Publications by authors named "Alessandro Veccia"

79 Publications

Retroperitoneal Robot-assisted Partial Nephrectomy: A Systematic Review and Pooled Analysis of Comparative Outcomes.

Eur Urol Open Sci 2022 Jun 26;40:27-37. Epub 2022 Apr 26.

Division of Urology, VCU Health, Richmond, VA, USA.

Context: Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity as primary minimally invasive surgical treatment for localized renal tumors, and it has preferably been performed with a transperitoneal approach. However, the retroperitoneal approach represents an alternative approach given potential advantages.

Objective: To provide an updated analysis of the comparative outcomes of retroperitoneal RAPN (R-RAPN) versus transperitoneal RAPN (T-RAPN).

Evidence Acquisition: A systematic review of the literature was performed up to September 2021 using MEDLINE, EMBASE, and Web of Science databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A sensitivity analysis was performed considering only matched-pair studies.

Evidence Synthesis: Seventeen studies, which were published between 2013 and 2021, were retrieved. None of them was a randomized clinical trial. Among the 6,266 patients included in the meta-analysis, 2261 (36.1%) and 4,005 (63.9%) underwent R-RAPN and T-RAPN, respectively. No significant difference was found in terms of baseline features. The T-RAPN group presented a higher rate of male patients (odds ratio [OR]: 0.86,  = 0.03) and larger tumor size (weighted mean difference [WMD]: 0.2 cm;  = 0.003). The R-RAPN group reported more frequent posterior renal masses (OR: 0.23;  < 0.0001). The retroperitoneal approach presented lower estimated blood loss (WMD: 30.41 ml;  = 0.001), shorter operative time (OT; WMD: 20.36 min;  = 0.0001), and shorter length of stay (LOS; WMD: 0.35 d;  = 0.002). Overall complication rates were 13.7% and 16.05% in the R-RAPN and T-RAPN groups, respectively (OR: 1.32;  = 0.008). There were no statistically significant differences between the two groups regarding major (Clavien-Dindo classification ≥3 grade) complication rate, "pentafecta" achievement, as well as positive margin rates. When considering only matched-pair studies, no difference between groups was found in terms of baseline characteristics. Posterior renal masses were more frequent in the R-RAPN group (OR: 0.6;  = 0.03). Similar to the analysis of the entire cohort, R-RAPN reported lower EBL (WMD: 35.56 ml;  < 0.0001) and a shorter OT (WMD: 18.31 min;  = 0.03). Overall and major complication rates were similar between the two groups. The LOS was significantly lower for R-RAPN (WMD: 0.46 d;  = 0.02). No statistically significant difference was found between groups in terms of overall PSM rates.

Conclusions: R-RAPN offers similar surgical outcomes to T-RAPN, and it carries potential advantages in terms of shorter OT and LOS. Available evidence remains limited by the lack of randomized clinical trials.

Patient Summary: In this review of the literature, we looked at comparative outcomes of two surgical approaches to robot-assisted partial nephrectomy. We found that the retroperitoneal technique offers similar surgical outcomes to the transperitoneal one, with potential advantages in terms of shorter operative time and length of hospital stay.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euros.2022.03.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9062267PMC
June 2022

Outcomes of Lymph Node Dissection in Nephroureterectomy in the Treatment of Upper Tract Urothelial Carcinoma: Analysis of the ROBUUST Registry.

J Urol 2022 Apr 4:101097JU0000000000002690. Epub 2022 Apr 4.

Department of Urology, Regina Elena National Cancer Institute, Rome, Italy.

Purpose: We sought to evaluate outcomes of lymph node dissection (LND) in patients with upper tract urothelial carcinoma.

Materials And Methods: We performed a multicenter retrospective analysis utilizing the ROBUUST (for RObotic surgery for Upper Tract Urothelial Cancer Study) registry for patients who did not undergo LND (pNx), LND with negative lymph nodes (pN0) and LND with positive nodes (pN+). Primary and secondary outcomes were overall survival (OS) and recurrence-free survival (RFS). Multivariable analyses evaluated predictors of outcomes and pathological node positivity. Kaplan-Meier analyses (KMAs) compared survival outcomes.

Results: A total of 877 patients were analyzed (LND performed in 358 [40.8%]/pN+ in 73 [8.3%]). Median nodes obtained were 10.2 for pN+ and 9.8 for pN0. Multivariable analyses noted increasing age (OR 1.1, p <0.001), pN+ (OR 3.1, p <0.001) and pathological stage pTis/3/4 (OR 3.4, p <0.001) as predictors for all-cause mortality. Clinical high-grade tumors (OR 11.74, p=0.015) and increasing tumor size (OR 1.14, p=0.001) were predictive for lymph node positivity. KMAs for pNx, pN0 and pN+ demonstrated 2-year OS of 80%, 86% and 42% (p <0.001) and 2-year RFS of 53%, 61% and 35% (p <0.001), respectively. KMAs comparing pNx, pN0 ≥10 nodes and pN0 <10 nodes showed no significant difference in 2-year OS (82% vs 85% vs 84%, p=0.6) but elicited significantly higher 2-year RFS in the pN0 ≥10 group (60% vs 74% vs 54%, p=0.043).

Conclusions: LND during nephroureterectomy in patients with positive lymph nodes provides prognostic data, but is not associated with improved OS. LND yields ≥10 in patients with clinical node negative disease were associated with improved RFS. In high-grade and large tumors, lymphadenectomy should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000002690DOI Listing
April 2022

Is Hypertension Associated with Worse Renal Functional Outcomes after Minimally Invasive Partial Nephrectomy? Results from a Multi-Institutional Cohort.

J Clin Med 2022 Feb 25;11(5). Epub 2022 Feb 25.

Department of Urologic Oncology, IRCCS "Regina Elena" National Cancer Institute, 00144 Rome, Italy.

Background: Hypertension (HTN) is a global public health issue. There are limited data regarding the effects of HTN in patients undergoing partial nephrectomy (PN) for renal tumors. To address this void, we tested the association between HTN and renal function after minimally invasive PN (MIPN).

