Off-clamp laparoscopic partial nephrectomy in a hybrid room after tumor embolization versus conventional partial nephrectomy: A propensity score matched pair analysis

OBJECTIVE

Off-clamp laparoscopic partial nephrectomy in a hybrid operating room after superselective arterial embolization (hLPN) is a promising minimally invasive approach. In this study, we compared the perioperative surgical outcomes of this innovative technique with the conventional standard of care laparoscopic partial nephrectomy (cLPN) technique.

PATIENTS AND METHODS

Overall, 86 and 127 patients treated with hLPN and cLPN, respectively, were included. These two techniques were compared in terms of surgical complications, estimated blood loss (EBL), operative time, length of stay (LOS), surgical margins, and Trifecta achievement rate (defined as warm ischemia duration <25 min, negative surgical margins and absence of complications). A propensity score based on age, gender, BMI, preoperative eGFR and tumor size was used for a 1:1 matching of patients of each group. After matching, 2 groups of 67 patients with similar characteristics were obtained.

RESULTS

Conversion rate to open surgery, complications and EBL were similar in both groups. Conversely, operative time, LOS and Trifecta rates favored hLPN. The multivariate analysis showed that hLPN had a 70% higher chance of Trifecta achievement than cLPN in all age groups and for all tumor size across the study population.

CONCLUSION

Compared to a conventional approach, off-clamp laparoscopic partial nephrectomy in a hybrid room after superselective arterial embolization showed satisfying immediate surgical outcomes and reached a higher rate of Trifecta achievement. Mid and long-term functional and oncological results are needed to establish this minimally invasive surgical alternative.

[Impact of partial nephrectomy in a hybrid operating room on the activity of kidney cancer surgery]

INTRODUCTION

Partial nephrectomy (NP) after embolization of tumor vessels (NPESH) in a hybrid room combines embolization of tumor vessels and enucleation of the tumor under laparoscopy in the same operative time. The purpose of this study was to assess the impact of the use of NPESH in the management of patients treated with surgery for a localized kidney tumor.

MATERIAL AND METHODS

Using the uroCCR database, we included all consecutive patients operated in a university hospital for localized kidney tumor. From 2011 to May 2015, patients were treated by Standard Partial Nephrectomy (NPS) Laparoscopic or Open and from May 2015 to May 2019 by NPESH. We evaluated characteristics of patients, tumors, perioperative data and complications. These data were compared by Student and Khi2 tests.

RESULTS

87 NPS were performed during Period 1 and 137 NPS were performed during period 2. The ASA score of patients undergoing NPESH was higher than NPS (P<0.0001). The tumor complexity and median tumor size were similar in the two groups (P=0.852 and P=0.48). The complication rate for NPS and NPESH was 55.2% and 33.6% (P=0.002). There were less severe complications in the NEPSH group (P=0.012). The median length of stay was 8 and 4 days for the NPS and NPESH groups (P<0.0001). Positive surgical margins were 2 (2.3%) and 6 (4.6%) for the NPS and NPESH group (P=0.713).

DISCUSSION

NPESH is an efficient technique compared to NPS. It seems to be an interesting alternative to limit renal ischemia, complication rate and length of stay for the management of localized kidney tumors.

Applications d’une méthode photométrique à l’étude des phénomenes de coagulation et de fibrinolyse

Nous présentons les applications d’une méthode photométrique à l’étude des phénomènes de coagulation et de fibrinolyse in vitro. Les variations positives d’absorbance du plasma à 3500 Å sous l’effet de la thrombine sont une mesure indirecte de la diffraction et, en conséquence, un indice de la vitesse et du degré de polymérisation de la fibrine. Les phénomènes de fibrinolyse se traduisent par des déflections négatives. L’avantage d’une telle méthode est qu’elle rend compte de processus de polymérisation qui n’aboutissent pas nécessairement à la formation d’un gel et qui échappent dès lors aux techniques fondées sur les qualités mécaniques de la fibrine normale. Nos résultats suggèrent :

a) Que, dans le milieu plasmatique, l’activité protéolytique de la plasmine est pratiquement conditionnée par l’apparition de son substrat préférentiel, la fibrine, bien que les inhibiteurs plasmatiques soient également distribués dans le système, avant comme après la polymérisation.

b) Qu’en plus de leur interférence avec la polymérisation normale de la fibrine, les produits de dégradation du fibrinogène ont un effet antithrombinique réel.

c) Qu’une mesure exacte et rapide du fibrinogène plasmatique est possible par la méthode décrite, ainsi qu’un diagnostic différentiel des causes d’une hypofibrinogénémie sévère (consommation vs protéolyse spontanée).

d) Qu’au cours d’un traitement thrombolytique, la photométrie permet une évaluation rapide et répétée du taux d’antistreptokinases, d’antiplasmines, du plasminogène activable, et de l’apparition de produits de lyse, même dans des conditions où le sang examiné est incoagulable.

