Three-dimensional topology-based T-index as an indicator of surgical difficulty of partial nephrectomy in patients with small renal mass

PURPOSE

To accurately describe the three-dimensional topology of renal tumors, our study suggests a new nephrometry scoring system, the T-index, that combines information about intraparenchymal extension and peripherality of the renal tumor.

MATERIALS AND METHODS

This study included 113 patients who underwent partial nephrectomy for small clear cell renal cell carcinoma between 2007 and 2014. Manual segmentation of the renal parenchyma, sinus, and tumor was performed using preoperative computed tomography images. The T-index was calculated by adding the reciprocals of the distances from all points on the tumor-parenchyma interface to the renal sinus. Correlations with perioperative factors and the impact of the T-index on postoperative complications were evaluated and compared with existing nephrometry scoring systems (PADUA, RENAL, contact surface area [CSA], and C-index).

RESULTS

The mean value of the T-index among the 113 patients was 116.1±100.5 (1/mm). The T-index showed the strongest correlation with perioperative factors compared with other nephrometry scoring systems. The T-index was able to predict the risk for postoperative complications, either overall (p=0.015) or major complications (p=0.030). A predictive model based on the T-index of the overall postoperative complications presented the best performance (area under the curve, 0.692; 95% CI, 0.599-0.776) compared with other nephrometry scoring systems.

CONCLUSIONS

The T-index can be considered as a single value comprising key structural indicators for surgical complexity. Our findings suggest that the T-index can provide a quantitative and objective scoring system associated with surgical difficulty and postoperative complications of partial nephrectomy.

Tumor enucleation for the treatment of T1 renal tumors: A systematic review and meta-analysis

Purpose

To evaluate the clinical efficacy and safety of tumor enucleation (TE) compared with partial nephrectomy (PN) for T1 renal cell carcinoma.

Materials and Methods

According to protocol, we searched multiple data sources for published and unpublished randomized controlled trials and nonrandomized studies (NRSs) in any language. We performed systematic review and meta-analysis according to the Cochrane Handbook for Systematic Reviews of Interventions and rated the certainty of the evidence (CoE) using the GRADE framework.

Results

We are uncertain about the effects of TE on perioperative (mean difference [MD] 3.38, 95% CI 1.52 to 5.23; I²=68%; 4 NRSs; 942 participants; very low CoE) and long-term (MD 2.31, 95% CI -1.40 to 6.01; I²=57%; 4 NRSs; 542 participants; very low CoE) residual renal function. TE may result in little to no difference in short-term residual renal function (MD 1.04, 95% CI 0.25 to 1.83; I²=0%; 2 NRSs; 256 participants; low CoE). We are uncertain about the effects of TE on cancer-specific mortality (risk ratio [RR] 0.90, 95% CI: 0.11 to 7.28; I²=0%; 2 NRSs; 551 participants; very low CoE) and major adverse events (RR 0.48, 95% CI: 0.30 to 0.79; I²=0%; 10 NRS; 2,360 participants; very low CoE).

Conclusions

While TE appears to have similar effects on short term postoperative residual renal function, there were uncertainties on mortality and major adverse events. However, we need rigorous RCTs to elucidate the effects of TE as the evidence stems mostly from NRSs.

Effect of the symptom-based alpha-blocker treatment on lower urinary tract symptoms in women: systematic review and meta-analysis

Aims

The aim of this study was to evaluate the effects of alpha blockers in women with lower urinary tract symptoms.

Methods

We conducted systematic review and meta-analysis on published a priori protocols. We searched multiple data sources for published and unpublished randomized controlled trials in any language. Primary outcomes included urologic symptom scores, quality of life, and overall adverse events. We performed meta-analysis using RevMan 5.3 and rated the certainty of evidence using Grading of Recommendations, Assessment, Development, and Evaluation.

