Xanthogranulomatous pyelonephritis: a comparison of open and minimally-invasive surgical approaches.

To compare perioperative outcomes between patients undergoing minimally-invasive (MIS) and open surgical approaches for the treatment of Xanthogranulomatous Pyelonephritis (XGP). Between 2007 and 2017 we retrospectively identified 40 patients undergoing nephrectomy at our institution for pathologically confirmed XGP. Patients whose operations were ultimately completed with open technique were analyzed with the open cohort, whereas patients whose operations were completed in entirety using any laparoscopic approach were analyzed with the MIS group. Twenty-three patients were analyzed in the open cohort, compared to seventeen in the MIS group. Three patients in the open cohort were converted intraoperatively from MIS to open approach. Compared to the open group, the MIS group less often had an abscess on preoperative CT (11.8% vs 54.5%; p = 0.006). The MIS group also had lower intraoperative blood loss (100 vs 400 mL; p < 0.001), lower rate of blood transfusion (0% vs 45.5%; p = 0.002), lower postoperative intensive care admission (0% vs 34.8%; p = 0.013), and shorter hospital stay (4 vs 7 days; p = 0.013). However, there was no significant difference in high-grade complications between these groups (5.9% vs 34.8%; p = 0.054). Preoperative CT scan may be an important factor when considering operative approach for treatment of XGP. Patients who are able to undergo MIS approach have less blood loss, shorter hospitalization, and are less likely to require intensive care admission, which may be related to the disease process, the surgical technique, or both.

Comparing oncologic outcomes in patients undergoing surgery for oncocytic neoplasms, conventional oncocytoma, and chromophobe renal cell carcinoma.

INTRODUCTION: Oncocytic neoplasms are renal tumors similar to oncocytoma, but their morphologic variations preclude definitive diagnosis. This somewhat confusing diagnosis can create treatment and surveillance challenges for the treating urologist. We hypothesize that these subtle morphologic variations do not drastically affect the malignant potential of these tumors, and we sought to demonstrate this by comparing clinical outcomes of oncocytic neoplasms to those of classic oncocytoma and chromophobe. METHODS: We gathered demographic and outcomes data for patients with variant oncocytic tumors. Oncologic surveillance was conducted per institutional protocol in accordance with NCCN guidelines. Descriptive statistics were used to compare incidence of metastasis and death against those for patients with oncocytoma and chromophobe. Three hundred and fifty-one patients were analyzed: 164 patients with oncocytoma, 28 with oncocytic neoplasms, and 159 with chromophobe tumors. RESULTS: Median follow-up time for the entire cohort was 32.4 months, (interquartile range 9.2-70.0). Seventeen total patients (17/351, 4.9%) died during the course of the study. In patients with oncocytoma or oncocytic neoplasm, none were known to metastasize or die of their disease. Only chromophobe tumors >6 cm in size in our series demonstrated metastatic progression and approximately half of these metastasized tumors demonstrated sarcomatoid changes. CONCLUSION: Variant oncocytic neoplasms appear to have a natural course similar to classic oncocytoma. These tumors appear to have no metastatic potential, and oncologic surveillance may not be indicated after surgery.

Assessing Cost of Robotic Utilization in Partial Nephrectomy with Increasing Utilization.

PURPOSE: To evaluate trends in utilization of robotic assistance in partial nephrectomy (PN) and assess the association between cost and utilization. PATIENTS AND METHODS: Using the 2009-2012 Nationwide Inpatient Sample database, we identified all adult (>17 years) patients undergoing PN for localized primary renal malignancy. Coding for robotic assistance (17.4 × ) began in the final quarter of 2008. The primary outcome was total hospital cost exclusive of physician fees. A multiple linear regression model was used to adjust for patient and hospital characteristics. RESULTS: Between 2009 and 2012, there were 32,664 (58%) open, 3498 (6%) laparoscopic, and 20,350 (36%) robot-assisted partial nephrectomies performed in the United States. Between 2009 and 2012, the total number of partial nephrectomies semiannually increased by 93% (5114-9845) with robotic partial nephrectomies (RPNs) representing >80% of the increase. RPN increased from 1029 cases in the first half of 2009 to 4840 in the last half of 2012 and surpassed utilization of open nephrectomy. The proportion of all partial nephrectomies performed with robotic assistance increased from 20% to 49% during the same period. After adjusting for demographics, Charlson comorbidity index, and hospital region, RPN went from $1,464 (p = 0.009) more than open in 2009 to $456 (p = 0.28) less than open in 2012. CONCLUSIONS: Utilization of RPN surpassed open in 2012 in the United States. The difference in cost between the robotic and open approaches decreased during the study period and by 2011 was not statistically different.

