Technique of Laparoscopic-Endoscopic Single-Site Surgery Radical Nephrectomy

Background

Laparoscopic-endoscopic single-site surgery (LESS) represents the closest surgical technique to scar-free surgery.

Objective

To assess the feasibility of LESS radical nephrectomy (LESS-RN).

Design, setting, and participants

Ten patients with body mass index (BMI) ≤30 underwent LESS-RN for renal tumour by two experienced laparoscopists.

Surgical procedure

TriPort (Olympus Winter &; Ibe, Hamburg, Germany) was inserted through a transumbilical incision. A combination of standard laparoscopic instruments and flexible grasper and scissors was used. A 5-mm 30° camera was also used. The standard laparoscopic transperitoneal nephrectomy technique was performed.

Measurements

Patient demographics, operative details, and final pathology were prospectively recorded. Postoperative evaluation of pain and use of analgesic medication were recorded.

Results and limitations

Ten cases were successfully accomplished (two right-sided tumours and eight left-sided tumours; tumour diameter ranges: 4–8 cm). The mean patient age was 63.5 yr (22–77 yr), and median BMI was 23.56 (18.2–26.6). The mean operative time was 146.4 min (120–180 min), and the mean blood loss was 202 ml (50–900 ml). Pathological examination observed organ-confined T1 renal cell carcinoma in nine cases and pT3b tumour in one case. One bleeding complication occurred. Limitations regarding the intraoperative instrument ergonomics and the requirement for ambidexterity of the surgeon were noted.

Conclusions

LESS-RN proved to be safe and feasible. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RN.     

Laparoendoscopic single-site and conventional laparoscopic radical nephrectomy result in equivalent surgical trauma: preliminary results of a single-centre retrospective controlled study

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the morbidity and scarring associated with surgical intervention, and it has been proposed to result in less induced surgical trauma than conventional laparoscopy.

Objective

Investigate the surgical trauma after LESS radical nephrectomy (LESS-RN) and laparoscopic radical nephrectomy (LRN).

Design, setting, and participants

This was a retrospective single-centre study including 66 patients: 31 patients underwent LESS-RN and 35 historical control patients who had undergone LRN. LRNs were performed between April 2008 and May 2009; LESS-RNs were performed between May 2009 and February 2011.

Intervention

LESS-RN and LRN were both performed via a transperitoneal access. Blood samples were collected pre- and intraoperatively at 6, 24, and 48 h, and at 5 d postoperatively.

Measurements

Serum concentrations of acute-phase markers, C-reactive protein (CRP), serum amyloid A (SAA) antibody, and interleukin 6 (IL-6) and interleukin 10 (IL-10) were measured at each time point by enzyme-linked immunosorbent assay. Clinical data were collected by reviewing the patient's records.

Results and limitations

There were no differences in serum CRP and SAA levels between the groups (CRP: p = 0.12; SAA: p = 0.09) at all time points. The changes in IL-6 levels in the LRN group were statistically significantly higher compared with the LESS-RN group at 6 h after surgery (p = 0.02), whereas the LESS-RN group showed statistically significantly higher IL-6 levels than the LRN group at 24 h after surgery (p = 0.02).Also, the serum levels of the anti-inflammatory cytokine IL-10 showed different kinetics in each group, being higher in the LESS-RN during the early postoperative phase (at 6 h: p = 0.01) and higher in the LRN group at 48 h after surgery (p = 0.01). The limitations of this study were its nonrandomized character and the small cohort of patients.

Conclusions

LESS-RN is as effective as LRN without compromising surgical and postoperative outcomes, but it does not add any significant advantage in comparison with traditional LRN in terms of systemic stress response and surgical trauma.     

A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma

Background

Nephron-sparing surgery (NSS) can safely be performed with slightly higher complication rates than radical nephrectomy (RN), but proof of oncologic effectiveness is lacking.

Objective

To compare overall survival (OS) and time to progression.

