Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy

ABSTRACT Purpose We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN). Patients and Methods We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI. Results Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04). Conclusion Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.

Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy.

PURPOSE: We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN). PATIENTS AND METHODS: We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI. RESULTS: Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04). CONCLUSION: Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.

Predictors of positive surgical margins in patients undergoing partial nephrectomy: A large single-center experience.

OBJECTIVE: To identify preoperative factors that predict positive surgical margins in partial nephrectomy. MATERIAL AND METHODS: Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. RESULTS: A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m2 vs. 81.2 mL/min/1.73 m2, p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins. CONCLUSION: In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons.

Significance of the nonneoplastic renal parenchymal findings in robotic partial nephrectomy series.

AIM: To describe the pathological characteristics of the peritumoral non-neoplastic renal parenchyma (NNRP) and to investigate their impact on long-term renal function after partial nephrectomy. MATERIALS AND METHODS: In our institutional robotic partial nephrectomy database, we identified 394 cases with pathological assessment of the NNRP and long-term postoperative renal functional follow-up. The NNRP was classified as normal (healthy renal parenchyma) or abnormal, based on the presence of arteriosclerosis, glomerulosclerosis, interstitial fibrosis, interstitial inflammation, and/or tubulopapillary hyperplasia. The primary outcome was a ≥ 20% decline in estimated glomerular filtration rate (eGFR) at 6 and 12 months after surgery. Multivariable analysis was used to assess the association between NNRP and eGFR decline, with adjustment for demographic, clinical, and tumor factors. RESULTS: Overall, 250 (63.5%) pathological specimens had abnormal NNRP features. The most prevalent isolated benign pathological feature was glomerulosclerosis (18.0%), followed by arteriosclerosis (16.8%), interstitial inflammation (12.4%), interstitial fibrosis (1.2%), and tubulopapillary hyperplasia (0.4%). The abnormal NNRP group was associated with older age (p = .01), preoperative diabetes mellitus (p = .01), and preoperative hypertension (p = .01). The preoperative eGFR was significantly lower in the abnormal NNRP group (p = .01). NNRP abnormalities were not significantly associated with eGFR decline at either 6 or 12 months. The only independent predictor of eGFR decline was warm ischemia time (p = .01), and this association was only observed at 12 months. CONCLUSION: NNRP features are associated with preoperative comorbidities and lower baseline eGFR; however, they are not independent predictors of long-term renal functional preservation after partial nephrectomy.

Correlation Between Residual Volume of Male Patients After Uroflowmetry and Random Residual Volume.

OBJECTIVES: Our aim was to examine correlation between Post-void residual urine (PVR) after uroflowmetry and random PVR. METHODS: Male patients reporting to the Urology outpatient clinic with LUTS were selected. Patients' age, prostate volume, bladder capacity, voided volume, maximum flow rate, average flow rate, random PVR and PVR after uroflowmetry were recorded. We evaluated the correlations between these parameters. Also we assessed if there was a difference between random PVR and PVR after uroflowmetry. We divided PVR after uroflowmetry and random PVR into three groups: Group 1: 0-50 mL, Group 2: 51-100 mL and Group 3: >100 mL. Also we divided the patients into two groups according to bladder capacity as Group 1: ≤400 mL and Group 2: >400 mL. We compared these groups to determine whether a significant difference. RESULTS: Seventy-seven patients applying to the urology outpatient clinic were assessed between 2013 and 2014. PVR after uroflowmetry was significantly higher than random PVR (P < 0.001). When we divided PVR after uroflowmetry and random PVR into three groups there was a significant difference between the groups (P = 0.02). When we divided the patients into two groups according to bladder capacity as Group 1: ≤400 mL and Group 2: >400 mL, PVR after uroflowmetry was different, but random PVR was similar (P < 0.001, P = 0.72). CONCLUSIONS: PVR after uroflowmetry seems to be incorrectly high in patients whose bladder capacity is above 400 mL.

Associations Between Prostate Volume and Oncologic Outcomes in Men Undergoing Focal Cryoablation of the Prostate.

