Urinary aquaporin 1 and perilipin 2: Can these novel markers accurately characterize small renal masses and help guide patient management?

OBJECTIVE: To evaluate the role of urine aquaporin 1 and perilipin 2 as biomarkers adjunct to renal mass biopsy in guiding the management of patients with small renal masses. METHODS: Preoperative aquaporin 1 and perilipin 2 levels in 57 patients with small renal masses undergoing partial nephrectomy were analyzed and compared with postoperative tumor histology. An algorithm was created utilizing aquaporin 1 and perilipin 2 in conjunction with renal mass biopsy. Cut-off values were implemented to maximize biomarker sensitivity and specificity. Renal mass biopsy utilization and intervention were then compared with rates in traditional renal mass biopsy algorithms. RESULTS: All clear cell and papillary renal cell carcinomas were correctly identified and assigned to the treatment path. All benign lesions were correctly sorted to a confirmatory renal mass biopsy path. Two chromophobe masses did not have elevated aquaporin 1 and perilipin 2, and would require renal mass biopsy. Compared with protocols that call for all small renal masses to be biopsied, confirmatory renal mass biopsy could have been safely avoided in 74% of patients with elevated aquaporin 1 and perilipin 2. Compared with protocols that do not utilize renal mass biopsy, surgical intervention would have been avoided in 23% of patients with benign masses. CONCLUSIONS: Aquaporin 1 and perilipin 2 possess high sensitivity and specificity for detecting clear cell and papillary renal cell carcinoma. Use of these markers might compliment renal mass biopsy in the characterization of small renal masses.

Ureteropelvic junction obstruction caused by metastatic cholangiocarcinoma.

We describe the rare case of a 61-year-old female with right ureteropelvic junction (UPJ) obstruction caused by metastatic cholangiocarcinoma. Her past medical history was notable for cholangiocarcinoma treated with neoadjuvant chemoradiation and two orthotopic liver transplants six years earlier. Urology was consulted when she presented with flank pain and urinary tract infection. Diagnostic workup demonstrated right UPJ obstruction. She was managed acutely with percutaneous nephrostomy. She subsequently underwent robotic pyeloplasty and intrinsic obstruction of the UPJ was discovered. Histological examination revealed adenocarcinoma, consistent with systemic recurrence of the patient's known cholangiocarcinoma.

Lymphoepithelioma-like carcinoma of the ureter: a rare presentation, synchronous with conventional urothelial carcinoma.

Lymphoepithelioma-like carcinoma (LELC) is a rare finding in the upper urinary tract. The presenting clinical findings mimic those of other more common upper-tract tumors, such as urothelial carcinoma. Preoperative imaging has not been shown to reliably predict the diagnosis of LELC. This tumor can be misdiagnosed as a reactive inflammatory lesion or lymphoma if the proper immunohistochemical stains for cytokeratin are not used.

Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1 791 patients.

OBJECTIVE: To evaluate the incidence of and risk factors for a urine leak in a large multicentre, prospective database of robot-assisted partial nephrectomy (RPN). PATIENTS AND METHODS: A database of 1 791 RPN from five USA centres was reviewed for urine leak as a complication of RPN. Patient and tumour characteristics were compared between patients with and those without postoperative urine leaks. Fisher's exact test was used for qualitative variables and Wilcoxon sum-rank tests were used for quantitative variables. A review of the literature on PN and urine leak was conducted. RESULTS: Urine leak was noted in 14/1 791 (0.78%) patients who underwent RPN. The mean (sd) nephrometry score of the entire cohort was 7.2 (1.9), and 8.0 (1.9) in patients who developed urine leak. The median (range) postoperative day of presentation was 13 (3-32) days. Patients with urine leak presented in delayed fashion with fever (two of the 14 patients, 14%), gastrointestinal complaints (four patients, 29%), and pain (five patients, 36%). Eight of the 14 patients (57%) required admission, while eight (57%) and nine (64%) had a drain or stent placed, respectively. Drains and stents were removed after a median (range) of 8 (4-13) days and 21 (8-83) days, respectively. Variables associated with urine leak included tumour size (P = 0.021), hilar location (P = 0.025), operative time (P = 0.006), warm ischaemia time (P = 0.005), and pelvicalyceal repair (P = 0.018). Upon literature review, the historical incidence of urine leak ranged from 1.0% to 17.4% for open PN and 1.6-16.5% for laparoscopic PN. CONCLUSION: The incidence of urine leak after RPN is very low and may be predicted by some preoperative factors, affording better patient counselling of risks. The low urinary leak rate may be attributed to the enhanced visualisation and suturing technique that accompanies the robotic approach.

