Predicting calyceal access for percutaneous nephrolithotomy with computed tomography multiplanar reconstruction

OBJECTIVES: Objective parameters in computed tomography (CT) scans that could predict calyceal access during percutaneous nephrolithotomy have not been evaluated. These parameters could improve access planning for percutaneous nephrolithotomy. We aimed to determine which parameters extracted from a preoperative multiplanar reconstructed CT could predict renal calyceal access during a percutaneous nephrolithotomy. METHODS: From January 2009 through April 2011, 230 patients underwent 284 percutaneous nephrolithotomies at our institution. Sixteen patients presented with complete staghorn calculi, and 11 patients (13 renal units) were analyzed. Five parameters were extracted from a preoperative reconstructed CT and compared with the surgical results of percutaneous nephrolithotomy. RESULTS: Fifty-eight calyces were studied, with an average of 4.4 calyces per procedure. A rigid nephroscope was used to access a particular calyx, and a univariate analysis showed that the entrance calyx had a smaller length (2.7 vs. 3.98 cm, p = 0.018). The particular calyx to be accessed should have a smaller length (2.22 vs. 3.19 cm, p = 0.012), larger angles (117.6 vs. 67.96,

Prospective randomized trial comparing the outcomes of open vs laparoscopic partial nephrectomy

Introdução: A nefrectomia parcial é considerada o tratamento padrão para tumores renais pequenos, menores que 4 cm, e a opção de preferência para tumores de 4 a 7 cm, quando factível. Nos últimos anos foi possível observar um grande crescimento na utilização de técnicas minimamente invasivas para a realização da cirurgia. No entanto, não existem estudos fornecendo dados com bom nível de evidência dando suporte para o uso destas técnicas. Objetivo: Comparar a incidência de complicações cirúrgicas, além de resultados funcionais e oncológicos, de pacientes submetidos a nefrectomia parcial aberta versus nefrectomia parcial videolaparoscópica. Materiais e Métodos: Pacientes com tumores renais de até 7 cm foram randomizados para receberem nefrectomia parcial aberta ou laparoscópica em randomização balanceada 1:1. Eram critérios de exclusão: tumores múltiplos, rim único, função renal menor que 30 ml/min, contraindicação à cirurgia aberta ou laparoscópica. A função renal foi avaliada com depuração estimado de creatinina e ritmo de filtração glomerular medido com EDTA no pré-operatório, aos 3 e 12 meses da cirurgia. Complicações foram registradas conforme classificação de Clavien. Resultados: Entre 2012 e 2020, 208 pacientes aceitaram participar do estudo e foram randomizados. 28 pacientes acabaram saindo do estudo após randomização. Sendo assim, 180 pacientes (84 no braço laparoscopia e 96 no braço aberto) foram incluídos na análise por intenção de tratamento. Não houve diferença entre os grupos em relação ao tempo de cirurgia, tempo de internação ou volume de sangramento. Pacientes submetidos a nefrectomia parcial aberta tiveram mediana de tempo de isquemia significativamente menor que o grupo laparoscópico (10 min X 13 min, p = 0,03), às custas de maior número de pacientes com isquemia zero (35,4% X 15,5%, p = 0,02). Não houve diferença na incidência de complicações pós-operatórias entre os grupos, seja em relação a todas as complicações ou em relação às complicações significativas (Clavien 2). Adicionalmente, não houve diferença em relação aos resultados oncológicos estudados. Já em relação à perda de função renal, os dados são consistentes com menor perda de função no grupo submetido a nefrectomia parcial laparoscópica, pincipalmente aos 12 meses da cirurgia. Conclusão: A nefrectomia parcial laparoscópica apresenta resultados semelhantes à nefrectomia parcial aberta em termos de resultados intraoperatórios, complicações cirúrgicas e resultados oncológicos. Existe uma vantagem em termos de preservação de função renal nos pacientes submetidos à cirurgia laparoscópica. Levando em consideração os benefícios associados ao acesso minimamente invasivo, a cirurgia laparoscópica deve ser preferida em centros de excelência e em mãos de cirurgiões experientesBackground: Partial nephrectomy is the standard treatment for renal tumors smaller than 7 cm and a trend toward minimally invasive surgery has increased. However, data that could support its use and benefit over open techniques is still lacking. Design: This is a prospective randomized controlled trial comparing surgical complications, functional and oncological outcomes in patients undergoing open partial nephrectomy (OPN) or laparoscopic partial nephrectomy (LPN). Intervention: Randomization (1:1) to open partial nephrectomy or laparoscopic partial nephrectomy for treatment of renal tumors smaller than 7 cm. Outcome measurements and statistical analysis: The primary endpoint is surgical complications up to 90 days after surgery. Secondary outcomes are comparison of surgical data, oncological and functional results. Results: We randomized 208 patients between 2012 to 2020 (110 OPN vs 98 LPN). Operative data showed no difference regarding operative time, warm ischemia time, estimated blood loss, transfusions or length of hospital stay. Zero ischemia was more frequent for OPN (35.4% vs 15.5%, p=0.02). There were no differences in overall complications, however OPN was associated with more abdominal wall complications (31.2% vs 13.1%). Regarding oncological outcomes, no difference was noted for positive surgical margins, recurrence or overall survival. LPN group had less kidney function reduction in 3 months (-5.2% vs -10%, p= 0.04) and 12 months after surgery (-0.8% vs -6.3%, p = 0.02), and a lower rate of downstage on the CKD classification in 12 months (14.1% vs 32.6%, p = 0.006). Conclusion: LPN has similar results to OPN regarding intraoperative data, complications and oncological outcomes. Minimally invasive partial nephrectomy may provide better kidney function preservation. More studies, specially including robotic surgeries, are necessary to confirm our finding

