Tumor diameter accurately predicts perioperative outcomes in T1 renal cancer treated with robot-assisted partial nephrectomy.

PURPOSE: To compare diameter as a continuous variable with categorical R.E.N.A.L. nephrometry score (RNS) in predicting surgical outcomes of robotic partial nephrectomy (RPN). METHODS: We retrospectively reviewed consecutive patients receiving RPN at our institution between July 2007 and June 2014 (n = 286). Three separate multivariate analyses were performed to assess the relationship between RNS components (R = radius, E = endophyticity, N = nearness to collecting system, L = location relative to polar lines), total RNS, and diameter as a continuous variable with operating time, warm ischemia time (WIT), and estimated blood loss (EBL). Each linear regression model's quality of fit to the data was assessed with coefficients of determination (R 2). RESULTS: Continuous tumor diameter and total RNS were each significantly correlated to operative time, EBL, and WIT (p < 0.001). Categorical R related to operative time (R = 2 vs. R = 1, p = 0.001; R = 3 vs. R = 1, p = 0.001) and WIT (R = 2 vs. R = 1, p = 0.003; R = 3 vs. R = 1, p = 0.016), but not to EBL. For each of these outcomes, diameter outperformed both R and total RNS, as assessed by R 2. Age, body mass index, Charlson Comorbidity Index, and anterior versus posterior location did not correlate with surgical outcomes. CONCLUSIONS: In this series of RPN from a high-volume center, surgical outcomes more closely related to tumor diameter than RNS. While RNS provides surgeons a standardized tool for preoperative planning of renal masses, tumor size may be employed as a more familiar measurement when counseling patients on potential outcomes.

Postoperative management factors affect urinary retention following posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigates postoperative urinary retention (POUR) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and the effects of postoperative analgesia and mobility on retention. High opioid use and decreased postoperative mobility are proposed risk factors for retention in adults. There is a paucity of literature on POUR in the adolescent population undergoing surgery for AIS. The impact of pain control and mobility on POUR in these patients is unknown. METHODS: A retrospective cohort study was conducted of adolescents (11-18 years) undergoing elective PSF for AIS at a single institution (2012-2018). POUR was defined as the inability to void > 8 h after catheter removal. Possible risk factors for retention including opioid usage and ambulatory status at the time of catheter removal were assessed on univariate and binomial logistic regression analyses. RESULTS: One hundred and thirty-six patients were included, with 21 (15.4%) experiencing POUR. On the day of catheter removal, 24 patients had not attempted ambulation; these patients had 2.5 times higher rate of POUR than those who were walking (30% vs. 12%, p = 0.04). Patients who developed retention ambulated a mean threefold shorter distance than those without POUR (45 vs. 136 feet, p = 0.04). On binomial logistic regression, decreased ambulation distance was associated with retention (p = 0.038). While opioid use was not significant on univariate analysis, higher opioid use on the day of catheter removal predicted retention on logistic regression (p = 0.001). POUR resolved in all patients (median duration 0.5 days, range 0-12 days). CONCLUSIONS: The development of POUR after PSF for AIS affects one in six patients but resolves quickly. Non-ambulatory patients and patients who received large doses of opioids on the day of catheter removal were more likely to develop POUR. LEVEL OF EVIDENCE: III.

Computed Tomography and Magnetic Resonance Findings of Fat-Poor Angiomyolipomas.

INTRODUCTION: Approximately 5% of angiomyolipomas (AMLs) are classified as "fat poor" due to lack of visually detectable fat on imaging, making them difficult to distinguish from renal cell carcinoma. Recent investigations have proposed CT and MR imaging features suggestive of fat-poor AML (fp-AML). Herein, we determined the frequency of these features in a cohort of fp-AMLs by retrospective review of preoperative imaging. METHODS: A pathology database query from January 2005 to August 2013 identified 49 renal specimens of AML with available imaging. A retrospective review of all CT and MR images of these 49 cases was conducted. Cases with visually detectable fat on imaging were excluded. RESULTS: A total of 26 fp-AMLs were identified. Thirteen lesions had available unenhanced CT images, of which eight (62%) were hyperdense compared to the adjacent renal parenchyma, while five (38%) were isodense. Twenty lesions had enhanced CT images: 14 (70%) and 6 (30%) with homogeneous and heterogeneous enhancement, respectively. Of the nine lesions with enhanced MR sequences, five (56%) were homogeneously enhancing, and four (44%) were heterogeneously enhancing. Eight of nine (89%) lesions had hypointense signal intensity (SI) on T2-weighted MR sequences, while one (11%) had hyperintense SI. None of the eight lesions displayed a decrease in signal on fat-suppressed sequences. CONCLUSIONS: In this study, we confirmed common imaging features of fp-AML: high attenuation on unenhanced CT sequences, homogeneous enhancement on CT, and hypointensity on T2-weighted MR. When these features are present, a renal mass biopsy may be prudent.

