Initial robotic assistance in the surgical management of renal cell carcinoma with level 4 cavoatrial thrombus.

We report a case of left-sided renal cell carcinoma (RCC) with level 4 cavoatrial tumor thrombus where robotic assistance was used to achieve hemostasis around the kidney in order to minimize coagulopathic hemorrhage from the nephrectomy bed during subsequent open completion nephrectomy and cavoatrial thrombectomy under extracorporeal circulation and hypothermic circulatory arrest. Robotic assistance allowed for meticulous dissection and ligation of parasitic and arterial vessels to the kidney, release of renal attachments, and exposure of the inferior vena cava. The kidney was mobilized while leaving the renal vein attached and tumor thrombus undisturbed using a "minimal touch" technique. Open completion nephrectomy and cavoatrial thrombectomy was then performed. An experienced cardiac anesthesia team performed intraoperative cardiac monitoring, including trans-esophageal echocardiography. A cardiothoracic surgeon was immediately available throughout the case. Cardiopulmonary bypass was initiated within 60 min of open incision with a total duration a circulatory arrest time of 25 min. There was no bleeding from the nephrectomy bed during bypass despite heparinization and hypothermia. A left RCC with level 4 thrombus may be approached with initial robotic assistance to achieve hemostasis of the nephrectomy bed for subsequent open completion nephrectomy and cavoatrial thrombectomy under extracorporeal circulation and hypothermic circulatory arrest.

Use of percutaneous nephrostomy and ureteral stenting in management of ureteral obstruction.

The management options for ureteral obstruction are diverse, including retrograde ureteral stent insertion or antegrade nephrostomy placement, with or without eventual antegrade stent insertion. There is currently no consensus on the ideal treatment or treatment pathway for ureteral obstruction owing, in part, to the varied etiologies of obstruction and diversity of institutional practices. Additionally, different clinicians such as internists, urologists, oncologists and radiologists are often involved in the care of patients with ureteral obstruction and may have differing opinions concerning the best management strategy. The purpose of this manuscript was to review available literature that compares percutaneous nephrostomy placement vs ureteral stenting in the management of ureteral obstruction from both benign and malignant etiologies.

Predicting lymph node invasion in patients treated with robot-assisted radical prostatectomy.

INTRODUCTION: To develop a nomogram to predict lymph node invasion (LNI) in the contemporary North American patient treated with robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: We included 2,007 patients treated with RARP and pelvic lymph node dissection (PLND) at a single institution between 2008 and 2012. D'Amico low risk patients underwent an obturator and hypogastric PLND, while extended PLND was reserved for intermediate/high risk patients. Logistic regression analysis tested the relationship between LNI and all available predictors. Independent predictors of LNI were used to develop a novel nomogram. Discrimination, calibration and decision-curve analysis were used to analyze the performance of our novel nomogram, and compare it to open radical prostatectomy (ORP)-based models, namely the Godoy nomogram. RESULTS: Overall, 5.3% of our patients harbored LNI. Median number of lymph nodes removed was 6.0 (interquartile range: 4-11). The most parsimonious multivariable model to predict LNI consisted of the following independent predictors: PSA value, clinical stage, and primary and secondary Gleason scores (all p ≤ 0.02). The discrimination of our novel model was 86.2%, and its calibration was virtually optimal. Using a 2% nomogram cut off, 58% of patients would be spared PLND, while missing only 9.4% of individuals with LNI. The novel nomogram compared favorably to the Godoy nomogram, when discrimination, calibration and net-benefit were used as benchmarks. CONCLUSIONS: Approximately 5% of contemporary North American patients harbor LNI at RARP. Our novel nomogram can accurately identify these patients, and this may help to improve patient selection, and avoid unnecessary PLND in the majority of patients.

Adverse Event Rates, Timing of Complications, and the Impact of Specialty on Outcomes Following Adrenal Surgery: An Analysis of 30-Day Outcome Data From the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).

