Trifecta and pentafecta outcomes following robot-assisted partial nephrectomy in a multi-institutional cohort of Indian patients

INTRODUCTION: The literature on studies reporting trifecta or pentafecta outcomes following robot-assisted partial nephrectomy (RAPN) in Indian patients is limited. The primary aim of this study was to report and evaluate the factors predicting trifecta and pentafecta outcomes following RAPN in Indian patients using the multicentric Vattikuti collective quality initiative (VCQI) database. METHODS: From the VCQI database for patients who underwent RAPN, data for Indian patients were extracted and analyzed for factors predicting the achievement of trifecta and pentafecta following RAPN. Trifecta was defined as the absence of complications, negative surgical margins, and warm ischemia period shorter than 25 min or zero ischemia. Pentafecta covers all the trifecta criteria as well as \u3e90% preservation of estimated glomerular filtration rate (eGFR) and no stage upgrade of chronic kidney disease at 12 months. RESULTS: In this study, among 614 patients, the trifecta was achieved in 374 patients (60.9%) and pentafecta was achieved in 24.2% of the patients. Patients who achieved trifecta had significantly higher mean age (54.1 vs. 51.0 years, P = 0.005), body mass index (BMI) (26.7 vs. 26.03 kg/m 2, P = 0.022), and smaller tumor size (38.6 vs. 41.4 mm, P = 0.028). The preoperative eGFR (84.2 vs. 91.9 ml/min, P = 0.012) and renal nephrometry score (RNS) (6.96 vs. 7.87, P ≤ 0.0001) were significantly lower in the trifecta group. Comparing patients who achieved pentafecta to those who did not, we noted a statistically significant difference between the two groups for tumor size (36.1 vs. 41.5 mm, P = 0.017) and RNS (6.6 vs. 7.7, P = 0.0001). On multivariate analysis, BMI and RNS were associated with trifecta outcomes. Similarly, only RNS was identified as an independent predictor of pentafecta. CONCLUSIONS: RNS and BMI were independent predictors of the trifecta. At the same time, RNS was identified as an independent predictor of pentafecta following RAPN

PADUA and R.E.N.A.L. nephrometry scores correlate with perioperative outcomes of robot-assisted partial nephrectomy: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database

Objectives: To evaluate and compare the correlations between Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) and R.E.N.A.L. [Radius (tumour size as maximal diameter), Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior (a)/posterior (p) descriptor and the Location relative to the polar line] nephrometry scores and perioperative outcomes and postoperative complications in a multicentre, international series of patients undergoing robot-assisted partial nephrectomy (RAPN) for masses suspicious for renal cell carcinoma (RCC). Patients and Methods: We retrospectively evaluated the clinical records of patients who underwent RAPN between 2010 and 2013 for clinical N0M0 renal tumours in four international centres that completed all the data required for the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database. All patients underwent preoperative computed tomography or magnetic resonance imaging to define the clinical stage and anatomical characteristics of the tumours. PADUA and R.E.N.A.L. scores were retrospectively assessed in each centre. Univariate and multivariate analyses were used to evaluate the correlations between age, gender, Charlson comorbidity index, clinical tumour size, PADUA and R.E.N.A.L. complexity group categories and warm ischaemia time (WIT) of >20 min, urinary calyceal system closure, and grade of postoperative complications. Results: Overall, 277 patients were evaluated. The median (interquartile range) tumour size was 33.0 (22.0\u201343.0) mm. The median PADUA and R.E.N.A.L. scores were eight and seven, respectively; 112 (40.4%), 86 (31.0%) and 79 (28.5%) patients were classified in the low-, intermediate- or high-complexity group according to PADUA score, while 118 (42.5%), 139 (50.1%) and 20 (7.2%) were classified in the low-, intermediate- or high-complexity group according to R.E.N.A.L. score, respectively. Both nephrometry tools significantly correlated with perioperative outcomes at univariate and multivariate analyses. Conclusion: A precise stratification of patients before PN is recommended to consider both the potential threats and benefits of nephron-sparing surgery. In our present analysis, both PADUA and R.E.N.A.L. were significantly associated with predicting prolonged WIT and high-grade postoperative complications after RAP