Design, setting, and participants

From March 1992 to January 2003, when the study was prematurely closed because of poor accrual, 541 patients with small (≤5 cm), solitary, T1–T2 N0 M0 (Union Internationale Contre le Cancer [UICC] 1978) tumours suspicious for renal cell carcinoma (RCC) and a normal contralateral kidney were randomised to NSS or RN in European Organisation for Research and Treatment of Cancer Genito-Urinary Group (EORTC-GU) noninferiority phase 3 trial 30904.

Intervention

Patients were randomised to NSS (n = 268) or RN (n = 273) together with limited lymph node dissection (LND).

Measurements

Time to event end points was compared with log-rank test results.

Results and limitations

Median follow-up was 9.3 yr. The intention-to-treat (ITT) analysis showed 10-yr OS rates of 81.1% for RN and 75.7% for NSS. With a hazard ratio (HR) of 1.50 (95% confidence interval [CI], 1.03–2.16), the test for noninferiority is not significant (p = 0.77), and test for superiority is significant (p = 0.03). In RCC patients and clinically and pathologically eligible patients, the difference is less pronounced (HR = 1.43 and HR = 1.34, respectively), and the superiority test is no longer significant (p = 0.07 and p = 0.17, respectively). Only 12 of 117 deaths were the result of renal cancer (four RN and eight NSS). Twenty-one patients progressed (9 after RN and 12 after NSS). Quality of life and renal function outcomes have not been addressed.

Conclusions

Both methods provide excellent oncologic results. In the ITT population, NSS seems to be significantly less effective than RN in terms of OS. However, in the targeted population of RCC patients, the trend in favour of RN is no longer significant. The small number of progressions and deaths from renal cancer cannot explain any possible OS differences between treatment types.     

Chronic kidney disease after nephrectomy in patients with small renal masses: a retrospective observational analysis

Context

Chronic kidney disease (CKD) is a worldwide health threat associated with increased cardiovascular disease and mortality.

Objective

To examine postoperative CKD in patients with small renal masses (SRMs) treated with partial nephrectomy (PN) or radical nephrectomy (RN).

Design, setting, and participants

A US National Cancer Institute Surveillance Epidemiology and End Results (SEER)–Medicare-linked retrospective cohort of 4633 T1aN0M0 renal cell carcinoma (RCC) patients who underwent PN or RN.

Outcome measurements and statistical analysis

The primary outcome of interest was the onset of CKD stage ≥3. Secondary end points comprised acute renal failure (ARF), chronic renal insufficiency (CRI), anemia in CKD, and end-stage renal disease (ESRD). Kaplan-Meier and Cox regression analyses were performed.

Results and limitations

Postpropensity matching resulted in 840 RN and PN patients. In multivariable analyses, RN patients were 1.9-, 1.4-, 1.8-, and 1.8-fold more likely to have an occurrence of CKD, ARF, CRI, and anemia in CKD, respectively (all p ≤ 0.004). The risk of ESRD between treatment groups failed to achieve statistical significance (p = 0.06).

Conclusions

PN is associated with more favorable postoperative renal function outcomes relative to RN in the setting of SRMs.     

Daily interruption of sedation in intensive care unit patients with renal impairment: remifentanil-midazolam compared to fentanyl-midazolam

Objective

We compared extubation time following daily interruption of sedation in intensive care unit patients with renal impairment with two sedation regimes remifentanil–midazolam and fentanyl–midazolam.

Study design

Prospective, randomized double-blind trial.

Patients and methods

Patients with renal impairment needing mechanical ventilation for more than 48 hours. Two groups: remifentanil (R) and fentanyl (F), Infusion rates were titrated to achieve the desired Ramsay score. The two groups received midazolam (2.5 mg then 0.1 mg/kg/h).

Results

Nineteen patients were included. Patient's characteristics, mean sedation time and sedation quality were comparable. Extubation time was significantly shorter in R group (1480 ± 980 versus 2880 ± 1280 min, P = 0.04). Weaning time was also shorter in R group (220 ± 164 versus 720 ± 480 min). Agitation on weaning was comparable in the two groups. Group R received significantly more morphine than group F after interruption of sedation.

