Anatomical Location of the Vesical Branches of the Inferior Hypogastric Plexus in Human Cadavers.

We have demonstrated in canines that somatic nerve transfer to vesical branches of the inferior hypogastric plexus (IHP) can be used for bladder reinnervation after spinal root injury. Yet, the complex anatomy of the IHP hinders the clinical application of this repair strategy. Here, using human cadavers, we clarify the spatial relationships of the vesical branches of the IHP and nearby pelvic ganglia, with the ureteral orifice of the bladder. Forty-four pelvic regions were examined in 30 human cadavers. Gross post-mortem and intra-operative approaches (open anterior abdominal, manual laparoscopic, and robot-assisted) were used. Nerve branch distances and diameters were measured after thorough visual inspection and gentle dissection, so as to not distort tissue. The IHP had between 1 to 4 vesical branches (2.33 ± 0.72, mean ± SD) with average diameters of 0.51 ± 0.06 mm. Vesical branches from the IHP arose from a grossly visible pelvic ganglion in 93% of cases (confirmed histologically). The pelvic ganglion was typically located 7.11 ± 6.11 mm posterolateral to the ureteral orifice in 69% of specimens. With this in-depth characterization, vesical branches from the IHP can be safely located both posterolateral to the ureteral orifice and emanating from a more proximal ganglionic enlargement during surgical procedures.

Preoperative Predictors of Surgical Success for Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

OBJECTIVE: To investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction (UPJO), proximal, and middle ureteral stricture disease. METHODS: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between April 2012 and December 2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of P <.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (P ≤.05 was considered statistically significant). RESULTS: Overall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% vs 25.7%, P <.01) and a higher proportion of patients who underwent ureteral rest (74.3% vs 48.6%, P <.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times ((confidence interval) CI 1.26-7.54, P = .01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, P = .01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSION: Surgical success of RUR for management of UPJO, proximal, and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

A sheep in wolf's clothing; a case of renal leiomyoma masquerading as hereditary leiomyomatosis and renal cell carcinoma.

Active surveillance has become a standard of care for the management of small renal masses. Decision to transition from surveillance to intervention relies on several factors including growth kinetics, histologic grade on biopsy and patient comorbidities. Management of renal masses in pregnancy presents a unique change when clinical triggers must be weighed with risk to fetus. We present the case of a third trimester patient with an enlarging and enhancing renal mass managed with robotic assisted laparoscopic partial nephrectomy. Histologic analysis was consistent with renal leiomyoma. Renal leiomyomas are a rare benign mesenchymal tumor influenced by changes in progesterone-estrogen axis.

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity.

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

Robot-assisted partial nephrectomy for complex renal tumors: Analysis of a large multi-institutional database.

INTRODUCTION: Highly complex renal masses pose a challenge to urologic surgeons' ability to perform robotic partial nephrectomy (RPN). Given the increased utilization of the robotic approach for small renal masses, we sought to characterize the outcomes and determine the safety and feasibility of RPN for complex renal masses from our large multi-institutional cohort. METHODS: We performed a retrospective analysis of patients with R.E.N.A.L. Nephrometry Scores ≥10 who underwent RPN in our multi-institutional cohort (N = 372). Baseline demographic, clinical and tumor related characteristics were evaluated with the primary endpoint of trifecta achievement (defined as negative surgical margin, no major complications, and warm ischemia time ≤25 min). Relationships between variables were assessed using the chi-square test of independence, Fisher exact test, Mann-Whitney U test, and Kruskal Wallis test. Logistic regression was used to evaluate the relationship between baseline characteristics and trifecta achievement. RESULTS: Of 372 patients in the study, mean age was 58 years, and median BMI was 30.49 kg/m2. The median tumor size was 4.3 cm (3.0-5.9 cm). Most of the patients had R.E.N.A.L. scores of 10 (n = 253; 67.01%). Overall, trifecta was achieved in 72.04% of patients. Stratifying intraoperative and postoperative outcomes by R.E.N.A.L. scores, there was no significant difference in trifecta achievement, operative time, warm ischemia time (WIT), open conversion, major complication, or positive margin rates. Length of hospital stay was significantly longer for higher R.E.N.A.L. scores (median days 2 vs. 1, P = 0.012). Multivariate analyses for factors associated with trifecta achievement concluded that age and baseline eGFR were independently associated with trifecta achievement. CONCLUSION: RPN is a safe and reproducible procedure for complex tumors with R.E.N.A.L. Nephrometry scores ≥10. Our results suggest excellent rates of trifecta achievement and short-term functional outcomes when performed by experienced surgeons. Long-term oncological and functional evaluation are needed to further support this conclusion.

