Article: Intraoperative and postoperative surgical complications after ureteroscopy, retrograde intrarenal surgery, and percutaneous nephrolithotomy: a systematic review - Minerva Urology and Nephrology 2021 June;73(3):309-32 - Minerva Medica - Journals

Background: Holmium laser enucleation of the prostate (HoLEP) is considered a safe and effective treatment in case of bladder outlet obstruction (BOO). Despite technical execution has evolved over time, from the standard three-lobes to the more recent en-bloc approaches, data comparing these two techniques are missing. The aim of the present study was to describe our en-bloc HoLEP with early apical release technique and compare peri- and postoperative results with the classical three-lobe approach in a single referral center. Materials and Methods: We prospectively analyzed all consecutive cases between 2017 and 2019 divided according to the type of approach. Patients were preoperatively studied through instrumental assessment and clinical evaluation, using validated questionnaires and then postoperatively at specific time frames. Linear regression analysis was performed to evaluate possible predictor of continuous variables. All the procedures were carried out by one single expert surgeon. Results: Overall, 168 patients were included, of which 81 were treated with classical three-lobes and 87 with en-bloc with early apical release technique. The two cohorts were comparable related to preoperative features and postoperative complication rate. Mean enucleation time (ET), lasing time, amount of energy delivered, and overall operative time were significantly lower in en-bloc procedures ( p < 0.05). Stepwise multivariable linear regression showed that en-bloc strategy can significantly predict shorter ET and lower energy delivered. Stress incontinence rate at 1-month follow-up was found to be significantly reduced in the en-bloc group, compared with the counterpart. Conclusions: Both techniques are effective and safe treatment options for BOO, since peri- and postoperative surgical and functional outcomes were favorable. En-bloc strategy may significantly decrease ET and the amount of energy delivered leading to a reduced early stress incontinence rate compared with the standard approach.

INTRODUCTION: Open pyeloplasty has been the first-line treatment for uretero-pelvic junction obstruction for decades. In the last years, minimally-invasive surgery (MIS) has gained popularity in the pediatrics field. Furthermore, recently, a great extension of Robot-assisted laparoscopic pyeloplasty (RALP) has been seen in younger and lighter-weight children as well as in redo cases. Herein we provided a comprehensive review of primary and redo RALP performed in children, particularly focusing on the different distribution of outcomes among the ages. EVIDENCE ACQUISITION: A systematic review of the literature was performed according to PRISMA recommendations and was conducted on surgical indication and technique, intraoperative nuances, peri- and postoperative outcomes of primary and redo RALP. EVIDENCE SYNTHESIS: Overall, 33 studies with 1448 patients were included for primary RALP and 7 studies with 101 patients for redo cases between 2000 and 2019. In particular, 4 studies aimed to compare RALP in different cohorts of children grouped on ages or weight and 4 studies evaluated technical feasibility and safety of RALP over laparoscopic and open approach in very young populations. Success rate for primary RALP was found >90% in all studies but one, with low complication rate and preoperative indication. In redo series, 96% of patients revealed a decreased hydronephrosis on postoperative imaging. CONCLUSIONS: RALP offers excellent outcomes in the pediatric population. However, there is still a strong need for higher quality evidence in the form of prospective observational studies and clinical trials. The rising of new robotic systems, such as single-port platform, might further enhance the applications of RALP in children.

