Adoption of robot-assisted radical nephroureterectomy permits a minimally invasive option for management of upper tract urothelial carcinoma in geriatric patients: comparison with non-geriatric patients with intermediate-term oncologic follow-up.

To assess the oncologic efficacy and safety of robot-assisted approach to radical nephroureterectomy (RARNU) in geriatric versus younger patients with upper tract urothelial carcinoma (UTUC). A single-center, retrospective cohort study was conducted from 2009 to 2022 of 145 patients (two cohorts: < 75 and ≥ 75 years old) with non-metastatic UTUC who underwent RARNU. Primary endpoint was UTUC-related recurrence of disease during surveillance (bladder-specific and metastatic). Safety was assessed according to 30-day, modified Clavien-Dindo (CD) classifications (Major: C.D. III-V). Survival estimates were performed using Kaplan-Meier method. There were 89 patients < 75 years (median 65 years) and 56 patients ≥ 75 years (median 81 years). Comparing the young versus geriatric cohorts: median follow-up 38 vs 24 months (p = 0.03, respectively) with similar 3-year bladder-specific recurrence survival (60% vs 67%, HR 0.70, 95% CI [0.35, 1.40], p = 0.31) and metastasis-free survival (79% vs 70%, HR 0.71, 95% CI [0.30, 1.70], p = 0.44). Expectedly, the younger cohort had a significant deviation in overall survival compared to the geriatric cohort at 1-year (89% vs 76%) and 3-years (72% vs 41%; HR 3.29, 95% CI [1.88, 5.78], p < 0.01). The 30-day major (1% vs 0) and minor complications (8% vs 14%, p = 0.87). Limitations include retrospective study design of a high-volume, single-surgeon experience. Compared to younger patients with UTUC, geriatric patients undergoing RARNU have similar oncologic outcomes at intermediate-term follow-up with no increased risk of 30-day perioperative complications. Thus, age alone should not be used to disqualify patients from definitive surgical management of UTUC with RARNU.

Safety and complications of continuation of aspirin therapy in patients undergoing robot-assisted laparoscopic simple prostatectomy.

To evaluate the safety and feasibility of continued perioperative aspirin at the time of robotic assisted simple prostatectomy (RASP). We performed a retrospective review of our IRB approved institutional database of patients who underwent RASP between 2013 and 2022. Comparative groups included patients taking aspirin in the perioperative period and those not taking aspirin pre-operatively. The primary outcome was any post-operative bleeding related complication using the modified Clavien-Dindo classification. Secondary outcomes included the identification of risk factors for increased blood loss in the entire study population, operative time, and blood transfusion requirement. 143 patients underwent RASP of which 55 (38.5%) patients continued perioperative aspirin therapy and 88 (61.5%) patients did not. Baseline demographics were similar between groups. Patients taking perioperative aspirin had a higher rate of hypertension (74.5% vs 58.0%, p = 0.04) and other cardiovascular disease (30.9% vs 11.4%, p = 0.007). Postoperative complications were similar between the groups (Clavien-Dindo ≥ 3; p = 0.43). Median blood loss (150 cc vs 150 cc, p = 0.38), percentage drop in hemoglobin (13.4 vs 13.2, p = 0.94) and blood transfusion rate (3.6 vs 1.1, p = 0.56) were also similar between groups. The median blood loss was 150 ml for the whole study population. On regression analysis, neither aspirin nor any other variable was associated with increased blood loss (> 150 ml). Aspirin can be safely continued perioperatively in patients undergoing RASP without any risk of bleeding related complications, blood loss, or increased transfusion rate.

Narrative review of nephron-sparing surgical management of upper tract urothelial carcinoma: is there a role for distal ureterectomy, segmental ureterectomy, and partial nephrectomy.