Laparoscopic skill laboratory in urological surgery: tools and methods for resident training

PURPOSE: Laparoscopy has certainly brought considerable benefits to patients, but laparoscopic surgery requires a set of skills different from open surgery, and learning in the operating room may increase surgical time, and even may be harmful to patients. Several training programs have been developed to decrease these potential prejudices. PURPOSES: to describe the laparoscopic training program for urological residents of the "Hospital das Clinicas" of the Sao Paulo Medical School, to report urological procedures that are feasible in dry and wet labs, and to perform a critical analysis of the cost-benefit relation of advanced laparoscopic skills laboratory. MATERIALS AND METHODS: The laparoscopic skill lab has two virtual simulators, three manual simulators, and four laparoscopic sets for study with a porcine model. The urology residents during their first year attend classes in the virtual and manual simulator and helps the senior urological resident in activities carried out with the laparoscopic sets. During the second year, the urological resident has six periods per week, each period lasting four hours, to perform laparoscopic procedures with a porcine model. Results: In a training program of ten weeks, one urological resident performs an average of 120 urological procedures. The most common procedures are total nephrectomy (30%), bladder suture (30%), partial nephrectomy (10%), pyeloplasty (10%), ureteral replacement or transuretero anastomosis (10%), and others like adrenalectomy, prostatectomy, and retroperitoneoscopy. These procedures are much quicker and caused less morbidity. CONCLUSION: Laparoscopic skills laboratory is a good method for achieving technical ability

Robotic Salvage Lymph Node Dissection After Radical Prostatectomy

ABSTRACTIntroduction and objective:Radical prostatectomy is a first-line treatment for localized prostate cancer. However, in some cases, biochemical recurrence associated with imaging-detected nodal metastases may happen. Herein, we aim to present the surgical technique for salvage lymph node dissection after radical prostatectomy.Materials and Methods:A 70 year-old asymptomatic man presented with a prostate-specific antigen (PSA) of 7.45ng/ mL. Digital rectal examination was normal and trans-rectal prostate biopsy revealed a prostate adenocarcinoma Gleason 7 (3+4). Pre-operative computed tomography scan and bone scintigraphy showed no metastatic disease. In other service, the patient underwent a robotic-assisted radical prostatectomy plus obturador lymphadenectomy. Pathologic examination showed a pT3aN0 tumor. After 6 months of follow-up, serum PSA was 1.45ng/mL. Further investigation with 11C–Choline PET/CT revealed only a 2-cm lymph node close to the left internal iliac artery. The patient was counseled for salvage lymph node dissection.Results:Salvage lymph node dissection was uneventfully performed. Operative time was 1.5 hour, blood loss was minimal, and there were no intra- or postoperative complications. The patient was discharged from hospital in the 1st postoperative day. After 12 months of follow-up, his PSA was undetectable with no other adjuvant therapy.Conclusion:Robotic salvage pelvic lymph node dissection is an effective option for treatment of patients with biochemical recurrence after radical prostatectomy and only pelvic lymph node metastasis detected by C11-Choline PET/CT

Does The Presence Of Median Lobe Affect Outcomes Of Robot-Assisted Laparoscopic Radical Prostatectomy?

This study presents an integrated k-means clustering and gravity model (IKCGM) for investigating the spatiotemporal patterns of nutrient and associated dissolved oxygen levels in Tampa Bay, Florida. By using a k-means clustering analysis to first partition the nutrient data into a user-specified number of subsets, it is possible to discover the spatiotemporal patterns of nutrient distribution in the bay and capture the inherent linkages of hydrodynamic and biogeochemical features. Such patterns may then be combined with a gravity model to link the nutrient source contribution from each coastal watershed to the generated clusters in the bay to aid in the source proportion analysis for environmental management. The clustering analysis was carried out based on 1 year (2008) water quality data composed of 55 sample stations throughout Tampa Bay collected by the Environmental Protection Commission of Hillsborough County. In addition, hydrological and river water quality data of the same year were acquired from the United States Geological Survey\u27s National Water Information System to support the gravity modeling analysis. The results show that the k-means model with 8 clusters is the optimal choice, in which cluster 2 at Lower Tampa Bay had the minimum values of total nitrogen (TN) concentrations, chlorophyll a (Chl-a) concentrations, and ocean color values in every season as well as the minimum concentration of total phosphorus (TP) in three consecutive seasons in 2008. The datasets indicate that Lower Tampa Bay is an area with limited nutrient input throughout the year. Cluster 5, located in Middle Tampa Bay, displayed elevated TN concentrations, ocean color values, and Chl-a concentrations, suggesting that high values of colored dissolved organic matter are linked with some nutrient sources. The data presented by the gravity modeling analysis indicate that the Alafia River Basin is the major contributor of nutrients in terms of both TP and TN values in all seasons. With this new integration, improvements for environmental monitoring and assessment were achieved to advance our understanding of sea-land interactions and nutrient cycling in a critical coastal bay, the Gulf of Mexico. © 2012 The Royal Society of Chemistry