Mini-laparoscopic sacrocolpopexy for apical and posterior female pelvic organ prolapse

Aim of the video

Mini-laparoscopic surgery is the future for most laparoscopic procedures. Although already applied in some gynaecological surgical interventions, this video is to our knowledge the first publication on the use of the mini-laparoscopic approach to sacrocolpopexy for apical and posterior pelvic organ prolapse following total hysterectomy.

Methods

The concept of mini-laparoscopic sacrocolpopexy presented in this video article was performed on 12 women with post-hysterectomy apical and posterior pelvic organ prolapse using mini-laparoscopic instruments and ports of 3 mm in diameter combined with a 12-mm umbilical port. Surgery was performed with the same principles as for the conventional laparoscopic procedure.

Results

The mean operating time was 70 min (SD?±?12). The tensile strength of the mini-laparoscopic instruments allowed appropriate manipulation of tissue consistent with that of conventional instruments. No difficulties or complications were experienced in comparison to a conventional technique. All patients were discharged from hospital on day 1 postoperatively.

Conclusions

The effectiveness, safety and feasibility of the mini-laparoscopic surgical technique was applied to sacrocolpopexy. Because of the initial favourable experience, the mini-laparoscopic sacrocolpopexy could become more widely used in the future.

     

Retrospective single-surgeon study of outcomes after laparoendoscopic single-site cholecystectomy and sigmoidectomy

Purpose

Laparoendoscopic single-site (LESS) surgery is performed through a single port but requires a larger incision than conventional laparoscopy, which theoretically increases the risk of laparoscopic port hernia. Our primary objective is to determine the trocar site hernia rate among our patients.

Methods

This retrospective study is based on the analysis of demographic, intraoperative, and postoperative data of 219 patients who underwent cholecystectomy or sigmoidectomy by LESS surgery between December 1st, 2009 and November 30th, 2012.

Results

Cholecystectomy and sigmoidectomy LESS surgery were performed on 190 and 29 patients, respectively. Three patients developed a trocar site hernia within a median follow-up time of 34.7 months. Eleven patients were obese, 20 had a history of abdominal surgery, and 20 had a preoperative umbilical hernia but none of them developed a trocar site hernia, neither did the 11 subsequently pregnant women. Significant association was found between preoperative umbilical hernia and early complications including incisional cellulitis and hematoma.

Conclusions

A rate of 1.4 % of trocar site hernia was observed in our study population. This rate is similar to the one reported after conventional laparoscopy. Peri-umbilical incision, longer than that with conventional laparoscopy, allowed better preexisting hernia handling, made anatomical closing easier among obese patients, and facilitated specimen extraction thus limiting traumatic operations.

     

The use of expanding ports in laparo-endoscopic single-site surgery may cause more pain: a meta-analysis of randomized clinical trials

Background

Previous meta-analyses on the clinical outcome after laparo-endoscopic single-site surgery (LESS) versus conventional laparoscopic surgery (CLS) have not revealed any major differences in postoperative pain between the two procedures. This meta-analysis aims to evaluate the difference in postoperative pain between the two procedures, focusing on whether LESS was conducted with a non-expanding port (LESSnonex) or a port expanding (LESSex) within the incision.

Method

EMBASE, Medline, PubMed, Science Citation Index Expanded, and Cochrane Central Register of Controlled Trials were searched for randomized clinical trials (RCTs) on LESS versus CLS for general abdominal procedures. Weighted mean difference (WMD) and Odds ratios (OR) were calculated with 95% confidence intervals (CI).

Results

A total of 29 RCTs with 2999 procedures were included. Pain (VAS 0–10) 6 h after surgery was significantly lower in the group where LESS was conducted with LESSnonex compared to CLS, WMD=?0.72 (??1.10 to ??0.33). Pain 18–24 h was significantly higher in the group where LESS was conducted with LESSex compared to CLS, WMD?=?0.38 (0.01–0.75). Wound-related complications were significantly more frequent in LESSex procedures compared to CLS, OR?=?1.94 (1.03–3.63).

