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Background Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. Methods A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. Results Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%). Conclusions This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

10% of all pediatric brain tumors arise in the brainstem. Amongst these gliomas are the most common while other entities are rare and infrequently described in the literature. In this study we investigated the prevalence of non-gliomatous tumors in the brainstem. Amongst the 1323 embryonal tumours received at the RBTC, we identified 17 cases of ETMRs (17/165) that presented as brainstem primaries. Previously grouped within CNS-PNETs, ETMR, is a new WHO diagnostic entity, characterized by C19MC alterations. ETMR is a disease of infancy, the clinical spectrum of which is poorly understood. ETMRs arise at multiple CNS locations including cerebrum being most common (60%,) followed by cerebellum (18%) and midline structures (6%); notably 10% were brainstem primaries, mimicking DIPG radiologically. All patients presented with a short history of progressive neurological symptoms, with most common signs and symptoms of cranial neuropathies, long tract signs and gait disturbance. Median age at diagnosis was 27 months (range 16-75months) with a male to female ratio of 0.9:1. Predominantly localized (M0-94%, M2-3 -6%) majority of patients underwent upfront biopsy or partial resection (15/17:88%), while complete tumor resection was achieved in 2 cases. All patients received heterogenous combination of chemotherapy with and without radiotherapy. Majority of patients progressed rapidly with median time to progression of 4 months and overall survival of < 13 months. The only long-term surviving patient had complete resection dose intensified chemotherapy and radiation (OS 202months). Primary ETMRs in the brainstem are under recognised entities and carry a dismal prognosis. Although rapidly progressive, prompt recognition, maximal resection and management with multimodal adjuvant therapy should be considered in cases with brainstem disease.

Many hospitals will continue to see a surge in COVID-19 cases and halt of elective cases, while others pass the surge and begin to restart elective surgeries. Regardless of the phase each hospital encounters, the safety of both patients and staff must be taken into account.1,2 This case report describes a patient who underwent urgent coronary artery bypass grafting (CABG) at the beginning of the COVID-19 surge. The initial postoperative course was uneventful and the patient was discharged on postoperative day 4. The patient presented nearly two weeks later with a subsequent severe COVID-19 infection complicated by STEMI and stroke. This case not only demonstrates the risks and potential complications of caring for cardiac surgery patients during the COVID-19 pandemic, it is the only known reported case of a patient developing severe COVID-19 infection after a CABG resulting in STEMI and stroke due to hypercoagulable state associated with COVID-19.

Introduction Ubiquitin-like with plant homeodomain and ring finger domains 1 (UHRF1) encodes a master regulator of DNA methylation that has emerged as an epigenetic driver in human cancers. To date, no studies have evaluated UHRF1 expression in malignant pleural mesothelioma (MPM). This study was undertaken to explore the therapeutic potential of targeting UHRF1 in MPM. Methods Microarray, real-time quantitative reverse transcription–polymerase chain reaction, immunoblot, and immunohistochemistry techniques were used to evaluate UHRF1 expression in normal mesothelial cells (NMCs) cultured with or without asbestos, MPM lines, normal pleura, and primary MPM specimens. The impact of UHRF1 expression on MPM patient survival was evaluated using two independent databases. RNA-sequencing, proliferation, invasion, and colony formation assays, and murine xenograft experiments were performed to evaluate gene expression and growth of MPM cells after biochemical or pharmacologic inhibition of UHRF1 expression. Results UHRF1 expression was significantly higher in MPM lines and specimens relative to NMC and normal pleura. Asbestos induced UHRF1 expression in NMC. The overexpression of UHRF1 was associated with decreased overall survival in patients with MPM. UHRF1 knockdown reversed genomewide DNA hypomethylation, and inhibited proliferation, invasion, and clonogenicity of MPM cells, and growth of MPM xenografts. These effects were phenocopied by the repurposed chemotherapeutic agent, mithramycin. Biochemical or pharmacologic up-regulation of p53 significantly reduced UHRF1 expression in MPM cells. RNA-sequencing experiments exhibited the pleiotropic effects of UHRF1 down-regulation and identified novel, clinically relevant biomarkers of UHRF1 expression in MPM. Conclusions UHRF1 is an epigenetic driver in MPM. These findings support the efforts to target UHRF1 expression or activity for mesothelioma therapy.

