Small renal masses in kidney transplantation : Overview of clinical impact and management in donors and recipients

Kidney transplantation is the best replacement treatment for the end-stage renal disease. Currently, the imbalance between the number of patients on a transplant list and the number of organs available constitutes the crucial limitation of this approach. To expand the pool of organs amenable for transplantation, kidneys coming from older patients have been employed; however, the combination of these organs in conjunction with the chronic use of immunosuppressive therapy increases the risk of incidence of graft small renal tumors. This narrative review aims to provide the state of the art on the clinical impact and management of incidentally diagnosed small renal tumors in either donors or recipients. According to the most updated evidence, the use of grafts with a small renal mass, after bench table tumor excision, may be considered a safe option for high-risk patients in hemodialysis. On the other hand, an early small renal mass finding on periodic ultrasound-evaluation in the graft should allow to perform a conservative treatment in order to preserve renal function. Finally, in case of a renal tumor in native kidney, a radical nephrectomy is usually recommended

En bloc resection of bladder tumour : the rebirth of past through reminiscence

© 2023. The Author(s).Peer reviewedPublisher PD

Clinical comparison between conventional and microdissection testicular sperm extraction for non-obstructive azoospermia: Understanding which treatment works for which patient

Objectives: The superiority of microdissection testicular sperm extraction (mTESE) over conventional TESE (cTESE) for men with non-obstructive azoospermia (NOA) is debated. We aimed to compare the sperm retrieval rate (SRR) of mTESE to cTESE and to identify candidates who would most benefit from mTESE in a cohort of Caucasian-European men with primary couple’s infertility. Material and methods: Data from 49 mTESE and 96 cTESE patients were analysed. We collected demographic and clinical data, serum levels of LH, FSH and total testosterone. Patients with abnormal karyotyping were excluded from analysis. Age was categorized according to the median value of 35 years. FSH values were dichotomized according to multiples of the normal range (N) (N and 1.5 N: 1-18 mIU/mL, and > 18 mIU/mL). Testicular histology was recorded for each patient. Descriptive statistics and logistic regression analyses tested the impact of potential predictors on positive SRR in both groups. Results: No differences were found between groups in terms of clinical and hormonal parameters with the exception of FSH values that were higher in mTESE patients (p = 0.004). SRR were comparable between mTESE and cTESE (49.0% vs. 41.7%, p = 0.40). SRRs were significantly higher after mTESE in patients with Sertoli cell-only syndrome (SCOS) (p = 0.038), in those older than 35 years (p = 0.03) and with FSH >1.5N (p 1.5N (p = 0.018). Moreover, increased FSH levels (p = 0.03) and both SCOS (p = 0.01) and MA histology (p = 0.04) were independent predictors of SRR failure. Conclusions: Microdissection and cTESE showed comparable success rates in our cohort of patients with NOA. mTESE seems beneficial for patients older than 35 years, with high FSH values, or when SCOS can be predicted. Given the high costs associated with the mTESE approach, the identification of candidates most likely to benefit from this procedure is a major clinical need

Role of Bed Assistant During Robot-assisted Radical Prostatectomy: The Effect of Learning Curve on Perioperative Variables

Background: A remote interaction between a console surgeon (CS) and a bedside surgeon (BS) makes the role of the latter critical. No conclusive data are reported about the length of the learning curve of a BS. Objective: To highlight the role of a BS during robot-assisted radical prostatectomy (RARP) and to analyze the effect of the learning curve of a BS on intra- and postoperative outcomes. Design, setting, and participants: From June 2013 to September 2016, 129 RARPs were performed by one expert CS (>1000 RARPs) and two BSs (residents). According to the learning curve of the BS, the patients were divided into three groups: group 1 (first 20 procedures), group 2 (21–40 procedures), and group 3 (>40 procedures). Outcome measurements and statistical analysis: Preoperative variables, pathological data, operating time (OT), blood loss (BL), number of lymph nodes excised (LE), length of hospital stay (LHS), and time to catheter removal (CR) were analyzed. Linear/logistic regression analyses tested the impact of BS experience on surgical outcomes. T test and chi-square test compared the outcomes of the two BSs. Results and limitations: Perfect interaction between CSs and BSs are requested to obtain the optimal exposure and avoid any conflict. On the linear regression model, BS learning curve was not related to OT, BL, LHS, and CR, but was related to LE (r2= 0.09; p = 0.03). On multivariate analyses, no correlation between BS experience and OT, BL, LHS, CR, LE, margin status, and complications (all p > 0.05) was found. Comparing the two BSs, no difference was found for the abovementioned outcomes in the first 40 surgeries (all p > 0.05). Study limitations include the limited cohort of patients and its retrospective nature. Conclusions: In this study, BS learning curve does not appear to influence the surgical outcomes; good experience of the CS was probably the explanation. Patient summary: In our experience, it is the primary surgeon who dictates the perioperative outcomes during robot-assisted radical prostatectomy. In this study, bedside surgeon learning curve does not appear to influence the surgical outcomes; good experience of the console surgeon was probably the explanation. In our experience, it is the primary surgeon who dictates the perioperative outcomes during robot-assisted radical prostatectomy

