Comparison of gelatine matrix-thrombin sealants used during laparoscopic partial nephrectomy

OBJECTIVE

To compare haemostasis and other outcomes after the use of bovine‐derived or porcine‐derived gelatine matrix‐thrombin sealants (GMTS) in a continuous series of patients during and for 6 months after laparoscopic partial nephrectomy (LPN).

PATIENTS AND METHODS

Between October 2006 and September 2007, a consecutive sample of 35 patients with renal tumours underwent LPN by a single surgeon at a referral centre. Group 1 (25 patients) received a bovine‐derived GMTS and Group 2 (10 patients) a porcine‐derived GMTS. All patients underwent LPN and received one of the two GMTS, applied to the resected bed before sutured renorrhaphy over oxidized nitrocellulose bolsters. Surgical and pathology variables, including ischaemia time, blood loss, tumour size, and serum creatinine values before and after LPN, were measured. Glomerular filtration rates were calculated before and after LPN. Haemostasis was ascertained by visual examination.

RESULTS

Intraoperative haemostasis was achieved in all cases. No associated complications occurred within 3 weeks of LPN. The two groups were comparable in age (median, 65 vs 69 years, P = 0.62), gender, tumour number and location, median ischaemia time (34 vs 28 min, P = 0.148), and blood loss (200 vs 150 mL, P = 0.518). One patient in Group 1 developed a urinary fistula. One patient in Group 2 experienced self‐limited gross haematuria.

CONCLUSIONS

Both the porcine‐ and bovine‐derived agents provided acceptable haemostasis without adverse events during LPN and in the early postoperative period. Occurrences of delayed haemorrhage and urinary fistula were not likely to be related to the choice of prothrombotic agent.     

Self-retaining barbed suture for parenchymal repair during laparoscopic partial nephrectomy; initial clinical experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This paper reports on outcomes for SRBS during conventional laparoscopic partial nephrectomy. In addition to an improvement in warm ischaemia time, we found that SRBS use during LPN may be beneficial in reducing rates of clinically significant haemorrhage.

OBJECTIVES

• ? To evaluate the efficacy of a self‐retaining barbed suture (SRBS) in achieving a secure and haemostatic renorrhaphy during laparoscopic partial nephrectomy (LPN).
• ? To compare perioperative outcomes for LPN with SRBS with those for LPN with conventional polyglactin suture, with specific attention to warm ischaemia time, blood loss and need for postoperative bleeding interventions.

PATIENTS AND METHODS

• ? Patients who underwent LPN between June 2007 and October 2010 were identified through an Institutional Review Board approved registry of oncological patients.
• ? Before July 2009, parenchymal repair after tumour excision was performed using absorbable polyglactin suture (Group 1), and subsequently, using SRBS (Group 2).
• ? Demographic, clinical, intraoperative and postoperative outcomes were compared for each group.

RESULTS

• ? LPN was performed in 49 patients in Group 1 and 29 in Group 2.
• ? Baseline demographic and clinical features, estimated blood loss, and transfusion and embolization rates were statistically similar for the cohorts.
• ? Mean warm ischaemia time (±SD) was significantly shorter for the SRBS group (26.4 ± 8.3 vs 32.8 ± 7.9; P= 0.0013).
• ? Bleeding requiring intervention (open conversion or transfusion ± embolization) was more common for Group 1 (9/49, 18.4% vs 1/29, 3.4%; P= 0.06).

CONCLUSIONS

• ? The use of SRBS for parenchymal repair during LPN in humans is safe and is associated with a significant reduction in warm ischaemia time.
• ? SRBS use during LPN may also reduce rates of clinically significant bleeding.
• ? Prospective, larger studies to confirm the value of SRBS use in minimally invasive partial nephrectomy are warranted.