Background To evaluate preoperative risk factors and postoperative outcomes in patients with preoperative renal insufficiency undergoing open surgical repair of the aortic root, ascending aorta, or aortic arch. Methods Our institutional database was reviewed for all patients undergoing elective aortic root, ascending aorta, and aortic arch open repairs. Patients were separated into two groups based on renal function. Patients with preoperative renal insufficiency were compared to those with normal renal function. Regression analyses were used to identify independent predictors of short and long term postoperative outcomes. Results The cohort consisted of 2140 patients, of which 55 had preoperative renal insufficiency (PRI). Patients with PRI were older and had worse cardiovascular risk profiles. On presentation, PRI patients were more likely to have lower ejection fraction. There was no difference in operative mortality between the two groups. The most frequent major postoperative complications among renal insufficiency patients were reoperation for bleeding (9.1%, P = .02). Logistic regression analysis indicated that PRI and left ventricular ejection fraction were independent predictors of major adverse events. Long-term survival was significantly reduced in preoperative renal insufficiency patients in the unmatched cohort. Conclusions Aortic patients with preoperative renal insufficiency have a higher risk profile of mortality. Renal insufficiency remains an independent predictor of adverse outcomes following aortic surgery and understanding this patient population can guide physicians to improve outcomes.

Aims Lipid formulations of amphotericin B, rather than conventional amphotericin (c-amB), are increasingly used despite limited data comparing these preparations in children. Data on the incidence of adverse effects with amphotericin B at standard doses are scarce. This study aimed to compare the adverse effects associated with standard doses of c-amB and liposomal amphotericin (l-amB) in children. Methods Children admitted to the Royal Children's Hospital Melbourne and treated with c-amB or l-amB between January 2010 and September 2013 were included. Clinical and laboratory data were retrospectively extracted from medical records to compare amphotericin-related infusion reactions, nephrotoxicity (glomerulotoxicity and tubulopathy) and hepatotoxicity. Results Seventy-six children received c-amB and 39 received l-amB. Standard drug administration (recommended dose and infusion time) occurred in 74% (56/76) of patients on c-amB and 85% (33/39) on l-amB. In these 89 children, infusion-related reactions were similar for both c-amB and l-amB (23% (13/56) vs. 9% (3/33); P = 0.15); none occurred in children aged

Objective: To determine seroprotection for the vaccine-preventable diseases (VPDs) measles, mumps, rubella, varicella and hepatitis B among new employees seen at a Victorian tertiary hospital staff clinic. Methods: Employees who presented to the staff clinic for immunisation assessment between 1 January 2012 and 31 December 2013 were included. Demographic data, self-reported disease history and previous vaccination status were reviewed retrospectively to determine impact on serological results. Results: A total of 1,901 new employees were included, 83% of whom were at risk of direct contact with blood or body substances. Overall, the proportion of workers seropositive to measles was 88%, mumps 90%, rubella 78%, varicella 93% and hepatitis B 80%. Staff born before 1966 were more likely to have positive measles or mumps serology but negative rubella or hepatitis B serology (p

The treatment of Mycobacterium abscessus complex (MABSC) pulmonary infections is an emerging challenge in patients with cystic fibrosis (CF). Multidrug therapy for prolonged durations is required and carries the significant burden of drug-related toxicity, cost and selective pressure for multiresistant bacteria. International guidelines acknowledge that clinical and in vitro data to support treatment regimens are limited, particularly in children. As part of a collaboration between the infectious diseases and respiratory units at our institution, we have developed a modified treatment guideline that aims to balance the aims of MABSC eradication and slowing disease progression with minimising drug toxicity and resistance. The outcomes of this treatment approach will be monitored and reported. In this manuscript, we discuss the available evidence for treatment choices and present our treatment guideline for paediatric patients with CF and MABSC infection.