[Hybrid operating room: For what?]

Hybrid operating rooms (HOR) are rooms that mix interventional radiology and surgical equipments. They are usually used in heart, vascular, orthopedic and neurosurgery, and make it possible to consider new minimally invasive procedures in urology. Thanks to these, we developed a new partial nephrectomy technique without renal pedicle clamping and without ischemia. Renal cancer is now diagnosed at localized stage in most of the cases, and its treatment is mostly based on nephron sparing surgery. However, the hemorrhagic character of this intervention requires a renal pedicle clamping whose long-term consequences on renal function are discussed. It also exposes to a classical complication: the renal artery pseudoaneurysm. Therefore, we developed a new laparoscopic partial nephrectomy technique without clamping or approach of renal pedicle, by a selective embolization of tumor vessels through an endovascular route, immediately before the surgery. HOR allowed the combination of the two procedures in the same time and space unit. Tumor staining by Bleu Patenté also aids the surgeon in its spotting. HOR allow a new approach in localized renal cancer management, and should be used in many other urologic surgeries in years to come. They represent a technological advancement by combining interventional radiologists and surgeons' expertise.

IgM peak independently predicts treatment-free survival in chronic lymphocytic leukemia and correlates with accumulation of adverse oncogenetic events

We examined the significance of IgM peaks in chronic lymphocytic leukemia (CLL), including its association with newly reported MYD88, BIRC3, NOTCH1 and SF3B1 mutations. A total of 27, 25, 41 and 57 patients with monoclonal IgM or IgG peaks (IgM and IgG groups), hypogammaglobulinemia (Hypo-γ group) and normal immunoglobulin serum levels (normal-γ group) were, respectively, included. IgM peaks were mainly associated with Binet stage C and the del(17p). Biased usage of IGHV3-48 was shared by both IgM and IgG groups. IGHV3-74 and IGHV4-39 gene rearrangements were specific for IgM and IgG peaks, respectively. SF3B1, NOTCH1, MYD88 and BIRC3 mutation frequencies were 12%, 4%, 2% and 2%, respectively, being over-represented in IgM, IgG and Hypo-γ groups for SF3B1, and being equal between normal-γ and IgM groups for MYD88. Overall, 76%, 87%, 49% and 42% of cases from IgM, IgG, Hypo-γ and normal-γ groups had at least one intermediate or poor prognosis genetic marker, respectively. By multivariate analysis, IgM peaks were associated with shorter treatment-free survival independently from any other univariate poor prognosis biological parameters, including IgG peaks, Hypo-γ, IGHV status, SF3B1 mutations, cytogenetics and lymphocytosis. Therefore, as with IgG peaks, IgM peaks aggravated the natural course of CLL, with increased accumulation of adverse genetic events.

Inferred cosmic-ray spectrum from Fermi large area telescope γ-ray observations of Earth's limb

Recent accurate measurements of cosmic-ray (CR) species by ATIC-2, CREAM, and PAMELA reveal an unexpected hardening in the proton and He spectra above a few hundred GeV, a gradual softening of the spectra just below a few hundred GeV, and a harder spectrum of He compared to that of protons. These newly discovered features may offer a clue to the origin of high-energy CRs. We use the Fermi Large Area Telescope observations of the γ-ray emission from Earth's limb for an indirect measurement of the local spectrum of CR protons in the energy range ∼90  GeV-6  TeV (derived from a photon energy range 15 GeV-1 TeV). Our analysis shows that single power law and broken power law spectra fit the data equally well and yield a proton spectrum with index 2.68±0.04 and 2.61±0.08 above ∼200  GeV, respectively.

MRI and venographic aspects of pelvic venous insufficiency

Pelvic venous insufficiency is a frequent pathology in multiparous women. Diagnosis can be made by chance or suspected in the case of symptoms suggesting pelvic congestion syndrome or atypical lower limb varicosity fed by pelvic leaks. After ultrasound confirmation, dynamic venography is the reference pretherapeutic imaging technique, searching for pelvic varicosity and possible leaks to the lower limbs. MRI is less invasive and allows a three-dimensional study of the varicosity and, with dynamic angiography, it can assess ovarian reflux. It also helps to plan or even sometimes avoid diagnostic venography.

