Development and Validation of a Risk-Adapted Scoring Model for Metachronous Upper Tract Urothelial Carcinoma following Radical Cystectomy.

PURPOSE: The incidence and risk factors for metachronous upper tract urothelial carcinoma (UTUC) following radical cystectomy (RC) remain incompletely defined, which has limited the ability to individualize postoperative surveillance. MATERIALS AND METHODS: A retrospective review of 2 institutional registries was performed to identify patients undergoing RC for urothelial carcinoma. Multivariable Cox proportional hazard models for metachronous post-RC UTUC were developed in one institutional data set and validated in the second institutional data set. A post-RC UTUC risk score was then developed from these models. RESULTS: A total of 3,170 RC patients were included from the training cohort and 959 RC patients from the validation cohort. At a median followup after RC of 4.6 years (IQR 2.1-8.7), 167 patients were diagnosed with UTUC. On multivariable analysis in the training cohort, risk factors for metachronous UTUC were the presence of positive urothelial margin (HR 2.60, p <0.01), history of bacillus Calmette-Guérin treatment prior to RC (HR 2.20, p <0.01), carcinoma in situ at RC (HR 2.01, p <0.01) and pre-RC hydronephrosis (HR 1.48, p=0.04). These factors had similar discriminative capacity in the training and validation cohorts (C-statistic 0.71 and 0.73, respectively). A UTUC risk score was developed with these variables which stratified patients into low (0 points), intermediate (1-3 points), and high risk (4+ points) for post-RC UTUC, with respective 5-year UTUC-free survivals of 99%, 96%, 89% in the training cohort and 98%, 96%, and 91% in the validation cohort. CONCLUSIONS: We developed and validated a risk score for post-RC UTUC that may optimize UTUC surveillance protocols after RC.

[Results of active surveillance for sporadic renal angiomyolipomas greater than 4cm: A pledge for active surveillance]. / Résultats de la surveillance active des angiomyolipomes sporadiques du rein de plus de 4cm : un plaidoyer en faveur de la surveillance active.

INTRODUCTION: Active surveillance (AS) of sporadic renal angiomyolipomas (AML) is under-utilised because of an old dogma fearing a life-threatening retroperitoneal hemorrhage when tumour size exceeds 4cm. The objective of this study was to report the outcome of AS in patients with sporadic AML greater than 4cm. METHODS: The results of AS in 35 patients managed for sporadic renal AML greater than 4cm were analysed. During AS, tumour growth, occurrence of new symptoms and/or complications, discontinuation of AS protocol, reason for discontinuation as well as subsequent treatment options were reported. RESULTS: Within a median follow-up of 36 months, 16 (46 %) patients discontinued AS at the end of the study period (mean follow-up 55±66, median 36 months). Patients who discontinued AS were more symptomatic at diagnosis but had similar age, mean tumour size and sex ratio. Active treatment-free survival was 66 % at 5 years. Retroperitoneal hemorrhage was reported in 3 (8.5 %) patients. None of these bleedings required transfusion or monitoring in an intensive care unit. Other reasons for discontinuation were pain (37 %), patient preference (19), changes in the radiological appearance of the tumour (19 %), and hematuria (6 %). CONCLUSION: This study showed that AS in AML bearing patients was feasible even in the setting of tumours larger than 4cm. More than 50% of the patients were still on AS at 5 years. Discontinuation of AS was not related to bleeding complications in most cases. LEVEL OF PROOF: 3.

[Robotic partial nephrectomy: five years retrospective analysis at a single center]. / Néphrectomie partielle laparoscopique assistée par robot : analyse monocentrique et rétrospective sur cinq ans.

INTRODUCTION: The aim of this study is to assess perioperative outcomes in a large series of robotic partial nephrectomy. PATIENTS AND METHODS: We performed a retrospective analysis of 413 patients undergoing a robotic partial nephrectomy in a single center between June 2006 and December 2011. We analyzed demographic characteristics, operative and postoperative outcomes. RESULTS: Mean age was 58.6±11.9 years, body mass index was 30.5±7.1 kg/m2 and median ASA score 3. Mean tumor size was 3.2±1.66 cm and was divided in low, moderate and high RENAL nephrometry score respectively in 40%, 44% and 16%. Operative time and warm ischemia time were respectively 191 and 21min. Mean estimated blood loss was 200 mL and there were 4.3% major complications (Clavien-Dindo System). Mean length of stay was 3.6 days. The latest estimated glomerular filtration rate (eGFR) was 74.84 mL/min×1.73 m2 with a mean decrease of 8.6%. In multivariate analysis, Charlson comorbidity index (P=0.005), preoperative eGFR (P<0.001) and warm ischemia time (P=0.0025) were found to be independent predictors of latest postoperative renal function. CONCLUSION: Robotic partial nephrectomy is feasible and safe in experienced hands. In our study preoperative renal function, Charlson comorbidity index and warm ischemia time were independent predictors of latest eGFR.