Methods: Using a multi-institutional database (2007-2017), we identified patients aged ≥ 18 years with a diagnosis of cT1 renal tumors treated with MIPN. Kaplan-Meier plots and Cox regression models addressed newly-onset CKD stage ≥ 3b or higher (sCKD). All analyses were repeated after 1:1 propensity score matching (PSM).

Results: Overall, 2144 patients were identified. Of those, 35% ( = 759) were yes-HTN. Yes-HTN patients were older, more frequently male and more often presented with diabetes. Yes-HTN patients harbored higher RENAL nephrometry scores and higher cT stages than no-HTN patients. Conversely, yes-HTN patients exhibited lower preoperative eGFRs. In the overall cohort, five-year sCKD-free survival was 86% vs. 94% for yes-HTN vs. no-HTN, which translated into a multivariable HR of 1.67 (95% CI: 1.06-2.63, = 0.026). After 1:1 PSM, virtually the same results were observed (HR 1.86, 95% CI: 1.07-3.23, = 0.027).

Conclusions: Yes-HTN patients exhibited worse renal function after MIPN when compared to their no-HTN counterparts. However, these observations need to be further tested in a prospective cohort study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/jcm11051243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8911097PMC
February 2022

Robotic Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multicenter Propensity-Score Matched Pair "tetrafecta" Analysis (ROBUUST Collaborative Group).

J Endourol 2022 Feb 25. Epub 2022 Feb 25.

Department of Urology, Changzheng Hospital, Second Military (Naval) Medical University, Shanghai, China.

To compare the outcomes of robotic radical nephroureterectomy (RRNU) and laparoscopic radical nephroureterectomy (LRNU) within a large multi-institutional worldwide dataset. The ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST) includes data from 17 centers worldwide regarding 877 RRNU and LRNU performed between 2015 and 2019. Baseline features, perioperative and oncologic outcomes, were included. A 2:1 nearest-neighbor propensity-score matching with a 0.001 caliper was performed. A univariable and a multivariable logistic regression model were built to evaluate the predictors of a composite "tetrafecta" outcome defined as occurrence of bladder cuff excision+LND+no complications+negative surgical margins. After matching, 185 RRNU and 91 LRNU were assessed. Patients in the RRNU group were more likely to undergo bladder cuff excision (81.9% 63.7%;  < 0.001) compared to the LRNU group. A statistically significant difference was found in terms of overall postoperative complications ( = 0.003) and length of stay ( < 0.001) in favor of RRNU. Multivariable analysis demonstrated that LRNU was an independent predictor negatively associated with achievement of "tetrafecta" (odds ratio: 0.09;  = 0.003). In general, RRNU and LRNU offer comparable outcomes. While the rate of overall complications is higher for LRNU in this study population, this is mostly related to low-grade complications, and therefore with more limited clinical relevance. RRNU seems to offer shorter hospital stay, but this might also be related to the different geographical location of participating centers. Overall, the implementation of robotics might facilitate achievement of a "tetrafecta" outcome as defined in the present study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/end.2021.0587DOI Listing
February 2022

The Impact of SARS-CoV-2 Pandemic on Time to Primary, Secondary Resection and Adjuvant Intravesical Therapy in Patients with High-Risk Non-Muscle Invasive Bladder Cancer: A Retrospective Multi-Institutional Cohort Analysis.

Cancers (Basel) 2021 Oct 21;13(21). Epub 2021 Oct 21.

Department of Urology, University of Bologna, S-Orsola-Malpighi Hospital, 40138 Bologna, Italy.

Background: To investigate the impact of COVID-19 outbreak on the diagnosis and treatment of non-muscle invasive bladder cancer (NMIBC).

Methods: A retrospective analysis was performed using an Italian multi-institutional database of TURBT patients with high-risk urothelial NMIBC between January 2019 and February 2021, followed by Re-TURBT and/or adjuvant intravesical BCG.

Results: A total of 2591 patients from 27 institutions with primary TURBT were included. Of these, 1534 (59.2%) and 1056 (40.8%) underwent TURBT before and during the COVID-19 outbreak, respectively. Time between diagnosis and TURBT was significantly longer during the COVID-19 period (65 vs. 52 days, = 0.002). One thousand and sixty-six patients (41.1%) received Re-TURBT, 604 (56.7%) during the pre-COVID-19. The median time to secondary resection was significantly longer during the COVID-19 period (55 vs. 48 days, < 0.0001). A total of 977 patients underwent adjuvant intravesical therapy after primary or secondary resection, with a similar distribution across the two groups ( = 453, 86% vs. = 388, 86.2%). However, the proportion of the patients who underwent maintenance significantly differed (79.5% vs. 60.4%, < 0.0001).

Conclusions: The COVID-19 pandemic represented an unprecedented challenge to our health system. Our study did not show significant differences in TURBT quality. However, a delay in treatment schedule and disease management was observed. Investigation of the oncological impacts of those differences should be advocated.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/cancers13215276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8582553PMC
October 2021

New Ultra-minimally Invasive Surgical Treatment for Benign Prostatic Hyperplasia: A Systematic Review and Analysis of Comparative Outcomes.

Eur Urol Open Sci 2021 Nov 22;33:28-41. Epub 2021 Sep 22.

Department of Oncology, Division of Urology, University of Turin, Turin, Italy.

Context: Benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) is diagnosed in up to 80% of men during their lifetime. Several novel ultra-minimally invasive surgical treatments (uMISTs) for BPH/benign prostatic obstruction (BPO) have become available over the past 5 yr.

Objective: To evaluate the perioperative and functional outcomes of recently introduced uMISTs for BPH/BPO, including Urolift, Rezūm, temporary implantable nitinol device, prostatic artery embolization (PAE), and intraprostatic injection.

Evidence Acquisition: A systematic literature search was conducted in December 2020 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science (registered on PROSPERO as CRD42021225014). The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Pooled and cumulative analyses were performed to compare perioperative and functional outcomes between study groups. A random-effects model using the DerSimonian and Laird method was used to evaluate heterogeneity. Stata version 15.0 software was used for all statistical analyses.