Background and Objective: Upper tract urothelial carcinoma (UTUC) is a relatively rare malignancy and radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is considered as the standard of care for high-risk non-metastatic disease. Loss of the renal unit secondary to RNU, especially in elderly patients, causes significant decline in overall renal function which in turn negatively impacts the overall survival (OS). Such radical surgeries can be spared in a select group of the patients with segmental ureterectomy (SU) or distal ureterectomy to salvage the ipsilateral kidney. In this article, we will review the oncological and renal function outcomes following such procedures. This review excludes endourologic procedures. Methods: This is a non-systematic review of the published literature focusing on the nephron-sparing surgical alternatives for the management of UTUCs. The following texts were used for literature search: "nephron-sparing surgery", "segmental ureterectomy", "total ureterectomy", "partial nephrectomy", and "ileal ureter". We included the articles indexed in PubMed, written in English language, and published within the last 15 years. Key Content and Findings: The main argument against the utilization of these procedures is the lack of high quality, level I evidence, which is due to the rarity of this disease and the rates of ipsilateral recurrences. Despite that, the evidence in support of these nephron-sparing surgical alternatives is increasing over time. Published literature including single/multi-centric studies & systematic reviews, suggests comparable oncological outcomes and significantly improved renal function preservation. Lymph node dissection (LND) at the time of nephron-sparing surgical alternatives is largely underutilized. Similarly, the role of neoadjuvant or adjuvant systemic chemotherapy following such procedures is also not established currently. Conclusions: With comparable oncological outcomes while preserving renal function, the nephron-sparing surgical alternatives to RNU are gaining momentum. These options can be offered to patients with low volume, localized UTUC with imperative indication for renal preservation such as solitary kidney, compromised baseline, and expected significant decline in post-RNU renal function without compromising oncological principles during surgery.

Presenting Pattern and Psychiatric Comorbidities in Rural versus Urban Substance Dependent Patients: A Hospital-Based Cross-Sectional Study.

Background: "Locality" is a significant factor in substance initiation, maintenance, and relapse. The pattern of substance dependence among rural and urban populations varies across studies and is scarcely studied, warranting further research. To compare presenting patterns (sociodemographic and drug-related variables), reasons for substance use, and psychiatric comorbidities (prevalence, type, and severity) between rural and urban substance-dependent groups. Materials and Methods: This study was a cross-sectional analytical study in a government de-addiction center, including rural and urban patient groups aged 18-65. International Classification of Diseases, Tenth Revision (ICD-10) criteria, and severity of dependence scale were used for diagnosing substance dependence. After detoxification, psychiatric comorbidity was assessed using brief psychiatric rating scale, Young's mania rating scale, and patient health questionnaire - somatic, anxiety, and depression symptoms scale. Post-analysis was performed to assess socioeconomic variables and access to de-addiction services. Results: The final sample was 500 (250 rural and 250 urban). The post-analysis sample size was 386 (211 rural and 175 urban). The mean age was 38.2 ± 12.4 years, mostly males (n = 495, 99%). Substance frequency was opioids (92%)> benzodiazepines (24.8%) > alcohol (22%) > cannabis (1.6%) for rural and opioids (91.2%) > alcohol (29.6%) > benzodiazepines (14.8%) > cannabis (2%) for urban patients. More than half of patients had comorbid nicotine dependence. Rural patients were more benzodiazepine dependent (P = 0.007), and urban were more opioid + alcohol dependent (P = 0.001). Rural patients had higher age (P = 0.012), less education (P < 0.001), positive family history of substance (P = 0.028), daily wagers, and farmers (P < 0.001) than urban patients who were younger, students (P = 0.002), businessmen and government employed (P < 0.001). Urban patients expended more on drugs (P < 0.001), had higher treatment attempts (P = 0.008), and had better availability and accessibility of de-addiction services (P < 0.001). More rural users initiated substances to "enhance performance," whereas urban ones initiated for "stress relief/novelty" (P < 0.001). For treatment seeking, "External pressure" was a more common reason in urban patients (P < 0.001), who also had more psychiatric comorbidities (P = 0.026). Conclusion: Significant pattern differences exist between rural and urban substance dependents, warranting emphasis on locality-specific factors for appropriate intervention.

Short-term Clinical Outcome of Previously Untreated and Treated Schizophrenia and Impact of Duration of Untreated Psychosis.