Diagnostic ureteroscopy for upper tract urothelial carcinoma : friend or foe?

The European Association of Urology guidelines recommend offering kidney-sparing surgery (KSS) as a primary treatment option to patients with low-risk tumours. Cystoscopy, urinary cytology, and computed tomography urography (CTU) do not always allow correct disease staging and grading, and sometimes there is even a lack of certainty regarding the diagnosis of UTUC. Diagnostic ureteroscopy (d-URS) may therefore be of crucial importance within the diagnostic framework and fundamental in establishing the appropriate therapeutic approach. A systematic review of the literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of interventions (ROBINS-I). Overall, from 3791 identified records, 186 full-text articles were assessed for eligibility. Finally, after a quantitative review of the selected literature, with the full agreement of all authors, 62 studies were considered relevant for this review. CTU has a sensitivity and specificity for UTUC of 92% and 95% respectively, but is not able to detect small or flat lesions with adequate accuracy. The sensitivity of voided urinary cytology for UTUC is around 67-76% and ranges from 43% to 78% for selective ureteric urine collection. As no technique offers a diagnosis of certainty, d-URS can allow an increase in diagnostic accuracy. In the present review the pros and cons of d-URS were analysed. This technique may provide additional information in the selection of patients suitable for neoadjuvant chemotherapy or KSS, distinguishing between normal tissue and low- and high-grade UTUC thanks to the emerging technologies. Information obtainable from d-URS and ureteroscopic-guided biopsy can prove extremely valuable when the diagnosis of UTUC is doubtful or KSS is being considered. Notwithstanding concerns remain regarding the potential risk of bladder recurrence, cancer dissemination, and/or delay in radical treatment. Abbreviations: CLE: confocal laser endomicroscopy; CSS: cancer-specific survival; CTU: CT urography; d-URS: diagnostic ureteroscopy; EAU: European Association of Urology; HR: hazard ratio; IMAGE1S: Storz professional imaging enhancement system; IVR: intravesical recurrence; KSS: kidney-sparing surgery; MFS: Metastasis-free survival; NAC: neoadjuvant chemotherapy; NBI: narrow-band imaging; OCT: optical coherence tomography; RFS: Recurrence-free survival; RNU: radical nephroureterectomy; ROBINS-I: Risk of Bias in Non-randomized Studies of interventions; URS(-GB): Ureteroscopy(-guided biopsy); UTUC: upper tract urothelial carcinoma; UUT: upper urinary trac

Low-dose CT scan in stone detection for stone treatment follow-up: is there a relation between stone composition and radiation delivery? Study on a porcine-kidney model