Conclusion

Daily interruption of sedation with remifentanil is associated with shorter weaning and extubation time in patients with renal impairment. However further studies are necessary to determine if this issue is associated with lower rate of ventilation induced complications.     

Endoscopic Combined Intrarenal Surgery in Galdakao-Modified Supine Valdivia Position: A New Standard for Percutaneous Nephrolithotomy?

Background

Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages.

Objective

To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis.

Design, setting, and participants

From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]).

Intervention

All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed.

Measurements

Patients’ mean age plus or minus standard deviation (± SD) was 53.1 yr ± 14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size ± SD was 23.8 mm ± 7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral.

Results and limitations

Mean operative time ± SD was 70 min ± 28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean ± SD: 5.1 d ± 2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems.

Conclusions

ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.     

A non-cancer-related survival benefit is associated with partial nephrectomy

Background

Partial nephrectomy (PN) may better protect against other-cause mortality (OCM) when compared with radical nephrectomy (RN) in patients with localized renal cell carcinoma (RCC).

Objective

Test the effect of treatment type on OCM.

Design, setting, and participants

Using the Surveillance Epidemiology and End Results–Medicare-linked database, 4956 RN patients (82%) and 1068 PN patients (18%) with T1a RCC were identified (1988–2005).

Measurements

To adjust for inherent differences between treatment types, we relied on propensity-matched analyses. One-to-one matching was performed according to age, sex, race, baseline Charlson comorbidity index (CCI), baseline diagnosis of hypercalcemia and hyperlipidemia, socioeconomic status (SES), population density, tumor size, and year of surgery. The 2- and 5-yr OCM rates were computed using cumulative incidence. Univariable and multivariable competing-risks regression analyses for prediction of OCM were performed according to treatment type. Adjustment was made for cancer-specific mortality (CSM), patient age, CCI, sex, race, SES, tumor grade, and year of surgery.

Results and limitations

Following propensity-based matching, 1068 RN patients were matched with 1068 PN patients. The 2- and 5-yr OCM rates after nephrectomy were 5.0% and 16.0% for PN versus 6.9% and 18.1% for RN, respectively. In the postpropensity multivariable analyses, patients who underwent PN were significantly less likely to die of OCM compared with their RN-treated counterparts (hazard ratio [HR]: 0.83; 95% confidence interval, 0.69–0.98; p = 0.04). Increasing age (HR: 1.08, p < 0.001), higher CCI (HR: 1.14, p < 0.001), female gender (HR: 0.79, p = 0.02), baseline hypercalcemia (HR: 2.05, p = 0.03), baseline hyperlipidemia (HR: 0.73, p = 0.003), and year of surgery (HR: 0.95, p = 0.003) were independent predictors of OCM.

Conclusions

Compared with PN-treated patients, RN-treated patients are more likely to die of OCM after surgery, even after adjusting for CSM, as well as baseline CCI. Consequently, PN should be offered whenever technically feasible.     

Renal damage caused by warm ischaemia during laparoscopic and robot-assisted partial nephrectomy: an assessment using Tc 99m-DTPA glomerular filtration rate

Background

Few studies assessing the functional change of each kidney following warm ischaemia after partial nephrectomy are available.

Objectives

Our aim was to identify the effects of the warm ischaemic time (WIT) on renal function after partial nephrectomy under the pneumoperitoneum.

Design, setting, and participants

Forty-four consecutive patients who underwent laparoscopic partial nephrectomy (LPN) or robot-assisted partial nephrectomy (RAPN) from June 2008 to May 2009 for a single cT1 renal tumour were included in this prospective protocol.

Measurements

Technetium Tc 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scintigraphy was used to determine the glomerular filtration rate (GFR) of both kidneys and each kidney individually. Tc 99m-DTPA GFR was performed preoperatively and 3 mo postoperatively. In addition, we analysed Tc 99m-DTPA scintigraphy GFR regionally in the healthy areas of the affected kidney.