Conclusion

The present meta-analysis indirectly indicates that the type of access device that is used for an abdominal LESS procedure may contribute to the development of early postoperative pain as the use of a non-expanding model was associated with a more advantageous outcome. Direct randomized comparison of LESSnonex and LESSex is warranted to confirm if the use of expanding access devices generates more pain and wound complications.

     

Efficacy of fourth-line targeted therapy in patients with metastatic renal cell carcinoma: a retrospective analysis

Introduction

Evidence for sequencing targeted therapy (TT) in patients with metastatic renal cell carcinoma (mRCC) beyond third line is limited. Treatment decisions for these sequence options are largely based on individual preferences and experience. The aim of this study was to describe the efficacy and toxicity of fourth-line TT.

Materials and methods

We retrospectively reviewed patients treated with fourth-line TT for mRCC after failure of previous treatment lines at a German academic high-volume center. Out of 406 patients treated in first line, 56 patients (14.8 %) were identified with more than three lines of TT. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan–Meier method. Cox proportional hazards models were applied to explore predictors of PFS and OS in uni- and multivariable analysis.

Results

For the fourth-line treatment, disease control rate was 35.7 %. Median OS from beginning of first-line therapy was 47.4 months (IQR 31.0–76.5). Primary resistance at first-line TT, metastatic disease at initial diagnosis and an intermediate MSKCC score were independent predictors of shorter OS from start of first-line TT. Median OS from the time of initiation of fourth-line therapy was 10.5 months (IQR 5.6–22.6). The corresponding median PFS for fourth-line TT was 3.2 months (IQR 1.6–8.0) and was not correlated with treatment response in first-line TT. The rate of toxicity-induced treatment termination was 16.1 %. Limitations are the retrospective and unicentric design with a limited number of patients.

Conclusions

Patients might benefit from subsequent treatment lines independently from treatment response in first line.

     

Medium-Term Results of Combined Laparoscopic Sleeve Gastrectomy and Modified Jejuno-Ileal Bypass in Bariatric Surgery

Background

The ideal bariatric operation achieves 70–100 % maintained excess weight loss, is simple with low operative risks, and maintains absorption of trace elements. Our aim was to find a bariatric procedure that achieves the above while avoiding drawbacks of current options.

Methods

A standard sleeve gastrectomy was combined with a modified jejuno-ileal bypass dividing the small bowel 75 cm distal to the duodeno-jejunal flexure, anastomosing it to the ileum 75 cm proximal to the ileocaecal valve. Operative and follow-up data were collected prospectively between December 2004 and January 2013.

Results

One hundred sixty-eight procedures were analysed (110 female, 58 male). Mean patient age was 43 years (IQR 37–47), and median preoperative body mass index (kg/m²) was 52 (IQR 49–59). All operations were completed laparoscopically. Excess weight loss was 78 % (IQR 70–83 %, 12 months, n?=?168), 79 % (IQR 70–85 %, 24 months), maintained at most recent follow-up with 77 % (IQR 68–84 %, n?=?168), and for 8 year follow-up alone 75 % (IQR 66–84 %, n?=?18). There was no operative mortality and 5.4 % morbidity. A 6.5 % of patients experienced transient vomiting. No symptoms of dumping or bacterial overgrowth were observed. All had normal liver enzymes. Hypocalcaemia (20.8 %) and zinc deficiency (25.6 %) resolved with oral supplementation. Type 2 diabetes mellitus resolved in 80.3 % and improved in the remainder of patients, hypertension resolved in 92.3 % and improved in the rest.

Conclusions

Whilst currently an investigative procedure, and within the studies limitations combined sleeve gastrectomy with modified jejuno-ileal bypass is safe and effective, and evades many problems associated with current bariatric operations whilst offering maintained excess weight loss.

     

Abdominal wall integrity after open abdomen: long-term results of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM)

Purpose

The open abdomen has become a standard technique in the management of critically ill patients undergoing surgery for severe intra-abdominal conditions. Negative pressure and mesh-mediated fascial traction are commonly used and achieve low fistula rates and high fascial closure rates. In this study, long-term results of a standardised treatment approach are presented.

