Comparison of Single-Port Robotic Donor Nephrectomy and Laparoscopic Donor Nephrectomy.

Purpose: To compare the intra- and postoperative outcomes of single-port robotic donor nephrectomies (SP RDNs) and laparoscopic donor nephrectomies (LDNs). Materials and Methods: We retrospectively reviewed our institutional database for patients who received LDN or SP RDN between September 2020 and December 2022. Donor baseline characteristics, intraoperative outcomes, postoperative outcomes, and recipient renal function were extracted and compared between LDN and SP RDN. SP RDN learning curve analysis based on operative time and graft extraction time was performed using cumulative sum analysis. Results: One hundred forty-four patients underwent LDN and 32 patients underwent SP RDN. LDN and SP RDN had similar operative times (LDN: 190.3 ± 28.0 minutes, SP RDN: 194.5 ± 35.1 minutes, p = 0.3253). SP RDN patients had significantly greater extraction times (LDN: 83.2 ± 40.3 seconds, SP RDN: 204.1 ± 52.2 seconds, p < 0.0001) and warm ischemia times (LDN: 145.1 ± 61.7 seconds, SP RDN: 275.4 ± 65.6 seconds, p < 0.0001). There were no differences in patient subjective pain scores, inpatient opioid usage, or Clavien-Dindo II+ complications. Short- and medium-term postoperative donor and recipient renal function were also similar between the groups. SP RDN graft extraction time and total operative time learning curves were achieved at case 27 and 13, respectively. Conclusion: SP RDN is a safe and feasible alternative to LDN that minimizes postoperative abdominal incisional scars and has a short learning curve. Future randomized prospective clinical trials are needed to confirm the findings of this study and to identify other potential benefits and drawbacks of SP RDNs.

Swiss LithoClast® Trilogy Lithotripter for Use in Robotic Pyelolithotomy.

Introduction: The Boston Scientific Swiss LithoClast® Trilogy lithotripter was intended for use in percutaneous nephrolithotomy. We performed, to our knowledge, the first two robotic pyelolithotomies using the Trilogy lithotripter for intracorporeal lithotripsy. Case Description: Two cases are presented involving a 65-year-old female with a complete left staghorn calculus and hydronephrosis secondary to a left ureteropelvic junction (UPJ) obstruction, and a 69-year-old male with a large left staghorn calculus and multiple large left sided simple renal cysts. In both cases, a robotic pyelolithotomy was scheduled for stone removal along with concurrent UPJ repair and cyst decortication respectively. Following pyeloplasty and cyst decortication respectively, and following stone visualization, the 2.4-mm Trilogy probe was inserted into the 12-mm assistant port and under direct visualization the stone was fragmented and removed using Trilogy's built-in mechanisms. Both patients were treated successfully without complications and were found to be stone-free on follow-up. Conclusion: The Trilogy lithotripter may be an effective tool for stone management when introduced during robotic pyelolithotomy and provides additional optionality when manual extraction poses challenges.

The Role of Experience: How Case Volume and Endourology-Fellowship Training Impact Surgical Outcomes for Ureteroscopy.

Introduction: Surgical experience is associated with superior outcomes in complex urologic cases, such as prostatectomy, nephrectomy, and cystectomy. The question remains whether experience is predictive of outcomes for less complex procedures, such as ureteroscopy (URS). Our study examined how case volume and endourology-fellowship training impacts URS outcomes. Methods: We retrospectively reviewed URS cases from 2017 to 2019 by high ureteroscopy volume urologists (HV), low ureteroscopy volume urologists (LV), endourology-fellowship trained (FT), and non-endourology FT (NFT) urologists. Surgical outcomes including stone-free rate (SFR), complication and reoperation rates, and postoperative imaging follow-up were analyzed between groups. Results: One thousand fifty-seven cases were reviewed across 23 urologists: 6 HV, 17 LV, 3 FT, and 20 NFT. Both FT and HV operated on more complex cases with lower rates of pre-stented patients. HV also operated on patients with higher rates of renal stones, lower pole involvement, and prior failed procedures. Despite this, FT and HV showed between 11.7% and 14.4% higher SFR, representing 2.7- to 3.6-fold greater odds of stone-free outcomes for primary and secondary stones. Additionally, HV and FT had a 4.9% to 7.8% lower rate of postoperative complications and a 3.3% to 4.3% lower rate of reoperations, representing 1.9- to 4.0-fold lower odds of complications. Finally, their patients had a 1.6- to 2.1-fold higher odds of postoperative imaging follow-up with a greater proportion receiving postoperative imaging within the recommended 3-month postoperative period. Conclusions: More experienced urologists, as defined by higher case volume and endourology-fellowship training, had higher SFR, lower complication and reoperation rates, and better postoperative imaging follow-up compared with less experienced urologists. Although less experienced urologists had outcomes in-line with clinical and literature standards, continued training and experience may be a predictor of better outcomes across multiple URS modalities.

