Correlation Between the Mayo Adhesive Probability Score and the Operative Time in Laparoscopic Donor Nephrectomy

BackgroundAdherent perinephric fat (APF) is a known risk factor of surgical difficulty during laparoscopic donor nephrectomy (LDN). The Mayo Adhesive Probability (MAP) score predicts APF accurately. The aim of this study is to identify the association between MAP score and operative time in LDN.MethodsWe retrospectively evaluated 154 kidney donors who underwent surgery from December 2017 to December 2019 at ?stanbul Ayd?n University Hospital and ?stinye University Hospital. All of the operations were done by 3 senior surgeons by a fully laparoscopic method. The MAP score was derived from computed tomography scans by 1 blinded reader. Demographic data, body mass index (BMI), MAP score, side selection, estimated glomerular filtration rate (eGFR), number of arteries and veins, operative time, hospital stay, and complications are recorded. Single and multiple variable analyses were used to evaluate the correlation between operative time and MAP score, BMI, side selection, and number of vascular structures.ResultsA total of 154 patients (79 men, 75 women) with a mean age of 44.4 ± 12.72 were included in this study. None of the cases were converted to open nephrectomy. There were no major complications. Mean BMI was 27.59 ± 4.32 kg/m², mean MAP score was 0.69 ± 1.15, and mean operative time was 40.25 ± 9.81 minutes. Although mean BMI was higher in women (28.19 ± 4.52 vs 27.03 ± 4.07; P < .05), mean MAP score was lower than in men (0.35 ± 0.86 vs 1.03 ± 1.29; P < .001). Older age, higher BMI, higher MAP score, and presence of multiple renal arteries were associated with longer operative time of LDN. The MAP score was associated with older age, male sex and higher BMI.ConclusionsThis study showed that different risk factors can affect operative time in LDN. The MAP score was significantly associated with longer operative time, especially in men, so it can be useful for predicting surgical difficulty in kidney donors.     

Mayo Adhesive Probability Score: An Accurate Image-based Scoring System to Predict Adherent Perinephric Fat in Partial Nephrectomy

Background

Image-based renal morphometry scoring systems are used to predict the potential difficulty of partial nephrectomy (PN), but they are centered entirely on tumor-specific factors and neglect other patient-specific factors that may complicate the technical aspects of PN. Adherent perinephric fat (APF) is one such factor known to make PN difficult.

Objective

To develop an accurate image-based nephrometry scoring system to predict the presence of APF encountered during robot-assisted partial nephrectomy (RAPN).

Design, setting, and participants

We prospectively analyzed 100 consecutive RAPNs performed by one surgeon and defined APF as the need for subcapsular renal dissection to isolate the renal tumor for RAPN.

Outcome measurements and statistical analysis

The scoring algorithm to predict the presence of APF was developed with a multivariable logistic regression model using a forward selection approach with a focus on improvement in the area under the receiver operating characteristic curve.

Results and limitations

Thirty patients (30%; 95% confidence interval, 21–40) had APF. Single-variable analysis noted an increased likelihood of APF in male patients (p < 0.001), higher body mass index (p = 0.003), greater posterior perinephric fat thickness (p < 0.001), greater lateral perinephric fat thickness (p < 0.001), and those with perirenal fat stranding (p < 0.001). Two of these variables, posterior perinephric fat thickness and stranding, were most highly predictive of APF in multivariable analysis and were therefore used to create a risk score, termed Mayo Adhesive Probability (MAP) and ranging from 0 to 5, to predict the presence of APF. We observed APF in 6% of patients with a MAP score of 0, 16% with a score of 1, 31% with a score of 2, 73% with a score of 3–4, and 100% of patients with a score of 5.

Conclusions

MAP score accurately predicts the presence of APF in patients undergoing RAPN. Prospective validation of the MAP score is required.

Patient summary

The Mayo Adhesive Probability score that we we developed is an accurate system that predicts whether or not adherent perinephric, or “sticky,” fat is present around the kidney that would make partial nephrectomy difficult.     

肾周脂肪梅奥粘连概率评分系统在肾癌后腹腔镜肾部分切除术中的应用

目的探讨肾周脂肪梅奥粘连概率评分系统（MAP）在肾癌后腹腔镜肾部分切除术中的临床应用价值。 方法回顾性分析2015年1月至2020年6月徐州医科大学附属淮安医院泌尿外科收治的行后腹腔镜肾部分切除术的153例肾癌患者的临床病例资料。依据MAP评分系统将其分为低度复杂组、中度复杂组和高度复杂组三组。比较各组间的手术时间、术中出血量、术中及术后并发症、术中热缺血时间、术后住院时间及术后血肌酐变化情况。 结果在153例患者中，低度复杂组68例，中度复杂组58例和高度复杂组27例。三组患者在年龄、性别、术前血肌酐水平、肿瘤最大径、肿瘤位置、BMI、RENAL评分等方面差异无统计学意义（P>0.05）。随着复杂程度的提高，手术时间、术中出血量也在不断增加（P<0.05）；而术中热缺血时间、术后住院时间及术后血肌酐水平无明显变化（P>0.05）。在术中并发症方面，随着复杂程度的提高，术中并发症的发生率也在增加（P<0.05），且高度复杂组的术后并发症发生风险是低度复杂组的13.895倍（P=0.002)，MAP评分系统预测术中并发症发生的精度较高（AUC=0.757，P=0.002）。但是术后并发症各组比较差异无统计学意义（P>0.05）。 结论MAP评分系统在肾癌后腹腔镜肾部分切除术中，对预估手术难度及术中并发症发生风险有较好的临床应用价值。     