Methods

Fifty-five patients who underwent OA management for different indications at our institution from 2006 to 2013 were enrolled. All patients were treated under a standardised algorithm that uses a combination of vacuum-assisted wound closure and mesh-mediated fascial traction. Structured follow-up assessments were offered to patients and included a medical history, a clinical examination and abdominal ultrasonography. The data obtained were statistically analysed.

Results

The fascial closure rate was 74 % in an intention-to-treat analysis and 89 % in a per-protocol analysis. The fistula rate was 1.8 %. Thirty-four patients attended follow-up. The median follow-up was 46 months (range 12–88 months). Incisional hernias developed in 35 %. Patients with hernias needed more operative procedures (10.3 vs 3.4, p = 0.03) than patients without hernia formation. A Patient Observer Scar Assessment Scale (POSAS) of 31.1 was calculated. Patients with symptomatic hernias (NAS of 2–10) had a significantly lower mean POSAS score (p = 0.04).

Conclusions

Vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) seem to result in low complication rates and high fascial closure rates. Abdominal wall reconstruction, which is a challenging and complex procedure and causes considerable patient discomfort, can thus be avoided in the majority of cases. Available results are based on studies involving only a small number of cases. Multi-centre studies and registry-based data are therefore needed to validate these findings.

     

Propensity Score Analysis of an Enhanced Recovery Programme in Upper Gastrointestinal Cancer Surgery

Introduction

The aim of this study was to examine the influence of an enhanced recovery programme (ERP) on outcomes of upper gastrointestinal (UGI) cancer surgery by means of propensity score-matched analysis.

Methods

Three hundred consecutive patients diagnosed with UGI cancer were studied prospectively before and after the introduction of an ERP. Multiple regression models, including propensity scores, were developed to assess confounding variables associated with undergoing surgery, and the risk adjusted association between treatment and length of hospital stay (LOHS).

Results

After regression for confounding factors, a cohort of 252 patients was available of whom 160 received ERP [median age 66 years (IQR 58–73), 119 male, 81 oesophageal, 79 gastric cancer] and 92 control [66 years (IQR 58–74), 74 male, 58 oesophageal, 34 gastric cancer]. ERP operative morbidity (Clavien–Dindo ≥3) and mortality were 13.8 and 3.1 % compared with 17.4 (p = 0.449) and 2.2 % (p = 0.658) in controls. Median ERP critical care and total LOS were 1 (IQR 0–1) and 13 (IQR 10–17) days, compared with 1 (IQR 1–2, p = 0.009) and 16 (IQR 13–26, p < 0.001) days. Multivariable analysis revealed ERP (HR 1.477, 95 % CI 1.084–2.013, p = 0.013), tumour location (HR 2.420, 95 % CI 1.624–3.606, p < 0.001), operative procedure (HR 1.143, 95 % CI 1.032–1.265, p = 0.010), and operative morbidity (HR 0.277, 95 % CI 0.179–0.429, p < 0.001) to be associated with LOHS.

Conclusion

An ERP in UGI cancer surgery was feasible, safe, and effective.

     

Comparison of strength of sacrocolpopexy mesh attachment using barbed and nonbarbed sutures

Introduction and hypothesis

We aimed to assess the pull-out strength of barbed and nonbarbed sutures used in sacrocolpopexy mesh fixation. We hypothesized there are no differences in the force needed to dislodge mesh from tissue using barbed and nonbarbed sutures of similar size.

Methods

Using the rectus fascia of three unembalmed cadavers, a 6 × 3 cm strip of polypropylene mesh was anchored to the fascia with sutures. The barbed sutures investigated were 2-0 V-Loc 180 (nine trials) and 3-0 bidirectional Quill? SRS PDO (five trials). The nonbarbed sutures included 2-0 PDS (nine trials), CV-2 GORE-TEX (nine trials) and 2-0 Prolene (nine trials). The free-end of the mesh was anchored to a pulley system fixed to a tensiometer to measure the peak force applied at the moment of mesh dislodgement (termed the pull-out force). The pull-out force was recorded. Continuous variables are presented as medians and interquartile ranges (IQR). Analysis of variance was used to compare the forces across the suture types.