Robot-assisted laparoscopic bladder diverticulectomy.

Robot-assisted laparoscopic bladder diverticulectomy (RALBD) has been increasingly reported in recent years. We review the technique of RALBD and the perioperative outcomes. We searched online databases to identify original articles related to RALBD. In the Method section, we describe our technique and reviewe several techniques for identification and robotic management of bladder diverticula. We identified 13 retrospective studies that met our criteria, with a total of 44 patients. The mean diverticulum size was 8.3 ± 3.6 cm, mean operative time was 186 ± 68 min, mean estimated blood loss was 86 ± 64 ml, and mean length of stay was 2.4 ± 1.7 days. In the majority of cases, patients with acquired diverticula underwent urethral catheter removal between 7 and 14 postoperative days while in the pediatric population with congenital bladder diverticula, Foley catheter removal usually occurred on postoperative day one. We conclude that a robotic technique is a feasible minimally invasive approach for bladder diverticulectomy. Potential benefits may include precise dissection of adjacent structures, as well as easier intracorporeal suturing. Further studies are needed to compare outcomes and costs versus other existing procedures.

Robotic-assisted laparoscopic partial nephrectomy for a 7-cm mass in a renal allograft.

Treatment options for a suspicious renal mass in a renal allograft include radical nephrectomy or nephron-sparing surgery (NSS). To our knowledge robotic-assisted laparoscopic partial nephrectomy (RPN) as treatment for a renal mass in a transplant kidney has not been previously reported. We report the case of RPN for a 7-cm renal mass in a transplanted kidney. A 35-year-old female with reflux nephropathy received a living-related donor kidney transplant in 1986. At 24 years after transplantation she had a 7-cm Bosniak III cystic mass of the allograft detected on computerized tomography (CT) scan. Preoperative creatinine was 2.2 mg/dL with an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m(2) . RPN was performed with bulldog clamping of the renal vessels, the graft was left in situ and immunosuppression was maintained postoperatively. Tumor diameter was 7.3 cm with a nephrometry score of 10a. Warm ischemia time (WIT) was 26.5 min. Estimated blood loss was 100 mL. There was no change between pre- and postoperative eGFR. There were no operative complications. Histology was papillary renal cell carcinoma type 1, nuclear grade 2. Margins were negative. RPN is a technically feasible treatment option for a suspicious renal mass in renal allografts.

[Single-port in urology]. / Single-port en urologie.

UNLABELLED: Single-port transumbilical laparoscopy has emerged as an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery. Within a short span, several clinical reports have emerged in the urologic literature. As this field is poised to move forward, a complete understanding of its evolution and current status seems imperative. We have summarized and reviewed the history of Single-Port across surgical disciplines. This review emphasizes nomenclature, surgical technique, instrumentation, and perioperative outcomes. EVIDENCE ACQUISITION: Using the National Library of Medicine database, the English language literature was reviewed for the past 40 years. Keyword searches included scarless, scar free, single-port/trocar/incision, laparoendoscopic single site surgery intraumbilical, and transumbilical. Within the bibliography of selected references, additional sources were retrieved. EVIDENCE SYNTHESIS: The major findings and surgical techniques described in these papers, are summarized in a chronological and subject-grouped manner. CONCLUSIONS: Single-port has made its initial forays into laparoscopic surgery. Ongoing refinement in technique and instrumentation is likely to expand its future role.

Reproducibility of wireless capsule endoscopy in the investigation of chronic obscure gastrointestinal bleeding.

BACKGROUND: Capsule endoscopy (CE) is a valuable tool in the diagnostic evaluation of obscure gastrointestinal bleeding, but limited information is available on the reproducibility of CE findings. OBJECTIVE: To compare two successive CE studies with push enteroscopy (PE) in patients presenting with chronic obscure gastrointestinal bleeding. METHODS: A prospective study was conducted. Ten patients (seven men and three women) with chronic obscure gastrointestinal bleeding and no contraindications for CE were eligible and completed the trial. For each patient, the first capsule was administered on day 1, the second capsule was administered on day 2 and PE was performed on day 3. Endoscopists were blinded to the capsule findings. Capsule findings were assessed independently by two investigators blinded to PE findings. RESULTS: A potential small intestinal bleeding source was found in 60% of the patients when all the studies were combined. A bleeding source was found in four patients in both CE studies. The second CE also identified a bleeding source in a fifth patient. Interobserver agreement by kappa analysis was 0.642 to 1.000 (P < or 05) for the CE studies. PE identified a potential small bowel bleeding site in four patients, including one patient who had negative CE studies. CONCLUSIONS: This study confirmed the reproducibility of CE findings on successive studies. Some patients did not have a source of bleeding in the small intestine, and all studies found this.

