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We read, with great interest, the thoughtful letter by Ficarra et al [1] regarding our recently proposed surface–intermediate–base (SIB) score for objectifying surgical technique reporting during nephron-sparing surgery (NSS) [2]. Some of the authors’ concerns address specific technical aspects of the SIB score assignment, whereas others offer opinions regarding the premise and purpose of the novel clinical research tool that we proposed. We thank Ficarra and colleagues for engaging us to clarify some of the nuances of the scoring system. Prior to our report, there were no standardised definitions for reporting NSS resection techniques in the literature. This void undermines objective and meaningful comparisons of outcomes between surgeons and institutions performing NSS. Indeed, many perioperative and postoperative outcomes are inherently influenced by the kidney surgeon’s resection strategy [3]. Consequently, standardised reporting of surgical techniques is essential. Below we address each of Ficarra and colleagues’ concerns.

The term trifecta includes all the parameters considered paramount regarding the functional, oncologic, and clinical efficacy and safety of a nephron-sparing procedure [1–3]. In our recently published study, we demonstrated that robotic laparoendoscopic single-site (R-LESS) partial nephrectomy (PN) cannot achieve the same trifecta results as the conventional approach, which must be emphasized to urologists worldwide [4]. This is probably because R-LESS PN performed according to the current fashion is almost like driving with the steering lock engaged, as correctly described by Minervini et al. [5]. The retrospective nature of the study and the low numbers of the population researched as reported by Komninos et al., as well as by Minervini and associates, could have engendered errors in the final results [4,5]. Therefore, we thoroughly checked and analyzed the baseline characteristics and the tumor complexity of both groups, to feel confident that we at least performed similar

The clinical management of pT3a pathologic-upstaged renal cell carcinoma (RCC) patients is actually controversial. Aim of this study was i) to assess the impact of pT3a upstaging on oncologic outcomes after robot-assisted partial nephrectomy (RAPN) for cT1-T2 RCC; ii) to explore clinical and surgical predictors of pT3a upstaging; iii) to evaluate the differential impact of perinephric fat invasion (PFI) or sinus fat invasion (SFI) on survival outcomes after RAPN in case of upstaged pT3a RCC.Clinical and surgical data from consecutive RCCs treated with RAPN in a single referral centre between January 2017 and June 2021 were prospectively collected and retrospectively reviewed. Pathological upstaging to pT3a tumors with fat invasion was further stratified in SFI or PFI. Uni- and multivariable analysis were fitted to explore clinical and surgical predictors of disease recurrence.Overall, 1852 patients were enrolled and 179 (9.7%) with pT3a upstaging were found. Median age was 65 (IQR 56-73) years with a median BMI of 25.6 (23.6-29.0). At a median follow up of 26 (9-38) months, 76 (4.1%) patients showed disease recurrence. Multivariable analysis confirmed PADUA score ≥10 (OR 1.76, CI 95% 1.18-1.91, p = 0.001), age at surgery (OR 1.04, CI 95% 1.01-1.06, p = 0.01), clinical tumor diameter (OR 1.31, CI 95% 1.17-1.47, p = 0.001), tumor necrosis (OR 1.54, CI 95% 1.08-1.88, p = 0.001) and nucleolar grading ≥3 (OR 1.27, CI 95% 1.01-1.44, p = 0.001) as independent predictors of pT3a upstaging. Multivariate Cox regression model showed pathological sinus fat invasion as an independent predictor of disease recurrence (HR 3.43, CI 95% 1.51-7.77, p = 0.003) in pT3a upstaged group.In pathologically upstaged pT3a RCCs, sinus fat invasion was confirmed as independent predictor of disease relapse. In this light, the definition of novel risk categories in the pT3a patients setting should be encouraged.

