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The objective of this study is to analyze the association between surgical day of the week and distance traveled with prolonged length of stay (LOS) following robotic-assisted partial nephrectomy (RAPN). 563 consecutive RAPN performed by a single surgeon were evaluated. Early week RAPN was considered Monday through Wednesday, while late-week RAPN was defined as surgery performed Thursday through Friday. Distance traveled for RAPN was evaluated as greater than or less than 60 miles. The respective groups were compared to see if the surgical day of the week or distance traveled influenced the hospital stay or prolonged hospital stay (defined as hospital length of stay equal or greater than 3 days). Overall, 213 patients (38.0%) undergoing RAPN experienced a prolonged LOS. A total of 380 patients underwent early week RAPN compared to 183 late-week RAPN. Patients undergoing late-week RAPN were more likely to have a prolonged LOS compared to early week RAPN (n = 81, 44% vs. n = 133, 35%, respectively; p = 0.004). 229 patients traveled less than 60 miles, while 332 patients traveled more than 60 miles to receive RAPN. 135 patients (40.7%) traveling more than 60 miles experienced a prolonged stay compared to 78 patients (34.1%) traveling less than 60 miles, although this difference was not statistically significant (p = 0.128). Patients who underwent RAPN at the end of the week were more likely to have a prolonged LOS, while distance traveled for RAPN did not appear to affect likelihood of prolonged LOS.
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Tempo de Internação , Nefrectomia , Procedimentos Cirúrgicos Robóticos , Centros de Atenção Terciária , Humanos , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Feminino , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Idoso , Neoplasias Renais/cirurgia , Estudos RetrospectivosRESUMO
OBJECTIVE: To evaluate the effect of disposable cystoscopes on the rate of symptomatic urinary tract infections (UTI) following post-renal transplant cystoscopic stent removal. METHODS: We performed a retrospective study of post-renal transplant cystoscopic stent removals in our outpatient clinic from March 2019 to March 2022. Our clinic converted to disposable cystoscopes in October 2021. All outpatient, phone, and portal encounters were reviewed for 30 days following the procedure. The primary outcome was the number of post-procedural symptomatic UTI within 30 days of the procedure. Symptomatic UTI was defined as fever, dysuria, or hematuria accompanied by a positive urine culture. RESULTS: A total of 323 patients had post-transplant stent removals including 123 with reusable scopes and 200 with disposable scopes. Around 1.6% (2/123) of patients with a reusable cystoscope experienced symptomatic UTI's. They had positive urine cultures for Escherichia coli and Klebsiella. 2.0% (4/200) of patients with a disposable cystoscopy had a symptomatic UTI. The 3 types of positive urine cultures they experienced were E Coli, Klebsiella, and Enterococcus. CONCLUSION: The conversion from reusable to disposable cystoscopes did not decrease symptomatic UTI following renal transplant stent removal.
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Objectives: To compare racial differences and pelvis dimensions between Caucasians and African Americans (AAs) and to develop a risk calculator and scoring system to predict the risk of prolonged operative time and presence of positive surgical margins (PSM) based on these dimensions. Materials and Methods: A retrospective review of 88 consecutive patients undergoing robot-assisted laparoscopic prostatectomy with a preoperative prostate MRI conducted. Data extraction included demographic, perioperative, and postoperative oncologic outcomes. Prostate-specific antigen (PSA) was obtained within 3 months postsurgery. Wilcoxon rank sum and Fisher's exact tests were used to compare continuous and categorical data, respectively. Single and multivariable regression analysis were used to determine contribution of each factor to the composite outcomes. A risk score was created based on this analysis for predicting the composite outcome. Results: We identified 88 consecutive patients with localized prostate cancer that underwent a preoperative prostate MRI. No statistically significant differences were found with respect to age, body mass index, or any postoperative outcome. PSA was lower at diagnosis (6.49 vs 9.72, p = 0.006) and operative times were shorter in Caucasians. Rates of PSM (13 vs 14, p = 0.35), biochemical recurrence (4 vs 2, p = 0.69), and complications did not vary between the groups. Caucasians had wider/shallower pelvis dimensions. Based on these variables, we found that the log (odds of OR time >3 hours or PSM) = -5.333 + 1.158 (if AA) +0.105 × PSA +0.076 × F -0.035 × G with an area under the receiver operating characteristic curve = 0.73. Using the predefined variables, patients can be risk stratified for PSM or prolonged operative times. Conclusions: Several pelvis dimensions were found to be shorter/narrower in AAs and were associated with longer operative times. The presented risk calculator and stratification system may be used to predict prolonged operative time or having PSM.