OBJECTIVE: To report on 30-day adverse event rates and timing of complications following adrenal surgery; further, to investigate the impact of specialty (general surgery vs urology) on these outcomes using a large prospective multi-institutional data registry. MATERIALS AND METHODS: Within the American College of Surgeons National Surgical Quality Improvement Program (2005-2012), patients undergoing adrenalectomy were identified (CPT-codes: 60540, 60545, 60650). Outcomes evaluated included complications, blood transfusion, length of stay, reintervention, readmission, and mortality. Complications were further evaluated in relation to discharge status (pre-/postdischarge). Multivariable regression models assessed association between specialty and 30-day morbidity/mortality. RESULTS: During the study period, 4844 patients underwent adrenalectomy (95.7% general surgery). The overall complication rate was 7.5% (n = 363); 43.2% of the complications occurred postdischarge with a substantial proportion of major complications, including cardiac, pulmonary, renal, neurologic, septic, and deep venous thrombosis/pulmonary embolism also occurring postdischarge (29.9%). The overall blood transfusion, reintervention, readmission, and mortality rates were 3.9%, 2.0%, 6.4%, and 0.6%, respectively. In adjusted analyses, specialty did not have an effect on any of the outcomes (P > .05 all). CONCLUSION: One in 13 patients suffers a complication postadrenalectomy. Approximately 40% of these complications occur postdischarge, primarily within the first 2 weeks of surgery. Accurate knowledge regarding 30-day adverse event rates and timing of complications that this study provides may facilitate improved patient-physician communication and encourage early patient follow-up in this critical window. Lastly, specialty does not seem to affect outcomes in American College of Surgeons National Surgical Quality Improvement Program participant hospitals.

When Should a Positive Surgical Margin Ring a Bell? An Analysis of a Multi-Institutional Robot-Assisted Laparoscopic Radical Prostatectomy Database.

OBJECTIVE: The impact of positive surgical margin (SM) on cancer control outcomes in prostate cancer patients is a subject of continuous debate. We test the hypothesis that the impact of SM on clinical recurrence (CR) rate may vary based on the other clinical/pathologic characteristics of the tumor. MATERIALS AND METHODS: We focused on 5290 patients treated with robot-assisted radical prostatectomy and pelvic node dissection, between 2002 and 2013, at three tertiary care centers. Regression tree analysis stratified patients into risk groups based on their tumor characteristics and the corresponding CR rate. Kaplan-Meier log-rank and multivariable Cox regression models tested the relationship between SM status and CR rate in each tree-generated risk group. RESULTS: Mean (median) follow-up time was 47.7 (39.0) months. Regression tree analysis that considered all available covariates, except SM status, divided patients based on their CR risk into the following risk groups: (1) high risk (any pT3b/pT4 disease); (2) intermediate risk (≤pT3a disease and pGS 8-10); (3) low risk (≤pT3a, pGS ≤7, and prostate-specific antigen [PSA] >9 ng/mL); and (4) very low risk (≤pT3a, pGS ≤7, and PSA ≤9 ng/mL). Positive SM had a significant detrimental impact on CR risk only in two groups: intermediate risk (p < 0.001) and high risk (p = 0.01). These observations were confirmed by multivariable analyses. CONCLUSIONS: Our findings show that positive SM had a detrimental impact on CR only in a minority of patients (15%), specifically in those with advanced pathologic stage and/or pathologically poorly differentiated tumor. For all the remaining patients (85%), positive SM by itself did not increase the risk of CR.

Long-term cancer control outcomes in patients with clinically high-risk prostate cancer treated with robot-assisted radical prostatectomy: results from a multi-institutional study of 1100 patients.