INTRODUCTION: The purpose of this study was to assess the relationship of total prostate volume (TPV) and oncologic outcomes following focal prostate cryoablation. MATERIALS AND METHODS: A query of the Cryo On-Line Database (COLD) registry for men who underwent primary focal prostate cryoablation revealed 829 patients with complete data. The impact of TPV on oncologic outcomes including progression-free survival (PFS) and post-cryoablation biopsy outcome was assessed using Kaplan-Meier curves and Cox and logistic regression models. RESULTS: The median follow-up time was 25.2 months (interquartile range [IQR], 12.7-48.2 months). The median age at time of treatment was 68 years (IQR, 63-74 years) with median prostate-specific antigen (PSA) 5.6 ng/mL (IQR, 4.4-7.5 ng/mL), and median TPV 35 mL (IQR, 26.5-46 mL). PFS was achieved in 83.2%, with positive post-cryoablation biopsy detected in 81 (35.7%) of 228 patients. Higher TPV was associated with higher biochemical progression (BP) using the Phoenix definition (39 vs. 34.5 mL; P = .003) and was an independent predictor of BP (hazard ratio, 1.01; P = .02). Conversely, men who had a positive post-cryoablation biopsy had significantly smaller median TPV on univariate and multivariate analyses (31 vs. 39 mL; P < .001), (odds ratio, 0.97; P = .001), respectively. Higher median pretreatment PSA density was associated with higher BP (0.18 vs. 0.16; P = .005) and positive post-cryoablation biopsy rates (0.2 vs. 0.16; P = .003). CONCLUSION: Prostate volume has contradictory effects on BP and post-cryoablation biopsy outcome in men who underwent primary focal prostate cryoablation. Remnant viable tissue in larger prostates continues to produce more PSA over time, which may impact BP. This may raise the need to develop a new definition for oncologic success following focal gland therapy rather than the American Society for Radiation Oncology (ASTRO) and Phoenix definitions.

Comparison of factors affecting the short-term presentation of results in the surgery of distal hypospadias in adults / Comparación de factores que afectan la presentación a corto plazo de los resultados en la cirugía de hipospadias distales en adultos

Introduction. To determine the factors affecting the success of distal hypospadias repair in adults. Material and methods. Medical records of adult patients who underwent distal hypospadias repair in our clinic were reviewed. Patient's age, external urethral meatus location, hypospadias status, anesthesia type, diversion type, nelaton diameter and surgeons were recorded as factors affecting surgery success. Only patients, operated with tubularisation incised plate urethroplasty (TIPU) technique, were included. Results were classified as successful, stricture, fistula and slough. We compared the factors affecting the success. SPSS 16.0 were used for statistical assessment and logistic regression analysis was used to determine success. p<0.05 was considered to show statistical significance. Results. One hundred and eight patients underwent distal hypospadias repair in our clinic. Mean age was 21.44±2.0. 38 patients had distal penile, 67 patients had subcoronal, 2 patients had coronal and 1 patient had glandular hypospadias. Eighty eight patients had primary, 12 secondary, 5 tertiary and 3 cripple hypospadias. Seventy eight patients underwent TIPU under local anesthesia, and 30 patients underwent under spinal anesthesia. Suprapubic catheter was used in 92 patients and transurethral catheter was used in 16 patients. Sixteen different surgeons performed the operations. Seventy operations were successful. Three stricture, 24 fistula, and 11 slough were determined. Overall success rate was 64.81%. Patient's age, external urethral meatus location, anesthesia type, diversion type, nelaton diameter and the surgeon difference did not affected surgical outcomes. Only hypospadias status (primary/redo) affected the success (p=0.037). Conclusion. The only factor affecting surgical outcomes of distal hypospadias repair in adults seems to be hypospadias status. It might be due to the lack of second layer in the redo operations (AU)