Background: Duration of untreated psychosis (DUP) is an important modifiable factor affecting schizophrenia outcomes. A dearth of research in India on untreated versus treated schizophrenia warrants further research. Methods: This was a longitudinal study in a tertiary hospital over 2 years. Inpatients diagnosed with schizophrenia (N = 116), aged 18-45, were divided into untreated and treated groups. Diagnostic confirmation, severity assessment, and clinical outcome were done using ICD-10 criteria, Positive and Negative Syndrome Scale (PANSS), and Clinical Global Impression (CGI) scale. Follow-up was done at 12 and 24 weeks. DUP was measured, and its association with the outcome was assessed. Results: Final analysis included 100 patients, 50 each of previously untreated and treated. Untreated patients had lower age and duration of illness (DOI), but higher DUP (p < .001). Treated patients showed much improvement on CGI-I at 12 weeks (p = .029), with no difference at 24 weeks. PANSS severity comparison showed no difference, and both groups followed a declining trend. In untreated patients, age of onset (AoO) was negatively correlated with severity (except general symptoms at baseline) at all follow-ups ('r' range = -0.32 to -0.49, p < .05), while DOI showed a positive correlation with negative and general symptoms at 12 weeks (r ~ 0.3, p < .05). Treated patients showed inconsistent and lower negative correlation between AoO and PANSS, with no correlation between severity and DOI. The mean sample DUP was 17.9 ± 31.6 weeks; it negatively correlated with education (r = -0.25, p = .01) and positively with PANSS severity ('r' range = 0.22 to 0.30, p < .05) at all follow-ups, especially negative symptoms. Patients with no or minimal improvement on CGI at 24 weeks had higher DUP (Quade's ANOVA F[1,98] = 6.24, p = .014). Conclusion: Illness variables in untreated schizophrenia affect severity, which has delayed improvement than treated schizophrenia. Higher DUP is associated with negative symptoms of schizophrenia.

Robot-Assisted Laparoscopic Ureteral Reconstruction for Malignant Pathology: Single-Center Experience with Analysis of Perioperative, Functional, and Oncologic Outcomes.

Introduction: Radical nephroureterectomy with bladder cuff excision (BCE) is the standard of care all high-risk upper tract urothelial carcinomas. With continued advancements, robot-assisted segmental ureteral resection can be employed for ureteral tumors for ipsilateral renal preservation. Herein, we are presenting our experience of different techniques classified by the affected ureteral segment, along with perioperative and intermediate to long-term functional and oncologic outcomes. Methods: From January 2008 to June 2021, a total of 17 patients underwent robot-assisted renal preserving excisional procedures for ureteral tumors. We collected and analyzed baseline, perioperative and follow-up outcomes parameters from our prospectively maintained institutional database. Eleven patients underwent segmental ureterectomy (SU) with BCE and ureteroneocystostomy with psoas hitch, five patients underwent SU with ureteroureteral anastomosis with/without psoas hitch, and one patient underwent ileal patch interposition after segmental ureteral excision. Results: Although majority of the patients had inconclusive or low-grade pathology on initial ureteroscopic biopsies, 73.33% of the patients were found to have high-grade tumors on final pathology report. Median tumor size was 2.7 cm (1-5.5 cm), and the median operative duration was 193 minutes (142-400 minutes). None of the procedures required conversion to open. Overall, only one patient (5.9%) had Clavien-Dindo grade ≥ III complication (pelvic abscess). At median follow-up of 41 months (7-156 months), four patients (26.67%) developed urothelial recurrences out of which only one patient required nephroureterectomy. Overall survival and nephroureterectomy-free survival were 86.67% and 92.31%, respectively. Conclusions: Our study provides a comprehensive review of various surgical approaches of robot-assisted renal sparing management for ureteral tumors. These procedures are surgically safe, feasible, and effective with satisfactory oncologic outcomes at intermediate to long-term follow-up. These procedures may be safely employed in select patients with a localized ureteral tumor to salvage the ipsilateral kidney and estimated glomerular filtration rate.

Cutaneous Ureterostomy or Ileal Conduit Urinary Diversion: Can We Spare the Bowel Following Radical Cystectomy in Patients with Solitary Functioning Kidney?