Clinical and treatment characteristics of secondary bladder malignancies following low dose rate brachytherapy for prostate cancer.

PURPOSE/OBJECTIVES: To characterize the clinical course and prognosis of bladder malignancies associated with prior prostate brachytherapy SUBJECTS/PATIENTS AND METHODS: We queried our institutional database for patients with bladder cancer (BC) diagnosed between January 2005 and April 2019 who had previously undergone low dose rate (LDR) prostate brachytherapy. Patients diagnosed with BC at least 1 year following LDR prostate brachytherapy with or without external beam radiation therapy were included. Clinical and disease-specific characteristics were abstracted from chart review and survival outcomes were estimated using Kaplan-Meier estimates. We compared the pathologic characteristics and prognosis of secondary BCs in our study cohort to those of BCs diagnosed after prostate cancer managed without radiation reported by the Surveillance, Epidemiology, and End Results (SEER) populational database from 2005 to 2018. RESULTS: Three hundred seventy-five patients were identified with combined diagnosis of prostate cancer and BC, 51 of whom met inclusion criteria in the study cohort. Median times from brachytherapy to BC diagnosis for the study and SEER cohort were 9.5 ± 4.5 and 6.3 ± 4.1 years, respectively. Compared to the SEER cohort, significantly greater proportion of BC from the study cohort presented with high-grade (study: 78.4%, SEER: 52.3%, P = 0.0008) and with MIBC (Study BC 35.3%, SEER BC: 17.5%, P = 0.0009). The study and the SEER cohort had similar 5-year overall survival (study: 67.9%, SEER: 58.0%, P = 0.1099), and 5-year cancer-specific survival (study: 81.0%, SEER: 82.8%, P = 0.5559). The 5-year progression-free survival for the study cohort was 43.7% (95% CI: 28.8-57.7). CONCLUSION: Compared to bladder cancers following prostate cancer managed without radiation, bladder malignancies following prostate LDR brachytherapy present with higher grade and are more likely to be muscle invasive. Despite the aggressive presenting features of postprostate brachytherapy BC, there were no differences in overall and cancer-specific survival between the groups.

Medium-Term Real-World Outcomes of Minimally Invasive Surgical Therapies for Benign Prostatic Hyperplasia: Water Vapor Thermal Therapy (Rezum) vs Prostatic Urethral Lift (UroLift) in a High-Volume Urban Academic Center.