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Neoplasias da Próstata , Procedimentos Cirúrgicos Robóticos , Robótica , Masculino , Humanos , Próstata/diagnóstico por imagem , Próstata/cirurgia , Antígeno Prostático Específico , Duração da Cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Margens de Excisão , Prostatectomia/métodos , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Fatores de RiscoRESUMO
OBJECTIVE: To report the impact of resection base inner layer renorrhaphy suture type on renal artery pseudoaneurysm (RAP) rate following robotic-assisted partial nephrectomy (RAPN). METHODS: Five hundred and sixty-three consecutive RAPNs performed by a single surgeon were retrospectively reviewed. Patients were classified into 3 categories: (1) No base suture, (2) monofilament barbed suture (2-0 V-Loc 180 absorbable suture, Medtronic, Minneapolis, MN), (3) polyglactin 910 (2-0 Vicryl coated suture, Ethicon Inc, Cincinnati, OH). In a secondary analysis, we evaluated suturing (Vicryl and V-Loc) vs no base suture. All patients had outer cortical renorrhaphy performed with 0-Vicryl suture utilizing the standard sliding clip technique. RESULTS: One hundred ten patients (19.5%) had V-Loc suturing, 255 patients (45.3%) had Vicryl suturing, and 198 patients (35.2%) had no base suture. Patients had a median age of 62.8years (interquartile range: 53.5-69.7) and median RENAL score was 8 (6-9). Median mass size from preoperative imaging was 3.0â¯cm (2.5-4.0) for V-Loc, 3.3â¯cm (2.5-4.2) for Vicryl, and 2.0â¯cm (1.8-3.0) for no base suture (Pâ¯<â¯.001). Overall, 21 patients (3.7%) developed a symptomatic postoperative RAP. The rate of RAP was 3.6% (4/110) for V-Loc, 3.9% (10/255) for 2-0 Vicryl, and 3.5% (7/198) for no base suture (Pâ¯=â¯1.00). Similarly, the rate of RAP was 3.5% (7/198) for no base suture and 3.8% (14/365) for base suture (Pâ¯=â¯1.00). CONCLUSION: Utilization of base suture and type of base suture used during RAPN was not predictive of postoperative RAP development.
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Falso Aneurisma , Procedimentos Cirúrgicos Robóticos , Humanos , Pessoa de Meia-Idade , Artéria Renal/cirurgia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Poliglactina 910 , Estudos Retrospectivos , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Suturas/efeitos adversos , Técnicas de Sutura/efeitos adversosRESUMO
INTRODUCTION: We evaluated for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable vs reusable cystoscopes. METHODS: Cystoscopies performed from June to September 2020 and from February to May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes, and the 2021 cystoscopies were performed with disposable cystoscopes. The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations, or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome. RESULTS: We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer (disposable: 153 [30.2%] and reusable: 143 [28.9%]). Reusable cystoscopes were associated with a higher number of 30-day encounters (35 [7.1%] vs 11 [2.2%], P < .001), urine cultures (73 [14.8%] vs 3 [0.6%], P = .005), and hospitalizations attributable to cystoscopy (1 [0.2%] vs 0 [0%], P < .001) than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope (17 [3.4%] vs 1 [0.2%], P < .001). CONCLUSIONS: Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.