Results

The highest pull-out force observed was with GORE-TEX (median 65.14 N, IQR 53.37–68.77 N) followed by Prolene (median 58.98 N, IQR 54.64–62.59 N), V-Loc (median 55.23 N, IQR 51.60–58.57 N), PDS (53.96 N, IQR 51.60–57.88 N), and Quill (44.44 N, IQR 17.27–47.38 N). All 2-0 and CV-2 caliber sutures had greater pull-out forces than 3-0 Quill sutures (p < 0.01). No significant differences in pull-out forces were observed between 2-0 and CV-2 caliber sutures (p > 0.05). In 35 of the 41 trials (85%), the mesh sheared from the tissue.

Conclusion

CV-2 ad 2-0 barbed and nonbarbed sutures had similar pull-out forces in an assessment of mesh fixation strength.

     

Bilateral endoscopic totally extraperitoneal (TEP) inguinal hernia repair does not impair male fertility

Purpose

Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation may affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients.

Methods

Fifty-seven male patients (22–60 years old) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh. The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status, and semen quality. All patients were assessed preoperatively and 6 months postoperatively.

Results

Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters or testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3 IU/L (IQR 3.4–5.3) versus postoperative median 5.0 IU/L (IQR 3.6–6.5), p = 0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0 ng/L (IQR 106.5–183.0) versus postoperative median 27.0 ng/L (IQR 88.3–170.9), p = 0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality.

Conclusions

Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair fertility, as no differences in testicular blood flow, testicular volume, or semen quality were observed. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be ascribed to these findings.

     

Mesenteric Lymphatic Vessel Density Is Associated with Disease Behavior and Postoperative Recurrence in Crohn’s Disease

Purpose

The aims of the present study were to examine the density of lymphatic vessels in the mesentery and to assess the predictive value of the mesenteric lymphatic vessel density for postoperative clinical recurrence.

Methods

Ileocolonic resection specimens were obtained from 53 patients with Crohn’s disease and 10 non-inflammatory bowel disease control subjects. Mesentery adipose tissues adjacent to the bowel wall were used for the histological quantification of lymphatic vessels using immunohistochemistry with the D2-40 antibody. The relationships between lymphatic vessel density and disease behavior, the presence of granulomas, the presence of creeping fat, and postoperative clinical recurrence were assessed.

Results

Median lymphatic vessel density in the mesentery adjacent to inflamed or non-inflamed intestine was lower in control subjects than in Crohn’s disease patients (2.13‰; interquartile range [IQR], 1.83–2.61; 8.34‰; IQR, 6.39–10.22; 4.43‰; IQR, 3.32–5.78; P ? 0.001). Increased mesenteric lymphatic vessel density was significantly associated with stricturing behavior, the presence of intestinal granulomas, the presence of creeping fat, and bowel thickness. Interestingly, patients with disease recurrence had an increased mesenteric lymphatic vessel density of the proximal mesenteric margin at the time of resection compared with those who did not have disease recurrence (6.23‰; IQR, 5.43–6.75 vs. 3.28‰; IQR, 2.93–4.29; P ? 0.001).

Conclusions

In addition to its correlation with disease behavior, bowel thickness, and the presence of intestinal granulomas and creeping fat, increased mesenteric lymphatic vessel density in the proximal margin is predictive of early clinical recurrence after surgery in patients with Crohn’s disease.

     

The outcome of proximal fifth metatarsal fractures: redefining treatment strategies

Background

To optimize the treatment strategy and reduce treatment costs of proximal fifth metatarsal fractures, clinical and patient-reported outcome, and its determinants were addressed.

Methods

A retrospective adult cohort study including 152 proximal fifth metatarsal fractures: 121 nonoperatively and 31 operatively treated. In the operative group, 21 were zone 1 and 10 zone 2 fractures. Median follow-up was 37.5 (IQR 20.8–52.3) months with a minimal follow-up of 6 months. Twenty-three demographic, fracture, and treatment characteristics were assessed as well as the healthcare costs. Outcome was assessed using the patient files, anterior-posterior and oblique X-rays, foot function index (FFI), visual analog score (VAS), and SF-36 questionnaires.

