Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes

ABSTRACT Objectives The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). Materials and methods From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. Results All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). Conclusions The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes.

OBJECTIVES: The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy). MATERIALS AND METHODS: From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded. RESULTS: All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7). CONCLUSIONS: The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

The ideal blood pressure target to prevent cardiovascular disease in type 2 diabetes: a neutral viewpoint.

Type 2 diabetes mellitus (T2DM) and essential hypertension are often associated, and retrospective data analyses suggest an association between lower blood pressure (BP) values and lower cardiovascular (CV) risk in patients with T2DM. However, the most recent intervention trials fail to demonstrate a further CV risk reduction, for BP levels <130/80 mm Hg, when compared to levels <140/90 mm Hg. Moreover, a J-shaped, rather than a linear, relationship of BP reduction with incident CV events has been strongly suggested. We here debate the main available evidences for and against the concept of 'the lower the better', in the light of the main intervention trials and meta-analyses, with a particular emphasis on the targets to be pursued in elderly patients. Finally, the most recent guidelines of the scientific societies are critically discussed.

[Nephroangiosclerosis and ischemic nephropathy: two different entities or two renal manifestations of the same systemic cardiovascular disease?]. / La nefroangiosclerosi e la malattia ateromasica ischemica renale: due entita' nosologiche diverse o solo due espressioni renali di una stessa patologia sistemica cardiovascolare?

Nephroangiosclerosis (NAS) is increasingly diagnosed in adult and elderly patients with slowly progressive chronic renal insufficiency. Since these patients usually present with arterial hypertension, this is considered the main cause of NAS (sometimes called, in fact, hypertensive NAS or hypertensive nephropathy). However, there is evidence that other factors such as aging, black race, smoking, and metabolic disturbances contribute to the development and progression of the disease. In some patients, these factors may be prominent while hypertension may be mild or even absent: this form has been denominated ischemic nephropathy (IN). Are NAS and IN really two different diseases or just different presentations of cardiovascular disease involving the kidney? The latter hypothesis is supported by evidence that (a) NAS and IN share a relative aspecificity in their clinical symptoms (low proteinuria, microhematuria, high blood pressure, dyslipidemia) and histopathological features (as determined in the few cases that undergo a kidney biopsy), and (b) there is a high likelihood that atheromatous and hypertensive lesions coexist in the same patient. In this ''Controversy in Nephrology'', Rosario Cianci and Alessandro Zuccala' analyze this issue and try to answer the following questions: 1 - Are NAS and IN two different diseases or two different expressions of the same disease? Rosario Cianci, ''They are two different diseases''. Alessandro Zuccala', ''They represent two different expressions of the same disease''. 2 - Is the pathogenesis different in nephroangiosclerosis and IN? Rosario Cianci, ''The pathogenesis is high blood pressure in NAS and renal ischemia in IN''. Alessandro Zuccala', ''NAS and IN share the same multifactorial pathogenesis: vascular metabolic alterations can cause chronic renal ischemia with or without hypertension''. 3 - Is a biopsy necessary for the diagnosis? Rosario Cianci, ''Yes, it is''. Alessandro Zuccala', ''No, it is not''. 4 - Is it possible to prevent or to slow the progression of the renal damage in this (these) disease(s)? Rosario Cianci, ''Yes it is, by reducing blood pressure''. Alessandro Zuccala', ''Normalization of blood pressure is not enough but all the other risk factors of vascular damage must be addressed, when possible''.

[Guidelines for management of hypertension: why doesn't evidence lead to unanimity?]. / Le Linee Guida sull'ipertensione: perché l'evidenza non porta all'unanimità?

Guidelines are systematically developed statements to assist practitioner and patient decisions, and are being used to describe care based on scientific evidence. However, presence of multiple guidelines on the same subject does not help physicians make the best decision about healthcare. In this paper we examined the more recent guidelines (GL) for the management of arterial hypertension: World Health Organization-International Society of Hypertension (WHO-ISH) GL, European Society of Hypertension-European Society of Cardiology (ESH-ESC) GL, British Hypertension Society (BHS-IV) GL, and the report of Joint National Committee (JNC-7) from USA. Some differences emerged on the definition of hypertension, the blood pressure targets and the thresholds for treatment, the quantification of cardiovascular risk, the choice of initial drugs. These differences are likely to be based on divergent opinions about the relationship between hypertension and global cardiovascular risk (CVR). In the JNC-7 report, hypertension is thought to be the mainstay of CVR, hence BP treatment is to be started, taking into account the entity of blood pressure values and apart from other risk factors (with the exception of diabetes and renal insufficiency). The other GL, particularly BHS-IV GL, establish the thresholds for the start of treatment mainly taking into account the global CVR. Actually, BHS-IV GL do not recommend the start of pharmacological treatment in mild hypertension, provided that the global CVR was lower than 20% in ten years. Moreover, the difference in definition of hypertension, BP targets, choice of starting drug, is likely to spring from this different view on hypertensionglobal cardiovascular risk relationship.

