Maximilian C. Kriegmair

Irreversible Electroporation for Surgical Renal Masses in Solitary Kidneys: Short-Term Interventional and Functional Outcome

PURPOSE To examine short-term outcomes and complications in patients with a solitary kidney treated with irreversible electroporation (IRE) for a potentially malignant renal mass. MATERIALS AND METHODS Five patients (2 female, 3 male; mean age, 66 y) with 7 lesions who underwent IRE for renal tumors in a solitary kidney between August 2014 and August 2015 were retrospectively reviewed. Changes in signal intensity (SI) of the treated lesion were evaluated on contrast-enhanced magnetic resonance imaging. To evaluate functional outcome, creatinine levels and estimated glomerular filtration rate (eGFR) were compared vs baseline after 1 day, 2-7 days, 3-6 weeks, and 6-12 weeks after the intervention. RESULTS Mean tumor diameter was 24.4 mm (range, 15-38 mm), with an average score of 7.7 (range, 4-9) per R.E.N.A.L. criteria (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines). There was a progressive, significant decrease in treated tumor SI on follow-up imaging (mean, 70%-82%), suggesting a treatment response rate of 100% at a mean follow-up of 6.4 months (range, 3-11 mo). Two minor acute complications (Society of Interventional Radiology class A) occurred: transient gross hematuria and stage I acute kidney failure. Overall, there was no significant decrease in eGFR (-2.75 mL/min) over 3 months, even though 1 patients eGFR decreased from > 60 mL/min/1.73m(2) to 44 mL/min/1.73m(2). CONCLUSIONS The data suggest that percutaneous IRE for renal mass in patients with a solitary kidney is safe and feasible. It may help to preserve renal function and offers promising short-term oncologic results.

Defining Renal Masses: Comprehensive Comparison of RENAL, PADUA, NePhRO, and C-Index Score.

Micro‐Abstract The study compares 4 established nephrometry systems—RENAL, PADUA, NePhRO, and C‐index—for their significance in predicting surgical outcome of partial nephrectomy in a cohort of 305 patients. All scores showed high association with surrogates of surgical complexity such as ischemia time or violation of the collecting system. Only RENAL, PADUA, and NePhRO score could predict postoperative complications. Background: Nephrometry scores are designed for standardized reporting of renal tumors and predicting complications. Multiple scores are available, but there is a lack of systematic comparison. Patients and Methods: A total of 305 consecutive patients admitted for open partial nephrectomy to 2 urological hospitals were prospectively assessed. Five cases with conversion to radical nephrectomy were excluded from further analysis. RENAL, PADUA, C‐index, and NePhRO scores were obtained from preoperative sectional imaging. Additionally, interobserver variance between 2 urologists and a radiologist was analyzed for 50 patients. Linear and ordered logistic regression was used to evaluate the association between scores and surgical parameters. Receiver operating characteristic analysis was employed to assess the predictive value for requirement of ischemia and opening of the collecting system. Results: High interobserver agreement was observed for RENAL (0.92 and 0.80), PADUA (0.81 and 0.85), NePhRO (0.94 and 0.82), and the C‐index (0.98 and 0.95). All scores showed a significant association with opening of the collecting system (P < .016), requirement of on‐clamp excision (P < .001), and ischemia time (P < .001). Logistic regression identified RENAL, PADUA, and NePhRO score to be an independent predictor for severe complications (P = .016, P = .011, and P = .005). No correlation was found for the C‐index (ß = 0.98; P = .779). Predictive effectiveness for opening of the collecting system and for on‐clamp excision showed comparable area under the curve values for the 4 scores. Conclusion: All scoring systems represent objective and reproducible measurement tools for renal tumor complexity, that correlate well with surgical outcome. RENAL, PADUA, and NePhRO score are comparable and seem to be superior to the more complex C‐index system.

Salvage radical prostatectomy for recurrent prostate cancer: verification of European Association of Urology guideline criteria

To analyse oncological and functional outcomes of salvage radical prostatectomy (SRP) in patients with recurrent prostate cancer and to compare outcomes of patients within and outside the European Association of Urology (EAU) guideline criteria (organ‐confined prostate cancer ≤T2b, Gleason score ≤7 and preoperative PSA level <10 ng/mL) for SRP.