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Cistoscópios , Infecções Urinárias , Humanos , Estudos Retrospectivos , Cistoscopia/métodos , Pacientes Ambulatoriais , Infecções Urinárias/diagnósticoRESUMO
OBJECTIVE: To analyze the contribution of nonprocedural operating room (OR) times to transurethral resection of bladder tumor (TURBT) operative efficiency. METHODS: Over a 24-month period, all nonprocedural OR times from TURBT surgeries performed at a single institution were prospectively collected. Nonprocedural times included: in-room to anesthesia release time, anesthesia release to cut time, and close to wheels out time. Procedural OR time was cut to close time. We also analyzed the impact of time of day on TURBT efficiency (morning vs afternoon). Comparisons between groups were made using the Wilcoxon rank sum test for continuous variables. RESULTS: We identified 777 consecutive TURBT procedures from 2019 to 2020. The median total OR time was 63 minutes (interquartile range: 50-81 minutes). The nonprocedural time occupied a median of 49.4% of the total operating time (interquartile range: 38.9%-60.4%). Median anesthesia release to cut time was slower when 1 TURBT was performed a day compared to 2 or more (13 minutes vs 12 minutes, P = .04). Median close to wheels out time was faster when there was 1 TURBT in a day (7 minutes vs 8 minutes, P = .02). Median in-room to anesthesia release time was faster in the morning than it was in the afternoon (10 minutes vs 11 minutes, P = .02). CONCLUSION: Nonprocedural times made up roughly half of the total TURBT operating time and should be considered in OR efficiency analyses. TURBT OR efficiency may be related to the number of TURBTs performed in a day as well as the time of day of TURBT start.
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Salas Cirúrgicas , Neoplasias da Bexiga Urinária , Humanos , Ressecção Transuretral de Bexiga , Neoplasias da Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/patologia , Cistectomia/métodos , Fatores de TempoRESUMO
To analyze operating room (OR) efficiency by evaluating fixed and variable OR times for open (OPN) and robotic-assisted partial nephrectomies (RAPN). We analyzed consecutive OPN and RAPN performed by one surgeon over a 24-month period. All patients were placed in the lateral decubitus position and secured with a beanbag regardless of approach. Fixed (non-procedural) OR times were prospectively collected and defined as: in-room to anesthesia-release time (IRAT), anesthesia release to cut time (ARCT), and close to wheels-out time (CTWO). Variable OR time was procedural cut to close time (CTCT). Comparisons of fixed and variable OR time points between OPN and RAPN were performed using the Wilcoxon rank-sum test. 146 RAPN and 31 OPN were evaluated from 2019-2020. Median IRAT was similar for RAPN versus OPN [20 min (IQR: 16-25) vs. 20 min (IQR: 16-26), P = 0.57]. Median ARCT was longer for RAPN than it was for OPN [40 min (IQR: 36-46) vs. 34 min (IQR: 30-39), P < 0.001]. Median CTWO was similar for OPN (12 min, IQR: 9-14) and RAPN (11 min, IQR: 7-15) (P = 0.89). Median CTCT was longer for RAPN (202 min, IQR: 170-236) compared to OPN (164 min, IQR: 154-184) (P < 0.001). In a single surgeon, partial nephrectomy series with the same patient positioning, utilization of robotic technology was associated with longer surgeon operating time as well as less efficient fixed OR times, specifically ARCT.
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Neoplasias Renais , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias Renais/cirurgia , Salas Cirúrgicas , Resultado do Tratamento , Nefrectomia , Estudos RetrospectivosRESUMO
BACKGROUND: Hyperactive parathyroid glands (PTGs) are in the mediastinum 4.3% of the time. Historically, localization and resection of these glands can be challenging. METHODS: We searched all operative notes involving a thoracic surgeon and a preoperative diagnosis of hyperparathyroidism from 2001 to 2019. RESULTS: Eighty-five cases were reviewed, of which 63 were included. Only 14 patients (22%) had de novo hyperparathyroid operations. Seventeen patients (27%) had single-photon emission computed tomography with computed tomography fusion (SPECT-CT) as the only preoperative localization test (excluding chest radiography and ultrasound), and all were resected successfully. The initial surgical approach was transcervical for 16 (27%) patients, however only 7 remained transcervical. 4 (6%) patients had an exploration in which the target lesion was resected but it was not parathyroid tissue. CONCLUSION: Most patients presenting with mediastinal PTG have had prior HPT surgery. The trend toward more focused HPT surgery may mean more de novo mediastinal PTG resections. An unambiguous functional and anatomic localization test, such as a spect-ct scan, is the best predictor of a successful resection. Ambiguous or discordant scans should be approached cautiously, and additional confirmatory tests are recommended. For suspected PTG located in the thymus, the thoracic surgeon should choose the most familiar approach to achieve complete thymectomy.