Port site metastasis after surgery for renal cell carcinoma: harbinger of future metastasis.

PURPOSE: Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon. MATERIALS AND METHODS: A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience. RESULTS: A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases had no identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher. CONCLUSIONS: Port site metastasis after minimally invasive surgery for renal cell carcinoma is a rare occurrence with a poor prognosis. In most cases port site metastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Do young patients with renal cell carcinoma feature a distinct outcome after surgery? A comparative analysis of patient age based on the multinational CORONA database.

PURPOSE: We analyzed the distinct clinicopathological features and prognosis of patients with renal cell carcinoma age 40 years or less compared to a reference group of patients 60 to 70 years old. MATERIALS AND METHODS: Overall 2,572 patients retrieved from a multicenter international database comprised of 6,234 patients with surgically treated renal cell carcinoma were included in this retrospective study. Clinical and histopathological features of 297 patients 40 years old or younger (4.8%) were compared to those of 2,275 patients (36.5%) 60 to 70 years old, who served as the reference group. Median followup was 59 months. The impact of young age and further parameters on disease specific mortality and all cause mortality was evaluated by multivariate Cox proportional hazards regression analyses. RESULTS: Young patients more frequently underwent nephron sparing surgery (27% vs 20%, p = 0.008) and regional lymph node dissection compared to older patients (38% vs 32%, p = 0.025). Organ confined tumor stage (81% vs 70%, p <0.001), smaller tumor diameter (4.5 vs 4.7 cm, p = 0.014) and chromophobe subtype (10% vs 4%, p <0.001) were significantly more frequent in young patients. On multivariate analysis older patients had a higher disease specific (HR 2.21, p <0.001) and all cause mortality (HR 3.05, p <0.001). The c indices for the Cox models were 0.87 and 0.78, respectively. However, integration of the variable age group did not significantly increase the predictive accuracy of the disease specific and all cause mortality models. CONCLUSIONS: Young patients with renal cell carcinoma (40 years old or younger) have significantly different frequencies of clinical and histopathological features, and a significantly lower all cause and disease specific mortality compared to patients 60 to 70 years old.

Successful Percutaneous Ultrasonic Lithotripsy of Gallstones.

Background: Acute calculous cholecystitis is the obstruction of the cystic duct by a gallstone that leads to inflammation of the gallbladder necessitating cholecystectomy. Case Series: We present the cases of 2 patients with acute calculous cholecystitis who were deemed ineligible candidates for cholecystectomy because of their complicating medical histories. Both patients initially underwent cholecystostomy and drain placement with interventional radiology for management of acute calculous cholecystitis. Their large gallstones remained refractory to attempts at removal by electrohydraulic lithotripsy via the cholecystostomy access. The patients' gallstones were successfully removed via percutaneous ultrasonic lithotripsy during a collaborative procedure with interventional radiology and urology. Conclusion: An interdisciplinary approach using percutaneous cholecystolithotomy with rigid ultrasonic lithotripsy is an effective method for removing challenging gallstones in patients for whom traditional approaches fail.

Effects of protein restriction on insulin-like growth factor (IGF)-1 in men with prostate cancer: results from a randomized clinical trial.

BACKGROUND: Insulin-like growth factor (IGF)-1 and its binding proteins are important in cancer growth, especially in prostate cancer. Observational studies suggest that protein restriction can lower IGF-1 levels. However, it is unclear whether an isocaloric protein-restricted diet affects IGF-1 and IGFBPs in men with prostate cancer. METHODS: In this academic, single-center, parallel-group, prospective, randomized, open-label, blinded end-point trial, 38 consenting overweight (BMI 30.5 ± 5.5 kg/m2) men with localized prostate cancer, aged 43-72 years, were randomized (1:1) with permuted blocks to 4-6 weeks of customized isocaloric PR diets (0.8 g protein/kg lean body mass) or their usual diet. Biomarkers influencing cancer biology, including serum IGF-1 and its binding proteins were measured longitudinally. RESULTS: Contrary to our hypothesis, feeding individuals an isocaloric protein-restricted diet did not result in a significant reduction in serum IGF-1. Moreover, there was no observed increase in serum IGFBP-1 or IGFBP-3 concentration. CONCLUSION: These findings demonstrate that protein restriction without calorie restriction does not reduce serum IGF-1 concentration or increase IGFBP-1 and IGFBP-3 in men with localized prostate cancer. Further research is needed to identify dietary interventions for safely and effectively reducing IGF-1 in this patient group.