To compare the outcomes between cutaneous ureterostomy and ileal conduit urinary diversion in patients with solitary functioning kidney, undergoing radical cystectomy. This study was a retrospective analysis of the patients, with solitary functioning kidney, who underwent radical cystectomy with either cutaneous ureterostomy or ileal conduit from January 2014 to May 2019. Baseline characteristics, perioperative outcomes, and follow-up renal function were evaluated and compared. For renal function outcomes, we assessed the estimated glomerular filtration rate (eGFR) and included patients with a follow-up of at least 2 years. A total of 43 patients were included in the study, 23 of them underwent cutaneous ureterostomy and 20 underwent ileal conduit urinary diversion. The two groups were similar with respect to their baseline demographic and clinical characteristics. Operative time (p < 0.001), time to drain removal (p = 0.016), postoperative length of hospital stay (p = 0.018), and bowel-related complications (p = 0.047) were significantly lower in patients who underwent cutaneous ureterostomy. The eGFR was comparable at baseline, and till 1 year of follow-up. But, there was a greater decline in eGFR over 2 years, in patients who received cutaneous ureterostomy (p = 0.039). The present study shows that cutaneous ureterostomy has better perioperative, and comparable short-term renal function outcomes over ileal conduit urinary diversion. However, over 2 years of follow-up, there was an increased likelihood, and greater degree of decline in eGFR in patients who received cutaneous ureterostomy.

Robotic nephroureterectomy in the management of upper tract urothelial cancer: inching toward standard of care?

Upper-tract urothelial carcinoma is a relatively rare malignancy. Current guidelines strongly recommend radical nephroureterectomy with bladder cuff excision and template-based lymph node dissection for all high-risk upper-tract urothelial carcinomas. Although the open approach is still considered the standard of care, evolution of minimally invasive approaches especially the robotic-assisted approach, has been found to be oncologically equivalent. Since its initial description in 2006, the surgical technique as well as the robotic surgical system has gone through a major evolution. With well-established advantages of the minimally invasive approach, robotic radical nephroureterectomy also has the ability to address both upper and lower urinary tract simultaneously without the need of patient repositioning, standardized single docking technique, ease of performing crucial steps like excision of ureterovesical junction and bladder cuff with watertight cystotomy closure, allowing perioperative instillation of intra-vesical chemotherapy. Robot-assisted radical nephro-ureterectomy and template-based lymph node dissection is gradually emerging as the current standard of care to achieve the best possible oncologic and functional outcomes. In this review article we are focusing on the evolution of this approach in the management of upper-tract urothelial carcinoma along with a review of oncologic outcomes.

Refractory lymphatic ascites following laparoscopic management of renal lymphangiectasia: An unusual presentation.

Renal lymphangiectasia characterised by either unilocular or multilocular cystic lesion in and around the kidney is an uncommon condition. Presentation of these lesions is quite varied, which along with its uncommon occurrence adds to the challenges in the management of this condition. Most of these cases are managed conservatively and very rarely need any intervention. We present an unusual complication of refractory lymphatic ascites following laparoscopic deroofing of a unilocular renal lymphangiectasia in a 21-year-old gentleman who presented with left flank pain. The ascitic fluid analysis suggested non-chylous lymphatic ascites. The surgical outcome was rather exasperating for the patient than the disease itself. Hence, in the interest of the patient with minimal symptoms, if the imaging is highly suggestive of renal lymphangiectasia, either no intervention or the least invasive procedures should be attempted, whenever possible.

Clinical Value of Patient-Specific Three-Dimensional Printing of Kidney Before Partial Nephrectomy: A Qualitative Assessment.

Objectives: To qualitatively assess the clinical usefulness of patient-specific high-fidelity three-dimensional (3D) print model of kidney before partial nephrectomy (PN) and to identify subset domains where it may help in clinical terms. Materials and Methods: Thirteen 3D models were printed for tumors having RENAL nephrometry score of ≥8. Their usage for PN was assessed prospectively using a qualitative questionnaire to be answered on a Likert scale of 1-10. The questions focused on realistic resemblance, preoperative dry surgical run, intertest comparison, surgical impact, and overall beneficence domains as perceived by primary surgeons with respect to surgical conduct during PN. Results: Mean RENAL score was 9.15 (8-11). Models were rated high (9.07 ± 0.86) for realistic resemblance domain and were rated better than contrast-enhanced computed tomography (CECT) (8.38 ± 0.87) and intraoperative ultrasonography (8.07 ± 1.26) for orientation regarding resection margins. A further marginal improvement to 8.2 ± 0.84 was noted against ultrasound where surgeon did a dry cut preoperatively. Use of superselective arterial approach in four, precise awareness about dissection of a major vessel in four, retroperitoneoscopic approach in one, and surgical margin awareness in three were directly attributed to the model. Overall utility of having a model printed was rated high (8.23 ± 1.3). Conclusion: The 3D print models of complex renal tumors have high realistic resemblance to actual patient's anatomy. They were rated better than preoperative CECT or intraoperative ultrasonography for orientation regarding surgical resection margins. It may also help change or modify the surgical plan in a subset of patients with a potential to improve overall outcomes in these complex cases.