Emergency department (ED) visits and readmissions after thoracic surgery are a major health care problem. We hypothesized that the addition of a novel post-discharge mobile app specific to thoracic surgery to an existing home care program would reduce ED visits and readmissions compared to a home care program alone.We conducted a prospective cohort study of patients undergoing major lung resection for malignant disease between November 2016 and May 2018. Patients received either home care alone (control group) or home care plus a patient-input mobile app (intervention group). Primary outcomes were 30-day readmission and ED visit rates. Secondary outcomes included reasons for ED visits and readmissions, perioperative complications, 30-day mortality, anxiety (assessed with the Generalized Anxiety Disorder-7 Scale [GAD-7]) and app-related adverse events. We compared outcomes between the 2 groups, analyzing the data on an intention-to-treat basis.Despite the greater number of open surgery and anatomic resections in the intervention cohort, patients in that group were less likely than those in the control group to visit the ED within 30 days of discharge (24.0% v. 38.8%,The addition of a mobile app to a home care program after thoracic surgery was associated with a reduced frequency of ED visits, in spite of the higher proportions of thoracotomies and anatomic resections in the app cohort. More studies are needed to evaluate the full effect of this new, emerging technology.

FloRIN reconfiguration technique was introduced in 2016 according to the IDEAL-Collaboration Guidelines, with the attempt to conjugate the advantages of both intracorporeal neobladder and robotic assistance. Herein we report functional outcomes of FloRIN reservoir, specifically focusing on urodynamic features.Consecutive patients treated with RARC and FloRIN reconstruction were prospectively collected from February 2016 to June 2020. Only patients with a minimum 6-month follow up were analyzed to obtain a stable grade of neobladder maturation before performing the urodynamic study (UDS). The FACT-BL and the QLQ-C30 EORTC questionnaires were used to evaluate urinary function and health-related QoL. Results were compared with a contemporary series of patients treated at the same Institution with open radical cystectomy (ORC) and Vescica Ileale Padovana (VIP).One hundred patients entered the study and 69 patients had complete functional data. Overall, 52 (75.4%) patients reached the daytime continence. Among these, 28 (40.6%) were dry (no pads during daytime), while 24 (34.8%) used one pad/12 h. Night-time continence was achieved by 45 (65.2%) patients. Complete UDS findings were available for 28 patients. No statistically significant differences were found with the VIP-ORC group except for neobladder compliance, being higher in the FloRIN group (p = 0.03). When evaluating QoL scores, RARC with FloRIN reconfiguration showed a better continence recovery, as well as a higher improvement in urgency domain (p = 0.01), psychological status (0.02) and physical self-acceptance (p = 0.02), compared to the VIP-ORC group.The FloRIN technique showed excellent functional outcomes when compared to the referral VIP-ORC procedure.

BACKGROUND: 60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described. METHODS: We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis. RESULTS: A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2-39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9-46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863). CONCLUSIONS: Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance. ispartof: JOURNAL OF THORACIC DISEASE vol:13 issue:10 pages:5835-5842 ispartof: location:China status: published