     

Neoadjuvant Chemoradiotherapy Affects the Indications for Lateral Pelvic Node Dissection in Mid/Low Rectal Cancer with Clinically Suspected Lateral Node Involvement: A Multicenter Retrospective Cohort Study

Background

Although lateral pelvic node dissection (LPND) is recommended for rectal cancer with clinically metastatic lateral pelvic lymph nodes (LPNs), LPNs may respond to neoadjuvant chemoradiotherapy (nCRT). Our aim was to determine the optimal indication for LPND after nCRT for mid/low rectal cancer.

Methods

Of 2,263 patients with clinical stage II/III mid/low rectal cancer who were managed at three tertiary referral hospitals, 66 patients underwent curative surgery including LPND after nCRT were included in this study. Risk factors for LPN metastasis were retrospectively analyzed and oncologic outcomes determined according to LPN response to nCRT.

Results

Persistent LPNs greater than 5 mm on post-nCRT magnetic resonance imaging were significantly associated with residual tumor metastasis, unlike responsive LPN after nCRT (short-axis diameter ≤5 mm) (pathologically, 61.1 % [22 of 36] vs. 0 % [0 of 30], P < 0.001). Multivariable analysis revealed post-nCRT LPN size as a significant and independent risk factor for LPN metastasis (odds ratio 2.390; 95 % confidence interval 1.104–4.069). Over a median follow-up of 39.3 months, the recurrence rate was lower in patients with responsive nodes than in patients with persistent nodes (20 % [6 of 30] vs. 47.2 % [17 of 36], P = 0.012). The 5-year overall survival and 5-year disease-free survival rates were lower in patients with persistent LPN than in patients with responsive LPN (44.6 % vs. 77.1 %, P = 0.034; 33.7 % vs. 72.5 %, P = 0.011, respectively).

Conclusions

In mid/low rectal cancer with clinically metastatic LPNs, the decision to perform LPND should be based on the LPN response to nCRT.     

Nicorandil‐induced penile ulcerations: a case series

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Partial nephrectomy is the standard treatment for the management of small renal masses, and laparoscopy has been widely used in this setting as it has all the principles of open procedures combined with the advantages of minimal invasiveness. Laparoscopic partial nephrectomy is feasible and has acceptable pathological results not only for small renal masses but also for large tumours, even if complication rate and ischemia time are still matters of debate.

OBJECTIVE

• ? To investigate the perioperative safety of laparoscopic partial nephrectomy (LPN) for large renal masses (>4 cm).

PATIENTS AND METHODS

• ? After Institutional Review Board approval, data from 100 consecutive patients who had undergone transperitoneal or retroperitoneal LPN at our institution from January 2005 to June 2009 were obtained from our prospectively maintained database.
• ? The patients were divided into two groups according to radiological tumour size: group A (67 patients) with tumours ≤4 cm and group B (33 patients) with tumours >4 cm.
• ? Demographic, perioperative and pathological data were evaluated.

RESULTS

• ? The two groups were comparable in terms of demographic data. Mean tumour size was 2.4 and 5 cm (P= 0.0001) for groups A and B, respectively. Group B tumours were more complex, as reflected by significantly more with a central location (P= 0.002), and by significantly more transperitoneal LPNs, pelvicalyceal repairs and longer warm ischaemia time (WIT; 19 vs 28 min).
• ? Complications were recorded in nine group A patients (13.4%) and nine group B patients (27.2%) (P= 0.09).
• ? There was no difference between preoperative and postoperative serum creatinine levels in either group, while a significant difference was found in postoperative estimated glomerular filtration rate between groups (P= 0.004).
• ? The incidence of carcinoma was comparable between the two groups.
• ? The incidence of positive surgical margins (PSMs) was 3.9% in group A, whereas no PSM was recorded in group B (P= 0.3).

CONCLUSIONS

• ? Laparoscopic partial nephrectomy for large tumours is feasible and has acceptable pathological results. However, the complication rate, in particular WIT, remains questionable.
• ? Further studies are required to better clarify the role of LPN in the management of tumours of this size.

