cT1a Renal Masses Less Than 2 versus 2 cm or Greater Managed by Robotic Partial Nephrectomy: A Propensity Score Matched Comparison of Perioperative Outcomes.

PURPOSE: We performed a single center evaluation to compare perioperative, pathological and functional outcomes of robotic partial nephrectomy of T1a renal masses less than vs greater than 2 cm. MATERIALS AND METHODS: Propensity score 1:1 matching of queried patients was performed using the institutional robotic partial nephrectomy database from January 2007 to January 2017. Matching was done by patient age, gender, race, body mass index, the Charlson comorbidity index, smoking status, diabetes, hypertension, hyperlipidemia, ASA® (American Society of Anesthesiologists®) score, estimated glomerular filtration rate, chronic kidney disease stage and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar line and abutting main renal artery or vein) score. We analyzed the records of 524 patients, including 262 with a renal mass less than 2 cm vs 262 with a renal mass 2 cm or greater. Perioperative, pathological and functional outcomes were evaluated. RESULTS: Smaller renal masses (less than 2 cm) were associated with significantly lower operative time, blood loss, ischemia time (mean ± SD 14.3 ± 9.58 vs 21.5 ± 9.51 minutes, p <0.001) and intraoperative transfusions (0% vs 2.7%, p = 0.015). Moreover, we found superior early renal functional outcomes as assessed by the estimated glomerular filtration rate on postoperative day 1 (mean 83.1 ± 21.3 vs 76.6 ± 22.0 mg/ml/1.73 m, p = 0.001), greater parenchymal preservation (mean 89.9% ± 9.45% vs 83.6% ± 8.20%, p <0.001) and a trend toward a lower rate of postoperative complications (13.5% vs 19.5%, p = 0.080). A higher incidence of malignancy was found in larger tumors (85.9% vs 74.8%, p = 0.002) but no difference was recorded in positive surgical margins. CONCLUSIONS: Robotic partial nephrectomy tends to be a low morbidity treatment modality for renal masses less than 2 cm. Although active surveillance is a common option for such tumors, robotic partial nephrectomy remains an alternative in select patients.

Achieving tumour control when suspecting sinus fat involvement during robot-assisted partial nephrectomy: step-by-step.

OBJECTIVES: To report a single expert robotic surgeon's step-by-step surgical technique for achieving local cancer control during robot-assisted PN (RAPN) for T3 tumours. PATIENTS AND METHODS: Since January 2010 to December 2016, the institutional RAPN database was queried for patients who underwent transperitoneal RAPN performed by a single surgeon for tumours ≤4 mm from the collecting system at preoperative computed tomography (three points on the 'N [Nearness]' R.E.N.A.L. nephrometry-score item) that were pT3a involving sinus fat at final pathology. Baseline characteristics, perioperative and oncological outcomes (particularly positive surgical margins, PSMs), were identified. RESULTS: Of 1497 masses that underwent RAPN, 512 scored 3 points on the 'N' item of the R.E.N.A.L. nephrometry score assessment. In all, 24 patients had pT3a tumours involving sinus fat at final pathology and represented the analysed cohort. RAPN were performed according to the here described technique. No PSMs were reported. Trifecta achievement was 54.2%. Within a median follow-up of 30 months, two and one patients had recurrence or metastasis, respectively. Two patients died unrelated to renal cancer. Retrospective analysis and limited follow-up represent study limitations. CONCLUSION: In a selected cohort of patients with renal tumours near the sinus fat at baseline R.E.N.A.L. nephrometry score assessment and confirmed pT3a at final pathology, the described RAPN technique was able to achieve optimal local cancer control.

"At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy.