Results

Alpha blockers likely reduced urological symptom score (mean difference: -1.50, 95% confidence interval: -2.91 to -0.09; moderate certainty of evidence). Alpha blockers may improve quality of life (standardized mean difference: -0.35, 95% confidence interval: -0.85 to 0.15; low certainty of evidence) and have little to no difference in overall adverse events (risk ratio: 1.09, 95% confidence interval: 0.55 to 2.15; low certainty of evidence). Based on five studies comparing combination therapy with alpha blockers and anticholinergics to anticholinergic monotherapy, combination therapy likely results in little to no difference in urological symptom score (mean difference: -0.35, 95% confidence interval: -1.98 to 1.27; moderate certainty of evidence) and quality of life (mean difference: -0.11, 95% confidence interval: -0.48 to 0.27; moderate certainty of evidence). We are very uncertain about the effect of combination therapy on overall adverse events (risk ratio: 1.07, 95% confidence interval: 0.40 to 2.84; very low certainty of evidence).

Conclusion

Alpha blocker monotherapy for the women with lower urinary tract symptoms regardless of the underlying cause likely has satisfactory efficacy compared with placebo. However, combination therapy with anticholinergics likely has no additional effect on urologic symptom score and quality of life compared with anticholinergic monotherapy.

Lessons learned from clinical outcome and tumor features of patients underwent selective artery embolization due to postoperative bleeding following 2076 partial nephrectomies: propensity scoring matched study

PURPOSE

To evaluate the clinical and tumor characteristics in patients undergoing selective artery embolization (SAE) for bleeding after partial nephrectomy (PN).

METHODS

We retrospectively evaluated patients who underwent SAE from 2076 patients who underwent PN. The clinical and tumor characteristics of these patients were analyzed using entire data and propensity score matching (PSM). 76 patients who underwent PN (control, n = 38 patients; SAE, n = 38) were enrolled in PSM.

RESULTS

SAE was performed in 41 patients who underwent open (19/1171), laparoscopic (4/60), and robot-assisted PN (18/845). The median period from PN to SAE was 12 days (interquartile range 8-24 day). The most common symptom of 31 (75.61%) patients was gross hematuria, followed by flank pain (3/41). Follow-up imaging revealed large pseudoaneurysm in 7 asymptomatic patients. The main reason for SAE on angiography was pseudoaneurysm (32/41), followed by arteriovenous fistula (5/41). Technical and clinical success was achieved in all patients. There was no statistical difference in the estimated glomerular filtration rate after 1 year, surgical methods, or baseline characteristics between the two groups. Conversely, there was statistically significant difference in ischemic time in the entire data and PSM. In the embolization group, renal masses showed statistically significant endophytic (p = 0.006) and posterior (p = 0.028) characteristics.

CONCLUSIONS

SAE is an effective method for controlling postoperative bleeding while preserving renal function after PN. And, we suggest more attentive postoperative surveillance about vascular complications in patients with longer ischemia time or renal masses with endophytic and posterior locations.

New era of robotic surgical systems

INTRODUCTION

To provide an update on the current status of robotic systems for surgery and the companies that produce these systems.

METHODS

A non-systematic literature review was performed by using the PubMED/MEDLINE electronic search engines. Existing patents for robotic companies and devices were researched by using the Google search engine.

RESULTS

Since the da Vinci Surgical System's patent expired, we have been able to predict the future of robotic companies based on the various robotic systems being developed. Currently, various attempts are being made to create consoles, robotic arms, cameras, handles, and instruments and to implement specific functions (e.g. haptic feedback, eye tracking). Herein, the benefits and limitations of each technology are identified, and likely future developments are described.

CONCLUSIONS

The robotic surgical systems are continually being developed by various companies around the world. New technologies have been increasingly implemented to improve on the capabilities of previously established systems and surgical ergonomics. Future studies may need to evaluate the strengths and weaknesses of each robotic surgical system.

Yonsei nomogram: A predictive model of new-onset chronic kidney disease after on-clamp partial nephrectomy in patients with T1 renal tumors

OBJECTIVES

To develop a predictive nomogram for chronic kidney disease-free survival probability in the long term after partial nephrectomy.

