Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence

BACKGROUND: The definition of the safest width of healthy renal margin to achieve oncological efficacy and therefore of the safest resection technique (RT) during partial nephrectomy (PN) continues to be widely debated. The aim of this study is to evaluate the prevalence of positive surgical margins (PSM), loco-regional recurrence (LRR) and renal recurrence (RER) rates after simple enucleation (SE) and standard partial nephrectomy (SPN) for malignant renal tumors in studies with a minimum follow-up of 2 years. EVIDENCE ACQUISITION: A systematic review of the English-language literature was performed through August 2016 using the Medline, Web of Science and Embase databases according to the PRISMA criteria. A systematic review and meta-analysis was performed in those studies that defined the exact anatomical location of recurrence after PN. EVIDENCE SYNTHESIS: Overall, 33 studies involving 11282 patients were selected for quantitative analysis. At a median follow up of 43 (SE) and 52 (SPN) months, the pooled estimates of the prevalence of PSMs, LRR and RER were 2.7% (95% CI: 1.5-4.6%, p<0.001) and0.4% (95% CI: 0.1-2.2%, p=0.018), 2.0% (95% CI: 1.4-2.8%, p<0.001) and 0.9% (95% CI: 0.5-1,7%p=0.04), 1.5% (95% CI: 0.9-2.3%, p=0.001) and 0.9% (95% CI: 0.5-1,7%, p=0.40) in patients undergoing SPN and SE, respectively. CONCLUSIONS: Our systematic analysis and meta-analysis demonstrates that SE is noninferior to SPN regarding PSM, LRR and RER rates in patients undergoing PN for malignant renal tumors. Further studies using standardized reporting tools are needed to evaluate the role of resection techniques for oncologic outcomes after PN

Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible?

To investigate the feasibility of RAPN on T1b renal mass by assessment of Trifecta and Pentafecta rate between T1a and T1b renal mass.We retrospectively reviewed the medical records of 277 cases of RPN performed from 2006 to 2015. Sixty patients with clinically T1b renal masses (> 4 cm and ≤ 7 cm) were identified, and from 180 patients with clinically T1a renal mass, 60 patients were matched with T1b renal mass by propensity score. Tumor complexity was investigated according to R.E.N.A.L nephrometry score. "Pentafecta" was defined as achievement of Trifecta (negative surgical margin, no postoperative complications and warm ischemia time of ≤ 25 minutes) with addition of over 90% estimated GFR preservation and no chronic kidney disease stage upgrading at 1 year postoperative period. Propensity score matching was performed by OneToManyMTCH. Logistic regression models were used to identify the variables which predict the Trifecta, and Pentafecta ac.Preoperative variables (age, sex, body mass index, ASA score) were similar between T1a and T1b after propensity score matching. The median R.E.N.A.L. nephrometry score was 8 vs 9 for T1a and T1b respectively (p<0.001). The median warm ischemia time was 20.1 min vs 26.2 min (p<0.001). Positive surgical margin rate was 5% vs 6.6% (p = 0.729) and overall complication rate of 13.3%. vs 15% (p = 0.793). The rate of achievement of Trifecta rate were 65.3% vs 43.3% (p = 0.017) and Pentafecta rate were 38.3% vs 26.7% (p = 0.172). For achievement of Pentafecta, R.E.N.A.L nephrometry score (HR 0.80; 95% CI (0.67-0.97); p = 0.031) was significant predictor of achieving Pentafecta. Subanalyis to assess the component of R.E.N.A.L nephrometry score, L component (location relative to the polar lines, HR 0.63; 95% CI (0.38-1.03); P = 0.064) was relatively important component for Pentafecta achievement.The rate of Pentafecta after RAPN was comparable between T1a and T1b renal masses. RAPN is a feasible modality with excellent long term outcome for patients with larger renal mass (cT1b)

Laparoscopic-assisted renal autotransplantation

To report our experience with laparoscopic nephrectomy and autotransplantation for the management of a variety of conditions with significant loss of healthy ureteral tissue or ureteral length. Renal autotransplantation has been described as an effective method for addressing this problem, avoiding the need for nephrectomy or complex ureteral replacement. In an effort to decrease the morbidity associated with traditional autotransplantation we elected to perform laparoscopic procurement of the kidney. Four patients underwent laparoscopic nephrectomy using a transperitoneal four-port technique and subsequent autotransplantation into the iliac fossa for the treatment of proximal ureteral avulsion (2 patients), ureteral malignancy, and ureteral stricture. All patients had less than 5 cm of viable ureter. All procedures were performed without intraoperative complications. All renal scans on postoperative day 1 demonstrated good perfusion. None of the patients had a postoperative rise in serum creatinine. On postoperative day 1, the mean creatinine value was 0.95 mg/dL. Three patients had an uneventful postoperative course. One patient, however, had loss of the graft because of renal vein thrombosis on postoperative day 7. She was later found to have an undiagnosed thrombophilic disorder (decreased levels of antithrombin III) and to have a recent history of oral contraceptive use. Laparoscopic nephrectomy with renal autotransplantation is a feasible minimally invasive alternative to treat patients who have significant ureteral loss. This approach avoids the need for an upper abdominal or flank incision, resulting in decreased morbidity. The initial follow-up studies indicated stable renal function. Additional long-term observation is currently under way