Gender differences in clinicopathological features and survival in surgically treated patients with renal cell carcinoma: an analysis of the multicenter CORONA database.

PURPOSE: To investigate gender differences in clinicopathological features and to analyze the prognostic impact of gender in renal cell carcinoma (RCC) patients undergoing surgery. METHODS: A total of 6,234 patients (eleven centers; Europe and USA) treated by radical or partial nephrectomy were included in this retrospective study (median follow-up 59 months; IQR 30-106). Gender differences in clinicopathological parameters were assessed. Multivariable Cox regression models were applied to determine the influence of parameters on disease-specific survival (DSS) and overall survival (OS). RESULTS: A total of 3,751 patients of the study group were male patients (60.2 %), who were significantly younger at diagnosis and received more frequently NSS than women. Significantly, more often high-grade tumors and simultaneous metastasis were present in men. Whereas tumor size and pTN stages did not differ between genders, clear-cell and chromophobe RCC was diagnosed less frequently, but papillary RCC more often in men. Gender also independently influenced DSS (HR 0.75, p < 0.001) and OS (HR 0.80, p < 0.001) with a benefit for women. However, inclusion of gender in multivariable models did not significantly gain predictive accuracies (PA) for DSS (0.868-0.870, p = 0.628) and OS (0.775-0.777, p = 0.522). Furthermore, no significantly different DSS and OS rates were found in patients undergoing NSS. CONCLUSIONS: This study demonstrates important gender differences in clinicopathological features and outcome of RCC patients with improved DSS and OS for women compared to men, even if solely patients with clear-cell RCC or M0-stage are taken into evaluation. However, inclusion of gender in multivariable models does not significantly gain PA of multivariable models.

Diagnostic Accuracy of 99mTc-Sestamibi SPECT/CT for Characterization of Solid Renal Masses.

Our objective was to assess the diagnostic accuracy of 99mTc-sestamibi SPECT/CT for characterizing solid renal masses. Methods: Imaging and clinical records of patients who underwent 99mTc-sestamibi SPECT/CT for clinical work-up of their solid renal masses from September 2018 to October 2021 were retrospectively reviewed. Histopathology formed the reference standard, and the diagnoses were categorized as malignant/concerning (renal cell carcinomas [RCCs] other than chromophobe histology) and benign/nonconcerning (oncocytic tumors including chromophobe RCC, other benign diagnoses) to calculate the sensitivity and specificity of 99mTc-sestamibi SPECT/CT and contrast-enhanced CT (ceCT). The clinical reads of the SPECT/CT images were used for visual classification of the lesions. Additionally, the SPECT images were manually segmented to obtain the maximum and mean counts of the lesion and adjacent renal cortex and maximum and mean lesion Hounsfield units. Results: 99mTc-sestamibi SPECT/CT was performed on 42 patients with 62 renal masses. A histopathologic diagnosis was available for 27 patients (18 male, 9 female) with 36 solid renal masses. ceCT findings were available for 20 of these patients. The most commonly identified single histologic type was clear cell RCC (13/36; 36.1%). Oncocytic tumors were the most common group of nonconcerning lesions (15/36), with oncocytoma as the predominant histologic type (n = 6). The sensitivity and specificity of SPECT/CT for diagnosing a nonconcerning lesion were 66.7% and 89.5%, respectively, compared with 10% and 75%, respectively, for ceCT. The lesion-to-kidney ratios for maximum and mean counts and maximum lesion Hounsfield units showed significant differences between the 2 groups (P < 0.05). The lesion-to-kidney mean count ratio at a cutoff of 0.46 showed a sensitivity and specificity of 87.5% and 86.67%, respectively, for detecting nonconcerning lesions, which was significantly higher than that of ceCT. Conclusion: The current literature on the utility of 99mTc-sestamibi SPECT/CT for characterization of solid renal masses is limited. We offer additional evidence of the incremental value of 99mTc-sestamibi SPECT/CT over ceCT for differentiating malignant or aggressive renal tumors from benign or indolent ones, thereby potentially avoiding overtreatment and its associated complications. Quantitative assessment can further increase the diagnostic accuracy of SPECT/CT and may be used in conjunction with visual interpretation.