OBJECTIVES: To investigate the influence of surgical modifiable factors on chronic kidney disease upstaging in a contemporary cohort of patients with normal and "at-risk" kidneys undergoing partial nephrectomy. METHODS: We reviewed 778 consecutive patients with (n = 634)/without (n = 144) chronic kidney disease or risk factors for chronic kidney disease in our institutional partial nephrectomy database. Chronic kidney disease upstaging was assessed using glomerular filtration rate measurements preoperatively and at 3-12 months postoperatively. Using a multivariate logistic regression, baseline clinicodemographic factors, and the operative measurements of excisional volume loss and warm and cold ischemia time on rates of chronic kidney disease upstaging were determined. Marginal effects were used to analyze the impact of ischemia time and generate interaction curves. RESULTS: Chronic kidney disease/risk factors for chronic kidney disease had equivalent rates of chronic kidney disease upstaging as the healthy kidney cohort (31.5% vs 38.2%, P = 0.15). Of the entire cohort, 2.8% were upstaged to stage IV-V chronic kidney disease. Multivariate analysis found a significant association between chronic kidney disease upstaging and excisional volume loss in both cohorts (no chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.63, P = 0.04; chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.42, P = 0.001). Only in the chronic kidney disease/risk factors for chronic kidney disease cohort, there was an association between ischemia type/duration and chronic kidney disease upstaging (odds ratio 1.04, P = 0.04). Warm ischemia began to predict an increased risk of chronic kidney disease upstaging at 17.6 min, which became statistically significant at 49 min. CONCLUSIONS: Chronic kidney disease upstaging is common after partial nephrectomy. Although volume loss unequivocally affects rates of upstaging irrespective of baseline renal function, warm ischemia time disproportionately influences "at-risk" kidneys. Therefore, strong consideration should be given to minimizing volume loss and using cold ischemia when extended clamp times are anticipated in "at-risk" kidneys.

Robotic partial nephrectomy after pazopanib treatment in a solitary kidney with segmental vein thrombosis.

OBJECTIVE: To demonstrate our surgical technique of robotic partial nephrectomy (RPN) in a patient with a solitary kidney who received neoadjuvant Pazopanib, highlighting the multidisciplinary approach. MATERIALS AND METHODS: In our video, we present the case of 77-year-old male, Caucasian with 6.6cm left renal neoplasm in a solitary kidney. An initial percutaneous biopsy from the mass revealed clear cell RCC ISUP 2. After multidisciplinary tumor board meeting, Pazopanib (800mg once daily) was administered for 8 weeks with repeat imaging at completion of therapy. Post-TKI image study was compared with the pre-TKI CT using the Morphology, Attenuation, Size, and Structure criteria showing a favorable response to the treatment. Thereafter, a RPN was planned3. Perioperative surgical outcomes are presented. RESULTS: Operative time was 224 minutes with a cold ischemia time of 53 minutes. Estimated blood loss was 800ml and the length of hospital stay was 4 days. Pathology demonstrated a specimen of 7.6cm with a tumor size of 6.5cm consistent with clear cell renal carcinoma ISUP 3 with a TNM staging pT1b Nx. Postoperative GFR was maintained at 24 ml / min compared to the preoperative value of 33ml / min. CONCLUSIONS: A multidisciplinary approach is effective for patients in whom nephron preservation is critical, providing na opportunity to select those that may benefi t from TKI therapy. Pazopanib may allow for PN in a highly selective subgroup of patients who would otherwise require radical nephrectomy. Prospective data will be necessary before this strategy can be disseminated into clinical practice. Available at: http://www.intbrazjurol.com.br/video-section/20180240_Garisto_et_al.

Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy.

PURPOSE: We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN). PATIENTS AND METHODS: We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI. RESULTS: Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04). CONCLUSION: Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.

Hilar Parenchymal Oversew: a novel technique for robotic partial nephrectomy hilar tumor renorrhaphy.