Planned caesarean in the interventional radiology cath lab to enable immediate uterine artery embolization for the conservative treatment of placenta accreta

AIM

To evaluate the feasibility and efficacy of routine uterine artery embolization (UAE) immediately after planned caesareans performed in the cath lab for conservative treatment of placenta accreta.

MATERIALS AND METHODS

A retrospective study included all patients who had a planned caesarean in the cath lab for conservative treatment of placenta accreta at Angers University Hospital, which is a tertiary care centre, from April 2001 to September 2010. Twelve patients underwent UAE immediately after caesarean with the placenta left partially or totally in situ. The success rate of embolization, blood loss, and complications were reported.

RESULTS

Diagnosis of abnormal placentation was confirmed by caesarean findings in 14 cases. Four patients had a percreta form with bladder invasion. In seven cases blood loss was insignificant and UAE was prophylactic; no secondary haemorrhage was observed in this group. Postpartum haemorrhage occurred in five cases: control of immediate postpartum bleeding by embolization was successful in three and failed in two leading to hysterectomy. In one case uterine necrosis occurred 6 weeks after embolization, requiring a hysterectomy. Delayed complications resulted in hysterectomy and partial bladder resection 3 months after delivery for one of the patients with placenta percreta.

CONCLUSION

UAE immediately after a caesarean performed in the cath lab is a feasible therapeutic option for conservative treatment of placenta accreta. Advantages include reducing stress and risks associated with transferring women with potentially unstable haemodynamics.

Measurement of separate cosmic-ray electron and positron spectra with the fermi large area telescope

We measured separate cosmic-ray electron and positron spectra with the Fermi Large Area Telescope. Because the instrument does not have an onboard magnet, we distinguish the two species by exploiting Earth's shadow, which is offset in opposite directions for opposite charges due to Earth's magnetic field. We estimate and subtract the cosmic-ray proton background using two different methods that produce consistent results. We report the electron-only spectrum, the positron-only spectrum, and the positron fraction between 20 and 200 GeV. We confirm that the fraction rises with energy in the 20-100 GeV range. The three new spectral points between 100 and 200 GeV are consistent with a fraction that is continuing to rise with energy.

Gamma-ray emission concurrent with the nova in the symbiotic binary V407 Cygni

Novae are thermonuclear explosions on a white dwarf surface fueled by mass accreted from a companion star. Current physical models posit that shocked expanding gas from the nova shell can produce x-ray emission, but emission at higher energies has not been widely expected. Here, we report the Fermi Large Area Telescope detection of variable gamma-ray emission (0.1 to 10 billion electron volts) from the recently detected optical nova of the symbiotic star V407 Cygni. We propose that the material of the nova shell interacts with the dense ambient medium of the red giant primary and that particles can be accelerated effectively to produce pi(0) decay gamma-rays from proton-proton interactions. Emission involving inverse Compton scattering of the red giant radiation is also considered and is not ruled out.

Fermi large area telescope search for photon lines from 30 to 200 GeV and dark matter implications

Dark matter (DM) particle annihilation or decay can produce monochromatic gamma rays readily distinguishable from astrophysical sources. gamma-ray line limits from 30 to 200 GeV obtained from 11 months of Fermi Large Area Space Telescope data from 20-300 GeV are presented using a selection based on requirements for a gamma-ray line analysis, and integrated over most of the sky. We obtain gamma-ray line flux upper limits in the range 0.6-4.5x10{-9} cm{-2} s{-1}, and give corresponding DM annihilation cross-section and decay lifetime limits. Theoretical implications are briefly discussed.

Incidence of gastrointestinal stromal tumors (GISTs) in France: Results of the PROGIST survey conducted among pathologists