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Glândulas Paratireoides , Humanos , Glândulas Paratireoides/diagnóstico por imagem , Glândulas Paratireoides/cirurgiaRESUMO
BK virus cystitis is known to occur following hematopoietic stem cell transplant (HSCT), but few cases exist in the literature following lung transplant. Because of the rarity of this presentation, patients may have missed diagnoses and prescribed ineffective treatments. We present our case of an atypical presentation of BK virus cystitis appearing as bladder carcinoma in situ in a lung transplant patient.
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OBJECTIVE: To validate a new baseline estimated glomerular filtration rate (NB-GFR) formula in a cohort of robotic-assisted partial nephrectomies (RAPN). METHODS: NB-GFR = 35 + preoperative GFR (× 0.65) - 18 (if radical nephrectomy) - age (× 0.25) + 3 (if tumor size >7 cm) - 2 (if diabetes). NB-GFR was calculated in 464 consecutive RAPN from a single surgeon cohort. 143 patients were excluded secondary to insufficient eGFR follow up. We analyzed NB-GFR accuracy utilizing the last observed eGFR 3-12 months post RAPN. Categorical variables were summarized with the frequency and percentage of patients. Numerical variables were summarized with the median, 25th percentile, and 75th percentile. RESULTS: The mean difference between observed and predicted NB-GFR was 4.6 ml/min/1.73m2 (95% CI -6.9 to 16.1 ml/min/1.73m2 ). There was a pattern of higher observed NB-GFRs being underestimated by the NB-GFR equation while lower observed NB-GFRs were overestimated by the NB-GFR equation. The NB-GFR formula had a high level of accuracy with 98.8% of predicted NB-GFRs falling within 30% of the observed NB-GFR (95% CI 86.8% to 99.5%). The median and interquartile range of the difference between observed and predicted NB-GFR was 3.9 ml/min/1.73m2 (IQR 0.7 to 8.2 ml/min/1.73m2 ). The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of predicted NB-GFR to identify those with an observed NB-GFR <60 ml/min/1.73m2 after RAPN was 98%, 92%, 88%, and 99%, respectively. CONCLUSION: The NB-GFR equation developed with partial and radical nephrectomy cohorts is accurate in predicting post-operative eGFR 3-12 months following RAPN.
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Neoplasias Renais , Procedimentos Cirúrgicos Robóticos , Humanos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Neoplasias Renais/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Nefrectomia/efeitos adversos , Taxa de Filtração Glomerular , Rim/diagnóstico por imagem , Rim/cirurgia , Rim/fisiologiaRESUMO
OBJECTIVE: To evaluate factors influencing fixed operating room time during holmium laser enucleation of the prostate. MATERIALS AND METHODS: A prospective observational study was performed for all holmium laser enucleation of the prostate (HoLEP) cases performed by a single surgeon over a 24-month period. Operating room (OR) time was divided into fixed and variable time. The variable time was defined as cut-to-close time. Fixed time included in room time to anesthesia release time (IRAT), anesthesia release time to cut time (ARCT), and close time to wheels out (CTWO). The effects of time of day and anesthesia personnel (AP) changes on fixed operating room time were evaluated. RESULTS: A total of 406 HoLEPs were analyzed. There was no statistically significant difference in nonprocedural OR times between morning and afternoon surgeries (IRAT, P = .38, ARCT P = .10, CTWO P = .77). Median nonprocedural OR times accounted for 27% (IQR: 22%-31%) of the total procedure time in the AM group and 29% (IQR: 24%-33%) in the PM group (P = .005). Of the HoLEPs,78.1% (178/228) experienced one or more AP changes during the procedure. The median fixed OR time was not significantly different between procedures with 1 AP and procedures with ≥2 APs (IRAT, P = .53; ARCT, P = .71; CTWO, P = .98). CONCLUSION: Fixed operating room time makes up a significant portion of HoLEP procedures and should be considered when evaluating OR efficiency. The time of day and number of anesthesia personnel involved did not affect the fixed OR times.