     

Laparoscopic partial nephrectomy: risk stratification according to patient and tumor characteristics

Purpose

Laparoscopic partial nephrectomy (LPN) is the treatment of choice for localized tumors in many centers. We aimed to evaluate differences in complication rates and outcome stratified by risk categories, depending on patient or tumor characteristics.

Methods

Eighty-one patients who underwent LPN for localized renal tumors between 2004 and 2007 were evaluated. Clinical and pathological data, including localization, size and infiltration depth (classified according to PADUA and RENAL score), at initial radiologic imaging were analyzed. Results were correlated with complications during or after surgery, operative time, warm ischemia time and clinical outcome.

Results

Overall complication rate was 13.6% for LPN (11 patients, Clavien-Dindo classification: II–III). No significant correlations were found for patient-based risk classification models (age?>?70?years, ASA-status?>2, BMI?>?30). A higher mean operative time was observed in centrally located tumors (P?=?0.045). Increased hemoglobin loss was observed in central (P?=?0.007), PADUA?>?8 (P?=?0.006) and RENAL?>?7 (P?=?0.002) tumors. Impaired renal function (creatinine increase in postoperative controls) was associated with tumor diameter?>?4?cm (P?=?0.023). Only central tumor growth had a significant predictive value for postoperative complications (P?=?0.007). In patients with central tumor growth (P?=?0.002), PADUA?>?8 (P?=?0.041) and RENAL?>?7 (P?=?0.044) scores, hospital stay was prolonged.

Conclusions

Uni and multifactorial scoring systems have been developed for LPN to identify potentially high-risk patients. In our series, only central tumor growth pattern enabled the prediction of increased operation time, hemoglobin loss, hospitalization as well as postoperative complications.     

Tumour in solitary kidney: laparoscopic partial nephrectomy vs laparoscopic cryoablation

Study Type – Therapy (cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Tumour in a solitary functioning kidney represents an absolute indication for nephron‐sparing surgery whenever technically feasible. We report the longest follow‐up data comparing laparoscopic partial nephrectomy and laparoscopic cryoablation in patients with solitary kidney with oncological follow‐up to five years.

OBJECTIVES

? We compare perioperative, functional and intermediate‐term oncological outcomes of laparoscopic partial nephrectomy (LPN) vs laparoscopic cryoablation (LCA) for small renal tumour in patients with a solitary kidney. ? A treatment algorithm is also proposed.

PATIENT AND METHODS

? Over a 10‐year period (02/1998‐09/2008), 78 patients with a small tumour in a functionally solitary kidney underwent LPN (n= 48) or LCA (n= 30). ? Baseline, perioperative, and follow‐up data were collected prospectively and analyzed retrospectively.

RESULTS

? Demographic data were similar between the LPN and LCA groups. Tumours were somewhat larger (3.2 vs 2.6 cm) in the LPN group. LPN was associated with greater blood loss (391 vs 162 mL; P= 0.003), and trended towards more post‐operative complications (22.9% vs 6.7%; P= 0.07). ? By 3 months post‐operative, eGFR decreased by 14.5% and 7.3% after LPN and LCA, respectively (P= 0.02). Post‐operative temporary dialysis was required after 3 LPN (6.2% vs 0%, P= 0.16). ? Median follow‐up time for LPN and LCA was 42.7 and 60.2 months, respectively. ? Local recurrence was detected in 4 (13.3%) LCA patients only (P= 0.02). ? Overall survival was comparable between LPN and LCA at 3 and 5 years, respectively (P= 0.74). The LPN group had superior cancer‐specific and recurrence‐free survival at 3 and 5 years compared to the LCA group (P < 0.05, for all comparisons).

CONCLUSIONS

? Given adequate technical expertise, both LPN and LCA are viable nephron‐sparing options for patients with tumour in a solitary kidney. ? Although LCA is technically easier and has superior functional outcomes, oncologic outcomes are superior after LPN.     