METHODS

A retrospective analysis was carried out of 698 patients with T1 renal tumors undergoing partial nephrectomy at a tertiary academic institution. A multivariable Cox regression analysis was carried out based on parameters proven to have an impact on postoperative renal function. Patients with incomplete data, <12 months follow up and preoperative chronic kidney disease stage III or greater were excluded. The study end-points were to identify independent risk factors for new-onset chronic kidney disease development, as well as to construct a predictive model for chronic kidney disease-free survival probability after partial nephrectomy.

RESULTS

The median age was 52 years, median tumor size was 2.5 cm and mean warm ischemia time was 28 min. A total of 91 patients (13.1%) developed new-onset chronic kidney disease at a median follow up of 60 months. The chronic kidney disease-free survival rates at 1, 3, 5 and 10 year were 97.1%, 94.4%, 85.3% and 70.6%, respectively. On multivariable Cox regression analysis, age (1.041, P = 0.001), male sex (hazard ratio 1.653, P < 0.001), diabetes mellitus (hazard ratio 1.921, P = 0.046), tumor size (hazard ratio 1.331, P < 0.001) and preoperative estimated glomerular filtration rate (hazard ratio 0.937, P < 0.001) were independent predictors for new-onset chronic kidney disease. The C-index for chronic kidney disease-free survival was 0.853 (95% confidence interval 0.815-0.895).

CONCLUSION

We developed a novel nomogram for predicting the 5-year chronic kidney disease-free survival probability after on-clamp partial nephrectomy. This model might have an important role in partial nephrectomy decision-making and follow-up plan after surgery. External validation of our nomogram in a larger cohort of patients should be considered.

Retzius-sparing robot-assisted radical prostatectomy using the Revo-i robotic surgical system: surgical technique and results of the first human trial

OBJECTIVE

To evaluate the safety and proficiency of the Revo-i^® robotic platform (Meere Company Inc.) in the treatment of prostate cancer (PCa).

PATIENTS AND METHODS

A prospective study was carried out on 17 patients with clinically localized PCa treated between 17 August 2016 and 23 February 2017 at our urology department using the Revo-i. Patients underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP). The primary objective was to describe the RS-RARP step-by-step surgical technique using the Revo-i. In addition, the safety of the Revo-i was assessed according to intra-operative and the postoperative complications within 30 days of surgery. Early oncological outcomes were also assessed according to surgical margin status and biochemical recurrence (BCR). Continence was defined as use of no or only one pad. Surgeons' satisfaction with the Revo-i was assessed using the Likert scale.

RESULTS

All surgeries were completed successfully, with no conversion to open or laparoscopic surgery. The median patient age was 72 years. The median docking time, console time, urethrovesical anastomosis time and estimated blood loss were 8 min, 92 min, 26 min and 200 mL, respectively. One patient was transfused intra-operatively as a result of blood loss of 1 500 mL. Postoperatively, two patients received blood transfusion, and there were no other serious/major complications. The median hospital stay was 4 days. At 3 months, four patients had positive surgical margins, one patient had BCR, and 15 patients were continent. Most of surgeons were satisfied with the Revo-i performance.

CONCLUSIONS

The first human study for the treatment of patients with localized PCa using the Revo-i robotic surgical system was carried out successfully. The peri-operative, early oncological and continence outcomes are encouraging. Further prospective studies are warranted to support our preliminary results.

Functional and oncological outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a multicentre comparative matched-pair analyses with a median of 5 years' follow-up

OBJECTIVES

To compare outcomes at a 5-year median follow-up among different partial nephrectomy (PN) approaches: robot-assisted (RAPN), laparoscopic (LPN) and open partial nephrectomy (OPN).