Results and limitations

Patients with WIT >28 min had a significantly greater decrease in the GFR of the affected kidney (p = 0.031). The GFR of the affected kidney showed a significant decrease perioperatively (46.4 ± 14.3 to 37.9 ± 11.9 ml/min per 1.73 m²; p = 0.003). The functional change of the nonaffected kidney showed an increasing trend (47.5 ± 13.8 to 51.4 ± 14.3 ml/min per 1.73 m²), although it was not statistically significant (p = 0.103). Regional Tc 99m-DTPA GFR of both affected kidney and nonaffected kidney showed no significant differences perioperatively (6.3 ± 1.8 to 6.1 ± 1.9 ml/min per 1.73 m²; p = 0.641; 6.6 ± 1.9 to 7.1 ± 2.0 ml/min per 1.73 m²; p = 0.200). On multivariate analysis, preoperative GFR, resected volume of marginal healthy tissue, and WIT were independent predictors for functional reduction of the affected kidney (p < 0.05). The study was limited by small numbers and short follow-up periods.

Conclusions

Stationary overall renal function after LPN or RAPN is masked possibly by functional compensation of the contralateral healthy kidney. The damage of the affected kidney estimated by scintigraphy occurs when WIT exceeds 28 min during partial nephrectomy under the pneumoperitoneum.     

Evaluation of NT-proBNP as an early biological marker of cardiac dysfunction in septic shock

Objective

To evaluate the NT-proBNP as a biological diagnosis marker of the myocardial dysfunction in septic shock.

Study design

Non-randomized prospective clinical study with written assent. The analysis of the data obtained was retrospective.

Patients and methods

All the patients with septic shock in the beginning of evolution (less than 24 h) were included. Patients with cardiac insufficiency, insufficient respiratory function and chronic renal insufficiency as well as cirrhotic patients were excluded. Among patients in shock, a NT-proBNP concentration measurement and a cardiac echography by transthoracic way were carried out at inclusion. The rates of NT-proBNP were compared with the data of the echography.

Results

Thirty-three patients in septic shock were included. On the whole of the collective, whether or not there is a cardiac dysfunction, the rates of NT-proBNP are not significantly different (11,306 ± 16,196 pg/ml versus 10,697 ± 12,346 pg/ml). By eliminating the patients with severe renal failure, we show that the NT-proBNP is non-significantly increased in the event of right and/or left ventricular failure (5751 ± 4180 pg/ml versus 1,256 ± 999 pg/ml).

Conclusion

The NT-proBNP can help to detect the cardiogenic share sometimes implied in the haemodynamic failure of the septic shock. However, because of the influence of the renal insufficiency and the respiratory, cardiologic and hepatic comorbidities on its secretion, its use cannot be recommended for patients in septic shock.     

Prevention of recurrent urinary tract infections by intravesical administration of hyaluronic acid and chondroitin sulphate: a placebo-controlled randomised trial

Background

Urinary tract infection (UTI) is a prevalent condition in women during their lifetime with a high rate of recurrence within 3–6 mo.

Objectives

Our aim was to investigate the efficacy and tolerability of the intravesical administration of combined hyaluronic acid (HA) and chondroitin sulphate (CS) in female patients with a history of recurrent UTI.

Design, setting, and participants

We conducted a prospective, randomised, double-blind, placebo-controlled study comparing the intravesical instillation of HA-CS with placebo in women with recurrent UTI.

Intervention

Participants were randomised to receive 50 ml of sterile sodium HA 1.6% and CS 2.0% solution (IALURIL^®) weekly for 4 wk and then monthly for 5 mo.

Measurements

The primary end point of the study was defined as the mean number of UTI per patient per year. Participants were evaluated addressing UTI status/urinary symptoms and with a general health-related quality-of-life (QoL) questionnaire at baseline and after 3, 6, 9, and 12 mo.