Impact of Variant Histology on Oncological Outcomes in Upper Tract Urothelial Carcinoma: Results From the ROBUUST Collaborative Group.

INTRODUCTION: Oncologic implications of variant histology (VH) have been extensively studied in bladder cancer; however, further investigation is needed in upper tract urothelial carcinoma (UTUC). Our study aims to evaluate the impact of VH on oncological outcomes in UTUC patients treated with radical nephroureterectomy (RNU). METHODS: A retrospective analysis was performed on patients who underwent a robotic or laparoscopic RNU for UTUC using the ROBUUST database, a multi-institutional collaborative including 17 centers worldwide. Logistic regression was used to assess the effect of VH on urothelial recurrence (bladder, contralateral upper tract), metastasis, and survival following RNU. RESULTS: A total of 687 patients were included in this study. Median (IQR) age was 71 (64-78) years and 470 (68%) had organ confined disease. VH was present in 70 (10.2%) patients. In a median follow-up of 16 months, the incidence of urothelial recurrence, metastasis, and mortality was 26.8%, 15.3%, and 11.8%, respectively. VH was associated with increased risk of metastasis (HR 4.3, P <.0001) and death (HR 2.0, P =.046). In multivariable analysis, VH was noted to be an independent risk factor for metastasis (HR 1.8, P =.03) but not for urothelial recurrence (HR 0.99, P =.97) or death (HR 1.4, P =.2). CONCLUSION: Variant histology can be found in 10% of patients with UTUC and is an independent risk factor for metastasis following RNU. Overall survival rates and the risk of urothelial recurrence in the bladder or contralateral kidney are not affected by the presence of VH.

A Multi-Institutional Experience Utilizing Boari Flap in Robotic Urinary Reconstruction.

Objectives: There is presently scarce literature describing the outcomes of patients undergoing robotic ureteral reconstruction (RUR) using the Boari flap (BF) technique. Herein, we report our prospective, multi-institutional experience using BF in patients undergoing robotic urinary reconstruction. Patients and Methods: We reviewed our prospective, multicenter database for all patients undergoing RUR between September 2013 and September 2021 in which a BF was utilized. Preoperative, perioperative, and follow-up data were collected and analyzed. Major complications were defined as a Clavien-Dindo classification grade >2. Surgical failure was defined as recurrent symptoms, obstruction on imaging, or the need for additional surgical interventions. Results: We identified 50 patients who underwent RUR using a BF. Four (8%) underwent the Single Port approach. Twenty-four patients (48%) were active or former tobacco users. Thirty-four patients (68%) had previously undergone abdominal surgery, 17 (34%) had prior ureteral stricture interventions, and 9 (18%) had prior abdominopelvic radiation. The most common stricture etiology was malignancy (34.4%). The median follow-up was 15.0 months with a 90% (45/50) success rate. The five documented cases of failure occurred at a median of 1.8 months following the procedure. Conclusion: In the largest prospective, multi-institutional study of patients undergoing RUR with BF in the literature to date, we demonstrate a low rate of complications and a high rate of surgical success in three tertiary academic medical centers. All observed failures occurred within 2 months of surgical intervention.