Anatomic comparison of traditional and enucleation partial nephrectomy specimens.

OBJECTIVE: To compare pseudocapsule (PC) properties of clear cell renal cell carcinoma tumors removed via both traditional partial nephrectomy (PNx) and enucleative techniques as well as quantify the difference in volume of normal renal parenchyma removed between groups. MATERIALS AND METHODS: A retrospective review of clear cell PNx specimens between 2011 and 2014 was performed. All patients undergoing tumor enucleation (TE) were included. A single pathologist reviewed the pathological specimens. This cohort was compared with a previously collected clear cell traditional PNx database. RESULTS: A total of 47 clear cell partial nephrectomies were reviewed (34 PNx and 13 TE). Invasion of tumor completely through the PC and positive surgical margins were seen in 2 (5.8%) and 1 (7.7%) of traditional and TE specimens, respectively (P = 0.82). PC mean (0.63 vs. 0.52mm), maximum (1.39 vs. 1.65mm), and minimum thickness (0.27 vs. 0.19mm) were similar between cohorts (P = 0.29, P = 0.36, and P = 0.44). Gross specimen volume varied considerably between the 2 groups (35.6 vs. 17.9cm3, P≤0.05) although tumor volume did not (12 vs. 14.2cm3, P = 0.64). The renal tumor consisted of only 37% of the total volume of the traditional PNx specimens compared to 80% of the volume in TEs (P<0.01). Four TE specimens (31%) were "true" TEs (no additional parenchyma identified outside of the PC). CONCLUSIONS: PC properties appear independent of surgical technique. True TEs are uncommon. Regardless, there is considerable volume discrepancy of normal renal parenchymal removed between enucleative and nonenucleative PNx groups.

Treatment and Clinical Outcomes of Patients with Teratoma with Somatic-Type Malignant Transformation: An International Collaboration.

PURPOSE: We assessed prognostic factors, treatments and outcomes in patients with teratoma with malignant transformation, a rare occurrence among germ cell tumors. MATERIALS AND METHODS: Data on patients diagnosed with teratoma with malignant transformation between June 1981 and August 2014 were collected across 5 referral centers. Chemotherapy was dichotomized as based on germ cell tumor or teratoma with malignant transformation. Cox analyses were done to evaluate prognostic factors of overall survival, the primary end point. Each factor was evaluated in a univariable model. Forward stepwise selection was used to construct an optimal model. RESULTS: Among 320 patients the tumor primary site was gonadal in 287 (89.7%), retroperitoneal in 17 (5.3%) and mediastinal in 16 (5%). Teratoma with malignant transformation and germ cell tumor were diagnosed concurrently in 130 patients (40.6%). A total of 49 patients (16.8%) initially presented with clinical stage I. The remaining patients were at good (123 or 42.3%), intermediate (42 or 14.4%) and poor (77 or 26.5%) risk for metastasis according to IGCCCG (International Germ Cell Cancer Collaborative Group). First line chemotherapy was given for germ cell tumor in 159 patients (49.7%), chemotherapy for teratoma with malignant transformation was performed in 14 (4.4%) and only surgery was done in 147 (45.9%). Median followup was 25.1 months (IQR 5.4-63.8). Five-year overall survival was 83.4% (95% CI 61.3 to 93.5) in patients with clinical stage I and it was also worse than expected in those with metastasis. On multivariable analyses nonprimitive neuroectodermal tumor histology (overall p = 0.004), gonadal primary tumor (p = 0.005) and fewer prior chemotherapy regimens (p <0.001) were independent predictors of better overall survival. Chemotherapy was not independently prognostic. CONCLUSIONS: Less heavily pretreated teratoma with malignant transformation with a gonadal primary tumor and nonprimitive neuroectodermal tumor histology appears to be associated with longer overall survival. Generally, teratoma with malignant transformation had a worse prognosis than germ cell tumor. Uncertainties persist regarding optimal chemotherapy.

