Complications of laparoscopic nephrectomy: the Mayo clinic experience

PURPOSE: We present the incidence of complications and conversions during laparoscopic nephrectomy performed for various indications and discuss methods to help prevent future complications. MATERIALS AND METHODS: From June 1999 to February 2003 at our institution 285 laparoscopic nephrectomy cases were performed, consisting of 113 radical nephrectomies, 101 donor nephrectomies, 27 simple nephrectomies, 23 partial nephrectomies and 21 nephroureterectomies. We reviewed the data base of patients who underwent laparoscopic nephrectomy to examine complications and analyze factors related to conversion to an open surgical procedure. RESULTS: Major complications occurred in 16 patients (5.6%). Major complications were surgical in 12 patients and medical in 4. Of the major surgical complications 3, 6, 1, 1 and 1 occurred during laparoscopic radical nephrectomy, donor nephrectomy, nephroureterectomy, simple nephrectomy and partial nephrectomy, respectively. The predominant major surgical complication was bleeding requiring conversion to an open surgical procedure. The overall conversion rate was 4% (12 patients), consisting of 6 emergency and 6 elective conversions. The remaining 27 patients experienced minor surgical or postoperative medical problems, such as urinary retention or wound infection. The mortality rate in our series was 0%. CONCLUSIONS: Laparoscopic renal surgery is becoming a routine procedure in the armamentarium of many urologists. Complications that are unique to laparoscopy exist but they should decrease with time with repetition and experience. We have learned many different precautions and procedures that should help decrease the risk of future complications associated with laparoscopic renal surgery.     

Complications of radical and partial nephrectomy in a large contemporary cohort

PURPOSE: Standardized criteria for reporting the early complications of urological procedures are lacking. We reviewed the early complications of radical nephrectomy (RN) and partial nephrectomy (PN) in a large contemporary cohort using a standardized complication grading scale. MATERIALS AND METHODS: Between 1995 and 2002, 1,049 patients underwent RN (66%) or PN (34%) for renal cortical neoplasm. Records were reviewed for perioperative complications. Complications were graded using a 5-tiered scale based on the severity of impact or intensity of therapy required. RESULTS: A total of 235 complications occurred in 180 patients (17%). Overall 55% and 31% of complications were grade I and grade II, respectively. There were 3 perioperative deaths (0.2%). PN was not associated with more complications compared to RN when accounting for other variables. PN cases had more procedure related complications compared to RN (9% versus 3%, respectively, p = 0.0001) due to complications of urinary leak and the reintervention rate was subsequently higher (2.5% versus 0.6%, p = 0.02). All but 1 of the reinterventions for PN involved either endoscopy or radiology. By multivariate analysis operative time (p <0.0001) and solitary kidney (p = 0.06) were associated with procedure related complications of PN. CONCLUSIONS: RN and PN are associated with low rates of serious morbidity and mortality. Compared to RN, PN is associated with higher rates of procedure related complications, the majority of which are minor. Overall, however, PN is not associated with more complications than RN.     

Short- and long-term complications of open radical prostatectomy according to the Clavien classification system

OBJECTIVE

To assess the use of the Clavien classification system in documenting the complications related to open retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

The medical records of 995 patients, who had open RRP during a period of 7 years, were reviewed retrospectively. Short‐ and long‐term complications were classified according to the recently revised Clavien classification system. We also compared the results with a recently reported series of laparoscopic and robotic RRP.

RESULTS

The overall complication rate was 26.9%; Grade I, Id, II, IIIa, IIIb and V complications were recorded in 3.4%, 3.9%, 12.8%, 2.6%, 3.8% and 0.3% of cases, respectively. Rectal injuries (10) and postoperative wound infections (24) were included in the Grade I category. Anastomotic leakage was recorded in 39 patients and rated as Grade Id. Grade II included cases of deep vein thrombosis (11), urinary tract infections (42), lymphorrhoeas (22) and haemorrhage requiring transfusion (53). Anastomotic strictures (26) and incisional hernias (38) were included in Grade IIIa and IIIb, respectively. Pulmonary embolism was fatal for three patients (0.3%) of Grade IV and V.

CONCLUSIONS

To avoid incoherence in reporting morbidity data, a reproducible and practical classification system is necessary. The Clavien system could provide, after refinement and validation, a common language among urologists.     

