A comparison of cytoreductive and non-cytoreductive management strategies for nephron-sparing approaches to tumours in solitary kidneys.

INTRODUCTION: Tumours in a solitary kidney pose challenges in management. Metastatic tumours and those in difficult locations complicate treatment further. The advent of immunotherapy has shed new light on the management of such tumours. We present a series of three cases treated with nephron-sparing surgery following neoadjuvant immunotherapy and compare the outcomes with patients who underwent robotic partial nephrectomy in a solitary kidney. METHODS: We present the outcomes of three patients with solitary kidney tumours who underwent delayed nephron-sparing surgery following good response to immunotherapy. All patients had solitary kidney following a previous nephrectomy, two of which were nonmetastatic but, due to size/location, not amenable to primary treatment; the third patient had metastatic disease and responded to immunotherapy. Two patients underwent robotic partial nephrectomy and one opted for cryotherapy. We compared the preoperative, intraoperative and postoperative parameters of the two patients who underwent robotic cytoreductive partial with patients who underwent robotic partial nephrectomy in a solitary kidney. RESULTS: Out of 231 partial nephrectomy patients in our centre, 2 underwent cytoreductive partial nephrectomy and 5 underwent solitary partial nephrectomy. There was no statistically significant difference in the patient demographics in the two groups. Patients in both groups had comparable operative time, warm ischaemia time, blood loss and length of stay. Two of the five patients in the non-cytoreductive robotic partial nephrectomy had Clavien Dindo 1 complications compared with one patient in the robotic cytoreductive partial nephrectomy group. This was not statically significant. CONCLUSION: Neoadjuvant immunotherapy can play a valuable role in shrinking renal tumours in solitary kidneys to facilitate robotic partial nephrectomies. There were no significant differences in the intra- and postoperative parameters in patients who underwent cytoreductive partial nephrectomy when compared with patients undergoing robotic solitary partial nephrectomy.

Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy.

INTRODUCTION: The learning curves analysed to date for robot-assisted laparoscopic prostatectomy are based on arbitrary cut-offs of the total cases. METHODS: We analysed a large dataset of robot-assisted laparoscopic prostatectomies from a single centre between 2008 and 2019 for assessment of the learning curve for perioperative outcomes with respect to time and individual cases. RESULTS: A total of 1,406 patients were evaluated, with mean operative time 198.08 minutes and mean console time 161.05 minutes. A plot of operative time and console time showed an initial decline followed by a near-constant phase. The inflection points were detected at 1,398 days (308th case) for operative time and 1,470 days (324th case) for console time, with a declining trend of 8.83 minutes and 7.07 minutes, respectively, per quarter-year (p<0.001). Mean estimated blood loss showed a 70.04% reduction between the start (214.76ml) and end (64.35ml) (p<0.001). The complication rate did not vary with respect to time (p=0.188) or the number of procedures (p=0.354). There was insufficient evidence to claim that the number of operations (p=0.326), D'Amico classification (p=0.114 for intermediate versus low; p=0.158 for high versus low) or time (p=0.114) was associated with the odds of positive surgical margins. CONCLUSIONS: It takes about 300 cases and nearly 4 years to standardise operative and console times, with a requirement of around 80 cases per annum for a single surgical team in the initial years to optimise the outcomes of robot-assisted laparoscopic prostatectomy.

The Lister AirSeal® port closure technique - Initial patient outcomes.

INTRODUCTION: The 12-mm AirSeal® port is widely used in robotically assisted laparoscopic prostatectomy due to its ability to maintain stable pneumoperitoneal pressures and smoke evacuation. However, it creates a potential risk of port site hernia. We have traditionally used EndoClose™ to perform full thickness closure of this port, but noted that patients experienced increased pain related to this procedure, which sometimes persisted for several months. Using the Da Vinci Si we performed peritoneal closure with 2-0 vicryl by switching the fourth arm to the right master controller. The external oblique sheath was closed outside with 1 Ethibond. MATERIALS AND METHODS: We performed this closure in 20 consecutive patients (group 1). Postoperative day 1, 2 and post-discharge telephone consultation pain scores (1-10) were recorded and compared with the previous 20 consecutive patients who had the EndoClose closure (group 2). RESULTS: We recorded an instructional video to enable reproduction of the new technique. The mean length of stay was 1.5 days for patients in group 1 and 1.9 days for those in group 2 (P = 0.04). There was no difference in operating time or average day 1 pain scores. Post-discharge follow-up call revealed 1 of 20 patients who had AirSeal port site pain in group 1 and 5 of 17 in group 2 (P = 0.04). Pain scores also tended to be higher for group 2. CONCLUSIONS: Our preliminary analysis of this novel technique to close the AirSeal port in two separate layers improves postoperative pain related to this port site.

Robotic Prostatectomy Has a Superior Outcome in Larger Prostates and PSA Density Is a Strong Predictor of Biochemical Recurrence.

