Valveless and conventional insufflation on pneumoperitoneum-related complications in robotic partial nephrectomy: a systematic review and meta-analysis of prospective studies.

INTRODUCTION: The use of pneumoperitoneum is an essential step for performing laparoscopic and robotic surgery. Pneumoperitoneum insufflation can cause complications such as pneumothorax, subcutaneous emphysema, and pneumomediastinum. The purpose of this meta-analysis is to compare the safety of using the conventional insufflation system versus a Valveless insufflation system as devices for manufacturing pneumoperitoneum in robotic-assisted nephrectomy. METHODS: A comprehensive literature search was conducted on PUBMED, EMBASE, SCOPUS, and Cochrane, from inception until January 2024. Randomized and nonrandomized prospective studies were included in the meta-analysis, performed by the R+ Rstudio. RESULTS: Three publications encompassing 478 patients were included. We observed no difference in SCE (OR 0.60, CI 95% 0.27;1.34, p = 0.134, I2 = 0), PNM (OR 0.82, CI 95% 0.24;2.78, p = 0.558, I2 = 0), When comparing groups conventional insufflation system (CIS) versus AirSealTM insufflation system (AIS) with pneumoperitoneum pressure of 15 mmHg or 12 mmHg. CONCLUSION: The presented data showed no difference between the AIS when compared with CIS in Pneumoperitoneum insufflation-related complications.

Robotic Partial Nephrectomy for Treating Renal Masses: Outcomes and Complications.

INTRODUCTION: Partial nephrectomy is the preferred treatment for renal tumors <7 cm. Robot-assisted laparoscopic approach is a minimally invasive method that offers advantages for resecting complex tumors. Here, we conducted a descriptive retrospective analysis of the first robotic partial nephrectomies (RPNs) performed at our center. MATERIALS AND METHODS: A retrospective cohort of 94 patients who consecutively underwent RPN at our center between November 2012 and December 2022 was investigated. Baseline patient data, tumor characteristics, intraoperative variables, pathological tumor analysis, and postoperative complications at 30 days were analyzed. RESULTS: The patients were followed up for a median of 25.3 months. Baseline values included a median age of 63 years and a median body mass index (BMI) of 28.1. Intraoperative variables comprised a median surgical time of 150 min and a median warm ischemia time of 16 min. The mean postoperative creatinine level was 1 mg/dL. The median tumor size was 41.9 mm, with a median PADUA score of 8 and a median RENAL score of 8. Resected tumors were predominantly cT1a (58.5%) and cT1b (39.3%), while the positive margin rate was 21.3%. A total of 19.2% of the patients experienced Clavien-Dindo complications, of which 11% were Clavien-Dindo I; 66.7%, Clavien-Dindo II; And 22.2%, Clavien-Dindo IIIb. However, no Clavien-Dindo IIIa or IV complications were reported. CONCLUSIONS: RPN is an effective and safe technique for treating solid renal masses, demonstrating a low complication rate and adequate oncologic control locally and distally.

Effect of a Collaborative Medical-Nursing Catheter Removal Protocol on Incidence of Urinary Tract Infections in Urology Patients: A Retrospective Study.

OBJECTIVE: Urology patients are often placed with a catheter following surgery. Hence, a high-quality and appropriate management and removal programme can considerably reduce catheter-associated complications such as urinary tract infections and improve patient comfort. This retrospective study investigated the impact of a collaborative medical-nursing catheter removal protocol on reducing the incidence of urinary tract infections in urological surgery patients. METHODS: Patients who underwent partial nephrectomy at our hospital between January 2021 and December 2022 were enrolled and allocated to a control and an observation group based on the method of urinary catheter removal. A physician was solely responsible for monitoring, evaluating, and removing the catheter in the control group, whereas a physician and nurses performed these catheter management activities in the observation group. The two groups were compared in terms of urinary tract infections, urinary tract irritation and hematuria signs, pain levels, and catheter retention time. RESULTS: A total of 178 patients were included, among which 88 were divided into the control group and 90 into the observation group according to their corresponding urinary catheter removal method entered into the medical records system. The general characteristics of the two groups were similar (p > 0.05). However, the rates of urinary tract infections and urinary tract irritation and hematuria signs in the observation group were lower than those in the control group (1.11% vs. 9.09%, χ2 = 5.902, p = 0.037; 5.55% vs. 15.91%, χ2 = 4.159, p = 0.041, respectively). The observation group also exhibited lower levels of urinary pain within 1 h post-catheter removal and shorter total catheter retention time than the control group (t = 2.497, p = 0.013; t = 2.316, p = 0.022, respectively). CONCLUSIONS: Collaborative medical-nursing catheter removal protocols for patients undergoing partial nephrectomy may effectively alleviate urinary pain, decrease the incidence of urinary tract infections and irritation and hematuria signs, and shorten catheter retention time, underscoring the clinical significance of its implementation in this specific population.

