Robot-assisted vs ultrasonography-guided transversus abdominis plane (TAP) block vs local anaesthesia in urology: results of the UROTAP randomized trial.

OBJECTIVES: To prospectively analyse robotically administered transperitoneal transversus abdominis plane (robot-assisted transversus abdominis plane [RTAP]) compared with both ultrasonography-guided transversus abdominis plane (UTAP) and local anaesthesia (LA) with regard to pain control and narcotic use in patients undergoing robot-assisted prostatectomy (RARP) or robot-assisted partial nephrectomy (RAPN). SUBJECTS/PATIENTS AND METHODS: Patients undergoing RARP or RAPN were randomized in a single-blind 2:2:1 fashion to RTAP:UTAP:LA, with the study powered to evaluate superiority of UTAP to LA and non-inferiority of RTAP to UTAP. We compared time to deliver the block, operating room time, postoperative pain scores using the visual analogue scale, and intra-operative and postoperative analgesia consumption. RESULTS: A total of 143 patients were randomized and received treatment. There was no significant difference in patient baseline characteristics. UTAP did not demonstrate superiority to LA in terms of pain control. RTAP and LA were faster to administer than UTAP (time to perform block 2.5 vs 2.5 vs 6.25 min; P < 0.001). There was no difference in postoperative narcotic, acetaminophen, ketorolac or ondansetron requirements among the three groups (P > 0.05). The study was terminated early due to the unexpected efficacy of LA. CONCLUSION: This study showed that UTAP and RTAP do not provide superior pain control to LA. The efficiency, effectiveness, and ease of administration of LA make it an excellent option for first-line therapy for postoperative analgesia.

The impact of metabolic syndrome components on urinary parameters and risk of stone formation.

PURPOSE: To investigate the relationship between metabolic syndrome (MS) and urinary abnormalities in stone-forming patients. Additionally, to delineate whether severity of urinary derangements is impacted by the number of co-occurring MS components. METHODS: Stone-forming patients who underwent initial metabolic workup prior to medical intervention at a comprehensive stone clinic were retrospectively reviewed and included in the study. Patients were given a six point (0-5) Metabolic Syndrome Severity Score (MSSS) based on the number of co-occurring MS components and split into six respective groups. Baseline clinical characteristics and metabolic profiles were compared between groups. RESULTS: Four-hundred-ninety-five patients were included in the study. Median age and median BMI was 58 years and 27.26 kg/m2, respectively. Several significant metabolic differences were noted, most notably a downward trend in median urinary pH (p < 0.001) and an upward trend in median urinary supersaturation uric acid (p < 0.001) across groups as MSSS increased. Multivariate analysis demonstrated an independent association between higher MSSS and increasing number of urinary abnormalities. A second multivariate analysis revealed that all MS components except hyperlipidemia were independently associated with low urinary pH. Additionally, obesity was independently associated with the greatest number of urinary abnormalities and had the strongest association with hyperuricosuria. CONCLUSIONS: Prior research has attributed the strong association of nephrolithiasis and MS to high prevalence of UA nephrolithiasis and low urinary pH. Our findings indicate that all MS components with the exception of hyperlipidemia were independently associated with low urinary pH suggesting a mechanism independent from insulin resistance.

Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy?

OBJECTIVE: To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD). PATIENTS AND METHODS: The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24 months, were included in the model for analysis. The median follow-up was 12.0 months (interquartile range 6.7-16.5; range 3.0-24.0 months). RESULTS: In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (ß = -1.20, 95% confidence interval [CI] -5.45, 3.06; P = 0.582) and OC and MAC RPN (ß = -1.57, 95% CI -5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. CONCLUSION: SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.

Addressing microaggressions in racially charged patient-provider interactions: a pilot randomized trial.