Outcomes of Laparoscopic Partial Nephrectomy after Fellowship Training

Background and Objectives:

Experienced surgeons at select high-volume centers have reported favorable outcomes of laparoscopic partial nephrectomy (LPN) in their contemporary experience. However, it is unclear whether recently fellowship-trained surgeons can replicate such outcomes. We evaluated LPNs performed by 3 surgeons in their initial years of independent practice following laparoscopic fellowship training.

Methods:

Prospectively maintained databases were queried for LPNs performed during the first 3.5 years of practice. Intraoperative parameters, oncological efficacy, and postoperative complications were analyzed.

Results:

Of 138 total LPNs (76 left, 62 right), the mean patient age was 57 years, mean tumor size was 2.52cm, and mean depth of invasion was 1.68cm. Mean OR time was 252 minutes, mean warm ischemia time (WIT) was 26 minutes, and mean estimated blood loss (EBL) was 202 mL. Complications occurred in 7 patients (5%), and conversions occurred in 9 patients (7%). Comparison of the first 15 vs. the last 15 cases demonstrated a significant reduction in mean OR time (204 min vs. 253 min, P=0.007), and mean WIT (24 min vs. 32 min, P<0.001). No significant change was demonstrated for tumor size (2.6 cm vs. 2.4 cm, P=0.390) or EBL (226 mL vs. 220 mL, P=0.922).

Conclusion:

Newly fellowship-trained surgeons performing LPN achieve initial outcomes comparable to those reported by highly experienced surgeons. Further experience reduced total operative and warm ischemia times.     

Postoperative haemorrhage following transurethral resection of the prostate (TURP) and photoselective vaporisation of the prostate (PVP)

INTRODUCTION

Intractable haemorrhage after endoscopic surgery, including transurethral resection of the prostate (TURP) and photoselective vaporisation of the prostate (PVP), is uncommon but a significant and life-threatening problem. The knowledge and technical experience to deal with this complication may not be wide-spread among urologists and trainees. We describe our series of TURPs and PVPs and the incidence of postoperative bleeding requiring intervention.

PATIENTS AND METHODS

We retrospectively reviewed 437 TURPs and 590 PVPs over 3 years in our institution. We describe the conservative, endoscopic and open prostatic packing techniques used for patients who experienced postoperative bleeding.

RESULTS

Of 437 TURPs, 19 required endoscopic intervention for postoperative bleeding. Of 590 PVPs, two patients were successfully managed endoscopically for delayed haemorrhage at 7 and 13 days post-surgery, respectively. In one TURP and one PVP patient, endoscopic management was insufficient to control postoperative haemorrhage and open exploration and packing of the prostatic cavity was performed.

CONCLUSIONS

Significant bleeding after endoscopic prostatic surgery is still a potentially life-threatening complication. Prophylactic measures have been employed to reduce peri-operative bleeding but persistent bleeding post-endoscopic prostatic surgery should be treated promptly to prevent the risk of rapid deterioration. We demonstrated that the technique of open prostate packing may be life-saving.     

Splenic artery embolisation in children and adolescents—An 8 year experience

Background

Non-operative management (NOM) is the treatment of choice in blunt splenic injuries in the paediatric population, with reported success rates exceeding 90%. Splenic artery embolisation (SAE) was added to our institutional treatment protocol for splenic injury in 2002. We wanted to review indications for SAE and the clinical outcome of splenic injury management in children admitted between August 1, 2002 and July 31, 2010.

Methods

Patients aged <17 years with splenic injury were identified in the institutional trauma and medical code registries. Patient charts and computed tomographic (CT) scans were reviewed.

Results

Of the 72 children and adolescents with splenic injury included during the 8 year study period, 66 patients (92%) were treated non-operatively and six underwent operative management. Severe splenic injury (OIS grade 3–5) was diagnosed in 67 patients (93%). SAE was performed in 22 of the NOM patients. Indications for SAE included – bleeding (n = 8), pseudoaneurysms (n = 2), contrast extravasation (n = 2), high OIS injury grade (n = 8) and prophylactic due to specific disease (n = 2). NOM was successful in all but one case (98%). For the patients aged ≤14 years, extravasation on initial CT scan correlated to delayed bleeding (p < 0.001). Two SAE procedure specific complications were registered, but resolved without significant sequelae.

