ABSTRACT
OBJECTIVE: To compare the incidence of postoperative flank bulges between patients with multiple-layer closure and single superficial-layer closure after retroperitoneal surgery via open flank incision in the SIngle versus MUltiple-LAyer wound Closure for flank incision (SIMULAC) trial. PATIENTS AND METHODS: The study was a randomised controlled, patient- and assessor-blinded, multicentre trial. Between May 2015 and February 2017, 225 patients undergoing flank incisions were randomised 1:1 to a multiple-layer closure (SIMULAC-I) or a single superficial-layer closure (SIMULAC-II) group. The primary outcome was the occurrence of a flank bulge 6 months after surgery. RESULTS: Overall, 177 patients (90 in SIMULAC-I, 87 in SIMULAC-II) were eligible for final assessment. The cumulative incidence of a flank bulge was significantly higher in the SIMULAC-II group (51.7%) compared to the SIMULAC-I group [34.4%; odds ratio (OR) 2.04, 95% confidence interval (CI) 1.11-3.73; P = 0.02]. Rate of severe postoperative complications (4.4% SIMULAC-I vs 10.3% SIMULAC-II; P = 0.21) or hernia (6.7% SIMULAC-I vs 10.3% SIMULAC-II; P = 0.59) was similar between the groups. There was no difference in pain (visual analogue scale) and the requirement for pain medication at 6 months postoperatively. Quality of life assessed with the European Quality of Life 5 Dimensions Questionnaire was higher in the SIMULAC-I group compared to the SIMULAC-II group at 6 months postoperatively, with a (median range) score of 80 (30-100) vs 75 (5-100) (P = 0.012). CONCLUSION: The overall risk of a flank bulge after flank incision is high. Multiple-layer closure after flank incision should be performed as a standard procedure.
Subject(s)
Hernia, Abdominal/etiology , Incisional Hernia/etiology , Postoperative Complications/etiology , Wound Closure Techniques/adverse effects , Adult , Aged , Double-Blind Method , Female , Humans , Male , Middle Aged , Pain, Postoperative/drug therapy , Pain, Postoperative/etiology , Prospective Studies , Quality of Life , Urologic Surgical Procedures/adverse effectsABSTRACT
BACKGROUND: Nephrometry scores are designed for standardized reporting of renal tumors and predicting complications. Multiple scores are available, but there is a lack of systematic comparison. PATIENTS AND METHODS: A total of 305 consecutive patients admitted for open partial nephrectomy to 2 urological hospitals were prospectively assessed. Five cases with conversion to radical nephrectomy were excluded from further analysis. RENAL, PADUA, C-index, and NePhRO scores were obtained from preoperative sectional imaging. Additionally, interobserver variance between 2 urologists and a radiologist was analyzed for 50 patients. Linear and ordered logistic regression was used to evaluate the association between scores and surgical parameters. Receiver operating characteristic analysis was employed to assess the predictive value for requirement of ischemia and opening of the collecting system. RESULTS: High interobserver agreement was observed for RENAL (0.92 and 0.80), PADUA (0.81 and 0.85), NePhRO (0.94 and 0.82), and the C-index (0.98 and 0.95). All scores showed a significant association with opening of the collecting system (P < .016), requirement of on-clamp excision (P < .001), and ischemia time (P < .001). Logistic regression identified RENAL, PADUA, and NePhRO score to be an independent predictor for severe complications (P = .016, P = .011, and P = .005). No correlation was found for the C-index (ß = 0.98; P = .779). Predictive effectiveness for opening of the collecting system and for on-clamp excision showed comparable area under the curve values for the 4 scores. CONCLUSION: All scoring systems represent objective and reproducible measurement tools for renal tumor complexity, that correlate well with surgical outcome. RENAL, PADUA, and NePhRO score are comparable and seem to be superior to the more complex C-index system.