Long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with autosomal dominant polycystic kidney disease.

PURPOSE: Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with adult dominant polycystic kidney disease presenting with refractory pain. MATERIALS AND METHODS: Between 1994 and 2003, 37 patients with adult dominant polycystic kidney disease underwent laparoscopic cyst decortication at Barnes-Jewish Hospital. A total of 19 patients (4 male, 15 female) with at least 3-year followup were included in the study. Renal function was evaluated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated glomerular filtration rate formula. End stage renal disease was defined as progression to transplant, dialysis or stage 5 chronic kidney disease. Hypertension was evaluated using the antihypertensive therapeutic index. Pain assessment was based primarily on a telephone questionnaire. RESULTS: At a mean followup of 10.9 years (range 6.4 to 16.9), 67% of evaluable patients reported more than 50% improvement in pain. Ten patients had progression to end stage renal disease--3 dialysis, 6 transplant, and 1 chronic kidney disease stage 5. Two patients had stage 5 chronic kidney disease at initial presentation. A comparison of preoperative estimated glomerular filtration rate between patients with and those without end stage renal disease revealed a lower preoperative estimated glomerular filtration rate in the former group (43.4 vs 75.4 ml/minute/1.73 m(2), p = 0.01). Of the patients 53% had an improved or stable antihypertensive therapeutic index at last followup, although no improvement in mean overall antihypertensive therapeutic index was noted (4.7 pre-laparoscopic cyst decortications vs 7.0 post-laparoscopic cyst decortications, p = 0.28). CONCLUSIONS: Durable pain relief but not hypertension control was seen at 10-year followup. Preoperative estimated glomerular filtration rate is a strong predictor of post-laparoscopic cyst decortication progression to end stage renal disease. A cautious approach with laparoscopic cyst decortication should be taken in patients with poor preoperative renal function.

Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group.

PURPOSE: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. MATERIALS AND METHODS: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. RESULTS: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. CONCLUSIONS: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

Robot-assisted pyeloplasty: outcomes for primary and secondary repairs, a single institution experience.

INTRODUCTION: Robotic Pyeloplasty (RAP) is a technique for management of ureteropelvic junction obstruction (UPJO). PURPOSE: To report outcomes of RAP for primary and secondary (after failed primary treatment) UPJO. MATERIALS AND METHODS: Single institution data of adult RAP performed from 2007 to 2009 was collected retrospectively following approval by our IRB. Database analysis included patient age, race, pre and post-operative imaging studies and perioperative variables including operative time, blood loss, pain and complications. RESULTS: Fifty-five adult patients underwent RAP (26 left/29 right) for UPJO including 9 secondary procedures from 2007 to 2009. Average follow-up was 16 months (1-36). Mean age was 41 years (18-71) with an average BMI of 27 (17-42); 32 were female. Most patients were diagnosed with preoperative diuretic renal scintigraphy and the obstructed side demonstrated mean function of 41% and t1/2 of 70 minutes. Mean operative time was 194 minutes with average blood loss less than 100 mL. Mean hospital stay was 1.7 days with an average narcotic equivalent dose of 15 mg. RAP for secondary UPJO took longer with more blood loss and had a lower success rate. Failure was defined as the need of another procedure due to persistent pain and/or obstruction after diuretic renal imaging. One patient (2%) with primary UPJO failed and 2 patients (22%) with secondary UPJO failed. One major complication occurred. CONCLUSION: RAP is a good option for the treatment of patients with UPJO. Reported series have established that endopyelotomy has inferior success rate for the treatment of primary UPJO which compromises the success of subsequent treatment as demonstrated in our higher failure rate with secondary UPJO repair.

Factors Associated with Ureteral Stent Failure in Patients with Malignant Ureteral Obstruction.