Purpose: Water vapor thermal therapy (WVTT, i.e., Rezum®) and prostatic urethral lift (PUL, i.e., Urolift®) are minimally invasive surgical therapy (MIST) options for benign prostatic hyperplasia (BPH). Few studies have directly compared the two procedures. We examined the clinical characteristics and postoperative outcomes of patients undergoing WVTT and PUL at our high-volume urban academic center. Methods: We reviewed our institutional MIST database to identify patients with prostate sizes ≥30 and ≤80 cc who underwent WVTT or PUL for treatment of BPH between January 2017 and September 2021. Pre- and postoperative outcomes, including retreatment rates, American Urological Association symptom score (AUA-SS), maximum flow (Qmax), postvoid residual (PVR), medication usage, trial of void success rates, catheterization requirements, and postoperative complications within 90 days were extracted and compared between procedures. Results: Three hundred seven patients received WVTT and 110 patients received PUL with average follow-up times of 11.3 and 12.8 months, respectively. WVTT patients showed significant improvements in AUA-SS, Qmax, and PVR, whereas PUL patients showed improvements in only AUA-SS and Qmax. Both WVTT and PUL patients with longitudinal follow-up demonstrated improvements in AUA-SS, Qmax, and PVR. Postoperatively, alpha-blocker utilization was significantly decreased following both WVTT and PUL (WVTT: 73.9%-46.6%, PUL: 76.4%-38.2%, both p < 0.001). Compared to patients receiving PUL, WVTT patients more frequently reported postoperative dysuria (22.8% vs 8.3%, p = 0.001) and nonclot-related retention (18.9% vs 7.3%, p = 0.005); PUL patients more frequently experienced postoperative clot retention (7.3% vs 2.6%, p = 0.027). There were no differences in rates of postoperative bladder spasm, trial of void success, urinary tract infections, or emergency department visits. Postoperative erectile dysfunction and retrograde ejaculation were rare and occurred at similar rates. Conclusion: In the real-world setting, WVTT and PUL have similar medium-term efficacy in improving symptoms and decreasing medication utilization for patients with BPH. Differences in postoperative complication profiles should inform patient counseling.

The Utilization and Safety of Same-Day Discharge After Transurethral Benign Prostatic Hyperplasia Surgery: A Case-Control, Matched Analysis of a National Cohort.

OBJECTIVE: To analyze the utilization and safety of same-day (SDD) vs standard-length discharge (SLD) for transurethral resection (TURP), holmium laser enucleation (HoLEP), and GreenLight photovaporization (GL-PVP) of the prostate. METHODS: Using the 2015-2019 ACS-NSQIP files, the annual proportion of TURP, HoLEP, and GL-PVP performed with SDD (length of stay [LOS] = 0 days) was calculated. Patients were stratified by LOS into SDD and SLD (TURP: LOS = 1-3 days, HoLEP and GL-PVP: LOS = 1-2 days); those with longer LOS were excluded. Patients were matched 1:1 by age, body mass index, American Society of Anesthesiologists score, and modified Charlson Comorbidity Index score. We compared 30-day unplanned readmissions, reoperations, and Clavien-Dindo (CD) complications between SLD and SDD, and evaluated predictors of adverse outcomes using logistic regression. RESULTS: Most GL-PVP patients underwent SDD, compared to a minority of TURP and HoLEP patients. SDD utilization increased, remained stable, and decreased over time for HoLEP, TURP, and GL-PVP, respectively. For 46,898 included cases (31,872 TURP, 2,901 HoLEP, 12,125 GL-PVP), rates of reoperation, CD I/II, or CD IV complications were comparable before and after matching. Compared to SLD, 30-day unplanned readmission rates for matched SDD patients were lower following TURP (3.48% vs 4.25%, P = .013) and HoLEP (1.93% vs 4.43%, P = .003). On multivariate regression, SLD correlated with unplanned readmission after TURP and HoLEP for both unmatched and matched cohorts. CONCLUSION: For appropriately selected patients, SDD after TURP, HoLEP, and GL-PVP did not confer increased risk of 30-day complications, suggesting patient selection for SDD is being done with appropriate safety nationally.

Adrenalectomy outcomes predicted by a 5-item frailty index (5-iFI) in the ACS-NSQIP database.

BACKGROUND: Frailty has been shown to be a predictor of adverse postoperative outcomes. This study aims to evaluate a 5-item frailty index (5-iFI) as a predictor of complications as well as healthcare resource utilization (HCRU) following adrenalectomy. METHODS: All adrenalectomy cases recorded in the ACS-NSQIP database from 2015 to 2018 were analyzed. Primary outcomes of interest were Clavien-Dindo [CD] I/II or CD IV complications and HCRU. HCRU outcomes were prolonged length of stay (PLOS), discharge to continued care (DCC), and unplanned 30-day readmission (UR). RESULTS: 4358 patients were included. Higher 5-iFI scores were associated with higher rates of CDI/II, CDIV, and increased HCRU (p < 0.05). On multivariate analysis, 5-iFI scores were found to be independent predictors of adverse clinical and HCRU outcomes. CONCLUSIONS: Frailty tools like the 5i-FI can be useful in preoperative risk-benefit analysis, patient counseling, and planning prehabilitation interventions.