Systematic classification and prediction of complications after nephrectomy in patients with metastatic renal cell carcinoma (RCC)

Study Type – Harm (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Radical nephrectomy for patients with metastatic renal cell carcinoma results in greater rates of morbidity than for those with less advanced disease. This study systematically characterizes complications associated with nephrectomy for metastatic RCC and identifies patient and disease characteristics that are associated with a greater risk of developing complications. Overall complications were relatively frequent, but major complications (grade 3 or greater) were rare. Increasing age and worsening performance status were associated with increased probability of complications. When complications were sustained, patients were less likely to receive systemic therapy in a timely fashion. These observations may influence the timing or patient selection for surgery or systemic therapy.

OBJECTIVE

• ? To evaluate and identify factors predictive for morbidity after radical nephrectomy in patients with metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

• ? We identified patients with mRCC who underwent nephrectomy at Memorial Sloan‐Kettering Cancer Center (MSKCC) between 1989 and 2009.
• ? Postoperative complications were characterised using a modified version of the Clavien‐Dindo classification system.
• ? Patient and disease characteristics, including a previously validated MSKCC risk‐stratification system using calcium, haemoglobin (Hb), lactate dehydrogenase, and Karnofsky Performance Status (KPS), were evaluated as predictors of postoperative complications using univariate and multivariable logistic regression models.
• ? The area under the receiver operating characteristic curve (AUC) was calculated for each model to assess predictive accuracy and corrected for overfit using 10‐fold cross validation.

RESULTS

• ? Over the study period, 195 patients with mRCC underwent nephrectomy; 53 (27%) developed grade ≥2 complications within 8 weeks of surgery.
• ? Pulmonary, thromboembolic events and anaemia requiring transfusion were the most common types of complications after nephrectomy in the metastatic setting.
• ? In univariate analysis, age, low albumin, low KPS, high corrected serum calcium, low serum Hb, and unfavourable MSKCC risk score were predictive of complications.
• ? Patients who sustained postoperative complications were less likely to receive systemic therapy within 56 days (odds ratio [OR] 0.32; 95% confidence interval [CI] 0.12–0.86; P= 0.024).
• ? A multivariable model containing KPS (OR 14.5; 95%CI 4.34–48.6; P < 0.001) and age (OR 1.04; 95%CI 1.01–1.08; P= 0.014) showed the greatest predictive accuracy (corrected AUC 0.72; 95%CI 0.63–0.80) for postoperative complications.

CONCLUSIONS

• ? Postoperative complications after radical nephrectomy in the setting of mRCC are common and occur frequently in older patients and those with worse KPS.
• ? These complications are important because they may delay or deny receipt of subsequent systemic therapy.

     

The relationship of Charlson comorbidity index and postoperative complications in elderly patients after partial or radical nephrectomy

Objectives

To compare preoperative Charlson comorbidity Index (CCI) and postoperative complications after oncologic kidney surgery in patients aged 70 or older. To compare CCI and need for interdisciplinary evaluation, consults to the emergency department and need of readmission are secondary objectives.

Decreased complications of contemporary laparoscopic partial nephrectomy: use of a standardized reporting system

PURPOSE: We report complications of laparoscopic partial nephrectomy in a contemporary cohort of 200 patients using a standardized complication reporting system. MATERIALS AND METHODS: The records of 200 consecutive patients undergoing laparoscopic partial nephrectomy between September 2003 and November 2005 were reviewed. Mean tumor size was 3 cm and mean parenchymal invasion depth was 1.8 cm. There were 97 central tumors (48.5%) and 9 tumors (4.5%) in a solitary kidney. Complication severity for each patient was graded using a 5-tiered scale based on National Cancer Institute Common Toxicity Criteria. Statistical analysis was done to assess risk factors associated with complication events. RESULTS: A total of 35 patients (17.5%) had complications. The overall complication rate was 19%. Of the complications 29%, 42%, 26% and 2.6% were grades I to IV, respectively. There were no grade V complications. Median blood loss was 150 ml. Hemorrhagic and urine leak complications occurred in 9 (4.5%) and 4 patients (2%), respectively. Conversion to open partial and laparoscopic radical nephrectomy was done electively in 2 (1%) and 1 patients (0.5%), respectively. Compared to previously reported data on the initial 200 patients in our laparoscopic partial nephrectomy cohort this contemporary group of 200 had statistically significant decreases in overall, urological and hemorrhagic complication rates despite an increase in tumor complexity (p = 0.02, 0.04 and 0.04, respectively). CONCLUSIONS: Increased experience with advanced laparoscopic techniques has allowed a significantly decreased complication rate following contemporary laparoscopic partial nephrectomy, which now appears comparable to that of open partial nephrectomy. A standardized complication reporting system is advocated.     

