Outcomes of minimally invasive partial nephrectomy among very elderly patients: Report from the resurge collaborative international database

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass.The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used.Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m(2). PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST]-4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01).In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available

Haemostatics in surgery and our experience in the enucleoresection of renal cell carcinoma

<p>Abstract</p> <p>Background</p> <p>30 patients, with T1 renal cell carcinomas (RCC) who underwent open enucleoresection of the tumour, were randomized to the use of a topical haemostatic agent (Floseal) or to an infrared-sapphire coagulator (ISC), to compare their efficacy in achieving haemostasis. Methods: Successful intra-operative haemostasis, intra- and post-operative bleeding, operative time, hospital discharge were evaluated.</p> <p>Results</p> <p>Statistically higher rates of successful haemostasis and shorter time-to-haemostasis (8,1 vs 12,9 min) were observed in the FloSeal group (p < 0.001 both). Patients operative time was not different between Group 1 vs 2 (58.7 ± 12 vs 62.4 ± 15; p > 0.05). The average blood loss during surgery was less (60 +/- 25.5 mL) for the FloSeal group than for the ISC group (85 +/- 40.5 mL) (p < 0.05). Postoperative blood loss was 25 +/- 5 mL and 40 +/- 45 mL for Floseal and ISC respectively, (p < 0.05). Length of the postoperative hospital discharge was 2.5 +/- 1.2 days for FloSeal group and 3.5 +/- 1.3 for the Group 2 (p < 0.05). No major immediate or delayed complications were observed in either Groups.</p> <p>Conclusions</p> <p>The use of Floseal and ISC offer a safe and efficacy haemostasis in the enucleoresection of RCC. Moreover, our results show a less intra-operative and post-operative blood loss as well as a shorter time to haemostasis of Floseal in respect to ISC.</p

Re: The Temporal Association of Robotic Surgical Diffusion with Overtreatment of the Small Renal Mass

xx

Contemporary minimally invasive surgery for adrenal masses: it's not all about (pure) laparoscopy

Not availabl

Outcomes of Laparoscopic and Robotic Partial Nephrectomy for Large (>4\ua0Cm) Kidney Tumors: Systematic Review and Meta-Analysis

Purpose: The aim of this study was to assess the outcomes of minimally invasive (laparoscopic and robotic) partial nephrectomy (MIPN) for large renal masses. Materials and Methods: A systematic literature review was performed up to September 2016 using multiple search engines to identify studies comparing MIPN for tumors larger than 4\ua0cm (>cT1a) with MIPN for tumors smaller than 4\ua0cm (cT1a). The preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria were used for article selection. Baseline demographics and surgical, functional, and oncological parameters were extracted from the included studies whenever available. An overall analysis including all studies was performed, then sensitivity analyses were performed for studies on laparoscopic partial nephrectomy (PN) only, and, finally, for studies on robotic PN only. Results: Overall, 13 case-control studies comparing the outcomes of PN in tumors 4\ua0cm (n\ua0=\ua01024) were included. Warm ischemia time was shorter for the <4\ua0cm group [weighted mean difference (WMD) 3.75\ua0min; 95% confidence interval (CI) 126.4 to 120.7; p\ua0=\ua00.01] and the odds of perioperative complications was lower [odds ratio (OR) 0.62; 95% CI 0.5\u20130.8; p\ua0<\ua00.001]. There were no significant differences in terms of postoperative estimated glomerular filtration rate (WMD 4.2\ua0ml/min; 95% CI 0.45\u20138.97; p\ua0=\ua00.08), as well as onset of postoperative chronic kidney disease (risk ratio 0.71; 95% CI 0.48\u20131.04; p\ua0=\ua00.08). In addition, no difference was found in the likelihood of positive surgical margins (OR 0.74; 95% CI 0.43\u20131.28; p\ua0=\ua00.29). Conclusions: MIPN represents a viable treatment option for renal masses larger than 4\ua0cm (higher than cT1a) as it offers good functional outcomes, without increased risk of positive surgical margins. An increased rate of complications should be taken into account when approaching these tumors

Laparoendoscopic single-site nephroureterectomy for upper urinary tract urothelial carcinoma: outcomes of an international multi-institutional study of 101 patients