Surgical management and outcomes of renal tumors with inferior vena cava extension among children: a single center retrospective study from Pakistan.

OBJECTIVE: The aim of this study was to assess management and determine outcomes of renal tumors with inferior vena cava (IVC) and intracardiac (IC) extension in a tertiary care center in Pakistan. METHODS: A retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, Pakistan. All patients from 1 to 18 years of age with renal tumors with intravascular extensions, surgically managed from January 1988 till June 2016, were included. Data was extracted by reviewing medical records, and the tumor details, treatment and outcomes were analyzed. RESULTS: A total of 18 patients out of the total 61 patients with renal tumors, presented with IVC and/or IC extension, with the majority involving the right kidney. Mean age was 5.9 (SD:4.9) and a female preponderance (56%) was seen. Wilms tumor (77%) was the most common tumor type, with the level of tumor extension into IVC predominantly being below the diaphragm (55.5%). Fourteen patients received preoperative chemotherapy, with tumor regression, seen in 10. Most patients underwent thrombectomy through the renal vein (56%). Regarding outcomes, frequency of mortality and morbidity was 1 and 2, respectively, with 7 patients having no recurrent 5 years post-surgery. CONCLUSION: A greater incidence (29.5%) of IVC and or IC Tumor extension was found compared to existing literature, which could likely be due to a higher referral rate to the center. Moreover, this is a single-center study and so a multi-center study is crucial to form an assessment of surgical management in resource-limited settings. Our study is the first from Pakistan on this particular renal tumor presentation. Considering the varying case presentations and surgical techniques used, further studies are needed to standardize surgical management and optimize patient outcomes.

Ultrasound-guided renal artery balloon catheter occluded hybrid partial nephrectomy (UBo-HPN) with branch renal artery occlusion: a single arm trial.

BACKGROUND: One key focus of partial nephrectomy is preserving renal function. Segmental renal artery occlusion with microdissection at the renal hilum confines ischemia, effectively reducing warm ischemic injury. Ultrasound-Guided Renal Artery Balloon Catheter Occluded Hybrid Partial Nephrectomy (UBo-HPN) can achieve branch occlusion without the need for dissecting the renal hilum. OBJECTIVE: To investigate the feasibility and safety of UBo-HPN of branch renal artery occlusion in the treatment of localized renal tumors. SUBJECT AND METHODS: A prospective single-arm analysis involving 20 patients with renal localized tumors underwent robot assisted UBo-HPN with branch renal artery occlusion from August 2021 to July 2023, with an average follow-up of 12 months. RESULTS: All patient was successfully operated on without conversion to conventional arterial clamping or radical nephrectomy. One case (5%) of minor complication occurred in the whole cohort, which was bruising around the puncture site. The mean total operative time was 95.8 min, with a mean operative time of 21.25 min for vascular intervention. The mean warm ischemia time was 20.35 min, and the median estimated blood loss was 50 ml. The median eGFR preservation percentage at postoperative 48 h, 30 days, and the latest follow-up were 87.52%, 91.47%, and 92.2%, respectively. After a median follow-up of 10.2 (2.3-19.2) months, no patients had radiological tumor recurrence or died from tumor-related causes. CONCLUSIONS: UBo-HPN with renal artery branch occlusion emerges as an efficient alternative to partial nephrectomy (PN), which achieved branch artery occlusion without dissecting the renal hilum. Long-term follow-up is expected for functional outcomes.

Clinical application and efficacy analysis of robot-assisted laparoscopic tumor enucleation combined with tumor aspiration in the treatment of renal hilar angiomyolipoma.

