Novel kidney segmentation system to describe tumour location for nephron-sparing surgery.

PURPOSE: To propose a novel system based on segmental renal anatomy for objectively reporting location of clinical T1 masses for nephron-sparing surgery. METHODS: The kidney was subdivided into 12 standard segments, based on the computed tomography images. In 103 patients (105 cT1 tumours), three blinded radiologists (A, B, and C) prospectively reported segmental tumour location, size, and tumour-feeding arteries. Baseline, peri-operative, and post-operative data of 98 patients who underwent partial nephrectomy (PN) were prospectively collected, and the correlation between segmental tumour location and peri-operative data was evaluated. Kappa statistics were used to measure the inter-observer agreements. RESULTS: Tumour location could be assigned to the defined renal segment in all cases. Median tumour size was 2.8 cm (range 0.6-5.8). Inter-observer concordance was as follows: A versus B 0.82 (95% CI 0.74-0.90); A versus C 0.89 (95% CI 0.83-0.95); and B versus C 0.84 (95% CI 0.76-0.92). First, second, third, and fourth segments were involved by the tumour in 23, 39, 17, and 21% of cases, respectively. Number of segments involved by the tumour correlated with tumour size (p = 0.007), number of tumour-feeding arteries (p = 0.001), estimated blood loss during PN (p = 0.03), and trended towards higher post-operative complication rate (p = 0.07). Tumour-feeding arteries were identifiable in 80 patients (76%). CONCLUSIONS: Kidney segmentation (KS) system is an objective and reproducible radiologic method of universally reporting tumour location according to 12 renal segments. By adding descriptive information on tumour characteristics in candidates for nephron-sparing surgery, this novel KS system could serve as an adjunct to current nephrometry systems.

Robotic intracorporeal urinary diversion: technical details to improve time efficiency.

OBJECTIVES: To present time-efficiency data during our initial experience with intracorporeal urinary diversion and technical tips that may shorten operative time early in the learning curve. PATIENTS AND METHODS: Data were analyzed in the initial 37 consecutive patients undergoing robotic radical cystectomy and intracorporeal urinary diversion in whom detailed stepwise operative time data were available. Median age was 65 years and median body mass index was 27. Neoadjuvant chemotherapy was administered in 6 patients and 11 patients had clinical evidence of T3 or lymph node-positive disease. Each component of the operation was subdivided into specific steps and operative time for each step was prospectively recorded. Peri-operative and follow-up data up to 90 days and final pathological data were recorded. RESULTS: All procedures were completed intracorporeally and robotically without need for conversion to open surgery or extracorporeal diversion. Median total operative time was 387 vs 386 minutes (p=0.2) and median total console time was 361 vs 295 minutes (p<0.007) for orthotopic neobladder and ileal conduit, respectively. Median time for radical cystectomy was 77 minutes, extended pelvic lymph node dissection was 63 minutes, and diversion was 111 minutes (ileal conduit 92 minutes and orthotopic neobladder 124 minutes). Median estimated blood loss was 250 mL, and median hospital stay was 9 days. High grade (Clavien grade 3-5) complications at 30 and 90 days follow-up were recorded in 6 (16%) and 9 (24%) patients, respectively. Over a median follow-up of 16 months, 12 (32%) patients experienced disease recurrence and 9 (24%) died from bladder cancer. These correspond to 1-year recurrence-free and overall survival of 64% and 70%, respectively. CONCLUSIONS: Intracorporeal urinary diversion following robotic radical cystectomy can be safely performed and reproducible in a time-efficient manner even during the early learning curve.