Impact of diverticular disease on prostate cancer risk among hypertensive men.

INTRODUCTION: Prostate cancer (PCa) is a heterogenous disease with multiple etiological factors playing a role in its development. Recently, chronic and systemic inflammatory conditions such as inflammatory bowel disease were identified as key risk factors influencing its development. The study aimed to evaluate the relationship between diverticular disease (DD) (local and acute inflammation) and PCa. METHODS: Hypertensive patients with DD and hypertensive controls were identified between 1995 and 2010 from the Statewide Planning and Research Cooperative System database. Cohorts were queried for PCa incidence through 2015. Univariable and multivariable logistic regression analyses were used for determining independent predictors of PCa diagnosis. RESULTS: A total of 51,353 patients with DD and 111,541 controls were identified. In all, 6.26% of DD developed PCa, and 3.71% of controls developed PCa (p < 0.01). DD was a significant risk factor for PCa (OR: 1.27 CI: 1.19-1.34, p < 0.01). On subgroup analysis, the patients diagnosed with DD <50 years old had an OR of 3.39 for PCa (CI: 2.52-4.56, p < 0.01), age 50-59 had an OR of 2.12 (CI: 1.86-2.15, p < 0.01), and age 60-69 had an OR of 1.20 (CI: 1.10-1.31, p < 0.01). Finally, age and race stratification showed that white patients <50 had an OR of 2.56 (CI: 1.75-3.76, p < 0.01), while black patients <50 had an OR of 3.98 (CI: 2.61-6.07, p < 0.01). The trend in differing odds between these populations was the same for age groups 50-59 and 60-69. CONCLUSION: Our analysis shows that DD is associated with diagnosis of PCa in hypertensive men. Importantly, the earlier the diagnosis of DD, the higher the odds for development of PCa, particularly in black men.

A Comparison of Pharmaceutical Prices for Generic Erectile Dysfunction and Benign Prostatic Hyperplasia Medication in 2 Socioeconomically Disparate New York City Neighborhoods.

INTRODUCTION: Erectile dysfunction (ED) and benign prostatic hyperplasia (BPH) are frequently managed with medications. Variability and poor understanding of medication prices have been shown to hinder patient adherence, leading to worse clinical outcomes. We sought to explore how pharmacy type and neighborhood socioeconomic status influence pricing for generic ED and BPH medications. METHODS: A total of 96 pharmacies within the adjacent higher income Upper East Side (UES) and lower income East Harlem (EH) New York City neighborhoods were classified as chain or independent. Telephone surveys identified cash prices for 30-day supplies of 14 medications including phosphodiesterase 5-inhibitors, 5-alpha reductase inhibitors, alpha blockers and antispasmodics. Pricing variability based on pharmacy type and neighborhood was evaluated using Mann-Whitney U-tests. RESULTS: Of 96 pharmacies, 81 responded (84.4%). Independent pharmacies showed significantly reduced prices for 9/14 and 14/14 medications in UES and EH, respectively. The greatest independent pharmacy price reductions were for tadalafil 20 mg (15.0-fold in UES, 26.7-fold in EH) and sildenafil (8.4-fold in UES, 15.4-fold in EH). The least significant reductions were in mirabegron (1.1-fold in UES, 1.2-fold in EH). Independent pharmacies in EH showed lower prices for 9/14 medications compared to those in UES. CONCLUSIONS: Across both neighborhoods, independent pharmacies offered consistently lower cash prices for ED and BPH medications. Lower independent pharmacy prices in the lower income EH neighborhood suggest that neighborhood socioeconomic status may impact pricing. Physicians and patients alike must understand the factors that influence pricing to ensure more optimal patient compliance for uninsured patients.

Robotic Single-Port Donor Nephrectomy with the da Vinci SP® Surgical System.