BACKGROUND: Ischemia time during partial nephrectomy (PN) is among the greatest determinants of acute kidney injury (AKI). Whether this association is affected by the preoperative risk of AKI has never been investigated.OBJECTIVE: To assess the effect of the interaction between the preoperative risk of AKI and ischemia time on the probability of AKI during PN.DESIGN, SETTING, AND PARTICIPANTS: Data of 944 patients treated with on-clamp PN for cT1 renal tumors were extracted from the Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease (RECORD2) database, a prospective multicenter project.OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We estimated the preoperative risk of AKI (defined according to the risk/injury/failure/loss/end-stage [RIFLE] criteria) according to age, baseline renal function, clinical stage, preoperative aspects and dimensions used for an anatomical (PADUA) score, and surgical approach. Classification and regression tree (CART) analysis identified patients at "high" and "low" risk of AKI. Finally, we plotted the probability of AKI over ischemia time stratified by the preoperative risk of AKI.RESULTS AND LIMITATIONS: Overall, 235 (25%) patients experienced AKI after surgery. At multivariable analysis, older patients, those with more complex tumors, those with higher baseline function, and those treated with open surgery had an increased risk of AKI (all p ≤ 0.011). According to the first split at CART analysis, patients were categorized as those with "high" and "low" risk of AKI having a probability of >40% or 20 min of ischemia was 13% versus 28% (absolute risk increase 15%). The risk of AKI for high-risk patients who had 20 min of ischemia was 31% versus 77%. This corresponds to an absolute risk increase of 45%. Limitations include retrospective data analyses and lack of surgeons' prior experience.CONCLUSIONS: Ischemia time during PN has different implications for patients with different health status. Clamp time seems less clinically relevant for patients in good conditions who may endure prolonged ischemia with a mild increase in the risk of AKI, whereas frail patients seem to be more vulnerable to ischemic damage even for short clamp time. For individualized intra- and postoperative management, duration of ischemia needs to be questioned in the context of the individual health status.PATIENT SUMMARY: Functional sequelae related to ischemia time during partial nephrectomy depend on baseline health status. The correlation between the duration of ischemia and baseline health status should be taken into account toward individualized intra- and postoperative management.

Background With the exception of very early-stage small cell lung cancer (SCLC), surgery is not typically recommended for this disease; however, incidental resection still occurs. After incidental resection, adjuvant salvage therapy is widely offered, but the evidence supporting its use is limited. This study aimed to explore proper adjuvant therapy for these incidentally resected SCLC cases. Methods Patients incidentally diagnosed with SCLC after surgery at the Shanghai Pulmonary Hospital in China from January 2005 to December 2014 were included in this study. The primary outcome was overall survival. Patients were classified into different group according to the type of adjuvant therapy they received and stratified by their pathological lymph node status. Patients' survival was analyzed using a Kaplan-Meier analysis and Cox regression analysis. Results A total of 161 patients were included in this study. Overall 5-year survival rate was 36.5%. For pathological N0 (pN0) cases (n=70), multivariable analysis revealed that adjuvant chemotherapy (ad-chemo) was associated with reduced risk of death [hazard ratio (HR): 0.373; 95% confidence interval (CI): 0.141-0.985, P=0.047] compared to omission of adjuvant therapy. For pathological N1 or N2 (pN1/2) cases (n=91), taking no adjuvant therapy cases as a reference, the multivariable analysis showed that ad-chemo was not associated with a lower risk of death (HR: 0.869; 95% CI: 0.459-1.645, P=0.666), while adjuvant chemo-radiotherapy (ad-CRT) was associated with a lower risk of death (HR: 0.279; 95% CI: 0.102-0.761, P=0.013). Conclusions Patients who incidentally receive surgical resection and are diagnosed with limited disease SCLC after resection should be offered adjuvant therapy as a salvage treatment. For incidentally resected pN0 cases, ad-chemo should be considered and for pN1/2 cases, ad-CRT should be received.

Background Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates. Methods Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered. Results Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%). Conclusion It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient’s outcome.

Prolonged air leaks are increasingly treated in the outpatient setting, with patients discharged with chest tubes in place. We evaluated the incidence and risk factors associated with readmission, empyema development and further interventions in this patient population.We undertook a retrospective cohort analysis of all patients from 4 tertiary academic centres (January 2014 to December 2017) who were discharged home with a chest tube after lung resection for a postoperative air leak lasting more than 5 days. We analyzed demographics, patient factors, surgical details, hospital readmission, reintervention, antibiotics at discharge, empyema and death.Overall, 253 of 2794 patients were analyzed (9.0% of all resections), including 30 of 759 from centre 1 (4.0%), 67 of 857 from centre 2 (7.8%), 9 of 247 from centre 3 (3.6%) and 147 of 931 from centre 4 (15.8%) (Discharge with chest tube after lung resection is associated with serious adverse events. Given the high risk of empyema development, removal of chest tubes should be considered, when appropriate, within 20 days of surgery. Our data suggest a potential need for proactive postdischarge outpatient management programs to diminish risk of morbidity and death.