Introducción. Determinar los factores que influyen en el éxito de la reparación de hipospadias distal en adultos. Materiales y métodos. Se revisaron las historias clínicas de los pacientes adultos que se sometieron a reparación de hipospadias distal en nuestra clínica. Los siguientes factores se consideraron factores que afectan al éxito de la operación:la edad del paciente, la localización del meato uretral externo, el estado de hipospadias, el tipo de anestesia, el tipo de desvío, el diámetro nelaton y los cirujanos. Solo se tuvieron en cuenta los pacientes operados con la técnica de plato incidido tubularizaciónuretroplastia (TIPU). Los resultados fueron clasificados como: exitoso, estenosis, fístulas y Slough. Se compararon los factores que influyeron en el éxito de la operación. Se utilizóSPSS 16.0 para la evaluación estadística, mientras que el análisis de regresión logística se utilizó para determinar el éxito. Para mostrar significación estadística, se usóla cifra p <0,05. Resultados. Ciento ocho pacientes fueron sometidos a reparación de hipospadias distal en nuestra clínica. La media de edad fue de 21.44 ± 2.0. 38 pacientes tenían pene distal, 67 pacientes, tenían hipospadiassubcoronal, 2 pacientes,coronal y 1 paciente,glanular. Ochenta y ocho pacientes lo tenían primario, 5 secundario y 3,terciario. Setenta y ocho pacientes fueron sometidos a TIPU bajo anestesia local y a 30 pacientes se les realizó bajo anestesia epidural. Se utilizóun catéter suprapúbico en 92 pacientes y una sonda transuretral, en 16 pacientes. Dieciséis cirujanos diferentes se encargaron de llevar a cabo las operaciones; setenta de las cuales tuvieron éxito y hubo, además,tres casos de estenosis, 24 fístulas y 11 Slough. En general la tasa de éxito fue del 64.81%. La edad del paciente, la localización del meato uretral externo, el tipo de anestesia, el tipo de desvío, el diámetro del Nelatony el hecho de haber sido realizados por diferentes cirujanos no afectaron a los resultados quirúrgicos. Solo el estado de hipospadias (primari/reconstrucción) afectó al éxito (p=0.037). Conclusión. El único factor que influye en los resultados quirúrgicos de reparación de hipospadias distal en adultos parece ser el estado de los propios hipospadias. Podría ser debido a la falta de aplicación de la segunda capa en las operaciones reconstructoras (AU)

Optimum outcome achievement in partial nephrectomy for T1 renal masses: a contemporary analysis of open and robot-assisted cases.

OBJECTIVES: To compare optimum outcome achievement in open partial nephrectomy (OPN) with that in robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: Using our institutional partial nephrectomy (PN) database, we reviewed 605 cases performed for unifocal clinical T1 renal masses in non-solitary kidneys between 2011 and 2015. Tetrafecta, which was defined as negative surgical margins, freedom from peri-operative complications, ≥80% renal function preservation, and no chronic kidney disease upstaging, was chosen as the composite optimum outcome. Factors associated with tetrafecta achievement were assessed using multivariable logistic regression, with adjustment for age, gender, race, Charlson comorbidity score, body mass index, chronic kidney disease, tumour size, tumour complexity and approach. RESULTS: The overall tetrafecta achievement rate was 38%. Negative margins, freedom from complications, and optimum functional preservation were achieved in 97.1%, 73.6% and 54.2% of cases, respectively. For T1a masses, the tetrafecta achievement rate was similar between approaches (P = 0.97), but for T1b masses, the robot-assisted approach achieved significantly higher tetrafecta rates (43.0% vs 21.3%; P < 0.01). On multivariable analysis, the robot-assisted approach had 2.6-fold higher odds of tetrafecta achievement than the open approach, primarily because of lower peri-operative morbidity, specifically related to wound complications. Positive surgical margin rates and renal function preservation were similar in the two approaches. CONCLUSIONS: Optimum outcomes are readily achieved regardless of PN approach. The robot-assisted approach may facilitate optimum outcome achievement for 4-7-cm masses by minimizing wound complications.

The Synergistic Influence of Ischemic Time and Surgical Precision on Acute Kidney Injury After Robotic Partial Nephrectomy.