Results and limitations

In the intention-to-treat analysis, 57 women were randomly allocated to HA-CS (n = 28) or placebo (n = 29). The UTI rate per patient per year at the end of the study (12 mo) (mean ± SD: −86.6% ± 47.6 vs −9.6% ± 24.6; mean difference: 77%; 95% confidence interval, 72.3–80.8; p = 0.0002) and the mean time to UTI recurrence (52.7 ± 33.4 vs 185.2 ± 78.7 d; p < 0.001) were significantly reduced after treatment with HA-CS compared with placebo. Overall urinary symptoms and QoL measured by questionnaires significantly improved compared with placebo (Pelvic Pain and Urgency/Frequency questionnaire symptom score: 14.53 ± 4.32 vs 9.88 ± 6.77; p = 0.004; SF-36 QoL score: 78.6 ± 6.44 vs 53.1 ± 4.72; p < 0.001). No serious adverse event was reported.

Conclusions

Compared with placebo, HA-CS intravesical instillations significantly reduced UTI rate without severe side effects while improving symptoms and QoL over a 12-mo period in patients with recurrent UTI.

Trial registration

ISRCTN 76354426.     

Endoluminal isoproterenol irrigation decreases renal pelvic pressure during flexible ureterorenoscopy: a clinical randomized, controlled study

Objectives

Irrigation during ureterorenoscopic procedures causes increased pelvic pressure (PP), which may lead to intrarenal backflow with potential harmful consequences. This study aims to investigate PP response to intraluminal administration of isoproterenol (β-agonist; ISO) during flexible ureterorenoscopy.

Methods

Twelve patients admitted for retrograde intrarenal stone surgery (RIRS) were included. Patients were randomized to (1) irrigation with saline (n = 6) or (2) irrigation with ISO 0.1 μg/mL (n = 6). Irrigation rate was standardized to 8 mL/min. A ureteral catheter was retrogradely placed in the renal pelvis for PP measurements. PP, heart rate (HR), and mean arterial pressure (MAP) were also measured.

Results

Baseline PP was 12.1 ± 4 mm Hg in the saline group and 10.3 ± 4 mm Hg in the ISO group (p = 0.44).In the saline group, PP increased to a mean 33 ± 12 mm Hg during ureterorenoscopy. In the ISO group, PP was a mean 19 ± 3 mm Hg (p = 0.029).During endoscopy, PP peaks as high as 328 mm Hg were noted during saline irrigation. The number of pressure peaks above 50 mm Hg was minimized dramatically during ISO irrigation (p = 0.035). No systemic side effects to ISO irrigation were observed.

Conclusion

For the first time, a randomized, controlled human study demonstrates that pharmacologic modulation of the ureter is possible during upper urinary tract endoscopy. The ability to relax ureteral tone during endoscopy may have clinical advantages.     

Secondary abdominal compartment syndrome in patients with toxic epidermal necrolysis

Introduction

Secondary abdominal compartment syndrome (ACS) is a severe complication in patients admitted to burn intensive care units (BICUs). Unlike patients with thermal burns, patients with toxic epidermal necrolysis (TEN) present with a different pathophysiology and usually require less fluid.

Patients and methods

We reviewed our registry of adult patients presenting with TEN in our 8-bed BICU over the course of 11 years and identified and analyzed patients treated for ACS and decompressive laparotomy (DL).

Results

From a total of 29 patients with bioptic confirmed TEN, 5 underwent DL due to ACS with a mean age of 57 years, mean percentage of total body surface area (TBSA) affected of 54 ± 25%, complete epidermolysis of 28 ± 24% TBSA, a mean severity of illness score (SCORTEN) of 3.8 ± 0.8, and a mean intra-abdominal pressure before DL of 33 ± 7 mmHg. Mortality was 100% in patients with ACS versus 33% without ACS.

Conclusion

An ACS that requires DL worsens the already critical condition of a TEN patient considerably. TEN-related impaired intestinal functionality and increasing intestinal edema due to systemic capillary leakage warrant early initiation of intra-abdominal pressure monitoring to identify patients at high risk of ACS.     

Effect of whole body vibration on leg muscle strength after healed burns: A randomized controlled trial

Objective

To investigate the effects of eight weeks whole body vibration training program on leg muscle strength (force-producing capacity) in adults after healed burns.