INTRODUCTION: A renorrhaphy technique which is effective for hemostasis but does not place undue tension on the branch vessels of the renal sinus remains one of the challenging steps after hilar tumor resection during robotic partial nephrectomy (RPN). The published V-hilar suture (VHS) technique is one option for reconstruction after an RPN involving the hilum. The objective of this video is to show a novel renorrhaphy technique, Hilar Parenchymal Oversew that has been effective for such cases. MATERIALS AND METHODS: We present two cases of RPN for renal hilar tumors. The first case depicts use of the VHS renorrhaphy technique for a tumor that abuts the renal hilum along 20% of its diameter. The second case demonstrates tumor resection and reconstruction for a tumor that has >50% involvement of the hilum along its diameter. After tumor resection, individual sinus vessels can be selectively oversewn with 2-0 Vicryl suture on SH needle. The remaining exposed parenchyma is controlled using the Hilar Parenchymal Oversew technique with a #0 Vicryl on CT-1 needle. RESULTS: For the Hilar Parenchymal Oversew surgery operative time was 225 min, estimated blood loss was 140 ml, warm ischemia time was 19 minutes, and there were no intraoperative complications. Pathology was consistent with clear cell renal cancer with negative margins. CONCLUSION: Robotic partial nephrectomy with the Hilar Parenchymal Oversew technique is a good alternative to VHS renorrhaphy in the management of renal hilar tumors "bulging" into the renal sinus with >50% of the tumor diameter abutting the hilum.

Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors.

PURPOSE: We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy. MATERIALS AND METHODS: We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan-Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated. RESULTS: Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease-free survival on Kaplan-Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease-free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five-year disease-free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01). CONCLUSIONS: High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.

When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center.

PURPOSE: We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. MATERIALS AND METHODS: Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. RESULTS: The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). CONCLUSIONS: At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.

Perioperative morbidity, oncological outcomes and predictors of pT3a upstaging for patients undergoing partial nephrectomy for cT1 tumors.

OBJECTIVES: To evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN). MATERIALS AND METHODS: Retrospective study of 1042 patients who underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test. RESULTS: The pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7, p < 0.01), higher hilar (h) location (27.5 vs. 14.8%, p < 0.01), higher grade (57.5 vs. 38.2%, p < 0.01), and higher positive surgical margins (18.6 vs. 5.8%, p < 0.01. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time and overall complications, though there were no differences in median e-GFR decline and major (Grade III-V) complications. Five-year RFS was 78.5% for pT3a group vs. 94.6% for pT1 group (log-rank p < 0.01). Male gender (OR 2.2, p < 0.01), and R.E.N.A.L. score (OR 2.3, p = 0.01) were preoperative predictors of upstaging. We acknowledge limitations in our study, most are inherent problems of retrospective studies. CONCLUSION: Perioperative morbidity, after partial nephrectomy, is acceptable in cT1/pT3 tumors in comparison to cT1/pT1; however, upstaged patients had a worse oncological outcome. cT1/pT3a tumors are associated with adverse clinico-pathological features. Preoperative risk predictors of upstaging were higher R.E.N.A.L. score and male gender.

Perceived comfort level of medical students and residents in handling clinical ethics issues.

BACKGROUND: Studies have shown that medical students and residents believe that their ethics preparation has been inadequate for handling ethical conflicts. The objective of this study was to determine the self-perceived comfort level of medical students and residents in confronting clinical ethics issues. METHODS: Clinical medical students and residents at the University of Maryland School of Medicine completed a web-based survey between September 2009 and February 2010. The survey consisted of a demographic section, questions regarding the respondents' sense of comfort in handling a variety of clinical ethics issues, and a set of knowledge-type questions in ethics. RESULTS: Survey respondents included 129 medical students (response rate of 40.7%) and 207 residents (response rate of 52.7%). There were only a few clinical ethics issues with which more than 70% of the respondents felt comfortable in addressing. Only a slight majority (60.8%) felt prepared, in general, to handle clinical situations involving ethics issues, and only 44.1% and 53.2% agreed that medical school and residency training, respectively, helped prepare them to handle such issues. Prior ethics training was not associated with these responses, but there was an association between the level of training (medical students vs residents) and the comfort level with many of the clinical ethics issues. CONCLUSIONS: Medical educators should include ethics educational methods within the context of real-time exposure to medical ethics dilemmas experienced by physicians-in-training.

Development and Internal Validation of a Nomogram for Predicting Renal Function after Partial Nephrectomy.