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Terapia a Laser , Lasers de Estado Sólido , Hiperplasia Prostática , Ressecção Transuretral da Próstata , Humanos , Masculino , Lasers de Estado Sólido/uso terapêutico , Próstata/cirurgia , Hiperplasia Prostática/cirurgia , Salas Cirúrgicas , Ressecção Transuretral da Próstata/métodos , Terapia a Laser/métodos , Hólmio , Resultado do Tratamento , Estudos RetrospectivosRESUMO
Objective: To evaluate the impact of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, on operating room (OR) efficiency for urologic procedures using the concept of fixed OR times. Patients and Methods: Over a 24-month period, urology OR data were prospectively collected. Operations were divided into fixed and variable time points. The fixed OR times were in-roomw to anesthesia-release time, anesthesia-release to cut time, in-room to cut time, and close to wheels-out time. Data from January 1, 2019, to December 31, 2019, were pre-COVID-19 data, and data from April 1, 2020, to December 31, 2020, were post-COVID-19 data. Operations were grouped into endoscopic, implant, major open, and robotic-assisted cases. In the post-COVID-19 era, all patients had a negative polymerase chain reaction test result within 48 hours of operation. The Wilcoxon rank sum test was used to compare the fixed OR times between the pre- and post-COVID-19 eras. Results: A total of 3189 procedures were evaluated: 2058 endoscopic operations (1124 in the pre-COVID-19 era and 934 in the post-COVID-19 era), 343 implant procedures (192 in the pre-COVID-19 era and 151 in the post-COVID-19 era), 222 major open procedures (119 in the pre-COVID-19 era and 103 in the post-COVID-19 era), and 566 robotic-assisted procedures (338 in the pre-COVID-19 era and 228 in the post-COVID-19 era). There were no fixed OR times in any of the examined groups that were negatively impacted by COVID-19. The percentage of the total OR time occupied by fixed OR variables in the pre-COVID-19 era was 40.6% for endoscopic operations, 41.1% for implant procedures, 29.8% for major open procedures, and 21.8% for robotic-assisted procedures. Conclusion: A substantial portion of the total OR time includes fixed time points. Furthermore, COVID-19 did not have a negative impact on fixed OR times in a negative testing environment. Urologic OR efficiency should be maintained in the post-COVID-19 era.
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Bladder leiomyomas are rare, benign tumors with a variety of clinical presentations. Surgical approach is typically based on symptomatology and leiomyoma location. Literature on robotic excision is limited. We present our case of a unique transvesical approach. The patient had rapid convalescence with no complications, suggesting robotic transvesical excision is a safe, effective treatment for bladder leiomyoma for suitable candidates.
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Objective: To analyze operating room (OR) efficiency by evaluating fixed OR times for three common urologic robot-assisted procedures. Methods: Over a 24-month period, we prospectively collected intraoperative data for 635 consecutive robot-assisted surgeries. Fixed (nonprocedural) OR times were evaluated for robot-assisted partial nephrectomy (RAPN) (n = 146), robot-assisted radical cystectomy (RARC) (n = 77), and robot-assisted radical prostatectomy (RARP) (n = 412). Fixed OR times were defined as nonprocedural time in the OR, including in-room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in-room time to cut time (IRCT; IRAT+ARCT), and close time to wheels out time (CTWO). The effects of operation time of day and the number of anesthesia personnel (AP) present in procedure on fixed OR times were also analyzed. Results: Fixed OR times occupied 15.1% (IQR: 12.9%-17.1%) (RARC), 26.6% (22.9%-30.8%) (RAPN), and 20.1% (17.4%-23.1%) (RARP) of total OR time. Time of day did not have a negative effect on fixed OR times for robotic urologic surgeries. Median AP count was highest for RARC (median: 3 and range: 1-7). We did not find any association between AP count and fixed OR times for any of the procedures (p ≥ 0.19). Conclusions: Fixed OR times made up a significant percentage of total OR time for robot-assisted procedures and should be incorporated into OR efficiency analyses. The number of AP per case and time of day of procedure did not negatively impact fixed OR times in urologic robotic surgeries.
