Simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion: step-by-step video-illustrated technique

ABSTRACT Introduction: One of the most remarkable characteristics of urothelial carcinomas is multifocality. However, occurrence of synchronous bladder cancer and upper urinary tract urothelial cancer (UTUC) is exceptional. Minimally invasive approach for these synchronous tumors was just occasionally reported (1-4). The aim of this video article is to describe step-by-step the technique for simultaneous laparoscopic nephroureterectomy and robot-assisted anterior pelvic exenteration with intracorporeal ileal conduit urinary diversion (ICUD). Patients and methods: A 66-year-old female presented with synchronous BCG refractory non-muscle invasive bladder cancer and a right-side UTUC. She was a former smoker and had previously been submitted to multiple transurethral resections of bladder tumor, BCG and right distal ureterectomy with ureteral reimplant. We performed a simultaneous laparoscopic right nephroureterectomy and robot-assisted anterior pelvic exenteration with totally intracorporeal ICUD. Combination of robot-assisted and pure laparoscopic approaches was proposed focusing on optimization of total operative time (TOT). Results: Surgery was uneventful. TOT was of 330 minutes. Operative time for nephroureterectomy, anterior pelvic exenteration and ICUD were 48, 135, 87 minutes, respectively. Estimated blood loss was 150mL. Postoperative course was unremarkable and patient was discharged after 7 days. Histopathological evaluation showed a pT1 high grade urothelial carcinoma plus carcinoma in situ both in proximal right ureter and bladder, with negative margins. Twelve lymph nodes were excised, all of them negative. Conclusion: In our preliminary experience, totally minimally invasive simultaneous nephroureterectomy and cystectomy with intracorporeal ICUD is feasible. Pure laparoscopic approach to upper urinary tract may be a useful tactic to reduce total operative time.

Estudo sobre terapia de ablação por radiofrequência combinado a inibidores de checkpoint do sistema imune em um modelo murino de carcinoma de células renais / Study on radiofrequency ablation therapy combined with immune checkpoint inhibitors in a murine model of renal cell carcinoma

Introdução: O carcinoma de células renais (CCR) em estágios avançados apresenta prognóstico reservado, com 20% de sobrevida em cinco anos. O advento da imunoterapia baseada nos inibidores de checkpoint (IC) tem mostrado resultados promissores em ensaios clínicos com pacientes portadores de tumores renais metastáticos. Apesar dos resultados animadores, ainda se busca melhorar as taxas de resposta terapêutica. Para tanto, muitas estratégias têm sido estudadas no intuito de sensibilizar tumores menos imunogênicos e entre elas encontra-se a ablação por radiofrequência (RF). Objetivo: O intuito do estudo é avaliar em modelo murino o impacto da ablação térmica do tumor de linhagem RENCA e seu potencial de influenciar a resposta imunológica do hospedeiro quando combinado a tratamento sistêmico imunoterápico. O racional do estudo consiste na potencialização da resposta imunológica devido a maior apresentação de antígenos tumorais após a lesão tecidual desencadeada pela RF. Materiais e métodos: 49 animais da linhagem Balb/c foram inoculados com a célula de tumor renal Renca em região de flanco direito. Quando os tumores atingiram volume alvo de 500mm3 os animais foram divididos em três grupos de acordo com o tratamento do tumor primário: controle (Grupo 1), RF associada a imunoterapia (Grupo 2); e monoterapia isolada com IC (Grupo 3). Os animais que foram tratados com sucesso nessa fase foram submetidos a reinoculação de células tumorais Renca em flanco esquerdo. A taxa de recorrência após a reintrodução das células tumorais em cada grupo foi então observada. Resultados: Após a reinoculação das células RENCA, a taxa de crescimento do tumor foi significativamente menor nos grupos 2 e 3 quando comparados ao grupo controle [0,0% vs. 0,0% vs. 73,3%, respectivamente (p<0,001)]. Não houve diferença na formação de tumores secundários após reinoculação de células tumorais entre os grupos 2 e 3. Conclusão: Animais submetidos a imunoterapia associada a RF ou imunoterapia isolada se mostraram menos propensos a crescimento tumoral após reinoculação com células Renca, o que sugere potencialização na formação de memória imunológica do hospedeiro. Adicionalmente, quando comparados os grupos 2 e 3, não observamos impacto significativo da RF nas taxas de crescimento do tumor secundário

Introduction: Renal cell carcinoma (RCC) in advanced stages has a poor prognosis, with a 20% survival rate over five years. The advent of immunotherapy based on checkpoint inhibitors (CI) has shown promising results in clinical trials with patients with metastatic kidney tumors. Despite encouraging results, efforts are still being made to improve therapeutic response rates. Therefore, many strategies have been studied in order to sensitize less immunogenic tumors and among them is radiofrequency (RF) ablation. Objective: The aim of the study is to evaluate in a murine model of renal adenocarcinoma (RENCA) the impact of RF ablation and its potential to influence immune response when combined with checkpoint inhibitors. The rationale of the study is to enhance immune response by increasing tumor antigens presentation after tissue damage triggered by RF. Materials and methods: 49 Balb/c mice were inoculated with the Renca renal tumor cells in the right flank region. When the tumors reached a target volume of 500 mm3, animals were divided into three groups according to the treatment of the primary tumor: control (Group 1), RF associated with immunotherapy (Group 2); and monotherapy with CI (Group 3). The animals that were successfully treated in this phase were reinoculated with Renca tumor cells on the left flank. The recurrence rate after the reintroduction of tumor cells in each group was observed. Results: After reinoculation of RENCA cells, the growth rate of the tumor was significantly lower in groups 2 and 3 when compared to the control group [0.0% vs. 0.0% vs. 73.3%, respectively (p <0.001)]. There was no difference in the formation of secondary tumors after reinoculation of tumor cells between groups 2 and 3. Conclusion: Animals submitted to immunotherapy associated with RF or immunotherapy alone had less tumor growth after reinoculation with Renca cells, which suggests the formation of more effective immune memory. In addition, when comparing groups 2 and 3, we did not observe a significant impact of RF on secondary tumor growth rates.

Completely endophytic renal tumor: A laparoscopic approach.

Kidney cancer is the third most common urologic malignancy and a 2% annual increase in the incidence has occurred over the past two decades, largely because of the increased utilization of imaging. The majority of these tumors are small, so the indications for nephron-sparing surgery and for minimally invasive surgery are continually expanding. Complex kidney lesions, such as those completely endophytic, are still a challenge even for experienced surgeons. Our objective is to demonstrate the operative technique for laparoscopic partial nephrectomy with the aid of intra-operative ultrasound in a man with a totally endophytic renal lesion. Case: A 52 years old man, asymptomatic, with incidental renal mass of 2.9 cm, completely endophytic (R.E.N.A.L score 9p) submitted to partial laparoscopic nephrectomy. Surgical time was 2 hours, with 20 minutes of ischemia. Pathological anatomy confirmed tumor of clear cells T1a, free margins.