10047

Background: GISTs are the most common mesenchymal tumors of the gastrointestinal tract but data on the annual incidence of this tumor is scarce due to previous lack of well-defined pathologic criteria. The aim of this study was to investigate the incidence of GISTs in France and describe the distribution according to age, sex, circumstances of discovery, localization and risk categories. Methods: This prospective epidemiologic study was performed among pathologists who were asked to declare all the cases of GIST over a one year period. All pathology centers (330 centers) in France were proposed to participate and asked to report exhaustively the cases diagnosed from 1 December 2004 to 30 November 2005. Results: 591 cases of GISTs were reported, 535 new cases and 56 cases of relapse. However, some large centers were not able to participate. So, the annual estimated incidence was 12 cases/million inhabitants in France. The main characteristics of the new cases of GIST were as follows: mean age 65 (± 13.2) (range: 16–93) years, 48.6% men and 51.4% women, circumstances of discovery: fortuitous 163 (30.5%), symptomatic 249 (46.5%), unknown 123 (23%). The primary tumor locations were: stomach 341 (63.7 %), small intestine 115 (21.5%), mesentery 35 (6.5%), colon/rectum 17 (3.2%), esophagus 4 (0.7%), unknown 23 (4.3%). 95.3% of GISTs were cKIT (CD117) + and 3.7 % were cKIT -. According to the Fletcher consensus criteria, based on tumor size and mitotic rate, among the 490 localized GISTs 14.7% were considered to be at very low prognostic risk, 25.5% at low-risk, 23.1 % at intermediate risk and 23.1 % at high-risk. For 13.6 % data were missing. Conclusions: This study is providing for the first time an estimation of the annual incidence of GISTs and a description of the characteristics of these tumors in France based on pathology registration. The true incidence may be slightly higher as some large centers were not able to reported their cases. These results are comparable to what has been reported in recent studies in other European countries.

No significant financial relationships to disclose.

The smallest carbamoyl-phosphate synthetase. A single catalytic subdomain catalyzes all three partial reactions

Escherichia coli carbamoyl-phosphate synthetase (CPSase) is comprised of a 40-kDa glutaminase (GLN) and a 120-kDa synthetase (CPS) subunit. The CPS subunit consists of two homologous domains, CPS.A and CPS.B, which catalyze the two different ATP-dependent partial reactions involved in carbamoyl phosphate synthesis. Sequence similarities and controlled proteolysis experiments suggest that the CPS subdomains consist, in turn, of three subdomains, designated A1, A2, A3 and B1, B2, B3 for CPS.A and CPS.B, respectively. Previous studies of individually cloned CPS.A and CPS. B from E. coli and mammalian CPSase have shown that homologous dimers of either of these "half-molecules" could catalyze all three reactions involved in ammonia-dependent carbamoyl phosphate synthesis. Four smaller recombinant proteins were made for this study as follows: 1) A1-A2 in which the A3 subdomain was deleted from CPS.A, 2) B1-B2 lacking subdomain B3 of CPS.B, 3) the A2 subdomain of CPS.A, and 4) the B2 subdomain of CPS.B. When associated with the GLN subunit, A1-A2 and B1-B2 had both glutamine- and ammonia-dependent CPSase activities comparable to the wild-type protein. In contrast, the 27-kDa A2 and B2 recombinant proteins, which represent only 17% of the mass of the parent protein, were unable to use glutamine as a nitrogen donor, but the ammonia-dependent activity was enhanced 14-16-fold. The hyperactivity suggests that A2 and B2 are the catalytic subdomains and that A1 and B1 are attenuation domains which suppress the intrinsically high activity and are required for the physical association with the GLN subunit.

Localization of a conformational energy-coupling determinant near the C terminus of the beta subunit of the F1F0-ATPase

Escherichia coli mutants in the beta subunit of the F1F0-ATPase can be complemented with the beta subunit from the obligate aerobe Bacillus megaterium. It has been shown that cells carrying such hybrid ATPases have an unusual energy-coupling phenotype. Although they are able to grow on minimal succinate medium, and therefore carry a functional ATP synthase, they are defective in the ability to grow anaerobically, indicating some defect in ATP-driven proton pumping (Scarpetta, M., Hawthorne, C. A., and Brusilow, W. S. A. (1991) J. Biol. Chem. 266, 18567-18572). In this study, chimeric beta subunits were constructed consisting of the E. coli or the B. megaterium beta subunit carrying the C-terminal 18% of the other's beta subunit. The phenotypes of an E. coli beta mutant complemented with these chimeric subunits showed that the energy-coupling defect was located in this C-terminal region. The E. coli beta subunit carrying the B. megaterium C-terminal region displayed the energy-coupling defect, while the B. megaterium beta subunit carrying the E. coli C-terminal region did not. In ATP-dependent fluorescence quenching assays, membranes isolated from cells displaying the energy-coupling defect also pumped protons less well than membranes isolated from cells that were able to grow anaerobically. These results demonstrate that the C terminus of the beta subunit is involved in the conformational coupling pathway, which, through the polypeptide backbone of the beta subunit, physically links ATP synthesis or hydrolysis to the energy of proton translocation.