Entry techniques in laparoscopic radical and partial nephrectomy: A multicenter international survey of contemporary practices

BACKGROUND: There is no clear consensus as to the optimal method of entry in laparoscopic renal surgery and no reports have compared them in Urology. To analyze contemporary practice patterns in entry technique and port placement for laparoscopic kidney surgery. METHODS: We identified 60 high volume urological laparoscopic centers. A purpose-built questionnaire was sent to surgeons. The survey included 22 questions regarding access techniques and port configuration during laparoscopic kidney surgery. Data on were collected and retrospectively analyzed. Concordance among port configurations was assessed using Cohen's Kappa statistics. RESULTS: The survey was sent to 60 surgeons and completed by 32 of them. Surgical procedures included were laparoscopic radical nephrectomy (1177 LRN/year) and laparoscopic partial nephrectomy (1047 LPN/year). The transperitoneal route was preferred (85%). Hasson technique was used for the access in 55% of the cases. Patient lateral recumbent position is the most frequently used during the port placement (41%). Although there is a high variability in the port positioning among the surgeons, in more than 90% of cases it was found a specific concordance in triangulation of optics and operating trocars. There were no significant differences between port configuration in LRN and LPN. Limitations include retrospective design and limited sample. CONCLUSIONS: A standard port configuration has not been previously reported in urological literature. Our study suggests that the transperitoneal approach, the Hasson technique and a specific triangulation of optics and operating trocars have a significant concordance in some high volume laparoscopic urologic centers

Effect of Preoperative Risk Group Stratification on Oncologic Outcomes of Patients with Adverse Pathologic Findings at Radical Prostatectomy - Fig 1

<p>Kaplan-Meier estimates of biochemical recurrence–free survival (BCRFS) after radical prostatectomy (RP) by the presence of adverse pathological findings (APFs) for (A) total (log-rank test, p <0.001), (B) low-risk (p = 0.027), (C) intermediate-risk (p <0.001), and (D) high-risk (p <0.001) patients.</p

Effect of Preoperative Risk Group Stratification on Oncologic Outcomes of Patients with Adverse Pathologic Findings at Radical Prostatectomy - Fig 2

<p>Cumulative incidence estimates of prostate cancer-specific mortality (PCSM) after radical prostatectomy (RP) using a competing risk analysis by adverse pathological findings (APFs) for (A) total (Gray’s modified log rank, p = 0.001), (B) low-risk (p = 0.903), (C) intermediate-risk (p = 0.253), and (D) high-risk (p = 0.010) patients.</p

Multicentric experience in Retzius-sparing robot-assisted radical prostatectomy performed by expert surgeons for high-risk prostate cancer

BACKGROUND: The study aim was to report the results of Retzius-Sparing robot-assisted radical Prostatectomy (RSP) in high-risk prostate cancer (HR-PCa) patients in a multicentric setting of expert surgeons and to analyze predictors of positive surgical margins (PSMs) and urinary continence recovery. METHODS: We retrospectively evaluated all consecutive HR-PCa patients who underwent RSP by expert surgeons in 7 centers. Pre-, peri-and postoperative features were collected. Minimum surgical experience required was 100 RSP cases. The oncological outcomes evaluated were PSMs and biochemical relapse (BCR). Urinary continence was defined as no pad or safety pad. Erectile function was defined as erections sufficient for intercourse. RESULTS: We collected 579 patients operated by 9 surgeons. Median age was 66, median PSA was 9,6 ng/mL. ISUP biopsy was 1 in 3.8%, 2 in 23%, 3 in 32,6%, 4 in 19,9%, 5 in 20,7; median surgical time was 195 minutes. Pathological stage was pT2 in 40,1%, pT3a in 35,9%, pT3b in 23,1%, and pT4 in 0,9% of cases. PSMs were present in 31,3% of cases. Urinary continence was achieved in 66,8% of cases one week after catheter removal. At 22 months (median follow-up), 89,1% patients were continent, BCR occurred in 27,5% patients. In multivariate analysis, PSA, prostate volume, surgical time were independent predictors of PSMs; ASA score and PSMs predicted urinary continence. CONCLUSIONS: We report the first multicentric experience of RSP for HR-PCa. Considering HR cases as those with the worst functional results, 89% of continent patients confirms that RSP helps achieve good functional results. (Cite this article as: Galfano A, Tappero S, Eden C, Dell'Oglio P, Fransis K, Guo H, et al. Multicentric experience in Retzius-sparing robot-assisted radical prostatectomy performed by expert surgeons for high-risk prostate cancer. Minerva Urol Nephrol 2022;74:607-14. DOI: 10.23736/S2724-6051.22.04857-1