OBJECTIVES: The da Vinci SP® Surgical System received U.S. Food and Drug Administration approval for urological procedures in 2018. Here, we describe the first experience performing single-port robot-assisted donor nephrectomy (RADN) using the da Vinci SP® surgical system, present 90-day clinical outcomes, and discuss tips for operative success. METHODS: Seven consecutive patients underwent single-port RADN at a single institution between September 1, 2020 and March 31, 2021. Surgery was performed through a single, 60 mm Pfannenstiel incision with a 12 mm periumbilical assistant port for suction and vascular stapling. Donor characteristics, operative details, 90-day donor clinical outcomes, and recipient renal function were retrospectively evaluated. RESULTS: Four female and three male patients successfully underwent single-port RADN without conversion to standard multiport or open approach. Six cases were left-sided. Estimated blood loss for each procedure was ≤ 50 mL. Mean operative time, warm ischemia time, and extraction time were 218.3 minutes (standard deviation [SD]: 16.3 minutes), 5 minutes 4 seconds (SD: 56 seconds), and 3 minutes 37 seconds (SD: 38 seconds). Mean pre-operative creatinine and estimated glomerular filtration rate were 0.79 mg/dL and 107.3 mL/min/1.73m2, respectively. At six week's follow up, they were 1.22 mg/dL and 66.1 mL/min/1.73m2. Average pain score at 48 hours postoperatively was 1.7/10. There were no Clavien-Dindo grade ≥ III complications within 90 days. All recipients experienced immediate and sustained return of renal function post-transplant. CONCLUSION: Single-port RADN is a technically feasible and safe procedure with the da Vinci SP® system and can confer acceptable functional and cosmetic outcomes. Future studies are needed to define long-term outcomes and compare with previously established techniques for donor nephrectomy.

Rezum therapy for patients with large prostates (≥ 80 g): initial clinical experience and postoperative outcomes.

PURPOSE: Rezum is a minimally invasive surgery for benign prostatic hyperplasia. Current guidelines recommend Rezum for prostates < 80 cc, but little data exist describing outcomes in patients with prostates ≥ 80 cc. We compare outcomes after Rezum between men with small < 80 cc (SP) and large ≥ 80 cc prostates (LP). METHODS: Patients undergoing Rezum between Jan 2017-Feb 2020 were subdivided by prostate volume (< 80, ≥ 80 cc). Outcomes were documented pre- and postoperatively. Descriptive analyses of urodynamics data (Qmax, PVR), symptom scores (AUA-SS, SHIM), disease management (medications, catheterization, retreatments), and clinical outcomes were conducted. RESULTS: 36 (17.6%) men had prostates ≥ 80 cc (LP mean prostate size 106.8 cc). LP men had improved Qmax and PVR postoperatively; those with longitudinal follow-up exhibited improved Qmax, PVR, and AUA-SS. After one year, alpha-blocker usage decreased significantly (LP 94.44-61.11%, p = 0.001, SP 73.96-46.15%, p = 0.001); other medication usage and self-catheterization rates remained unchanged. Compared to SP patients, differences in passing trial void (LP 94.44%, SP 93.45%), postoperative UTI (LP 19.44%, SP 10.12%), ED visits (LP 22.22%, SP 17.86%), readmissions (LP 8.33%, SP 4.76%), and retreatment (LP 8.33%, SP 4.76%) were insignificant. However, mean days to foley removal (LP 9, SP 5.71, p = 0.003) and urosepsis rates (LP 5.56%, SP 0.00%, p = 0.002) differed. CONCLUSION: In select LP patients, Rezum provided short-term symptomatic relief and improved voiding function comparable to SP patients. Postoperatively, though alpha-blocker usage decreased significantly, use of other medications did not change, and nearly two-thirds of patients still needed alpha-blockade. Further efforts should explore the possibility of expanding Rezum's inclusion criteria.

Disposable versus Reusable Cystoscopes: A Micro-Costing Value Analysis in High-Volume and Low-Volume Urology Practices.