OBJECTIVE: To examine the dynamic and potentially synergistic influence of warm ischemia time (WIT) and excisional volume loss (EVL) on predicted rates of postpartial acute kidney injury (AKI) across a range of tumor complexities, and to investigate whether these modifiable variables sensitize the kidney to each other's damaging influence. MATERIALS AND METHODS: We retrospectively reviewed 1245 patients between 2006 and 2016 with bilateral kidneys and enhancing renal masses in our single-institution robotic partial nephrectomy (PN) database. EVL was calculated as the difference between specimen and tumor volume based on pathologic measurements. Multivariate logistic regressions, followed by marginal effects, were run to examine the interaction of ischemia type, EVL, and radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line score on rates of AKI. RESULTS: We found a significant interaction effect of WIT and log EVL on predicted AKI (P < .001). Each doubling of EVL caused a 4.03% and 8.46% increased probability of AKI for WIT of <25 and >25 minutes, respectively. At an EVL of >5.5 cm3, prolonged WIT had statistically greater odds of causing AKI. These predicted effects on AKI were amplified for increasing radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line scores (P < .001). CONCLUSION: Although the adverse functional effects of WIT and parenchymal volume loss during PN have previously been described in isolation, our findings suggest that their influence on AKI is synergistic, especially in complex tumors. As such, additional attention should be given to limiting warm ischemia and maximizing surgical precision to avoid a "double hit" on postoperative renal function.

Excisional Precision Matters: Understanding the Influence of Excisional Volume Loss on Renal Function After Partial Nephrectomy.

Renal function after partial nephrectomy (PN) may depend on modifiable factors including ischemia time, excision of healthy parenchyma (excisional volume loss, EVL), and reconstructive methods. We retrospectively reviewed our institutional robotic PN database to identify the predictors of glomerular filtration rate (GFR) preservation (GFR-P) at 3-12 mo postoperatively, during which GFR decline plateaus. Baseline clinical, sociodemographic, and radiologic characteristics were captured. Univariate and multivariate (MV) linear regression analyses were performed and marginal effects were employed to examine the relative effect of EVL on renal function. A total of 647 patients who underwent robotic PN had GFR data at a median follow-up of 6 mo. On MV models, EVL was significantly correlated with GFR-P following log transformation (p=0.001). Each doubling of EVL caused a 1.5% decrease in GFR-P. Ischemia time and tumor complexity were not significantly associated with GFR-P. In summary, GFR-P after PN appears to be significantly associated with the excised volume of benign parenchyma. PATIENT SUMMARY: At a high-volume tertiary care center, we investigated the impact of surgical factors on kidney function after kidney cancer surgery. We found that the surgical precision with which the tumor is excised significantly impacts kidney function at 3-12 mo after surgery.

Perioperative morbidity, oncological outcomes and predictors of pT3a upstaging for patients undergoing partial nephrectomy for cT1 tumors.

OBJECTIVES: To evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN). MATERIALS AND METHODS: Retrospective study of 1042 patients who underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test. RESULTS: The pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7, p < 0.01), higher hilar (h) location (27.5 vs. 14.8%, p < 0.01), higher grade (57.5 vs. 38.2%, p < 0.01), and higher positive surgical margins (18.6 vs. 5.8%, p < 0.01. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time and overall complications, though there were no differences in median e-GFR decline and major (Grade III-V) complications. Five-year RFS was 78.5% for pT3a group vs. 94.6% for pT1 group (log-rank p < 0.01). Male gender (OR 2.2, p < 0.01), and R.E.N.A.L. score (OR 2.3, p = 0.01) were preoperative predictors of upstaging. We acknowledge limitations in our study, most are inherent problems of retrospective studies. CONCLUSION: Perioperative morbidity, after partial nephrectomy, is acceptable in cT1/pT3 tumors in comparison to cT1/pT1; however, upstaged patients had a worse oncological outcome. cT1/pT3a tumors are associated with adverse clinico-pathological features. Preoperative risk predictors of upstaging were higher R.E.N.A.L. score and male gender.

When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center.

PURPOSE: We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. MATERIALS AND METHODS: Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. RESULTS: The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). CONCLUSIONS: At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.