Rationale: Whereas asbestos burden has been linked to cytogenetic alterations in malignant pleural mesotheliomas, epigenetic aberrations induced by these fibers have not been fully delineated. Objectives: The objective of this study was to establish an in vitro model to characterize early epigenetic events potentially contributing to malignant pleural mesothelioma. Methods: Normal human mesothelial cells (LP9 and LP3) were cultured with or without crocidolite asbestos fibers (1 or 2 μg/cm(2)) for up to 10 days. Messenger RNA, microRNA, and protein levels were assessed by quantitative reverse transcriptase–polymerase chain reaction and immunoblot techniques. Methylation-specific polymerase chain reaction, pyrosequencing, and quantitative chromatin immunoprecipitation techniques were used to correlate changes in gene expression with epigenetic alterations in the respective promoters. Results: Asbestos mediated time- and dose-dependent repression of Ras association domain–containing protein 1 (RASSF1A), p16 kinase 4a inhibitor (p16INK4a), and p14 alternative reading frame (p14ARF) in normal mesothelial cells; this phenomenon coincided with upregulation of DNA methyltransferase 1 (DNMT1) as well as increased expression of enhancer of zeste homolog 2 (EZH2). Upregulation of EZH2 coincided with repression of microRNA 26A and microRNA 101, which target the 3′ untranslated region of the EZH2 transcript. Silencing of RASSF1A, p16INK4a, and p14ARF coincided with recruitment of EZH2 and concomitant increases in the PRC-2–mediated repressive histone mark, histone H3 lysine 27 trimethylation (H3K27me3), and decreased levels of histone H3 lysine 27 acetylation (H3K27ac3) (histone activation mark) within the respective promoters. Asbestos induced de novo DNA methylation in the promoter of RASSF1A, but not within the INK4a/ARF locus. 5-Aza-2′-deoxycytidine (0–0.5 μM for 72 h) induced dose-dependent activation of RASSF1A (but not p16/p14) in malignant pleural mesothelioma cells; this phenomenon coincided with DNA demethylation and decreased occupancy of DNA methyltransferase 3B within the RASSF1A promoter. Conclusions: Asbestos mediates rapid inactivation of Hippo, Retinoblastoma, and p53 tumor suppressor pathways in normal human mesothelial cells via epigenetic repression of RASSF1A, p16INK4A, and p14ARF, respectively. This in vitro model may prove useful for delineating the sequence of epigenetic events contributing to malignant pleural mesothelioma, and the development of novel strategies for treatment and possible prevention of these neoplasms.

Osteoarticular infections with Gram positive bacteria present an increasing challenge in an era of multidrug-resistant organisms. Prolonged intravenous antibiotic treatment is often required, with associated risks, costs and difficulties with administration; a safe, effective oral option would be ideal for this indication. Pristinamycin, an oral streptogramin antibiotic with bactericidal activity against Gram positive organisms including methicillin-resistant Staphylococcus aureus, has been used for over 50 years in Europe for the treatment of osteoarticular infections. We review the published evidence for the treatment of native bone and prosthesis-related osteoarticular infections with pristinamycin.

Acute ischemia in chronic type B dissections carries high rates of morbidity and mortality. A 29-year-old woman with a chronic type B dissection presented with acute abdominal pain. Imaging revealed a worsening dissection with pseudocoarctation causing near complete occlusion of the true lumen by the false lumen. We placed purposefully undersized stent grafts to treat acute mesenteric ischemia by improving true lumen flow. The patient was discharged on postoperative day 4 without adverse events. We suggest that endovascular rescue by placing undersized stent grafts can provide improved flow to the mesenteric vessels with continued false lumen flow to vital organs.