INTRODUCTION: Disposable single-use cystoscopes have become increasingly available, demonstrating comparable quality to reusable cystoscopes while eliminating the need for reprocessing and repairs. However, high costs remain a concern. To clarify the role for these scopes, we performed a cost analysis comparison between the single-use Ambu® aScope™ 4 cystoscope and reusable Olympus® CYF-VHR and V2 cystoscopes in 2 clinical settings: a high-volume multi-provider practice and low-volume single-provider practice. METHODS: The number of cystoscopies at each center was recorded between January and December 2019. Elements in the micro-costing analysis included the original purchasing price of the cystoscopes plus accessory equipment, sterilization supplies, repair costs, and personnel. Costs were amortized over 5 or 10 years and calculated on a per-case basis. An annual total cost analysis was performed to evaluate the cost-effectiveness of each device for each facility. RESULTS: In 2019, 1,984 and 245 cystoscopic procedures were performed at the high and low-volume clinics, respectively. At the high-volume multi-provider practice, per-case cost for reusable cystoscopy amounted to $65.98 compared to $227.18 for single-use cystoscopy, with reusable equipment more cost-effective after 294 cystoscopies. At the low-volume single-provider practice, the per-case cost for reusable cystoscopy was $232.62 compared to $461.18 for single-use cystoscopy, with reusable equipment more cost-effective after 19 cases. CONCLUSIONS: Based on this micro-costing analysis, per-case costs favor reusable cystoscopes. While single-use cystoscope pricing may be prohibitive for large and small facilities at this present time, these instruments are powerful adjuncts to urologists' armamentaria when portability and efficiency are prioritized.

Robotic-assisted simple prostatectomy versus open simple prostatectomy: a New York statewide analysis of early adoption and outcomes between 2009 and 2017.

The factors driving early adoption of robotic-assisted simple prostatectomy (RASP) for large gland BPH have not yet been identified. This study aims to determine the patient, provider, and facility level differences and predictors in undergoing RASP versus OSP. This population-based cohort study used data from the all-payer New York State Statewide Planning and Research Cooperative System (SPARCS) database. Patient, provider, and facility characteristics for each cohort were analyzed, and a multivariate analysis was conducted to identify predictive factors associated with undergoing RASP versus OSP. From 2009 to 2017, 1881 OSP and 216 RASP cases were identified. RASP utilization increased from 2.6% of all cases in 2009 to 16.8% in 2017. Patient demographics were similar between both cohorts. Median length of stay was shorter for RASP patients (3 vs. 4 days, p < 0.001), and OSP was associated with a long length of stay (> 7 days) (p < 0.001). There were no significant differences in 30- and 90-day readmission rates or 1-year mortality. More OSP patients were discharged to continued care facilities than RASP patients (p = 0.049), and more RASP patients were discharged to home compared to OSP patients (p = 0.035). Positive predictors for undergoing RASP included teaching hospital status, medium and high hospital bed volume, high hospital operative volume, high surgeon volume, and surgeons that graduated within 15 years of surgery. As RASP shows favorable perioperative outcomes, the diffusion of robotic technology and newer graduates entering the workforce may augment the upward trend of RASP utilization.

Focal Ablative Therapy for Renal Cell Carcinoma in Transplant Allograft Kidneys.

OBJECTIVE: To evaluate outcomes after focal ablative therapy for renal cell carcinoma (RCC) in transplant allograft kidneys. METHODS: After institutional review board approval, patients with a history of RCC in a transplanted allograft kidney who underwent focal ablative therapy were identified. Complete chart reviews were performed and the relevant data were extracted for cumulative analysis. RESULTS: Six patients were treated with focal ablative therapy for RCC in a transplanted allograft kidney at our institutional between 2010 and 2017. Masses were diagnosed at a median of 8 years (range 1 month-8 years) after transplantation. Median mass size was 3 cm. Three patients were treated with microwave ablation, 1 with percutaneous irreversible electroporation, 1 with laparoscopic cryoablation, and 1 with open cryoablation. Median follow-up was 45 months (range 8-61 months). The median creatinine level was 1.65 before ablation and 1.58 1 year after ablation. No patients required dialysis after ablation. No patients developed local recurrence during the follow-up period. However, 1 patient developed lymph node metastases 4 years after ablation. Two patients died during follow-up of other causes. At the time of death both patients had functioning grafts. CONCLUSION: Focal ablative therapies are a feasible, renal-sparing intervention for the management of RCC in renal allografts at intermediate-term follow-up.