Robotic ureteral reconstruction for recurrent strictures after prior failed management.

Objectives: To describe our multi-institutional experience with robotic ureteral reconstruction (RUR) in patients who failed prior endoscopic and/or surgical management. Materials and Methods: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RUR between 05/2012 and 01/2020 for a recurrent ureteral stricture after having undergone prior failed endoscopic and/or surgical repair. Post-operatively, patients were assessed for surgical success, defined as the absence of flank pain and obstruction on imaging. Results: Overall, 105 patients met inclusion criteria. Median stricture length was 2 (IQR 1-3) centimetres. Strictures were located at the ureteropelvic junction (UPJ) (41.0%), proximal (14.3%), middle (9.5%) or distal (35.2%) ureter. There were nine (8.6%) radiation-induced strictures. Prior failed management included endoscopic intervention (49.5%), surgical repair (25.7%) or both (24.8%). For repair of UPJ and proximal strictures, ureteroureterostomy (3.4%), ureterocalicostomy (5.2%), pyeloplasty (53.5%) or buccal mucosa graft ureteroplasty (37.9%) was utilized; for repair of middle strictures, ureteroureterostomy (20.0%) or buccal mucosa graft ureteroplasty (80.0%) was utilized; for repair of distal strictures, ureteroureterostomy (8.1%), side-to-side reimplant (18.9%), end-to-end reimplant (70.3%) or appendiceal bypass (2.7%) was utilized. Major (Clavien >2) post-operative complications occurred in two (1.9%) patients. At a median follow-up of 15.1 (IQR 5.0-30.4) months, 94 (89.5%) cases were surgically successful. Conclusions: RUR may be performed with good intermediate-term outcomes for patients with recurrent strictures after prior failed endoscopic and/or surgical management.

Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience.

We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia.

Background: We compared outcomes of robot-assisted simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia (BPH). Methods: We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between May 2013 and January 2021. Postoperatively, urinary function was assessed using the American Urological Association symptom score (AUASS) and quality of life (QOL) score. Results: Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%), and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift, or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p = 0.40), estimated blood loss (p = 0.32), robotic console time (p = 0.86), or major 30-day postoperative (Clavien >2) complications (p = 0.80) between both groups. With regard to urinary function, the mean improvement in preoperative and postoperative AUASS (p = 0.31), QOL scores (p = 0.11), and continence rates was similar between both groups. Conclusion: For management of patients with BPH and lower urinary tract symptoms, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery vs those that did not undergo prior prostate surgery.

The State of Robotic Partial Nephrectomy: Operative, Functional, and Oncological Outcomes From A Robust Multi-Institution Collaborative.

OBJECTIVE: To describe the most recent surgical, functional, and oncological outcomes of RPN utilizing one of the largest, prospectively maintained, multi-institution consortium of patients undergoing robotic renal surgery. MATERIALS AND METHODS: Data was obtained from a prospectively maintained multi-institutional database of patients who underwent RPN for clinically localized kidney cancer between 2018 and 2022 by 9 high-volume surgeons. Demographic and tumor characteristics as well as operative, functional, and oncological outcomes were queried. RESULTS: A total of 2836 patients underwent RPN. Intraoperative, postoperative, and 30-day major complication rates were 2.68%, 11.39%, and 3.24%, respectively. Median tumor size was 3.0 cm. Tumors with low complexity had a shorter median operative time, lower median EBL, shorter median ischemia time, lower postoperative complication rate, and lower decline in renal function There was no significant difference between tumor complexities with respect to the rate of conversion to radical nephrectomy, conversion to open, major complications, and positive margins. Lower BMI, smaller clinical tumor size, lower tumor complexity, and higher baseline eGFR were significantly associated with trifecta achievement. CONCLUSION: Patient BMI, baseline eGFR, and tumor characteristics such as size and complexity are the most important predictors of trifecta achievement. Patients with complex tumors should be counseled that they are at increased risk of complications and worsening renal function after robotic partial nephrectomy.