[Reciprocal changes in the ST segment in acute inferior myocardial infarction. Value of delay in appearance]

The significance of a "reciprocal" ST depression (ST(-)) in the acute phase of myocardial infarction remains controverted. This may be due to ST(-) not having the same determinants when studied at an early stage (less than 6 hours) or later (greater than 6 hours). The purpose of this study was to find out whether "reciprocal" ST(-) correlates with the same parameters when measured on very early ECG's (before 6 hours) or at a distance from the onset of infarction. The parameters concerned are coronary lesions, extent of the infarction and left ventricular function. ECG was performed in 46 patients with inferior infarct aged from 26 to 70 years (mean 50.8 +/- 9.2 years) between 2-6 h, 6-12 h, 12-24 h and 24-48 h from the beginning of pain. The sum of ST(-) on V1V2V2V4 (V1-4), D1aV1V1 to V6 and L1aV1V5V6, and the sum of ST elevation on L2L3aVf were measured at each period of time. The extent of global and anterior territory hypokinesia, the ejection fraction and the left coronary impairment were evaluated between the 2nd and 4th weeks. At 2-6 hours (a) the sum of ST(-) was greater (though not significantly), and the sum of ST elevation on L2L3aVf was significantly greater (p less than 0.001) when the left anterior descending artery (LAD) was not involved than when it was involved; (b) there was no difference between patients with and without ST depression (on all lead groups) in the degree of left ventricular hypokinesia and ejection fraction value.(ABSTRACT TRUNCATED AT 250 WORDS)

[Influence of intravenous clonidine on normal and pathological sinus and atrioventricular nodes and carotid sinus sensitivity]

A number of clinical observations have suggested that clonidine may be responsible for dizziness and even syncope. The aim of this study was to assess the effects of this drug on normal and pathological sinus and AV nodes and on carotid sinus sensitivity. 19 patients were investigated (average age: 73 years). 14 patients complained of dizziness or syncope, including 3 patients with spontaneous sinus node dysfunction. 5 patients were asymptomatic; 3 were investigated for severe sinus bradycardia (1 on clonidine); 1 patient had sinoatrial block and 1 patient underwent pre-operative assessment for intraventricular block. The sinus node was studied using Mandel's method at 100, 120 and 150/min; the AV node was studied by the extrastimulus method with fixed atrial cycle of 600 ms. The following parameters were measured: Wenckebach point, AH interval in spontaneous and paced cycle length of 600 ms, effective refractory periods. Carotid sinus sensitivity was tested by right and left carotid sinus massage. These parameters were measured under basal conditions and 15 and 30 minutes after IV injection of 0.150 mg of clonidine. Two groups of patients were identified from the results under basal conditions: group 1:11 patients with corrected post-stimulation pauses less than 525 ms, and group 2:8 patients with at least one corrected post-stimulation pause of over 525 ms. Clonidine influenced the post-stimulation pauses significantly in both groups. However, the number of pathological pauses increased much more in group 2 than in group 1.(ABSTRACT TRUNCATED AT 250 WORDS)

[Continuous ecopathological survey. 2. Typology of dairy cattle farms with high and low fertility]

Management characteristics were analysed in two groups of dairy herds (20 to 60 cows per herd) during a continuous eco-pathological survey, in relation to high and low fertility. 59.8% of the cows from the eleven high fertility herds were successfully inseminated at first service and 11.4% of the cows inseminated for the first time more than 40 days post-partum required 3 or more services. The corresponding values were 51.1 and 25.6% for the ten low fertility herds. Other reproductive criteria (calving-first service interval, disturbed oestrus cycles), which more depend on the reproduction management, were not different between the two groups. Feeding system greatly varied in the low fertility group. Frequent changes in diet composition, a longer period of "green" forages distribution (crucifers, grass silage) as well as less utilisation of concentrates are some of the reasons which can explain the low fertility. Calving occurred mainly from February to April in low fertility herds, at the transition from winter diets to grazing. Milk production was lower, 4 580 kg per cow and per year vs 5 520 kg for high fertility group. Milk production falls were more frequent and Holstein semen was less used. Tied housing conditions, and higher incidence of Fasciola hepatica and abomasal mematodes characterised low fertility herds; inversely, the clinical pathology appeared to be less frequent in this group. Soil manganese concentration was lower (16.3 ppm) in the low fertility group as compared to the other group (30.9 ppm); this could be explained by less schistose rocks where the low fertility farms are localized. In conclusion, the risk factors associated with low fertility may be attributed to: the composite system of feeding in addition to the use of "green" forages, a lack of proper programming with regards to the season of calving, and the high frequency of parasitic infestations, with special reference to liver fluke.