Long-term outcomes of catheterizable continent urinary channels: What do you use, where you put it, and does it matter?

INTRODUCTION: Appendicovesicostomy (APV) and Monti ileovesicostomy (Monti) are commonly used catheterizable channels with similar outcomes on short-term follow-up. Their relative long-term results have not been previously published. OBJECTIVE: Our goal was to assess long-term durability of APV and Monti channels in a large patient cohort. STUDY DESIGN: In this retrospective cohort study, we retrospectively reviewed consecutive patients ≤21 years old undergoing APV and Monti surgery at our institution (1990-2013). We collected data on demographics, channel type, location, continence and stomal and subfascial revisions. Kaplan-Meier survival and Cox proportional hazards analysis were used. RESULTS: Of 510 patients meeting inclusion criteria, 214 patients had an APV and 296 had a Monti (50.5% spiral Monti). Median age at surgery was 7.4 years for APV (median follow-up: 5.7 years) and 8.7 years for Monti (follow-up: 7.7 years). Stomal stenosis, overall stomal revisions and channel continence were similar for APV and Monti (p ≥ 0.26). Fourteen APVs (6.5%) had subfascial revisions compared to 49 Montis (16.6%, p = 0.001). On survival analysis, subfascial revision risk at 10 years for APV was 8.6%, Monti channels excluding spiral umbilical Monti: 15.5% and spiral umbilical Monti: 32.3% (p < 0.0001, Figure). On multivariate regression, Monti was 2.09 times more likely than APV to undergo revision (p = 0.03). The spiral Monti to the umbilicus, in particular, was 4.23 times more likely than APV to undergo revision (p < 0.001). Concomitant surgery, gender, age and surgery date were not significant predictors of subfascial revision (p ≥ 0.17). Stomal location was significant only for spiral Montis. DISCUSSION: Our study has several limitations. Although controlling for surgery date was a limited way of adjusting for changing surgical techniques, residual confounding by surgical technique is unlikely, as channel implantation technique was typically unrelated to channel type. We did not include complications managed conservatively or endoscopically. In addition, while we did not capture patients who were lost to follow-up, we attempted to control for this through survival analysis. CONCLUSIONS: We demonstrate, durable long-term results with the APV and Monti techniques. The risk of channel complications continues over the channel's lifetime, with no difference in stomal complications between channels. At 10 years after initial surgery, Monti channels were twice as likely to undergo a subfascial revision (1 in 6) than APV (1 in 12). The risk is even higher in for the spiral umbilical Monti (1 in 3).

Differentiating reconstructive techniques in partial nephrectomy: a propensity score analysis.