A comparison of outcomes between transperitoneal and retroperitoneal robotic assisted partial nephrectomy in patients with completely endophytic kidney tumors.

INTRODUCTION: Retroperitoneal robotic partial nephrectomy (RPN) has been shown to have comparable outcomes to the transperitoneal approach for renal tumors. However, this may not be true for completely endophytic tumors as they pose significant challenges in RPN with increased complication rates. Hence, we sought to compare the safety and feasibility of retroperitoneal RPN to transperitoneal RPN for completely endophytic tumors. METHODS: We performed a retrospective analysis of patients who underwent RPN for a completely endophytic renal mass using either transperitoneal or retroperitoneal approach from our multi-institutional database (n = 177). Patients who had a solitary kidney, prior ipsilateral surgery, multiple/bilateral tumors, and horseshoe kidneys were excluded from the analysis. Overall, 156 patients were evaluated (112 [71.8%] transperitoneal, 44 [28.2%] retroperitoneal). Baseline characteristics, perioperative and postoperative data were compared between the surgical transperitoneal and retroperitoneal approach using Chi-square test, Fishers exact test, t test, Mood median test and Mann Whitney U test. RESULTS: Of the 156 patients in this study, 86 (56.9%) were male and the mean (SD) age was 58 (13) years. Baseline characteristics were comparable between the 2 approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (19.6 [SD = 7.6] minutes vs. 19.5 [SD = 10.2] minutes, P = 0.952), operative time (157.5 [SD = 44.8] minutes vs. 160.2 [SD = 47.3] minutes, P = 0.746), median estimated blood loss (50 ml [IQR: 50, 150] vs. 100 ml [IQR: 50, 200], P = 0.313), median length of stay (1 [IQR: 1, 2] day vs. 1 [IQR: 1, 2] day, P = 0.126) and major complication rate (2 [4.6%] vs. 3 [2.7%], P = 0.621). No difference was observed in positive surgical margin rate (P = 0.1.00), delta eGFR (P = 0.797) and de novo chronic kidney disease occurrence (P = 1.000). CONCLUSION: Retroperitoneal and transperitoneal RPN yielded similar perioperative and functional outcomes in patients with completely endophytic tumors. In well-selected patients with purely endophytic tumors, either a retroperitoneal or transperitoneal approach could be considered without compromising perioperative and postoperative outcomes.

A Propensity-Matched Comparison of the Perioperative Outcomes Between Single-Port and Multi-Port Robotic Assisted Partial Nephrectomy: A Report from the Single Port Advanced Research Consortium (SPARC).

Purpose: Single-port (SP) robotic surgery is a new technology and early in its adoption curve. The goal of this study is to compare the perioperative outcomes of SP to multi-port (MP) robotic technology for partial nephrectomy. Materials and Methods: This is a prospective cohort study of patients who have undergone robot-assisted partial nephrectomy using SP and MP technology. Baseline demographic, clinical, and tumor-specific characteristics and perioperative outcomes were compared using χ2, t-test, and Mann-Whitney U test in the overall cohort and in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. Results: After propensity matching, 146 SP patients were matched with 146 MP patients. SP and MP groups had similar mean age (58 ± 12 years vs 59 ± 12 years; p = 0.606) and proportion of men (54.11% vs 52.05%; p = 0.725). The SP had a longer mean ischemia (18.29 ± 10.49 minutes vs 13.79 ± 6.29 minutes; p < 0.001). Estimated blood loss (EBL) and length of hospital stay (LOS), operative time, positive margin rate, and any complication rate were similar between the two groups. Conclusions: SP partial nephrectomy had a longer ischemia time, and a comparable LOS, EBL, operative time, positive margin rates, and complication rates to MP. These early data are encouraging. However, the role of SP requires further study and should evaluate safety and long-term data when compared with the standard MP technique.