Conclusion

After SAE was added to the institutional treatment protocol, 22 of 66 NOM paediatric patients underwent SAE. NOM was successful in 98% and a 90% splenic preservation rate was achieved. Contrast extravasation correlated to delayed splenic bleeding in children ≤14 years.     

RENAL nephrometry score predicts surgical outcomes of laparoscopic partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? For small renal tumours, partial nephrectomy provides excellent cancer control and preserves renal function. The RENAL Nephrometry Score is useful for quantifying anatomic features relevant to surgical decision‐making. In patients undergoing laparoscopic partial nephrectomy, this study shows a correlation between RENAL Nephrometry Score and estimated blood loss, warm ischemia time, and length of hospital stay, suggesting that the RENAL Nephrometry Score may be useful for predicting the technical challenge posed by a renal tumour.

OBJECTIVE

? To assess the use of the RENAL Nephrometry Score (RNS), which has been proposed as an anatomical classification system for renal masses, aiming to predict surgical outcomes for patients undergoing laparoscopic partial nephrectomy (LPN).

MATERIALS AND METHODS

? In the present study, 159 consecutive patients who underwent LPN were reviewed and RNS was calculated for 141 patients with solitary renal masses who had complete radiographic data. ? Renal tumours were categorized by RNS as low (nephrometry sum 4–6), intermediate (sum 7–9) and high (sum 10–12).

RESULTS

? Of the 141 patients, there were 43 (30%) low, 91 (65%) intermediate and seven (5%) high score lesions. There was no statistically significant difference in the demographics of the three groups. ? There was a significant difference in warm ischaemia time (16 vs 23 vs 31 min; P < 0.001), estimated blood loss (163 vs 312 vs 317 mL; P= 0.034) and length of hospital stay (1.2 vs 1.9 vs 2.3 days; P < 0.001) between the low, intermediate and high score groups, respectively. There was no difference in overall operative time (P= 0.862), transfusion rate (P= 0.665), complication rate (P= 0.419), preoperative creatinine clearance (P= 0.888) or postoperative creatinine clearance (P= 0.473) between the groups. ? Sixty‐one lesions (43%) were anterior and 80 (57%) were posterior. No difference was found among any intra‐operative, pathological or postoperative outcomes when comparing anterior vs posterior lesions.

CONCLUSIONS

? In patients undergoing LPN, a higher RNS was significantly associated with an increased estimated blood loss, warm ischaemia time and length of hospital stay. ? The RNS may stratify tumours based on the technical difficulty of performing LPN.     

Outcomes of immediate dental implants in vascularised bone flaps for mandibular reconstruction

Background

The aim of this study is to assess the outcomes of immediate implant placement for dental rehabilitation following mandibular reconstruction with vascularised bone flaps in a single Australian tertiary cancer centre.

Methods

A retrospective analysis of patients who underwent immediate dental implant or delayed placement in vascularised bone flaps was performed. Primary outcome measures assessed included the number of implants placed, operative time, complication rates, time to radiotherapy initiation, dental rehabilitation rates and time to dental rehabilitation.

Results

In total, 187 dental implants were placed in 52 patients, of which 34 patients underwent immediate implant placement and 18 had delayed implant placement. There were no significant differences in the postoperative complication rate (32% immediate vs. 33% delayed, P = 0.89) or time to postoperative radiotherapy (median 42 days immediate vs. 47 days delayed, P = 0.24). Dental rehabilitation was achieved in 62% of the immediate cohort versus 78% of the delayed cohort. The time to be fitted with a dental prosthesis was significantly shorter in the immediate cohort (median 150 days immediate vs. 843 days delayed, P = 0.002).

Conclusions

The placement of immediate dental implants at the time of primary reconstruction of the mandible is a safe procedure and facilitates timely dental rehabilitation.     

