Partial nephrectomy should be classified as an inpatient procedure: Results from a statewide quality improvement collaborative.

OBJECTIVES: To examine length of stay (LOS) and readmission rates for all minimally-invasive partial nephrectomy (MIPN) and MI radical nephrectomy (MIRN) performed for localized renal masses ≤7 cm in size (cT1RM) within 12 Michigan urology practices. Both RN and PN are commonly performed in treating cT1RM. Although technically more complex and associated with higher complication rates, Centers for Medicare & Medicaid Services considers MIPN an outpatient procedure and MIRN is inpatient. METHODS: We collected data for renal surgeries for cT1RM at MUSIC-KIDNEY practices between May 2017-February 2020. Data abstractors recorded clinical, radiographic, pathologic, surgical, and short-term follow-up data into the registry for cT1RM patients. RESULTS: Within MUSIC-KIDNEY, 807 patients underwent MI renal surgery at 12 practices. Median LOS for cT1RM patients after MIPN (n = 531, 66%) was 2 days and after MIRN (n = 276, 34%) was also 2 days. Among patients undergoing laparoscopic or robotic PN, 171 (32%), 230 (43%), and 130 (24%) stayed ≤1, 2, ≥3 days. Among patients undergoing laparoscopic or robotic RN, 81 (29%), 112 (41%), and 83 (30%) stayed ≤1, 2, ≥3 days. No significant difference was observed between MIPN and MIRN on LOS commensurate with outpatient surgery (≤1-day, OR = 0.97, P = 0.87). CONCLUSIONS: Less than one-third of patients had a LOS ≤1-day and LOS was comparable for MIPN and MIRN. Centers for Medicare & Medicaid Services should be advised that MIPN is a more complex surgery than MIRN, most patients receiving a MIPN will require a ≥2-day hospital stay and it would be more appropriate to classify MIPN an inpatient procedure with MIRN.

Influence of hospital volume on nephrectomy mortality and complications: a systematic review and meta-analysis stratified by surgical type.

OBJECTIVES: The provision of complex surgery is increasingly centralised to high-volume (HV) specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy. METHODS: Medline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score and most likely to introduce bias from misclassification of standardised hospital volume. RESULTS: Some 226 372 patients from 16 publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume-outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy.HV hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61 to 0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29 to 0.81, p<0.01), respectively. In addition, radical nephrectomy in HV hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73 to 0.92, p<0.01). No significant volume-outcome relationship in mortality (OR 0.84, 95% CI 0.31 to 2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55 to 1.30, p=0.44) was observed for partial nephrectomy. CONCLUSIONS: Our findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by HV hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.

Standardized reporting of resection technique during nephron-sparing surgery: the surface-intermediate-base margin score.

A standardized reporting system of nephron-sparing surgery resection techniques is lacking. The surface-intermediate-base scoring system represents a formal reporting instrument to assist in interpretation of reported data and to facilitate comparisons in the urologic literature.

External validation of a claims-based algorithm for classifying kidney-cancer surgeries.

BACKGROUND: Unlike other malignancies, there is no literature supporting the accuracy of medical claims data for identifying surgical treatments among patients with kidney cancer. We sought to validate externally a previously published Medicare-claims-based algorithm for classifying surgical treatments among patients with early-stage kidney cancer. To achieve this aim, we compared procedure assignments based on Medicare claims with the type of surgery specified in SEER registry data and clinical operative reports. METHODS: Using linked SEER-Medicare data, we calculated the agreement between Medicare claims and SEER data for identification of cancer-directed surgery among 6,515 patients diagnosed with early-stage kidney cancer. Next, for a subset of 120 cases, we determined the agreement between the claims algorithm and the medical record. Finally, using the medical record as the reference-standard, we calculated the sensitivity, specificity, and positive and negative predictive values of the claims algorithm. RESULTS: Among 6,515 cases, Medicare claims and SEER data identified 5,483 (84.1%) and 5,774 (88.6%) patients, respectively, who underwent cancer-directed surgery (observed agreement = 93%, kappa = 0.69, 95% CI 0.66 - 0.71). The two data sources demonstrated 97% agreement for classification of partial versus radical nephrectomy (kappa = 0.83, 95% CI 0.81 - 0.86). We observed 97% agreement between the claims algorithm and clinical operative reports; the positive predictive value of the claims algorithm exceeded 90% for identification of both partial nephrectomy and laparoscopic surgery. CONCLUSION: Medicare claims represent an accurate data source for ascertainment of population-based patterns of surgical care among patients with early-stage kidney cancer.