PATIENTS AND METHODS

We retrospectively analysed 1 308 patients who underwent PN (RAPN, n = 380; LPN, n = 206; OPN, n = 722) between 2006 and 2012 at one of four academic centres. We performed 1:1:1 propensity-score-matching adjustment based on confounding variables among groups, and 366 patients (122 in each group) were included in the final analysis. Survival rates were analysed using the Kaplan-Meier method.

RESULTS

The median follow-up periods were 60, 59.8 and 64.1 months for RAPN, LPN and OPN, respectively. In the matched groups, RAPN resulted in significantly lower mean estimated blood loss compared with LPN (P = 0.025) and OPN (P = 0.040), while LPN was associated with a longer mean operating time compared with RAPN (P = 0.001) and OPN (P = 0.001). The hospital stay was shorter in the RAPN group (P = 0.008). Regarding the oncological outcomes, there were no significant differences among the three groups in local recurrence rate (P = 0.882), distant metastasis rate (P = 0.816) or deaths from cancer (P = 0.779). At latest follow-up, the incidence of chronic kidney disease (CKD) upstaging was significantly lower in RAPN compared with LPN (20.55% vs 32%; P = 0.035) and OPN (20.5% vs 33.6%; P = 0.038). The 5-year CKD free-survival rate was significantly higher (78.4%) in the RAPN group compared with 58.8% and 65.8% in the LPN and OPN groups, respectively (log-rank P = 0.031).

CONCLUSIONS

In the present study, RAPN, LPN and OPN had similar local recurrence, distant metastasis and cancer-related death rates at a 5-year median follow-up. In terms of functional outcomes, RAPN was associated with a lower incidence of CKD upstaging compared with OPN and LPN.

Estimated glomerular filtration rate's time to nadir after robot-assisted partial nephrectomy: Predictors and clinical significance on renal functional recovery

OBJECTIVES

To investigate the impact of postoperative time to nadir of estimated glomerular filtration rate on renal functional changes after robot-assisted partial nephrectomy.

METHODS

From 2006 to 2015, 287 patients with renal mass who underwent robot-assisted partial nephrectomy in a referral center were analyzed. The cohort was evaluated based on their time to develop nadir: group 1 (no nadir), group 2 (<48 h) and group 3 (≥48 h). The outcome measures were to evaluate the renal function recovery between groups, risk factors for development of nadir ≥48 h, as well as predictors of chronic kidney disease upstaging.

RESULTS

The mean estimated glomerular filtration rate percentage change was the worst in group 3 compared with groups 1 and 2, with 13.8%, -0.67% and 8%, respectively (P < 0.001). Chronic kidney disease upstaging was more common in group 3 compared with the other groups (P < 0.001). Age, tumor size, PADUA score and warm ischemia time were predictors of developing ≥48 h estimated glomerular filtration rate nadir (odds ratio 1.04, P = 0.002; odds ratio 1.43, P < 0.001; odds ratio 1.24, P = 0.018; odds ratio 1.05, P < 0.001), respectively. The 5-year probability of freedom from chronic kidney disease upstaging was lower in group 3 (75.6%) compared with the other groups - 88.1% and 100% (P = 0.003). Time to nadir ≥48 h was a predictor of chronic kidney disease upstaging (odds ratio 3.02, P = 0.022).

CONCLUSIONS

A continuous decline in estimated glomerular filtration rate (≥48 h) after partial nephrectomy is associated with increased risk of poor functional recovery overtime. Age, tumor size, PADUA score and warm ischemia time are independent predictors of developing ≥48 h time to nadir of estimated glomerular filtration rate. This higher risk subgroup should be targeted for stricter follow up to allow early detection of future risk of renal functional decline.

Novel robotic systems and future directions

Robot-assistance is increasingly used in surgical practice. We performed a nonsystematic literature review using PubMed/MEDLINE and Google for robotic surgical systems and compiled information on their current status. We also used this information to predict future about the direction of robotic systems based on various robotic systems currently being developed. Currently, various modifications are being made in the consoles, robotic arms, cameras, handles and instruments, and other specific functions (haptic feedback and eye tracking) that make up the robotic surgery system. In addition, research for automated surgery is actively being carried out. The development of future robots will be directed to decrease the number of incisions and improve precision. With the advent of artificial intelligence, a more practical form of robotic surgery system can be introduced and will ultimately lead to the development of automated robotic surgery system.