Robotic-assisted vs. laparoscopic donor nephrectomy: a retrospective comparison of perioperative course and postoperative outcome after 1 year.

Safety is of utmost importance in live donor nephrectomies. In this study, we describe our initial experience with robot-assisted laparoscopic donor nephrectomy (RDN) in comparison with the standard laparoscopic donor nephrectomy (LDN). We retrospectively reviewed 95 patients who either underwent RDN or LDN performed by a single surgeon from 2011 to 2016 at a tertiary institution. Donor perioperative course and postoperative outcome along with recipient outcomes were compared. Of the 95 cases, 73 were classified as LDN and 22 were classified as RDN. There were no significant differences between the two groups in age, sex, BMI, race, and ASA status. Operative times (p < 0.001) were longer in the RDN group, but eventually approached LDN times. Warm ischemia (p = 0.002) and extraction times (p = 0.05) were also longer in the RDN cohort. The donor length of hospital stay, complication rates, and postoperative change in eGFR from baseline were similar in both cohorts up to 1 year. Recipient outcomes, including delayed graft function, graft failure, and renal function up to 1 year, were also comparable. In this study, we compared the longest postoperative course so far in both donors and recipients between RDN and LDN. Up to 1 year, RDN does not negatively impact outcomes. Proficiency with RDN also quickly improved to match LDN, making it a suitable procedure for newer surgeons.

Utilization Trends and Short-term Outcomes of Robotic Versus Open Radical Cystectomy for Bladder Cancer.

OBJECTIVE: To compare utilization trends and short-term outcomes of robotic versus open radical cystectomy for bladder cancer since the introduction of the robotic modifier (ICD-9 17.4x). MATERIALS AND METHODS: Using the Statewide Planning and Research Cooperative System database, an all-payer administrative system on all hospital discharges in New York State, we identified patients undergoing radical cystectomy (57.71) with a diagnosis of bladder cancer (188.0-188.9, 233.7, 236.7) from October 2008 to December 2012. Primary outcomes were inpatient complications and mortality at index stay. RESULTS: Of the 2525 patients, 24.2% (610 of 2525) underwent robotic and 75.8% (1915 of 2525) underwent open radical cystectomy. The proportion of robotic cases increased from 19.9% (119 of 597) in 2009 to 28.9% (173 of 598) in 2012 (P < .05). From 2009 to 2012, the number of open surgeons decreased from 117 to 109, and that of robotic increased from 56 to 66. Robotic patients had lower approach-specific surgeon and hospital volume, and more likely underwent lymph node dissection, ileal conduit diversion, blood transfusion, and prolonged length of stay. On multivariate analysis, robotic approach conferred a reduced risk of blood transfusion (odds ratio: 0.600, 95% confidence interval: 0.492-0.732, P < .0005) but had no association with prolonged length of stay. There were no significant differences in inpatient complications or mortality at index stay, parenteral nutrition, length of stay, hospital charges, readmission rates up to 90 days, or mortality up to 90 days between the surgical approaches. CONCLUSION: Despite the rapid dissemination and more recent experience of robotic radical cystectomy, we report lower rates of blood transfusion and otherwise similar short-term outcomes with open radical cystectomy.

Utilization trends and outcomes up to 3 months of open, laparoscopic, and robotic partial nephrectomy.

The aim of the study was to compare the utilization trends and short-term outcomes of open, laparoscopic, and robotic partial nephrectomy in New York State since the introduction of the robotic modifier in October 2008. The Statewide Planning and Research Cooperative System database is an all-payer, administrative database covering all hospital discharges within New York State. All patients who underwent partial nephrectomy (ICD-9 55.4) for kidney cancer (189.0) from October 2008 to December 2012 were identified. Patients with a minimally invasive modifier (54.21, 54.51) without the robotic modifier (17.4x) were categorized in the laparoscopic cohort. Logistic regression was performed to assess outcomes by surgical approach. Of the 5107 patients, 57.9% (2959/5107) underwent open, 12.1% (617/5107) laparoscopic, and 30.0% (1531/5107) robotic partial nephrectomy. From 2009 to 2012, the percentage of robotic cases increased from 17.7 to 39.8%. In comparison to open patients, those undergoing laparoscopic and robotic approaches, respectively, were less likely to receive blood transfusion (OR 0.54, p < 0.0005 and OR 0.45, p < 0.0005) and to experience a prolonged length of stay (OR 0.52, p < 0.0005 and OR 0.30, p < 0.0005). Patients undergoing robotic approach were also less likely to have an inpatient complication (OR 0.74, p = 0.004) and be readmitted within one (OR 0.73, p = 0.005) and 3 months (OR 0.69, p < 0.0005), but were at higher risk of excess hospital charges (OR 1.216, p = 0.01). Robotic partial nephrectomy is the predominant minimally invasive approach in New York State. Minimally invasive partial nephrectomy has multiple short-term advantages over open, with the costlier robotic approach having additional advantages with less inpatient complication and readmission risk.