Endoscopic full-thickness plication for the treatment of GERD: long-term multicenter results.

BACKGROUND: The purpose of the present study was to assess the long-term safety and durability of effect for endoscopic full-thickness plication for the treatment of symptomatic gastroesophageal reflux disease (GERD). The Plicator (NDO Surgical, Inc., Mansfield, MA) used delivers a transmural suture through the gastric cardia to restructure the antireflux barrier. Published reports have shown the Plicator procedure to be effective in reducing GERD symptoms and medication use at 1 year post-plication. METHODS: Twenty-nine patients with chronic heartburn requiring maintenance daily anti-secretory therapy were treated at five sites. Patients received a single full-thickness plication in the gastric cardia 1cm below the gastroesophageal junction (GE) junction. Re-treatments were not permitted. Patients were evaluated at baseline for GERD symptoms and medication use. Intermediate (12 month) and long-term subject follow-up (median follow-up: 36.4 months; range, 31.2-43.9 months) were completed to evaluate procedure safety and durability of effect. RESULTS: Twenty-nine patients completed the 12-month and 36-month follow-up. All procedure-related adverse events occurred acutely, and no new events were observed during extended follow-up. At 36-months post-procedure, 57% (16/28) of baseline proton pump inhibitor (PPI)-dependent patients remained off daily PPI therapy. Treatment effect remained stable from 12- to 36-months, with 21/29 patients off daily PPI at 12 months compared to 17/29 patients at 36-months. Median GERD- Health Related Quality of Life (HRQL) scores remained significantly improved at 36 months versus baseline off-meds scores (8 versus 19, p < 0.001). In addition, the proportion of patients achieving > or = 50% improvement in GERD-HRQL score was consistent from 12 months (59%) to 36 months (55%). CONCLUSIONS: Endoscopic full-thickness plication can reduce GERD symptoms and medication use for at least 3-years post-procedure. Treatment effect is stable from 1 to 3 years, and there are no long-term procedural adverse effects.

Precut papillotomy versus persistence in difficult biliary cannulation: a prospective randomized trial.

BACKGROUND AND STUDY AIMS: Failed biliary cannulation occurs in up to 10% of patients undergoing ERCP. There is some controversy as to the safety and efficacy of using precut techniques to achieve biliary cannulation in difficult cases. To date, no randomized trial has compared the success and complication rates of precut with the rates for persistence when biliary cannulation is difficult. The aim of this study was to compare the success rates and complication rates of precut with the success rates and complication rates of persistence in cases of difficult biliary cannulation. PATIENTS AND METHODS: Patients without prior sphincterotomy who required biliary cannulation were screened. A "difficult biliary cannulation" was arbitrarily defined as failed cannulation after 12 minutes. These patients were then randomized to continue treatment by needle-knife cut over the roof of the papilla or by persistence with a non-wire-guided, single-lumen papillotome. "Primary" success was defined as deep cannulation within 15 minutes of randomization. Primary and final success rates and complication rates within 30 days after ERCP were compared. RESULTS: Over a 38-month period a total of 642 patients were screened. Patients in whom biliary cannulation was successful within a time period of 12 minutes or less formed the reference group (n = 580). The remainder of the patients were randomly assigned to the "precut" arm (n = 32) or to the "persistence" arm (n = 30). Primary success rates and complication rates were similar in the precut and persistence arms (75% and 4% respectively for the precut arm vs. 73% and 9% for the persistence arm). The final successful cannulation rate in the entire group of 642 patients was 99.5%. CONCLUSIONS: In experienced hands, precut papillotomy and persistence in cannulation are equally effective in cases of difficult cannulation, with a similar complication rate.

Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up.

BACKGROUND AND STUDY AIMS: Endoscopic ductal decompression therapy has become an established method of treating patients with painful obstructive chronic pancreatitis. Smaller series, mostly with a medium-term follow-up period, have reported encouraging results. The present analysis presents long-term follow-up data from a large multicenter patient cohort. PATIENTS AND METHODS: Patients with painful chronic pancreatitis and with ductal obstruction due to either strictures and/or stones treated endoscopically at eight different centers underwent follow-up after 2 - 12 years (mean 4.9 years). The patients' clinical data, the rate of technical success, and complications were recorded from the charts. Follow-up data were prospectively obtained using structured questionnaires; the main parameter for evaluating treatment success was a significant reduction in pain (no pain or only weak pain). RESULTS: Follow-up data were obtained from 1018 of 1211 patients treated (84%) with mainly strictures (47%), stones (18%), or strictures plus stones (32%). At the long-term follow-up, 60% of the patients had their endotherapy completed, 16% were still receiving some form of endoscopic treatment, and 24% had undergone surgery. The long-term success of endotherapy was 86% in the entire group, but only 65% in an intention-to-treat analysis. There were no significant differences between the patient groups with regard to either strictures, stones, or both. Pancreatic function was not positively affected by endoscopic therapy. CONCLUSIONS: Endoscopic ductal decompression therapy offers relief of pain in two-thirds of the patients when it is used as the only form of treatment. One-quarter of the patients have to undergo surgery.