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Procedimentos Cirúrgicos Robóticos , Robótica , Cistectomia/métodos , Humanos , Masculino , Salas Cirúrgicas , Duração da Cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate predictors of abnormal routine postoperative day 1 (POD1) labs in patients with normal pre-operative renal function following robotic assisted partial nephrectomy (RAPN) and the associated clinical outcomes of these lab results. METHODS: We analyzed 500 consecutive RAPN from a single surgeon series. Patients with chronic kidney disease (CKD) III or greater were excluded from the study. Three hundred ninty-three RAPN were included in the analysis. Routine POD1 lab tests including hemoglobin (Hgb), creatinine, potassium, and sodium were evaluated to determine rates of abnormal values and rates of clinical intervention. Abnormal Hgb at POD1 was defined as <8 g/dL or ≥3 g/dL decrease from the preoperative (baseline) value. Abnormal sodium (Na) preoperatively and postoperatively was defined as <135 mEq/L or >145 mEq/L. Abnormal potassium (K) was defined preoperatively and POD1 as <3.5 mEq/L or >5 mEq/L. RESULTS: Of 37.4% (147/393) had one or more abnormal labs at POD1. Of the 101 patients with abnormal Hgb, 15 patients required blood transfusion. Twenty-six patients had abnormal sodium for which two were treated with IV fluids. Twenty-seven patients had potassium abnormalities (12/25 were hypokalemia). Acute kidney injury stage I was seen in 27 patients (6.9%) and stage II in 3 (0.8%). Patients with abnormal labs were more likely to have larger renal mass, higher R.E.N.A.L. scores, intraoperative complications, longer operative times, and higher EBL on multivariate analysis. CONCLUSION: POD1 serum laboratory tests appear to be necessary following RAPN in patients with normal pre-operative renal function.
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Neoplasias Renais , Procedimentos Cirúrgicos Robóticos , Feminino , Humanos , Rim/fisiologia , Rim/cirurgia , Neoplasias Renais/complicações , Masculino , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Potássio , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , SódioRESUMO
OBJECTIVE: To evaluate perioperative outcomes of resident trainee involvement in tumor resection and renorrhaphy during robotic assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: We analyzed 500 consecutive RAPN in a single surgeon prospectively maintained database. Cases with resident performed tumor resection and renorrhaphy (N = 71) were case matched on R.E.N.A.L. score and RAPN year using a greedy matching algorithm. Perioperative variables were compared to attending cases. RESULTS: There were no statistically significant differences in high grade postoperative complications (resident: 3% vs attending: 6%, P = .68), positive margins (resident: 1% vs attending: 3%, P = .31), length of stay (resident: 2.0 vs attending: 2.0 days, P = .73), and 30 day readmission (resident: 7% vs attending: 11%, P = .56). However, residents had a statistically significant longer warm ischemia time (median 21 vs 15 minutes, P <.001), thus less likely to achieve trifecta (66% vs 85%, P = .02). Resident involvement had longer median operative time (197 vs 184 minutes, P = .03). No statistically significant difference in functional volume loss (P = .12) or surface intermediate base margin score (P = .66) between residents and attending was found. No difference in post-operative creatinine change was found at 1 day and 1 month (resident: 0.2 vs attending: 0.1 mg/dL, P = .4 and resident: 0.1 vs attending: 0.1 mg/dL, P = .6, respectively). CONCLUSION: Supervised resident console involvement in tumor resection and renorrhaphy during RAPN is safe and does not increase rates of complications. Residents have longer median warm ischemia time compared to attending only cases, but this does not appear to impact post-operative renal function.