BACKGROUND: Racial bias in medical care is a significant public health issue, with increased focus on microaggressions and the quality of patient-provider interactions. Innovations in training interventions are needed to decrease microaggressions and improve provider communication and rapport with patients of color during medical encounters. METHODS: This paper presents a pilot randomized trial of an innovative clinical workshop that employed a theoretical model from social and contextual behavioral sciences. The intervention specifically aimed to decrease providers' likelihood of expressing biases and negative stereotypes when interacting with patients of color in racially charged moments, such as when patients discuss past incidents of discrimination. Workshop exercises were informed by research on the importance of mindfulness and interracial contact involving reciprocal exchanges of vulnerability and responsiveness. Twenty-five medical student and recent graduate participants were randomized to a workshop intervention or no intervention. Outcomes were measured via provider self-report and observed changes in targeted provider behaviors. Specifically, two independent, blind teams of coders assessed provider emotional rapport and responsiveness during simulated interracial patient encounters with standardized Black patients who presented specific racial challenges to participants. RESULTS: Greater improvements in observed emotional rapport and responsiveness (indexing fewer microaggressions), improved self-reported explicit attitudes toward minoritized groups, and improved self-reported working alliance and closeness with the Black standardized patients were observed and reported by intervention participants. CONCLUSIONS: Medical providers may be more likely to exhibit bias with patients of color in specific racially charged moments during medical encounters. This small-sample pilot study suggests that interventions that directly intervene to help providers improve responding in these moments by incorporating mindfulness and interracial contact may be beneficial in reducing racial health disparities.

Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: a propensity-score analysis of patients without impaired renal function.

OBJECTIVES: To assess the benefit of selective arterial clamping (SAC) as an alternative to main renal artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) in patients without underlying chronic kidney disease (CKD). PATIENTS AND METHODS: Our study cohort comprised 665 patients without impaired renal function undergoing MAC (n = 589) or SAC (n = 76) during RAPN from four medical institutions in the period 2008-2015. We compared complication rates, positive surgical margin (PSM) rates, and peri-operative and intermediate-term renal functional outcome between 132 patients undergoing MAC and 66 undergoing SAC after 2-to-1 nearest-neighbour propensity-score matching for age, sex, body mass index, RENAL nephrometry score, tumour size, baseline estimated glomerular filtration rate (eGFR), American Society of Anesthesiologists (ASA) score, Charlson comorbidity index (CCI) and warm ischaemia time (WIT). RESULTS: In propensity-score-matched patients, PSM (5.7 vs 3.0%; P = 0.407) and complication rates (13.8 vs 10.6%; P = 0.727) did not differ between the MAC and SAC groups. The incidence of acute kidney injury for MAC vs SAC (25.0 vs 32.0%; P = 0.315) within the first 30 days was similar. At a median follow-up of 7.5 months, the percentage reduction in eGFR (-9.3 vs -10.4%; P = 0.518) and progression to CKD ≥ stage 3 (7.2 vs 8.5%; P = 0.792) showed no difference. CONCLUSIONS: Our study findings show no difference in PSM rates, complication rates or intermediate-term renal functional outcomes between patients with unimpaired renal function who underwent SAC vs those who underwent MAC. When expected WIT is low, the routine use of SAC may not be necessary. Further studies will need to determine the role of SAC in patients with a solitary kidney or with significantly impaired renal function.

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases.

OBJECTIVE: To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center. METHODS: Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations. RESULTS: A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05). CONCLUSION: Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

A 1.9 mm Trilogy lithotripter in mini percutaneous nephrolithotomy Description of technique and case outcomes.

