Mariaconsiglia Ferriero

Laparoscopic versus Open Nephroureterectomy: Perioperative and Oncologic Outcomes from a Randomised Prospective Study

BACKGROUND Laparoscopic nephroureterectomy (LNU) is increasingly being used instead of open nephroureterectomy (ONU) for the treatment of urothelial carcinoma (UC) of the upper urinary tract (UUT), but the evidence of equal oncologic effectiveness is still lacking. OBJECTIVE To present perioperative and oncologic results from a prospective randomised study comparing ONU and LNU. DESIGN, SETTING, AND PARTICIPANTS Eighty patients with nonmetastatic UUT UC and without previous history of UC were enrolled. Of those, 40 patients (group A) randomly received ONU and 40 patients (group B) randomly received LNU. INTERVENTIONS ONU was performed through a flank incision with a lower quadrant incision to allow excision of a bladder cuff. Transperitoneal LNU was performed with a four-trocar technique, and bladder cuff was detached with a 10-mm LigaSure device. MEASUREMENTS Perioperative data were compared with the student t test. Bladder tumour-free survival (BTFS), metastasis-free survival (MFS), and cancer-specific survival (CSS) curves for both groups were compared with the log-rank test before and after stratifying patients for pT category and tumour grade. RESULTS AND LIMITATIONS Operative times were comparable, while mean blood loss and mean time to discharge were significantly lower in group B (both p values <0.001). At a median follow-up of 44 mo, BTFS, CSS, and MFS were not significantly different between the two groups (log rank test; BTFS: p=0.86; CSS: p=0.2; MFS: p=0.124). When matched for pT3 and high-grade tumours, CSS and MFS were significantly different between the two groups in favour of ONU (p=0.039 and p=0.004, respectively, for pT3 tumours; p=0.078 and p=0.014, respectively, for high-grade tumours). The limitations of our study include the small sample size, the single-centre experience, the personal choice of laparoscopic technique, and not performing lymphadenectomies. Perioperative data and preliminary oncologic results were presented at 22nd Congress of the European Association of Urology, Berlin, Germany. CONCLUSIONS In patients with organ-confined UUT UCs, LNU has the advantages of minimal invasiveness and oncologic outcomes comparable to those of ONU, while its effectiveness in patients with advanced stage diseases remains to be proven.

Stage-specific impact of extended versus standard pelvic lymph node dissection in radical cystectomy

To evaluate the impact of an extended versus a standard pelvic lymph node dissection on disease‐free survival and cancer‐specific survival of patients with non‐metastatic muscle‐invasive urothelial carcinoma of the bladder treated with radical cystectomy.

Diffusion-weighted magnetic resonance imaging in patients selected for radical cystectomy: detection rate of pelvic lymph node metastases.

Study Type – Diagnostic (exploratory cohort)

Laparoscopic and Robotic Partial Nephrectomy With Controlled Hypotensive Anesthesia to Avoid Hilar Clamping: Feasibility, Safety and Perioperative Functional Outcomes

PURPOSE We evaluated the feasibility and safety of laparoscopic and robotic assisted partial nephrectomy with controlled hypotensive anesthesia to avoid hilar clamping and eliminate renal ischemia. MATERIALS AND METHODS A total of 60 patients with renal tumors who were candidates for nephron sparing surgery and had no contraindication to hypotensive anesthesia underwent partial nephrectomy without hilar clamping and with controlled hypotension during tumor excision. A total of 40 laparoscopic partial nephrectomies and 20 robotic assisted partial nephrectomies were done. All patients who were candidates for laparoscopic or robotic assisted partial nephrectomy regardless of tumor site, size or growth pattern were included in study. The surgical field was assessed for bleeding and visibility using a numerical rating scale. RESULTS Median tumor size was 3.6 cm (range 1.8 to 10), median operative time was 2 hours (range 1 to 3.5), median blood loss was 200 ml (range 30 to 700 ml) and median hospital stay was 3 days (range 3 to 8). All margins were negative. The median duration of controlled hypotension with a median mean arterial pressure of 65 mm Hg (range 55 to 70) was 14 minutes (range 7 to 16). No patient required intraoperative transfusion but 4 (6.6%) required transfusion postoperatively. Complications developed postoperatively in 3 patients, ie port site bleeding, hemorrhage and hematoma, respectively. Median preoperative and postoperative serum creatinine was 0.9 and 1.10 mg/dl, respectively. The median preoperative and postoperative estimated glomerular filtration rate was 87.20 and 75.60 ml/minute/1.73 m2, respectively. CONCLUSIONS Controlled hypotension allowed laparoscopic and robotic assisted partial nephrectomy to be done without renal hilar clamping. All procedures were completed safely and perioperative outcomes are encouraging.

Risk assessment of stone formation in stapled orthotopic ileal neobladder.