Design

Randomized controlled trial.

Setting

Faculty of Physical Therapy, Cairo University.

Subjects

Thirty-one burned patients participated in the study and were randomized into whole body vibration group and control group. Non-burned healthy adults were assessed similarly to burned subjects and served as matched healthy controls.

Methods

The whole body vibration group performed an eight weeks vibration program three times a week on a vibration platform; the control group received home based physical therapy program without vibration training.

Main measures

Assessment of knee extensors and ankle planter flexor strength by isokinetic dynamometer at 150°/s were performed at the beginning of the study and at the end of the training period for both groups.

Results

Subjects with burns more than 36% TBSA produced significantly less torque in the quadriceps and calf muscle than non-burned healthy subjects. Patients in whole body vibration group showed a significant improvement in knee extensor and ankle planter flexor strength as compared with those in the control group. Knee extensor strength and percent improvement was 233.40 ± 5.74 (64.93 ± 3.03 change score) and 38.54% for the vibration group and 190.07 ± 3.99 (21.66 ± 4.41 change score) and 12.86% for the control group, ankle plantar flexor strength and percent improvement was 156.27 ± 5.95 (54.53 ± 6.16 change score) and 53.70% for the vibration group and 116.13 ± 3.24 (14.66 ± 2.71 change score) and 14.52% for the control group.

Conclusions

Participation in whole body vibration program resulted in a greater improvement in quadriceps and calf muscle strength in adults with healed thermal burn compared to base line values; a WBV program is an effective for strength gain in rehabilitation of burned patients.     

Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes

Background

Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors.

Objective

To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity.

Design, setting, and participants

A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis.

Intervention

LPN or RPN.

Outcome measurements and statistical analysis

Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis.

Results and limitations

There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m² compared with 30.7 kg/m², p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m², p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p < 0.001) and a higher decrease in percentage of eGFR (−16.0% compared with −12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study.

Conclusions

RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings.     

Short-term functional and oncologic outcomes of nephron-sparing surgery for renal tumours ≥ 7 cm

Background

Nephron-sparing surgery (NSS) for renal tumours preserves renal function and has become the standard approach for small renal tumours. Little is known about perioperative and oncologic outcomes of patients following NSS in renal tumours ≥7 cm in the presence of a healthy contralateral kidney.

Objective

To analyse oncologic outcomes and perioperative morbidity in patients treated by NSS for renal tumours ≥7 cm.

Design, setting, and participants

In total, 5767 patients were treated for renal tumours at two institutions from 1984 to 2009. In 91 patients, elective NSS was performed for renal tumours ≥7 cm.

Measurements

Complication rates were assessed in detail and stratified using the Clavien-Dindo score (CDS). Oncologic outcomes for overall survival (OS), cancer-specific survival (CSS), and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Logistic regression analysis was used to identify clinical risk factors for complications and prognosticators that have an oncologic impact on OS.

Results and limitations

The median follow-up was 28 mo (range: 1–247 mo). Twenty-seven patients (29.6%) had perioperative complications and, of these, 89.1% had CDS grade 1 and 2.Twenty-seven percent of the 91 patients had benign lesions. Seven patients (10.6%) died from cancer-related causes. The 5- and 10-yr rates for OS, CSS, and PFS were 88% and 64%, 97% and 83%, and 91% and 78%, respectively. None of the analysed parameters had an impact on morbidity or OS in the univariate analysis. Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome.

Conclusions

NSS for renal tumours ≥7 cm can be performed with acceptable complication rates and with oncologic outcomes comparable to radical nephrectomy studies. Our findings support NSS whenever technically feasible to reduce the loss of renal function.     

Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases

Background

Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon.

Objective

We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients.

Design, setting, and participants

We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions.

Measurements

Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded.

Results and limitations

Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p = 0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3 ± 7.4 min vs 19.6 ± 10.0 min; p = <0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons’ prior robotic experience.

Conclusions

The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.     