Practice trends for perioperative intravesical chemotherapy in upper tract urothelial carcinoma: Low but increasing utilization during minimally invasive nephroureterectomy.

INTRODUCTION: Perioperative intravesical chemotherapy (IVC) at or around the time of radical nephroureterectomy (RNU) reduces the risk of intravesical recurrence. Guidelines since 2013 have recommended its use. The objective of this study is to examine IVC utilization and determine predictors of its administration within a large international consortium. METHODS AND MATERIALS: Data was collected from 17 academic centers on patients who underwent robotic/laparoscopic RNU between 2006 and 2020. Patients who underwent concomitant radical cystectomy and cases in which IVC administration details were unknown were excluded. Univariate and multivariate analyses were utilized to determine predictors of IVC administration. A Joinpoint regression was performed to evaluate utilization by year. RESULTS: Six hundred and fifty-nine patients were included. A total of 512 (78%) did not receive IVC while 147 (22%) did. Non-IVC patients were older (P < 0.001), had higher ECOG scores (P = 0.003), and had more multifocal disease (23% vs. 12%, P = 0.005). Those in the IVC group were more likely to have higher clinical T stage disease (P = 0.008), undergone laparoscopic RNU (83% vs. 68%, P < 0.001), undergone endoscopic management of the bladder cuff (20% vs. 4%, P = 0.008). Multivariable regression showed that decreased age (OR 0.940, P < 0.001), laparoscopic approach (OR 2.403, P = 0.008), and endoscopic management of the bladder cuff (OR 7.619, P < 0.001) were significant predictors favoring IVC administration. Treatment at a European center was associated with lower IVC use (OR 0.278, P = 0.018). Overall utilization of IVC after the 2013 European Association of Urology (EAU) guideline was 24% vs. 0% prior to 2013 (P < 0.001). Limitations include limited data regarding IVC timing/agent and inclusion of minimally invasive RNU patients only. CONCLUSIONS: While IVC use has increased since being added to the EAU UTUC guidelines, its use remains low at academic centers, particularly within Europe.

Estimated Glomerular Filtration Rate Decline at 1 Year After Minimally Invasive Partial Nephrectomy: A Multimodel Comparison of Predictors.

Background: Long-term renal function after partial nephrectomy (PN) is difficult to predict as it is influenced by several modifiable and nonmodifiable variables, often intertwined in complex relations. Objective: To identify variables influencing long-term renal function after PN and to assess their relative weight. Design setting and participants: A total of 457 patients who underwent either robotic (n = 412) or laparoscopic PN (n = 45) were identified from a multicenter international database. Outcome measurements and statistical analysis: The 1-yr estimated glomerular filtration rate (eGFR) percentage loss (1YPL), defined as the eGFR percentage change from baseline at 1 yr after surgery, was the outcome endpoint. Predictors evaluated included demographic data, tumor features, and operative and postoperative variables. Bayesian multimodel analysis of covariance was used to build all possible models and compare the fit of each model to the data via model Bayes factors. Bayesian model averaging was used to quantify the support for each predictor via the inclusion Bayes factor (BFincl). High-dimensional undirected graph estimation was used for network analysis of conditional independence between predictors. Results and limitations: Several models were found to be plausible for estimation of 1YPL. The best model, comprising postoperative eGFR percentage loss (PPL), sex, ischemia technique, and preoperative eGFR, was 207 times more likely than all the other models regarding relative predictive performance. Its components were part of the top 44 models and were the predictors with the highest BFincl. The role of cold ischemia, solitary kidney status, surgeon experience, and type of renorraphy was not assessed. Conclusions: Preoperative eGFR, sex, ischemia technique, and PPL are the best predictors of eGFR percentage loss at 1 yr after minimally invasive PN. Other predictors seem to be irrelevant, as their influence is insignificant or already nested in the effect of these four parameters. Patient summary: Kidney function at 1 year after partial removal of a kidney depends on sex, the technique used to halt blood flow to the kidney during surgery, and kidney function at baseline and in the early postoperative period.