BACKGROUND: For renal hilar angiomyolipoma, general surgical resection is often quite challenging. The aim of this study is to evaluate the safety and efficacy of an innovative robot-assisted laparoscopic strategy that combines tumor enucleation with tumor aspiration in the treatment of renal hilar angiomyolipoma. METHODS: The clinical data of 38 patients with renal hilar angiomyolipoma who went through robotic tumor enucleation combined with tumor aspiration in the Department of Urology, the Affiliated Hospital of Nanjing University Medical School, from December 2019 to December 2022 were retrospectively analyzed. The basic characteristics, the perioperative variables, intraoperative procedures, and postoperative complications were all recorded. Patients were followed up to evaluate the angiomyolipoma recurrence and the renal function by urologic CT or ultrasound and renal function tests. RESULTS: All surgeries were successfully completed without conversion to radical nephrectomy or open surgery. One patient developed urinary extravasation 10 days after surgery, and was readmitted to the hospital for transurethral ureteral stenting considering the injury of the renal collecting system. The median operative time was 181.5 (123.8-206.3) min, the warm ischemia time was 20.0 (17.3-24.0) min, the blood loss was 125 (100.0-262.5) ml, and no patients received blood transfusion during and after surgery. The median hospitalization time was 7.0 (6.0-9.0) days, and the duration of indwelling drainage tube was 2.0 (2.0-3.0) days. The serum creatinine (Scr) on the first day, 3 months, and 6 months after surgery were 55.5 (50.8-62.8) µmol/L, 55.5 (48.0-62.0) µmol/L and 54.0 (51.8-63.5) µmol/L, respectively, and there was no significant difference compared with the preoperative level 56.0 (47.8-60.3) µmol/L. All patients were followed up after surgery, and the urinary CT scan or renal color doppler ultrasound, and renal function were reexamined. The median follow-up time of all patients was 19.0 (14.75-33.0) months, and no local recurrence of angiomyolipoma was seen in all patients. CONCLUSIONS: The surgical strategy of robot-assisted laparoscopic tumor enucleation combined with tumor aspiration is safe and effective in the treatment of renal hilar angiomyolipoma.

Open versus mini-invasive partial and radical nephrectomy complications: results from the French national health database.

BACKGROUND: Laparoscopic surgery is associated with a lower morbidity than open surgery. No recent data compared kidney cancer surgery in the French population using the National Health Insurance database (PMSI-MCO). AIMS: We explore and compare the surgical morbidity rates between laparoscopic and open laparotomy for kidney cancer. METHODS: The initial length of stay and complications parameters during the three postoperative months were described for renal cancer in every French center in 2018. We compared Relative Risks (RR [95% CI]) between laparoscopic and open surgery for both radical and partial nephrectomy. RESULTS: Among 8,162 patients, 3,525 had a radical nephrectomy, 978 open, 2,547 laparoscopic surgeries; 4,637 patients had partial nephrectomies, 1,778 open 2,859 laparoscopic surgeries. For radical surgery, the most common complications were urinary infections (7.8%), acute renal failure (8.9%), sepsis (8.4%), bleeding (9.3%), and postoperative anemia (5.9%); the RR for laparoscopic versus open surgery were respectively 0.68 [0.54;0.86], 0.71 [0.57;0.88], 0.69 [0.55;0.86], 0.83 [0.66;1.03], 0.56 [0.43;0.73]. For partial nephrectomies, the most common complications were urinary infections (7.7%), bleeding (11.6%), and postoperative anemia (5.8%), with RR of 0.71 [0.58;0.87], 0.61 [0.52;0.71], and 0.64 [0.51;0.81]. The mean length of stay was 7.7 for open radical nephrectomy, 6.3 for laparoscopic radical nephrectomy, 7.5 for open partial nephrectomy, and 5 for laparoscopic partial nephrectomy. CONCLUSIONS: The laparoscopic approach had fewer postoperative complications and a shorter length of stay than open surgery for partial and radical nephrectomy. The PMSI analysis provided an exhaustive description of surgical practice for kidney cancer and surgical complications in France. CLINICAL TRIAL NUMBER: Not applicable.

Robot-assisted resection of renal tumor in children and comparison with laparoscopic surgery.

