Intranodal Ultrasound-Guided Percutaneous Methylene Blue Injection for the Identification of Leakage Point during Laparoscopic Repair of Refractory Chylous Ascites after Laparoscopic Lymphadenectomy for Kidney Cancer.

Chylous ascites is an uncommon complication after surgery that can result in malnutrition and immunodeficiency. Therefore, surgical interventions are reserved for refractory patients, and the primary success factor for these interventions is locating the point of leakage, which is often tricky. We describe a case of a 56-year-old male with chylous ascites after laparoscopic radical nephrectomy and lumbo-aortic lymphadenectomy for kidney cancer. The patient was initially managed with dietary modifications and drainage placement. Afterward, lymphography with Lipiodol, percutaneous embolization of the leakage point, and total parenteral nutrition were established. Finally, the patient underwent laparoscopic repair after identifying the leakage point by injecting methylene blue through an inguinal node. Complete resolution was achieved, and no complications related to the procedure were recorded. Intranodal methylene blue injection can be an invaluable tool to identify the point of leakage in selected patients to improve the outcomes of surgical repair of refractory chylous ascites.

Long-Term Oncological and Functional Outcomes After Robot-Assisted Partial Nephrectomy for Clinically Localized Renal Cell Carcinoma.

BACKGROUND: To evaluate long-term oncological and renal function outcomes in patients treated with robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma (RCC). PATIENTS AND METHODS: Patients undergoing RAPN for clinically localized RCC between January 2014 and December 2019 at a tertiary robotic reference center were evaluated. Clinical course, pathologic characteristics, and long-term outcomes were obtained from our institutional review board-approved RCC database. RESULTS: A total of 234 patients were available for analysis. Median follow-up was 46 months (10.8-97.8 months), with 77 patients (32.9%) having at least 5-years of follow-up. Pathology revealed clear-cell RCC in 67.5% (n = 158). Among unfavorable factors, nuclear grades 3 or 4 were found in 67 (29.4%), lymphovascular invasion in 10 (4.3%), positive surgical margins in 22 (9.4%), necrosis in 21 (9%), and sarcomatoid pattern in 2 patients (0.9%). At 12 months, mean serum creatinine was 1.04 mg/dL and 12.9% of patients experienced upstaging in chronic kidney disease. Overall recurrence-free survival at 5-years was 97.8%. There were five local (2.1%) and two distant (0.9%) recurrences, none of them resulting in cancer-specific death. Median time to recurrence was 20 months (11-64 months). Warm ischemia time [hazard ratio (HR) = 1.14, p = 0.034] and sarcomatoid pattern (HR = 124.57, p = 0.001) were the only variables associated with local relapse. CONCLUSIONS: Data from this large cohort demonstrate that patients undergoing RAPN have a low incidence of local and distant relapse, resulting in excellent long-term survival while preserving stable renal function in most patients.

Nefrectomía parcial single-port apoyada con el uso de pinza magnética robótica / Partial nephrectomy single-port supported by the use of robotic magnetic clamp

La Nefrectomía parcial es la técnica quirúrgica ideal en tumores T1 si técnicamente es posible, preservando una mayor cantidad de tejido renal funcional. El abordaje laparoscópico se asocia a menores tiempos de hospitalización, menor dolor y reinserción laboral precoz. El apoyo del abordaje single-port (LESS) se asocia a menos dolor y mejores resultados estéticos, pero conlleva a una mayor complejidad técnica, sin embargo esta dificultad puede ser eliminada con el apoyo robótico, conservando los beneficios de la técnica single port. La tecnología magnética LEVITA facilita aún mas la técnica, pudiendo ser utilizada también en cirugía laparoscópica convencional. MATERIALES Y MÉTODOS: Presentamos el caso de un paciente de sexo masculino de 64 años, sin antecedentes mórbidos, con hallazgo incidental de tumor renal de 1.6 x 1.5 cm en polo inferior izquierdo, R.E.N.A.L. score 6P. Se realizó nefrectomía parcial robóticamente asistida single port. El tiempo operatorio fue de 270 minutos, sangrado estimado de 200cc. Los márgenes fueron negativos. La creatinina en el último control (1.0 mg/dl) es similar a la preoperatoria inmediata (0.9 mg/dl). CONCLUSIONES: La Nefrectomía parcial robóticamente asistida utilizando solo una incisión permite disminuir la morbilidad perioperatoria y mejorar los resultados cosméticos sin que esto signifique una mayor complejidad en la técnica quirúrgica. La tecnología magnética LEVITA es una herramienta útil a considerar en el arsenal del cirujano robótico / laparoscopista.(AU)

INTRODUCTION: Partial nephrectomy is the ideal surgical technique in T1 tumors if technically possible, preserving a greater amount of functional renal tissue. The laparoscopic approach is associated to shorter hospitalization time, less pain and early return to work. Support single-port approach is associated with less pain and better cosmetic results but leads to greater technical complexity. However, the latter difficulty can be eliminated with the robotic support, preserving the benefits of the single-port technique. The LEVITA magnetic technology makes it even easier to apply the technique, and can also be used in conventional laparoscopic surgery. MATERIALS AND METHODS: We report the case of a 64-year old male patient without morbid history, with incidental 1.6 x 1.5 cm kidney tumor finding in the left lower pole, R.E.N.A.L. 6P score. Robot-assisted single port partial nephrectomy was performed. The operating time was 270 minutes, estimated blood loss of 200cc. The margins were negative. The ultimate creatinine control (1.0 mg / dl) is similar to the immediate preoperative (0.9 mg / dl). CONCLUSIONS: Robot-assisted partial nephrectomy using only one incision allows reduction of perioperative morbidity and improvement of cosmetic results without greater complexity in surgical technique. The LEVITA magnetic technology is a useful tool to consider in the arsenal of a robotic / laparoscopic surgeon.