Laparoscopic needle-retrieval device for improving quality of care in minimally invasive surgery.

BACKGROUND: Loss of a needle during laparoscopic surgery is a rare but potentially serious adverse event that can cause prolonged operative time and patient harm. Standard recovery techniques currently include instrument count, standard visual search, and plain abdominal x-rays. We developed a laparoscopic instrument to speed the retrieval of lost needles in the abdomen and pelvis. STUDY DESIGN: We performed in vivo testing of a novel articulating laparoscopic magnet in a porcine model. Three experienced surgeons and 3 inexperienced surgeons conducted 116 needle-retrieval trials with the device and 58 trials with a standard visual approach. Surgeons were blind to the locations of randomly placed surgical needles within the abdominal cavity. Time to recovery was measured and capped at 15 minutes. Analysis was performed using univariate and multivariable methods. RESULTS: The magnetic device was able to retrieve needles significantly faster than the standard approach (2.9 ± 4.0 minutes vs 8.0 ± 6.0 minutes; p < 0.0001). On multivariable analysis, faster recovery time remained independently significant when controlling for surgeon experience, needle size (small, medium, or large), and needle location (by quadrant) (p < 0.0001). There were 2 (2%) injuries to abdominal organs during the device trials and 4 (7%) injuries during the standard trials (p = 0.182). CONCLUSIONS: Recovery of lost surgical needles during porcine laparoscopic surgery is safe and feasible with a simple articulating magnetic device. Our initial in vivo experience suggests that recovery is markedly faster using the magnetic device than the standard approach, even in the hands of experienced laparoscopic surgeons. This device will be particularly useful as minimally invasive robotic and single-site surgical techniques are adopted and, in the future, it should be integrated into the standard protocol for locating lost needles during surgery.

Trends and variations in utilization of nephron-sparing procedures for stage I kidney cancer in the United States.

PURPOSE: The incidental detection of early-stage kidney tumors is increasing in the United States. Nephron-sparing approaches (NS) to managing these tumors are equivalent to radical nephrectomy (RN) in oncologic outcomes and have a decreased impact on renal function. Our objective was to evaluate trends in the use of NS over the past decade and the socioeconomic factors associated with its use. METHODS: The National Cancer Database was queried to identify patients with stage I kidney cancer between 2000 and 2008. Patients were classified by the type of surgery as NS (local destruction and local excision) or RN. Patients were further categorized by age, race, insurance status, and income. Log-binomial regression was used to estimate prevalence ratios (PR) for the proportion of NS to RN according to demographic and socioeconomic characteristics. RESULTS: From 2000 to 2008, there were 142,194 cases of kidney cancer reported to the NCDB. In these cases, 43,034 (30.3 %) patients had NS, and 86,431 (60.78 %) patients had RN. The prevalence of NS increased 10 % per year (PR = 1.10, p < 0.0001)-from 20.0 % in 2000 to 45.1 % in 2008. Older age, lower income, Black race, Hispanic ethnicity, and lack of health insurance were associated with a decreased prevalence of NS. CONCLUSIONS: NS as a treatment for stage I kidney cancer has increased steadily since 2000. Age, racial, and socioeconomic differences may exist in the utilization of NS. Additional analyses, with patient level data, are required to address the independent significance of these variables in an effort to develop strategies to mitigate these potential disparities.