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Internato e Residência/estatística & dados numéricos , Neoplasias Renais/cirurgia , Corpo Clínico Hospitalar/estatística & dados numéricos , Nefrectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Técnicas de Sutura/educação , Idoso , Creatinina/sangue , Feminino , Humanos , Rim/fisiopatologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Neoplasia Residual , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Duração da Cirurgia , Readmissão do Paciente , Período Perioperatório , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Técnicas de Sutura/efeitos adversos , Isquemia QuenteRESUMO
OBJECTIVE: To present our experience with three patients surgically treated for suspected recurrent renal cell carcinoma whose final pathology was consistent with tumefactive fat necrosis. METHODS: Three patients underwent definitive therapy for biopsy proven renal cell carcinoma (cryoablation, partial nephrectomy, and nephrectomy) and later demonstrated evidence of recurrent renal cell carcinoma on follow up imaging. All three patients underwent surgical resection of the suspected recurrences with final pathology consistent with tumefactive fat necrosis. RESULTS: The three patients were 60, 74, and 39-years old, respectively. The previous definitive therapies for renal cell carcinoma were percutaneous ablation, RAPN, and nephrectomy. Each patient had previous surgical pathology that confirmed prior renal cell carcinoma. Signs of recurrence on diagnostic imaging occurred 2 years, 23 months, and 8 months post-definitive therapy. CONCLUSION: In patients with a history of renal cell carcinoma, consideration of fat necrosis should be taken into account upon seeing imaging concerning for tumor recurrence. Continued analysis of cases with such a diagnosis will be beneficial in recognizing this possibility to avoid unnecessary surgery or therapy when possible.
Assuntos
Carcinoma de Células Renais , Necrose Gordurosa , Neoplasias Renais , Recidiva Local de Neoplasia/diagnóstico , Complicações Pós-Operatórias , Adulto , Idoso , Biópsia/métodos , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/cirurgia , Criocirurgia/efeitos adversos , Criocirurgia/métodos , Diagnóstico Diferencial , Necrose Gordurosa/diagnóstico por imagem , Necrose Gordurosa/etiologia , Necrose Gordurosa/cirurgia , Feminino , Humanos , Neoplasias Renais/patologia , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Nefrectomia/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Reoperação/métodos , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoRESUMO
Background: To evaluate robotic-assisted partial nephrectomy (RAPN) renal outcomes associated with ancillary pathology findings in non-neoplastic renal parenchymal tissue. Methods: Tissue samples from 378 RAPNs were analyzed for glomerular disease (GD), vascular disease (VD), and tubulointerstitial disease (TD). One hundred and fifty-two patients were excluded due to insufficient non-neoplastic tissue for analysis and 4 patients were excluded due to calyceal diverticulum. Non-neoplastic tissue was evaluated for GD (negative, moderate, or global), VD (absent, mild, moderate, or severe), and TD (present or absent). Associations of ancillary pathology factors with patient characteristics were explored using the non-parametric Kendall tau-test and propensity score adjusted longitudinal mixed effects regression models were used to evaluate associations of these pathology factors with changes in estimated glomerular filtration rate (eGFR) following RAPN. Results: One hundred and fifty-three (68.9%) patients had hypertension and 50 (22.5%) patients had diabetes. The majority of patients did not have any GD (N = 158, 71.2%) or TD (N = 186, 83.8%) while 129 (58.1%) had VD. VD was categorized as absent (N = 93, 41.9%), mild (N = 45, 20.3%), moderate (N = 76, 34.2%), and severe (N = 8, 6.8%). Older age (P = 0.018), hypertension (P < 0.001), and high grade MAP score (P = 0.047) were associated with a higher number of ancillary pathology factors. High grade MAP score (P = 0.03, P = 0.002) and hypertension (P = 0.02, P < 0.001) were individually associated with GD severity and VD severity, respectively. Older age was also individually associated with VD severity (P = 0.002) and hypertension was associated with TD (P = 0.04). Moderate-to-severe VD was associated with a worse change in eGFR from pre-RAPN to 1-month post-RAPN compared to those with mild or no VD (difference in mean change, -3.4 ml/kg/1.73m2; 95% CI, -6.6 to -0.2 ml/kg/1.73m2; P = 0.036). Conclusions: Moderate-to-severe VD in non-neoplastic renal parenchyma is associated with post-operative changes in eGFR. Older age, hypertension, and high grade MAP scores are associated with the number of ancillary pathologies observed in RAPN specimens.