INTRODUCTION: We aimed to evaluate the novel use of a 1.9 mm Trilogy lithotripter probe with varying locations and composition of renal stones. METHODS: We prospectively enrolled patients to undergo mini percutaneous nephrolithotomy (mPCNL) procedures using the 1.9 mm (instead of the standard 1.5 mm) Trilogy probe from August 2021 to April 2022. Several adjunctive irrigation measures compensated for reduced flow with the larger probe. The primary outcome was treatment efficiency. Patient demographics, preoperative demographics, and comorbidities, as well as real-time surgical data were extracted. Statistical analysis was performed using Kruskal-Wallis tests to compare stone type and location. RESULTS: A total of 110 patients were included in this study. The median total treatment time was 6.8 minutes, median lithotripsy time was 3.3 minutes, median stone treatment efficiency was 0.34 mm/min, and treatment efficacy was 50.4 (lithotripter time/treatment time). Overall median lithotripter efficiency was 104.6 mm3/min. Treatment efficiency was similar among stone composition (p=0.245) and location (p=0.263). Lithotripter 3D and 1D efficiency was also similar among stone composition (p=0.637 and p=0.766, respectively). Lithotripter 1D efficiency was nearly twice as fast in the lower pole compared to other stone locations (p=0.010). The overall broken probe rate for this procedure was 12%, mostly at the beginning, suggesting a learning curve. Five patients had minor complications, including one patient who required admission to the hospital for postoperative pain management. CONCLUSIONS: The 1.9 mm Trilogy lithotripter can be effective in mPCNL procedures with the use of easily implementable adjunctive irrigation techniques, decreasing the gap between lithotripsy time and total treatment time.

Interpersonal complementarity in the mental health intake: a mixed-methods study.

The study examined which socio-demographic differences between clients and providers influenced interpersonal complementarity during an initial intake session; that is, behaviors that facilitate harmonious interactions between client and provider. Complementarity was assessed using blinded ratings of 114 videotaped intake sessions by trained observers. Hierarchical linear models were used to examine how match between client and provider in race/ethnicity, sex, and age were associated with levels of complementarity. A qualitative analysis investigated potential mechanisms that accounted for overall complementarity beyond match by examining client-provider dyads in the top and bottom quartiles of the complementarity measure. Results indicated significant interactions between client's race/ethnicity (Black) and provider's race/ethnicity (Latino) (p = .036) and client's age and provider's age (p = .044) on the Affiliation axis. The qualitative investigation revealed that client-provider interactions in the upper quartile of complementarity were characterized by consistent descriptions between the client and provider of concerns and expectations as well as depictions of what was important during the meeting. Results suggest that differences in social identities, although important, may be overcome by interpersonal variables early in the therapeutic relationship. Implications for both clinical practice and future research are discussed, as are factors relevant to working across cultures.

Is metformin use associated with changes in urinary parameters in stone formers?

INTRODUCTION: Diabetes mellitus (DM) is associated with an increased risk of nephrolithiasis and is often treated with metformin. The relationship between metformin and nephrolithiasis formation remains unclear, as studies have demonstrated conflicting results. METHODS: We conducted a cross-sectional analysis of stone-forming patients at our stone clinic prior to the initiation of stone-directed medical management. Patients were grouped based on diabetic status and diabetic medication regimen. Outcomes evaluated were 24-hour urinary parameters and specimen stone type using univariate Kruskal-Wallis and Chi-squared analyses. Multivariate analyses controlling for metabolic syndrome components and HbA1c were performed. RESULTS: Data were available for 505 patients, of whom 147 were diabetic and 358 were not. On multivariate analyses controlling for HbA1c and other comorbidities, diabetic patients on metformin still had worse urinary parameters, including urine pH, than non-diabetic patients (pH=-0.33, -0.37, p<0.05). Patients with DM on metformin did not exhibit significant differences in 24-hour urine findings compared to patients with DM not on metformin (p>0.05 for all urinary parameters). CONCLUSIONS: Stone-forming patients with DM on metformin were associated with urinary abnormalities similar to those not on metformin. Cohort studies comparing urinary parameters of patients prospectively started on metformin are necessary to further elucidate metformin's role, if any, in combatting nephrolithiasis.

Novel treatment of upper tract urothelial carcinoma in situ with docetaxel in BCG refractory patients.

