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International Journal of Surgery... Jul 2024
Comparing the oncologic outcomes of local tumor destruction vs. local tumor excision vs. partial nephrectomy in T1a solid renal masses: a population-based cohort study from the SEER database- correspondence.
PubMed: 38954667
DOI: 10.1097/JS9.0000000000001894 -
Journal of Robotic Surgery Jul 2024To assess the robotic-assisted partial nephrectomy (RAPN) trifecta rate within a fellowship program. Patients undergoing RAPN 01/01/2010-01/07/2023 were enrolled from a...
To assess the robotic-assisted partial nephrectomy (RAPN) trifecta rate within a fellowship program. Patients undergoing RAPN 01/01/2010-01/07/2023 were enrolled from a prospectively maintained database. All cases were performed jointly with surgical fellows, except when privately insured. Patients were excluded if they were converted to open or radical nephrectomy. The primary outcome was achieving the 'trifecta' of negative surgical margins, no complications < 30 days post-operatively and warm ischaemia time (WIT) < 25 min. The secondary outcomes were factors associated with trifecta success. Ethics approval was obtained. In the enrolment period, 355 patients underwent intended RAPN, of whom seven were excluded due to conversion to conversion to radical nephrectomy (6 patients) or conversion to open (one). Amongst the 348 eligible patients, median age was 60 years, 115 (33%) were female and 19 were private patients. WIT was < 25 min for 324/337 patients (96%), surgical margins were negative in 325 (93%), 294 (84%) were complication-free at 30 days and 301/320 (94%) had a < 30% decline in estimated glomerular filtration rate at 3-6 months postoperatively. Subsequently, trifecta outcomes were achieved in 253/337 (75%) patients. Comparing with patients without those with trifecta success were similar in all thirteen measured patients and tumour factors. In a teaching hospital, with a fellowship training programme, trifecta outcome is achievable for most RAPN patients, and at a rate comparable to international standards. Fellowship centres should monitor their outcomes to ensure high patient outcomes are maintained alongside training requirements.
Topics: Humans; Nephrectomy; Robotic Surgical Procedures; Female; Middle Aged; Male; Fellowships and Scholarships; Treatment Outcome; Kidney Neoplasms; Aged; Margins of Excision; Warm Ischemia; Postoperative Complications; Adult
PubMed: 38954074
DOI: 10.1007/s11701-024-01941-7 -
Cureus Jun 2024Introduction Laparoscopic nephrectomies are safe, with low complication rates in skilled hands. However, traditional approaches may be unsuitable for conditions such as...
Introduction Laparoscopic nephrectomies are safe, with low complication rates in skilled hands. However, traditional approaches may be unsuitable for conditions such as post-renal abscesses, long-standing urinomas, non-functioning kidneys post-pyeloplasty, pyelolithotomies, post-partial nephrectomy recurrences, tuberculous kidneys, pyelonephritis, and redo-renal surgeries. This study describes a modified retrograde nephrectomy technique and its outcomes in 40 cases. Methods We reviewed 40 cases where the retrograde nephrectomy technique was used. Surgeons opted for this method based on intraoperative findings and initial difficulties in accessing the lower pole area. Results Traditional dissection was challenging due to adhesions in the lower pole. The retrograde technique, starting from the renal hilum, allowed early ligation of renal arteries and veins, reducing bleeding risks and facilitating safer caudal dissection. Conclusions The retrograde nephrectomy technique offers a safer and more efficient alternative for complex nephrectomies. Early vascular control minimizes hemorrhage risk, making it a valuable method in challenging renal surgeries.
PubMed: 38952611
DOI: 10.7759/cureus.61482 -
IScience Jun 2024Aging is closely associated with inflammation, which affects renal function reserve (RFR) in the kidneys. This study aims to investigate the impact of reduced RFR...
Aging is closely associated with inflammation, which affects renal function reserve (RFR) in the kidneys. This study aims to investigate the impact of reduced RFR reduction on kidney aging and the influence of renal inflammation and RFR reduction on this process. Natural aging rats and those subjected to unilateral nephrectomy (UNX), 1/6 nephrectomy (1/6NX), and unilateral ureteral obstruction (UUO) were observed at 6, 12, 18, and 21 months. Our findings suggest that RFR reduction and renal inflammation can accelerate kidney aging, and inflammation contributes more. Metabolomics analysis revealed alterations in amino acid metabolism contribute to RFR decline. Furthermore, experiments confirmed the involvement of pentose phosphate pathway (PPP) in promoting aging though inflammation. Our research provides novel insights into for the mechanism of kidney aging and provides indirect support for clinical treatment decisions, such as addressing kidney inflammation, stones, or tumors that may necessitate partial or complete nephrectomy.
PubMed: 38947529
DOI: 10.1016/j.isci.2024.110045 -
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 -
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 -
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