[The sympathetic system and neuroendocrine hypertension]. / il sistema simpatico e le ipertensioni neuroendocrine.

Sporadic pheochromocytoma is a rare tumor that should be taken into account in patients with hypertensive crisis, arrhythmias, and panic disorder. Familial pheochromocytoma is frequently found in subjects with von Hippel-Lindau disease, multiple endocrine neoplasia type II, neurofibromatosis, and SDHD gene mutations. The prevalence of sporadic pheochromocytoma is very low, approximately 0.05% among subjects with essential hypertension and even less in the general population. However, aggressive diagnostic intervention is recommended whenever a pheochromocytoma is suspected because the uncontrolled catecholamine release from the tumor can lead to serious and potentially lethal complications. Plasma free metanephrines have been shown to have high sensitivity and specificity in the biochemical diagnosis of sporadic and familial pheochromocytoma. Measurement of 24-hour urinary fractionated metanephrines may be an acceptable alternative in many patients. The current approach to the diagnostic localization of pheochromocytoma relies on computed tomography (CT), magnetic resonance imaging (MRI) and [123-I] and [131-I] MIBG scintigraphy. CT and MRI have very high sensitivity but low specificity, whereas MIBG scintigraphy has good specificity but its sensitivity is less than optimal, especially for the detection of metastases. In difficult cases, PET imaging appears to be promising.

[Refractory hypertention in a female patient with renal failure]. / Un caso di ipertensione refrattaria in donna con insufficienza renale.

We report one sixty-seven years-old female who presented with hypertension refractory to antihypertensive drugs. She had an elevated BP for approximately 15 years. In the last 8-10 months her hypertension had become difficult to control. Her BP ranged between 180/100 mmHg and 220/1220 mmHg on atenolol 100 mg once daily, methyldopa 500 mg three times daily, furosemide 25 mg twice daily, doxazosine 4 mg twice daily. When she was referred to our unit serum creatinine was 2.3 mg/dL and she had a mild proteinuria (70 mg/dL) without microematuria. Ultrasonography showed a left kidney size in the low-normal range (LD 11 cm) and a small right kidney (LD 9 cm). Renal angiography showed a severe, ostial stenosis of the left renal artery and a total thrombosis of the right renal artery with a blood supply to the right kidney provided by collateral channels. An ACE-I was added to the therapy but a sharp increase in serum creatinina (up to 6.4 mg/dL) prompted us to withdraw the drug. She underwent a renal angioplasty on the left side and a Palmaz stent was placed. The control angiography showed a good anatomical result. Three months after the manoeuvre the patient was again referred to our unit with headache, nausea vomiting and hyper-tension refractory to amlodipine 10 mg/day, doxazosine 4 mg twice a a day, atenolol 50 mg/day, furosemide 50 mg/day. A doppler ultrasonography and a magnetic resonance angiogram showed no restenosis on the treated artery. An ACE-I was again administered and BP on this drug was 145/90 mmHg after one month and 130/85 after three months. Headache, nausea and vomiting disappeared. Serum creatinina kept unchanged (2.2 mg/dL). Comment. In this case the benefit of angioplasty on blood pressure control was indirect. Apparently the manoeuvre showed no effect on blood pressure, but the angioplasty allowed us to use of an ACE-Inhibitor, without any negative effect on renal function, and thus to adequately control blood pressure.

[Imaging strategies for renovascular disease]. / L'imaging dell'ipertensione renovascolare.

Renovascular disease (RVD) is detected with increasing frequency because with an aging population, atherosclerosis and its consequences are seen more frequently. RVD has three component parts: renal artery stenosis (RAS), renovascular hypertension (RVH), and ischemic nephropathy (IN). Each component should be recognized by the appropriate diagnostic tool. The proper techniques and procedures to establish an anatomical RAS diagnosis are: computed tomography angiography, magnetic resonance (MR) angiography and catheter angiography, which is the gold standard. The presence of RAS can also be disclosed through increased systolic blood flow velocity at the level of the narrowed renal artery by an echo color-Doppler. Once the presence of RAS is demonstrated the diagnosis of RVH and/or IN should be performed. The RVH diagnosis needs to demonstrate a causal link between RAS and blood pressure (BP) increase; a causal link between RAS and the reduction in glomerular filtration rate (GFR) is mandatory for the IN diagnosis. Techniques and procedures suggesting that BP is increased and/or GFR is reduced based on RAS are captopril enhanced renoscintigraphy, BP gradient across the stenosis, captopril modification of Doppler parameters and captopril modification of MR curves. The resistive index obtained by color-Doppler could be a structural damage marker of the intrarenal arterioles. A rational approach to the problem demands that each technique is chosen according patient clinical characteristics.

