min; p < 0.001), lower likelihood of postoperative onset of chronic kidney disease (RR 0.36; p < 0.001), and lower decline in eGFR (WMD −8.6 ml/min; p < 0.001). The PN group had a lower likelihood of tumor recurrence (OR 0.6; p < 0.001), cancer-specific mortality (OR 0.58; p = 0.001), and all-cause mortality (OR 0.67; p = 0.005). Four studies compared PN ( n = 212) to RN ( n = 1792) in the specific case of T2 tumors (>7 cm). In this subset of patients, the estimated blood loss was higher for PN (WMD 107.6 ml; p < 0.001), as was the likelihood of complications (RR 2.0; p < 0.001). Both the recurrence rate (RR 0.61; p = 0.004) and cancer-specific mortality (RR 0.65; p = 0.03) were lower for PN. Conclusions PN is a viable treatment option for larger renal tumors, as it offers acceptable surgical morbidity, equivalent cancer control, and better preservation of renal function, with potential for better long-term survival. For T2 tumors, PN use should be more selective, and specific patient and tumor factors should be considered. Further investigation, ideally in a prospective randomized fashion, is warranted to better define the role of PN in this challenging clinical scenario. Patient summary We performed a cumulative analysis of the literature to determine the best treatment option in cases of localized kidney tumor of higher clinical stage (T1b and T2, as based on preoperative imaging). Our findings suggest that removing only the tumor and saving the kidney might be an effective treatment modality in terms of cancer control, with the advantage of preserving the kidney function. However, a higher risk of perioperative complications should be taken into account when facing larger tumors (clinical stage T2) with kidney-sparing surgery.
Purpose
To provide a systematic analysis of the comparative outcomes of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in the treatment of prostate cancer ...based on the best currently available evidence.
Methods
An independent systematic review of the literature was performed up to February 2021, using MEDLINE
®
, EMBASE
®
, and Web of Science
®
databases. Preferred reporting items for systematic review and meta-analysis (PRISMA) recommendations were followed to design search strategies, selection criteria, and evidence reports. The quality of the included studies was determined using the Newcastle–Ottawa scale for non-randomized controlled trials. Demographics and clinical characteristics, surgical, pathological, and functional outcomes were collected.
Results
Twenty-six studies were identified. Only 16 “high-quality” (RCTs and Newcastle–Ottawa scale 8–9) studies were included in the meta-analysis. Among the 13,752 patients included, 6135 (44.6%) and 7617 (55.4%) were RARP and LRP, respectively. There was no difference between groups in terms of demographics and clinical characteristics. Overall and major complication (Clavien–Dindo ≥ III) rates were similar in LRP than RARP group. The biochemical recurrence (BCR) rate at 12months was significantly lower for RARP (OR: 0.52; 95% CI 0.43–0.63;
p
< 0.00001). RARP reported lower urinary incontinence rate at 12months (OR: 0.38; 95% CI 0.18–0.8;
p
= 0.01). The erectile function recovery rate at 12months was higher for RARP (OR: 2.16; 95% CI 1.23–3.78;
p
= 0.007).
Conclusion
Current evidence shows that RARP offers favorable outcomes compared with LRP, including higher potency and continence rates, and less likelihood of BCR. An assessment of longer-term outcomes is lacking, and higher cost remains a concern of robotic versus laparoscopic prostate cancer surgery.
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.
Clear cell renal cell carcinoma (ccRCC) is the most frequent histological kidney cancer subtype. Over the last decade, significant progress has been made in identifying the genetic and metabolic ...alterations driving ccRCC development. In particular, an integrated approach using transcriptomics, metabolomics, and lipidomics has led to a better understanding of ccRCC as a metabolic disease. The metabolic profiling of this cancer could help define and predict its behavior in terms of aggressiveness, prognosis, and therapeutic responsiveness, and would be an innovative strategy for choosing the optimal therapy for a specific patient. This review article describes the current state-of-the-art in research on ccRCC metabolic pathways and potential therapeutic applications. In addition, the clinical implication of pharmacometabolomic intervention is analyzed, which represents a new field for novel stage-related and patient-tailored strategies according to the specific susceptibility to new classes of drugs.
Future of robotic surgery in urology Rassweiler, Jens J.; Autorino, Riccardo; Klein, Jan ...
