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Urology Jun 2024To describe the trocar disposition, docking angles, surgical times, functional outcomes and complications experienced during the first 30 surgeries with Hugo™ RAS...
OBJECTIVE
To describe the trocar disposition, docking angles, surgical times, functional outcomes and complications experienced during the first 30 surgeries with Hugo™ RAS platform performed by a high volume Da Vinci Xi®`s surgeon.
METHODS
Retrospective, observational, descriptive study was performed between May-December 2023. Safety and feasibility of the procedures were evaluated considering console and docking time (min), perioperative complications (Clavien-Dindo classification), blood loss (mL), collision of the arms during the procedures (Yes/No). For radical prostatectomies (RARP) the urinary continence and sexual function were also evaluated.
RESULTS
RARP, simple prostatectomies (RASP), partial nephrectomies (RAPN), and cystectomy (RARC) were performed. Trocar placement, docking, and bed assistant ergonomics were important challenges. Patient positioning, trocar placement, and robotic arm positioning had to be adapted. The median console operative time for RARP and RASP was 78 (60-120) minutes and 79 (58-125) minutes, respectively. The median docking time for both RARP and RASP was 10 (5-20) minutes. Of patients undergoing RARP, 94.5% recovered sexual function and no patient used more than one PAD per day after 90 days of the surgery. The median console operative and docking time for RAPN was 82 (80-130) minutes and 12 minutes (7-19) minutes, respectively. Blood loss in all patients was less than 200 mL and all none procedure presented major complications.
CONCLUSION
For a high volume surgeon with motivated and well-trained multidisciplinary team, the implementation of HUGO™ RAS system for urological program is safe and smooth. Adaptations were necessary to achieve equivalent surgical technique and results. Docking position and bed assistant ergonomics are the major challenges.
PubMed: 38945486
DOI: 10.1016/j.urology.2024.06.052 -
Urologic Oncology Jun 2024Ipsilateral local recurrence (LR) after partial nephrectomy (PN) for renal cell carcinoma (RCC) may result from a metachronous tumor or PN bed recurrence. To date,...
PURPOSE
Ipsilateral local recurrence (LR) after partial nephrectomy (PN) for renal cell carcinoma (RCC) may result from a metachronous tumor or PN bed recurrence. To date, literature has predominantly reported ipsilateral LRs collectively, although the pathophysiology and prognostic implications of these event may be distinct. We sought to assess variables associated with LR and evaluated associations of LR with metastasis and death from RCC.
MATERIALS AND METHODS
We identified adults undergoing PN for unilateral, sporadic, localized RCC from 2000 to 2019 using a prospectively maintained, single institution registry. LR was defined as new, enhancing tumor within/near the PN bed on MRI/CT. Cox proportional hazards models were used to create a preoperative risk score for LR and to examine the association of LR with metastasis and CSS following PN among patients with clear cell RCC.
RESULTS
In a cohort of 2,164 PNs, 106 true LRs were identified, for a 10-year incidence of 6.2%. A preoperative risk score for LR based on age, symptoms, solitary kidney, complex tumor necessitating open partial nephrectomy, and cT stage was created (c-index = 0.73). Postoperatively, positive margins, pT stage, and clear cell subtype were associated with LR. Notably, 21% (23/106) of patients with LR presented with synchronous metastases. Following LR, 5-year metastasis-free and cancer-specific survival were 64% and 71%, respectively. LR remained associated with metastasis (HR 6.25; P < 0.001) and death from RCC (HR 1.93; P = 0.03) on multivariable analysis.
CONCLUSIONS
We developed a preoperative risk score to identify patients at risk for LR following PN. LR was an independent risk factor for metastasis and death from RCC. Further study is warranted to determine whether treatment of LR improves oncologic outcomes.
PubMed: 38945735
DOI: 10.1016/j.urolonc.2024.05.004 -
Orvosi Hetilap Jun 2024
Topics: Humans; Nephrectomy; Robotic Surgical Procedures; Kidney Neoplasms; Female; Male; Retrospective Studies; Hungary; Middle Aged; Treatment Outcome; Operative Time; Laparoscopy; Aged; Adult
PubMed: 38944819
DOI: 10.1556/650.2024.33067 -
The French Journal of Urology Jun 2024Enhanced recovery after surgery (ERAS) is a combination of multimodal pathways to improve surgical outcomes. Recommendations for radical cystectomy have been published...
BACKGROUND
Enhanced recovery after surgery (ERAS) is a combination of multimodal pathways to improve surgical outcomes. Recommendations for radical cystectomy have been published by the ERAS society for the cystectomy but a lack of evidence is observed for urological procedures such as nephrectomy (Ne) and radical prostatectomy (RP). The aim of our study was to evaluate the impact of enhanced recovery protocol implementation for Ne ad RP at our academic institution.