Digital Mapping of the Urinary Bladder: Potential for Standardized Cystoscopy Reports

OBJECTIVE To develop a standardized digital reporting tool for cystoscopy of the urinary bladder using panoramic imaging. MATERIALS AND METHODS An image processing and stitching software (Endorama) was developed to generate panoramic images from cystoscopy data. In a processing phase, algorithms were modulated and refined by reference to cystoscopy sequences (n = 30). Subsequently, standard systematic cystoscopies (n = 12) were recorded in patients undergoing transurethral resection of a bladder tumor to create panoramic images. RESULTS All sequences were applicable for the development and refinements of the software. Processing increasingly allowed the creation of images illustrating large parts of the bladder and relevant anatomic landmarks in different locations. The pathway covered by the endoscope during the intervention was illustrated as a route in the respective digital image. During the application phase, panoramic images were successfully created in 10 out of 12 cases. The resolution of the images was 4096 × 2048 pixels and the images required a median digital memory of 3.9 MB (3.4-5.7). The panoramic images illustrated 22 relevant findings of which 7 were papillary tumors. CONCLUSION High-quality digital panoramic maps of the urinary bladder were created using specifically processed data of videocystoscopy. In this preliminary series, relevant findings were illustrated in the respective image. Our tool may help improve standardization of cystoscopy reports and reduce interobserver variability.

Association between Lymph Node Counts and Oncological Outcomes in Lymph Node Positive Prostate Cancer

BACKGROUND While the diagnostic value of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) is undisputed, its therapeutic benefit remains a matter of debate. OBJECTIVE To investigate the association between total and positive lymph node (LN) counts and oncological outcomes in pN1 patients at RP. DESIGN, SETTING, AND PARTICIPANTS The records of 706 LN-positive patients undergoing RP and PLND between 1998 and 2012 in a single center were analyzed. The median follow-up was 47.8 mo. INTERVENTION RP and PLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The number of harvested and positive LNs and their influence on biochemical recurrence-free survival, metastasis-free survival, and cancer-specific survival was evaluated using univariate and multivariate Cox regressions. The number of harvested LNs was used as a continuous and dichotomous variable with a cut-off of 13 LNs. RESULTS AND LIMITATIONS The mean (median) number of removed LNs was 15.0 (13) and the mean (median) number of positive LNs was 2.4 (1). In multivariate analysis, the number of removed LNs did not significantly influence oncologic outcomes (biochemical recurrence, metastasis-free survival, or cancer-specific survival). The occurrence of metastasis and cancer-specific mortality significantly increased with higher number of positive LNs. The main limitation was the retrospective nature of the study. CONCLUSIONS While a higher number of positive LNs were significantly associated with worse oncological outcomes, the number of removed LNs was not a significant predictor. PATIENT SUMMARY We found that only the number of positive lymph nodes (LNs) but not the total number of removed LNs was a factor adversely influencing oncological outcomes in LN-positive patients undergoing radical prostatectomy.

ZIRK-Technique: Zero Ischemia Resection in the Kidney for High-Risk Renal Masses: Perioperative Outcome

Objectives: This study evaluates the feasibility and safety of open-partial nephrectomies in the ZIRK-technique (Zero Ischemia Resection in the Kidney) for renal masses with high-risk anatomical features - objectified by the PADUA score. Methods: We identified 40 consecutive cases of partial nephrectomies performed without clamping of the renal artery in our department of urology. Retrospective analysis of the preoperative CT or MRI scans showed 27 cases with a PADUA score ≥8, of which 15 cases had a score ≥10. Cases were in particular assessed regarding operation time (ORT), estimated blood loss (EBL), surgical margins and postoperative complications using the Clavien classification. Results: The mean age of the study population was 67.6 years with an average BMI of 26.8 kg/m2. The mean ORT was 1:46 with an average EBL of 521 ml. Clavien grade II complications were observed seven times, while 3 patients had a grade IIIa complication. Despite complex and adverse location of the tumors, nephron-sparing surgery without ischemia could be performed with negative surgical margins for all cases. EBL, transfusion rate and complication were considerably more frequent in high-risk tumors. Conclusion: Highly complex renal tumors, PADUA ≥10, can be resected in ZIRK-technique with good operative outcome and a low complication rate.

Open Partial Nephrectomy for High-Risk Renal Masses Is Associated with Renal Pseudoaneurysms: Assessment of a Severe Procedure-Related Complication

Objectives. A symptomatic renal pseudoaneurysm (RPA) is a severe complication after open partial nephrectomy (OPN). The aim of our study was to assess incidence and risk factors for RPA formation. Furthermore, we present our management strategy. Patients and Methods. Clinical records of consecutive patients undergoing OPN were assessed for surgical outcome and postoperative complications. Renal masses were risk stratified for tumor complexity according to the PADUA score. Uni- and multivariate analysis for symptomatic RPAs were performed using the t-tests and logistic regression. Results. We identified 233 patients treated with OPN. Symptomatic RPAs were observed in 13 (5.6%) patients, on average 14 (4–42) days after surgery. Uni- and multivariate analysis identified tumor complexity to be an independent predictor for symptomatic RPAs (p = 0.004). There was a significant correlation between RPAs and transfusion and the duration of stay (p < 0.001 and p = 0.021). Symptomatic RPAs were diagnosed with CT scans and successfully treated with arterial embolization. Discussion. Symptomatic RPAs are not uncommon after OPN for high-risk renal masses. A high nephrometry score is a predictor for this severe complication and may enable a risk-stratified followup. RPAs can successfully be located by CT angiography, which enables targeted angiographic treatment.