Robotic nurse duties in the urology operative room: 11 years of experience

The robotic nurse plays an essential role in a successful robotic surgery. As part of the robotic surgical team, the robotic nurse must demonstrate a high level of professional knowledge, and be an expert in robotic technology and dealing with robotic malfunctions. Each one of the robotic nursing team “nurse coordinator, scrub-nurse and circulating-nurse” has a certain job description to ensure maximum patient's safety and robotic surgical efficiency. Well-structured training programs should be offered to the robotic nurse to be well prepared, feel confident, and maintain high-quality of care.

Impact of Pretreatment Hydronephrosis on the Success Rate of Shock Wave Lithotripsy in Patients with Ureteral Stone

PURPOSE

To evaluate predictors of the success rate for one session of shock wave lithotripsy (SWL), focusing on the relationships between pretreatment hydronephrosis grade and one-session SWL success rates.

MATERIALS AND METHODS

The medical records of 1824 consecutive patients who underwent an initial session of SWL for treatment of urinary stones between 2005 and 2013 were reviewed. After exclusion, 700 patients with a single, 4-20 mm diameter radiopaque calculus were included in the study.

RESULTS

The mean maximal stone length (MSL) and skin-to-stone distance were 9.2±3.9 and 110.8±18.9 mm, respectively. The average values for mean stone density (MSD) and stone heterogeneity index (SHI) were 707.0±272.1 and 244.9±110.1, respectively. One-session success rates were 68.4, 75.0, 75.1, 54.0, and 10.5% in patients with hydronephrosis grade 0, 1, 2, 3, and 4, respectively. Patients were classified into success or failure groups based on SWL outcome. Multivariate logistic regression analyses revealed that MSL [odds ratio (OR) 0.888, 95% confidence intervals (CI): 0.841-0.934, p<0.001], MSD (OR 0.996, 95% CI: 0.995-0.997, p<0.001), SHI (OR 1.007, 95% CI: 1.005-1.010, p<0.001), and pretreatment hydronephrosis grade (OR 0.601, 95% CI: 0.368-0.988, p=0.043) were significantly associated with one-session success.

CONCLUSION

Pretreatment grades 3 or 4 hydronephrosis were associated with failure of SWL in patients with a single ureteral stone. In the presence of severe hydronephrosis, especially hydronephrosis grade 4; physicians should proceed cautiously in choosing and offering SWL as the primary treatment for ureteral stone.

Special issues in the treatment of paediatric bipolar disorder

Paediatric bipolar disorder (PBD) is an increasingly diagnosed disorder affecting an estimated 1% of children and adolescents. Pharmacological treatment studies in PBD have lagged far behind those in adults. Children are currently treated with pharmacological agents, most of which have proven efficacy in adults. However, PBD is distinct from adult forms of bipolar disorder (BD) and may present unique treatment challenges. PBD often presents with rapid cycling and mixed manic states and a high co-morbidity with behavioural and attention disorders. Early onset depression may also be an early sign of PBD. Due to developmental considerations, the diagnosis of BD may be difficult to make in children without semi-structured interviews. This report discusses the special issues that should be considered when treating PBD and reviews the current literature regarding pharmacotherapy of this population. Mood stabilisers have been studied mostly in an open, uncontrolled fashion but there is growing evidence that lithium, divalproex and carbamazepine are effective in treating PBD. More recent treatment options include atypical antipsychotics and newer anticonvulsants. Other novel agents are currently being investigated in adult BD and may prove applicable to the paediatric form. Finally, based on the available data, a treatment algorithm for PBD is proposed.