INTRODUCTION: To assess whether volumetric measurements can differentiate functional changes between reconstructive techniques after partial nephrectomy. MATERIALS AND METHODS: One hundred and fifty-six patients undergoing partial nephrectomy for a single renal mass were retrospectively studied between 2008 and 2012. Computed tomography scans were available for volume calculations on 56 (18 non-renorrhaphy and 38 renorrhaphy). Institutional review board approval was obtained. The primary outcome was %volume loss in the operated kidney, which was calculated from three-dimensional reconstructions using a semiautomatic segmentation algorithm. Multivariable regression and propensity score analysis was performed. RESULTS: Volumetric analysis detected a difference in mean %volume loss between two-layer reconstruction (cortical renorrhaphy and base-layer) and base-layer only (15.6% versus 3.8%, p < 0.001). The mean %glomerular filtration rate (GFR) loss was also greater in the two-layer group (8.9% versus 2.4%, p = 0.03). Demographics were similar between groups except the two-layer group was older, had more males, and increased ischemia time. On multivariable regression the presence of two-layer closure (ß = -15.2%, p < 0.001) and tumor diameter (ß = -7.4, p = 0.004) were significant predictors of %volume loss while ischemia time (p = 0.88) was not. Two-layer closure remained a predictor on propensity-adjusted analysis (ß = -14.3, p = 0.004). The base-layer only group had two (5.3%) urine leaks and two (5.3%) bleeding complications. The two-layer group had two (1.7%) urine leaks and three (2.5%) bleeding complications (p = 0.23, 0.41). CONCLUSIONS: Volume loss calculated from CT scans can be used to monitor postoperative renal function. Techniques for renal reconstruction and tumor diameter are associated with volume and functional loss after partial nephrectomy and should be controlled for in future studies.

National Trends in the Performance of Robot-Assisted Sacral Colpopexy.

PURPOSE: Robot-assisted sacral colpopexy (RASC) utilization trends and influencing factors were examined. RASCs were compared with nonrobotic vaginal suspension procedures (non-RASC) used to treat patients with vaginal prolapse. Hospital costs associated with each approach were also examined. The presence of certain factors may predict increased use of RASC. METHODS: The National (Nationwide) Inpatient Sample database was queried from 2009 to 2011 to identify patients undergoing RASC and non-RASC. Multivariable logistic regression was used to evaluate variables associated with RASC utilization, adjusting for age, comorbidities, concurrent procedures, hospital region, primary payer, and year. Multiple linear regression was used to evaluate variables associated with hospital costs when adjusting for operative approach, concurrent procedures, comorbidities, presence of complications, hospital region, and year. RESULTS: Of the 125,869 patients who underwent vaginal vault suspension of any type, 14,601 (12%) were RASC. Total in-hospital complication rates were similar between RASC and non-RASC (8% RASC, 7% non-RASC, P=0.360). The proportion of patients undergoing RASC increased throughout the study period (odds ratio [OR] 1.58, P<0.001), with this increase being most pronounced in the South (OR 2.22, P<0.001). Fifty-four percent of RASC patients vs 48% of non-RASC patients underwent concurrent hysterectomy (P=0.007). Patients with private insurance (OR 1.73, P=0.001) or Medicare (OR 1.43, P=0.033) as their primary payer were at significantly increased odds of RASC compared with Medicaid patients, and private insurance was associated with increased reimbursement. On multiple linear regression, RASC was independently associated with a $4825 increase in hospital costs (95% confidence interval $4161-$5490, P<0.001). There were independent regional differences in cost associated with vaginal suspension, with the West being the most expensive (P<0.001). CONCLUSION: While RASC utilization increased over the study period as a treatment option for vaginal prolapse, the majority of vaginal suspension procedures were still performed via non-RASC methods. RASC was associated with equivalent complications yet significantly higher costs.

Functional and Clinicopathologic Outcomes Using a Modified Vescica Ileale Padovana Technique.

OBJECTIVE: To evaluate the clinicopathologic and functional outcomes of a modified Vescica ileale Padovana (VIP) neobladder technique. METHODS: Data for 160 patients at a single institution who underwent radical cystectomy and orthotopic VIP neobladder creation between 1998 and 2013 were analyzed. Modified VIP technique involved longitudinal opening of the small bowel close to the anterior mesenteric border instead of along the true anti-mesentery. This allowed for creation of a dependent neourethral funnel and a large serosal surface for ureteral anastomosis, distant from any suture lines. RESULTS: Mean age for the entire cohort was 59.5, with 9% female and 64% with muscle invasive disease prior to cystectomy. Within 30 days of surgery, 16 patients (10%) developed a Clavien grade 3-4 complication and there were no deaths. Ninety-six percent reported minor or no daytime urinary leakage at 12 months, and 70% reported minor or no nighttime urinary leakage. Two- and five-year overall survival rates were 84.2% and 72.6% , respectively. Seven patients developed a ureteral stricture (4%), three (2%) had bladder neck contractures, two (1%) experienced urethral recurrence, and there were no vesicovaginal fistulas. CONCLUSIONS: This modified VIP neobladder technique achieves favorable functional, survival, and recurrence outcomes similar to other published orthotopic continent diversions. Its near spheroidal shape lowers internal pressure, allowing for improved continence at physiologic filling capacity, and its offset bowel opening helps prevent unnecessary stretch to the native urethra, even in large individuals. The widened uretero-enteric anastomosis site distant from bowel suture lines contributes to decreased stricture rates and its placement on the dome of the neobladder facilitates endoscopic access should strictures occur. Finally, lack of posterior overlapping suture lines also mitigates the risk of fistulae formation in females should anterior vaginal wall excision or entry be unavoidable.