BACKGROUND: Robot-assisted surgery (RAS) is being performed with increasing frequency in pediatric oncology. We report our experience with RAS for renal tumors in children and compare the outcomes between RAS and laparoscopic surgery (LAS). METHODS: A total of 23 patients with renal tumor who underwent minimally invasive surgery (MIS) between January 2020 and December 2023 were included in the study. The inclusion criteria enrolled in this study was unilateral tumors with maximum tumor diameter less than 10 cm. Patients who had enlarged lymph node, venous thrombosis, preoperative tumor rupture, bilateral renal tumor, or extrarenal extension on imaging were deemed contraindications and excluded. Patient demographics, operative details, postoperative outcomes and follow-up were recorded. RESULTS: Among these patients, 17 underwent RAS and 6 underwent LAS. In the RAS group, the median age was 64 months (range, 9-156) with a median weight of 19.48 kg (range, 8.4-46.5); the maximum tumor diameter at operation was 55.65 mm (range, 22-88); the operation time was 188.8 min (range, 120-210), the intraoperative blood loss was 20 ml (range, 5-50), and the length of postoperative hospital stay was 4 days (range 1-9). There was no significant difference in patients' age, weight, location, tumor size, histological pattern and operation time between the two groups (P > 0.05). The RAS group had a significantly less intraoperative blood loss (P = 0.026) and less length of postoperative stay (P = 0.01) than the LAS group. CONCLUSION: Our initial experience suggested that RAS in pediatric renal tumor was feasible and safe, and it reduced surgical trauma and accelerate postoperative recovery for the patients. Due to the limitations of sample size and study quality, the clinical importance of these findings still needs to be further verified.

Intraoperative dexmedetomidine administration and acute kidney injury in patients undergoing unilateral partial nephrectomy: a retrospective study.

Partial nephrectomies are associated with an increased risk of acute kidney injury (AKI), but dexmedetomidine administration may improve renal outcomes. We hypothesized that intraoperative dexmedetomidine administration would be associated with a decrease in AKI development in patients undergoing unilateral partial nephrectomy. In this retrospective study, adult patients who underwent unilateral partial nephrectomy from April 2016 to October 2023 were included. Exclusion criteria were a history of end-stage renal disease, ineligible procedures (i.e., aborted procedure, conversion to radical nephrectomy, surgery on a horseshoe kidney), and reoperation within three days of the initial nephrectomy. Patients were categorized according to whether they received intraoperative dexmedetomidine. The primary outcome was AKI incidence within three days of surgery; AKI was defined according to the Kidney Disease Improving Global Outcomes definition. Propensity score matching (PSM) was conducted to account for potential confounders (age, body mass index, sex, American Society of Anesthesiologists score, final surgical approach, clamping-related ischemia for >15 min). We included 1,632 patients; 214 received dexmedetomidine and 1,418 did not. Before PSM, the AKI rate was 31.2% in patients who received dexmedetomidine and 25.7% in patients who did not (p = 0.081). After PSM, the AKI rate was 31.3% in patients who received dexmedetomidine and 27.6% in those who did not (p = 0.396). The post-PSM odds ratio for AKI following dexmedetomidine administration during unilateral partial nephrectomy was 0.910 (95% CI: 0.585-1.142; p = 0.677). Intraoperative dexmedetomidine was not associated with a reduction in postoperative AKI incidence or severity after unilateral partial nephrectomy.

Totally Robotic Donor Nephrectomy for Living Donors Using a Novel Technique: Single-Center Experience.