Posterior tibial nerve stimulation: is the once-a-week protocol the best option?

AIM: Aim of our study was to compare the results of posterior tibial nerve stimulation (PTNS) performed weekly with those of PTNS performed 3 times per week in patients with overactive bladder syndrome. METHODS: Thirty-five patients (28 females, 7 males) with overactive bladder syndrome not responding to antimuscarinic therapy were enrolled in a prospective study. A total of 17 out of 35 patients were randomly assigned to group A and treated with a PTNS protocol based on weekly stimulation sessions; 18 out of 35 patients were randomly assigned to group B and treated with a PTNS protocol based on stimulation sessions performed 3 times per week. All subjects were evaluated by means of 24 h bladder diaries, quality of life questionnaires (I-QoL, SF36) and urodynamic evaluation before and after treatment. Patients were asked after each stimulation session to give their opinion on the efficacy of the treatment. We have considered ''success'' those patients who presented a reduction >50% of the micturition episodes/24 h (ME/24) or (if incontinent) of the incontinence episodes/24 h (IE/24). Results before and after treatments in both groups were collected and statistically compared. RESULTS: As a whole, 11/17 patients (63%) in group A and 12/18 patients (67%) in group B were considered ''success''; 4/11 (36%) incontinent patients in group A and 5/11 (45%) incontinent patients in group B were completely cured after treatment. In both groups, patients reported subjective improvement after 6-8 stimulation sessions. CONCLUSIONS: Our findings seem to show that the periodicity of stimulation does not effect the results of PTNS treatment. The advantage of more frequent stimulation sessions is to achieve earlier a clinical improvement.

[Hypertension, atherosclerosis and kidney]. / Ipertensione, aterosclerosi e rene.

Cardiovascular risk is dramatically increased in patients with end-stage renal disease (ESRD). However, even minor dys-functions such as microalbuminuria or a mild increase in serum creatinine (Cr) have a major impact on cardiovascular risk. Increased cardiovascular risk is present in multiple populations, including general populations, patients with moderate risk such as hypertensives, and high-risk patients including patients with heart failure and myocardial necrosis. There are many mechanisms underpinning the increased cardiovascular risk. Regarding atherosclerosis, the kidney can be victim or villain. On the one hand, both kidney disease per se and renal insufficiency can induce vascular damage, thereby increasing cardiovascular risk. Kidney disease without renal insufficiency can cause an increased prevalence in hypertension, dyslipidemia (nephrotic syndrome), sympathetic system hyperactivity, and in renin angiotensin system hyperactivity. A moderate-severe renal insufficiency can induce an increase in many vasculotoxic substances such as ADMA, lipoprotein(a), homocysteine, disturbances in calcium and phosphate metabolism, anemia and left ventricular hypertrophy. A more severe renal insufficiency can induce the ominous malnutrition-inflammation-atherosclerosis (MIA) syndrome. On the other hand, the kidney can be the victim of atherosclerosis. Ischemic nephropathy, caused by atherosclerotic renal artery disease and atheroembolism from abdominal aorta are two examples. Finally, it is important to consider that the kidney, being an organ with a wide vasculature, could be a sophisticated sensor of subclinical cardiovascular damage.

Role of 5-aminolevulinic acid in the diagnosis and treatment of superficial bladder cancer: improvement in diagnostic sensitivity.

OBJECTIVES: To use 5-aminolevulinic acid (5-ALA) in diagnostic cystoscopy and during transurethral resection of the bladder (TURB) to treat transitional cell carcinoma. The efficacy of this new technique was compared with standard cystoscopy. METHODS: The 5-ALA, instilled in the bladder 2 hours before cystoscopy, makes the pathologic tissue fluorescent when illuminated with blue light (375 to 400 nm). This allows a better recognition of the neoplastic forms for both diagnostic and therapeutic purposes during TURB. This method has been used since May 1997 on 49 patients in whom bladder tumor was diagnosed either immediately or during postchemotherapy follow-up. RESULTS: One hundred seventy-nine biopsies were taken of fluorescent and nonfluorescent areas (3.5 per patient) to check the effectiveness of the new method compared with standard cystoscopy. A good correlation was found between 5-ALA cystoscopy and the histopathologic diagnosis, with a good sensitivity (87%). The 5-ALA cystoscopy allowed the diagnosis of a tumor in 24 patients with negative standard cystoscopic findings. Furthermore, 5-ALA cystoscopy detected 7 cases of carcinoma in situ. Neither local nor systemic (because of endovesical instillation) side effects were noted. CONCLUSIONS: We believe that 5-ALA could be routinely used in the diagnosis of superficial bladder tumors, as it was shown to improve the diagnostic sensitivity for carcinoma in situ and to reduce the risk of recurrence related to missed cancerous lesions or incomplete TURB.