Robotic Assisted Laparoscopic Augmentation Ileocystoplasty.

INTRODUCTION: Augmentation ileocystoplasty is a common treatment in adults with low capacity bladders due to neurogenic bladder dysfunction. We describe here our technique for robotic assisted laparoscopic augmentation ileocystoplasty in an adult with a low capacity bladder due to neurogenic bladder dysfunction. MATERIALS AND METHODS: The patient is a 35 years-old man with neurogenic bladder due to a C6 spinal cord injury in 2004. Cystometrogram shows a maximum capacity of 96cc and Pdet at maximum capacity of 97cmH2O. He manages his bladder with intermittent catheterization and experiences multiple episodes of incontinence between catheterizations. He experiences severe autonomic dysreflexia symptoms with indwelling urethral catheter. He has previously failed non operative management options of his bladder dysfunction. Our surgical technique utilizes 6 trocars, of note a 12mm assistant trocar is placed 1cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the enteric anastomosis. Surgical steps include: development of the space of Retzius/dropping the bladder; opening the bladder from the anterior to posterior bladder neck; excision of a segment of ileum; enteric anastomosis; detubularizing the ileal segment; suturing the ileal segment to the incised bladder edge. RESULTS: The surgery had no intraoperative complications. Operative time was 286 minutes (4.8 hours). Estimated blood loss was 50cc. Length of hospital stay was 8 days. He did experience a postoperative complication on hospital day 3 of hematemesis, which did not require blood transfusion. Cystometrogram at 22 days post operatively showed a maximum bladder capacity of 165cc with a Pdet at maximum capacity of 10cmH2O. CONCLUSIONS: As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. In this case we successfully performed a robotic assisted laparoscopic augmentation ileocystoplasty displaying improvement in measurable functional outcomes.

Robotic Assisted Radical Cystoprostatectomy and Intracorporeal Ileal Conduit Urinary Diversion for a Kidney Transplant Recipient.

INTRODUCTION AND OBJECTIVES: Robotic assisted radical cystectomy (RARC) is an alternative to open radical cystectomy. As experience is gained with the RARC approach the technique is being applied to more complex surgical cases. We describe here our technique for RARC with intracorporeal ileal conduit urinary diversion for a renal transplant recipient. MATERIALS AND METHODS: The patient is a 60-year old man with high-grade muscle invasive bladder cancer. He has a history of renal failure due to polycystic kidney disease and received a deceased donor renal transplant in 2008. His hospital course at time of transplant was complicated by low-level BK virus viremia. Interestingly his trans-urethral bladder tumor resection specimen at time of bladder cancer diagnosis stained positive for SV40. His native kidneys were anuric so bilateral laparoscopic nephrectomy was performed in a staged fashion 2 weeks prior to RARC. Our surgical technique utilizes 6 trocars, of note a 12-mm assistant trocar is placed 1 cm superior to the pubic symphysis, and this trocar is solely used to pass a laparoscopic stapler to facilitate the excision of the ileal segment and the stapled enteric anastomosis. Surgical steps include: identification of native ureters bilaterally (removed en bloc with the bladder specimen); identification of the transplanted ureter at the right bladder dome; posterior bladder and prostate dissection along Denonvilliers' fascia; development of the space of Retzius; ligation and transection of the bladder and prostate vascular bundles; apical prostate dissection and transection of urethra; left pelvic lymphadenectomy; ilium resection for creation of the ileal conduit; stapled enteric anastomosis; ureteroileal anastomosis; maturation of the ileal conduit stoma. RESULTS: The surgery had no intraoperative complications. Operative time was 443 minutes (7.4 hours). Estimated blood loss was 250 cc. Length of hospital stay was 5 days. The patient did not experience any postoperative complications. The patient maintained good renal graft function with no decline in eGFR to date. CONCLUSIONS: As surgeon comfort and experience with robotic assisted surgery grows, robotic surgery can successfully be applied to less frequently performed procedures. Here we successfully performed a robotic assisted radical cystoprostatectomy with intracorporeal ileal conduit urinary diversion for a renal transplant recipient.