Evidence Synthesis: The initial electronic search identified 3978 papers, of which 48 ultimately met the inclusion criteria and were included in the analysis. Pooled analysis revealed a uMIST benefit in terms of International Prostate Symptom Score (IPSS; -9.81 points, 95% confidence interval [CI] -11.37 to -8.25 at 1 mo; -13.13 points, 95% CI -14.98 to -11.64 at 12 mo), maximum flow rate (from +3.66 ml/s, 95% CI 2.8-4.5 to +4.14 ml/s, 95% CI 0.72-7.56 at 12 mo), and postvoid residual volume (-10.10 ml, 95% CI -27.90 to 7.71 at 12 mo). No negative impact was observed on scores for the International Index of Erectile Function-5, Male Sexual Health Questionnaire-Ejaculatory Dysfunction bother and function scales (overall postintervention change in pooled median score of 1.88, 95% CI 1.34-2.42 at the start of follow-up; and 1.04, 95% CI 0.28-1.8 after 1 yr), or the IPSS-Quality of Life questionnaire.

Conclusions: Novel uMISTs can yield fast and effective relief of LUTS without affecting patient quality of life. Only Rezūm, UroLift, and PAE had a minimal impact on patients' sexual function with respect to baseline, especially regarding preservation of ejaculation.

Patient Summary: We reviewed outcomes for recently introduced ultra-minimally invasive surgical treatments for patients with lower urinary tract symptoms caused by benign prostate enlargement or obstruction. The evidence suggests that these novel techniques are beneficial in terms of controlling symptoms while preserving sexual function.

Take Home Message: Novel ultra-minimally invasive treatments can yield fast and effective relief of lower urinary tract symptoms without affecting a patient's quality of life.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euros.2021.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8473553PMC
November 2021

Warm ischemia time length during on-clamp partial nephrectomy: does it really matter?

Minerva Urol Nephrol 2022 Apr 26;74(2):194-202. Epub 2021 Jul 26.

Department of Urology, Hospital S. Bassiano, Bassano del Grappa, Vicenza, Italy.

Background: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN).

Methods: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m. Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages.

Results: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study.

Conclusions: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.21.04466-9DOI Listing
April 2022

Risk factors for progression of chronic kidney disease after robotic partial nephrectomy in elderly patients: results from a multi-institutional collaborative series.

Minerva Urol Nephrol 2021 Jun 22. Epub 2021 Jun 22.

Department of Urology, Regina Elena National Cancer Institute, Rome, Italy.

Background: Robotic partial nephrectomy (RPN) in patients ≥75 years is certainly underused with concerns regarding surgical quality and a negligible impact on renal function. The aim of this study was to identify predictors of progression of chronic kidney disease for purely off-clamp (ocRPN) and on-clamp RPN (onRPN) in elderly patients on a multi-institutional series.

Methods: A collaborative minimally-invasive renal surgery dataset was queried for "RPN" performed between July 2007 and March 2021 and "age≥75 years". A total of 205 patients matched the inclusion criteria. Descriptive analyses were used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQR) were reported for continuous variables. Baseline, perioperative and functional data were compared between groups. New-onset of stages 3b,4,5 CKD in onRPN and ocRPN cohorts was computed by Kaplan-Meier analysis. Univariable and multivariable Cox regression analyses were performed to identify predictors of progression to severe CKD (sCKD [stages ≥3b]). For all statistical analyses, a two-sided p < 0.05 was considered significant.

Results: Mean age of the cohort considered was 78 years (IQR 76-80). At a median follow-up of 29 months (IQR 14.5-44.5), new onset CKD-3b and CKD-4,5 stages was observed in 16.6% and 2.4% of patients, respectively. At Kaplan-Meier analysis, onRPN was associated with a significantly higher risk of developing sCKD (p=0.002). On multivariable analysis, hypertension (HR 2.64; 95% CI 1.14-6.11; p=0.023), on-clamp approach (HR 3.41; 95% CI 1.50-7.74; p=0.003) non-achievement of trifecta (HR 0.36; 95% CI 0.17-0.78; p=0.01) were independent predictors of sCKD.

Conclusions: RPN in patients≥75 years is a safe surgical option. On-clamp approach, hypertension and non-achievement of trifecta were independent predictors of sCKD in the elderly after RPN.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.21.04469-4DOI Listing
June 2021

Is off-clamp robot-assisted partial nephrectomy beneficial for renal function? Data from the CLOCK trial.

BJU Int 2022 02 4;129(2):217-224. Epub 2021 Jul 4.

Urology Unit Careggi Hospital, University of Florence, Florence, Italy.

Objectives: To compare the functional outcomes of on- vs off-clamp robot-assisted partial nephrectomy (RAPN) within a randomized controlled trial (RCT).

Materials And Methods: The CLOCK study (CLamp vs Off Clamp the Kidney during robotic partial nephrectomy; NCT02287987) is a multicentre RCT including patients with normal baseline function, two kidneys and masses with RENAL scores ≤ 10. Pre- and postoperative renal scintigraphy was prescribed. Renal defatting and hilum isolation were required in both study arms; in the on-clamp arm, ischaemia was imposed until the completion of medullary renorraphy, while in the off-clamp condition it was not allowed throughout the procedure. The primary endpoint was 6-month absolute variation in estimated glomerular filtration rate (AV-GFR); secondary endpoints were: 12, 18 and 24-month AV-GFR; 6-month estimated glomerular filtration rate variation >25% rate (RV-GFR >25); and absolute variation in ipsilateral split renal function (AV-SRF). The planned sample size was 102 + 102 cases, after taking account crossover of cases to the alternate study arm; a 1:1 randomization was performed. AV-GFR and AV-SRF were compared using analysis of covariation, and RV-GFR >25 was assessed using multivariable logistic regression. Intention-to-treat (ITT) and per-protocol analyses (PP) were performed.

Results: A total of 160 and 164 patients were randomly assigned to on- and off-clamp RAPN, respectively; crossover was observed in 14% and 43% of the on- and off-clamp arms, respectively. We were unable to find any statistically significant difference between on- vs off-clamp with regard to the primary endpoint (ITT: 6-month AV-GFR -6.2 vs -5.1 mL/min, mean difference 0.2 mL/min, 95% confidence interval [CI] -3.1 to 3.4 [P = 0.8]; PP: 6-month AV-GFR -6.8 vs -4.2 mL/min, mean difference 1.6 mL/min, 95% CI -2.3 to 5.5 [P = 0.7]) or with regard to the secondary endpoints. The median warm ischaemia time was 14 vs 15 min in the ITT analysis and 14 vs 0 min in the PP analysis.