Results

The median FFI, physical SF-36, and VAS scores did not significantly differ between nonoperatively and operatively treated patients. The FFI and physical SF-36 were predominantly affected by a history of mobility impairment and pre-existent cardiovascular diseases, whereas mental SF-36 correlated significantly with higher ASA-score. Overall complication rate was 5.9% (4.1 vs. 12.9%; p?=?0.065, nonoperative vs. operative, respectively). Nonunion was recorded in only one (nonoperatively) treated patient. The total healthcare costs for operative treatment were 4.2 times higher compared to nonoperative treatment (€1960 vs. €463 per patient, respectively).

Conclusion

Overall, the clinical and patient-reported outcome was good. The foot function and quality of life were mainly affected by comorbidity, rather than fracture and treatment-related variables. Although nonoperatively treated patients indicated decreased mental quality of life, our study indicates that proximal fifth metatarsal fractures can safely be treated nonoperatively without the risk of nonunion, with fewer complications and lower healthcare costs.

Level of evidence

3.

     

Risk factors for osteoporotic fractures in persons with spinal cord injuries and disorders

Summary

Clinical risk factors for fracture were explored among Veterans with a spinal cord injury. At the end of 11 years of follow-up, the absolute risk of fracture was approximately 20 %. Among the clinical and SCI-related factors explored, a prior history of fracture was strongly associated with incident fracture.

Introduction

Few studies to date have comprehensively addressed clinical risk factors for fracture in persons with spinal cord injury (SCI). The purpose of this study was to identify risk factors for incident osteoporotic fractures in persons with a SCI that can be easily determined at the point of care.

Methods

The Veteran’s Affairs Spinal Cord Dysfunction Registry, a national database of persons with a SCI, was used to examine clinical and SCI-related risk factors for fracture. Incident fractures were identified in a cohort of persons with chronic SCI, defined as SCI present for at least 2 years. Cox regression models were used to estimate the risk of incident fractures.

Results

There were 22,516 persons with chronic SCI included in the cohort with 3365 incident fractures. The mean observational follow-up time for the overall sample was 6.2 years (median 6.0, IQR 2.9–11.0). The mean observational follow-up time for the fracture group was 3.9 years (median 3.3, IQR 1.4–6.1) and 6.7 years (median 6.7, IQR 3.1–11.0) for the nonfracture group. By the end of the study, which included predominantly older Veterans with a SCI observed for a relatively short period of time, the absolute (i.e., cumulative hazard) for incident fractures was 0.17 (95%CI 0.14–0.21). In multivariable analysis, factors associated with an increased risk of fracture included White race, traumatic etiology of SCI, paraplegia, complete extent of SCI, longer duration of SCI, use of anticonvulsants and opioids, prevalent fractures, and higher Charlson Comorbidity Indices. Women aged 50 and older were also at higher risk of sustaining an incident fracture at any time during the 11-year follow-up period.

Conclusions

There are multiple clinical and SCI-related risk factors which can be used to predict fracture in persons with a SCI. Clinicians should be particularly concerned about incident fracture risk in persons with a SCI who have had a previous fracture.

     

Serologic and radiographic outcome of total hip arthroplasty with CoCr modular neck at mid-term follow-up

Purpose

The aim of this study is a radiographic evaluation and to determine serologic values of chromium and cobalt in the blood and urine of patients who have been implanted with a Stryker^® ABG II Modular Neck and see if there is correlation with the features of prosthesis and patients.

Methods

The study involves the collection of data from patients operated on for total hip model with the ABG II Modular Neck with a minimum follow-up of 1 year.

Results

We evaluated 22 patients who underwent implantation of a hip prosthesis with modular neck in CoCr. Of these, the average Cr in the blood was 0.63 μgL^?1 (range 0.1–2.15 μgL^?1), the average of Co in the blood was 3.50 μgL^?1 (range 0.62–7.78 μgL^?1), the average Cr in the urine was 1.24 μgL^?1 (range 0.48–2.21 μgL^?1), and the average Co in urine was 14.22 μgL^?1 (range 3.3–31.2 μgL^?1). None of these patients had undergone revision surgery.