The development of new therapies has lagged behind for rare cancers without defined therapeutic targets. Adrenocortical cancer is no exception. Mitotane, an older agent considered “adrenolytic,” is used both to control symptoms in advanced disease and as adjuvant therapy after surgical resection. Molecular characterization of adrenocortical cancer has deepened our understanding of this genetically complex disease while identifying subgroups whose importance remains to be determined. Unfortunately, such studies have yet to demonstrate a therapeutic target for drug development, and to date, no targeted therapy has achieved meaningful outcomes. Consequently, first-line therapy for metastatic disease remains a combination regimen of etoposide, doxorubicin, and cisplatinum established in a randomized clinical trial. In addition to evaluating recent studies in adrenocortical cancer, we raise one critical clinical issue—the risk of peritoneal dissemination following laparoscopic resection of adrenocortical cancer. In a retrospective case series of 267 patients referred to the NCI for the treatment of recurrent or advanced adrenocortical cancer, we found extensive peritoneal dissemination in 25 of the 45 patients (55.6%) who had undergone laparoscopic resection, compared with only 7 of the 222 patients (3%) who had undergone an open resection (P < 0.0001). Although this has been debated in the literature, our data argue for an end to laparoscopic resection of adrenocortical cancers to avoid peritoneal dissemination, a complication of laparoscopy that is uniformly fatal. Clin Cancer Res; 22(20); 4989–5000. ©2016 AACR. See all articles in this CCR Focus section, “Endocrine Cancers: Revising Paradigms.”

Purpose Adoptive cell transfer, the infusion of large numbers of activated autologous lymphocytes, can mediate objective tumor regression in a majority of patients with metastatic melanoma (52 of 93; 56%). Addition and intensification of total body irradiation (TBI) to the preparative lymphodepleting chemotherapy regimen in sequential trials improved objective partial and complete response (CR) rates. Here, we evaluated the importance of adding TBI to the adoptive transfer of tumor-infiltrating lymphocytes (TIL) in a randomized fashion. Patients and Methods A total of 101 patients with metastatic melanoma, including 76 patients with M1c disease, were randomly assigned to receive nonmyeloablative chemotherapy with or without 1,200 cGy TBI before transfer of tumor-infiltrating lymphcytes. Primary end points were CR rate (as defined by Response Evaluation Criteria in Solid Tumors v1.0) and overall survival (OS). Clinical and laboratory data were analyzed for correlates of response. Results CR rates were 24% in both groups (12 of 50 v 12 of 51), and OS was also similar (median OS, 38.2 v 36.6 months; hazard ratio, 1.11; 95% CI, 0.65 to 1.91; P = .71). Thrombotic microangiopathy was an adverse event unique to the TBI arm and occurred in 13 of 48 treated patients. With a median potential follow-up of 40.9 months, only one of 24 patients who achieved a CR recurred. Conclusion Adoptive cell transfer can mediate durable complete regressions in 24% of patients with metastatic melanoma, with median survival > 3 years. Results were similar using chemotherapy preparative regimens with or without addition of TBI.

Purpose: Adoptive transfer of activated autologous tumor-infiltrating lymphocytes (TIL) can mediate complete, durable regressions in patients with metastatic melanoma. Responding patients generally do not have significant changes in noncutaneous RECIST targets before 30 to 60 days following TIL infusion, and complete responses are often not confirmed for 1 to 2 years. There is a critical need for a biomarker that can provide early information regarding the likelihood and duration of a response to enable rational decisions about altering therapy. We wished to evaluate the role of circulating tumor DNA (ctDNA) in separating responding from nonresponding patients. Experimental Design: We studied BRAF V600E ctDNA levels by a sensitive allele-specific PCR assay in 388 serum samples from 48 patients who received TIL immunotherapy at the NCI and correlated differences in the dynamic patterns of their ctDNA measurements with response outcomes. Results: A strong correlation was found between the presence or absence of an early serum peak of V600E ctDNA, and the likelihood of an objective response. Furthermore, patients that developed an early ctDNA peak and cleared their serum of V600E ctDNA were highly likely to achieve a complete response over the next 1 to 2 years. Patients that showed no peak of V600E ctDNA failed to achieve an objective response, with one exception. Conclusions: We show that the dynamic changes occurring in BRAF V600E ctDNA levels within the first month following T-cell transfer immunotherapy in metastatic melanoma can be used to rapidly identify responding from nonresponding patients, potentially allowing clinicians to make critical treatment-related decisions in a more timely manner. These data also suggest that the majority of tumor killing by TIL occurs very early after the initiation of therapy. Clin Cancer Res; 22(22); 5480–6. ©2016 AACR.