Systemic dissemination of tumor cells during transurethral resection in patients with bladder tumor and its clinical relevance: A follow up study.

OBJECTIVE: Tumor cells are shed during transurethral resection of bladder tumor (TURBT) and form the basis for use of single dose immediate chemotherapy instillation to reduce recurrences. Systemic dissemination of these cells along with the irrigation fluid is also possible but not consistently proven. In this study, we evaluated such dissemination of tumor cells into the circulation during TURBT and its clinical impact. METHODS: Patients with primary presentation of bladder tumor who underwent TURBT were included. Peripheral venous blood samples before and after TURBT were analyzed for circulating tumor cells (CTCs) using flow-cytometry. A CD45 negative cell with positive expression of cytokeratin 18, 19, and EpCam was defined as CTC. The CTC counts, pre and post TURBT, were compared and correlated with final histopathology. The patients were also followed up for any local and/or systemic recurrences. RESULTS: Nine (16.98%) out of 53 patients developed a measurable rise in CTCs after TURBT. All of these patients had high grade and muscle invasive disease. Overall, a measurable rise in CTCs was seen in 9 out of 17 (52.94%) patients with muscle invasive disease. There was no difference in the clinico-pathological stage or the status of cystectomy and/or chemotherapy between those who did or did not show a rise in CTCs. On follow up, 7 patients with muscle invasive disease developed local and/or systemic recurrences and the rise in CTCs was not found to be associated with adverse oncological outcomes. CONCLUSIONS: This study confirms the hypothesis of inadvertent dissemination of tumor cells into the circulation during TURBT, especially in patients with high grade and muscle invasive disease. The long-term oncological impact of such dissemination remains to be confirmed.

Curious case of myxoid adipocytic tumour with ureteropelvic junction obstruction in horseshoe kidney: dilemma in management.

Isolated renal involvement by myxoid adipocytic tumour is a very rare presentation. We are reporting a horseshoe kidney with ureteropelvic junction obstruction (UPJO) with myxolipoma, which was revealed after routine histopathological evaluation postbilateral open pyeloplasty. We evaluated the patient thoroughly and after detailed discussions with the patient and parents, took the decision to manage the patient on active surveillance with interval imaging and renal dynamic scans. Managing a myxolipoma associated with UPJO is a novel experience as a surgeon, by virtue of its extreme rarity. Isolated myxolipoma of renal pelvis in association with UPJO and horseshoe kidney has never been reported earlier to the best of our knowledge. The patient has not progressed at follow-up of 30 months with occasional mild abdominal discomfort. We intend to closely monitor the patient in similar fashion. Any significant progression of disease or renal failure shall entail nephrectomy with excision of mass and subsequent renal replacement therapy.

Double trouble: pelvi-ureteric junction obstruction and renal cell carcinoma in right to left crossed fused ectopia.

Crossed renal ectopia is a rare occurrence. The majority of the crossed units are fused to their ipsilateral mate. Pelvi-ureteric junction obstruction (PUJO) in crossed fused moieties has been reported very rarely. Similarly, malignancy arising in the crossed over moieties is a rare occurrence too. Only a few cases have been reported earlier. We are here reporting an unusual case with coexistent PUJO and renal cell carcinoma in the crossed over moiety of right to left crossed fused ectopia. To the best of our knowledge, this is the first reported case with both these pathologies, coexisting, in the crossed over moiety. The patient underwent open radical nephrectomy of the right moiety via a lower midline incision. Surgery in this scenario is very challenging due to complex anatomy with aberrant vasculature, which needs for dissection within the renal parenchyma, similar to nephron-sparing surgery to separate from the normal moiety.

Treatment options for unstable trochanteric fractures: Screw or helical proxima femoral nail.