Conclusions

Our study seems to indicate that the restoration of offset and age are correlated with the release of metal ions, although the correlation is weak and needs better methodological studies and a greater number of patients to confirm this hypothesis.

Study type

Case series Level of Evidence 4.

     

Prognoses and treatment strategies for synchronous peritoneal dissemination of colorectal carcinoma

Purpose

We devised a simple dichotomous classification system and showed sufficient reproducibility to indicate treatment strategies for peritoneal metastasis of colorectal cancer.

Methods

We included 67 patients with peritoneal metastasis of colorectal cancer and classified them according to the largest lesion size, number of lesions and number of regional peritoneal metastases. The oncological data were recorded and compared.

Results

According to the univariate analyses, the prognoses were significantly better in patients with ≤3 disseminated lesions than in those with ≥4, and in patients with disseminated lesions in only one region than in those with ≥2 lesions. A multivariate analysis showed that primary tumor resection and the presence of peritoneal metastases in only one region were favorable factors for the patient survival. Patients with disseminated lesions in only one region (localized group) and those with nonlocalized lesions had three-year survival rates of 45.6 and 12.2 %, respectively. Finally, primary tumor resection improved the prognoses in both the localized and nonlocalized groups.

Conclusions

Colorectal cancer patients were categorized into localized and nonlocalized groups according to the number of regions with peritoneal metastasis, and significant prognostic associations were demonstrated. Subsequent analyses of the oncological data suggested that primary tumor resection contributes to an improved prognosis in all patients with synchronous peritoneal metastases.

     

Impact of body mass index on the oncological outcomes of patients treated with radical nephroureterectomy for upper tract urothelial carcinoma

Purpose

To evaluate the association between body mass index (BMI) and oncological outcomes in patients treated with radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC).

Methods

We retrospectively reviewed 237 consecutive patients treated with RNU for UTUC at our institution between 1990 and 2012. Univariable and multivariable cox regression models investigated the association of BMI with disease recurrence, cancer-specific mortality, and overall mortality.

Results

From the 237 patients, 104 (44%) had a BMI < 25 kg/m², 88 (37%) had a BMI between 25 and 29.9 kg/m², and 45 (19%) had a BMI ≥ 30 kg/m² at the time of surgery. Within a median follow-up of 44 months (IQR: 24–79), 53 patients (22.4%) experienced a disease recurrence, 85 patients (35.9%) had bladder recurrence, and 44 patients (18.6%) died from the disease. The 5 year recurrence-free and cancer-specific survival rates were, respectively, 32 and 56% for BMI ≥ 30 kg/m², 45 and 74% for patients with BMI 25–29.9 kg/m², and 69 and 81% for patients with BMI < 25 kg/m². In multivariable analyses that adjusted for the effects of the standard clinico-pathological features, BMI ≥ 30 kg/m² was associated with a higher risk of disease recurrence (HR 3.23; 95% CI 2.3–6.6, p < 0.001) and cancer-specific mortality (HR 3.84; 95% CI 2.8–6.5; p < 0.001).

Conclusions

Obesity was independently associated with higher risks of disease recurrence and cancer-specific mortality in patients treated with RNU for UTUC.

     

Impact of novel techniques on minimally invasive adrenal surgery: trends and outcomes from a contemporary international large series in urology

Objective

To evaluate contemporary international trends in the implementation of minimally invasive adrenalectomy and to assess contemporary outcomes of different minimally invasive techniques performed at urologic centers worldwide.

Methods

A retrospective multinational multicenter study of patients who underwent minimally invasive adrenalectomy from 2008 to 2013 at 14 urology institutions worldwide was included in the analysis. Cases were categorized based on the minimally invasive adrenalectomy technique: conventional laparoscopy (CL), robot-assisted laparoscopy (RAL), laparoendoscopic single-site surgery (LESS), and mini-laparoscopy (ML). The rates of the four treatment modalities were determined according to the year of surgery, and a regression analysis was performed for trends in all surgical modalities.

