Role of intraoperative ultrasound in robotic-assisted radical nephrectomy with inferior vena cava thrombectomy in renal cell carcinoma

Value of Non-Contrast-Enhanced Vessel Wall MR Imaging in Assessing Vascular Invasion of Retroperitoneal Tumors

BACKGROUND

Due to their location and growth patterns, retroperitoneal tumors often involve the surrounding blood vessels. Clinical decisions on a proper treatment depend on the information on this condition. Evaluation of blood vessels using non-contrast-enhanced vessel wall MRI may provide noninvasive assessment of the extent of tumor invasion to assist clinical decision-making.

PURPOSE

To investigate the performance and potential of non-contrast-enhanced vessel wall MRI in evaluating the degree of vessel wall invasion of retroperitoneal tumors.

STUDY TYPE

Prospective.

POPULATION

Thirty-seven participants (mean age: 60.59 ± 11.77 years, 59% male) with retroperitoneal tumors close to vessels based on their diagnostic computer tomography.

FIELD STRENGTH/SEQUENCES

3 T; vessel wall MRI sequences: two-dimensional T2-weighted MultiVane XD turbo spin-echo (2D-T2-MVXD-TSE) and three-dimensional T1-weighted motion sensitized driven equilibrium fat suppression turbo spin-echo (3D-T1-MSDE-TSE) sequences; conventional MRI sequences: T2-weighted fat suppression turbo spin-echo (T2-FS-TSE), T2-weighted turbo spin-echo (T2-TSE), modified Dixon T1-weighted fast field echo (T1-mDixon-FFE), and diffusion-weighted echo planar imaging (DWI-EPI) sequences.

ASSESSMENT

All patients underwent preoperative imaging using both non-contrast conventional and vessel wall MRI sequences. Images obtained from conventional and vessel wall MRI sequences were evaluated independently by three junior radiologists (3 and 2 years of experience in reading MRI) and reviewed by one senior radiologist (25 years of experience in reading MRI) to assess the degree of vessel wall invasion. MRI were validated results from the clinical standard diagnosis based on surgical confirmation or histopathological reports. Interobserver agreement was determined based on the reports from three readers with similar years of experiences. Intraobserver variability was assessed based on categorizing and recategorizing the vessels of 37 patients 1 month apart.

STATISTICAL TESTS

Intra-class correlation efficient (ICC), Chi-square test, McNemar test, area under the receiver-operating characteristic curve (AUC), Delong test, P < 0.05 was considered significant.

RESULTS

The accuracy of vessel wall MRI (91.96%, 95% CI: 85.43-95.71; 103 of 112) in detecting the degree of vessel wall invasion was significantly higher than that of conventional MRI (75%, 95% CI: 66.24-82.10; 84 of 112). The interobserver variability or reproducibility in categorization of the degree of vascular wall invasion was good in evaluating images from conventional and vessel wall MRI sequences (ICC = 0.821, 95% CI: 0.765-0.867 and ICC = 0.881, 95% CI: 0.842-0.913, respectively).

DATA CONCLUSION

Diagnosis of vessel wall invasion of retroperitoneal tumors and assessment of its severity can be improved by using non-contrast-enhanced vessel wall MRI.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 3.

Robotic Vena Cava Thrombectomy with Three-dimensional Augmented Reality Guidance

Robotic surgery has recently been used for treatment of renal cell carcinoma (RCC) and neoplastic thrombus located in the renal vein or inferior vena cava (IVC). Accurate identification of the thrombus location is crucial, and three-dimensional augmented reality (3D AR) may be valuable in achieving this. We enrolled patients with nonmetastatic RCC and level 0-I venous thrombus (Mayo Clinic classification) for robot-assisted radical nephrectomy and thrombectomy with 3D AR guidance. Five patients were prospectively enrolled; three had a level 0 thrombus and two had a level I thrombus. The mean operative time was 123 ± 15 min, mean IVC clamping time was 9.4 ± 6.8 min, and mean estimated blood loss was 750 ± 150 ml. The AR system allowed precise estimation of the thrombus location in all cases. No intraoperative complications or postoperative Clavien-Dindo grade >2 complications occurred. Use of 3D AR guidance allowed correct estimation of the limits of the thrombus and guided the surgeon in selecting an appropriate surgical strategy.

Surgical Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

Most kidney cancers are primary renal cell carcinomas (RCC) of clear cell histology. RCC is unique in its ability to invade into contiguous veins - a phenomenon terms venous tumor thrombus. Surgical resection is indicated for most patients with RCC and an inferior vena cava (IVC) thrombus in the absence of metastatic disease. Resection also has an important role in selected patients with metastatic disease. In this review, we discuss the comprehensive management of the patient with RCC with IVC tumor thrombus, emphasizing a multidisciplinary approach to the surgical techniques and perioperative management.