There is a lack of evidence on acute kidney injury (AKI) and new-onset chronic kidney disease (CKD) after surgery for localised renal masses (LRMs) in patients with two kidneys and preserved baseline renal function. To evaluate the prevalence and risk of AKI and new-onset clinically significant CKD (csCKD) in patients with a single renal mass and preserved renal function after being treated with partial (PN) or radical (RN) nephrectomy. We queried our prospectively maintained databases to identify patients with a preoperative estimated glomerular filtration rate (eGFR) of ≥60 ml/min/1.73 m² and a normal contralateral kidney who underwent PN or RN for a single LRM (cT1-T2N0M0) between January 2015 and December 2021 at four high-volume academic institutions. PN or RN. The outcomes of this study were AKI at hospital discharge and the risk of new-onset csCKD, defined as eGFR <45 ml/min/1.73 m², during the follow-up. Kaplan-Meier curves were used to examine csCKD-free survival according to tumour complexity. A Multivariable logistic regression analysis assessed the predictors of AKI, while a multivariable Cox regression analysis assessed the predictors of csCKD. Sensitivity analyses were performed in patients who underwent PN. Overall, 2469/3076 (80%) patients met the inclusion criteria. At hospital discharge, 371/2469 (15%) developed AKI (8.7% vs 14% vs 31% in patients with low- vs intermediate- vs high-complexity tumours, p < 0.001). At the multivariable analysis, body mass index, history of hypertension, tumour complexity, and RN significantly predicted the occurrence of AKI. Among 1389 (56%) patients with complete follow-up data, 80 events of csCKD were recorded. The estimated csCKD-free survival rates were 97%, 93% and 86% at 12, 36, and 60 mo, respectively, with significant differences between patients with high- versus low-complexity and high- versus intermediate-complexity tumours (p = 0.014 and p = 0.038, respectively). At the Cox regression analysis, age-adjusted Charlson Comorbidity Index, preoperative eGFR, tumour complexity, and RN significantly predicted the risk of csCKD during the follow-up. The results were similar in the PN cohort. The main limitation of the study was the lack of data on eGFR trajectories within the 1st year after surgery and on long-term functional outcomes. The risk of AKI and de novo csCKD in elective patients with an LRM and preserved baseline renal function is not clinically negligible, especially in those with higher-complexity tumours. While baseline nonmodifiable patient/tumour-related characteristics modulate this risk, PN should be prioritised over RN to maximise nephron preservation if oncological outcomes are not jeopardised. In this study, we evaluated how many patients with a localised renal mass and two functioning kidneys, who were candidates for surgery at four referral European centres, experienced acute kidney injury at hospital discharge and significant renal functional impairment during the follow-up. We found that the risk of acute kidney injury and clinically significant chronic kidney disease in this patient population is not negligible, and was associated with specific baseline patient comorbidities, preoperative renal function, tumour anatomical complexity, and surgery-related factors, in particular the performance of radical nephrectomy.

Objective: To provide a step-by-step overview of the University of Florence technique for robotic living donor nephrectomy (LDN), focusing on its technical nuances and perioperative outcomes.Methods: A dedicated robotic LDN program at our Institution was codified in 2012. Data from patients undergoing robotic LDN from 2012 to 2019 were prospectively collected. All robotic LDNs were performed by a highly experienced surgeon, using the da Vinci Si robotic platform in a three-arm configuration. In this report we provide a detailed overview of our surgical technique for robotic LDN. The main objective of the study was to evaluate the technical feasibility and safety of the technique, including perioperative surgical complications rate and mid-term functional outcomes.Results: Overall, 36 patients undergoing robotic LDNs were included in the study. Of these, 28 (78%) were left LDNs. Median (IQR) donor pre-operative eGFR was 88 (75.6–90) ml/min/1.73 m². In all cases, robotic LDN was completed without need of conversion. The median (IQR) overall operative time was 230 (195–258) min, while the median console time was 133 (IQR 117-166) min. The median (IQR) warm ischemia time was 175 (140–255) s. No intraoperative adverse events or 90-d major surgical complications were recorded. At a median (IQR) follow-up of 24 months (IQR 11-46), median (IQR) eGFR patients undergoing in living donor nephrectomy was 57.4 (47.9; 63.9) ml/min/1.73 m².Conclusions: In our experience, robotic LDN is technically feasible and safe. The use of robotic surgery for LDN may provide distinct advantages for surgeons while ensuring optimal donors' perioperative and functional outcomes.