Tumor size and invasiveness matters for partial nephrectomy: External validation and modification of the arterial based complexity score

Outcome of partial nephrectomy (PN) depends on anatomic features of the renal tumor, which can be assessed by nephrometry scores. The aim was to externally validate and refine the Arterial Based Complexity (ABC) score and to compare it to established systems.

Interrupted versus continuous suturing for vesicourethral anastomosis during radical prostatectomy: protocol for a systematic review and meta-analysis

Introduction Radical prostatectomy is the mainstay of treatment for prostate cancer. The vesicourethral anastomosis is a critical step, which most likely impacts urinary continence and urethral stenosis. To date, it still remains unclear whether interrupted and continuous suturing for the anastomosis have different outcomes. Therefore, the aim of this systematic review and meta-analysis is to compare different suture techniques for vesicourethral anastomosis in terms of surgical and functional parameters. Methods and analysis A comprehensive literature search will be conducted covering MEDLINE, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov. Studies comparing interrupted versus continuous suturing will be included in the analyses. No language restrictions will be applied. Screening, data extraction, statistical analysis and reporting will be done in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Quality assessment will be performed with the help of the Cochrane Collaboration’s tool for assessing risk of bias and the Newcastle-Ottawa Scale for assessing quality of non-randomised studies. The quality of evidence will be evaluated with the Grading of Recommendations Assessment, Development and Evaluation. The primary outcome will be the time until removal of the urinary catheter. Secondary outcomes include rate of extravasation, length of hospital stay, time needed to perform the anastomosis, continence level at defined postoperative intervals and development of urethral strictures. Quantitative analysis will be calculated if meaningful. Ethics and dissemination In order to meet the highest ethical and methodological standards. we followed the PRISMA Protocol 2015 checklist. Each item was answered appropriately. For systematic reviews the ethical issues are strictly methodological as only data that were published earlier will be used. The full manuscript will be submitted to a peer-reviewed journal. Furthermore, the results will be presented on national and international congresses. Trial registration number International prospective register of systematic reviews PROSPERO CRD42017076126.

The Role of Pelvic Lymph Node Dissection During Radical Prostatectomy in Patients With Gleason 6 Intermediate-risk Prostate Cancer

OBJECTIVE To analyze the benefit of pelvic lymph node dissection (PLND) in patients with biopsy Gleason grade ≤ 6, cT ≤ 2b, and prostate-specific antigen (PSA) 10-20 ng/mL (main study cohort), as the indication for PLND during radical prostatectomy remains uncertain in patients with nonhigh-risk tumors. MATERIALS AND METHODS The main study cohort included 1383 patients with low intermediate-risk cancer undergoing radical prostatectomy with or without PLND between 1994 and 2013. Positive lymph node (LN) rates were reported and compared to patients with higher (≥20 ng/mL; n = 314) and lower (<10 ng/mL; n = 6861) PSA. Oncological outcome was assessed by Cox regressions in patients with a minimum follow-up of 5years. RESULTS In the main study cohort (PSA 10-20 ng/mL), PLND was performed in 867 (62.7%) patients with a median number of removed LNs of 11 (interquartile range 16-6). Positive LNs were detected in 3.3% of these patients. Compared to the main study cohort, patients with preoperatively higher PSA ≥ 20 ng/mL (or lower PSA < 10 ng/ml) underwent PLND in 83.8% (32.7%) of the cases, with 8.0% (1.8%) showing positive LNs. Median follow-up in the main study cohort was 84.5 months. Biochemical recurrence (BCR) occurred in 20.6% of these men. The 5-year and 10-year BCR-free survival rates were 82.2% and 75.6% for those with PLND, and 83.4% and 75.8% for patients without PLND. PLND was not a significant factor influencing BCR-free, metastasis-free, or cancer-specific survival in the main study cohort. CONCLUSION Positive LNs are rare in patients with Gleason grade ≤ 6, cT ≤ 2b, and PSA 10-20 ng/mL. Performing PLND had no statistical influence on oncologic outcome and therefore should be decided upon on an individual basis.