Prediction of complications after partial nephrectomy by RENAL nephrometry score

Introduction

Discussing and planning the appropriate management for suspicious renal masses can be challenging. With the development of nephrometry scoring methods, we aimed to evaluate the ability of the RENAL nephrometry score to predict both the incidence of postoperative complications and the change in renal function after a partial nephrectomy.

Methods

This was a retrospective study including 128 consecutive patients who underwent a partial nephrectomy (open and laparoscopic) for renal lesions in a tertiary UK referral centre. Univariate and multivariate ordinal regression models were used to identify associations between Clavien–Dindo classification and explanatory variables. The Kendall rank correlation coefficient was used to examine an association between RENAL nephrometry score and a drop in estimated glomerular filtration rate (eGFR) following surgery.

Results

An increase in the RENAL nephrometry score of one point resulted in greater odds of being in a higher Clavien–Dindo classification after controlling for RENAL suffix and type of surgical procedure (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.04–1.64, p=0.043). Furthermore, a patient with the RENAL suffix ‘p’ (ie posterior location of tumour) had increased odds of developing more serious complications (OR: 2.60, 95% CI: 1.07–6.30, p=0.042). A correlation was shown between RENAL nephrometry score and postoperative drop in eGFR (Kendall’s tau coefficient -0.24, p=0.004).

Conclusions

To our knowledge, this is the first study that has shown the predictive ability of the RENAL nephrometry scoring system in a UK cohort both in terms of postoperative complications and change in renal function.     

Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: analysis of the National Surgical Quality Improvement Project database

Background

An aging surgical population places an increasing burden on surgeons to accurately risk stratify and counsel patients. Preoperative frailty assessments are a promising new modality to better evaluate patients but can often be time consuming. Data regarding frailty and hepatectomy outcomes have not been published to date.

Method

Using the National Surgical Quality Improvement Project database, we examined hepatectomy patients 2005 to 11 and correlated frailty scores with outcomes of major morbidity, mortality, and extended length of stay, using a previously validated modified frailty index score. Frailty was compared against age, American Society of Anesthesiologists class, and other common risk variables.

Results

Multivariate regression identified frailty as the strongest predictor of Clavien 4 complications (OR = 40.0, 95% CI = 15.2 to 105.0), and mortality (OR = 26.4, 95% CI = 7.7 to 88.2). As the frailty score increased, there was a statistically significant increase in Clavien 4 complications, mortality, and extended length of stay (P < .001 for all).

Conclusions

Frailty is a significant factor in morbidity and mortality after hepatectomy. Use of the modified frailty index allows for feasibility of data collection in a busy clinical setting.     

Complications of contemporary open nephron sparing surgery: a single institution experience

PURPOSE: Open nephron sparing surgery (NSS) is now the standard of care for small renal tumors irrespective of overall renal function. More recently laparoscopic NSS with hilar clamping has emerged, albeit with relatively longer ischemic times. We reviewed our experience with contemporary open NSS, comparing complication rates to those of historical controls and updating data for comparison with minimally invasive procedures. MATERIALS AND METHODS: From 1985 to 2001, 823 open NSSs were performed at our institution. Early (within 30 days of NSS) and late (30 days to 1 year) complications were compared using the chi-square and Wilcoxon rank sum tests between procedures performed in 1985 to 1995 (control group of 343 patients) and 1996 to 2001 (contemporary group of 480). RESULTS: In the control vs the contemporary group there were significant decreases in intraoperative blood loss (median 550 vs 350 cc, p <0.001), chronic renal insufficiency/failure (14.6% vs 8.1%, p = 0.003), dialysis need (7.0% vs 2.1%, p <0.001) and any early (13.4% vs 6.9%, p = 0.002) or late (32.4% vs 24.6%, p = 0.014) complication. In the contemporary group 50% of patients did not require pedicle clamping, 32% underwent warm ischemia (median 12 minutes) and 18% underwent cold ischemia (median 27 minutes). In addition, patients with a warm ischemia time of 20 minutes or less had fewer early complications than patients with greater than 20 minutes of ischemia, although this did not attain statistical significance (3.8% vs 13.6%, p = 0.063). CONCLUSIONS: Complications resulting from open NSS have significantly decreased with time. Contemporary open NSS is associated with minimal morbidity, and decreases the need for pedicle clamping and overall ischemia time.     