Risk factors for delayed bleeding after endoscopic submucosal dissection for gastric neoplasm

Background

Delayed bleeding is one of the major complications of endoscopic submucosal dissection (ESD). The aim of this study is to determine the incidence rate and clinical factors associated with delayed bleeding? as well as the time interval between bleeding and ESD for gastric neoplasm.

Methods

We investigated 647 lesions in 582 consecutive patients undergoing ESD for gastric neoplasm.

Results

Delayed bleeding after ESD was evident in all 28 lesions from 28 patients (4.33% of all specimens, 4.81% of patients), and all achieved endoscopic hemostasis. Resected specimen width (??40?mm) was the only significant factor associated with delayed bleeding on univariate and multivariate analysis. In early delayed bleeding (bleeding occurring on or before the fourth postoperative day), wide resected specimen and tumor location in the lower third of the stomach were significant risk factors. In late delayed bleeding (bleeding occurring after the fifth operative day), wide resected specimen, tumor location in the middle third of the stomach, hypertension, and high body mass index (??25?kg/m²) were significant factors. Delayed bleeding in patients with tumors in the upper and middle third of the stomach (median 8.0?days; range 1?C20?days) occurred significantly later as compared with patients who had tumors in the lower third (median 2.0?days; range 1?C34?days).

Conclusions

Risk factors for delayed bleeding, and the probable underlying mechanism involved, differed depending on the time elapsed between surgery and the bleeding episode.     

Laparoscopic partial nephrectomy for technically challenging tumours

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To investigate the outcomes of laparoscopic partial nephrectomy (LPN) for endophytic tumours and those located near the hilum or the posterior upper‐pole, as these pose a technical challenge.

PATIENTS AND METHODS

Technically challenging tumours were defined as endophytic, hilar, or at the posterior upper‐pole (group 1), and were compared to tumours in other locations (group 2). We collected data prospectively for all patients undergoing LPN at our institution, including baseline patient and tumour characteristics, surgical and postoperative outcomes. Two‐sided t‐test or rank‐sum test, and chi‐square or exact tests were used as appropriate for comparison of continuous and categorical variables, respectively, with P < 0.05 considered to indicate statistical significance.

RESULTS

There were 184 patients treated with LPN (42 in group 1 and 142 in group 2) between 2002 and 2008 by one surgeon (A.L.S.). Groups 1 and 2 were similar in terms of baseline variables (age, sex, body mass index, comorbidities, previous surgery, renal function and haematocrit) and in tumour size. LPN for challenging tumours resulted in a higher rate of collecting system repair (78% in group 1, 61% in group 2, P = 0.03). However, operative (surgery time, warm ischaemia time, blood loss, intraoperative complications) and postoperative outcomes (renal function, nadir haematocrit, complication rate, hospital stay and positive margin rate) were similar between the groups.

CONCLUSIONS

With developing experience LPN can be safe for technically challenging renal tumours in well selected patients.     

Laparoscopic partial nephrectomy for tumours >4 cm compared with smaller tumours: perioperative results

Objective  

The use of laparoscopic partial nephrectomy (LPN) in patients with tumours >4 cm remains to be further evaluated. We report our experience with LPN in tumours >4 cm compared with tumours ≤4 cm.     

Initial experiences with the Hemopatch<Superscript>®</Superscript> as a hemostatic agent in zero-ischemia partial nephrectomy

Purpose

Nephron-sparing surgery (NSS) is the gold standard treatment for resectable renal tumors. In the last decade, laparoscopic partial nephrectomy (LPN) has evolved in technical, surgical and oncological aspects and is an accepted treatment option for local-stage renal tumors. Improvements in not only surgical techniques, but also potent hemostats have encouraged this evolution. Here, we report our initial experiences with a new hemostatic agent, Hemopatch^® (polyethylene glycol-coated collagen patch, Baxter), in zero-ischemia LPN.