Conclusion: In patients with regular baseline function and two kidneys, we found no evidence of differences in functional outcomes for on- vs off-clamp RAPN.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/bju.15503DOI Listing
February 2022

Retroperitoneal versus transepritoneal robot-assisted partial nephrectomy for postero-lateral renal masses: an international multicenter analysis.

World J Urol 2021 Nov 29;39(11):4175-4182. Epub 2021 May 29.

Division of Urology, VCU Health, Richmond, VA, 23298-0118, USA.

Purpose: To assess the outcomes of retroperitoneal robot-assisted partial nephrectomy (r-RAPN) in a large cohort of patients with postero-lateral renal masses comparing to those of transperitoneal RAPN (t-RAPN).

Methods: Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN ("study group") and t-RAPN ("control group"). Baseline characteristics, intraoperative, and postoperative data were collected and compared.

Results: Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170 min, p < 0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p = 0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥ III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p = 0.9). There was no difference in hospital re-admission rate, median length of stay, and PSM rate. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p = 0.7).

Conclusion: r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with postero-lateral renal tumors. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00345-021-03741-2DOI Listing
November 2021

Risk Factors for Intravesical Recurrence after Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Cancer (ROBUUST Collaboration).

J Urol 2021 Sep 21;206(3):568-576. Epub 2021 Apr 21.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.

Purpose: Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort.

Materials And Methods: We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence.

Results: A total of 485 (396 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031).

Conclusions: IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/JU.0000000000001786DOI Listing
September 2021

Single-stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

Minerva Urol Nephrol 2022 Apr 29;74(2):233-241. Epub 2021 Mar 29.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RNU is growing. The introduction of the Xi system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi robotic RNU.

Methods: Single stage Xi robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed.

Results: Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Post-operative complications were 26 (17.7%), with 4 major (2.7%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0).

Conclusions: Single stage Xi RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.21.04247-8DOI Listing
April 2022

Systemic combining inflammatory score (SCIS): a new score for prediction of oncologic outcomes in patients with high-risk non-muscle-invasive urothelial bladder cancer.

Transl Androl Urol 2021 Feb;10(2):626-635

Department of Neurosciences, Sciences of Reproduction and Odontostomatology, Urology Unit, University of Naples "Federico II", Naples, Italy.

Background: An accurate and early diagnosis of bladder cancer (BC) is essential to offer patients the most appropriate treatment and the highest cure rate. For this reason, patients need to be best stratified by class and risk factors. We aimed to develop a score able to better predict cancer outcomes, using serum variables of inflammation.

Methods: A total of 1,510 high-risk non-muscle invasive bladder cancer (NMIBC) patients were included in this retrospective observational study. Patients with pathologically proven T1 HG/G3 at first TURBT were included. Systemic combined inflammatory score (SCIS) was calculated according to systemic inflammatory markers (SIM), modified Glasgow prognostic score (mGPS), and prognostic nutritional index (PNI) dichotomized (final score from 0 to 3).

Results: After 48 months of follow-up (IQR 40.0-73.0), 727 patients recurred (48.1%), 485 progressed (32.1%), 81 died for cancer (7.0%), and 163 died for overall causes (10.8%). Overall, 231 (15.3%) patients had concomitant Cis, 669 (44.3%) patients had multifocal pathology, 967 (64.1%) patients had tumor size >3 cm. Overall, 357 (23.6%) patients received immediate-intravesical therapy, 1,356 (89.8%) received adjuvant intravesical therapy, of which 1,382 (91.5%) received BCG, 266 (17.6%) patients received mitomycin C, 4 (0.5%) patients received others intravesical therapy. Higher SCIS was independently predictive of recurrence (hazard ratio HR 1.5, 1.3 and 2.2) and cancer specific mortality for SCIS 0 and 3 (HR: 1.61 and 2.3), and overall mortality for SCIS 0 and 3 (HR: 2.4 and 3.2). Conversely, SCIS was not associated with a higher probability of progression.

Conclusions: The inclusion of the SCIS in clinical practice is simple to apply and can help improve the prediction of cancer outcomes. It can identify patients with high-grade BC who are more likely to experience disease mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/tau-20-1272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947442PMC
February 2021

Robot-assisted vesico-vaginal fistula repair: technical nuances.

Int Braz J Urol 2021 Mar-Apr;47(2):684-685

Urology Unit ASST Spedali Civili Hospital, University of Brescia, Brescia, Italy.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.0749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993969PMC
August 2020

Radical prostatectomy technique in the robotic evolution: from da Vinci standard to single port-a single surgeon pathway.

J Robot Surg 2022 Feb 7;16(1):21-27. Epub 2021 Feb 7.

Department of Urology, College of Medicine, University of Illinois at Chicago, 820 S Wood Street, Chicago, IL, 60612, USA.

To describe perioperative outcomes following robot-assisted prostatectomy performed by a single surgeon during transitions between da Vinci standard/Si/Xi and the single port. Perioperative data were retrospectively evaluated of the first 40 consecutive robot-assisted radical prostatectomies performed by a single surgeon using the da Vinci standard, Si, Xi and single port. A total of 160 patients were included. We matched standard vs Si (Match 1), Si vs Xi (Match 2) and Xi vs single port (Match 3) cohort. Mann-Whitney and Fisher's tests were used to test the difference among the groups. Univariate and multivariate logistic regression analyses were adopted to evaluate the predictors of overall and major complications. Single-port procedures in Match 3 showed significant shorter median operative time than Xi. Both Si and single-port groups showed significantly less median blood loss, a shorter median length of stay, respectively, than standard group in Match 1 and than Xi group in Match 3. 1 standard group patient required conversion to open surgery for an unsolvable conflict of the robotic arms. No other intraoperative complications were noted. On univariate and multivariate analyses, the da Vinci platform model was not a predicting factor of major complications (Clavien-Dindo ≥ 3). We described how technological progress impacted peri and postoperative outcomes during transitions between robotic surgical platforms for radical prostatectomy. In particular, the technological improvements associated to the increased surgeon's expertise made the transition to the single port safe and effective when compared with previous platforms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11701-021-01194-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8863749PMC
February 2022

A Preoperative Nomogram to Predict Renal Function Insufficiency for Cisplatin-based Adjuvant Chemotherapy Following Minimally Invasive Radical Nephroureterectomy (ROBUUST Collaborative Group).