Ketorolac: safe and effective analgesia for the management of renal cortical tumors with partial nephrectomy

PURPOSE: Ketorolac has demonstrated advantages as a supplement to opioid based analgesia in several surgical settings, including donor nephrectomy. To our knowledge there has been no published data to date on the use of ketorolac in patients undergoing partial nephrectomy. We compared analgesia with ketorolac and opioids to analgesia with opioids alone with regard to pain control, postoperative recovery and effects on renal function in patients with renal cortical tumors surgically managed by partial nephrectomy. MATERIALS AND METHODS: Records for 154 patients treated with partial nephrectomy for renal cortical tumors were retrospectively analyzed. Clinicopathological variables examined were age, gender, medication use, comorbidity profile, operation side, estimated blood loss, hospital stay, operative duration, American Society of Anesthesiologists class, histopathology results, perioperative transfusion status, ischemia type (warm vs cold vs none), duration of renal artery cross clamping, tumor size and intraparenchymal location, pathological stage and perioperative complications. Postoperative duration to the initiation of solid diet, discontinuation of patient controlled analgesia and overall pain control were assessed. Serum creatinine was measured during the preoperative period, and at 1, 3 or greater and 30 or greater days postoperatively. RESULTS: Patients who received ketorolac demonstrated superior postoperative recovery with an earlier return to solid diet and earlier discontinuation of patient controlled analgesia. Treatment groups were similar with respect to changes in serum creatinine, blood loss, transfusion rates and complication rates. Ketorolac was not associated with an increased risk of acute renal failure. CONCLUSIONS: Ketorolac is a safe and effective supplement to opioid based analgesia for pain control after partial nephrectomy.     

Diabetes is predictive of longer hospital stay and increased rate of Clavien complications in spinal surgery in the UK

Introduction

Diabetes is a common co-morbidity of patients undergoing spinal surgery in the UK but there are no published studies from the UK, particularly with respect to length of hospital stay and complications. The aims of this study were to identify complications and length of hospital stay in patients with diabetes undergoing spinal surgery.

Methods

Data were collected retrospectively for 111 consecutive patients with diabetes (and 97 age and sex matched control patients, identified using computer records) who underwent spinal surgery between 2004 and 2010 in a single centre. The data collected included operative time, blood loss, details of surgery, Clavien complications and length of hospital stay.

Results

No significant differences were found by group in operative time, blood loss, instrumentation, use of graft or revision surgery. Overall complication rates were higher in the patients with diabetes than in the controls (28.8% vs 15.5%). The mean hospital stay was significantly longer for patients with diabetes than for control patients (4.6 vs 3.2 days, p<0.001).

Conclusions

This study identified a significantly higher Clavien grade I complication rate and length of hospital stay in patients with diabetes undergoing spinal surgery than control patients (p=0.02). This has resulted in a predictive model being generated. Of note, no infections were seen in patients with diabetes, suggesting that infection rates in this particular group of patients undergoing spinal surgery might not be as high as considered previously.     

Surgical complications of laparoendoscopic single‐site donor nephrectomy: a retrospective study

The single‐port approach has been associated with an unacceptably high rate of umbilical port hernias in large series of patients undergoing single‐port cholecystectomy and colectomy and with additional surgical risks thought secondary to technical and ergonomic limitations. A retrospective review of 378 consecutive laparoendoscopic single‐site(LESS) donor nephrectomies performed between 04/15/2009 and 04/09/2014 was conducted. Twelve patients (3%) developed an umbilical hernia. Eleven (92%) were female and eight (73%) of these patients had a prior pregnancy. Hernias were reported 13.5 ± 6.9 months after donation, and the mean size was 5.1 ± 3.7 cm. Seven additional cases (1.9%) required a return to the operating room for internal hernia (2), evisceration (1), bleeding (1), enterotomy (1), and wound infection (2). The original incision was utilized for reexploration. One patient required emergent conversion to an open procedure for bleeding during the initial donation. There were no mortalities. Recipient patient and graft survival were 99% and 99% at 1 year, respectively. Although reports associated with earlier experiences with single‐site procedures suggested an unacceptably high rate of hernias at the surgical site, this does not seem to be the case at our center. This technique is a reliable surgical technique for left donor nephrectomy at this institution.     