METHODS
We performed a retrospective, monocentric, comparative analysis, pre and post implementation of an enhanced recovery protocol for patients undergoing robotic-assisted radical prostatectomy or nephrectomy (partial or total) for cancer. The primary endpoint was the mean length of stay (LOS). Secondary endpoints included 30-days readmission, postoperative complications, 90 days survival, and oncologic outcome at 6 months.
RESULTS
We included 264 patients between January, 2019, and December, 2020. Statistical analysis was performed separately by type of surgery. The LOS of patients included in the ERP protocol was decreased on average by 1,3 days IC95% [ -2.50; -0.08], p<0.001 for nephrectomies and by 2.2 days IC95% [-3.72; -0.62] p<0.001 for prostatectomies, compared to non-ERP patients. There were no more re-admisson, death or oncologic recurrence.
CONCLUSION
In our experience, ERP for oncological nephrectomy and prostatectomy reduced the length of stay, without increasing postoperative complications and readmission.
PubMed: 38944244
DOI: 10.1016/j.fjurol.2024.102674 -
BMC Urology Jun 2024To evaluate the predictive value of individual components of the R.E.N.A.L scoring system for Laparoscopic (LPN) and Robotic Partial Nephrectomy (RPN).
BACKGROUND
To evaluate the predictive value of individual components of the R.E.N.A.L scoring system for Laparoscopic (LPN) and Robotic Partial Nephrectomy (RPN).
METHODS
Patients that had undergone a Laparoscopic (LPN) or Robotic Partial Nephrectomy (RPN) between 2018 and 2023 were reviewed. Our data collection included Race, Ethnicity, Age, BMI, R.E.N.A.L nephrometry score, and complications. Cases that achieved trifecta outcomes were designated as "Group A" and cases that did not achieve trifecta were "Group B". All the data were collected using REDCap database.
RESULTS
A total of 111 cases were included, Group A consisted of 82% of all cases, whereas Group B 18%. Radius score demonstrated significant distinction concerning trifecta attainment and was the most predictive component of the 5 scoring metrics of the nephrometry system. In a subgroup analysis, R-score of 3 or a renal mass measuring ≥ 7 cm, was a significant independent negative predictor for trifecta outcomes, as well as tumor size at presentation.
CONCLUSION
Renal nephrometry score is predictive of trifecta outcomes for patients undergoing laparoscopic or robotic partial nephrectomy. Radius of mass was the most effective predictive component of the nephrometry score for trifecta prediction.
Topics: Humans; Robotic Surgical Procedures; Nephrectomy; Laparoscopy; Male; Female; Middle Aged; Kidney Neoplasms; Treatment Outcome; Aged; Retrospective Studies; Predictive Value of Tests
PubMed: 38943111
DOI: 10.1186/s12894-024-01518-4 -
The Lancet. Oncology Jun 2024The standard of care for patients with intermediate-to-high risk renal cell carcinoma is partial or radical nephrectomy followed by surveillance. We aimed to investigate...
Perioperative nivolumab versus observation in patients with renal cell carcinoma undergoing nephrectomy (PROSPER ECOG-ACRIN EA8143): an open-label, randomised, phase 3 study.
BACKGROUND
The standard of care for patients with intermediate-to-high risk renal cell carcinoma is partial or radical nephrectomy followed by surveillance. We aimed to investigate use of nivolumab before nephrectomy followed by adjuvant nivolumab in patients with high-risk renal cell carcinoma to determine recurrence-free survival compared with surgery only.
METHODS
In this open-label, randomised, phase 3 trial (PROSPER EA8143), patients were recruited from 183 community and academic sites across the USA and Canada. Eligible patients were aged 18 years or older with an Eastern Cooperative Oncology Group performance status of 0-1, with previously untreated clinical stage T2 or greater or T N+ renal cell carcinoma of clear cell or non-clear cell histology planned for partial or radical nephrectomy. Selected patients with oligometastatic disease, who were disease free at other disease sites within 12 weeks of surgery, were eligible for inclusion. We randomly assigned (1:1) patients using permuted blocks (block size of 4) within stratum (clinical TNM stage) to either nivolumab plus surgery, or surgery only followed by surveillance. In the nivolumab group, nivolumab 480 mg was administered before surgery, followed by nine adjuvant doses. The primary endpoint was investigator-reviewed recurrence-free survival in patients with renal cell carcinoma assessed in all randomly assigned patients regardless of histology. Safety was assessed in all randomly assigned patients who started the assigned protocol treatment. This trial is registered with ClinicalTrials.gov, NCT03055013, and is closed to accrual.
