Minerva Urology and Nephrology最新文献

Background: Bilateral synchronous renal masses (BSRMs) are a rare finding, and the optimal treatment strategy remains undetermined. This study depicts the management of BSRM at eight European high-volume centers.

Methods: This is a retrospective analysis of prospective institutional databases collecting all patients presenting with clinical T1-2 N0 M0 BSRMs between 1993 and 2020 at 8 tertiary referral high-volume centers for renal cancer treatment in Europe. The treatment options included active surveillance (AS), tumor ablation (TA) and surgery (partial and radical nephrectomy).

Results: Overall, 134 patients were analyzed. Renal mass biopsy prior treatment was performed in 8% of cases. 15%, 4%, and 81% of patients underwent AS, a combination of surgery and TA, and bilateral (one-stage or two-stage) surgery. Among patients undergoing bilateral surgery (N.=109), a staged approach was chosen in 78% (N.=85) of cases treating the lower complexity tumor first in 51/85 (60%) cases and in 34/85 (40%) treating the higher complexity tumor first. Concordance of the histological analysis was found in 77% of patients with 10% of bilateral benign masses.

Conclusions: Even if considering only referral centers, a high heterogeneity for decision-making in the treatment of BSRM should be expected. Advances in genetic diagnosis, the implementation of novel imaging technologies, and the strengthening role of alternative treatment, may lead to a standardized decision-making process in the setting of BSRMs.

Background: The American Urologic Association (AUA) and the European Association of Urology (EAU) guidelines endorse percutaneous nephrolithotomy (PCNL) for symptomatic stones larger than 20 mm despite significant risks such as bleeding and urosepsis. Robotic pyelolithotomy (RPL) is emerging as an appealing alternative to PCNL, particularly for patients with anatomical variations like pelvic or horseshoe kidneys, malrotation, previous unsuccessful PCNL, and congenital renal anomalies such as ureteropelvic junction obstruction (UPJO).

Methods: A retrospective observational study was conducted involving patients from Miulli Hospital and A. Gemelli University Hospital between February 2016 and December 2023. Adults with large renal stones, including both pelvic and caliceal stones, who underwent either RPL or PCNL were included. The primary outcome was the Stone-Free Rate (SFR) at 12 months. Secondary outcomes included operative time, estimated blood loss, delta hemoglobin, delta creatinine, hospital stay length, and complications. This study compares the effectiveness and outcomes of PCNL and RPL using Propensity Score-Inverse Probability Treatment Weighting (PS-IPTW) analysis.

Results: No statistically significant differences were found in the 12-month SFR between RPL and PCNL, both in the calyceal-pelvic (73.6% vs. 70.6%; P=0.722) and pelvic groups (91% vs. 91.7%; P=1). Complication rates were also similar between RPL and PCNL in both the calyceal-pelvic (15.4% vs. 14.3%; P=0.856) and renal pelvic groups (27.3% vs. 10.8%; P=0.225, with Clavien-Dindo Grade ≥3 complications in 9% vs. 8.9% and 4.4% vs. 0%, respectively. RPL showed significant advantages in operation time in the pyelocaliceal (P<0.001) and pelvic groups (P=0.006), delta creatinine (P=0.018) in the pyelocaliceal group, and hospital stay length in the pelvic group (P=0.011).

Conclusions: RPL demonstrated similar success and complication rates compared to PCNL, with significantly lower intraoperative time, delta creatinine rate, and hospital stay length. RPL is a safe, effective, and minimally invasive treatment option, particularly valuable for large renal stones in patients with complex anatomy and those requiring concomitant renal reconstructive procedures.

Background: Transperitoneal approach to robot-assisted pyeloplasty (RAP) have been preferred in the last decades because of the use of multi-port robotic platforms. However, this approach is linked to notable issues, such as pneumoperitoneum and lateral decubitus position, which is associated with potential soft tissues injuries, and it is a time-consuming procedure. Single-port (SP) platform was introduced to potentially address these issues. Our aim was to describe perioperative surgical and functional outcomes of SP-RAP, including our preliminary results comparing the transperitoneal and LAA approaches.

Methods: Data from a prospectively maintained dataset of all consecutive patients undergoing SP-RAP between 2019 and 2024 were retrospectively reviewed. Early procedures were performed using transperitoneal midline access, while later procedures utilized the low anterior access (LAA) approach. Patients' demographics, perioperative data, and surgical and functional outcomes were collected.

Results: Overall, 34 patients underwent the procedure without intraoperative complications or conversion to an alternative approach. The median age was 46.5 (range: 35-56) years. The transperitoneal approach was used for the first 17 (50%) procedures, while the remaining 17 (50%) underwent LAA SP-RAP. Nonoperative room time, postoperative opioid dose, and length of hospital stay were significantly lower in the LAA group (P<0.001 in all cases), with all patients in the LAA group being discharged on the same day. No differences were observed in operative time or postoperative renal function.