Introduction Thymic epithelial tumors are rare mediastinal malignancies that can be invasive and difficult to treat. Insulin-like growth factor-1 receptor (IGF-1R) is a transmembrane receptor implicated in the regulation of cell metabolism, growth, and survival. As higher levels of IGF-1R protein expression may be associated with relative sensitivity to anti-IGF-1R antibody treatment, we investigated IGF-1R expression in thymic malignancies. Methods Sixty-three thymic tumors (56 thymomas and seven thymic carcinomas) were analyzed for total IGF-1R expression using immunohistochemistry with a specific antibody (clone G11, Roche-Ventana, Tucson, AZ). Expression levels were correlated with relevant clinical and pathologic variables, including epidermal growth factor receptor and KIT expression, and patient outcome. Results IGF-1R staining was negative in 13 (21%) cases, low (1+) in 20 (32%) cases, moderate (2+) in 20 (32%) cases, and high (3+) in 10 (16%) cases. Moderate to high IGF-1R staining was observed in 6 of 7 (86%) thymic carcinomas and in 24 of 56 (43%) thymomas ( p = 0.039). Moderate to high IGF-1R staining was associated with high epidermal growth factor receptor staining ( p = 0.015). By multivariate analysis, only tumor stage and histologic type were significant prognostic factors on time to progression (hazard ratio [HR] = 4.12, 95% confidence interval [CI]: 1.98–14.23; p = 0.010 and HR=2.79, 95% CI: 1.62–12.50; p = 0.018, respectively). There was no association between IGF-1R expression and time to progression (HR = 3.07, 95% CI: 0.38–24.59; p = 0.291). Conclusion A majority of thymic malignancies display moderate to high expression of IGF-1R. The lack of preclinical models prevented us to further study the functional consequences of anti-IGF-1R therapy in this setting. However, given correlations in other cancers, these data support the evaluation of anti-IGF-1R inhibitors in thymic tumors.

Background There can be considerable overlap in the clinical presentation and laboratory features of dengue, malaria, and enteric fever, three important causes of fever in returned travelers. Routine laboratory tests including full blood examination (FBE), liver function tests (LFTs), and C-reactive protein (CRP) are frequently ordered on febrile patients, and may help differentiate between these possible diagnoses. Methods Adult travelers returning to Australia who presented to the Royal Melbourne Hospital with confirmed diagnosis of dengue, malaria, or enteric fever between January 1, 2000 and March 1, 2013 were included in this retrospective study. Laboratory results for routine initial investigations performed within the first 2 days were extracted and analyzed. Results There were 304 presentations including 58 with dengue fever, 187 with malaria, and 59 with enteric fever, comprising 56% of all returned travelers with a febrile systemic illness during the study period. Significant findings included 9-fold and 21-fold odds of a normal CRP in dengue compared with malaria and enteric fever, respectively. The odds of an abnormally low white cell count (WCC) were also significantly greater in dengue versus malaria or enteric fever. Approximately one third of dengue presentations and almost half of the malaria presentations had platelet counts

Objective—To compare pharmacokinetics of enrofloxacin administered IV and in various oral preparations to ewes. Animals—5 mature Katahdin ewes weighing 42 to 50 kg. Procedure—Ewes received 4 single-dose treatments of enrofloxacin in a nonrandomized crossover design followed by a multiple-dose oral regimen. Single-dose treatments consisted of an IV bolus of enrofloxacin (5 mg/kg), an oral drench (10 mg/kg) made from crushed enrofloxacin tablets, oral administration in feed (10 mg/kg; mixture of crushed enrofloxacin tablets and grain), and another type of oral administration in feed (10 mg/kg; mixture of enrofloxacin solution and grain). The multiple-dose regimen consisted of feeding a mixture of enrofloxacin solution and grain (10 mg/kg, q 24 h, for 7 days). Plasma concentrations of enrofloxacin and ciprofloxacin were measured by use of high-performance liquid chromatography. Results—Harmonic mean half-life for oral administration was 14.80, 10.80, and 13.07 hours, respectively, for the oral drench, crushed tablets in grain, and enrofloxacin solution in grain. Oral bioavailability for the oral drench, crushed tablets in grain, and enrofloxacin in grain was 47.89, 98.07, and 94.60%, respectively, and median maximum concentration (Cmax) was 1.61, 2.69, and 2.26 µg/ml, respectively. Median Cmax of the multiple-dose regimen was 2.99 µg/ml. Conclusions and Clinical Relevance—Enrofloxacin administered orally to sheep has a prolonged half-life and high oral bioavailability. Oral administration at 10 mg/kg, q 24 h, was sufficient to achieve a plasma concentration of 8 to 10 times the minimum inhibitory concentration (MIC) of any microorganism with an MIC ≤ 0.29 µg/ml. (Am J Vet Res 2002; 63:1012–1017)