Complications of retroperitoneoscopic living donor nephrectomy: single center experience after 164 cases

Objectives  Retroperitoneoscopic living donor nephrectomy (RLDN) is used by only a few centers worldwide. Similar to laparoscopic living donor nephrectomy it offers the donor rapid convalescence and excellent cosmetic results. However, concerns have been expressed over the safety of endoscopic living donor nephrectomy. Methods  We review the results of 164 consecutive RLDN from November 2001 to November 2007. Complications were classified into intra- and early postoperative. Results  Mean donor age was 53.4 ± 10.7 years (27–79). Left kidneys were harvested in 76% of cases. Mean operation time was 146 ± 44 min (55–270), and warm ischemia time 131 ± 45 s (50–280). In two patients (1.2%) conversion to open nephrectomy was necessary. The intraoperative complication rate was 3.0%. In the postoperative period we observed in 17.7% minor complications with no persisting impairments for the donor. The rate of major complications in the early postoperative period was 4.3%. Three patients (1.8%) necessitated revision, due to laceration of the external iliac artery in one patient and chyloretroperitoneum in two patients. Mean donor creatinine was 113.1 ± 26.6 mg/dl (63–201) on the first postoperative day, and 102.0 ± 22.2 mg/dl (68–159) on the fifth postoperative day. Conclusion  Retroperitoneoscopic living donor nephrectomy can be performed with acceptable intraoperative and early postoperative morbidity. Operation times and warm ischemia times are comparable to the open approach.     

Partial nephrectomy for patients with a solitary kidney: the Memorial Sloan-Kettering experience

OBJECTIVE: To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival. PATIENTS AND METHODS: We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined. RESULTS: The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively. CONCLUSIONS: Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.     

Analysis of complications following partial and total nephrectomy for renal cancer in a population based sample

PURPOSE: We determined the frequency and predictors of complications of partial and total nephrectomy in a population based sample. MATERIALS AND METHODS: There were 3,019 partial and 18,575 total nephrectomies identified from the Nationwide Inpatient Sample data set of the Healthcare Cost and Utilization Project (2000 to 2003). The prevalence of International Classification of Diseases, 9th Revision coded complications following nephrectomy was determined. Hospital and patient related factors associated with the occurrence of a complication were determined by logistic regression analysis. We evaluated the impact of complications on in-hospital mortality, length of stay and hospital charges. RESULTS: Respiratory, digestive and bleeding complications were the most common, with similar patterns for partial nephrectomy and total nephrectomy. Significant predictors of complications after total nephrectomy included age, male sex, comorbidity severity index and hospital location (rural vs urban), while comorbidity was the only significant predictor for partial nephrectomy complications. Any complication had a significant impact on in-hospital mortality, total charges and length of stay. Digestive and urinary complications, hemorrhage, and postoperative infections had a significant impact on in-hospital mortality after partial nephrectomy, while these same complications, in addition to respiratory and cardiac complications, had a significant impact on total charges and length of stay. All except digestive complications had a significant impact on mortality, hospital charges and length of stay for patients undergoing total nephrectomy. CONCLUSIONS: In a population based cohort partial nephrectomy and total nephrectomy are associated with low morbidity and mortality profiles, and all complications affect mortality, length of hospital stay and charges.     

The influence of comorbidity on treatment and survival of triple‐negative breast cancer

Concomitant comorbidity is a key factor in treatment decision‐making for breast cancer. The aim of this study was to determine how the Charlson Comorbidity Index (CCI) affected treatment and risk of mortality of women with TNBC, the subtype with the poorest prognosis. We accessed 20 177 cases of TNBC from the California Cancer Registry 2000‐2015 with documented Charlson Comorbidity Index (CCI). Cox Regression was used to compute the adjusted risk of breast cancer‐specific mortality for a CCI of 1 (low comorbidity) and 2+ (high comorbidity) vs a CCI of 0 (no comorbidity). Logistic regression was used to compute the association of CCI with treatment of mastectomy, lumpectomy + radiation, and chemotherapy. Analyses were conducted separately for each stage. Patients with high comorbidity CCI (2+) were less likely to receive systemic chemotherapy irrespective of Stage. High comorbidity was associated with higher breast‐specific mortality in all stages of disease. High comorbidity did not have an effect on the use of lumpectomy and radiation of stage 1 breast cancer but was associated with reduced use in stages 2‐4. Comorbidity was not associated with decreased risk of mastectomy except for patients with high comorbidity in stage 3. Concomitant comorbidity influences treatment decisions and breast cancer‐specific mortality in patients with TNBC.