BACKGROUND: Non-contrast CT scan (NCCT) is becoming the standard imaging modality in urinary stone disease. Radiation dose remains an issue, especially for those patients who may need to undergo several CT scans for this indication during their lifetime. Low-dose and ultra-low-dose protocols exist, but there is limited data on the relationship between the minimum radiation dose capable of detecting stone fragments and stone composition.METHODS: Seven different kinds of human kidney stone were selected. Fragments of 1, 2, 4 and 7 mm were obtained for each stone. Four fragments of the same material were placed in a porcine kidney. A CT scan was then used to scan the kidney at decreasing dosages of 140, 70, 30, 15 and 7mAs. The scans were repeated for each type of stone. Images were reviewed by two radiologists independently with the intent of identifying the stone composition and providing information on its position, dimensions and Hounsfield units (HU).RESULTS: All types of stone were visible at all settings. Only the 1-mm uric-acid fragment was not detected by both radiologists at 7 and 15 mAs. Dose Length product (DLP) decreased with the reduction in mAs. In terms of HU a statistically significant difference was observed between calcium-based and non-calcium-based stones. Stone dimensions and HU were not affected by the reductions in mAs.CONCLUSIONS: Ultra-low-dose CT has a good detection rate for all kinds of stone, even when the fragment size is small. Only small uric acid fragments need higher energy settings in order to be detected. When the stone composition is known after surgery for urolithiasis, the most appropriate CT scan setting could be suggested by the urologist during their follow-up.</p

Comparison of Flexible Ureterorenoscope Quality of Vision : an in Vitro Study

Introduction: Flexible ureterorenoscopy (fURS) is one of the best solutions for treatment of renal calculi <2 cm and for upper urinary tract urothelial carcinoma conservative treatment. An adequate quality of vision is mandatory to help surgeon get better outcomes. No studies have been done, to our knowledge, about what fURS in the market has the best quality of vision. Materials and Methods: Seven different fURS were used to compare the image quality (Lithovue, Olympus V, Olympus V2, Storz Flex XC - in White Light and in Clara+Chroma mode - Wolf Cobra Vision, Olympus P6, and Storx Flex X2). Two standardized grids to evaluate contrast and image definition and three stones of different composition were filmed in four standardized different scenarios. These videos were shown to 103 subjects (51 urologists and 52 nonurologists) who had to evaluate them with a rating scale from 1 (very bad) to 5 (very good). Results: No difference in terms of scores was observed for sex of the participants. Digital (D) ureterorenoscopes were rated better than fiber optics (FOs) ureterorenoscopes. Overall, Flex XC White Light and XC Clara+Chroma image quality resulted steadily better than other fURS (p < 0.0001). Olympus V generally provided a vision better than Lithovue. Cobra Vision and Olympus V2 had superimposable values that were significantly lower than Lithovue's ones. Olympus P6 and Storz X2 offered a low quality of vision compared to the others. In the medium simulating bleeding, Olympus V and V2 significantly improved their scores of 12% and 8.1%, contrary to rest of the ureterorenoscopes. Conclusion: D ureterorenoscopes have a better image quality than FO ones. The only disposable ureterorenoscope tested was comparable to the majority of other D ureterorenoscopes. The best image quality was provided by Storz D ureterorenoscopes, being Clara Chroma the favorite Spies Mode, according to literature

Robot-assisted radical cystectomy and ileal conduit with Hugo™ RAS system: feasibility, setting and perioperative outcomes

ABSTRACT Introduction: Robotic approach has shown its feasibility and safety with respect to open approach for radical cystectomy (1). The performances of Hugo™ RAS system (Medtronic, Minneapolis, USA) have been demonstrated in several clinical scenarios (2-5). We report the feasibility and surgical settings of the first series of robot-assisted radical cystectomy (RARC) with intracorporeal ileal-conduit performed with Hugo™ RAS system. Methods: Two patients were submitted to RARC with ileal conduit at our institution. The trocar placement scheme and the operating room setting with docking angles of the four arms were already described (6). A 12-mm and a 5-mm trocar for the assistant were placed. In both cases, an ileal-conduit with a Wallace type-1 uretero-enteric derivation was performed intra-corporeally. Results: The first patient was a 71-year-old male with a very-high risk non-muscle invasive bladder cancer(BC), and the second patient was a 64-year-old male with a diagnosis of T2 high-grade BC. Operative times were 360 and 420 minutes with a docking time of 12 and 9 minutes, respectively. No intraoperative complications occurred. The estimated blood loss was 200ml and 400ml, respectively. The second patient developed an ileus on postoperative day 4 (Clavien-Dindo grade 2). No positive surgical margins were recorded. No recurrence nor progression occurred during follow-up. Conclusion: RARC with intracorporeal ileal conduit urinary diversion is feasible with Hugo™ RAS system. We provided insight into the surgical setting using this novel robotic platform to help new adopters to face this challenging procedure. These findings may help a wider distribution of robotic programs for BC treatment