To report a large multi-institutional series of laparoendoscopic single-site (LESS) nephroureterectomy (NU). Data on all cases of LESS-NU performed between 2008 and 2012 at 15 institutions were retrospectively gathered. The main demographic data and perioperative outcomes were analysed. The study included 101 patients whose mean (sd) age was 66.4 (9.9) years and mean (sd) body mass index was 24.8 (4) kg/m(2), and of whom 29.7% had undergone previous abdominal/pelvic surgery. The mean (sd) operating time was 221.4 (73.7) min, estimated blood loss 231.7 (348.0) mL. A robot-assisted LESS technique was applied in 25.7% of cases. An extra trocar was inserted in 28.7% of cases to complete the procedure. Conversion to open surgery was necessary in three cases (3.0%). There was no bladder cuff excision in 20.8% of cases, and excision was carried out using a variety of techniques in the remaining cases. Six intra-operative complications occurred (5.9%). The mean (sd) length of hospital stay was 6.3 (3.5) days. The overall postoperative complication rate was 10.0%, and most of the complications were low grade (Clavien grades 1 and 2). The mean tumour size was 3.1 (1.9) cm. Pathological staging was pTis in two patients, pTa in 12 patients, pT1 in 42 patients, pT2 in 20 patients, pT3 in 23 patients and pT4 in two patients. Pathological grade was high in 71 and low in 30 patients. At a mean follow-up of 14 months, six patients (5.9%) had died. Disease recurrence (including distant and bladder recurrence) was detected in 22.8% of patients, with a mean time to recurrence of 11.5 months. This study reports the largest multi-institutional experience of LESS-NU to date. Peri-operative outcomes mirror those of published standard laparoscopy series. Despite encouraging early findings, longer follow-up is needed to determine the oncological efficacy of the procedure

Laparoendoscopic Single-site Partial Nephrectomy: A Multi-institutional Outcome Analysis

Background: Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS. Objective: To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN. Design, setting, and participants: Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis. Intervention: Each group performed LESS-PN according to its own protocols, entry criteria, and techniques. Outcome measurements and statistical analysis: Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short

Analysis of oncological outcomes and renal function after laparoendoscopic single-site (LESS) partial nephrectomy: a multi-institutional outcome analysis

Objective To report on a large multi-institutional series of laparoendoscopic single-site (LESS) partial nephrectomy (PN) and analyse renal function and short-term oncological outcomes. Material and Methods We conducted a retrospective analysis of consecutive cases of LESS-PN performed between November 2007 and March 2012 at 11 participating institutions. Demographic data and data on the main peri-operative outcomes and complications were gathered and analysed. Kidney function was evaluated by measuring serum creatinine concentration and estimated glomerular filtration rate (eGFR). Chronic kidney disease was defined in stages for each patient according to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative. Results A total of 190 cases were included in this analysis. The mean renal tumour size was 2.6cm, and the mean PADUA score was 7.2. The median operating time was 170min with a median estimated blood loss of 150mL. A clampless technique was used in 70 cases (36.8%) and the median warm ischaemia time (WIT) was 16.5min. PADUA score independently predicted the length of WIT (low vs high score: odds ratio 5.11, CI 1.50-17.41, P = 0.009; intermediate vs high score: odds ratio 5.13, CI 1.56-16.88, P = 0.007). The overall postoperative complication rate was 14.7%. Where a clamping technique was used, a significant increase in serum creatinine concentration and a significant decrease in eGFR were observed postoperatively and at 6 months. On multivariate analysis PADUA score was the only predicting factor. Overall survival rates were 99, 97 and 88% at 12-, 24- and 36-month follow-up, respectively, while disease-free survival rates were 98% at 12-month and 97% at 24- and 36-month follow-up. Conclusion The study showed that LESS-PN is effective in terms of renal function preservation and oncological control at short- and intermediate-term follow-up

Precision surgery and genitourinary cancers

The landscape of the surgical management of urologic malignancies has dramatically changed over the past 20 years. On one side, better diagnostic and prognostic tools allowed better patient selection and more reliable surgical planning. On the other hand, the implementation of minimally invasive techniques and technologies, such as robot-assisted laparoscopy surgery and image-guided surgery, allowed minimizing surgical morbidity. Ultimately, these advances have translated into a more tailored approach to the management of urologic cancer patients. Following the paradigm of “precision medicine”, contemporary urologic surgery has entered a technology-driven era of “precision surgery”, which entails a range of surgical procedures tailored to combine maximal treatment efficacy with minimal impact on patient function and health related quality of life. Aim of this non-systematic review is to provide a critical analysis of the most recent advances in the field of surgical uro-oncology, and to define the current and future role of “precision surgery” in the management of genitourinary cancers