BJU international,
December 2017, Letnik:
120, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Objectives
To provide a comprehensive overview of the current status of the field of robotic systems for urological surgery and discuss future perspectives.
Materials and Methods
A non‐systematic ...literature review was performed using PubMed/Medline search electronic engines. Existing patents for robotic devices were researched using the Google search engine. Findings were also critically analysed taking into account the personal experience of the authors.
Results
The relevant patents for the first generation of the da Vinci platform will expire in 2019. New robotic systems are coming onto the stage. These can be classified according to type of console, arrangement of robotic arms, handles and instruments, and other specific features (haptic feedback, eye‐tracking). The Telelap ALF‐X robot uses an open console with eye‐tracking, laparoscopy‐like handles with haptic feedback, and arms mounted on separate carts; first clinical trials with this system were reported in 2016. The Medtronic robot provides an open console using three‐dimensional high‐definition video technology and three arms. The Avatera robot features a closed console with microscope‐like oculars, four arms arranged on one cart, and 5‐mm instruments with six degrees of freedom. The REVO‐I consists of an open console and a four‐arm arrangement on one cart; the first experiments with this system were published in 2016. Medicaroid uses a semi‐open console and three robot arms attached to the operating table. Clinical trials of the SP 1098‐platform using the da Vinci Xi for console‐based single‐port surgery were reported in 2015. The SPORT robot has been tested in animal experiments for single‐port surgery. The SurgiBot represents a bedside solution for single‐port surgery providing flexible tube‐guided instruments. The Avicenna Roboflex has been developed for robotic flexible ureteroscopy, with promising early clinical results.
Conclusions
Several console‐based robots for laparoscopic multi‐ and single‐port surgery are expected to come to market within the next 5 years. Future developments in the field of robotic surgery are likely to focus on the specific features of robotic arms, instruments, console, and video technology. The high technical standards of four da Vinci generations have set a high bar for upcoming devices. Ultimately, the implementation of these upcoming systems will depend on their clinical applicability and costs. How these technical developments will facilitate surgery and whether their use will translate into better outcomes for our patients remains to be determined.
Prostate cancer (PCa) is the most common worldwide diagnosed malignancy in male population. The diagnosis, the identification of aggressive disease, and the post-treatment follow-up needs a more ...comprehensive and holistic approach. Radiomics is the extraction and interpretation of images phenotypes in a quantitative manner. Radiomics may give an advantage through advancements in imaging modalities and through the potential power of artificial intelligence techniques by translating those features into clinical outcome prediction. This article gives an overview on the current evidence of methodology and reviews the available literature on radiomics in PCa patients, highlighting its potential for personalized treatment and future applications.
Aim of this study was to analyse the association between the use of diagnostic ureteroscopy (URS) and the development of intravesical recurrence (IVR) in patients undergoing radical ...nephroureterectomy (RNU) for high‐risk upper tract urothelial carcinoma. A systematic review of the published data was performed up to December 2016, using multiple search engines to identify eligible studies. A formal meta‐analysis was conducted of studies comparing patients who underwent URS before RNU with those who did not. Hazard ratios (HRs), with their 95% confidence intervals (CIs), from each study were used to calculate pooled HRs. Pooled estimates were calculated using a fixed‐effects or random‐effects model according to heterogeneity. Statistical analyses were performed using RevMan, version 5. Seven studies were included in the systematic review, but only six of these were deemed fully eligible for meta‐analysis. Among the 2 382 patients included in the meta‐analysis, 765 underwent diagnostic URS prior to RNU. All examined studies were retrospective, and the majority examined Asian populations. The IVR rate ranged from 39.2% to 60.7% and from 16.7% to 46% in patients with and without prior URS, respectively. In the pooled analysis, a statistically significant association was found between performance of URS prior to RNU and IVR (HR 1.56, 95% CI 1.33–1.88; P < 0.001). There was no heterogeneity in the observed outcomes, according to the I2 statistic of 2% (P = 0.40). Within the intrinsic limitations of this type of analysis, these findings suggest a significant association between the use of diagnostic URS and higher risk of developing IVR after RNU. Further research in this area should be encouraged to further investigate the possible causality behind this association and it potential clinical implications.
PDF