FINDINGS
Between Feb 2, 2017, and June 2, 2021, 819 patients were randomly assigned to nivolumab plus surgery (404 [49%]) or surgery only (415 [51%]). 366 (91%) of 404 patients assigned to nivolumab plus surgery and 387 (93%) of 415 patients assigned to surgery only group started treatment. Median age was 61 years (IQR 53-69), 248 (30%) of 819 patients were female, 571 (70%) were male, 672 (88%) were White, and 77 (10%) were Hispanic or Latino. The Data and Safety Monitoring Committee stopped the trial at a planned interim analysis (March 25, 2022) because of futility. Median follow-up was 30·4 months (IQR 21·5-42·4) in the nivolumab group and 30·1 months (21·9-41·8) in the surgery only group. 381 (94%) of 404 patients in the nivolumab plus surgery group and 399 (96%) of 415 in the surgery only group had renal cell carcinoma and were included in the recurrence-free survival analysis. As of data cutoff (May 24, 2023), recurrence-free survival was not significantly different between nivolumab (125 [33%] of 381 had recurrence-free survival events) versus surgery only (133 [33%] of 399; hazard ratio 0·94 [95% CI 0·74-1·21]; one-sided p=0·32). The most common treatment-related grade 3-4 adverse events were elevated lipase (17 [5%] of 366 patients in the nivolumab plus surgery group vs none in the surgery only group), anaemia (seven [2%] vs nine [2%]), increased alanine aminotransferase (ten [3%] vs one [<1%]), abdominal pain (four [1%] vs six [2%]), and increased serum amylase (nine [2%] vs none). 177 (48%) patients in the nivolumab plus surgery group and 93 (24%) in the surgery only group had grade 3-5 adverse events due to any cause, the most common of which were anaemia (23 [6%] vs 19 [5%]), hypertension (27 [7%] vs nine [2%]), and elevated lipase (18 [5%] vs six [2%]). 48 (12%) of 404 patients in the nivolumab group and 40 (10%) of 415 in the surgery only group died, of which eight (2%) and three (1%), respectively, were determined to be treatment-related.
INTERPRETATION
Perioperative nivolumab before nephrectomy followed by adjuvant nivolumab did not improve recurrence-free survival versus surgery only followed by surveillance in patients with high-risk renal cell carcinoma.
FUNDING
US National Institutes of Health National Cancer Institute and Bristol Myers Squibb.
PubMed: 38942046
DOI: 10.1016/S1470-2045(24)00211-0 -
Journal of Imaging Informatics in... Jun 2024To assess the effectiveness of the vViT model for predicting postoperative renal function decline by leveraging clinical data, medical images, and image-derived...
Predicting EGFR Status After Radical Nephrectomy or Partial Nephrectomy for Renal Cell Carcinoma on CT Using a Self-attention-based Model: Variable Vision Transformer (vViT).
OBJECTIVE
To assess the effectiveness of the vViT model for predicting postoperative renal function decline by leveraging clinical data, medical images, and image-derived features; and to identify the most dominant factor influencing this prediction.
MATERIALS AND METHODS
We developed two models, eGFR10 and eGFR20, to identify patients with a postoperative reduction in eGFR of more than 10 and more than 20, respectively, among renal cell carcinoma patients. The eGFR10 model was trained on 75 patients and tested on 27, while the eGFR20 model was trained on 77 patients and tested on 24. The vViT model inputs included class token, patient characteristics (age, sex, BMI), comorbidities (peripheral vascular disease, diabetes, liver disease), habits (smoking, alcohol), surgical details (ischemia time, blood loss, type and procedure of surgery, approach, operative time), radiomics, and tumor and kidney imaging. We used permutation feature importance to evaluate each sector's contribution. The performance of vViT was compared with CNN models, including VGG16, ResNet50, and DenseNet121, using McNemar and DeLong tests.
RESULTS
The eGFR10 model achieved an accuracy of 0.741 and an AUC-ROC of 0.692, while the eGFR20 model attained an accuracy of 0.792 and an AUC-ROC of 0.812. The surgical and radiomics sectors were the most influential in both models. The vViT had higher accuracy and AUC-ROC than VGG16 and ResNet50, and higher AUC-ROC than DenseNet121 (p < 0.05). Specifically, the vViT did not have a statistically different AUC-ROC compared to VGG16 (p = 1.0) and ResNet50 (p = 0.7) but had a statistically different AUC-ROC compared to DenseNet121 (p = 0.87) for the eGFR10 model. For the eGFR20 model, the vViT did not have a statistically different AUC-ROC compared to VGG16 (p = 0.72), ResNet50 (p = 0.88), and DenseNet121 (p = 0.64).
CONCLUSION
The vViT model, a transformer-based approach for multimodal data, shows promise for preoperative CT-based prediction of eGFR status in patients with renal cell carcinoma.
PubMed: 38940889
DOI: 10.1007/s10278-024-01180-0 -
Experimental and Therapeutic Medicine Aug 2024Mixed epithelial and stromal tumors (MESTs) of the kidney are rare renal neoplasms, primarily affecting middle-aged women. These tumors are characterized by a mix of...