BACKGROUND: Long-term cancer control outcomes in clinically high-risk prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP) remain unknown. OBJECTIVE: To report on long-term biochemical recurrence (BCR)-free survival, clinical recurrence (CR)-free survival, and salvage therapy rates in these patients. Given the heterogeneity of high-risk patients, a second objective was to stratify them according to their BCR risk (using preoperative parameters), in an effort to counsel them better preoperatively regarding their cancer control outcomes. DESIGN, SETTING, AND PARTICIPANTS: We evaluated 1100 D'Amico high-risk PCa patients who underwent RARP between 2002 and 2013 at three tertiary care centers. OUTCOME MEASURES AND STATISTICAL ANALYSES: Outcomes consisted of BCR-free survival, CR-free survival, and salvage therapy rates. Regression tree analysis stratified patients into novel risk groups based on preoperative characteristics and corresponding BCR risk. Kaplan-Meier curves estimated BCR-free survival, CR-free survival, and salvage therapy rates in the entire cohort and after stratification according to the novel risk groups (RGs). RESULTS AND LIMITATIONS: Median age and prostate-specific antigen (PSA) were 63 yr and 6.5 ng/ml, respectively. Biopsy Gleason score (GS) was ≥8 in 57.7%. Mean follow-up was 53 mo (median: 49 mo). At 10 yr, BCR-free survival, CR-free survival, and salvage therapy rates were 50%, 87%, and 37%, respectively. Regression tree analysis stratified patients into five novel RGs): RG1, very low risk (GS ≤6); RG2, low risk (PSA ≤10 ng/ml; GS: 7); RG3, intermediate risk (PSA ≤10 ng/ml; GS ≥8); RG4, high risk (PSA >10 ng/ml; GS: 7); RG5, very high risk (PSA >10 ng/ml; GS ≥8). In these RGs, the 10-yr BCR-free survival rates were 86%, 70%, 36%, 31%, and 26% (p<0.001), respectively; the 10-yr CR-free survival rates were 99%, 96%, 85%, 67%, and 55% (p<0.001), respectively; and the 10-yr salvage therapy rates were 9.8%, 16%, 42%, 47%, and 64% (p<0.001), respectively. CONCLUSIONS: Most patients with clinically high-risk PCa treated with RARP alone remain CR free at long term. Nonetheless, almost 37% of the patients at 10 yr require salvage therapy. Our novel tool allows accurate stratification of these heterogeneous patients according to their BCR, CR, and salvage therapy risks. This may help inform patients preoperatively about their cancer control outcomes postoperatively. PATIENT SUMMARY: Robot-assisted radical prostatectomy confers lasting long-term oncologic control in most high-risk prostate cancer patients. Our novel risk grouping might serve as a useful tool for setting expectations and counseling patients regarding their cancer control outcomes.

Causes of emergency department visits following thyroid and parathyroid surgery.

IMPORTANCE: With reimbursement being increasingly tied to outcome measures, minimizing unexpected health care needs in the postoperative period is essential. This article describes reasons for emergency department (ED) evaluation, rates of readmission to the hospital, and significant risk factors for readmission during the postoperative period. OBJECTIVE: To describe the subset of patients requiring ED evaluation within 30 days of thyroidectomy or parathyroidectomy and their associated risk factors. DESIGN, SETTING, AND PATIENTS: Retrospective chart review in a tertiary care center of adult patients who underwent thyroidectomy or parathyroidectomy between January 1, 2009 and October 7, 2010. Patients were identified from an institutional review board-approved database. Postoperative patients who visited the emergency department (ED) within the first 30 days following surgery were selected and compared with the postoperative patients who did not visit the ED. EXPOSURES: Thyroidectomy or parathyroidectomy. MAIN OUTCOMES AND MEASURES: Statistical analysis evaluated the association of demographic and clinical characteristics between the patients who required ER evaluation and those who did not. Clinical characteristics evaluated included type of surgery, medical comorbidities, and proton pump inhibitor (PPI) usage. Multiple logistic regression predicted the odds of an ED visit based on presence of diabetes, gastroesophageal reflux disease (GERD), or PPI use. RESULTS: Of the 570 patients identified, 64 patients required a visit to the ER a total of 75 times for issues including paresthesias (n = 28), wound complications (n = 8), and weakness (n = 6). Fifteen hospital admissions occurred for treatment of a variety of postoperative complications. A significant association was found between the presence of diabetes (P = .03), GERD (P = .04), and the current use of PPIs (P = .03). When controlling for diabetes and GERD, we found that patients taking PPIs were 1.81 times more likely to visit the ED than patients not taking PPIs (P = .04). CONCLUSIONS AND RELEVANCE: Patients taking PPIs are 1.81 times more likely to require ED evaluation than those who are not taking PPIs.