Introduction: Management of malignant ureteral obstruction (MUO) with ureteral stents remains a clinical challenge, often involving frequent stent exchanges attributable to stent failure or other urological complications. We report our institutional experience with ureteral stents for management of MUO, including analysis of clinical factors associated with stent failure. Methods: We performed a retrospective review of patients treated with indwelling ureteral stents for MUO in nonurothelial malignancies at our tertiary-care institution between 2008 and 2019. Univariate Cox proportional hazards analysis was performed to identify clinical variables associated with stent failure and stent-related complications. Stent failure was defined as need for unplanned stent exchange, placement of percutaneous nephrostomy (PCN), or tandem stents. Results: In our cohort of 78 patients, the median (range) number of stent exchanges was 2 (0-17) during a total stent dwell time of 4.3 (0.1-40.3) months. Thirty-four patients (43.6%) developed a culture-proven urinary tract infection (UTI) during stent dwell time. Thirty-five patients (44.8%) had stent failure. Twenty-two patients (28.2%) underwent unplanned stent exchanges, 23 (29.5%) required PCN after initial stent placement, and 6 (7.7%) required tandem stents. Ten (28.6%) patients with stent failure were treated with upsized stents, which led to resolution in seven patients. Stent failure occurred with 20/44 (45.4%) Percuflex™, 15/27 (55.6%) polyurethane, and 2/3 (66.7%) metal stents. In patients with ≥2 exchanges (N = 45), median time between exchanges was 4.1 (2.0-14.8) months. Bilateral stenting and history of radiation predicted UTI development. Median overall patient survival after initial stent placement was 19.9 months (95% CI 16.5-37.9 months). Conclusions: Ureteral stent failure poses a significant medical burden to patients with MUO. Better methods to minimize stent-related issues and improve patient quality of life are needed. Using a shared decision-making approach, clinicians and patients should consider PCN or tandem stents early in the management of MUO.

Comparison of the Safety and Efficacy of Valveless and Standard Insufflation During Robotic Partial Nephrectomy: A Prospective, Randomized, Multi-institutional Trial.

OBJECTIVE: To use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation - AIS) at the conventional pressure of 15 mm Hg in robot-assisted partial nephrectomy - a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system. MATERIALS AND METHODS: Three high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mm Hg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach. RESULTS: Two hundred and two patients were accrued. SCE was decreased in the AIS 12 mm Hg group (p=0.003). PTX and PMS rates were not statistically significantly different across the 3 insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups - with lower SCE rates for AIS 12 mm Hg regardless of surgical approach. CONCLUSION: AIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mm Hg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.

Racial Comparison of Patients Undergoing Minimally Invasive Partial Nephrectomy for Renal Masses at a Large Volume Tertiary Center.

Introduction and Objective: African American (AA) race has been identified to have a higher incidence of chronic kidney disease (CKD) and worse renal cancer survival compared with Caucasian Americans (CA), irrespective of tumor size, pathologic type, and surgical procedure. We aimed to compare the outcomes between CA and AA patients undergoing minimally invasive partial nephrectomy (PN) at our high-volume center. Materials and Methods: We queried our PN data repository from 2007 to 2017. We identified 981 cases of PN (robotic n = 943 and laparoscopic n = 38), of which there were 852 CA and 129 AA patients. We compared age, sex, body mass index (BMI), operative time, estimated blood loss (EBL), nephrometry score, tumor size, pre- and postoperative estimated glomerular filtration rate (eGFR), length of stay, Charlson Comorbidity Index (CCI), tumor characteristics, and 30-day complication rate. We then estimated the overall survival and disease-specific survival. Results: Age, BMI, operative time, EBL, nephrometry score, tumor size, CCI, length of stay, and sex were not statistically different. The mean preoperative eGFR was higher in the AA cohort (91.4 mL/min/1.73 m2 vs 86.1 mL/min/1.73 m2, p = 0.007); however, at 1 year, there was no mean difference (76.8 mL/min/1.73 m2 vs 74.5 mL/min/1.73 m2, p = 0.428). There was a higher percentage of Fuhrman Grade 3/4 in the AA cohort (33.3% vs 22.5%, p = 0.044). The AA cohort had a 2.66 × higher incidence of papillary renal cell carcinoma (RCC) (34.9% vs 13.1%, p < 0.001) and unclassified RCC (3.9% vs 0.4%, p = 0.001). There was no difference in tumor stage (p = 0.260) or incidence of benign histology (15.3% vs 11.6%, p = 0.278). There were no differences in 30-day complications (p = 0.330). The median follow-up was 43.2 months. By using Kaplan-Meier curves, there was no observed difference in overall survival (p = 0.752) or disease-free survival (p = 0.403). Conclusions: Our cohort of AA and CA patients with intermediate follow-up showed no worse outcomes for CKD or survival when undergoing laparoscopic or robotic PN. For low-stage renal cancer, there was no difference in overall survival and disease-free survival at a median follow-up of 43.2 months among AA patients, despite having higher grade tumors and a higher percentage of unclassified RCC. Our cohort of AA patients did have a higher incidence of papillary RCC. The equivalent overall survival and disease-free survival could be due to the earlier discovery of lower stage renal masses incidentally identified on imaging studies performed equally for other reasons in both AA and CA patients.