Generalized tonic-clonic activity after remifentanil administration.

IMPLICATIONS: This is the first report of seizure-like activity in an adult who received remifentanil. This report confirms that opioid administration can be associated with generalized tonic-clonic seizure-like activity. It is suggested that this reaction could be referred to as the "opioid-seizure syndrome."

Reutilization of accessories in gastrointestinal endoscopic practice.

The key issues that determine the decision between reusable versus disposable accessories are cost and functionality. In most health-care systems the availability and dissemination of endoscopic services relates directly to the resources (i.e. budget) of that system. Given the limitations of health-care budgets, access to endoscopic services will depend upon the cost efficiency of endoscopic practice. The onus on endoscopists and health-care providers, therefore, is to meticulously evaluate the necessary steps for safe reutilization of accessories. This paper addresses the principles of reuse, quality assurance and particularly disinfection practices. Any change to a more costly disposable accessory policy must bear the responsibility of denied access to endoscopic services in a system with finite resources.

Sphincterotomy-associated biliary strictures: features and endoscopic management.

BACKGROUND: "Sphincterotomy stenosis" is a recognized late complication of endoscopic biliary sphincterotomy. The narrowing is limited to the biliary orifice and can be managed simply by repeat sphincterotomy. A similar but poorly characterized post-sphincterotomy complication involves narrowing that extends from the biliary orifice for a variable distance along the bile duct, beyond the duodenal wall. This lesion cannot be managed by repeating the sphincterotomy. METHODS: Six patients (3 men) are described with sphincterotomy associated biliary strictures, all smooth and high grade, presenting at a median of 19 months (range 8 to 60 months) after sphincterotomy. Further sphincterotomy was not possible as an intra-duodenal segment of bile duct was no longer visible. Endoscopic management consisted of serial incremental stent exchange at 2- to 4-month intervals. The goal of therapy was to place two 11.5F stents side-by-side. RESULTS: Stricture resolution was documented by cholangiography in all patients. One patient with a stricture resistant to treatment required three 10F stents side-by-side, and another underwent treatment to a maximum of adjacent 11.5F and 7F stents. Two 11.5F stents were eventually placed in the other four patients. Overall median duration of stent placement was 12.5 months. At a median of 26.5 months of stent-free follow-up, all patients remain asymptomatic. CONCLUSION: Sphincterotomy-associated biliary strictures are a distinct late complication of biliary sphincterotomy. These recalcitrant lesions are not amenable to repeat sphincterotomy; however, the results of this study suggest that they may be managed successfully by serial placement of stents of incrementally increasing diameter.

Long-term use of mesalamine (Rowasa) suppositories in remission maintenance of ulcerative proctitis.

OBJECTIVE: The purpose of this study was to evaluate the efficacy and safety of a single nightly 500-mg Rowasa (mesalamine) suppository as maintenance therapy for patients with ulcerative proctitis in remission. METHODS: In this 24-month, multicenter, double-blind trial, 65 patients with ulcerative proctitis in clinical and endoscopic remission were randomized to receive either a single nightly 500-mg rectal mesalamine (Rowasa) suppository or matching placebo as sole therapy. Efficacy was assessed by time to relapse (defined as rectal bleeding or increase in stool frequency for > or =1 wk and active inflammation upon endoscopy). RESULTS: Mean time to relapse was 453.4 days for mesalamine-treated patients and 158.0 days for placebo-treated patients. Survival analysis demonstrated that time to relapse was significantly greater for mesalamine-treated patients than for placebo-treated patients (p < 0.001). In addition, at both 12 and 24 months, the proportion of placebo-treated patients (86% at 12 months and 89% at 24 months) who relapsed was significantly (p < or = 0.001) greater than mesalamine-treated patients (32% and 46%, respectively). No statistically significant differences occurred between treatment groups in the reporting of any particular adverse event or the number of patients reporting adverse events. CONCLUSIONS: The results demonstrate that mesalamine suppositories are efficacious, well tolerated, and safe for the long-term maintenance of remission of ulcerative proctitis.