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.

Outcomes of Flexible Ureterorenoscopy for Solitary Renal Stones in the CROES URS Global Study.

PURPOSE: We determined the efficacy and safety of flexible ureterorenoscopy for single intrarenal calculi and further stratified efficacy by stone burden. MATERIALS AND METHODS: CROES collected prospective data on consecutive patients with urinary stones treated with ureterorenoscopy at 114 centers worldwide for 1 year. Only patients who underwent flexible ureterorenoscopy for a solitary renal stone were included in study. Preoperative and intraoperative characteristics, and postoperative outcomes were evaluated. Relationships between stone size and the stone-free rate, operative time, complications, hospital stay and need for re-treatment were determined. RESULTS: A total of 1,210 patients with a solitary kidney stone less than 10 (52.2%), 10 to 20 (43.2%) and greater than 20 mm (4.6%) were treated with flexible ureterorenoscopy. The stone-free rate negatively correlated with stone size when adjusted for body mass index. Operative time positively correlated with stone size when adjusted for body mass index. The single session stone-free rate was 90% and 80% for stones less than 10 and less than 15 mm, respectively. Patients with stones greater than 20 mm achieved a 30% stone-free rate, more often needed re-treatment and were more often rehospitalized. There was no difference in the overall complication rate by stone size. However, patients with a stone greater than 20 mm showed a higher probability of fever after flexible ureterorenoscopy than those with a smaller stone. CONCLUSIONS: Our data indicate that flexible ureterorenoscopy for a single intrarenal stone is a safe procedure. Best results after single session flexible ureterorenoscopy were obtained for stones less than 15 mm.

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.

The 'buoy' stent: evaluation of a prototype indwelling ureteric stent in a porcine model.

OBJECTIVE To assess a prototype ureteric 'buoy' stent with a 10 F upper body tapering to a 3F tail, developed to potentially reduce stent-related irritative symptoms while providing an adequate mould for healing after endopyelotomy. MATERIALS AND METHODS Eighteen Yucatan minipigs had the stent placed either into the intact ureter (phase I) or after Acucise proximal endoureterotomy (phase II). Buoy stents were compared to 10/7 F endopyelotomy stents and to standard 7 F stents in phases I and II, respectively. The pigs were assessed for vesico-ureteric reflux, hydronephrosis and infection, before stent insertion and at harvest. Stents were weighed before and after placement and the removal force was measured. Pressure/flow studies, antegrade nephrostograms and specimens for histopathology from the renal pelvis, ureter and vesico-ureteric junction (VUJ) were obtained at harvest. RESULTS Thirteen minipigs survived the entire study. Ureteric flow with the stents in situ was better for buoy stents than for 10/7 F stents (P < 0.005). Ureteric flow after endoureterotomy and subsequent stent removal was similar for buoy stents and standard 7 F stents. None of the stents refluxed. There was no difference between stents in removal force, weight change or incidence of hydronephrosis. At 1 and 12 weeks, buoy stents tended to produce lower histopathological alteration scores than control stents, especially at the VUJ (phase I, 2.0 vs 3.9, P = 0.092; phase II, 0.6 vs 1.7, P = 0.18). CONCLUSIONS The novel buoy stents are easily placed and removed via the urethra. They can cause less VUJ inflammation than standard stents while allowing for adequate ureteric flow and healing after proximal endoureterotomy.

Programa continuo de detección precoz de cáncer de próstata: análisis crítico a dos años de su implementación / Prostate cancer screening: a crytical analysis of a two years study

Introducción: La creciente demanda por controles periódicos por parte de la población motivó la creación de un programa continuo de detección precoz de Cáncer de Próstata en nuestro centro. El objetivo de este trabajo fue evaluar en forma crítica esta experiencia a dos años de su implementación. Material y Método: 774 pacientes solicitando un “chequeo” prostático fueron atendidos bajo esta modalidad en el período comprendido entre septiembre de 2003 y julio de 2005. La evaluación consistió en una encuesta, un tacto rectal y un antígeno prostático específico (APE).Resultados: 67 pacientes (9,1 por ciento) presentaron un APE alterado y/o un tacto rectal sospechoso. De éstos, 34 pacientes fueron sometidos a biopsia. No se registraron tactos alterados en presencia de APE dentro de rangos normales. El estudio histopatológico demostró cáncer en 14 de las 34 biopsias (41,2 por ciento), lo que se traduce en una tasa de detección global de 1,89 por ciento. Al comparar los tumores con aquellos detectados durante el mismo período en pacientes de la consulta urológica habitual (n=111) no se establecieron diferencias significativas con respecto a las características clínicas ni histopatológicas. La tasa de adherencia al control anual durante el segundo año fue del 5,7 por ciento. Conclusión: El programa continuo de detección precoz responde adecuadamente a la creciente demanda por parte de la población a pesar de la baja adherencia. Sin embargo, la justificación del screening es aún discutible, a pesar del aparente beneficio individual.

Introduction: The increasing concerns about periodic controls by the population led to the creation of a specialized screening program in our institution. The aim of the study was to evaluate this experience two years after its implementation. Matherial and Methods: 774 patients asking for “prostate screening” were evaluated under this modality between September 2003 and July 2005. The evaluation included a brief questionnary, a digital rectal examination (DRE) and a prostate specific antigen (PSA). Results: 67 patients (9.1 percent) had an elevated PSA level and/or a suspicious DRE. There were no suspicious DRE’s in presence of a normal PSA level. A transrectal ultrasound guided biopsy was performed in 34 patients; cancer was found in 14 (41.2 percent). The global detection rate was 1.89 percent. The comparison of screen detected and those tumors diagnosed in normal urological practice did not reveal any significant differences in terms of clinical or histhopathological features. The annual control adherence rate during the second year was 5.7 percent. Conclusion: The early detection program responds adequately to the increasing demand for preventive prostatic control by the population despite of the low adherence observed. However, screening for prostate cancer remains a controversial issue.