Methods

Seven patients with confirmed renal masses were enrolled and subjected to zero-ischemia LPN. In all cases, Hemopatch^® was applied to the tumor resection site after suturing of the renal parenchyma. The following clinical data were captured for analysis: staging information, PADUA and RENAL nephrometry scores, operation time, blood loss, complications, pathology and hospitalization length.

Results

The median tumor size was 30.0 mm (range 9.5–72). The median PADUA and RENAL nephrometry scores were 6 (range 6–7) and 4 (range 4–6), respectively. All LPNs were performed with the zero-ischemia technique. In six of the seven patients, parenchymal suturing of the resection site was performed. No uncontrolled bleeding was observed. The median operation duration was 139 min (range 103–194), the median blood loss was 325 cc (range 50–700) and the median hospitalization length was 6 days (range 4–7). Hemopatch^® provided sufficient hemostasis in all cases. No postoperative complications were observed.

Conclusions

Although this study is limited to a small set of initial experiences with Hemopatch^® in LPN, it proves the feasibility and reliability of this new hemostat. Following further evaluation in prospective randomized comparative studies, Hemopatch^® might represent a promising tool in NSS.

     

Laparoscopic partial nephrectomy for multiple tumours: feasibility and analysis of peri-operative outcomes

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Laparoscopic nephron‐sparing procedures have been increasingly utilized. However, in the presence of multiple tumours the procedure choice is usually shifted to radical nephrectomy. In view of favourable perioperative outcomes, the benefits of minimally‐invasive, nephron‐sparing surgery in experienced hands could be safely extended to patients presenting with multiple ipsilateral renal masses.

OBJECTIVE

• ? To describe our experience with laparoscopic partial nephrectomy (LPN) for multiple kidney tumours and compare the outcomes with LPN performed for single masses.

PATIENTS AND METHODS

• ? Retrospective analysis of medical records of patients undergoing LPN at our institution between 2005 and 2009 was performed.
• ? The cohort was divided in two groups based on tumour focality: group 1, LPN for a single tumour (n= 99) and group 2, LPN for multiple ipsilateral tumours (n= 12).
• ? The groups were compared with regards to demographic and peri‐operative variables.

RESULTS

• ? Demographic variables were not different between the groups. Median dominant tumour size was 3.1 cm (interquartile range [IQR] 2.4–4.0) and 4.0 cm (2.3–5.9) in groups 1 and 2, respectively.
• ? Median secondary tumour size in group 2 was 1.0 cm (1.0–1.8).
• ? Operative times were longer in group 2 compared with group 1 (220 vs 160 min, P= 0.009).
• ? Warm ischaemia times (WIT) (23 vs 22 min) and estimated blood loss (EBL) (100 vs 85 mL) were similar.

CONCLUSIONS

• ? LPN is a viable option for the treatment of multiple ipsilateral renal tumours.
• ? Peri‐operative outcomes are similar to standard LPN with the exception of longer operative time.
• ? In experienced hands, the advantages of minimally invasive surgery may be extended to select patients with ipsilateral multifocal renal tumours.

     

Laparoscopic partial nephrectomy: beyond the straightforward T1a

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally‐invasive surgery may be safely extended to patients with more complex renal masses.

OBJECTIVE

• ? To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion.

PATIENTS AND METHODS

• ? Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005–2010.
• ? 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66).
• ? Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra‐ and postoperative complications).

RESULTS

• ? In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases.
• ? Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL).
• ? Operative times were longer in group 2 (190 vs 140min, P < 0.001).
• ? Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547).
• ? There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2).

CONCLUSION

• ? With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally‐invasive surgery to those of nephron‐sparing approach.

     

Prevalence of prostate cancer in men with haematuria: a systematic review and meta-analysis

Objectives

To investigate the prevalence of prostate cancer in men attending evaluation for haematuria, as this could help healthcare providers to determine whether men with haematuria should have prostate examinations performed.

Methods

The study was performed according to a pre-specified protocol uploaded to the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022299383). A systematic search of MEDLINE, Ovid and Google Scholar was performed in December 2021. Two independent researchers evaluated all titles, available abstracts, and full texts. We included studies on adult men (aged ≥18 years) describing haematuria and prostate cancer.