BACKGROUND: Selection of patients for upfront cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC) has to be improved. OBJECTIVE: To evaluate a new scoring system for the prediction of overall mortality (OM) in mRCC patients undergoing CN. DESIGN, SETTING, AND PARTICIPANTS: We identified a total of 519 patients with synchronous mRCC undergoing CN between 2005 and 2019 from a multi-institutional registry (Registry for Metastatic RCC [REMARCC]). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cox proportional hazard regression was used to test the main predictors of OM. Restricted mean survival time was estimated as a measure of the average overall survival time up to 36 mo of follow-up. The concordance index (C-index) was used to determine the model's discrimination. Decision curve analyses were used to compare the net benefit from the REMARCC model with International mRCC Database Consortium (IMDC) or Memorial Sloan Kettering Cancer Center (MSKCC) risk scores. RESULTS AND LIMITATIONS: The median follow-up period was 18 mo (interquartile range: 5.9-39.7). Our models showed lower mortality rates in obese patients (p = 0.007). Higher OM rates were recorded in those with bone (p = 0.010), liver (p = 0.002), and lung metastases (p < 0.001). Those with poor performance status (

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 ...

Objectives The Rotterdam Prostate Cancer Risk calculator (RPCRC) has been validated in the past years. Recently a new version including multiparametric magnetic resonance imaging (mpMRI) data has been released. The aim of our study was to analyze the performance of the mpMRI RPCRC app. Methods A series of men undergoing prostate biopsies were enrolled in eleven Italian centers. Indications for prostate biopsy included: abnormal Prostate specific antigen levels (PSA>4 ng/ml), abnormal DRE and abnormal mpMRI. Patients’ characteristics were recorded. Prostate cancer (PCa) risk and high-grade PCa risk were assessed using the RPCRC app. The performance of the mpMRI RPCRC in the prediction of cancer and high-grade PCa was evaluated using receiver operator characteristics, calibration plots and decision curve analysis. Results Overall, 580 patients were enrolled: 404/580 (70%) presented PCa and out of them 224/404 (55%) presented high-grade PCa. In the prediction of cancer, the RC presented good discrimination (AUC = 0.74), poor calibration (p = 0.01) and a clinical net benefit in the range of probabilities between 50 and 90% for the prediction of PCa (Fig. 1). In the prediction of high-grade PCa, the RC presented good discrimination (AUC = 0.79), good calibration (p = 0.48) and a clinical net benefit in the range of probabilities between 20 and 80% (Fig. 1). Conclusions The Rotterdam prostate cancer risk App accurately predicts the risk of PCa and particularly high-grade cancer. The clinical net benefit is wide for high-grade cancer and therefore its implementation in clinical practice should be encouraged. Further studies should assess its definitive role in clinical practice.

Aim of the study was to evaluate the Florence intracorporeal neobladder (FloRIN) oncological and functional outcomes at the end of assessment phase (phase 3) IDEAL-Guidelines.This single-institution prospective series included consecutive patients treated with robot-assisted radical cystectomy (RARC) and FloRIN reconfiguration technique from February 2016 to June 2020. Functional features were evaluated six months after surgery. Patients were grouped into four quartiles according to time of radical cystectomy and impact of learning curve improvement was evaluated.One-hundred FloRIN were completed with a median console time of 373 (IQR: 312-415) minutes. Two cases were converted to open surgery. No intraoperative complications occurred. At pathological examination, 30% of patients were staged as pT ≤ 1 and 47% as pT ≥ 3. Transitional cell carcinoma was present in 87% of cases. Carcinoma in situ (CIS) and nodal involvement were observed in 38% and 29% of patients, respectively. At a median follow-up time of 17 (IQR: 7-28) months, 20 clinically relevant events (Clavien-Dindo≥3) occurred. Operative time significantly decreased throughout the series (median minutes 435; 395; 365 and 330 in the four quartiles, respectively; p 0.001). Similarly, early Clavien-Dindo≥3 postoperative complications rate significantly decreased across the series (number of events: 1; 4; 0; 0; p = 0.03). Overall, 75% and 65% of patients achieved day-time and nigh-time continence, respectively. Twenty-seven patients experienced disease recurrence. Cancer-specific and overall survival were equal to 80%.RARC with FloRIN reconfiguration showed worthy functional and survival outcomes, with learning curve improvement significantly influencing operative time and early complications rate across series.