Is Ureteroscopy Needed Prior to Nephroureterectomy? An Evidence-Based Algorithmic Approach.

OBJECTIVE: To develop an evidence-based approach to the diagnostic workup of suspicious upper urinary tract lesions. METHODS: The PubMed database was searched using the following terms with a filter for English language: "upper tract urothelial carcinoma" and "upper tract transitional cell carcinoma," along with the following corresponding terms: "cost," "epidemiology," "diagnosis," "ureteroscopy," and "workup." A total of 404 articles were returned, and 33 were reviewed in full based on relevance. RESULTS: Computed tomography urogram is both sensitive and specific (96% and 99%). Cytology is utilized for its specificity (89%-100%). Ureteroscopy and biopsy of an upper tract lesion can be helpful in equivocal cases but can pose challenges in terms of yield and eventual pathologic upstaging. Due to the high sensitivity and specificity of other noninvasive tests, ureteroscopy can be obviated in select cases. We assess the available evidence and devise an algorithm for the evaluation of an upper tract urothelial carcinoma lesion. CONCLUSION: Ureteroscopy can be omitted as part of the diagnostic workup in appropriately selected cases of upper tract urothelial carcinoma.

Diagnostic Utility of Selective Upper Tract Urinary Cytology: A Systematic Review and Meta-analysis of the Literature.

The diagnosis of upper tract urothelial carcinoma (UTUC) can be a challenging diagnostic pursuit. To date, there is no large-scale study assessing the statistical utility (eg, sensitivity and specificity) of selective cytology. Herein, we systematically reviewed and meta-analyzed the published literature to evaluate the efficacy of selective cytology for the detection of UTUC in patients with a suspicious clinical profile Selective cytology confers a high specificity but marginal sensitivity for the detection of UTUC. The sensitivity is greater for high-grade UTUC lesions. The statistical assessment of its utility is limited by the heterogeneity and bias of previous studies.

Comparing Expert Reported Outcomes to National Surgical Quality Improvement Program Risk Calculator-Predicted Outcomes: Do Reporting Standards Differ?

INTRODUCTION: Expert-reported outcomes and complications may not reflect the standardized coding that can be provided by independent, third-party evaluations. The goal of this article is to compare expert-reported complications with standardized coding by the National Surgical Quality Improvement Program (NSQIP). The procedures evaluated were laparoscopic radical nephrectomy (LRN), robot-assisted radical prostatectomy (RARP), and radical cystectomy (RC). METHODS: The 10 largest LRN, RARP, and RC series were reviewed for reported complications. An index patient was derived from each series using patient demographic data. Index patients were entered into the NSQIP surgical risk calculator (SRC), which provides 11 predicted outcomes based on inputted data. SRC-predicted outcomes were compared with available complication rates in each series. RESULTS: Across the 30 studies, 172 out of 330 (52%) of NSQIP-provided outcome types were presented within expert manuscripts. Death and venous thromboembolism (VTE) were the most commonly reported (27 and 23 studies, respectively), whereas urinary tract infection (UTI) (9) and pneumonia (10) were the least commonly presented. Comorbidities and follow-up duration were reported in 8 out of 30 and 17 out of 30 studies, respectively. For LRN, the median number of reported outcomes was 3 (range 1-5). LRN experts demonstrated a shorter mean length of stay (LOS) (2.5 days, SD=1.7) (p<0.001). In RARP studies, a median of 7.5 (3-11) outcomes was reported. Experts outperformed NSQIP RARP predictions in serious complications (p<0.001), any complication (p<0.001), surgical site infection (p=0.025), UTI (p<0.001), and VTE (p=0.002). RC manuscripts reported a median of 7 (2-11) outcomes. RC experts had higher rates of serious complications (p<0.001), reoperation (p<0.001), and death (p<0.001) than predicted by SRC. CONCLUSION: The level of standardization in reporting of outcomes differs between expert series and NSQIP, thus making comparisons difficult.