Mixed epithelial and stromal tumors (MESTs) of the kidney are rare renal neoplasms, primarily affecting middle-aged women. These tumors are characterized by a mix of epithelial and stromal components. While generally benign, MESTs require accurate diagnosis and appropriate management due to the potential for malignant transformation. The present study reports the case of a 75-year-old male patient who underwent a partial nephrectomy following the incidental discovery of a kidney tumor. Histopathological examination revealed a partially cystic tumor with solid areas, measuring 26 mm in diameter. The tumor had cysts lined with cuboidal cells and an ovarian-like stroma. The solid component consisted of elongated cells with eosinophilic cytoplasm and oval nuclei, showing angiocentric growth around small blood vessels without nuclear atypia or mitoses. Since the morphology of the solid component could not reveal the differentiation of those cells, immunohistochemical staining was performed and a myopericytoma/myofibroma component was established, mostly based on the positivity of smooth muscle actin, muscle-specific actin, h-caldesmon, estrogen receptor, progesterone receptor, solute carrier family 2 facilitated glucose transporter member 1 and collagen IV, along with a lack of staining for desmin, CD34, CD31 and CD99. Thus, to the best of our knowledge, for the first time in the literature, MEST with myopericytoma/myofibroma stromal component in a male patient was reported.
PubMed: 38939172
DOI: 10.3892/etm.2024.12610 -
Surgical Endoscopy Jun 2024Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to...
BACKGROUND
Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology.
STUDY DESIGN
Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital.
RESULTS
A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] - 23 to - 10), 8-min decrease for RAPN (95% CI - 14 to - 2), 24-min decrease for RPL-4 (95% CI - 29 to - 19), and no significant change for TRH (- 7 min; 95% CI - 17 to 3).
CONCLUSION
The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications.
PubMed: 38937312
DOI: 10.1007/s00464-024-10998-2 -
European Urology Oncology Jun 2024A hilar location for a renal tumour is sometimes viewed as a limiting factor for safe partial nephrectomy. Our aim was to evaluate perioperative, oncological, and...
Robot-assisted Partial Nephrectomy for Hilar and Nonhilar Renal Masses: Comparison of Perioperative, Oncological, and Functional Results in a Multicentre Prospective Cohort (NEPRAH Study, UroCCR 175).
BACKGROUND AND OBJECTIVE
A hilar location for a renal tumour is sometimes viewed as a limiting factor for safe partial nephrectomy. Our aim was to evaluate perioperative, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) for hilar tumours (RAPN-H) in comparison to RAPN for nonhilar tumours (RAPN-NH).
METHODS
We conducted an observational, multicentre cohort study using prospectively collected data from the French Research Network on Kidney Cancer (UroCCR). The registry includes data for 3551 patients who underwent RAPN for localised or locally advanced renal masses between 2010 and 2023 in 29 hospitals in France. We studied the impact of a hilar location on surgery, postoperative renal function, tumour characteristics, and survival. We also compared rates of trifecta achievement (warm ischaemia time [WIT] <25 min, negative surgical margins, and no perioperative complications) between the groups. Finally, we performed a subgroup analysis of RAPN without vascular clamping. Variables were compared in univariable analysis and using multivariable linear, logistic, and Cox proportional-hazards models adjusted for relevant patient and tumour covariates.
KEY FINDINGS AND LIMITATIONS
The analytical population included 3451 patients, of whom 2773 underwent RAPN-NH and 678 underwent RAPN-H. Longer WIT (β = 2.4 min; p < 0.01), longer operative time (β = 11.4 min; p < 0.01) and a higher risk of postoperative complications (odds ratio 1.33; p = 0.05) were observed in the hilar group. Blood loss, the perioperative transfusion rate, postoperative changes in the estimated glomerular filtration rate, and trifecta achievement rates were comparable between the groups (p > 0.05). At mean follow-up of 31.9 mo, there was no significant difference in recurrence-free survival (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.58-1.2; p = 0.3), cancer-specific survival (HR 1.1, 95% CI 0.48-2.6; p = 0.79), or overall survival (HR 0.89, 95% CI 0.52-1.53; p = 0.69).
CONCLUSIONS AND CLINICAL IMPLICATIONS
Patient and tumour characteristics rather than just hilar location should be the main determinants of the optimal surgical strategy for hilar tumours.
PATIENT SUMMARY
We found that kidney tumours located close to major kidney blood vessels led to a longer operation and a higher risk of complications during robot-assisted surgery to remove the tumour. However, tumours in these locations were not related to a higher risk of kidney function loss, cancer recurrence, or death.
PubMed: 38937207
DOI: 10.1016/j.euo.2024.06.003