INTRODUCTION: Patients with upper-tract carcinoma in situ (UT-CIS) that have failed treatment with BCG are recommended for radical nephroureterectomy (RNU). We describe a cohort of patients with BCG-refractory UT-CIS that were treated with docetaxel, a novel agent in the approach to topical therapy. METHODS: Patients with pathologically proven UT-CIS from 2012 to 2020 with an imperative indication for organ preservation and history of BCG-refractory disease were included. Each patient underwent ureteroscopy with biopsy and selective cytology pre- and postinduction, and after each maintenance course. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology, and absence of clinical progression. No response (NR) was defined as persistence of lesions after induction or absence of visualized lesions with persistently positive cytology. RESULTS: Seven patients and 10 renal units were treated. Six of the 10 renal units had initial CR (60%). Three patients with NR went on to have RNU, one of which subsequently died due to cancer-specific mortality. One patient with bilateral disease had NR in 10 renal unit and cure in the other. This patient subsequently developed recurrence in his remaining renal unit. A second patient had CR in both kidneys for 6 years, but 1 year after finishing maintenance regimen developed HG disease in 1 ureter. Average follow-up was 33 months. CONCLUSION: This study demonstrates efficacy of docetaxel as a treatment option for patients with UT-CIS with a contraindication to RNU after failing BCG. Response rates of 60% appear to be similar to those of BCG-refractory bladder CIS.

Extravesical Ectopic Ureteral Calculus Obstruction in a Completely Duplicated Collecting System.

Background: Complete ureteral duplication is uncommon and occasionally associated with ureteral stone obstruction. Even rarer is ectopic insertion of a ureter into the urethra. Case Presentation: We describe a case of a 75-year-old man with a history of robot-assisted laparoscopic prostatectomy and complete unilateral duplicated collecting system with a ureteral stone obstructing an ectopic ureter inserting into the urethra. The stone was effectively treated using ureteroscopy with laser lithotripsy. Conclusion: Ectopic ureters can be located in any of the Wolffian duct structures, and can perhaps be relocated iatrogenically secondary to bladder neck reconstruction during a prostatectomy. This should be kept in mind when performing ureteroscopy on this patient population.

Infected Renal Cyst: Elusive Diagnosis and Percutaneous Management.

Background: Benign renal cysts are relatively common in older adults, usually found incidentally on CT. However, an infected renal cyst is a rare complication. While a course of antibiotic therapy is generally the first-line treatment, indications for definitive operative intervention include chronic pain, recurrent urinary tract infection, hematuria, abscess formation, and/or impaired renal function. Case Presentation: A 61-year-old male urologist with no significant medical history was hospitalized at an outside facility for fever, chills, and abdominal pain. Initial diagnosis was pyelonephritis in the setting of a recently passed stone, with absence of hydronephrosis and a large, simple right renal cyst, but he failed to improve with intravenous antibiotics and developed intractable hiccups. Serial CT scans demonstrated onset of mild upper pole hydronephrosis and no change in the benign-appearing simple cyst. Interventional radiology planned drainage of the upper pole calices with a diagnosis of infundibular stenosis, but upon insistence of a urology consultant who suspected occult infection of the cyst, drains were placed into the collecting system and the cyst, with the return of a jet of purulent fluid upon cyst puncture. Conclusion: The patient subsequently recovered and was discharged and seen at our facility where he was definitively treated with percutaneous endoscopic marsupialization of the cyst into the collecting system and fulguration of the infected cyst wall with complete resolution.

Deceived by a CT Scan: The Case of the Misrepresented Stone Size.

Background: CT has become the gold standard for radiographic evaluation of urolithiasis. CT is highly sensitive for detecting kidney stones and provides valuable information regarding stone size, composition, location, and overall stone burden. Although CT can provide reliable estimations of stone size, we have encountered an instance in which it can be deceiving. Motion artifact in CT images can cause a warping distortion effect that makes renal stones appear larger than they actually are. Case Presentation: We describe a case of a 37-year-old woman with a history of kidney stones and obesity presenting with intermittent flank pain and gross hematuria, found to have a large lower pole renal calculus that appeared deceptively large on CT imaging. Given the apparent size and location of the stone, the patient was counseled and consented for a percutaneous nephrolithotomy (PCNL). Although the stone was initially suspected to be >2 cm based on the preoperative CT scan, intraoperative pyelography revealed a much smaller than expected radio-dense stone. The patient was stone free after PCNL without any immediate postoperative complications. However, her course was later complicated by delayed bleeding causing significant clot hematuria, perinephric hematoma, and reactive pleural effusion. Conclusion: Although CT is especially valuable in preparing for surgery based on its ability to outline collecting system anatomy, it is important to remember that it can be deceiving. Correlation with kidney, ureter, and bladder radiograph and ultrasound is critical to understanding the clinical case and planning the optimal surgical approach.