Is Hypertension Associated with Worse Renal Functional Outcomes after Minimally Invasive Partial Nephrectomy? Results from a Multi-Institutional Cohort.

BACKGROUND: Hypertension (HTN) is a global public health issue. There are limited data regarding the effects of HTN in patients undergoing partial nephrectomy (PN) for renal tumors. To address this void, we tested the association between HTN and renal function after minimally invasive PN (MIPN). METHODS: Using a multi-institutional database (2007-2017), we identified patients aged ≥ 18 years with a diagnosis of cT1 renal tumors treated with MIPN. Kaplan-Meier plots and Cox regression models addressed newly-onset CKD stage ≥ 3b or higher (sCKD). All analyses were repeated after 1:1 propensity score matching (PSM). RESULTS: Overall, 2144 patients were identified. Of those, 35% (n = 759) were yes-HTN. Yes-HTN patients were older, more frequently male and more often presented with diabetes. Yes-HTN patients harbored higher RENAL nephrometry scores and higher cT stages than no-HTN patients. Conversely, yes-HTN patients exhibited lower preoperative eGFRs. In the overall cohort, five-year sCKD-free survival was 86% vs. 94% for yes-HTN vs. no-HTN, which translated into a multivariable HR of 1.67 (95% CI: 1.06-2.63, p = 0.026). After 1:1 PSM, virtually the same results were observed (HR 1.86, 95% CI: 1.07-3.23, p = 0.027). CONCLUSIONS: Yes-HTN patients exhibited worse renal function after MIPN when compared to their no-HTN counterparts. However, these observations need to be further tested in a prospective cohort study.

Robotic partial nephrectomy for management of renal mass in patients with a solitary kidney: can we expand the indication to T2 and T3 disease?

BACKGROUND: Management of complex renal masses is challenging in a solitary kidney setting. We retrospectively compared oncological and renal functional outcomes between robotic and open partial nephrectomy (PN) in patients with a pT2-pT3 renal mass and a solitary kidney. METHODS: From a multi-institutional series, we identified 20 robotic partial nephrectomies (RPN) and 15 open partial nephrectomies (OPN) patients confirmed to have a pT2 or pT3 renal cancer. Surgeries were performed between January 2012 and July 2019. Patients with familial renal cell carcinoma, prior ipsilateral PN, or multiple ipsilateral synchronous tumors were excluded from the analysis. Baseline characteristics, perioperative and postoperative outcomes were compared using χ2 test, Fisher's Exact Test, Mann-Whitney U Test, and Student's t-test. RESULTS: Baseline characteristics were comparable. Cold ischemia was utilized more in the open group (92.9% vs. 15.8%, P<0.001). OPN group had a longer ischemia time (48.9 min vs. 27.3 min, P<0.001), a higher major complication rate (38.5% vs. 11.1%, P=0.009), and a higher length of stay was (5 vs. 3.5 days, P=0.023). Positive surgical margin rate was comparable (20% OPN vs. 15% RPN; P=1.000). At a mean follow up of 21 months local recurrence rates (1 OPN vs. 2 RPN, P=1.000) were comparable, chronic kidney disease upstaging rate (46.7% OPN vs. 45.0% RPN, P=0.922) and estimated glomerular filtration rate preservation at one year (75.2%% in OPN vs. 79.1% RPN, P=0.707) were comparable. CONCLUSIONS: In select cases and experienced hands, the robotic approach offers a reasonable alternative to open surgery in patients with pT2 and pT3 tumors and a solitary kidney.

Robotic vs Laparoscopic Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multicenter Propensity-Score Matched Pair "tetrafecta" Analysis (ROBUUST Collaborative Group).