OBJECTIVES: Robot-assisted laparoscopic donor nephrectomy for living donor transplant debuted successfully in the year 2000 and has since gained global acceptance. We assessed our practice of robotassisted living donor nephrectomy and applied an innovative technical approach. MATERIALS AND METHODS: We conducted a retrospective analysis of data from patients who underwent robot-assisted living donor nephrectomy for the period from January 2015 to December 2023. The patient group who had undergone the modified surgical technique was included in the study. We recorded and evaluated the following characteristics: age, sex, body mass index (measured in kilograms body mass per meter squared), donor-recipient relationship, site of operation (right or left side), operation time, warm ischemia time, intraoperative complications, mean estimated blood loss, transfusion requirements, and graft status. RESULTS: There were 55 donors in the study (24 female, 31 male), with a median body mass index of 28 (range, 19-32) and a median age of 43 years (range, 19-65 years). The donor-recipient relationships were as follows: parent in 26 (47%), spouse in 8 (15%), firstdegree relative in 9 (16%), and second-degree, thirddegree, and fourth-degree relatives in 12 cases (22%). Median operation time was 134 minutes (range, 123-278 minutes). Right kidney nephrectomy was performed in 8 of 55 donors, and left kidney nephrectomy was performed 47 of 55 donors. No graft loss occurred among the recipients. CONCLUSIONS: Our experience with this new technique confirmed the feasibility of robotic nephrectomy for living donor kidney transplant as a safe and effective procedure. Notwithstanding the beneficial aspects, the primary drawback of this procedure is its significant cost, thereby necessitating attention toward substantial reduction of the associated expenses in the future by development of new techniques such as those we have described in this study.

The association of anatomical renal mass complexity with surgical approach, Hb drop, and the rate of blood transfusion.

INTRODUCTION: The third most prevalent malignant neoplasm involving the urinary tract is renal cell carcinoma (RCC), encompassing nearly 3.5% of the entire cancers afflicting the body. The aim of this research was to explore how the R.E.N.A.L. nephrometry score relates to the decisions made regarding surgery in individuals with localized RCC. METHODS: This prospective study, assessed patients with localized parenchymal renal masses (stages I and II) tentatively diagnosed as RCC. Utilizing preoperative multiphasic renal CT scans and MRI, the R.E.N.A.L. score categorized masses for nephrometry values. Inclusion criteria involved collecting patient data, and data collection utilizing a structured format focusing on the nephrometry grading system. RESULTS: The study included 64 patients aged (mean ± SD) 49.78 ± 12.35 yrs. Undergoing renal mass surgery, there were 17 (26.5%) low, 28 (43.8%) moderate and 19 (29.7%) high-complexity lesions. All patients with a low Nephrometry score (n = 17) underwent partial nephrectomy, and all cases with a high score (n = 19) underwent radical nephrectomy. For those with a moderate Nephrometry score (n = 28), 13 (46.4%) underwent partial nephrectomy, while the remaining 15 (53.6%) cases underwent radical nephrectomy. Morbidity was low, and no mortality occurred at 180 days. Patients who had lesions fully above or below polar lines were less likely to need blood transfusions. A trend towards higher Fuhrman grades in patients receiving transfusions suggests a potential link between tumor aggressiveness and bleeding risk. CONCLUSIONS: Our findings provide insight on the utilization of the R.E.N.A.L. nephrometry score in forecasting perioperative, post-surgical, and oncological results. Such data might help optimize surgical methods and pre-operative patient counseling.

Incidence and Pattern of Recurrence after Surgical Resection in Organ-Confined Renal Cell Carcinoma.

PURPOSE: To evaluate the incidence and pattern of recurrence after surgery in patients with organ-confined renal cell carcinoma (RCC) to establish an appropriate follow-up plan. MATERIALS AND METHODS: In this retrospective study, we evaluated data from 2960 patients who underwent radical or partial nephrectomy for stage 1 or 2 RCC. We investigated the location of first recurrence and recurrence-free survival (RFS) by plotting Kaplan-Meier curves and analyzed the associated variables using Cox regression analysis. RESULTS: During a median follow-up of 59 months, the 10-year RFS rates were 94.5%, 75.0%, and 57.9%, for T1a, T1b, and T2 RCC, respectively. A total of 211 patients experienced recurrence: 67 after 5 years, and 14 after 10 years. The most common sites of the first recurrence were the lungs, bones, and contralateral kidneys. Male sex, older age, higher pathologic T stage, higher nuclear grade, clear-cell RCC, and presence of differentiation were associated with recurrence. Among patients followed up for more than 60 months, higher pathologic T stage and grade, as well as clear cell RCC were predictors of RFS. CONCLUSION: Late recurrence after surgery is common in patients with organ-confined RCC, with recurrence occurring even after 10 years. Consequently, long-term follow-up, of perhaps 10 years or more, including imaging studies of the abdomen, lungs, and bone, should be considered for the early detection of recurrence.

Meta-analysis and systematic review of factors predicting conversion to radical nephrectomy following robotic-assisted partial nephrectomy in renal cancer patients.