Loss of renal function can be a clinically impactful event after partial nephrectomy (PN). We aimed to create a model to predict loss of renal function in patients undergoing PN. Data for 1897 consecutive patients who underwent PN with warm ischemia between 2008 and 2017 were extracted from our institutional database. Loss of renal function was defined as upstaging of chronic kidney disease in terms of the estimated glomerular filtration rate (eGFR) at 3 mo after PN. A nomogram was built based on a multivariable model comprising age, sex, body mass index, baseline eGFR, RENAL score, and ischemia time. Interval validation and calibration were performed using data from 676 patients for whom complete data were available. Receiver operator characteristic (ROC) curves with 1000 bootstrap replications were plotted, as well as the observed incidence versus the nomogram-predicted probability. We also applied the extreme training versus test procedure known as leave-one-out cross-validation. After internal validation, the area under the ROC curve was 76%. The model demonstrated excellent calibration. At an upstaging cutoff of 27% probability, upstaging was predicted with a positive predictive value of 86%. PATIENT SUMMARY: In this report, we created a model to predict postoperative loss of renal function after partial nephrectomy for renal tumors. Inputting baseline characteristics and ischemia time into our model allows early identification of patients at higher risk of renal function decline after partial nephrectomy with good predictive power.

Robotic radical prostatectomy after aborted prostatectomy: still feasible? The experience from a tertiary care center.

To describe the surgical management of patients who had radical prostatectomy previously attempted but aborted due to diverse causes. Patients who underwent an "aborted prostatectomy" were extracted from the institutional prostatectomy database. A description of the tailored robotic approach was reported for each case. Tips and tricks for the accomplishment of robotic prostatectomy after aborted prostatectomy were reported. Six clinical cases were analyzed. Three patients had aborted prostatectomy due to complicated dissection hindered by pelvic mesh and bowel adhesions; one prostatectomy was aborted due to anesthesiology/respiratory matters; one for narrow pelvis; one due to abnormal pelvic vascular anatomy. All patients successfully underwent robotic prostatectomy at our institution. In five patients, standard transperitoneal robotic approach was performed. In one patient, robotic transperineal approach was mandatory. Median operative time was 282 min (86-460). Median estimated blood loss was 325 mL (50-1000). Two patients had positive surgical margins. One patient was found with nodal metastasis at final pathology. Neither perioperative nor postoperative complications were reported. At last follow-up, PSA was undetectable in 5/6 patients. Even after previous aborted prostatectomy, robot-assisted prostatectomy is feasible, with acceptable results. The case-by-case tailoring of the technique is the key for a successful intervention.

Renal Arterial Pseudoaneurysm After Partial Nephrectomy: Literature Review and Single-Center Analysis of Predictive Factors and Renal Functional Outcomes.

INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) represents the current surgical standard for T1 tumors. Renal arterial pseudoaneurysm is a rare but potentially life-threatening complication reported after PN. The aim of this study was to identify the factors associated with the occurrence of pseudoaneurysm after PN, specifically focusing on those requiring management with selective embolization. A literature review of the topic was performed. METHODS: A retrospective review of the institutional PN database was performed from January 2011 to December 2016. Patients who underwent embolization for pseudoaneurysm represented a separated cohort to be compared with other patients (controls). Patients' and tumors' characteristics were considered. Univariable and multivariable analyses were used to test their eventual association with the occurrence of pseudoaneurysm. RESULTS: A total of 1417 cases were evaluated. At a median of 21 days (interquartile range = 10-34), 20 patients (1.4%) developed postoperative pseudoaneurysm. The majority of patients (70%) presented with gross hematuria. The clinical suspicion was confirmed by contrast-enhanced computed tomography scan with angiography. Selective embolization was performed using endovascular coils. Technical success and clinical success rates were 100% and 95%, respectively. No difference was found in percentage estimated glomerular filtration rate (eGFR) preserved between patients who underwent embolization versus controls (median 82.6% versus 86.3%, P = .35). No differences in age, baseline renal function (as assessed by glomerular filtration rate [GFR]), tumor size, and R.E.N.A.L. were found between patients who reported and did not report pseudoaneurysm. In patients who developed pseudoaneurysm, longer operative time (225.6 minutes versus 193 minutes, P = .04), and cold ischemia time (48 minutes versus 29 minutes, P = .03) were reported. CONCLUSION: In our series, the occurrence of pseudoaneurysm was associated with longer operative and cold ischemia times. In patients who underwent selective embolization, renal function remained comparable with that of controls.