Evaluation of practice efficiency with a novel sheathed flexible cystoscope: a randomized controlled trial.

OBJECTIVES: The processing of standard flexible cystoscopes is time-consuming and potentially hazardous to healthcare staff. We evaluated a novel flexible cystoscope system containing a disposable sheath, which obviates the need for chemical processing. METHODS: A total of 100 patients undergoing office cystoscopy were randomized into a "sheath" or a control group (n = 50 for each group). Disposable Slide-On sheaths and the CST-2000 Flexible Cystoscope System were used in the former group. A standard 16F flexible cystoscope, manually cleaned and disinfected with Cidex OPA or Rapicide, was used in the control group and the preparation times were recorded. Questionnaires to assess cystoscope setup, handling, optical quality, and patient comfort were completed by the physician, nursing staff, and patients. RESULTS: Data were available for 97 patients. The mean total time required for preparation of the cystoscopes was 10.7, 14.7, and 42.2 minutes for the sheath (n = 49), Rapicide (n = 21), and Cidex OPA (n = 27), respectively (P <0.01 for all comparisons). The control group scored better than the sheath group with regard to ease of cystoscope insertion (9.1 versus 7.7), cystoscope handling (8.8 versus 8.1), and irrigation setup (8.8 versus 8.2; all P < or = 0.01). No statistically significant difference was found between groups for procedure time, optical quality, or patient comfort, either during or after the procedure. CONCLUSIONS: The EndoSheath System can save 4 to 31 minutes of processing time while avoiding exposure to irritants found in conventional soaking methods. Although maneuvering of the sheathed cystoscope was slightly more difficult, the optical quality and patient comfort were similar to those of standard flexible cystoscopy.

In-vivo evaluation of flow characteristics of novel metal ureteral stent.

PURPOSE: To characterize the flow of a novel ureteral stent composed of a nickel-cobalt-chromium-molybde-num alloy and compare it with flow in a standard ureteral stent. MATERIALS AND METHODS: Six 6F Resonance stents and six 6F standard Black Beauty ureteral stents were placed in six Yucatan minipigs, with each pig serving as its own control. Flow assessment was performed on all stents via a nephrostomy tube delivering a standard rate of 0.9% saline at 35 cm H(2)O. Flow studies on the standard stents encompassed extraluminal (i.e., lumen of stent occluded with a guidewire), intraluminal (i.e., ureter secured to stent with a constricting suture), and combined (i.e., open lumen without constricting suture) flow. In the Resonance stent, only combined and intraluminal flow could be addressed, as there is no access to the lumen of this stent. RESULTS: With the Resonance stent, intraluminal flow was much greater than combined flow, with mean values of 5.15 mL/min and 2.50 mL/min, respectively (P = 0.057; SD = 7.73). Intraluminal flow was similar to combined flow in the 6F standard stent, with mean values of 7.34 mL/min and 7.30 mL/min, respectively (P = 0.88; SD = 1.76). The standard stent had significantly greater combined flow than the Resonance stent (P = 0.023) but not intraluminal flow (P = 0.247). Of note, whereas it was possible to occlude the 6F standard stent completely with a ureteral ligature (i.e., no guidewire placed in the lumen), it was not possible to occlude the Resonance stent regardless of how tightly the suture was tied. CONCLUSION: The Resonance metal alloy stent provides less overall flow than a standard stent. However, under circumstances of extrinsic ureteral compression sufficient to occlude a standard stent (e.g., extrinsic compression plus an internal guidewire), the metal stent continues to provide satisfactory drainage.

Pancreatic autotransplantation in chronic pancreatitis.

The apancreatic state secondary to resective surgery for chronic pancreatitis is associated with a high rate of late morbidity and mortality that is due, in part, to endocrine insufficiency. Resective procedures should, therefore, be used very selectively. Over the last 2 decades we have seen a shift from extensive distal resections to limited proximal resections. This is because of the lowering of the operative mortality of pancreatic head resection and its better results in pain relief, while preserving in situ the body and tail of the gland with its metabolic functions. Islet autotransplantation and segmental pancreatic autotransplantation were introduced in 1977 and 1978, respectively. Over 150 and 25 cases of these operations have been reported, respectively. Both techniques are evolving with a goal to improve results. Procedures placing the graft in the iliac fossa and anastomosing the pancreatic duct to the jejunum are now favored over groin placement and duct occlusion. Islet autotransplants achieve a higher yield of islet cells and decrease the exocrine impurity of the preparation. Both methods can prevent or delay the onset of diabetes mellitus, and when diabetes mellitus does occur, it is frequently easier to manage. The long-term function of the grafts appears to be dependent on the beta-cell mass available in the diseased pancreas, the loss of cells related to the transplant procedure, and the characteristics of gradual loss of function from the type of transplant used. Although extensive pancreatic resections are occasionally required, the possibility of autotransplantation should be considered in those patients.

Thalidomid in der Dermatologie / Thalidomide in dermatology

Based on present publications we review indications of the therapy of dermatoses with thalidomide as well as possible mechanisms of action and side effects of this drug. In reactional states of leprosy the use of thalidomide is established. Further indications are chronic cutaneous lupus erythematosus, prurigo nodularis, and eventually recurrent aphthosis and certain photodermatoses not responding to usual treatment. Therapeutical trials of thalidomide in diseases in which such a treatment is only occasionally or not at all mentioned in the literature will be reported. Concerning the mechanisms of action emphasis is put on a possible immunosuppression by thalidomide. Among the side effects the thalidomide neuropathy is stressed.