Eur Urol Focus 2022 Jan 3;8(1):173-181. Epub 2021 Feb 3.

OLV Hospital, Aalst, Belgium;ORSI Academy, Melle, Belgium.

Background: Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU).

Objective: To create a model predicting renal function decline after minimally invasive RNU.

Design, Setting, And Participants: A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m at 3 mo after RNU. Patients with baseline eGFR >50 ml/min/1.73 m (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis.

Outcome Measurements And Statistical Analysis: Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR <50 ml/min/1.73 m was built based on the coefficients of the least absolute shrinkage and selection operation (LASSO) logistic regression. The discrimination, calibration, and clinical use of the nomogram were investigated.

Results And Limitations: The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p < 0.001) and cancer-specific death risk (HR: 5.19, p < 0.001) was statistically significant. The limitation mainly lies in its retrospective design.

Conclusions: A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection.

Patient Summary: We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2021.01.014DOI Listing
January 2022

Association of statin use and oncological outcomes in patients with first diagnosis of T1 high grade non-muscle invasive urothelial bladder cancer: results from a multicenter study.

Minerva Urol Nephrol 2021 12 13;73(6):796-802. Epub 2021 Jan 13.

Section of Urology, Unit of Andrology and Kidney Transplantation, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.

Background: We aimed to test the hypothesis that the immune-modulatory effect of statins may improve survival outcomes in patients with non-muscle invasive bladder cancer (NMIBC). We focused on a cohort of patients diagnosed with high risk NMIBC, that were treated with intravesical BCG immunotherapy.

Methods: We included patients at first diagnosis of T1 high grade NMIBC after transurethral resection of bladder (TURB). All procedures were performed at 18 different tertiary institutions between January 2002 and December 2012. Univariable and multivariable models were used to test differences in terms of residual tumor, disease recurrence, disease progression and overall mortality (OM) rates.

Results: Overall, 1510 patients with T1 high grade NMIBC at TURB were included in our analyses. Of these, 402 (26.6%) were statin users. At multivariable analysis, statin use was associated with a higher rate of high-grade BC at re-TURB (OR: 1.37, 95%CI: 1.04-1.78; P=0.022), while at follow-up it was not independently associated with OM (HR: 0.71, 95%CI: 0.50-1.03; P=0.068) and disease progression rates (HR: 0.97, 95%CI: 0.79-1.19; P=0.753). Conversely, statin use has been shown to be independently associated with a lower risk of recurrence (HR:0.80, 95%CI: 0.67-0.95; P=0.009). The median recurrence-free survival was 47 (95%CI 40-49) months for those classified as non-statin users vs. 53 (95%CI 48-68) months in those classified as statin users.

Conclusions: Statin daily intake do not compromise oncological outcomes in high risk NMIBC patients treated with BCG. Moreover, statin may have a beneficial effect on recurrence rates in this cohort of patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.20.04076-XDOI Listing
December 2021

Development of a Novel Risk Score to Select the Optimal Candidate for Cytoreductive Nephrectomy Among Patients with Metastatic Renal Cell Carcinoma. Results from a Multi-institutional Registry (REMARCC).

Eur Urol Oncol 2021 04 29;4(2):256-263. Epub 2020 Dec 29.

Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain. Electronic address:

Background: Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved.

Objective: To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN.

Design, Setting, And Participants: We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]).

Outcome Measurements And Statistical Analysis: Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model's discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores.

Results And Limitations: The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (<80%) and those with more than three metastases had also higher OM rates (p = 0.026 and 0.040, respectively). The C-index of the REMARCC model was higher than that of the MSKCC and IMDC models (66.4% vs 60.4% vs 60.3%). After stratification, 113 (22.0%) patients were classified to have a favorable (no risk factors), 202 (39.5%) an intermediate (one or two risk factors), and 197 (38.5%) a poor (more than two risk factors) prognosis. Moreover, 72 (17.2%) and 51 (13.9%) patients classified as having an intermediate and a poor prognosis according to MSKCC and IMDC categories, respectively, would be reclassified as having a good prognosis according to the REMARCC score.

Conclusions: Our findings confirm the relevance of tumor and patient features for the risk stratification of mRCC patients and clinical decision-making regarding CN. Further prospective external validations are required for the scoring system proposed herein.

Patient Summary: Current stratification systems for selecting patients for kidney removal when metastatic disease is shown are controversial. We suggest a system that includes tumor and patient features besides the systems already in use, which are based on blood tests.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euo.2020.12.010DOI Listing
April 2021

How Can the COVID-19 Pandemic Lead to Positive Changes in Urology Residency?

Front Surg 2020 24;7:563006. Epub 2020 Nov 24.

University of Salerno, Salerno, Italy.

The COVID-19 outbreak, in a few weeks, overloaded Italian hospitals, and the majority of medical procedures were postponed. During the pandemic, with hospital reorganization, clinical and learning activities performed by residents suffered a forced remodulation. The objective of this study is to investigate how urology training in Italy has been affected during the COVID-19 era. In this multi-academic study, we compared residents' training during the highest outbreak level with their previous activity. Overall 387 (67.1%) of the 577 Italian Urology residents participated in a 72-h anonymous online survey with 36 items sent via email. The main outcomes were clinical/surgical activities, social distancing, distance learning, and telemedicine. Clinical and learning activity was significantly reduced for the overall group, and after categorizing residents as those working only in COVID hospitals, both "junior" and "senior" residents, and those working in any of three geographical areas created (Italian regions were clustered in three major zones according to the prevalence of COVID-19). A significant decrease in outpatient activity, invasive diagnostic procedures, and endoscopic and major surgeries was reported. Through multivariate analysis, the specific year of residency has been found to be an independent predictor for all response modification. Being in zone 3 and zone 2 and having "senior" resident status were independent predictors associated with a lower reduction of the clinical and learning activity. Working in a COVID hospital and having "senior" resident status were independent predictors associated with higher reduction of the outpatient activity. Working in zone 3 and having "senior" resident status were independent predictors of lower and higher outpatient surgical activity, respectively. Working in a COVID hospital was an independent predictor associated with robotic surgical activity. The majority of residents reported that distance teaching and multidisciplinary virtual meetings are still not used, and 44.8% reported that their relationships with colleagues decreased. The COVID-19 pandemic presents an unprecedented challenge, including changes in the training and education of urology residents. The COVID era can offer an opportunity to balance and implement innovative solutions that can bridge the educational gap and can be part of future urology training.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fsurg.2020.563006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732553PMC
November 2020

Nomogram predicting 30-day mortality after nephrectomy in the contemporary era: Results from the SEER database.