Results

Overall, a total of 737 adrenalectomies were performed across participating institutions and included in this analysis: 337 CL (46 % of cases), 57 ML (8 %), 263 LESS (36 %), and 80 RA (11 %). Overall, 204 (28 %) operations were performed with a retroperitoneal approach. The overall number of adrenalectomies increased from 2008 to 2013 (p = 0.05). A transperitoneal approach was preferred in all but the ML group (p < 0.001). European centers mostly adopted CL and ML techniques, whereas those from Asia and South America reported the highest rate in LESS procedures, and RAL was adopted to larger extent in the USA. LESS had the fastest increase in utilization at 6 %/year. The rate of RAL procedures increased at slower rates (2.2 %/year), similar to ML (1.7 %/year). Limitations of this study are the retrospective design and the lack of a cost analysis.

Conclusions

Several minimally invasive surgical techniques for the management of adrenal masses are successfully implemented in urology institutions worldwide. CL and LESS seem to represent the most commonly adopted techniques, whereas ML and RAL are growing at a slower rate. All the MIS techniques can be safely and effectively performed for a variety of adrenal disease.

     

Significant increase in detection of prostate cancer recurrence following radical prostatectomy with an early imaging acquisition protocol with <Superscript>18</Superscript>F-fluorocholine positron emission tomography/computed tomography

Purpose

To highlight a new imaging acquisition protocol during ¹⁸F-fluorocholine PET/CT in patients with biochemical recurrence after RP.

Methods

A total of 146 patients with PSA levels between 0.2 and 1 ng/ml with negative conventional imaging who did not receive salvage treatment were prospectively enrolled. Imaging acquisition protocol included an early dynamic phase (1–8 min), a conventional whole body (10–20 min), and a late phase (30–40 min). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were measured. Univariable and multivariable analyses were performed to identify independent predictors of positive PET/CT.

Results

The median trigger PSA was 0.6 ng/ml (IQR 0.43–0.76). Median PSA doubling time (PSA DT) was 7.91 months (IQR 4.42–11.3); median PSA velocity (PSAV) was 0.02 ng/ml per month (IQR 0.02–0.04). Overall, ¹⁸F-fluorocholine PET/CT was positive in 111 of 146 patients (76 %). Out of 111 positive examinations, 80 (72.1 %) were positive only in the early dynamic phase. Sensitivity, specificity, PPV, NPV, and accuracy were 78.9, 76.9, 97.2, 26.3, and 78.7 %, respectively. At multivariable logistic regression, trigger PSA ≥ 0.6 ng/ml [odds ratio (OR) 3.13; p = 0.001] and PSAV ≥ 0.04 ng/ml per month (OR 4.95; p = 0.004) were independent predictors of positive PET/CT. The low NPV remains the main limitation of PET/CT in this setting of patients.

Conclusions

The increased sensitivity, thanks to the early imaging acquisition protocol, makes ¹⁸F-fluorocholine PET/CT an attractive tool to detect prostate cancer recurrences in patients with a PSA level <1 ng/ml.

     

NGAL distinguishes steroid sensitivity in idiopathic nephrotic syndrome

Background

Idiopathic nephrotic syndrome (NS) is the most common glomerular disorder of childhood. Invasive biopsy remains the diagnostic method of choice for NS. Prognosis correlates with steroid responsiveness, from sensitive (SSNS) to resistant (SRNS). Neutrophil gelatinase-associated lipocalin (NGAL) has been demonstrated to be a powerful risk marker of chronic kidney disease progression. We set out to determine if urine NGAL can distinguish between patients with SRNS, SSNS, and healthy controls.

Methods

Urine and clinical data were collected from patients at Cincinnati Children's Hospital who were recently diagnosed with active nephrotic syndrome as well as healthy controls. Participants included SRNS (n?=?15), SSNS (n?=?14), and healthy controls (n?=?10). Urinary NGAL was measured by ELISA and normalized to creatinine.

Results

Median NGAL was significantly (p?p?r?=??0.5, p?

Conclusions

NGAL levels differentiate SSNS from SRNS and correlate with disease severity in SRNS.