Robot-assisted approach improves surgical outcomes in obese patients undergoing partial nephrectomy.

OBJECTIVES: To assess the impact of approach on surgical outcomes in otherwise healthy obese patients undergoing partial nephrectomy for small renal masses. PATIENTS AND METHODS: Using our institutional partial nephrectomy database, we abstracted data on otherwise healthy (Charlson comorbidity score ≤1 and bilateral kidneys), obese patients (body mass index >30 kg/m2 ) with small renal masses (<4 cm) treated between 2011 and 2015. The primary outcomes were intra-operative transfusion, operating time, length of hospital stay (LOS), and postoperative complications. The association between approach, open (OPN) vs robot-assisted partial nephrectomy (RAPN), and outcomes was assessed by univariable and multivariable logistic regression analyses. Covariates included age, gender, obesity severity, tumour size and tumour complexity. RESULTS: Of 237 obese patients undergoing partial nephrectomy, 25% underwent OPN and 75% underwent RAPN. Apart from larger tumour size in the OPN group (2.8 vs 2.5 cm; P = 0.02), there was no significant difference between groups. The rate of intra-operative blood transfusion (1.1 vs 10%; P = 0.01), the median operating time (180 vs 207 min; P < 0.01) and the median ischaemia time (19.5 vs 27 min; P < 0.01) were all greater for OPN. The LOS was significantly shorter for RAPN (3 vs 4 days; P < 0.01). While the overall complication rate was higher for OPN (15.8 vs 31.7%; P < 0.01), major complications were not significantly different (5.6 vs 1.7%; P = 0.20). On multivariable analyses, OPN independently predicted longer operating time, longer length of stay, and more overall complications. CONCLUSIONS: At a high-volume centre, the robot-assisted approach offers less blood transfusion, shorter operating time, faster recovery, and fewer peri-operative complications compared with the open approach in obese patients undergoing partial nephrectomy for small renal masses. In this setting, RAPN may be a preferable treatment option.

Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors.

PURPOSE: We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy. MATERIALS AND METHODS: We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan-Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated. RESULTS: Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease-free survival on Kaplan-Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease-free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five-year disease-free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01). CONCLUSIONS: High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.

Non-modifiable factors predict discharge quality after robotic partial nephrectomy.

PURPOSE: To identify predictors of poor discharge quality after robotic partial nephrectomy (RPN) at a large academic center. METHODS: We queried our institutional RPN database for consecutive patients treated between 2011 and 2015. The primary outcome was poor discharge quality, defined as length of stay >3 days and/or unplanned readmission. The association between patient, disease, and provider factors and overall discharge quality was assessed using univariate and multivariable analyses. RESULTS: Of 791 cases, 219 (27.7 %) had poor discharge quality. On univariate analysis, factors associated with poor discharge quality were older age (p < .01), black race (p = .01), social insurance (p < .01), higher ASA score (p < .01), chronic kidney disease (p < .01), increased tumor size (p < .01), and higher tumor complexity (p = .01). Surgeon case volume did not predict discharge quality (p = .63). After adjustment for covariates on multivariable analysis, race (p = .01), ASA (p = .02), CKD (p < .01), tumor size (p = .02), and tumor complexity (p = .03) still predicted poor discharge quality. In particular, the odds of poor discharge quality were highest in the setting of CKD (OR 2.62, 95 % CI 1.72-4.01), black race (OR 2.17, 95 % CI 1.32-3.57), and higher ASA (OR 1.49, 95 % CI 1.07-2.08). CONCLUSIONS: Non-modifiable patient and disease factors predict poor discharge quality after RPN. Risk adjustment for these factors will be important for determining future reimbursement for RPN providers.

Robotic and open partial nephrectomy for localized renal tumors larger than 7 cm: a single-center experience.