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: Feasibility and Evaluation of Initial Outcomes.

PURPOSE: To evaluate outcomes of post-holmium laser enucleation of the prostate (HoLEP) robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: Using an institutional database, we identified 11 HoLEP patients who subsequently underwent RARP. These were matched 1:2 to RARP patients without a previous transurethral surgical procedure. Variables matched were age, pre-RARP prostate-specific antigen level, and biopsy Gleason score. Urinary continence and sexual function were evaluated by physician questioning, American Urological Association symptom score, and Sexual Health in Men (SHIM) scores. Descriptive statistics were used to compare cohorts. RESULTS: RARP pathologic outcomes were similar between cases and controls. Twenty-seven percent of previous HoLEP patients reached strict urinary continence (leak free, pad free) at last follow-up compared with 64% of matched controls (P=0.071). The average (range) SHIM score at last follow-up was 2.6 (1-5) for previous HoLEP patients compared with 13.9 (5-20) (P<0.001). The posterior bladder neck and apical dissections were significantly more challenging in the setting of previous HoLEP and necessitated a low threshold for wider resection to minimize positive surgical margins. CONCLUSIONS: Post-HoLEP RARP is challenging but preliminarily appears safe and feasible when performed by an experienced robotic surgeon. Patients should be counseled regarding expectations of urinary continence and sexual function in this setting.

The impact of hospital volume on postoperative complications following robot-assisted partial nephrectomy.

PURPOSE: We sought to evaluate the relationship between hospital volume and postoperative complications following robot-assisted partial nephrectomy (RAPN) using the Nationwide Inpatient Sample. MATERIALS AND METHODS: We identified patients undergoing RAPN between 2009 and 2011. Hospitals were divided into volume-based tertiles for each year (high, medium, low). Descriptive analyses were performed using Pearson's chi-squared and Student's t-test. Multivariable logistic regression assessed the association between hospital volume and postoperative complications, adjusting for age, gender, hospital region, type of hospital, primary payer, comorbidities, and kidney cancer. RESULTS: We identified 17,583 cases from 323 hospitals, of which 112 were low volume, 112 medium volume, and 99 high volume. 13,645 (78%) cases were performed at high-volume institutions. Eleven percent of patients developed an in-hospital postoperative complication, with 15% at low-volume, 12% at medium-volume, and 10% at high-volume hospitals (p=0.071). In addition, blood transfusion was less common at high-volume hospitals (p=0.015). On multivariable logistic regression, high-volume hospitals had 42% decreased odds of postoperative in-hospital complications (95% confidence interval 0.37-0.90; p=0.016). Complications were associated with a $4500 increase in hospital costs. CONCLUSIONS: High-volume hospitals are associated with decreased blood transfusions and complications. With the recognition that high-volume RAPN hospitals are independently associated with improved clinical outcomes, further studies should be performed to determine the role of the hospital and surgeon volume thresholds in the performance of RAPN.

National trends in the utilization of robotic-assisted radical cystectomy: an analysis using the Nationwide Inpatient Sample.