Results

We screened 4252 titles and abstracts when available and assessed 350 studies in full text. In total, 65 studies were included and 42 was summarised in a meta-analysis. In total, 18 752 men with haematuria were included, and the pooled prevalence (95% confidence interval [CI]) of prostate cancer was 3.0% (2.0–4.1%). In men with macroscopic haematuria, the pooled prevalence (95% CI) of prostate cancer was 5.9% (2.9–9.9%; n = 265/5373). In men with microscopic haematuria, the pooled prevalence (95% CI) of prostate cancer was 1.4% (0.8–2.2%; n = 71/6642).

Conclusion

Our findings indicate that the prevalence of prostate cancer is considerable in men attending evaluation for haematuria. Therefore, digital rectal examination and prostate-specific antigen measurement should become a standard procedure for all men with haematuria, especially for men with macroscopic haematuria.     

Transumbilical single-port laparoscopic partial nephrectomy

OBJECTIVE

To present the initial experience with laparoscopic partial nephrectomy (LPN) performed through a transumbilical single port.

PATIENTS AND METHODS

Between November 2007 and April 2008, five selected patients underwent single‐port LPN (SPLPN) for renal tumours. All procedures were performed through a single intraumbilical multichannel laparoscopic port. A 2‐mm grasper was inserted through a 2‐mm Veres needle‐port in the anterior axillary line to aid in tissue retraction and sutured renal reconstruction. The technique of standard multiport LPN was replicated, with the renal hilum clamped.

RESULTS

SPLPN was successfully completed in four patients, while an additional 5‐mm port was required in one patient. The median (range) tumour size was 3 (1–5.9) cm. The median (range) operating time was 270 (240–345) min and the estimated blood loss was 150 (100–600) mL. The median (range) warm ischaemia time was 20 (11–29) min. The median (range) length of the umbilical incision was 2.5 (2.5–4) cm. The median (range) hospital stay was 3(3–22) days. There were no intraoperative complications. All surgical margins were negative for tumour. There were no postoperative complications in four patients. One patient had postoperative bleeding and pulmonary embolism.

CONCLUSIONS

SPLPN is technically feasible, albeit more challenging than conventional LPN. Proper case selection is essential. Advances in single‐port specific instrumentation are needed before these procedures can become a part of mainstream urological laparoscopy.     

Laparoscopic partial nephrectomy with segmental renal artery clamping: technique and clinical outcomes

Background

Warm ischemic injury is one of the most important factors affecting renal function in partial nephrectomy (PN). The technique of segmental renal artery clamping emerges as an alternative to conventional renal artery clamping for renal hilar control.

Objective

To evaluate the feasibility and efficiency of laparoscopic PN (LPN) with segmental renal artery clamping in comparison with the conventional technique.

Design, setting, and participants

A total of 75 patients underwent LPN from June 2007 to November 2009. All patients had T1a or T1b tumor in one kidney and a normal contralateral kidney. Thirty-seven patients underwent surgeries with main renal artery clamping, and 38 underwent surgeries with segmental artery clamping.

Intervention

All procedures were performed by the same laparoscopic surgeon.

Measurements

Blood loss, operation time, warm ischemia (WI) time, and complications affected renal function before and after operation were recorded.

Results and limitations

All LPNs were completed without conversion to open surgery or nephrectomy. The novel technique slightly increased WI time (p < 0.001) and intraoperative blood loss (p = 0.006), while it provided better postoperative affected renal function (p < 0.001) compared with the conventional technique. The total complication rate was 12%. Among the 38 cases where segmental renal artery clamping was performed, 7 had to convert to the conventional method. Tumor size and location influenced the number of clamped segmental arteries. Long-term postoperative renal function is still awaited.

Conclusions

LPN with segmental artery clamping is safe and feasible in clinical practice. It minimizes the intraoperative WI injury and improves early postoperative affected renal function compared with main renal artery clamping.