Minimal effective dose of dysport and botox in a rat model of neurogenic detrusor overactivity

Background

Two botulinum toxins A have been evaluated for the treatment of refractory neurogenic detrusor overactivity (NDO) in humans: Dysport (abobotulinumtoxinA) and Botox (onabotulinumtoxinA). However, these two distinct commercialized products have different potency units and are not interchangeable.

Objective

Assessment of the dose response and determination of minimal effective dose (MED) for Dysport and Botox in spinal cord–injured (SCI) rats with NDO.

Design, setting, and participants

Female, adult, Sprague-Dawley rats (n = 98) underwent T8-T9 spinal cord transection. Nineteen days after spinal cord injury, rats received intradetrusor injections (25 μl injected, eight sites) of vehicle (V); Dysport 2, 5, 7.5, 10, and 12.5 U; and Botox 0.8, 2, 5, 7.5, and 10 U. Two days after injection, continuous cystometry was performed in conscious rats.

Measurements

Voiding contractions (VC) were assessed by duration of VC, intercontraction interval, voided volume, maximal pressure, pressure threshold change, and intravesical baseline pressure (BP), while nonvoiding contractions (NVC) were evaluated by amplitude, frequency, and volume threshold to elicit NVC. MEDs for Dysport and Botox were determined by analysis of variance step-down trend test.

Results and limitations

MEDs for Dysport and Botox were 10 U and 7.5 U, respectively. Regarding VC, only BP significantly decreased after 10 U Dysport and 7.5 U Botox compared to V (from 3.7 ± 0.6 to 1.5 ± 0.1 and 1.4 ± 0.3 mm Hg, respectively; p < 0.01 and p < 0.001, respectively). Dysport (10 U) and Botox (7.5 U) significantly inhibited NVC by decreasing their amplitude (from 7.4 ± 1.1 to 5.8 ± 0.5 and 5.4 ± 0.6 mm Hg, respectively; p < 0.05); frequency (from 2.2 ± 0.4 to 1.5 ± 0.2 and 1.3 ± 0.3 NVC per minute, respectively; p < 0.01); and increasing volume threshold to elicit NVC (from 29.8 ± 3.7 to 47.6 ± 6.9 and 47.7 ± 6.3%, respectively; p < 0.05 and p < 0.001, respectively).

Conclusions

This is the first preclinical dose-ranging study with Dysport and Botox under standardized conditions showing similar inhibiting effects on NDO, albeit at different MEDs. It highlights the importance of distinguishing each preparation for predicted outcomes and doses to be used. Further studies in patients with NDO are warranted to confirm these experimental results.     

Electrical nerve localization: non-linear relationship between intensity and pulse duration to stimulate a nerve

Objective

When performing a peripheral nerve block, the current allowing local anaesthetic injection is between 0.3 and 0.5 mA. It has never been assessed if such a threshold remains the same whatever be the pulse duration. The aim of this study was to determine the minimal current required to stimulate a nerve while different pulse durations were applied, and to evaluate the importance of the placement of the cutaneous electrode.

Study design

Prospective study.

Patients and methods

One hundred and twenty posterior popliteal sciatic (S), femoral (F), or median (M) nerve blocks performed with a nerve stimulator were included. The minimal current for a clearly visible motor response of the corresponding muscle was recorded with a pulse duration set at 50, 150 and 300 μs. The same procedure was repeated with the electrode sited on the controlateral side, before injection of local anaesthetic.

Results

The mean lowest charge of current required to stimulate a nerve was 24 ± 8 nC at 50 μs. At 150 and 300 μs, it has to be increased by 175 % (42 ± 14 nC) and 280 % (67 ± 23 nC), respectively. No significant difference in the charge required was noted either among S, F, or M, or by changing the cutaneous electrode position. Adequate anaesthesia was noted in all cases.

Conclusion

The relationship between intensity and pulse duration is not linear. Moreover, a low charge of current does not seem to be appropriate with pulse duration equal or superior to 300 μs. The location of the cutaneous electrode does not seem to be important.