Percutaneous sclerotization of simple renal cysts with 95% ethanol followed by 24-48 h drainage with nephrostomy tube.

AIM OF THE STUDY: We propose some technique devices for treating simple renal cysts with percutaneous puncture (PCN) to reduce recurrences. MATERIALS AND METHODS: Between January 1995 and December 1998, a series of 42 patients, 13 females and 29 males, ranging in age between 49 and 73 were treated for symptomatic kidney cystic disease. The cysts varied between 7.4 and 13.6 cm in diameter and from 100 to 570 cm(3) in volume. This technique consists of echo-guided emptying of the cyst, and slowly inserting a quantity of pure 95% ethanol, equivalent to about 1/3 of the cyst volume, into the cavity. This acts as a sclerosant agent on the cyst walls. The protocol of this technique also includes positioning a curled drainage catheter, for 24-48 h, in suction, to ensure a correct collapse of the cyst walls and to avoid cyst recurrence. RESULTS: Of the 42 patients treated, only 4 did not complete the protocol. In 3 cases, the patients were not able to stand the procedure because of intense pain during cyst filling with alcohol. The other patient had intracystic hemorrhage. The results were evaluated by ultrasonography at 7 days post-operatively and then at 1, 3, 6, 9 and 12 months later. There was a further follow-up lasting from 12 to 36 months. Of 38 patients treated, 29 (76%) did not have any recurrence. 8 patients (21%) developed a small liquid layer of 3-4 cm, which did not enlarge in subsequent check-ups. We observed a recurrence, which spontaneously reduced in volume, only in 1 patient. CONCLUSIONS: This procedure was simple to apply in an out-patient setting and used low-cost materials which are easily obtained. Moreover, the results appear to confirm the validity of this technique.

3 R study: renal outcome in renal ischemia: revascularisation or medical treatment.

Ischemic nephropathy refers to the kidney damage following stenosis or an obstructive lesion in the main kidney arteries. This disorder has been overlooked in the past and a more rational and specific use of clinical criteria, and the development of not very invasive techniques with a good diagnostic accuracy such as spiral CT angiography, NMR angiography and echo-colour-Doppler have improved our ability to identify these patients. It is therefore likely that, in the next few years, we will find ourselves treating an increasing number of patients with renovascular ischemic disorders. Transluminal angioplasty and, more recently, the use of endovascular stents, have led to a marked improvement in the treatment of stenoses and, together with vascular surgery, allow to treat almost all patients with this disorder. There is, however, a lack of prospective and controlled studies, which demonstrate the long term benefit of revascularization treatment, as compared with optimum conservative treatment in reducing cardiovascular mortality, cardiovascular events and preserving renal function. The Ischemic Nephropathy Study Group of the Italian Society of Nephrology has organized a prospective, controlled study over a period of three years, aimed at comparing the effect of revascularization versus medical therapy in 300 patients with renal artery stenosis, ranging between 50 and 90 per cent, who will be randomly assigned to the two treatments. End point will be cardiovascular mortality and morbidity and need for renal replacement therapy.

The deletion polymorphism of the angiotensin-converting enzyme is associated with nephroangiosclerosis.

The D allele of the angiotensin-converting enzyme (ACE) gene has been linked with diabetic nephropathy and IgA glomerulonephritis and with faster renal disease progression. The association of this allele with nephroangiosclerosis has been scarcely investigated. We have tested this association in 45 hypertensive patients (all whites) with well defined nephroangiosclerosis (diagnosis established on the basis of renal biopsy in all cases) and moderate to severe renal failure. As studies of genetic association of small size often produce conflicting results, besides a control group of 343 Italian patients with essential hypertension and normal renal function, we elected to use also a very large control group of race-matched subjects taken from a meta-analysis of 27,565 whites. The proportion of patients with the D allele (64%) was higher in patients with nephroangiosclerosis than that in Italian hypertensives (54%) and in whites (54%). DD and DI genotypes were more prevalent in patients than in control groups. The dominant model (DD and DI v II: nephroangiosclerosis v Italian controls: chi2 = 6.19, P = .012; nephroangiosclerosis v whites chi2 = 6.86, P = .009) fitted the data better than the codominant and the recessive model (P < or = .022). The D allele is associated with nephroangiosclerosis with a dominant effect in the sample of patients studied. Although intervention studies are needed to see whether these findings imply a causal association, our data suggest that this allele may at least act as disease marker in nephroangiosclerosis.

