Hiury Andrade

Robotic Partial Nephrectomy in the Treatment of Renal Angiomyolipoma

PURPOSE To present the experience and efficacy of Robotic Partial Nephrectomy (RPN) for the management of renal angiomyolipomas (AMLs) with regard to renal function preservation and perioperative outcomes. PATIENTS AND METHODS We retrospectively searched our RPN database for pathologically confirmed renal AML patients between 2006 and 2014. Clinical presentation, perioperative complications, and postoperative outcomes of the patients were analyzed. Preoperative imaging findings were reviewed to examine their ability to predict pathology of AML. RESULTS From 1005 RPN performed in our center during the study period, 53 patients met our inclusion criteria. The mean age at presentation was 54.1 (± 13) years, and 42 (79.2%) patients were female. Median tumor size was 2.8 (interquartile range [IQR], 1.8-4.6) cm. The indication for RPN was suspicious radiologic features for malignancy in 42 (79.2%) patients and acute retroperitoneal hemorrhage risk and pain in 11 (20.8%) patients who were found to have AML according to preoperative imaging. Mean estimated blood loss was 198 (± 194) mL, and 5 (9.4%) patients required blood transfusion. Postoperative complications occurred in 8 (15%) patients. Median estimated glomerular filtration rate within the latest follow-up was 86.9 (IQR, 69.7-100.1) mL/minute/1.73 m(2) with a median of 91% (IQR, 80.4-103) preservation. None of patients developed urinary fistula or pseudoaneurysm requiring second intervention. No local recurrences occurred with a median follow-up of 7 (IQR, 1-17) months. CONCLUSION Given the low complication rate and preservation of renal function after RPN for AML, it can be considered a reliable method for AML treatment. The majority of AMLs were not suspected based on preoperative imaging. Further diagnostic methods are needed to differentiate benign from malignant lesions.

Is Extensive Parenchymal Resection During Robotic Partial Nephrectomy Justified? A Match-Paired Comparison of Two Extirpative Surgical Modalities for Treatment of a Complex Renal Neoplasm

OBJECTIVE To analyze the outcomes of robotic partial nephrectomy (RPN) in patients where nephron-sparing surgery would have mandated a large amount of renal volume resection. METHODS Patients undergoing RPN with extensive volume resection (≥30%), from 2006 to 2014, were identified. Pre- and postoperative CT/MRI-based volumetric assessment of the operated kidney was performed. To address the possible benefits of RPN, we matched this cohort to patients undergoing laparoscopic radical nephrectomy (LRN). The groups were matched for tumor size, R.E.N.A.L. nephrometry score, age-adjusted Charlson comorbidity index (ACCI), and preoperative estimated glomerular filtration rate (eGFR). Demographics, perioperative, functional, and oncologic outcomes were compared between the groups. Multivariable analysis of factors predicting chronic kidney disease (CKD) upstaging (type of surgery, R.E.N.A.L. score, ACCI, and baseline eGFR) was performed. RESULTS In total, 52 patients undergoing RPN were matched to 52 LRN patients. The median R.E.N.A.L. score (interquartile range) was 9 (9-10) for both groups. Demographic variables were comparable between the groups. The median renal volume preservation in the RPN group was 57.0% (47.2-67.2). The rates of overall and major complications were comparable between RPN and LRN. The RPN group had higher overall eGFR preservation (75.8% vs 68.5%; p = 0.01) and a lower rate of CKD upstaging (26.9% vs 50.6%; p = 0.001). On multivariable analysis, LRN and baseline eGFR were significant predictors of CKD upstaging (odds ratio [OR] 4.26; 95% CI [1.80-10.12]; p = 0.001 and OR 0.98; 95% CI [0.96-0.99]; p = 0.03, respectively). During the median follow-up time of 21 (9-36) months, local recurrence, metastasis, and cancer-specific and overall survival were comparable between RPN and LRN. CONCLUSION RPN requiring extensive volume resection provides renal functional preservation without significant increase in surgical complications or compromising short-term oncologic outcomes.

Reoperative Laparoscopic Ureteropelvic Junction Obstruction Repair in Children: Safety and Efficacy of the Technique.

Purpose: Failure after pyeloplasty for ureteropelvic junction obstruction in children may occur in up to 10% of cases. Therapeutic options include Double‐J® stent placement, endoscopic treatment and reoperation. Laparoscopic and robotic reoperative modalities seem safe and efficacious, although pediatric series are limited in the literature. We report the largest known series of reoperative laparoscopic ureteropelvic junction obstruction repair in children and compare this approach to primary laparoscopic pyeloplasty. Materials and Methods: We reviewed all children undergoing laparoscopic pyeloplasty at a single institution from 2004 to 2015. Reoperative laparoscopic ureteropelvic junction obstruction repair was compared to primary pyeloplasty. Groups were analyzed regarding demographics, operative time, complications, length of hospital stay and success, defined by improvement of symptoms, ultrasound and renogram. Results: We identified 11 cases of reoperation (8 redo pyeloplasties and 3 ureterocalycostomies) and 71 primary pyeloplasties. Groups were not different in age, gender or weight. Median followup was 37 months. Median time between primary pyeloplasty and reoperation was 34 months. Median operative time was 205 minutes for the reoperative group and 200 for primary pyeloplasty (p = 0.98). Length of stay was longer in the reoperative group (p = 0.049), although no major complications were recorded in this group. All reoperative cases and 96% of primary pyeloplasty cases remained asymptomatic following surgery (p = 0.99). Postoperative improvement was similar for both groups on ultrasound (90% for reoperation vs 92% for primary pyeloplasty, p = 0.99) and renogram (80% vs 88%, p = 0.6). Conclusions: Laparoscopy seems to be safe and effective for management of failed pyeloplasty in children. Based on our data, reoperation is as safe and effective as primary pyeloplasty.