Objectives. The aims of this study were to compare the outcomes of robotic assisted laparoscopic prostatectomy (RALP) between patients who had larger (≥75 g) and smaller (<75 g) prostates and to evaluate the performance of PSA density (PSAD) in determining the oncological outcome of surgery. Methods and Materials. 344 patients who underwent RALP at a single institution were included in the study. Preoperative risk factors and postoperative, oncological outcomes, erectile function, and continence status were recorded prospectively. Results. During a mean follow-up of 20 months, biochemical recurrence (PSA > 0.2) was observed in 15 patients (4.3%). Prostate size ≥75 g was associated with lower Gleason score on final pathology (P = 0.004) and lower pathological stage (P = 0.02) but an increased length of hospital stay (P = 0.05). PSAD on binary logistic regression independently predicted biochemical recurrence (BCR) when defined as postoperative PSA >0.1 (P = 0.001) and PSA >0.2 (P = 0.039). In both instances PSA was no longer a significant independent predictor. Conclusions. RALP in large prostates (≥75 g, <150 g) is as safe as RALP in smaller prostates and is associated with a lower pathological grade and stage. Higher PSAD is independently associated with BCR and is superior to PSA as a predictor of BCR after RALP.

Biopsy of the red patch at cystoscopy: is it worthwhile?

OBJECTIVE: At cystoscopy red patches of urothelium are commonly seen within the bladder and frequently biopsied in order to exclude carcinoma in situ (CIS), which classically presents as a red, velvety patch. This appearance however is not specific and it is possible that many lesions are biopsied without significant benefit to the patient. The objective of this study was to determine whether routine biopsy of red patches seen in the bladder at cystoscopy is warranted. PATIENTS AND METHODS: 193 biopsies were taken from red patches seen at flexible and rigid cystoscopy during a 4-year period from December 1997 to January 2002 and examined by histopathology. Patients included in the study were those on cystoscopic follow-up for transitional cell carcinoma (TCC) of the bladder and those undergoing investigation for haematuria or lower urinary tract symptoms. RESULTS: In 193 (17.7% of total biopsies) red patch biopsies, malignancy was found in 23 (11.9%) and 18 of 23 (78.3%) were CIS. No malignancies were detected in red patches from patients under the age of 60 years. CONCLUSION: Red patch biopsy yields a positive finding of malignancy in 12% and was concluded to be a valuable exercise, particularly in those over the age of 60 years and on follow-up for TCC.

Testicular implants and patient satisfaction: a questionnaire-based study of men after orchidectomy for testicular cancer.

OBJECTIVES: To assess the satisfaction of men with their testicular implants after undergoing orchidectomy for testicular cancer, and to determine their reasons for accepting or declining a prosthesis. PATIENTS AND METHODS: In all, 424 men who had undergone radical orchidectomy and were part of the testicular cancer follow-up programme were sent an anonymous questionnaire comprising 10 questions covering two main areas. First, the reasons for accepting or declining an implant and second (if they received an implant) their satisfaction with the size, position, feel, shape and overall comfort; 234 men (55%) responded. RESULTS: About a third (71 men) accepted an implant, a third declined and a third were not offered the choice. Of the men who replied 91% felt that it was extremely important to be offered an implant at the time of surgery. Of the 71 who received an implant, 19 (27%) were dissatisfied and felt that they had an average or poor cosmetic result. The reasons for this dissatisfaction are presented and discussed. CONCLUSIONS: All men undergoing orchidectomy should be offered a testicular implant, irrespective of age. Sample implants in all sizes should be available in the outpatient department. This will give men realistic expectations and allow them to choose a suitable size of implant. The dimensions of the available implants should be improved to create a more elliptical prosthesis, to avoid dissatisfaction with the shape. Adequate fixation to the base of the scrotum is important to avoid the 'high riding' implant.

Expression of the developmental and oncogenic PAX2 gene in human prostate cancer.

PURPOSE: In the human prostate cancer cell lines LNCaP, DU145 and PC3, 27 primary prostate cancers, 10 benign prostatic hyperplasia specimens and 5 normal prostates we investigated the expression pattern of PAX2, a member of the PAX family of developmental control genes. PAX2 is expressed at high levels in developing undifferentiated cells of the urogenital system and is repressed upon terminal differentiation with no expression in normal adult cells. It is also been shown to be a proto-oncogene in mice and is expressed in human renal cell carcinoma. MATERIALS AND METHODS: PAX2 expression was assessed at the RNA level by reverse transcriptase-polymerase chain reaction and Southern blot analysis using specific sets of nucleotides. The expression pattern of PAX2 was reconfirmed at the protein level by immunofluorescence in the cell lines, and by Western blot analysis in primary human prostate cancers and benign prostatic tissue. RESULTS: Using reverse transcription-polymerase chain reaction combined with Southern hybridization PAX2 expression was detected in 52% of primary cancers and all 3 cell lines. PAX2 expression in these samples was confirmed at a protein level using immunoblotting and immunofluorescence. PAX2 messenger RNA was not detected in any benign or normal prostatic samples. Immunoblotting of protein from benign prostatic hyperplasia samples confirmed the lack of expression of PAX2 protein. CONCLUSIONS: The expression of PAX2 in prostate cancer compared to nonmalignant prostates is statistically significant (Fisher's exact test p = 0.0004). These results suggest a possible role for PAX2 in prostate cancer. Although previous studies have suggested a role for PAX2 for supporting proliferation in undifferentiated cells, no correlation of PAX2 expression with Gleason score was found in prostate cancer.