Transperitoneal Robot-assisted Partial Nephrectomy with Minimum Follow-up of 5 Years: Oncological and Functional Outcomes from a Single Institution.

BACKGROUND: Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive nephron-sparing technique with excellent perioperative and intermediate oncological outcomes. However, long-term oncological outcomes have not been reported to date. OBJECTIVE: To report oncological and functional outcomes of RAPN among patients with minimum follow-up of 5 yr. DESIGN, SETTING, AND PARTICIPANTS: Data for consecutive patients undergoing RAPN since October 2006 were extracted from a prospectively-maintained institutional PN database. Patients with benign tumors, genetic mutations, prior radical or ipsilateral PN, and those with follow-up of <5 yr were excluded. INTERVENTION: Transperitoneal RAPN for renal cell carcinoma (RCC). OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic, perioperative, postoperative, functional, and oncological data were evaluated. A linear random-effects model was used to estimate the effect of follow-up duration on the estimated glomerular filtration rate (eGFR) after adjustment for potential confounders. Univariable competing-risks regression analyses were performed to evaluate the hazard ratio (HR) for cancer-related events for the variables of interest. RESULTS AND LIMITATIONS: A total of 278 RAPNs for RCC were included. eGFR was significantly lower at follow-up time points than at baseline. At last follow-up (median 46 mo, interquartile range 30-58) the mean eGFR difference was -10.6ml/min (95% confidence interval -12.56 to -8.66; p < 0.0001). There were 28 deaths (10.1%) in the cohort during the follow-up period, of which five (1.8%) were related to metastatic RCC. The 5-yr and 7-yr cumulative incidence of RCC deaths was 1.80% at both 5 and 7 yr, while the cumulative incidence of local recurrence was 3.61% and 4.16%, and that of metastasis was 3.24% and 4.57% at 5 and 7 yr, respectively. Univariable competing-risks regression revealed that higher Fuhrman grade (HR 8.76; p = 0.051), larger tumor size (HR 1.67; p < 0.0001), and tumor necrosis (HR 16.73; p = 0.0019) were independent predictors of RCC death. The retrospective design and potential selection bias due to patient selection in the early RAPN experience may limit the generalizability of the findings. CONCLUSIONS: This is the first study reporting minimum oncological follow-up of 5 yr after RAPN. The results demonstrate excellent long-term oncological outcomes after RAPN in a selected cohort of patients. Our data confirm that the renal functional deterioration after RAPN remains stable over time after the early postoperative decrease. PATIENT SUMMARY: Robot-assisted partial nephrectomy is being more widely used as a standard treatment for small localized renal cell carcinomas. This study reveals excellent long-term cancer control for both local recurrences and distant metastases. Renal function is stable after an initial postoperative deterioration.

Variability in Partial Nephrectomy Outcomes: Does Your Surgeon Matter?