An improved sample preparation procedure for analysis of carcinogenic ethyl carbamate (EC) in wine by GC-MS-SIM is proposed. Differences over AOAC reference procedure were: (1) use of EC-d5 as internal standard instead of less similar propyl carbamate; (2) extraction by diethyl ether instead of more toxic dichloromethane, and (3) concentration by vacuum automated parallel evaporation instead of more time and work consuming rotary evaporation. Mean recovery was 104.4%, intraday precision was 6.7% (3.4 μg L(-)(1)) and 1.7% (88.5 μg L(-)(1)), regression coefficient was 0.999 in the linear working range of 3-89 μg L(-)(1), and limits of detection and quantification were 0.4 and 1.2 μg L(-)(1). Applicability was demonstrated by analysis (in triplicate) of 5 wine samples. EC concentration ranged from 5.2 ± 0.2 to 29.4 ± 1.5 μg L(-)(1). The analytical method is selective, accurate, repeatable, linear, and has similar method performance as the reference method along with the several mentioned advantages.

Capacity to attach to urinary tract epithelium is a virulence factor in E.coli causing UTI (1). The aim of the present study was to correlate ability to attach to human urinary tract epithelium and to agglutinate erythrocytes from various species, thus indirectly clearifying the bacterial surface structures, pili, involved in attachment. Methods: About 450 E.coli strains isolated from girls with acute pyelonephritis, acute cystitis, asymptomatic bacteriuria and from the stools of healthy children were tested for capacity to attach to human urinary tract epithelial cells (2) and to agglutinate human, guinea pig and horse erythrocytes and yeast cells (3). Results: Almost 100 per cent correlation was found between adhesive capacity and mannose-resistant agglutination of human erythrocytes. Mannose sensitive agglutination of guinea pig erythrocytes gave no such correlation. Conclusion: Agglutination of human erythrocytes by E.coli may be a simple risk test for urinary isolates. References: (1) Svanborg Eden et al. Lancet II:490, 1976, (2) Svanborg Eden et al. Infect.Immun. 18:767, 1977, (3) Korhonen and Svanborg Eden, submitted for publ.

Purpose: To study symptomatic UTI occurring in the infants screened for bacteriuria (part I).

PURPOSE: We compared standard robot-assisted radical prostatectomy and Retzius-sparing robot-assisted radical prostatectomy in a multicenter study using prospective patient reported outcome measures of functional recovery and quality of life plus standard pentafecta outcomes. MATERIALS AND METHODS: Patient and physician reported data on 483 patients who underwent robot-assisted radical prostatectomy and Retzius-sparing robot-assisted radical prostatectomy from August 2017 to April 2020 by 3 experienced surgeons had been prospectively collected. Perioperative and pentafecta outcomes were analyzed using SPSS software. Patient reported outcome measures for urinary function, erectile function and quality of life were reported at baseline and at 7 days and 1, 3, 6, 9 and 12 months postoperatively. RESULTS: A total of 201 patients underwent robot-assisted radical prostatectomy and 282 had Retzius-sparing robot-assisted radical prostatectomy. Patient and tumor characteristics were similar except for fewer low risk and more intermediate risk disease in robot-assisted radical prostatectomy vs Retzius-sparing robot-assisted radical prostatectomy (p

Context Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. Objective To critically analyze the current status of laparoscopic and robotic repair of UPJO. Evidence acquisition A systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. Evidence synthesis Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population. Conclusions Laparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.