Family environment of children and adolescents with bipolar parents

OBJECTIVES

The effect of family environment on the development of bipolar disorder (BD) in children is not known. We sought to characterize families with children at high risk for developing BD in order to better understand the contributions of family environment to the development of childhood BD.

METHODS

We collected demographic data and parental ratings on the Family Environment Scale (FES) for 56 children (aged 6-18 years) from 36 families with at least one biological parent with BD. The cohort had previously been psychiatrically diagnosed according to semistructured interviews.

RESULTS

Statistical comparisons with normative data indicated that parents' ratings were significantly lower on the FES Cohesion and Organization scales and were significantly higher on the FES Conflict scale. Multivariate analyses of variance indicated that families with both parents having a mood disorder had no significantly different FES scores than families with only one parent with a mood disorder (BD). Diagnostic data indicated that while 54% of the children in the sample had an Axis I disorder and 14% had BD, FES scores did not differ significantly for subjects with or without an Axis I disorder, or with or without BD.

CONCLUSIONS

Families with a bipolar parent differ from the average family in having less cohesion and organization, and more conflict. Despite this difference, it does not appear that the environment alone of families with a bipolar parent determines the outcome of psychopathology in the children, or that the psychopathology of the children determines the family environment.

Mood stabilizer augmentation with olanzapine in acutely manic children

We report on three cases of acutely manic prepubertal children diagnosed with bipolar disorder who were treated with olanzapine in addition to their existing mood stabilizer regimens. All three had marked improvement of their manic symptoms within 3-5 days of beginning olanzapine therapy as measured by clinician-rated instruments. Adverse effects included sedation and weight gain. These results suggest that olanzapine may have an antimanic or mood stabilizing effect in acutely manic children with bipolar disorder.

Psychiatric phenomenology of child and adolescent bipolar offspring

OBJECTIVE

To establish prodromal signs of and risk factors for childhood bipolar disorder (BD) by characterizing youths at high risk for BD.

METHOD

Structured diagnostic interviews were performed on 60 biological offspring of at least one parent with BD. Demographics, family histories, and parental history of childhood disruptive behavioral disorders were also assessed.

RESULTS

Fifty-one percent of bipolar offspring had a psychiatric disorder, most commonly attention-deficit/hyperactivity disorder (ADHD), major depression or dysthymia, and BD. BD in offspring tended to be associated with earlier parental symptom onset when compared with offspring without a psychiatric diagnosis. Bipolar parents with a history of childhood ADHD were more likely to have children with BD, but not ADHD. Offspring with bilineal risk had increased severity of depressed and irritable mood, lack of mood reactivity, and rejection sensitivity, while severity of grandiosity, euphoric mood, and decreased need for sleep were not preferentially associated with such offspring.

CONCLUSIONS

Bipolar offspring have high levels of psychopathology. Parental history of early-onset BD and/or childhood ADHD may increase the risk that their offspring will develop BD. Prodromal symptoms of childhood BD may include more subtle presentations of mood regulation difficulties and less presence of classic manic symptoms.

Differences in thyroid function between bipolar manic and mixed states

BACKGROUND

High rates of thyroid axis abnormalities have been reported in most studies of patients with rapid-cycling bipolar disorder. Mixed states share similarities with rapid-cycling, including close temporal occurrence of manic and depressive symptoms, predominance in women, poor outcome, and less robust response to lithium compared with pure mania; however, thyroid axis abnormalities have not been well studied in mixed mania.

METHODS

To test the hypothesis that mixed states are associated with a higher prevalence of hypothyroidism than pure mania, immunoreactive triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) concentrations were determined from serum obtained at the time of admission in 37 consecutive patients with DSM-III-R bipolar disorder, manic or mixed.

RESULTS

The mean TSH concentration was significantly higher, and the mean T4 concentration was significantly lower in patients with mixed mania compared with pure mania. There were no significant differences in T3 concentration or in previous lithium exposure.

CONCLUSIONS

These findings suggest thyroid axis dysfunction is more common in bipolar mixed than in bipolar manic patients.