Contemporary Pure Laparoscopic vs Robot-Assisted Laparoscopic Radical Nephrectomy: Is the Transition Worth It?

Introduction: The proportion of robotic procedures continues to rise. The literature reinforces that robotic procedures take longer and are often more costly. We compared cost and perioperative outcomes of laparoscopic radical nephrectomy (LRN) and robot-assisted radical nephrectomy (RARN) at our high-volume center. Materials and Methods: We retrospectively reviewed our 2012-2015 data repository for patients undergoing RARN and LRN for a renal mass. Perioperative and oncologic outcomes were compared. We performed a multivariate analysis of operative time, estimated blood loss, length of stay (LOS), and overall and major 90-day complication rates while controlling for demographic data, Charlson comorbidity index (CCI), tumor size, and surgeon factors. We compared fixed, variable, and distinct procedural costs. Results: We identified 99 LRN and 95 RARN cases. There was no difference in demographic data, tumor size, preoperative renal function, and malignant histology. LRN patients had more comorbidities (49.5% vs 27.3% CCI 2+, p = 0.018). The mean preoperative glomerular filtration rate was higher in the robotic cohort (84.8 vs 75.1, p = 0.48). Mean operative time was 32.7 minutes longer (p = 0.002) and estimated blood loss 145 mL higher (p = 0.007) for the RARN cohort. There was no difference in mean LOS. Major and all 90-day complication rates were no different. The mean procedural cost for RARN was higher by $464 when controlling for operative time (p < 0.001). Fixed costs were not statistically different. Variable costs for RARN were estimated to be $2,310 higher (p = 0.045). Conclusions: Even with cost-conscious, experienced renal surgeons, RARN is associated with a longer procedure, higher supply costs, and higher hospitalization costs. There was no difference in positive surgical margin and complications. There were fewer 30-day readmissions for the RARN cohort, which may represent under-recognized cost savings. With fewer LRN cases in the United States each year, discussion to address cost is warranted. Without better outcomes for robotic surgery, a change in reimbursement to cover costs is unlikely to happen.

Initial Experience with Single-Port Robot-Assisted Radical Cystectomy: Comparison of Perioperative Outcomes Between Single-Port and Conventional Multiport Approaches.

Background: The surgical techniques and devices used to perform radical cystectomy have evolved significantly with the advent of laparoscopic and robotic methods. The da Vinci® Single-Port (SP) platform (Intuitive Surgical, Inc., Sunnyvale, CA) is an innovation that allows a surgeon to perform robot-assisted radical cystectomy (RARC) through a single incision. To determine if this new tool is comparable to its multiport (MP) predecessors, we reviewed a single-surgeon experience of SP RARC. Materials and Methods: We identified patients at our institution who underwent RARC between August 2017 and June 2020 by one surgeon at our institution (n = 64). Using propensity scoring analysis, patients whose procedure were performed with the SP platform (n = 12) were matched 1:2 to patients whose procedure was performed with the MP platform (n = 24). Univariable analysis was performed to identify differences in any perioperative outcome, including operative time, estimated blood loss (EBL), lymph node yield, 90-day complication/readmission rates, and positive surgical margin (PSM) rates. Results: Patients who had an SP RARC on average had a lower lymph node yield than those who had an MP RARC (11.9 vs 17.1, p = 0.0347). All other perioperative outcomes, including operative time, EBL, 90-day complication rates, 90-day readmission rates, and PSM rates, were not significantly different between the SP and MP RARC groups. Conclusions: Based on their perioperative outcomes, the SP platform is a feasible alternative to the MP platform when performing RARC. The SP's perioperative outcomes should continue to be evaluated as more SP RARCs are performed.

Incisional Lumbodorsal Hernias Following Retroperitoneal Robotic Partial Nephrectomies for Small Renal Masses at a High-Volume Tertiary Referral Center.

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.