Purpose: To compare the outcomes of robotic radical nephroureterectomy (RRNU) and laparoscopic radical nephroureterectomy (LRNU) within a large multi-institutional worldwide dataset. Materials and Methods: The ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST) includes data from 17 centers worldwide regarding 877 RRNU and LRNU performed between 2015 and 2019. Baseline features, perioperative and oncologic outcomes, were included. A 2:1 nearest-neighbor propensity-score matching with a 0.001 caliper was performed. A univariable and a multivariable logistic regression model were built to evaluate the predictors of a composite "tetrafecta" outcome defined as occurrence of bladder cuff excision+LND+no complications+negative surgical margins. Results: After matching, 185 RRNU and 91 LRNU were assessed. Patients in the RRNU group were more likely to undergo bladder cuff excision (81.9% vs 63.7%; p < 0.001) compared to the LRNU group. A statistically significant difference was found in terms of overall postoperative complications (p = 0.003) and length of stay (p < 0.001) in favor of RRNU. Multivariable analysis demonstrated that LRNU was an independent predictor negatively associated with achievement of "tetrafecta" (odds ratio: 0.09; p = 0.003). Conclusions: In general, RRNU and LRNU offer comparable outcomes. While the rate of overall complications is higher for LRNU in this study population, this is mostly related to low-grade complications, and therefore with more limited clinical relevance. RRNU seems to offer shorter hospital stay, but this might also be related to the different geographical location of participating centers. Overall, the implementation of robotics might facilitate achievement of a "tetrafecta" outcome as defined in the present study.

A Preoperative Nomogram to Predict Renal Function Insufficiency for Cisplatin-based Adjuvant Chemotherapy Following Minimally Invasive Radical Nephroureterectomy (ROBUUST Collaborative Group).

BACKGROUND: Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU). OBJECTIVE: To create a model predicting renal function decline after minimally invasive RNU. DESIGN, SETTING, AND PARTICIPANTS: A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m2 at 3 mo after RNU. Patients with baseline eGFR >50 ml/min/1.73 m2 (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR <50 ml/min/1.73 m2 was built based on the coefficients of the least absolute shrinkage and selection operation (LASSO) logistic regression. The discrimination, calibration, and clinical use of the nomogram were investigated. RESULTS AND LIMITATIONS: The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p < 0.001) and cancer-specific death risk (HR: 5.19, p < 0.001) was statistically significant. The limitation mainly lies in its retrospective design. CONCLUSIONS: A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection. PATIENT SUMMARY: We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy.

The role of RENAL score in predicting complications after robotic partial nephrectomy.

BACKGROUND: The aim of this study was to evaluate the association between tumor complexity based on RENAL nephrometry score and complications. METHODS: We retrospectively identified 2555 patients who underwent RPN for renal cell carcinoma. Major complication was defined as Clavien Grade ≥3. The relationship between baseline demographic, clinical characteristics, perioperative and postoperative outcomes, and tumor complexity were assessed using χ2 test of independence, Fisher's Exact Test and Kruskal Wallis Test. An unadjusted and adjusted logistic regression model was used to assess the relationship between major complication and demographic, clinical characteristics, and perioperative outcomes. RESULTS: There was a significant relationship between tumor complexity and WIT (P<0.001), operative time (P<0.001), estimated blood loss (P<0.001), and major complication (P=0.019). However, there was no relationship with overall complications (P=0.237) and length of stay (LOS) (P=0.085). In the unadjusted model, higher tumor complexity was associated with major complication (P=0.009). Controlling for other variables, there was no significant difference between major complication and tumor complexity (low vs. moderate, P=0.142 and high, P=0.204). LOS (P<0.001) and operative time (P=0.025) remained a significant predictor of major complication in the adjusted model. CONCLUSIONS: Tumor complexity is not associated with an increase in overall or major complication rate after RPN. Experience in high-volume centers is demonstrating a standardization of low complications rates after RPN independent of tumor complexity.