Conclusions: Outcomes for SP pyeloplasties appear promising, and the LAA approach may help optimize operating room time, promote faster patient recovery, and reduce postoperative opioid use.

Introduction: Minimally invasive simple prostatectomy (MISP) and endoscopic enucleation of the prostate (EEP) are appropriate candidates for the large prostate. However, their comparative effectiveness and safety remain unclear. This study aims to conduct a comprehensive analysis comparing the efficacy and safety of MISP and EEP.

Evidence acquisition: We conducted a systematic search of the PubMed, Embase, and Cochrane Library databases to identify eligible studies comparing MISP and EEP. Data analysis was performed using Review Manager 5.3. Risk of bias was assessed with the ROBINS-I and the ROB2.0 assessment tool.

Evidence synthesis: The results of analyzing 13 studies involving 2271 patients showed that EEP had significant lower operative time (MD [CI]: 41.59 [14.62-68.56]), catheterization time (MD [CI]: 4.35 [3.31-5.38]), length of stay (MD [CI]: 2.16 [0.70-3.61]), and Hb decreases (MD [CI]: 0.46 [0.06-0.87]). MISP demonstrated significantly better long-term (MD [CI]: -0.46 [-0.89; -0.03]) and short-term QoL (MD [CI]: -0.38 [-0.66; -0.10]) and short-term Qmax (MD [CI]: 2.04 [0.06-4.03]). Efficacy outcomes were comparable in postoperative IPSS, PVR and PSA between MISP and EEP procedures. No significant differences were observed in resection weight, overall complications, blood transfusions, or urinary incontinence between MISP and EEP.

Conclusions: Overall, EEP and MISP are both effective treatment options for large-volume BPH, providing comparable efficacy outcomes and long-term maintenance. EEP, on the other hand appears to have better perioperative outcomes, but it has a higher rate of short-term postoperative incontinence.

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly performed in challenging tumor constellations like multiple renal masses.

Methods: The objective was to investigate influencing factors on postoperative renal function (PRF) after ipsilateral robot-assisted partial nephrectomy of multiple tumors (iRAPN-MT). In this retrospective multicenter study, perioperative data of 132 trans- or retroperitoneal iRAPN-MT for ≥ two tumors were analyzed focusing on influencing factors on PRF and acute kidney injury including RIFLE and trifecta criteria. The impact of patient-, surgery- and tumor-related factors was investigated via uni- and multivariate regression analyses.

Results: The majority of patients had two renal masses, with three or more lesions in 19%. Median operative time was 175 minutes. Eighty-five percent of the tumors were dissected on-clamp with a median cumulative warm ischemia time (WITsum) of 15 minutes. Trifecta criteria were fulfilled in 57%. In regression analyses, WITsum, BMI and preoperative eGFR had an impact on eGFR loss before discharge (median -11.6 mL/min). BMI and Charlson Comorbidity Index were independent predictors for the lowest RIFLE stage during hospitalization.

Conclusions: iRAPN-MT for multiple ipsilateral renal masses is feasible with good trifecta rates. While mostly unmodifiable patient-associated parameters were independent predictors on PRF impairment, WITsum was identified as a surgery-related independent parameter.

Background: To report the first case series of RARC using a simplified technique for intracorporeal stentless neobladder formation.

Methods: From October 2022 to February 2023, 10 patients with high-risk bladder cancer underwent RARC at our Institution. RARC with extended pelvic lymph node dissection and totally intracorporeal neobladder using Hugo RAS system. Surgical steps of this novel reservoir are shown in the complementary video. Continuous data were presented as median and interquartile ranges (IQR) while frequencies and proportions were used to report categorical variables and compared by means of Mann-Whitney U test and Chi-square test, respectively. One-year outcomes were recorded.

Results: All procedures were successfully performed. Median console time for neobladder configuration was 192 min (IQR, 170-219). A decrease in median operative time was observed in the second half of the series (305 vs. 322 minutes; P=0.12). Two patients (20%) experienced a minor complication (ileus and UTI, Clavien-Dindo II). At 12-months follow-up, renal function was preserved in all patients. Overall, 12-months daytime and night-time continence rates were 80% and 60%, respectively. The limited number of cases represents the main limitation of the current study.

Conclusions: This simplified robotic assisted intracorporeal neobladder technique demonstrates a good safety profile in this series of patients. Simplifying robotic intracorporeal surgical techniques could potentially contribute to its reproducibility and popularization in the urologic community.