BACKGROUND: Understanding physician-level discrepancies is increasingly a target of US healthcare reform for the delivery of quality-focused patient care. OBJECTIVE: To estimate the relative contributions of patient and surgeon characteristics to the variability in key outcomes after partial nephrectomy (PN). DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of 1461 patients undergoing PN performed by 19 surgeons between 2011 and 2016 at a tertiary care referral center. INTERVENTION: PN for a renal mass. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS: Hierarchical linear and logistic regression models were built to determine the percentage variability contributed by fixed patient and surgeon factors on peri- and postoperative outcomes. Residual between- and within-surgeon variability was calculated while adjusting for fixed factors. RESULTS AND LIMITATIONS: On null hierarchical models, there was significant between-surgeon variability in operative time, estimated blood loss (EBL), ischemia time, excisional volume loss, length of stay, positive margins, Clavien complications, and 30-d readmission rate (all p<0.001), but not chronic kidney disease upstaging (p=0.47) or percentage preservation of glomerular filtration rate (p=0.49). Patient factors explained 82% of the variability in excisional volume loss and 0-32% of the variability in the remainder of outcomes. Quantifiable surgeon factors explained modest amounts (10-40%) of variability in intraoperative outcomes, and noteworthy amounts of variability (90-100%) in margin rates and patient morbidity outcomes. Immeasurable surgeon factors explained the residual variability in operative time (27%), EBL (6%), and ischemia time (31%). CONCLUSIONS: There is significant between-surgeon variability in outcomes after PN, even after adjusting for patient characteristics. While renal functional outcomes are consistent across surgeons, measured and unmeasured surgeon factors account for 18-100% of variability of the remaining peri- and postoperative variables. With the increasing utilization of value-based medicine, this has important implications for the goal of optimizing patient care. PATIENT SUMMARY: We reviewed our institutional database on partial nephrectomy performed for renal cancer. We found significant variability between surgeons for key outcomes after the intervention, even after adjusting for patient characteristics.

Predictors of positive surgical margins in patients undergoing partial nephrectomy: A large single-center experience.

OBJECTIVE: To identify preoperative factors that predict positive surgical margins in partial nephrectomy. MATERIAL AND METHODS: Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. RESULTS: A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m2 vs. 81.2 mL/min/1.73 m2, p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins. CONCLUSION: In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

The neural correlates of the affective response to unreciprocated cooperation.

Humans excel at reciprocal altruism in which two individuals exchange altruistic acts to their mutual advantage. The evolutionary stability of this system depends on recognition of and discrimination against non-reciprocators, and the human mind is apparently specialized for detecting non-reciprocators. Here we investigate the neural response to non-reciprocation of cooperation by imaging human subjects with fMRI as they play an iterated Prisoner's dilemma game with two assumed human partners. Unreciprocated cooperation was associated with greater activity in bilateral anterior insula, left hippocampus and left lingual gyrus, compared with reciprocated cooperation. These areas were also more responsive to unreciprocated cooperation than to unsuccessful risk taking in a non-social context. Finally, functional connectivity between anterior insula and lateral orbitofrontal cortex (OFC) in response to unreciprocated cooperation predicted subsequent defection. The anterior insula is involved in awareness of visceral, autonomic feedback from the body and, in concert with the lateral orbitofrontal cortex, may be responsible for negative feeling states that bias subsequent social decision making against cooperation with a non-reciprocating partner.

Infrared Light Structured Sensor Three-dimensional Approach to Estimate Kidney Volume: A Validation Study.

OBJECTIVE: To validate a new procedure for the three-dimensional estimation of total renal parenchyma volumeusing a structured-light infrared laser sensor. METHODS: To evaluate the accuracy of the sensor for assessing renal volume, we performed 3 experiments. Twenty freshly excised porcine kidneys were obtained. Experiment A, the water displacement method was used to obtain a determination of the renal parenchyma volume after immersing every kidney into 0.9% saline. Thereafter a structured sensor (Occipital, San Francisco, CA) was used to scan the kidney. Kidney sample surface was presented initially as a mesh and then imported into MeshLab (Visual Computing Lab, Pisa, Italy) software to obtain the surface volume. Experiment B, a partial excision of the kidney with measurement of the excised volume and remnant was performed. Experiment C, a renorrhaphy of the remnant kidney was performed then measured. Bias and limits of agreement (LOA) were determined using the Bland-Altman method. Reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Experiment A, the sensor bias was -1.95mL (LOA: -19.5 to 15.59, R2 = 0.410) with slightly overestimating the volumes. Experiment B, remnant kidney after partial excision and excised kidneyvolume were measured showing a sensor bias of -0.5mL (LOA -5.34 to 4.20, R2= 0.490) and -0.6mL (LOA: -1.97.08 to 0.77, R2 = 0.561), respectively. Experiment C, the sensor bias was -0.89mL (LOA -12.9 to 11.1, R2= 0.888). ICC was 0.9998. CONCLUSION: The sensor is a reliable method for assessing total renal volume with high levels of accuracy.