Ultrasound-Guided Access in a Malrotated Kidney: Optimally Safe and Effective.

Background: Management of renal calculi in a patient with kidney malrotation can be difficult because of complexity and alteration of collecting system anatomy. Pyelolithotomy, whether open, laparoscopic, or robotic, has been shown to be an effective method of stone removal in this patient population; however, it is not always ideal because of its invasiveness and increased morbidity. Ideally, a percutaneous approach may be less invasive, and if feasible, it can optimize patient safety and stone-free status. Case Presentation: Here we present a case of a 68-year-old Caucasian female who presented with 2.7 cm stone in the renal pelvis of a severely malrotated left kidney, which was managed using a combination of fluoroscopy and ultrasound (US)-guided percutaneous nephrolithotomy. Conclusion: US-guided access properly delineates the anatomic complexities of a severely malrotated kidney and permits safe percutaneous management of large stones. This is because fluoroscopic guidance alone may lead to inadvertent adjacent visceral organ trauma and increased risk of parenchymal and intrarenal vascular injury.

A qualitative study of microaggressions against African Americans on predominantly White campuses.

BACKGROUND: Pierce's (The Black seventies: an extending horizon book, 1970) conception of "subtle and stunning" daily racial offenses, or microaggressions, remains salient even 50 years after it was introduced. Microaggressions were defined further by Sue and colleagues (Am Psychol 62:271, 2007), and this construct has found growing utility as the deleterious effects of microaggressions on the health of people of color continues to mount. Microaggressions are common on campuses and contribute to negative social, academic, and mental health outcomes. METHOD: This paper explores how Black college students' experiences correspond to or differ from the microaggression types originally proposed by Sue et al. (Am Psychol 62:271, 2007). Themes were identified from focus group data of students of color (N = 36) from predominately White institutions (PWIs) of higher learning (N = 3) using interpretative phenomenological analysis. RESULTS: We identified 15 categories of racial microaggressions, largely consistent with the original taxonomy of Sue et al. but expanded in several notable ways. New categories in our data and observed by other researchers, included categories termed Connecting via Stereotypes, Exoticization and Eroticization, and Avoidance and Distancing. Lesser studied categories identified included Sue et al.'s Denial of Individual Racism, and new categories termed Reverse Racism Hostility, Connecting via Stereotypes, and Environmental Attacks. DISCUSSION: While previous literature has either embraced the taxonomy developed by Sue and colleagues or proposed a novel taxonomy, this study synthesized the Sue framework in concert with our own focus group findings and the contributions of other researchers. Improving our understanding of microaggressions as they impact people of color may better allow for improved understanding and measurement of this important construct.

The Impact of Obesity in Patients Undergoing Robotic Partial Nephrectomy.

