New technologies and applications of laparoscopic and robotic surgery in urology

Background: cool and dry gas insufflation during laparoscopy induces hypothermia and cytokine increase, with significant perioperative morbidity. Few studies have suggested that warmed and humidified insufflation leads to an improved body core temperature (BCT) maintenance, a reduction of the inflammatory response and an improved quality of postoperative course, compared with standard insufflation. Objective: to assess if warmed and humidified CO2 insufflation with HumiGard™ device can achieve significant benefits over standard insufflation in terms of risk of hypothermia and cytokine response, in the setting of robot-assisted radical prostatectomy (RARP). Design: prospective, randomized, controlled clinical trial (September, 2015, June, 2016). Setting: single center study in a tertiary hospital. Participants: 64 patients with prostate cancer undergoing RARP were randomized, 32 to the treatment group and 32 to the control group. Intervention: the treatment group (H+WB) received warmed, humidified CO2 insufflation with HumiGard™ device, plus hot air warming blanket; the control group (WB) received standard CO2 insufflation, plus hot air warming blanket. Main outcomes and measures: BCT, plasma levels of cytokines IL-6 and TNF-α, pain scores, and intraoperative parameters. The data were analyzed according to the Bayesian paradigm. Results: intraoperative BCT increased in both groups during surgery, with a statistically significant difference favoring group H+WB, ending at 0.2°C higher on average than group WB. The overall BCT increase was 0.088 degree per hour in the WB group, with an additional 0.064 degree per hour in the H+WB group. No difference across groups, at none of the time points, could be shown as far as mean serum cytokine levels was concerned. No statistical differences were noted for pain scores and the other intraoperative parameters. Conclusions: during RARP, warm and humidified CO2 insufflation with the HumiGard™ device was more effective than the standard CO2 insufflation in maintaining the patient’s heat homeostasis, even if the difference was minimal. No benefit could be shown in terms of cytokine levels and pain scores. Trial registration: Clinicaltrials.gov Identifier: NCT0258697

Awake Da Vinci robotic partial nephrectomy: First case report ever in a situation of need

We report a unique case of a robotic partial nephrectomy performed under continuous spinal anesthesia (CSA). A 63-year-old woman, active smoker with mild obesity and previous right pneumonectomy, was diagnosed with a growing 5.5-cm renal right cystic tumor. Being at high risk for general anesthesia, a loco-regional approach was indicated. Therefore, after multidisciplinary discussion, a robotic-assisted partial nephrectomy under CSA was considered mandatory. After T4-T5 sensory and motor block, retroperitoneoscopic robot-assisted surgery was successfully performed. Postoperative period was uneventful, with optimal pain control. This unique case demonstrates the feasibility of robotic surgery under CSA, for imperative indications

Safety and Feasibility of Transperineal Targeted Microwave Ablation for Low- to Intermediate-risk Prostate Cancer

BACKGROUND: Focal therapy has emerged as an interesting option for localized low- to intermediate-risk prostate cancer (PCa). Targeted microwave ablation (TMA) is a novel FT modality involving targeted delivery of microwave energy under multiparametric magnetic resonance imaging (MRI)/ultrasound guidance. OBJECTIVE: To describe the step-by-step procedure for TMA and report early functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: This was an experimental phase 1–2 trial in 11 patients diagnosed with a single, MRI-visible PCa lesion of up to 12 mm, scored as International Society of Urological Pathology grade group (GG) 1 or 2. SURGICAL PROCEDURE: Transperineal TMA under MRI/ultrasound image fusion guidance. MEASUREMENTS: We recorded patient and PCa features; intraoperative and postoperative parameters; pain (Visual Analog Scale [VAS]) and adverse events (Common Terminology Criteria for Adverse Events v5.0); and prostate-specific antigen (PSA), International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) scores at 1 wk and 1, 3, and 6 mo. RESULTS AND LIMITATIONS: The median patient age was 67 yr (interquartile range [IQR] 18). Median PSA was 5.4 ng/ml (IQR 1.8), median prostate volume was 51 cm(3) (IQR 35), and median lesion size on MRI was 10 mm (IQR 4). Ten patients had GG 2 PCa and one had GG 1 disease. The median procedure time was 40 min (IQR 30). No intraoperative complications were reported. All treatments were performed on a day-case basis and no patients were discharged with a urinary catheter. Postoperatively, no grade ≥2 complications were reported. No significant changes in PSA (p = 0.46), IPSS (p = 0.39), or IIEF-5 scores (p = 0.18) scores were reported. The postoperative VAS score at 24 h was 0 for all patients. CONCLUSIONS: TMA is safe, feasible, and well tolerated in patients with low- to intermediate-risk PCa. Oncological outcomes are still awaited. PATIENT SUMMARY: Targeted microwave therapy is safe and feasible for selected patients with low- to intermediate-risk prostate cancer. The procedure is well tolerated and does not require a urinary catheter after the procedure. Cancer control outcomes are still awaited