Preliminary experience of oblique occlusion technique in robot-assisted infrahepatic inferior vena cava thrombectomy: step-by-step procedures and short term outcomes

Background

We aimed to compare the oncological outcomes between the oblique occlusion technique and the traditional technique for robot-assisted radical nephrectomy (RARN) with inferior vena cava (IVC) thrombectomy, and to explore the safety and effectiveness of the oblique occlusion technique.

Methods

Overall, 21 patients with renal cell carcinoma (RCC) and IVC tumor thrombus (TT) were admitted to our hospital from August 2019 to June 2020. All the patients underwent RARN with IVC thrombectomy, of which the IVC oblique occlusion technique was used in 11 patients and traditional occlusion technique was used in 10 patients. The oblique occlusion technique refers to oblique blocking from the upper corner of the right renal vein to the lower corner of the left renal vein using a vessel tourniquet or a vessel clamp (left RCC with IVCTT as an example).

Results

Compared with patients in the traditional group, those in the oblique group had lower serum creatinine at follow-up (3 month) (95 ± 21.1 vs. 131 ± 30.7 μmol/L, P = 0.03). There was no significant difference in operation time [149 (IQR 143–245) min vs. 148 (IQR 108–261) min, p = 0.86], IVC clamping time [18 (IQR 12–20) min vs. 20 (IQR 14–23) min, p = 0.41], and estimated intraoperative blood loss [300 (IQR 100–800) mL vs. 500 (IQR 175–738) mL, p = 0.51] between both groups. During a 16-month (range, 15–23 months) follow-up period, two cases progressed in the oblique group and three cases progressed in the traditional group.

Conclusions

The modified IVC oblique occlusion technique procedure is relatively safe and effective in RARN with IVC thrombectomy. The IVC oblique occlusion technique may play a role in the protection of renal function.

Inhibitory Effect of Ursolic Acid on Proliferation and Migration of Renal Carcinoma Cells and Its Mechanism

Background

Renal carcinoma is one of the most common malignant tumors in the urinary system. Autophagy can be both activated and inhibited in renal carcinoma, and it plays a double-edged role in the development of renal carcinoma. In the early stage of cancer, autophagy can suppress tumors. In the late stage, autophagy contributes to the survival of tumor cells in an unfavorable environment, and some autophagy-related proteins P62, LC3B, and beclin-1 have become indicators of the prognosis of patients with renal carcinoma.

Aim

To demonstrate that ursolic acid activates autophagy in renal carcinoma 786-O cells by inhibiting the hedgehog signaling pathway.

Methods

The effect of ursolic acid on the viability of 786-O cells was determined by the MTT method; the effect of ursolic acid on the proliferation and migration of 786-O cells was examined by crystalline violet staining and scratch assay, respectively. For the study of autophagy, we firstly screened the time points. Western blot assay was used to detect the expression level of autophagic protein P62 at different time points of ursolic acid on 786-O. Then, the Cell MeterTM Autophagy Assay Kit was used to detect the effect of different doses of ursolic acid on the autophagic fluorescence intensity of 786-O cells; the Western blot method was used to detect the effect of different doses of ursolic acid on the expression levels of LC3II and P62 proteins in 786-O cells. Further, AdPlus-mCherry-GFP-LC3B adenovirus transfection was used to detect the effect of ursolic acid on the autophagic flow of 786-O cells; ursolic acid was combined with the autophagy inhibitor chloroquine (CQ) to detect the expression level of autophagy protein LC3II by Western blot. In terms of mechanism, the effect of ursolic acid on hedgehog signaling pathway-related proteins in 786-O cells was detected by Western blot.

Results

Ursolic acid inhibited the activity, proliferation, and migration of 786-O cells, enhanced the fluorescence intensity of autophagosomes in 786-O cells, increased the expression level of autophagy marker protein LC3II, and inhibited the expression level of P62 in a time and dose-dependent manner; ursolic acid activated the autophagic flow in 786-O cells, which showed that ursolic acid caused the accumulation of autophagic fluorescent spots and enhanced the fluorescence intensity of autophagosomes. Ursolic acid activated the autophagic flow in 786-O cells, as evidenced by the accumulation of autophagic fluorescent spots and enhanced fluorescence intensity of autophagosomes, and the combined use of the autophagy inhibitor CQ increased the expression level of LC3II compared to ursolic acid alone; ursolic acid decreased the expression levels of PTCH1, GLI1, SMO, SHH, and c-Myc and increased the expression level of Sufu in the hedgehog signaling pathway.

Conclusion

Ursolic acid activates autophagy in renal carcinoma 786-O cells, probably by inhibiting hedgehog signaling pathway activity.

Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.