Complications after robotic partial nephrectomy at centers of excellence: multi-institutional analysis of 450 cases.

PURPOSE: We evaluated the incidence of perioperative complications after robotic partial nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system. RESULTS: A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths. CONCLUSIONS: Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively.

Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases.

BACKGROUND: Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon. OBJECTIVE: We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions. MEASUREMENTS: Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded. RESULTS AND LIMITATIONS: Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p=0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3±7.4 min vs 19.6±10.0 min; p=<0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons' prior robotic experience. CONCLUSIONS: The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.

Pyospermia in an adult cohort with persistent lower urinary tract symptoms and a history of ablated posterior urethral valve.

PURPOSE: To assess for the presence of lower urinary tract symptoms and abnormal semen parameters in adults with a history of PUV. MATERIALS AND METHODS: The study involved 29 male patients, aged 17-51 (mean 21.5 years), with a history of PUV. Ten had more severe symptoms of frequency, urgency and enuresis, and agreed to detailed study. Medical history, urine analysis, ultrasonography and voiding cystourethrogram were completed for all. Magnetic resonance imaging of the bladder, prostate, seminal vesicles and ejaculatory ducts, ultrasonography of the prostate, as well as semen analysis and culture, and measurement of serum levels of follicle-stimulating hormone, luteinizing hormone and testosterone were performed on the 10/29 patients with severe symptoms. RESULTS: Of the 8/10 patients who provided acceptable semen culture data, 88% (7/8) showed significant bacterial growth and pyospermia. On semen analysis, 3/8 patients had profound decreases in sperm count, 6/8 < 50% motility and 4/8 ≤ 30% normal forms. pH range for semen was 7.2-7.8 (mean 7.45). For all 10 patients, follicle-stimulating and luteinizing hormone values were within normal range. Elongation of the prostate was the only radiologic variant of the sex accessory structures. CONCLUSION: A significant finding of pyospermia and bacterial growth in semen culture is reported in a subpopulation of young men with a history of PUV and severe lower urinary tract symptoms. This may have an impact on fertility.

Trends in renal tumor surgery delivery within the United States.

BACKGROUND: Most small renal tumors are amenable to partial nephrectomy (PN). Studies have documented the association of radical nephrectomy (RN) with an increased risk of comorbid conditions, such as chronic kidney disease. Despite evidence of equivalent oncologic outcomes, PN remains under used within the United States. In this study, the authors identified the most recent trends in kidney surgery for small renal tumors and determined which factors were associated with the use of PN versus RN within the United States. METHODS: A population-based patient cohort was analyzed using the Surveillance, Epidemiology and End Results cancer registry (SEER 1999-2006). The authors identified 18,330 patients ages 40 to 90 years who underwent surgery for kidney tumors

Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes.

PURPOSE: Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. MATERIALS AND METHODS: We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. RESULTS: The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). CONCLUSIONS: Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

Outcome of valve ablation in late-presenting posterior urethral valves.

OBJECTIVE: To explore the symptoms, radiological findings and outcome after valve ablation in patients who present late with posterior urethral valves (PUV) and who typically have mild forms of the disease with often minimal upper tract changes; these patients frequently escape detection by ultrasonography in utero and the diagnosis may be delayed to as late as adolescence. PATIENTS AND METHODS: The charts of 70 boys (mean age 7.46 years, range 2-14) diagnosed late with PUV and treated with value ablation were retrospectively reviewed. Before ablation, history of voiding habits, voiding frequency, presence of enuresis, dysuria and the incidence of gross haematuria was recorded. Findings of a physical examination, laboratory testing (urine analysis and serum creatinine levels), ultrasonography and voiding cysto-urethrography (VCUG) were noted. After valve ablation, a review included a detailed voiding history and re-examination of abnormal variables including an assessment of enuresis, voiding frequency and ultrasonography. The mean (range) follow-up was 25 (1-78) months. One patient was lost after his first follow-up visit, but data were included to that time. RESULTS: The most common presenting symptom was voiding dysfunction; 47 (67%) presented with nocturnal enuresis, 42 (60%) with urinary frequency and 12 (17%) with a history of urinary tract infection. On physical examination 12 (17%) had mild age-corrected hypertension. Microhaematuria was present in 21 (30%) but all patients had normal serum creatinine levels. Ultrasonography showed hydronephrosis in 33 (47%) and a postvoid residual volume in 57 (81%). On VCUG, 52 (79%) patients had clear evidence of PUV, 22 (31%) bladder trabeculation, 11 (16%) vesico-ureteric reflux and eight (11%) diverticula. On cystoscopy, 67 (96%) patients presented with the classic sail-shaped PUV and three a ring-shaped valve. After surgical ablation of the valve most patients dramatically improved; 31 of 42 (74%) had resolution of urinary frequency, 24 of 33 (73%) of diurnal enuresis and 17 of 47 (38%) nocturnal enuresis. Of 57 patients, 39 (68%) established good bladder emptying. Of 33 affected, 20 (60%) had some reduction of hydronephrosis but 63% continued to have some symptoms of voiding dysfunction. CONCLUSION: PUV should be considered in boys presenting with voiding dysfunction. After valve ablation most patients improve dramatically. Despite surgery, enuresis, urinary frequency and poor bladder emptying persisted in some and required further treatment. The continued bladder dysfunction suggested that irreversible urinary tract damage may have occurred. Even in this apparently mildly affected group, long-term follow-up is essential.