PURPOSE: To compare treatment outcome of screw proximal femoral nail (PFN) system with that of a helical PFN. METHODS: The study included 77 patients with closed unstable intertrochanteric fracture classified as AO 31A2&31A3, between June 2008 to August 2011. Inclusion criteria were: all mature skeletons above 50 years of age; closed unstable trochanteric fracture classified as AO 31A2&A3. Exclusion criteria were: immature skeleton, pathological fracture of any cause other than osteoporosis, inability to walk inde- pendently prior to injury. Patients were randomized to 2 treatment groups based on admission sequence. Forty patients were treated with screw PFN and thirty seven were treated with helical PFN. RESULTS: Both groups were similar in respect of time of surgery, blood loss and functional assessment and duration of hospitalization. In screw PFN group 2 patients had superficial wound infection, 1 patient had persistent hip pain and 1 patient had shortening>1 cm but<2 cm, while in helical PFN group 1 patient had superficial wound infection. CONCLUSION: Both screw and helical PFN are very effective implants in osteoporotic and unstable trochanteric fractures even in Indian patients where the bones are narrow and neck diameter is small. It is an implant of choice for osteoporotic and unstable trochanteric fractures.

Rare presentation of giant cell tumor of bone in the lateral end of the clavicle.

PATIENT: Male, 30 FINAL DIAGNOSIS: Giant cell bone tumor Symptoms: Bone swelling • pain MEDICATION: - Clinical Procedure: - Specialty: Oncology. OBJECTIVE: Unusual clinical course. BACKGROUND: Cooper first reported giant cell tumors (GCT) in the 18(th) century. The clavicle is a rare site for tumors. Metastatic tumors are more common than benign. This is the first case of GCT lateral end of clavicle to be reported in the literature. CASE REPORTS: A 30-year-man was admitted with a 1-year history of progressively increasing swelling and pain over the left lateral end of the clavicle. The plain radiograph and PET scan revealed an expansile radiolucent lesion in the lateral end of the clavicle. Swelling was epiphsio-metaphyseal in location. It demonstrated geographical type of destruction with a narrow zone of transition. There was no periosteal reaction or soft-tissue component. The mitotic activity was found to be 0-1/10 HPF. Diagnosis was confirmed histopathologically. A wide excision of the mass, including 3 cm of healthy tissue of the clavicle, was performed. CONCLUSIONS: The presence of an expansile lytic lesion of the lateral end of the clavicle should be taken seriously and complete radiological and histopathological investigation should be done and giant cell tumor of the bone should be kept in mind despite its rarity.

Clinical correlation of magnetic resonance imaging with symptom complex in prolapsed intervertebral disc disease: A cross-sectional double blind analysis.

INTRODUCTION: Low backache (LBA) is one of the most common problems and herniated lumbar disc is one of the most commonly diagnosed abnormalities associated with LBA. Disc herniation of the same size may be asymptomatic in one patient and can lead to severe nerve root compromise in another patient. OBJECTIVE: To evaluate correlation between the clinical features of disc collapse and magnetic resonance imaging (MRI) finding to determine the clinical importance of anatomical abnormalities identified by MRI technique. SUMMARY: From January 2010 to January 2012, 75 otherwise healthy patients (43 males 32 females) between the age of 19 and 55 years (average age was 44.5 years) with low back pain and predominant complaint of root pain who presented to our clinic were included in the study. MATERIALS AND METHODS: Proper screening was done to rule out previous spine affection and subjected to MRI. RESULTS: The results were analyzed under four headings viz. disc herniation, disc degeneration, thecal sac deformation and neural foramen effacement. All patients had a visual analog score (VAS) score more than 6. The interrater correlation coefficient kappa was calculated to be k=0.51. There were total 44 patients with herniation, 25 patients had mild, one patient had moderate degree of thecal sac deformation, 21 patients had one or more levels of foraminal effacement by the herniated tissue, 100% of the patients had disc degeneration ranging from grade 1 to 3 at different levels; and 48 patients (64%) had radiculopathy, six (8%) patients had bilateral and others had ipsilateral affection. CONCLUSION: In our study, the correlation was made between clinical findings and MRI findings. It can safely be concluded that treating physician should put more emphasis on history, clinical examination, and make the inference by these and then should correlate the clinical findings with that of MRI to reach a final diagnosis.