Int J Urol 2021 Mar 14;28(3):309-314. Epub 2020 Dec 14.

Division of Urology, Virginia Commonwealth University Health, Richmond, Virginia, USA.

Objectives: To assess contemporary 30-day mortality rates after partial and radical nephrectomy in USA, and to develop a predictive model of 30-day mortality.

Methods: We relied on the National Cancer Institute Surveillance, Epidemiology and End Results database. A multivariable logistic regression analysis was fitted to predict 30-day mortality. A nomogram was built based on the coefficients of the logit function. Internal validation was carried out using the leave-one-out cross-validation. Calibration was graphically investigated.

Results: A total of 102 146 patients who underwent partial nephrectomy (n = 36 425; 35.7%) or radical nephrectomy (n = 65 721; 64.3%) between 2005 and 2015 were included in the analysis. The median age at diagnosis was 62 years. A total of 11 921 (11.7%) patients were African American. The clinical stage was T1-T2 in 79 452 (77.8%), T3 in 16 141 (15.8%) and T4/T1-4-M1 in 6553 (6.4%) patients. Overall, 497 deaths occurred during the initial 30 days after nephrectomy (0.49% 30-day mortality rate). Stratified by type of surgery, the 30-day mortality rate was 0.16% for partial nephrectomy and 0.67% for radical nephrectomy. At univariate analyses, age, tumor size, stage and surgical procedure emerged as predictors of 30-day mortality (all P < 0.001). All of these covariates were included in the multivariable logistic regression model. The area under the curve after leave-one-out cross-validation was 0.808 (95% confidence interval 0.788-0.828), and the model showed good calibration in the range of predicted probability <10%.

Conclusions: Contemporary rates of 30-day mortality in patients undergoing radical or partial nephrectomy are very low. Age and tumor stage are key determinants of 30-day mortality. We present a predictive model that provides individual probabilities of 30-day mortality after nephrectomy, and it can be used for patient counseling prior surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/iju.14461DOI Listing
March 2021

Robot-assisted partial nephrectomy: 7-year outcomes.

Minerva Urol Nephrol 2021 08 17;73(4):540-543. Epub 2020 Nov 17.

Division of Urology, VCU Health, Richmond, VA, USA -

Background: The role of robot-assisted partial nephrectomy (RAPN) in the management of renal masses has exponentially grown over the past 10 years. Nevertheless, data on long term outcomes of the procedure remains limited. Herein we report oncological and functional outcomes of patients who underwent RAPN for a malignant mass with a median follow-up of 7 years, the longest follow-up to date.

Methods: A retrospective analysis of an international multicenter database was performed. All consecutive patients undergoing surgery between 2009 and 2013 with a minimum of 3-year follow-up and complete data on renal function were included. Demographics, surgical and perioperative outcomes were analyzed. Overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were evaluated using Kaplan-Meier analysis.

Results: Overall, our study cohort was composed of eighty-five patients with a median follow-up of 88 months. Median clinical tumor size was 3 cm, with mostly (74.1%) clinical stage T1a, and median RENAL score 6. Final histopathologic analysis revealed clear cell RCC in 76.5% of cases. PSM was present in seven patients (8.2%). Eleven overall deaths (12.9%) occurred in the cohort during the follow-up period. Two of these (2.33%) were attributed to metastatic RCC. The OS, CSS, and DFS rates were 91.7%, 97.7%, and 91.7% at 84 months, respectively. Regarding the renal functional outcomes, seventeen patients (20.1%) presented a CKD upstaging in our cohort.

Conclusions: Our findings show excellent 7-year oncologic and functional outcomes of the procedure, which duplicate those achieved in historical series of open and laparoscopic surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.20.04151-XDOI Listing
August 2021

Single overnight stay after robot-assisted partial nephrectomy: a bi-center experience.

Minerva Urol Nephrol 2021 12 17;73(6):773-780. Epub 2020 Nov 17.

Division of Urology, VCU Health, Richmond, VA, USA -

Background: Despite hospital length of stay (LOS) being shorter for robot-assisted partial nephrectomy (RAPN) compared to its open counterpart, several series in the literature report on average a LOS of 2-3 days or more. We aimed to assess factors predicting a prolonged length of stay (beyond a single overnight stay) in patients undergoing RAPN.

Methods: Patients who underwent RAPN between 2010 and 2019 at two USA Centers were included and divided into two groups according to LOS: the study group included all patients who were discharged on POD1, whereas the control group included patients with LOS ≥2 days. Demographics, surgical and perioperative outcomes were compared between the groups. Multivariable logistic regression analyses were used to identify independent predictors of LOS ≥2.

Results: Overall, 173 (60.5%) patients discharged on POD1, and 113 (39.5%) discharged on POD≥2. Patients in the study group presented a lower mean BMI (29 vs. 32, P=0.02). Retroperitoneal approach was performed in 13.3% patients with shorter LOS (P<0.001). There was a statistically significant difference in median OT (144 vs. 168 min, P=0.005) and WIT (19 vs. 23 min, P=0.001). We observed six postoperative complications (3.6%) in patients discharged on POD1 and 35 (30.5%) in control group (P<0.001). Major complications (Clavien-Dindo grade ≥III) were observed in three of POD1 patients (1.8 vs. 6.1%, P<0.001). There was no difference in hospital readmission rate. On logistic regression analysis, independent predictors of prolonged LOS were OT (OR=1.01, 95% CI: 1.0-1.2, P=0.001), and occurrence of a postoperative complication (OR=2.2, 95% CI: 2.0-2.5, P<0.001).