The role of urinary KIM-1, NGAL, CA19-9 and β2-microglobulin in the assessment of ureteropelvic junction obstruction in adults

Abstract Purpose: The objective of this study is to evaluate the diagnostic properties of urinary biomarkers in adults with ureteropelvic junction obstruction: KIM-1, NGAL, CA19-9, and β2-microglobulin. We also assessed urinary biomarker concentrations following pyeloplasty. Material and methods: We prospectively studied adults from December 2013 to February 2015. We included 47 patients with a mean age of 38.6 ± 12.7 years. Each patient provided four samples of voided urine for biomarker measurement, one at pre-operative consultation and the others at 1, 3, and 6 months of post-operative follow-up. The control group consisted of 40 healthy individuals with no hydronephrosis on ultrasound evaluation. Results: KIM-1 had an area under the curve of 0.79 (95% CI 0.70–0.89), NGAL 0.71 (95% CI 0.61–0.83), CA19-9 0.70 (95% CI 0.60–0.81), and β2-microgloblin 0.61 (95% CI 0.50–0.73). KIM-1 was the most sensitive marker with a cut-off of 170.4 pg/mg creatinine (sensitivity 91.4%, specificity 59.1%), whereas CA19-9 was the most specific with a cut-off of 51.3 U/mg creatinine (sensitivity 48.9%, specificity 88.0%). Urinary concentrations of biomarkers decreased after pyeloplasty. Conclusions: The evaluation of urinary biomarkers is useful in adults undergoing pyeloplasty. KIM-1, NGAL, and CA19-9 were elevated and significantly decreased after surgery.

PD40-05 EVALUATION OF LAPAROSCOPIC PYELOPLASTY AS AN ALTERNATIVE TO NEPHRECTOMY IN ADULTS WITH POORLY FUNCTIONING KIDNEYS DUE TO URETEROPELVIC OBSTRUCTION

INTRODUCTION AND OBJECTIVES: Laparoscopic pyeloplasty has been considered the gold-standard treatment for adults with ureteropelvic junction obstruction (UPJO). Likewise, it is well established in adults that a symptomatic non-functioning renal unit should be removed. This study aimed to evaluate safety, kidney function recovery and symptoms improvement after laparoscopic pyeloplasty in adults with poorly functioning kidneys due to UPJO. METHODS: Retrospective data analysis from August 2008 to November 2015, from a prospectively maintained database, was performed. Patients with poorly functioning kidney who underwent Anderson-Hynes dismembered laparoscopic pyeloplasty were included. In one patient, the retroperitoneal approach was preferred due to multiple previous abdominal surgeries. Poor function was defined as a split renal function of 15% in renal scintigraphy with Tc-99m DMSA. Pre and postoperative data were compared regarding differential renal function (DRF) and symptoms. Success was defined as split renal function stabilization (absolute variation of less than 5% in renal scintigraphy) and symptoms improvement. Outcome (renal function stabilization, intra and pos-op complications and symptoms) was further compared to a similar group of patients who underwent Anderson-Hynes dismembered laparoscopic pyeloplasty in normal functioning renal units. RESULTS: We identified 167 patients who underwent laparoscopic pyeloplasty in our service. From those, 14 patients had poor renal function, with a mean age of 37 years (23 60 years). No major intra or post-operative complications were seen. At a mean follow up of 21.2 months (4-53 m) all patients reported symptoms improvement, no cases of recurrent pyelonephritis or stone formation was seen. Until this date, no patient needed further surgical treatment as re-pyeloplasty, endoscopic treatment or nephrectomy. Complete symptom resolution was seen in 10 patients (71%). One patient, despite showing complete symptom resolution, had decreased postoperative DRF in renal scintigraphy. Overall success rate was 92.8% (13/14). Split renal function remained stable in 11 patients (78,6%), considerably decreased in 1 (7.1%) and considerably increased in 2 (14.3%) patients. Renal function stabilization, intra and post-operative complications were statically similar (p>0.05) when compared to patients with normal functioning renal units who underwent the same procedure. No patient with normal functions renal units showed improvement in DRF measured with Tc99m DMSA. CONCLUSIONS: Laparoscopic pyeloplasty is an alternative to nephrectomy in adults with poorly functioning kidneys due to UPJO, enabling good symptom control with possible considerable improvement in renal function. In this study, laparoscopic pyeloplasty in this of patients showed similar outcomes and success rates to those presented by patients with normal functioning renal units.

V4-01 PERINEAL ROBOT ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (P-RALP)

Fig. 2. Comparison of microvascular remodeling in the urinary bladder of control, interstitial cystitis/painful bladder syndrome (IC/PBS) and Ketamine-induced cystitis (KC) patients under electron microscopy. (A) Controls, basement membrane (arrowheads), (i) Small vessel, and (ii) Greater vessel. (B) IC/PBS, basement membrane (arrowheads) and mast cells (long arrow), (i) Small vessel, and (ii) Greater vessel