OBJECTIVES: To determine temporal and regional trends in utilization of robotic-assisted radical cystectomy (RARC) in the United States and to explore factors associated with utilization of robotic assistance. MATERIALS AND METHODS: Using 2009 to 2011 data from the Nationwide Inpatient Sample, we identified radical cystectomy cases that were performed using either open or robotic assistance and applied Nationwide Inpatient Sample discharge weights to determine national incidence. Univariable and multivariable logistic regressions were performed to assess regional trends and characteristics associated with having RARC. Descriptive analysis was performed using the chi-square test, the Student t test, and the Mann-Whitney U test. RESULTS: Of the 29,719 radical cystectomy patients, 3,733 were RARC (12.6%). Although there was no change in the proportion of RARC performed annually (P = 0.702). Length of stay was 1 day longer for open cystectomy than RARC (P<0.001). On multivariate regression, patients whose primary payer was Medicaid were less likely than private insurance patients to undergo RARC (odds ratio = 0.60, P = 0.074). Additionally, patients in the south were at 50% reduced odds of undergoing RARC (odds ratio = 0.49, P = 0.044). Median hospital costs were $5,000 greater for RARC (P<0.001). CONCLUSIONS: Regional variation in utilization should be monitored to ensure equal access to new technology and to assess potential overuse of new technology. Although RARC is associated with higher median hospital costs, further studies to assess its benefits are warranted.

Short-term morbidity and mortality of Indiana pouch, ileal conduit, and neobladder urinary diversion following radical cystectomy.

PURPOSE: Literature surrounding Indiana pouch (IP) urinary diversion suggests a higher incidence of complications and longer operative time compared with ileal conduit (IC) and neobladder (NB). We sought to assess short-term complications of IP diversions compared with other diversions at our institution. MATERIALS AND METHODS: Using institutional National Surgical Quality Improvement Program data, we identified radical cystectomy cases performed for bladder cancer at Indiana University from January 2011 until June 2013. During this time period, the National Surgical Quality Improvement Program randomly evaluated approximately 70% of radical cystectomies performed for urothelial carcinoma at our institution. Multivariable logistic regression was performed to identify factors associated with Clavien grade III-V complications. RESULTS: A total of 233 cases were identified, 139 IC, 39 IP, and 55 NB. Mean (standard deviation) operative times for IC, IP, and NB were 257 (84), 383 (78), and 327 (88) minutes, respectively (P<0.001). Half of the patients required blood transfusion during the hospitalization. The overall rate of complications was significantly lower among NB (P = 0.009). Overall, 12% of patients developed a Clavien grade III-V complication, with no difference observed between groups (P = 0.884). After controlling for preoperative confounders, IP patients were not at increased odds of developing a Clavien III-V complication compared with IC (odds ratio = 1.38, P = 0.599). CONCLUSIONS: At a high-volume center, the incidence of serious complications was similar between diversion types. IP patients were more likely to experience minor complications. Patients should be counseled regarding rates of short-term complications and blood transfusion.

Examining the relationship between operative time and hospitalization time in minimally invasive and open urologic procedures.

OBJECTIVE: To explore the relationship between operative time, approach, and length of stay (LOS) in partial nephrectomy (PN), radical prostatectomy (RP), and adrenalectomy (AD). MATERIALS AND METHODS: Using the National Surgical Quality Improvement Program database, we identified all PN, RP, and AD from 2010 to 2012. Non-prostate cancer RP were excluded. The primary outcome was LOS. Descriptive comparisons were drawn between open and minimally invasive surgery (MIS) for each surgery. Multiple linear regression assessed the impact of open versus MIS and operative time on LOS when controlling for confounders. RESULTS: We identified 3760 PN (60% MIS), 12,081 RP (82% MIS), and 1684 AD (76% MIS) cases for inclusion. Differences in operative time were identified. In PN and RP, MIS mean operative time was 10 to 23 minutes longer (p<0.001 each); while for AD, open was 35 minutes longer (p<0.001). Open procedures had consistently longer median LOS (p<0.001 all). Results of the linear regression are given next. CONCLUSIONS: Operative time and surgical approach are directly associated with LOS, independent of complications and patient comorbidities.