Conclusions: Our findings confirm that a single overnight stay after RAPN is feasible and safe. In our experience, and within the limitations of the present analysis, prolonged operative time and occurrence of immediate postoperative complications translate into higher risk of prolonged hospital stay. Besides adopting a minimally invasive approach, surgeons should also implement perioperative care pathways facilitating early discharge without increasing the risk of readmission.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.20.04054-0DOI Listing
December 2021

Robotic-assisted Partial Nephrectomy for "Very Small" (<2 cm) Renal Mass: Results of a Multicenter Contemporary Cohort.

Eur Urol Focus 2021 Sep 3;7(5):1115-1120. Epub 2020 Nov 3.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Background: Patient with "very small" (<2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with "very small" renal masses have not been reported.

Objective: To assess the outcomes of RAPN among patients with "very small" renal masses.

Design, Setting, And Participants: This was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size: <2 cm ("very small" renal mass, study group) and 2-4 cm (control group).

Intervention: RAPN for renal masses.

Outcome Measurements And Statistical Analysis: Baseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A "trifecta" was used as surrogate of "surgical quality."

Results And Limitations: Overall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of <2 cm (34.5%) and 667 (65.5%) had a renal mass of 2-4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p < 0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p < 0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p < 0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a "trifecta" achievement of 90.6%. The retrospective design may limit the generalizability of the findings.

Conclusions: Whenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for "very small" renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity.

Patient Summary: In this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for "very small" renal masses (<2 cm), as it carries minimal risk of complications and has minimal impact on renal function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.euf.2020.10.001DOI Listing
September 2021

Active surveillance for small renal masses in elderly patients does not increase overall mortality rates compared to primary intervention: a propensity score weighted analysis.

Minerva Urol Nephrol 2021 12 29;73(6):781-788. Epub 2020 Sep 29.

Department of Urology, Instituto Valenciano de Oncología (IVO), Valencia, Spain -

Background: The aim of the study was to test the effect of active surveillance (AS) versus primary intervention (PI) on overall mortality (OM) in elderly patients diagnosed with SRM.

Methods: Elderly patients (75 years or older) diagnosed with SRMs (<4 cm) and treated with either PI (i.e. partial nephrectomy or kidney ablation) or AS between 2009 and 2018 were abstracted from the renal surgery in the elderly (RESURGE) and Delayed Intervention and Surveillance for small Renal Masses (DISSRM) datasets, respectively. OM rates were estimated among groups with Kaplan Meier method and Cox proportional hazards regression models after applying inverse probability of treatment weighting (IPTW). Multivariable logistic regression model was used to estimate IPTW. Covariates of interest were those unbalanced and/or significantly correlated with the treatment choice or with OM.

Results: A total of 483 patients were included; 121 (25.1%) underwent AS. Sixty patients (12.4%) died. Overall, 6.7% of all deaths were related to cancer. IPTW-Kaplan Meier curves showed a 5-year overall survival rates of 70.0±3.5% and 73.2±4.8% in AS and PI groups, respectively (IPTW-Log-rank P value=0.308). IPTW-Cox regression model did not show meaningfully increased OM rates in AS group (HR: 1.31, 95% CI: 0.69-2.49).

Conclusions: AS represents an appealing treatment option for very elderly patients presenting with SRM, as it avoids the risks of a PI while not compromising the survival outcomes of these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.23736/S2724-6051.20.03785-6DOI Listing
December 2021

Using biomarkers in patients with positive multiparametric magnetic resonance imaging: 4Kscore predicts the presence of cancer outside the index lesion.

Int J Urol 2021 Jan 27;28(1):47-52. Epub 2020 Sep 27.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objectives: To evaluate if the blood biomarker, 4Kscore, in addition to multiparametric magnetic resonance imaging information could identify patients who would benefit from undergoing only a targeted biopsy.

Methods: We retrospectively analyzed a population of 256 men with positive multiparametric magnetic resonance imaging who underwent standard + targeted biopsy at Mount Sinai Hospital, New York, NY, USA. 4Kscore (OPKO Health, Miami, FL, USA) was sampled from all patients before biopsy. Uni- and multivariable binary logistic regression analyses were carried out to predict clinically significant prostate cancer, defined as International Society of Urological Pathology grade group ≥2, in standard biopsy cores. The model with the best area under the curve was selected and internal validation was carried out using the leave-one-out cross-validation.

Results: The developed model showed an area under the curve of 0.86. Carrying out only targeted biopsy in patients with a model-derived probability <12.5% resulted in 39.5% (n = 101) fewer standard biopsies and a 33.9% (n = 20) reduction of detecting grade group 1 disease, while missing grade group ≥2 in 5.2% (n = 4) using standard biopsy only and 1.1% (n = 1) using standard biopsy + targeted biopsy.

Conclusions: 4Kscore in combination with multiparametric magnetic resonance imaging can help to reduce unnecessary standard biopsy and decrease detection of clinically insignificant prostate cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/iju.14385DOI Listing
January 2021

Outcomes of robot-assisted partial nephrectomy for completely endophytic renal tumors: A multicenter analysis.

Eur J Surg Oncol 2021 05 16;47(5):1179-1186. Epub 2020 Aug 16.

Division of Urology, VCU Health, Richmond, VA, USA. Electronic address:

Introduction: Multicenter retrospective analysis of robotic partial nephrectomy for completely endophytic renal tumors (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) was performed.

Materials And Methods: Patients' demographics, tumor characteristics, perioperative, functional, pathological and oncological data were analyzed and compared with those of patients with exophytic and mesophytic masses (i.e. 1 and 2 points for the 'E' domain, respectively). Multivariable logistic regression analysis was used to assess variables for trifecta achievement (negative margin, no postoperative complications, and 90% estimated glomerular filtration rate [eGFR] recovery).