Suprapubic transvesical single-port technique for control of lower end of ureter during laparoscopic nephroureterectomy for upper tract transitional cell carcinoma

Context : Various minimally invasive techniques - laparoscopic, endoscopic or combinations of both - have been described to handle the lower ureter during laparoscopic nephroureterectomy but none has received wide acceptance. Aims : We describe an endoscopic technique for the management of lower end of ureter during laparoscopic nephroureterectomy using a single suprapubic laparoscopic port. : Transurethral resectoscope is used to make a full thickness incision in the bladder cuff around the ureteric orifice from 1 o′clock to 11 o′clock. A grasper inserted through the transvesical suprapubic port is used to retract the ureter to complete the incision in the bladder cuff overlying the anterior aspect of the ureteric orifice. The lower end of ureter is subsequently sealed with a clip applied through the port. This is followed by a laparoscopic nephrectomy and the specimen is removed by extending the suprapubic port incision. Our technique enables dissection and control of lower end of ureter under direct vision. Moreover, surgical occlusion of the lower end of the ureter prior to dissection of the kidney may decrease cell spillage. The clip also serves as a marker for complete removal of the specimen. Results : Three patients have undergone this procedure with an average follow up of 19 months. Operative time for the management of lower ureter has been 35, 55 and 40 minutes respectively. A single recurrence was detected on the opposite bladder wall after 9 months via a surveillance cystoscopy. There has been no residual disease or any other locoregional recurrence. Conclusions : The described technique for management of lower end of ureter during laparoscopic nephroureterectomy adheres to strict oncologic principles while providing the benefit of a minimally invasive approach

Multiparametric magnetic resonance imaging-transrectal ultrasound fusion prostate biopsy: A prospective, single centre study

Introduction: Transrectal rectal ultrasound (TRUS)-guided systematic biopsy is the gold standard for diagnosis of prostate cancer. However, systematic biopsy has high false-negative rate and often misses anteriorly located tumors. Magnetic resonance imaging (MRI)-TRUS fusion biopsy can potentially improve cancer detection by better visualization and targeting of cancer focus. We evaluated the role of fusion biopsy in detection of prostate cancer and the association of prostate imaging reporting and data system (PI-RADS) score for predicting cancer risk and its aggression. Methods: Ninety-six consecutive men with suspected prostate cancer underwent MRI-TRUS fusion-targeted biopsy of suspicious lesions and standard 12 core biopsy from May 2014 to July 2015 in our institution. All patients underwent 3.0 T multiparametric MRI before biopsy. mp-MRI included T2W, DWI, DCE and MRS sequences to identify lesions suspicious for prostate cancer. Suspected lesions were scored according to PI-RADS scoring system. Comparison of cancer detection between standard 12 core biopsy and MRI-TRUS fusion biopsy was done. Detection of prostate cancer was primary end point of this study. Results: Mean age was 64.4 years and median prostate-specific antigen was 8.6 ng/ml. Prostate cancer was detected in 57 patients (59.3%). Of these 57 patients, 8 patients (14%) were detected by standard 12 core biopsy only, 7 patients (12.3%) with MRI-TRUS fusion biopsy only, and 42 patients (73.7%) by both techniques. Of the 7 patients, detected with MRI-TRUS fusion biopsy alone, 6 patients (85.7%) had Gleason ≥7 disease. Prostate cancer was detected on either standard 12 core biopsy or MRI-TRUS fusion biopsy in 0%, 42.8%, 74%, and 89.3% patients of suspicious lesions of highest PI-RADS score 2, 3, 4, and 5, respectively. Conclusions: MRI-TRUS fusion prostate biopsy improves cancer detection rate when combined with standard 12 cores biopsy and detects more intermediate or high-grade prostate cancer (Gleason ≥7). With increasing PI-RADS score, there is an increase chance of detection of cancer as well as its aggressiveness