Pancreatic supplements reduce symptomatic response of healthy subjects to a high fat meal.

In a double-blind, crossover study, we determined whether microencapusulated pancreatic enzymes reduce postprandial symptoms experienced by healthy volunteers after ingestion of a high calorie, high fat meal. At 7 AM, 18 subjects ingested 185 g of cookies (1196 calories and 72 g of fat) with three pancrelipase capsules or a placebo. The severity of gastrointestinal symptoms and flatus passages were recorded for 15-17 hr, and end-alveolar samples were obtained hourly for 10 hr. Ingestion of pancreatic supplements was associated with a significant (P = 0.049) reduction in bloating over the entire recording period, and with significant reductions in bloating, gas, and fullness during the dinner to bedtime period. Pancreatic supplements had no significant effect on breath H2 or CH4 concentration. The finding that pancreatic supplements reduce postprandial symptoms in healthy subjects suggests that these supplements also might be beneficial in irritable bowel syndrome.

The expression of PAX5 in human transitional cell carcinoma of the bladder: relationship with de-differentiation.

OBJECTIVE: To investigate the expression of PAX genes, a family of developmental control genes (which encode nine nuclear transcription factors essential for embryogenesis and are proto-oncogenes in mice) in human transitional cell carcinoma (TCC) of the bladder. MATERIALS AND METHODS: PAX gene expression was assessed in three established bladder cancer cell lines and 29 primary tumours using the reverse transcriptase-polymerase chain reaction and Southern analysis. RESULTS: All three established TCC cell lines and 79% of primary TCCs expressed PAX5 mRNA. There was a significantly higher proportion of PAX5 expression in malignant than in benign urothelium (P=0.02, Fisher's exact test); nine of 12 pTa tumours (mucosa-confined), seven of eight pT1 (invading lamina propria) and eight of nine pT2 (invading muscle) expressed PAX5. A higher proportion of tumours with increasing de-differentiation expressed PAX5, which correlates well with the expression pattern of PAX5 in development. In well-differentiated tumours (grade 1), half expressed PAX5, compared with 84% of moderately to poorly differentiated tumours (grades 2/3). The odds ratio for PAX5 expression in malignancy suggests that it increases the risk of malignancy four-fold. CONCLUSION: These data support a role for the PAX family in oncogenesis, by identifying another human neoplasm in which they are inappropriately expressed. PAX5 expression in undifferentiated TCC cells may contribute to pathogenesis by supporting cellular proliferation in the de-differentiated state. Furthermore, the high incidence of PAX5 expression suggests its potential use as a diagnostic tool and therapeutic target in TCC.

Lactose maldigestion is not an impediment to the intake of 1500 mg calcium daily as dairy products.

BACKGROUND: A National Institutes of Health consensus conference concluded that a daily calcium intake of 1500 mg reduces the severity of osteoporosis. Because dairy products are the main natural source of dietary calcium, a diet providing 1500 mg Ca must contain large quantities of dairy products. However, it is widely believed that the lactose content of these products will not be tolerated by persons with lactose maldigestion (approximately 30% of the adult US population). OBJECTIVE: We evaluated the symptoms of lactose maldigestion and digestion when the diet was supplemented with dairy products providing 1300 mg Ca/d. DESIGN: Sixty-two women (31 with lactose maldigestion and 31 without) were studied in a double-blind, randomized protocol. Symptoms were compared during 1-wk periods when the diet was supplemented with 480 mL (2 cups) milk, 56 g cheese, and 240 mL yogurt provided as conventional products (34 g lactose/d) or as lactose-hydrolyzed products (2 g lactose/d). RESULTS: Women who digested lactose reported no significant difference in symptoms between the 2 treatment periods. Women with lactose maldigestion reported significantly increased flatus frequency and subjective impression of rectal gas during the period of high lactose intake; however, bloating, abdominal pain, diarrhea, and the global perception of overall symptom severity were not significantly different between the 2 treatment periods. CONCLUSION: The symptoms resulting from lactose maldigestion are not a major impediment to the ingestion of a dairy-rich diet supplying approximately 1500 mg Ca/d.