Introduction: As the prevalence of obesity increases worldwide, an increasing proportion of surgical candidates have an elevated body mass index (BMI), with associated metabolic syndrome. Yet there exists limited evidence regarding the effect of elevated BMI on surgical outcomes in robotic surgeries. We examined whether obese patients had worse perioperative outcomes and postoperative renal function after robotic partial nephrectomies (RPNs). Materials and Methods: We performed a multi-institutional analysis of 1770 patients who underwent RPNs between 2008 and 2015, allowing time for the data set to mature. Associations between BMI, as a continuous and categorical variable, and perioperative outcomes, acute kidney injury (AKI, >25% reduction in estimated glomerular filtration rate [eGFR]) at discharge, and change in eGFR per month were analyzed. AKI and eGFR were evaluated using multivariable logistic and linear regression models adjusted for confounders, including age, Charlson comorbidity index, tumor size, and the identity of the surgeon. Results: In total 45.2% (n = 529) of patients were found to be obese, with a greater prevalence of hypertension and diabetes in overweight and obese patients. Obese patients were more likely to have malignant tumors (>77% vs 68%, p < 0.001) and trended toward having larger tumors (3.0 cm vs 2.8 cm; p = 0.061). Heavier patients required longer operative times (166-196 minutes vs 155 minutes; p < 0.001), although equivalent warm ischemia times (p = 0.873). Obesity did not correlate with an increased complication rate (p > 0.05). On multivariable analysis, obesity (odds ratio [OR] = 1.81; p = 0.031), male sex (OR = 1.54; p = 0.028), and larger tumor size (OR = 1.23; p < 0.001) were associated with a significant increase in the likelihood of AKI at discharge. BMI above normal weight was not associated with greater eGFR decline per month post-RPN. Conclusions: Obesity was associated with equivalent perioperative outcomes and long-term renal function. Further research is warranted into how obesity and metabolic syndrome may foster a more aggressive tumor environment. RPN appears to be an equally safe operative option for patients regardless of obesity status.

Reevaluating Warm Ischemia Time as a Predictor of Renal Function Outcomes After Robotic Partial Nephrectomy.

OBJECTIVE: To explore whether variation of warm ischemia time (WIT) is associated with functional and perioperative outcomes following robotic partial nephrectomy (RPN). MATERIALS AND METHODS: Six hundred sixty eight patients, each with 2 kidneys, undergoing RPNs for a cT1 tumor were identified from a U.S. multi-institutional database. The associations between WIT, normal excisional volume loss (EVL), and surgical and renal function outcomes, including acute kidney injury at discharge and percent change in eGFR at up to 24 months post-RPN, were evaluated using Spearman's rank correlation test as well as multivariable models controlling for tumor, surgeon, and patient characteristics. RESULTS: WIT was weakly correlated with EVL (r = 0.32, P < .001), blood loss (r = 0.34, P < .001), and length of stay (r = 0.35, P < .001). WIT was found to be significantly associated with acute kidney injury at discharge (odds ratio = 6.23; confidence interval 1.52, 30.39). Extended WIT was not found to be significantly associated with renal function decline at 1 year post RPN (P > .05). CONCLUSION: Extended WIT is associated with worse perioperative outcomes. While controlling for tumor size and EVL, effects on short-term renal function were still seen after as short as 20 minutes. Efforts to limit warm ischemia time should continue to be implemented during RPN to maximize postoperative renal function.

Is Off Clamp Always Beneficial During Robotic Partial Nephrectomy? A Propensity Score-Matched Comparison of Clamp Technique in Patients with Two Kidneys.

OBJECTIVE: The majority of patients undergoing partial nephrectomy (PN) present with a clinical T1a tumor with both kidneys present. Some groups have advocated using off-clamp (Off-C) techniques to eliminate warm ischemia whenever possible, even when elective. We evaluated whether Off-C technique during robotic PN (RPN) provides any functional benefit over main arterial clamping (MAC) in these patients. Subjects/Patients and Methods: A total of 351 patients with a R.E.N.A.L. nephrometry score (RNS) <10, T1a tumor, and two kidneys who underwent RPN from five high-volume surgeons between 2008 and 2016 were retrospectively identified from a multi-institutional database. MAC and Off-C patients were 2 to 1 nearest neighbor propensity score matched on tumor size, RNS, % endophytic, tumor location, age, gender, body mass index, comorbidities, baseline estimated glomerular filtration rates (eGFRs), and surgeon performing the RPN. Preoperative, surgical, and postoperative outcomes were compared. RESULTS: After propensity score matching, 82 MAC and 41 Off-C RPN patients were compared with no remaining statistically significant differences in baseline demographic or tumor-specific characteristics, including tumor size (p = 0.203) or RNS (p = 0.744). There were no significant differences in complications (p = 0.141), positive surgical margins (p = 0.625), or non-neoplastic parenchymal volume removed (p = 0.138). Off-C RPN had significantly higher estimated blood loss (100 mL vs 50 mL, p < 0.001), but no increased rate of transfusion (p = 0.328). There were no significant differences in rates of acute kidney injury (p = 0.132) nor percentage change in eGFRs (p = 0.763) at discharge. Freedom from progression of chronic kidney disease (CKD) stage was 87.7% for MAC and 91.1% for Off-C at 12 months. The percentage change in eGFRs (p = 0.457) and CKD stage progression (p = 0.866) was not different at last follow-up (median 9.2 months). CONCLUSION: Our data showed that the use of Off-C RPN marginally increased blood loss without providing a renal function benefit. In two-kidney patients presenting with a T1a renal tumor, Off-C RPN may not be necessary.