Single Session of Robotic Human Cadaver Training: The Immediate Impact on Urology Residents in a Teaching Hospital.

INTRODUCTION AND OBJECTIVE: To evaluate the immediate impact of robotic human cadaver training on the confidence with robotic surgery among urology residents. METHODS: After a preliminary survey assessing baseline skills, our institution's urology residents attended a single session of robotic training on fresh-frozen human cadavers, supervised by staff urologists. Post-training, both the residents and the supervisors were administered a survey querying the improvement of robotic skills and the sentiments toward the cadaver laboratory compared with alternative trainings (answers were given by Likert scale: 1 = negative/5 = positive). RESULTS: Twenty-two residents and five supervisors completed the surveys. Median residents' age was 32 years (IQR 29-33). Median year of residency was 4 (IQR 3-6). One hundred percent of the residents were familiar with robotics (86.4% had previous experience as bedside assistant; 90.9% have performed a median of 15 procedures at console). Post-training the residents evaluated their confidence with port placement and docking, EndoWrist® manipulation, Camera and Clutching, Fourth Arm Integration, and Needle Control and Driving with median scores of 4 (IQR 4-5), 4 (IQR 4-5), 4 (IQR 4-5), 4 (IQR 4-4), and 4 (IQR 3-4), with significant perceived improvement in all skills (P < .045). Almost all of them (86.4%) rated the cadaver training 5. When asked about the superiority of human cadaver training with respect to the virtual simulator and the pig laboratory, residents gave median scores of 5 (IQR 5-5) and 4 (IQR 3-5). At univariate analysis, increased experience with robotics was found to be inversely associated with improvement in the "camera and clutching" skill (P < .048). The supervisors felt that human cadaver training was effective in improving the residents' robotic skills (median answer of 5, IQR 4-5). CONCLUSIONS: Human cadaver robotic training demonstrated great acceptability among both the residents and the supervisors. It allowed for immediate improvement of the residents' robotic skills.

Robotic Single-port Partial Prostatectomy for Anterior Tumors: Transvesical Approach.

OBJECTIVE: To evaluate the feasibility of a single-port transvesical robotic approach for anterior partial prostatectomy in a cadaver model. MATERIALS AND METHODS: The cadavers were placed in a lithotomy position and secured to the operating table. A 3-cm midline incision was made in the suprapubic skin fold. After opening the Retzius space, a single-port mini device (GelPOINT, Rancho Margarita, CA) was introduced percutaneously directly into the bladder. The da Vinci Si robotic platform (Intuitive Surgical, Sunnyvale, CA) was docked to the GelPOINT by inserting 2 8-mm (robotic arms) and 1 12-mm (camera) trocar through the GelSeal Cap. The surgical steps for en bloc anterior prostatectomy were performed in the following order: (1) retrograde dissection of transition zone at the bladder neck, (2) lateral excision of the peripheral zone, and (3) urethrovesical anastomosis. Primary outcomes such as intraoperative complications, rate of conversion to standard techniques, and operative times were recorded. RESULTS: Single-port transvesical robotic approach for anterior partial prostatectomy was technically completed in 2 male cadavers. Both cases were completed successfully using the da Vinci Si surgical system without conversion or the need for additional ports. There were no intraoperative complications. The total operative time was 124.1 and 81.3 minutes. Step-specific times are listed in Table 1. CONCLUSION: Transvesical robotic partial prostatectomy is technically feasible using a single-port approach in a preclinical model. Further studies are needed for evaluation on patients with anterior localized prostate cancer. Prospective comparison with standard surgical techniques and focal therapy are warranted. Refinement of this technique may potentially expand the role of single-site surgery in the clinical practice.