The present study aimed to assess the safety and efficacy of robot-assisted radical prostatectomy (RARP) in patients with prostate cancer (PCa) under anticoagulant (AC) and/or antiplatelet (AP) therapy, as compared to a control group, and to establish possible differences in postoperative-related morbidity. Data of all consecutive patients submitted to elective RARP for PCa from June 2017 to May 2020 at our institution were prospectively collected. Patients were divided according to the use of AC/AP therapy at surgery. The primary endpoint was to determine differences in 90-day postoperative complication rate, while secondary endpoints included differences in transfusion rate, readmission rate and postoperative oncological outcomes between the two groups. Sub-groups analysis was separately performed for patients undergoing pelvic lymphadenectomy and nerve-sparing procedures. Overall, 822 patients were included in the study and divided in 704 control-group patients (group A) and 118 patients under AC/AP therapy at surgery (group B). Despite the higher estimated blood loss between AC/AP takers and the control group, we did not find a significant difference in terms of 90-day postoperative complication rate, transfusion rate, readmission rate and postoperative oncological outcomes (all p > 0.05). In the cohort of patients undergoing nerve-sparing prostatectomy, a higher rate of complications and transfusions were found. At multivariate analysis, ASA score and ongoing medications were independently associated with complication in this sub-group. RARP can be safely and effectively performed in patients with PCa and ongoing AC/AP agents. Attention has to be paid in candidates for nerve-sparing procedures.

Patient with "very small" (2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with "very small" renal masses have not been reported.To assess the outcomes of RAPN among patients with "very small" renal masses.This was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size:2 cm ("very small" renal mass, study group) and 2-4 cm (control group).RAPN for renal masses.Baseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A "trifecta" was used as surrogate of "surgical quality."Overall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of2 cm (34.5%) and 667 (65.5%) had a renal mass of 2-4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a "trifecta" achievement of 90.6%. The retrospective design may limit the generalizability of the findings.Whenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for "very small" renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity.In this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for "very small" renal masses (2 cm), as it carries minimal risk of complications and has minimal impact on renal function.

Background Cytoreductive nephrectomy (CN) plays an important role in the treatment of a subgroup of metastatic renal cell carcinoma (mRCC) patients. Objective We aimed to evaluate morbidity associated with this procedure and identify potential predictors thereof to aid patient selection for this procedure and potentially improve patient outcomes. Design, setting, and participants Data from 736 mRCC patients undergoing CN at 14 institutions were retrospectively recorded in the Registry for Metastatic RCC (REMARCC). Outcome measurements and statistical analysis Logistic regression analysis was used to identify predictors for intraoperative, any-grade (AGCs), low-grade, and high-grade (HGCs) postoperative complications (according to the Clavien-Dindo classification) as well as 30-d readmission rates. Results and limitations Intraoperative complications were observed in 69 patients (10.9%). Thrombectomy (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.08–1.75, p = 0.009) and adjacent organ removal (OR 2.7, 95% CI 1.38–5.30) were significant predictors of intraoperative complications at multivariable analysis. Two hundred seventeen patients (29.5%) encountered AGCs, while 45 (6.1%) encountered an HGC, of whom 10 (1.4%) died. Twenty-four (3.3%) patients had multiple postoperative complications. Estimated blood loss (EBL; OR 1.49, 95% CI 1.08–2.05, p = 0.01) was a significant predictor of AGCs at multivariable analysis. CN case load (OR 0.13, 95% CI 0.03–0.59, p = 0.009) and EBL (OR 2.93, 95% CI 1.20–7.15, p = 0.02) were significant predictors solely for HGCs at multivariable analysis. Forty-one patients (11.5%) were readmitted within 30 d of surgery. No significant predictors were identified. Results were confirmed in a subanalysis focusing solely on patients treated in the contemporary targeted therapy era. Conclusions Morbidity associated with CN is not negligible. Predictors of high-grade postoperative morbidity are predominantly indicators of complex surgery. EBL is a strong predictor of postoperative complications. CN case load correlates with lower high-grade morbidity and highlights the benefit of centralization of complex surgery. However, risks and benefits should be balanced when considering CN in mRCC patients. Patient summary We studied patients with metastatic renal cancer to evaluate the outcomes associated with the surgical removal of the primary kidney tumor. We found that this procedure is often complex and adverse events are not uncommon. High intraoperative blood loss and a small number of cases performed at the treating center are associated with a higher rate of postoperative complications.