Evaluating the risk factors for the conversion from robotic-assisted partial nephrectomy (RAPN) to radical nephrectomy (RN). Through a comprehensive database search encompassing PubMed, Web of Science, Embase, and the Cochrane Library, we identified pertinent English-language research published by June 2024. We utilized the NOS scale for quality assessment. The aggregate effect was quantified via the odds ratio (OR), alongside a 95% confidence interval (CI). Sensitivity analyses were conducted using both fixed-effects and random-effects models to evaluate reliability. The meta-analytical process was facilitated by the Stata 18 software suite. Our meta-analysis encompassed a total of 8 retrospective studies and 3 prospective studies, totaling 4056 patients. We found that increasing patient age (OR: 1.04; 95% CI 1.00-1.08; P = 0.005), higher American Society of Anesthesiologists (ASA) scores (3 or above) (OR: 2.74; 95% CI 1.52-4.93; P = 0.001), elevated R.E.N.A.L. scores (7 or above) (OR: 2.49; 95% CI 1.57-3.95; P < 0.001), and the use of off-clamp RAPN (OR: 7.21; 95% CI 2.60-19.93; P < 0.001) significantly raised the odds of surgical conversion. On the other hand, male sex (OR: 1.04; 95% CI 0.67-1.62; P = 0.858), the side of the tumor (OR: 0.97; 95% CI 0.48-1.95; P = 0.936), tumor size (OR: 3.43; 95% CI 0.57-20.55; P = 0.177), body mass index (BMI) (OR: 1.03; 95% CI 0.96-1.11; P = 0.426), clinical stage (OR: 3.78; 95% CI 0.46-30.70; P = 0.214), and the use of single-port RAPN (OR: 0.54; 95% CI 0.16-1.78; P = 0.31) did not show a statistically significant link to an increased conversion risk. This meta-analysis elucidates the critical risk factors for the conversion from robotic-assisted partial nephrectomy to radical nephrectomy, providing significant guidance for preoperative risk assessment and clinical decision-making. However, our findings necessitate validation through studies with larger sample sizes.

Impact of tumor dissecting technique on trifecta achievement in patients requiring extended warm ischemia during robot-assisted partial nephrectomy.

PURPOSE: To clarify specific factors associated with surgical outcomes in robot-assisted partial nephrectomy (RAPN) that require extended warm ischemia time (WIT), which may have a negative impact, but cannot always be avoided. METHODS: We included 1,182 patients who had RAPN performed between January 2016 and December 2022 from a prospectively generated multi-institutional RAPN database, divided into normal WIT (nWIT) (≤ 20 min; 843 patients) and extended WIT (eWIT) (> 20 min; 339 patients) groups. Primary outcome measures were WIT and the Surface-Intermediate-Base (SIB) margin score, which contribute to postoperative trifecta achievement. Results were compared between the two groups using logistic regression. RESULTS: Patients in the eWIT group had larger tumors, higher RENAL nephrometry scores, and lower SIB scores than those of the nWIT group. The trifecta achievement rate was significantly different between the two groups (nWIT: 70.1 vs. 49.0%, p < 0.001). In the nWIT group, WIT (coefficient: -0.105 [standard error 0.020], p < 0.001) and SIB score (coefficient: -0.107 [0.053], p = 0.045) were significant predictors of trifecta achievement. In the eWIT group, the SIB score (coefficient - 0.216 [0.082], p = 0.008) was significantly associated with trifecta attainment, whereas WIT only showed a trend toward significance. Limitations included a lack of long-term survival, renal function, and chronic complications data. CONCLUSIONS: For patients with eWIT during RAPN, the tumor dissection technique may be more important than WIT in predicting postoperative outcomes. Further prospective studies are required to confirm our results.

Impact of a kidney-adjusted ERAS® protocol on postoperative outcomes in patients undergoing partial nephrectomy.