La edad es un factor predictor independiente para recurrencia tumoral en el cáncer de vejiga no músculo invasor: resultados de una serie local / Age is an independent predictor for tumoral recurrence in non muscle-invasive bladder cancer: results of a local series

Introducción: El cáncer de vejiga es en su mayoría una enfermedad de pacientes de edad avanzada. El objetivo del estudio fue evaluar la edad como factor pronóstico en una cohorte de pacientes chilenos con cáncer de vejiga no músculo invasor. Material y métodos: Se revisaron retrospectivamente los registros clínicos de 107 pacientes tratados por un cáncer no-músculo invasor de vejiga confirmado histológicamente. Se determinaron asociaciones de la edad con parámetros clínicos e histopatológicos, así como con recurrencia y progresión tumoral. Finalmente se realizó un análisis multivariado para identificar factores predictores de los desenlaces mencionados. Resultados: La mediana de edad fue 65 años (rango 29-94). Se observó una significativa asociación de unos pacientes jóvenes con el tabaquismo activo. Por otro lado, los pacientes mayores a 65 años mostraron una asociación significativa con la presencia de recurrencia y progresión tumoral en el análisis univariado. Finalmente, una edad por sobre los 65 años fue el predictor independiente más importante para la recurrencia en el análisis multivariado, por sobre el estadío pT. Conclusiones: Existen varios factores clínicos y psicosociales que contribuyen al significativo poder predictor de una edad > 65 años en el pronóstico de un paciente con un cáncer de vejiga no músculo invasor. Por lo mismo, cada paciente debe ser evaluado en forma integral, tomando en cuenta las distintas dimensiones involucradas. En un escenario de progresivo envejecimiento de la población, el urólogo debe estar preparado para resolver adecuadamente esta situación.

Introduction: Bladder cancer is most frequently a disease of the elderly. The aim of the study was to evaluate the impact of age on prognosis in a cohort of Chilean patients with non muscle-invasive bladder cancer. Methods: The medical records of 107 patients treated for non muscle-invasive bladder cancer at our institution were retrospectively reviewed. Associations of age with clinical and histopathological parameters were assessed, as well as with tumoral recurrence and progression. Finally, a multivariate analysis was performed in order to identify predictive factors for the mentioned outcomes. Results: The median age was 65 years (range 29-94). Younger patients showed a significant association with an active smoking status. On the other hand, a significant association of age > 65 years with tumoral recurrence and progression was observed on univariate analysis. Age was also the most important predictive factor for recurrence on the multivariate analysis, even more than the pT stage. Conclusions: There are several clinical and psychosocial factors related to the significant predictive power of a higher age on the prognosis of patients with non muscle-invasive bladder cancer. Therefore, every patient should be assessed integrally, taking into account all the different dimensions involved. In an era of an aging population, the urologist must be prepared to handle with this situation.

Initial experience in laparoscopic partial nephrectomy for renal tumor with clamping of renal vessels.

PURPOSE: To describe our initial experience with laparoscopic partial nephrectomy (LPN) with clamping of the renal vessels before tumor excision and suturing of the renal parenchyma. PATIENTS AND METHODS: Between July 2001 and April 2002, 19 consecutive patients underwent transperitoneal LPN in our institution, 14 for tumors <4 cm with suspicion of renal-cell cancer and 5 for suspicion of angiomyolipoma at CT with one tumor confirmed histopathologically by percutaneous needle biopsy. We divided these patients into the first 10 cases (Group 1) and the last 9 cases (Group 2). One patient had end-stage renal disease but was not on dialysis; the remaining patients had elective partial nephrectomy. Initially, a ureteral catheter was placed. The partial nephrectomy was performed with clamping of the renal vessels, so that the tumor was excised with cold scissors. Intracorporeal cooling of the kidney was achieved by a ureteral catheter connected to a 4 degrees C solution flowing to the renal pelvis during the whole procedure until the clamps were released. Intracorporeal free-hand suturing was exclusively used to close the collecting system (when opened) and to approximate the renal parenchyma. RESULTS: All procedures were completed laparoscopically. The mean renal warm ischemia time was 28.5+/-7 minutes (range 15-47 minutes). The mean laparoscopic operating time was 125+/-37 minutes (range 90-390 minutes). The mean intraoperative blood loss was 290+/-276 mL (range 25-1200 mL). Two patients required blood transfusion, and four had complications. There was immediate deterioration in renal function (creatinine 1.42+/-0.56 mg/dL), but improvement was seen at 1 month (1.17+/-0.34 mg/dL). There were no statistically significant differences in operative features and outcomes in Groups 1 and 2, but there were improvements in the mean operating time by 30 minutes, the mean intraoperative blood loss by 113 mL without any transfusion, and the mean renal warm ischemia time by 6 minutes. There was only one patient in Group 2 with a complication. The surgical margin was negative for tumor for all patients. Postoperative pathology examination showed renal-cell cancer in 11 patients (pT1), oncocytoma in 3 patients, and angiomyolipoma in 5 patients. The mean tumor grade was 2. The mean tumor size was 25.8+/-11.6 mm with a mean tumor-free margin of 2.6+/-2.4 mm. The median follow-up is 3 months, so oncologic outcome cannot be assessed. CONCLUSION: The technique of LPN can be standardized and should be proposed for small tumors when they are not invading the hilum. Clamping the renal pedicle allows better vision for more accurate tumor excision with a safety margin and hemostatic suturing of the parenchymal defect, resulting in less blood loss and shorter operative time, parameters that improve with experience.