Predictors of Medical and Surgical Complications After Robot-Assisted Partial Nephrectomy: An Analysis of 1139 Patients in a Multi-Institutional Kidney Cancer Database.

INTRODUCTION: Previous robot-assisted partial nephrectomy (RAPN) studies have identified various predictors of overall and major postoperative complications, but few have evaluated the specific role of these factors in the development of medical and surgical complications. In this study, we present an analysis of the modifiable and nonmodifiable variables influencing medical and surgical complications in a contemporary series of patients who underwent RAPN and were followed in a prospectively maintained, multi-institutional kidney cancer database. METHODS: A retrospective review of all patients who underwent RAPN at four institutions between 2008 and 2015 was performed. Multivariable logistic regression models were used to determine predictors of medical and surgical postoperative complications. RESULTS: Data from 1139 patients were available for analysis. Sixty-seven patients (5.8%) experienced a medical postoperative complication, and 82 (7.1%) experienced a surgical complication. Decreasing baseline estimated glomerular filtration rate (eGFR) (odds ratio [OR] = 0.98, p = 0.003), greater estimated blood loss (EBL) (OR = 1.002, p = 0.001), and operating surgeon (OR = 8.01, p < 0.001) were associated with an increased likelihood of surgical complications, while decreasing baseline eGFR (OR = 0.99, p = 0.054) and operating surgeon (OR = 1.96, p = 0.054) were associated with an increased likelihood of medical complications. CONCLUSION: We present complication risks in a large contemporary cohort of patients undergoing robotic partial nephrectomy (RPN) with only 11.3% of patients experiencing a medical or surgical postoperative complication. Prospective candidates for robotic PN with poor baseline renal function and/or risk factors for greater EBL, including a high body mass index, or a complex renal mass should be counseled appropriately on their increased risk for a medical or surgical postoperative complication.

The impact of computer use on therapeutic alliance and continuance in care during the mental health intake.

Advances in information technology within clinical practice have rapidly expanded over recent years. Despite the documented benefits of using electronic health records, which often necessitate computer use during the clinical encounter, little is known about the impact of computer use during the mental health visit and its effect on the quality of the therapeutic alliance. We investigated the association between computer use and quality of the working alliance and continuance in care in 104 naturalistic mental health intake sessions. Data were collected from 8 safety-net outpatient clinics in the Northeast offering mental health services to a diverse client population. All intakes were video recorded. Use of computer during the intake session was ascertained directly from the recording of the session (n = 22; 22.15% of intakes). Working alliance was assessed from the session videotapes by independent reliable coders, using the Working Alliance Inventory, Observer Form-bond scale. Therapist computer use was significantly associated with the quality of the observer-rated therapeutic alliance (Coefficient = -6.29, SE = 2.2, p < .01; Cohen's effect size of d = -0.76), and client's continuance in care (Odds ratio = .11, CI = 0.03-0.38; p < .001). The quality of the observer-rated working alliance and client's continuance in care were significantly lower in intakes in which the therapist used a computer during the session. Findings indicate a cautionary call in advancing computer use within the mental health intake, and demonstrate the need for future research to identify the specific behaviors that promote or hinder a strong working alliance within the context of psychotherapy in the technological era.