PURPOSE: To compare perioperative outcomes between robotic partial nephrectomy and open partial nephrectomy for localized >7 cm tumors. METHODS: We identified patients in our institutional review boards approved database who underwent robotic partial nephrectomy or open partial nephrectomy for treatment of renal tumors >7 cm in size between January 2009 and August 2015. The operative-postoperative outcomes and complications were compared between groups. RESULTS: The number of patients with >7 cm renal tumors treated at our center with robotic partial nephrectomy and open partial nephrectomy were 54 and 56, respectively. Patients' demographics and tumor characteristics were similar between groups. Likewise, there were no significant difference between the groups in duration of operation, positive surgical margin rates and incidence of malignant disease rates. Median ischemia time was lower in robotic partial nephrectomy group (31.5 vs. 35 min., p = 0.02). Patients undergoing robotic partial nephrectomy had significantly lower intraoperative blood transfusion rates (9.4 vs. 30.4 %, p = 0.008) and shorter length of hospital stay (3.5 vs. 5.3 days, p < 0.001). The incidence of overall complications (robotic arm, 18.5 % vs. open arm, 28.6 %, p = 0.26) and major complications (robotic arm, 3.7 % vs. open arm, 12.5 %, p = 0.16) was comparable between the two groups. The readmission rate within 30-days after discharge was higher in open partial nephrectomy group (p = 0.03). There was no difference in the median percentage estimated glomerular filtration rate preservation and chronic kidney disease upstaging between groups. CONCLUSIONS: Localized renal tumors >7 cm and amenable to partial nephrectomy can be considered suitable for robotic approach.

Multiple Tumor Excisions in Ipsilateral Kidney Increase Complications After Partial Nephrectomy.

INTRODUCTION: The surgical morbidity of ipsilateral synchronous multifocality (ISM) is poorly characterized. We assessed the impact of ISM on complications after robotic partial nephrectomy (RPN). PATIENTS AND METHODS: We abstracted data on RPN cases performed between 2006 and 2015 at our institution. Multifocal disease was characterized by >1 renal mass on preoperative imaging or >1 mass excision during RPN. The primary outcome was the rate of overall postoperative complications. The association between multifocality and complications was evaluated using univariate and multivariable analyses. RESULTS: Of 1121 cases, 59 (5.3%) had >1 ipsilateral renal mass and 50 (4.5%) required >1 excision. The overall complication rate was 20.3% (230/1121). The radiographic number of ipsilateral renal masses was not significantly associated with complications (20.2% for 1 mass vs. 25.4% for >1 mass, p = 0.338). However, the actual number of ipsilateral mass excisions performed during RPN was significantly associated with complications (20.2% for ≤2 excisions vs. 42.9% for >2 excisions, p = 0.037). Major complications were higher (14.3% vs. 5.3%) for >2 versus ≤2 excision(s), but this difference was not significant (p = 0.174). The most common complications associated with multiple excisions were transfusion, urine leak, arrhythmia, venous thromboembolism, and ileus. On multivariable analysis, number of excisions independently predicted complications (OR 3.1, 95% CI 1.03-9.33, p = 0.041). Other independent predictors of complications included age, race, Charlson score, body mass index, RENAL score, and surgeon experience. CONCLUSIONS: ISM requiring ≥2 excisions is associated with increased morbidity after RPN. Pending external validation, this information may facilitate clinical decision-making and preoperative patient counseling.

Is robotic partial nephrectomy convenient for solitary kidney?

Nephron sparing surgery (NSS) is the gold standard treatment option for patients with a solitary kidney in order to preserve renal function. Open partial nephrectomy (OPN) has been long considered the standard care for NSS. Robotic partial nephrectomy (RPN) is being gradually used more commonly even for solitary kidney and complex tumors. There was no difference between RPN and OPN regarding the rate of intraoperative-postoperative complications and positive surgical margin (PSM) (RPN: 7.5%, OPN: 8%) for patients with solitary kidney who underwent partial nephrectomy for small renal masses. Warm ischemia time (WIT) in all of our studies was within the safe range of <25 minutes which is acceptable ischemia time for robotic approaches. More studies are needed in order to evaluate kidney function. In conclusion with increasing experience, solitary kidney tumors can be managed safely with robotic approach. For patients having complex tumors with a potential of WIT >25 minutes, administration of intracorporeal ice slush during surgery may be considered.