The prognostic value of basal DNA damage level in peripheral blood lymphocytes of patients affected by bladder cancer

Bladder cancer (BC) is one of the most aggressive malignancies of the urinary tract, with the highest lifetime treatment costs per patient of all cancers, due to the high rate of recurrences requiring continuous surveillance. An early diagnosis is essential to improve survival of patients with BC. Noninvasive and sensitive molecular biomarkers are needed to improve current strategies for the detection and monitoring of BC. Previous studies suggested that elevated DNA damage levels and suboptimal nucleotide excision DNA repair (NER) may be associated with BC

Direct healthcare costs of non-metastatic castration-resistant prostate cancer in Italy

Objectives: The management of non-metastatic castration-resistant prostate cancer (nmCRPC) is rapidly evolving; however, little is known about the direct healthcare costs of nmCRPC. We aimed to estimate the cost-of-illness (COI) of nmCRPC from the Italian National Health Service perspective. Methods: Structured, individual qualitative interviews were carried out with clinical experts to identify what healthcare resources are consumed in clinical practice. To collect quantitative estimates of healthcare resource consumption, a structured expert elicitation was performed with clinical experts using a modified version of a previously validated interactive Excel-based tool, EXPLICIT (EXPert eLICItation Tool). For each parameter, experts were asked to provide the lowest, highest, and most likely value. Deterministic and probabilistic sensitivity analyses (PSA) were carried out to test the robustness of the results. Results: Ten clinical experts were interviewed, and six of them participated in the expert elicitation exercise. According to the most likely estimate, the yearly cost per nmCRPC patient is €4,710 (range, €2,243 to €8,243). Diagnostic imaging (i.e., number/type of PET scans performed) had the highest impact on cost. The PSA showed a 50 percent chance for the yearly cost per nmCRPC patient to be within €5,048 using a triangular distribution for parameters, and similar results were found using a beta-PERT distribution. Conclusions: This study estimated the direct healthcare costs of nmCRPC in Italy based on a mixed-methods approach. Delaying metastases may be a reasonable goal also from an economic standpoint. These findings can inform decision-making abou

Adrenal Ganglioneuroma with Multifocal Retroperitoneal Extension: A Challenging Diagnosis

A ganglioneuroma (GN) is the rarest and most benign of the neuroblastic tumors and originates from neural crest cells wherever sympathetic nervous tissue exists, such as in the retroperitoneum and adrenal gland. The diagnosis can be very challenging, given the rarity and asymptomatic presentation of this neoplasia, and can be achieved only by means of histological evaluation. Although benign, a few cases of metastatic GNs have been reported in the literature. The prognosis, however, seems to be excellent after surgical resection. We describe a rare case of multifocal retroperitoneal GN, diagnosed incidentally in a 46-year-old woman, with para-aortic and adrenal localizations. After intraoperative pathological diagnosis was made, complete excision of all the visible masses was performed. The postoperative period was uneventful and she was recurrence free 3 months after surgery. To our knowledge, this is the first case report of a multifocal retroperitoneal GN. Among the broad differential diagnoses of adrenal incidentalomas, an adrenal location of neuroblastic tumors should not be forgotten