PURPOSE: Evaluation of a kidney-adjusted enhanced recovery after surgery (ERAS®) protocol (kERAS) in patients undergoing nephron-sparing surgery (PN). METHODS: The kERAS protocol is a multidimensional protocol focusing on optimized perioperative fluid and nutrition management as well as strict intraoperative and postoperative blood pressure limits. It was applied in a prospective cohort (n = 147) of patients undergoing open or robotic PN. Patients were analyzed for the development of acute postoperative renal failure (AKI), achievement of TRIFECTA criteria, upstaging or new onset of chronic kidney disease (CKD) and length of hospital stay (LOS) and compared to a retrospective cohort (n = 162) without application of the protocol. RESULTS: Cox regression analyses could not confirm a protective effect of kERAS on the development of AKI post-surgery. A positive effect was observed on TRIFECTA achievement (OR 2.2, 95% CI 1.0-4.5, p = 0.0374). Patients treated with the kERAS protocol showed less long-term CKD upstaging compared to those treated with the standard protocol (p = 0.0033). There was no significant effect on LOS and new onset of CKD. CONCLUSION: The implementation of a kERAS protocol can have a positive influence on long-term renal function in patients undergoing PN. It can be used safely without promoting AKI. Furthermore, it can be realized with a manageable amount of additional effort.

Omission of intraoperative drain placement during robotic partial nephrectomy and robotic radical prostatectomy is safe: an analysis of 18,000 patients.

PURPOSE: Placement of a drain during robotic assisted partial nephrectomy (RAPN) and robotic assisted radical prostatectomy (RARP) is standard practice for many urologists and can aid in assessment and management of complications such as urine leak, lymphocele, or bleeding. However, drain placement can cause discomfort and delay patient discharge, with questionable benefit. We aim to assess the correlation between drain placement with post operative complications. METHODS: The NSQIP targeted database was queried for patients who underwent RAPN or RARP from 2019 to 2021. Our primary outcomes included 30-day complication rates stratified by intraoperative drain placement. Secondary outcomes included procedure-specific complications, length of stay (LOS), and readmissions. Multivariable regression analyses, with Bonferroni correction, were performed for each post-operative complication. RESULTS: We identified 4738 and 13,948 patients who underwent RAPN and RARP, respectively. Drains were not placed in 2258 (47.7%) and 6700 (48%) patients, respectively. On adjusted multivariable analysis in the RAPN cohort, omission of drain placement was associated with decreased LOS (ß -0.45; 99.58% CI [-0.59, -0.32]) but no difference in overall complication rates. After adjusted analysis in the RARP cohort, omission of drain placement was associated with decreased risk of any complication (OR 0.73 [0.62-0.87]), infectious complication (OR 0.66 [0.49-0.89]), and LOS (ß -0.30 [-0.37, -0.24]). CONCLUSIONS: Using a large contemporary database, this study demonstrates that omission of drains during RAPN and RARP was safe without increased risk of postoperative complications. Despite inherent selection bias in this cohort, our data suggests that routine drain placement is not necessary for these procedures.

Intraperitoneal laparoscopic technique in trendelenburg position: an effective surgical method for pyelolithotomy, pyeloplasty, and heminephrectomy in patients with horseshoe kidneys.

PURPOSE: To evaluate the safety and feasibility of intraperitoneal laparoscopic surgery in Trendelenburg position (ILSTP) for pyelolithotomy, pyeloplasty, and heminephrectomy in patients with horseshoe kidneys (HSKs). METHODS: Between March 2021 and March 2024, three patients with HSKs underwent ILSSP. Of these three patients, two with pelvi-ureteric junction obstruction with recurrent kidney stones underwent pyelolithotomy and pyeloplasty, one with symptomatic nonfunctioning left moiety of a HSK was managed with heminephrectomy. RESULTS: Mean operating time was 114 ± 64.8 (44-172) min, and estimated blood loss was 63.3 ± 51.3 (20-120) ml. The mean hospital stay was 3.3 ± 1.5 (2-5) days. There were no major intra- or post-operative complications. CONCLUSIONS: ILSTP is a feasible and effective technique for performing pyelolithotomy, pyeloplasty, and heminephrectomy in patients with HSKs.

Implementation of surgical rehearsal utilizing patient specific hydrogel kidney phantoms prior to complex renal cancer surgery: a pilot study.