Heminefrectomía retroperitoneoscópica / Retroperitoneoscopic heminephrectomy

La práctica de las técnicas de cirugía minimamente invasiva (CMI) en el espacio retroperitoneal, presenta una dificultad adicional debida a la ausencia de una cavidad real y a la presencia de un denso tejido graso que envuelve las estructuras, lo que obliga a la creación artificial de un espacio de trabajo. Se presentan tres casos de heminefrectomía polar superior vía retroperitoneoscópica en pacientes de tres meses, seis meses, y seis años. En todos se colocó un puerto de 1 cm para la óptica y dos de 0,5 cm para el instrumental, la utilización del bisturí ultrasónico resultó de gran utilidad para escindir de forma exangüe el tejido renal. No se precisó el uso de drenajes y todos los pacientes abandonaron el hospital en las primeras 48 horas tras la intervención. Desde que en 1994 Figenhans y Clayman comunicaron la primera nefrectomía laparoscópica en el niño, la técnica se ha ido generalizando y sus ventajas frente a la cirugía convencional son actualmente universalmente aceptadas. Sin embargo, aunque menos difundida, la vía retroperitoneoscópica para la práctica de la heminefrectomía polar permite una disección del hilio renal extremadamente precisa y una excelente diferenciación del parénquima correspondiente a cada hemirriñón, compatibilizando la extirpación del hemirriñón enfermo con la máxima conservación de la función del otro hemirriñón y de la glándula suprarrenal (AU)

The practice of minimally invasive surgery techniques in the retro-peritoneal space presents additional difficulties. Due to the absence of a real cavity and the presence of a dense fat tissue involving the structures, the need for an artificial space to work in is necessary. We present three cases of the retro-peritoneal superior heminephrectomy present in a 3-months, 6-months and a 6-year old children. In all cases a 1 centimeter port for the optique and two 0.5 centimeter ports for the instruments were situated, and the use of harmonic scalpel was satisfactory to remove renal tissue without bleeding. Drainages were unnecessary and all of the children left the hospital within the first 48 post-operative hours. Since 1994, when Figenhans and Clayman communicated the first laparoscopic nephrectomy in children, the technique has been used generally and their forward advances in conventional surgery are now universally accepted. Furthermore, the practice of polar retro-peritoneoscopic heminephrectomy allowed a very precise renal hiliar dissection and an excellent differentiation of each hemirenal tissue, separating the ill kidney and preserving the maximum function possible for the other half-kidney and the adrenal gland (AU)

Rotura yatrógena de uréter secundaria a litotricia extracorpórea por ondas de choque / Iatrogenic rupture of the ureter following extracorporeal shock wave lithotripsy

La litotricia extracorpórea por ondas de choque es el tratamiento de elección de la mayoría de los cálculos urinarios, estimándose que sólo en el 5% de los casos es necesario recurrir a técnicas de cirugía abierta. Las complicaciones derivadas de esta técnica son, en la mayoría de los casos, leves, transitorias y con escasa repercusión clínica, observándose sólo en casos aislados lesiones urológicas o extraurológicas de gravedad. Dichas complicaciones se producen bien por la propia acción del cálculo o sus fragmentos, o bien por la acción de las ondas de choque. Presentamos un caso de rotura ureteral secundaria al tratamiento de un cálculo ureteral mediante litotricia extracorpórea por ondas de choque, que derivó en un absceso retroperitoneal periureteral, y fue tratado mediante nefroureterectomía