Results: Overall, 147 patients were included in the study group. Patients with a completely endophytic mass had bigger tumors (mean 4.2 vs. 4.1 vs. 3.2 cm; p < 0.001) on preoperative imaging and higher overall R.E.N.A.L. score. There was no difference in mean operative time. Estimated blood loss was higher in the endophytic group (mean 177.75 vs. 185.5 vs. 130 ml; p = 0.001). Warm ischemia time was shorter for the exophytic group (median 16 vs. 21 vs. 22 min; p < 0.001). Postoperative complications were more frequent in patients with endophytic tumor (24.8% vs. 19.5% vs. 14.8%; p < 0.001). Six (4.5%) patients had positive surgical margins, there was no difference between groups. Trifecta was achieved in 44 patients in endophytic group (45.4 vs. 68.8 and 50.9%, p < 0.001). Multivariable analysis for trifecta revealed that clinical tumor size (odds ratio: 0.667, 95% confidence interval: 0.56-0.79, p < 0.001) was only significant predictor for trifecta achievement.

Conclusions: Our findings confirm that RAPN in case of completely endophytic renal masses can be performed with acceptable outcomes in centers with significant robotic expertise.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejso.2020.08.012DOI Listing
May 2021

Ureteral location is associated with survival outcomes in upper tract urothelial carcinoma: A population-based analysis.

Int J Urol 2020 Nov 9;27(11):966-972. Epub 2020 Aug 9.

Division of Urology, Department of Surgery, VCU Health System, Richmond, Virginia, USA.

Objectives: To evaluate the prognostic value of tumor location in patients with upper tract urothelial carcinoma.

Methods: Within the Surveillance, Epidemiology and End Results Incidence Database, 6619 upper tract urothelial carcinoma cases were identified, including 3719 confined to the renal pelvis and 2971 to the ureter. Predictors of surgical technique (kidney sparing surgery versus radical nephroureterectomy), as well as 2- and 5-year cancer-specific survival and overall survival were evaluated.

Results: Median follow-up time was 29 months (interquartile range 0-126 months) for both groups. Multivariate logistic analysis showed tumor dimension as the only factor associated with radical nephroureterectomy (odds ratio 1.02; P < 0.001). Ureteral 2- and 5-year overall survival were lower (log-rank P = 0.001) compared with renal pelvis. When stratifying tumor location according to dimensions, a ureteral carcinoma >3 cm was associated with the worst 2- and 5-year cancer-specific mortality (Pepe-Mori P < 0.001), and overall survival (log-rank P < 0.001). The 2- and 5-year cancer-specific mortality (Pepe-Mori P < 0.001) and overall survival were the worst for ureteral ≥T3 tumors (log-rank P < 0.001). The 2- and 5-year cancer-specific mortality (Pepe-Mori P < 0.001) and overall survival (log-rank P < 0.001) were the worst for ureteral grade III-IV cancers. Ureteral tumor location (subdistribution hazard ratio 1.18, P < 0.001), tumor dimension ≥3 (subdistribution hazard ratio 1.25, P < 0.001), T staging (T2-4 all P < 0.001), grading (grade III subdistribution hazard ratio 2.20, P = 0.001; grade IV subdistribution hazard ratio 2.39, P < 0.001) were found to be associated with higher cancer mortality.

Conclusions: Ureteral tumor location in upper tract urothelial carcinoma seems to be associated with worse oncological outcomes, especially in the case of advanced disease. Although the type of surgical treatment does not seem to impact survival, surgeons should use caution in adopting a kidney-sparing surgery for patients with ureteral upper tract urothelial carcinoma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/iju.14336DOI Listing
November 2020

Radical penectomy, a compromise for life: results from the PECAD study.

Transl Androl Urol 2020 Jun;9(3):1306-1313

Department of Urology, ASL 2 Abruzzo, Hospital "S. Pio da Pietrelcina", Vasto, Italy.

Background: The use of organ sparing strategies to treat penile cancer (PC) is currently supported by evidence that has indicated the safety, efficacy and benefit of this surgery. However, radical penectomy still represents up to 15-20% of primary tumor treatments in PC patients. The aim of the study was to evaluate efficacy in terms of overall survival (OS) and disease-free survival (DFS) of radical penectomy in PC patients.

Methods: Data from a retrospective multicenter study (PEnile Cancer ADherence study, PECAD Study) on PC patients treated at 13 European and American urological centers (Hospital "Sant'Andrea", Sapienza University, Roma, Italy; "G.D'Annunzio" University, Chieti and ASL 2 Abruzzo, Hospital "S. Pio da Pietrelcina", Vasto, Italy; Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Hospital of Budapest, Hungary; Department of Emergency and Organ Transplantation, Urology and Andrology Unit II, University of Bari, Italy; Hospital "Spedali Civili", Brescia, Italy; Istituto Europeo di Oncologia, University of Milan, Milan, Italy; University of Modena & Reggio Emilia, Modena, Italy; Hospital Universitario La Paz, Madrid, Spain; Ceara Cancer Institute, Fortaleza, Brazil; Virginia Commonwealth University, Richmond, VA, USA; Aristotle University of Thessaloniki, Thessaloniki, Greece; Maria Skłodowska-Curie Memorial Cancer Center, Warsaw, Poland) between 2010 and 2016 were used. Medical records of patients who specifically underwent radical penectomy were reviewed to identify main clinical and pathological variables. Kaplan-Meier method was used to estimate 1- and 5-year OS and DFS.

Results: Of the entire cohort of 425 patients, 72 patients (16.9%) treated with radical penectomy were extracted and were considered for the analysis. The median age was 64.5 (IQR, 57.5-73.2) years. Of all, 41 (56.9%) patients had pT3/pT4 and 31 (43.1%) pT1/pT2. Moreover, 36 (50.0%) were classified as pN1-3 and 5 (6.9%) M1. Furthermore, 61 (84.7%) had a high grade (G2-G3) with 6 (8.3%) positive surgical margins. The 1- and 5-year OS rates were respectively 73.3% and 59.9%, while the 1- and 5-year DFS rates were respectively 67.3% and 35.1%.

Conclusions: PC is an aggressive cancer particularly in more advanced stage. Overall, more than a third of patients do not survive at 5 years and more than 60% report a disease recurrence, despite the use of a radical treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/tau.2020.04.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354339PMC
June 2020
-->