Ischemic nephropathy.

Ischemic nephropathy, involving stenotic lesions in the renal arteries, associated with renal insufficiency, is now recognized as a frequent disease. It may be responsible for a significant proportion of end stage renal disease, at least in the Caucasian population. Some non-invasive but reliable techniques such as echo-color-Doppler, gadolinium-enhanced magnetic resonance and spiral CT angiography are now available for diagnosis. Revascularization with either angioplasty, stent or surgery improves renal function in many patients. In the near future systemic and/or local medical therapy will provide better answers for renovascular disease.

Renovascular disease in diabetes mellitus: treatment by percutaneous transluminal renal angioplasty.

BACKGROUND: Diabetes mellitus is an important cause of end-stage renal failure (ESRF). Although classic diabetic nephropathy accounts for the majority of patients reaching ESRF, renovascular disease, which is frequent in such patients, plays an increasingly important role. Percutaneous transluminal renal angioplasty (PTRA) has been proven to be an efficacious measure for renal revascularization. METHODS: Ninety-nine patients with diabetes mellitus and renal artery stenosis, corresponding to 16.6% of the entire population of diabetic patients, were treated by PTRA or with the Palmaz-Schatz stent in our clinic. Technical success was achieved by PTRA in 92/99 patients, in 10 patients a Palmaz-Schatz stent was implanted. RESULTS: Hypertension was cured in eight and improved in 44 patients. In 47 patients, there was no impact on blood pressure. An improvement in renal function was evident 1 month after PTRA in 8/27 patients. A further improvement occurred in another four patients after 6 months. The re-stenosis rate was 22% after 5 years. Serious complications occurred in seven patients (one patient required surgery and two patients had regular dialysis treatment). CONCLUSIONS: Renovascular disease is an important cause of ESRF in diabetic patients. PTRA is a valid tool to revascularize renal artery stenosis and improve blood pressure control and renal function both in diabetic and non-diabetic patients.

Progression of renal failure and hypertensive nephrosclerosis.

Data provided by end-stage renal disease (ESRD) registries document a progressive and striking increase in the incidence of hypertension-related ESRD over the years, and its prevalence supports the classic statement that the kidney may be a victim of hypertension. Two clinical conditions should be considered separately when the role of hypertension in progressive renal disease is discussed: (a) hypertension and primary renal disease and (b) progressive renal disease in essential hypertension. The appearance of systemic hypertension is one of the major risk factors for the progressive deterioration of primary renal disease both in experimental models and in humans. Strict blood pressure control is able to significantly reduce the disease progression to renal failure. Angiotensin-converting enzyme inhibitors probably show a better nephroprotective action than other antihypertensive agents. Long-lasting hypertension may induce ESRD in some patients through hypertensive nephrosclerosis. In many cases of progressive renal disease associated with essential hypertension, particularly in elderly Caucasians, atheromatous renovascular disease via renal artery stenosis and/or cholesterol microembolization represent the main cause of ESRD.

Ischemic nephropathy: diagnosis and treatment.

Recent epidemiologic studies have shown that ischemic nephropathy secondary to stenosis or obstruction of the main renal arteries in the cause of renal insufficiency in a growing number of subjects. The clinicians dealing with renovascular disease need non-invasive diagnostic tools and effective therapeutic measures to successfully face the problem. Duplex ultrasound scanning is a non-invasive, non expensive diagnostic tool and when an experienced, dedicated technologist is available, it should be suggested as the first-step test. Magnetic resonance angiography and spiral CT angiography play an ancillary role in detecting patients with renovascular disease. Captopril-enhanced (CE) scintigraphy when positive indicates the activation of intrarenal renin-angiotensin system and may be useful in detecting patients with renal artery stenosis. Moreover, CE scintigraphy can play an important role in the choice between the revascularization and a wait-and-see approach. As a matter of fact, the presence of an activated intrarenal renin-angiotensin system furnishes theoretical as well practical reasons in favour of the revascularization. In the recent years percutaneous transluminal renal angioplasty has become the cornerstone of therapeutic strategy. The introduction of the metallic stent has dramatically improved its efficacy in ostial stenoses and has reduced the indication for surgical revascularization.