Extracorporeal shock wave lithotripsy is the treatment of choice in most cases of urinary calculi, with the estimation that open surgery is only necessary in 5% of all cases. In most cases, the complications derived from this technique are slight, transitory and of little clinical importance, with isolated cases of serious urological or extraurological injury. These complications are either caused by the action of the stone itself or its fragments, or by the action of shock waves. We present a case of ureteral rupture following treatment of a ureteral calculus using extracorporeal shock wave lithotripsy which led to a periureteral retroperitoneal abscess that was treated by nephroureterectomy

[Renal carcinoma in Silesian macroregion]. / Rak nerki w makroregionie Slaskim.

UNLABELLED: Renal carcinoma is the third most frequent neoplasm of urinary system. There is 3500 cases of this neoplasm in Poland per year. Basic treatment includes surgery. Assessment of renal-cell carcinoma occurrence in Silesian and Opole voivodeship. Inquiry was sent to 20 urological departments. Data including patients treated in year 2000 number of treated patients, age, sex, tumor location and size, number and mode of operations, as well as histopathological examination were taken into consideration. Population of studiend region represents 15.4% of Polish population. Neoplasms of urinary tract equal 19.2% hospitalizations and renal carcinoma 3.1%. 690 patients /259 F, 431 M/ with renal carcinoma were treated Among treated, there were; 1 patient under 30, 121 aged 30 to 50, 568 over 50. Renal carcinoma occurred in 329, 350 and 11 cases on the right, on the left and bilaterally, respectively 625 patients underwent surgery and 65 were disqualified because of poor general state and progression of disease 589 radical nephrectomies and 36 conservative operations were performed; 386 achieved by retroperitoneal and 239 intraperitoneal access. In 277 cases tumor size <5 cm, in 413 >5 cm. In 550 cases histopathological grade was assessed; G1--168 cases, G2--292 cases, G3--90 cases. Histopathological examination of lymph nodes was performed in 388 patients and metastases were found in 64 patients. 49 patients were assigned to immunotherapy. CONCLUSIONS: (1) frequency of renal carcinoma occurrenceis is equal in both voivodeships. (2) renal carcinoma incidence in regional populations is almost twofold higher in men. (3) limited spectrum of histopathological examinations influences results assessment and treatment prognosis.

Reduction of risk following endotoxin injection in unilaterally nephrectomized rats.

In this study the consequences of unilateral nephrectomy on the survival rate of rats were examined under severe pathological conditions including injection of a lethal dose of endotoxin (exogenic LPS), cecal puncture (endogenic LPS), injection of LPS concomitantly with renal ischemia as well as a simultaneous injection of LPS and glycerol to the leg muscle in order to induce acute renal failure. Sham operated rats did not exhibit higher survival rates than the nephrectomized rats. In most cases there was even a decrease in the percent age rate of deaths in the nephrectomized rats. Improvement in the resistance of the nephrectomized rats to pathophysiological stress occurred when stress was induced immediately following nephrectomy as well as when stress was induced 30 days following nephrectomy. No significant differences were found in blood pressure, heart rate, hematocrit, rate of respiration and body temperature in the nephrectomized rats as compared to rats that did not undergo nephrectomy. A possible explanation for our results is that the solitary kidney excretes more LPS into the urine.

[Kidney injuries due to skiing]. / Les traumatismes du rein à ski.

From 1974 to 1993, the authors admitted 212 patients with renal trauma to their department. A large proportion of these cases were due to skiing accidents. Based on a retrospective study of 78 patients admitted to the Grenoble urology department, the authors describe the features of this trauma. 91% of patients were males with a mean age of 27.5 years, with 9% of type III trauma. Treatment was surgical in 55% of cases. Total nephrectomy was performed in 21% of patients. Partial nephrectomy was performed in 25.5% of cases, with a morbidity of 45%, predominantly consisting of fistulas.