INTRODUCTION: With the advancement of surgical technology, the opportunity to integrate novel surgical preparation is imperative to improve patient outcomes and enhance safety. METHODS: Patient specific perfused kidney phantoms including the tumor, parenchyma, artery, vein, and calyx were fabricated using 3D-printing and hydrogel injection molding from scans of 25 patients scheduled for robotic partial-nephrectomy (RAPN). Models are validated for anatomical accuracy, mechanical, functional properties and surrounded by the other models of relevant anatomy in a body cast for a simulated surgical rehearsal. We investigated the impact of these preoperative rehearsals preceding complex RAPN by analyzing changes in surgeons' decisions following review of both axial-imaging and following rehearsal simulation. Predictive ability of these rehearsal platforms was compared to live surgery outcomes and trifecta of cases as an outcome was calculated. RESULTS: 25 patients with complex renal tumors, average 9.8 nephrometry score and 4.9 cm mean tumor diameter were consented. Mean blood loss and WIT were 193.2 ml and 19.8 min. Two Clavien 2 complications were reported at 30-day postoperative. Trifecta was achieved in 17 (68%) of surgical cases. Surgeons' confidence in their ability to complete a partial nephrectomy and ability to predict WIT significantly increased from initial viewing the axial imaging to after the rehearsal. The correlation coefficient between the procedural clinical data collected during the rehearsals and live surgery were calculated. CONCLUSION: The application of this versatile method for creating authentic perfused kidney phantoms can result in increased confidence in surgical plan and thus improved surgical performance and outcomes.

Urine leak and vascular complications following robotic partial nephrectomy: a contemporary single-center experience.

Urine leak (UL) and vascular complications (VC), i.e., pseudoaneurysms and arteriovenous fistulas are well-described complications of robotic-assisted partial nephrectomy (RAPN). Historically, UL incidence ranges from 0.3 to 17% and VC from 0.8 to 5.6%. We report the contemporary experience of UL and VC from a single, high-volume center in cases of RAPN. 447 patients were identified from an IRB-approved Renal Tumor Database of 2174 cases who underwent RAPN from 1/2017 to 5/2023. VC occurred in 9 cases (4 pseudoaneurysms, 1 AV fistula, 4 concurrent AV fistula/pseudoaneurysm), UL occurred in 9 (2.0%), and there was one concurrent case of VC and UL. Collecting-system entry occurred in five VC cases and five UL cases. For VCs, the median nephrometry score and maximal tumor diameter was 8 (IQR 3.0) and 3.8 (0.9) cm, respectively, and 8 (3.0) and 3.7 (1.1) cm for UL cases, respectively. Most complications occurred with tumors ≤ 4 mm from the collecting system (n = 7 VC, n = 6 UL). VCs presented after 18 (6.0) days, 6 with gross hematuria; 3 required clot irrigation, 1 required continuous bladder irrigation, and 8 required embolization. No patients required postoperative transfusion. Patients with UL presented after a median of 1 (12) day, with 5 cases detected by elevated creatinine in drain fluid and the remainder detected on routine ultrasound. The duration of UL was 13 (41) days with only 2 cases requiring stenting and one case requiring a drainage catheter. No patients required kidney re-operation or removal. Our rate of VC and UL following RAPN are low and consistent with other contemporary series. Complications occurred in patients with high nephrometry scores or tumors located close to the collecting system. Both complications generally present early and can be managed without kidney re-operation or removal.

A Case of Primary Ewing Sarcoma of the Kidney: Robotic-Assisted Nephron-Sparing Surgery, a Feasible Alternative in Treatment of Localized Disease.

Extra-skeletal Ewing sarcoma (EWS) occurs in about 12% of EWS patients; at the same time, primary involvement of the kidneys remains extremely rare. Since it was first described in 1975, only a small case series have been reported worldwide. About 95% of surgically treated patients with EWS of the kidney described in the literature underwent nephrectomy, and the remaining patients only had a tumor biopsy. Nephron-sparing surgery (NSS) has not been sufficiently investigated as an alternative in the local surgical treatment of localized disease, mostly as a result of technically unfeasible provisions of negative surgical margins. In this report, we present a unique case of primary EWS of the kidney with an asymptomatic course without radiographic signs that suggest a highly aggressive disease, successfully locally treated with robotic-assisted NSS. This report showcases that robotic-assisted NSS could be a feasible alternative in treatment of localized disease yielding equally good oncological results while, at the same time, creating better prerequisites for necessary adjuvant chemotherapy.