Background Despite better renal function following nephron-sparing surgery (NSS) relative to radical nephrectomy (RN), there is no consensus with respect to the long-term sequelae associated with surgery. Objective To investigate the effect of surgery and the temporal pattern of two different cardiovascular event (CVe) categories after NSS versus RN. Design, setting, and participants We collected data of 898 patients with cT1–2 N0 M0 renal mass and no history of CVe treated with NSS versus RN. CVe categories were dichotomised in (1) de novo hypertension (HT) and (2) other major cardiovascular events (MCEs). Outcome measurements and statistical analysis Multivariable competing regression analyses (MVAs) tested the adjusted effect of surgery type on each CVe category. Results and limitations Among patients treated with RN, 38% of HT events occurred immediately after surgery. Conversely, in NSS counterparts, the onset of HT was diluted over the years after surgery (10% of HT events in the first 6 mo). When an MCE was considered, an increasing long-term time-dependent prevalence of the outcome was observed in both groups, with no statistically significantly difference between NSS and RN. At MVA, RN was associated with a higher HT risk (hazard ratio [HR] 2.89; p = 0.006) than but a similar MCE risk (HR 0.85; p = 0.6) to NSS. Conclusions Relative to RN, NSS showed an independent protective effect on HT but not on MCEs. In patients with no history of preoperative HT or MCEs, the onset of HT after RN is a very early event, due probably to the acute loss of renal parenchyma. This is not the case for the other cardiovascular morbidity, which develops in the long-term period, regardless of the type of surgery performed. Patient summary In renal cancer patients without a medical history of cardiopathy, preserving healthy kidney tissue at surgery is associated with a decreased risk of developing postoperative hypertension.

Temporomandibular joint (TMJ) osteoarthritis is a degenerative disease, characterized by gradual cartilage degradation, bone remodeling, synovitis, and chronic pain. Due to the limited self-healing capacity in condylar cartilage, traditional clinical therapy have limited symptom-modifying and structure-modifying effects to restore impaired cartilage as well as other TMJ tissues. In last years, stem cell-based therapy has collected much attention as a possible approach toward tissue repair and regeneration. Mesenchymal stem cells (MSCs), derived from the bone marrow, synovium, and even umbilical cord, play a role as seed cells for the cartilage regeneration of TMJ. MSCs possess multilineage differentiation potential, including chondrogenic differentiation as well as osteogenic differentiation. In addition, the modulations of MSCs exert anti-inflammatory and immunomodulatory effects under aberrant conditions. Furthermore, MSCs combined with appropriate scaffolds can form cartilaginous or even osseous compartments to repair damaged tissue and impaired function of TMJ. In this review, we will describe the potential sources of MSCs and novel approaches for the cartilage regeneration of TMJ, particularly focusing on the MSC-based therapy and tissue engineering.