PURPOSE The increasing trend of performing radical cystectomy with a minimally invasive approach has made stapled neobladders an attractive alternative to hand-sewn pouches. To date, data on the incidence and clinical impact of stone formation in long surviving neobladder cases are scarce. We report a long-term, single-center experience of stapled orthotopic ileal neobladder and identify predictors of stone formation. MATERIALS AND METHODS From May 2001 to October 2012, 445 consecutive patients (388 male, 57 female) underwent radical cystectomy and stapled orthotopic ileal neobladder. Univariable and multivariable analyses were performed to identify independent predictors of an increased risk of stone formation. RESULTS At a median followup of 41 months (IQR 16-58) neobladder stone formation occurred in 41 patients (9.2%). All of these patients successfully underwent endoscopic stone lithotripsy with 34 as outpatient procedures. On univariable Cox analysis only female gender (p = 0.001, HR 3.29, 95% CI 1.59-6.83) and intermittent self-catheterization (p <0.001, HR 15.2, 95% CI 5.87-39.5) were associated with an increased risk of stone formation. On multivariable analysis the only independent predictor of stone formation was intermittent self-catheterization (p = 0.001, HR 8.98, 95% CI 2.59-31.1). CONCLUSIONS In our series of stapled orthotopic ileal neobladders the rate of stone formation was comparable to that reported in the literature for completely hand-sewn ileal reservoirs. The only variable independently predictive of stone formation was intermittent self-catheterization.

Zero-Ischemia Minimally Invasive Partial Nephrectomy

In the last decade, many authors reported single center experiences of “off-clamp”, “clamp-less”, or “unclamped” minimally invasive partial nephrectomy (MIPN). These procedures, despite the potential risk of increased intraoperative blood loss, attempted to minimize the loss of renal function by eliminating ischemic renal injury. “Zero ischemia” MIPN has emerged as new treatment option in 2011, initially performed under controlled hypotension, and later mainly by performing a “superselective microdissection”. The former technique minimizes the arterial bleeding from the renal stump, allowing surgeon to dissect the tumor in a bloodless field; the latter consists of identifying, antegradely from the renal hilum, the tertiary and quaternary arterial branches directly supplying the kidney neoplasm, and then selectively controlling them before dissecting the renal mass. This review critically analyzes these techniques, focusing on perioperative, oncologic and functional outcomes.

Development and external validation of lymph node density cut-off points in prospective series of radical cystectomy and pelvic lymph node dissection

Objective:  To identify lymph node density thresholds and their prognostic role in patients who underwent radical cystectomy and pelvic lymph node dissection, and to validate findings in an external series.

Robotic Intracorporeal Padua Ileal Bladder: Surgical Technique, Perioperative, Oncologic and Functional Outcomes

BACKGROUND Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a challenging procedure. The need for surgical skills and the long operative times have led to concern about its reproducibility. OBJECTIVE To illustrate our technique for RARC and totally intracorporeal orthotopic Padua ileal bladder. DESIGN, SETTING, AND PARTICIPANTS From August 2012 to February 2014, 45 patients underwent this technique at a single tertiary referral centre. SURGICAL PROCEDURE RARC, extended pelvic lymph node dissection, and intracorporeal partly stapled neobladder. Surgical steps are demonstrated in the accompanying video. MEASUREMENTS Demographics, clinical, and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. RESULTS AND LIMITATIONS Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305min (interquartile range [IQR]: 282-345). Median estimated blood loss was 210ml (IQR: 50-250). Median hospital stay was 9 d (IQR: 7-12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8%, and 77.8%, respectively, while severe complications occurred in17.8%, 17.8%, and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Two-yr disease free survival, cancer specific survival, and overall survival rates were 72.5%, 82.3%, and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. CONCLUSIONS Our experience supports the feasibility of totally intracorporeal neobladder following RARC. Operative times and perioperative complication rates are likely to be reduced with increasing experience. PATIENT SUMMARY We report the outcomes of our first 45 consecutive patients who underwent robot-assisted radical cystectomy with intracorporeal neobladders. Perioperative, oncologic, and functional outcomes support this technique as a feasible and safe surgical option in tertiary referral centres.

Early and late urodynamic assessment of simplified Indiana pouch with multiple taeniamyotomies

Study Type – Therapy (outcomes research)
Level of Evidence 2c

Robotic Intracorporeal Continent Cutaneous Diversion

Purpose: Robotic intracorporeal urinary diversion has mostly been done for ileal conduit or orthotopic neobladder diversion. We present what is to our knowledge the initial series, detailed technique and outcomes of the robotic intracorporeal Indiana pouch with a minimum 1‐year followup. Materials and Methods: Ten patients underwent robotic radical cystectomy, pelvic lymphadenectomy and intracorporeal Indiana pouch urinary diversion for cancer in 9 and benign disease in 1. Data were collected prospectively. Baseline demographics, pathology data, and 1‐year complication rates and functional outcomes were assessed. Results: All 10 cases were successfully completed intracorporeally without open conversion. Median total operative time was 6 hours, including 3.5 hours for pouch creation. Median blood loss was 200 cc and median hospital stay was 10 days. Four Clavien grade 1‐2 and 3 Clavien 3‐5 complications occurred. None of the patients had a bowel leak. One noncompliant patient requested undiversion to an ileal conduit. The remaining 9 patients successfully catheterized the ileal channel and were completely continent at the last followup at a median of 13.7 months (range 12.3 to 15.2). Study limitations include small sample size and short followup. Conclusions: We present what is to our knowledge the initial series of robotic completely intracorporeal Indiana pouch diversion. Early perioperative data indicate acceptable operative efficiency and complication rates. Longer followup is required to assess the functional outcomes of this less commonly performed diversion.