Prospective assessment and histological analysis of adherent perinephric fat in partial nephrectomies

Objectives

The complexity of partial nephrectomy (PN) is partly anticipated by morphometric tumor-based scores that do not consider patient-related issues such as adherent perinephric fat (APF). Also, the objective is to prospectively assess the predictive factors of APF during PN, its effect on complications, and to correlate it to the histological reality.

Trifecta outcomes of modified robot-assisted simple enucleation and standard robot-assisted partial nephrectomy for treating clinical T1b renal cell carcinoma

BackgroundTo compare perioperative outcomes and Trifecta achievement of modified robot-assisted simple enucleation (MRASE) with robot-assisted partial nephrectomy (RAPN) for treating clinical T1b renal tumors.MethodsWe analyzed 203 patients who underwent MRASE or RAPN for clinical T1b renal tumors at our institution from September 2014 to June 2018. The two groups were compared regarding perioperative outcome variables. Trifecta was defined as no perioperative complications, negative surgical margin, and ischemia time ≤25 minutes.ResultsIn all, 139 patients underwent MRASE and 64 underwent RAPN respectively. Patients in the MRASE group had shorter operative time (197.7 vs. 215.6 min, P=0.039) and warm ischemic time (21.2 vs. 24.1 min, P=0.004) in comparison to the RAPN group. The groups were comparable in estimated blood loss (230.5 vs. 269.8 mL, P=0.259). Tumor bed suturing was performed with a significantly lower frequency in the MRASE group than in the RAPN group (11.5% vs. 90.6%, P<0.01). The incidence of perioperative complications was similar. The rate of positive surgical margins was similar in both groups (2.2% vs. 6.3%, P=0.284). Trifecta was achieved in 61.2% and 42.2% of MRASE and RAPN patients (P=0.012). On multivariable analysis, the type of procedure, RENAL score, estimated blood loss, and operative time were positive factors for the achievement of Trifecta.ConclusionsIn this series MRASE was superior to RAPN with regard to the achievement of Trifecta in treating T1b renal tumors. Besides, MRASE had better outcomes for shorter operative time, shorter warm ischemic time, and less need for tumor bed suturing as compared with RAPN.     

Total robotic surgical volume influences outcomes of low-volume robotic-assisted partial nephrectomy over an extended duration

IntroductionThe objective of this study was to examine the surgeon’s experience of low-volume robotic-assisted partial nephrectomy (RAPN) over an extended duration, and whether a high-volume fellowship training influenced the outcomes.MethodsData on all RAPN at a tertiary center performed by a uro-oncologist were retrospectively collected. The surgeon experience was assessed by examining perioperative outcomes among three groups of consecutive patients (first=14, second=14, third=15 patients, respectively).ResultsBetween February 2014 and February 2020, 45 RAPNs were performed out of a total of 200 robotic procedures. The median tumor size was 3 cm, and 28 (65%) patients had a R.E.N.A.L nephrometry score (RNS) ≥7. The median operative time and warm ischemia time (WIT) were 190 and 16 minutes, respectively. The median estimated blood loss (EBL) was 100 mL. Two (4%) patients had a positive surgical margin (PSM). Overall, five (12%) complications were recorded. All except one were minor (Clavien I–II). The median followup was 26.2 months. Trifecta and pentafecta were achieved in 40 (93%) and 27 (81.8%) patients, respectively. Increased surgeon experience was significantly associated with a shorter operative time and less EBL. Furthermore, there was an independent association between surgeon experience and operative time and EBL, and between RNS and operative time and WIT.ConclusionsWith fellowship training and subsequent adequate total number of robotic procedures during practice, it is possible to perform RAPN with favorable perioperative outcomes in the setting of low-volume of cases over an extended duration.     

A ureteral stricture disease score and classification system: correlation with upper urinary tract reconstructive surgery complexity

BackgroundTo develop an original and standardized ureteral stricture disease (USD) score and classification system for quantifying ureter stricture characteristics, assessing complexity of the minimally invasive upper urinary tract reconstructive (UUTR) surgical procedure, formulating preoperative plans, and offering objective comparisons of surgical techniques between different institutions and surgeons.MethodsWe retrospectively reviewed a test set of 64 patients and a validation set of 170 patients who underwent minimally invasive UUTR surgery from January 2018 to January 2021. Three factors were selected to be included in the USD score and classification system: (I) stricture etiology (E, 1–2 points); (II) stricture segment (S, 0–3 points); and (III) length of stricture (L, 1–5 points). The UUTR surgery involves low-complex surgeries (cystoscopy with ureteral dilation and stent placement, ureteropyeloplasty, end to end repair, ureteral reimplantation) and high-complex surgeries (onlay repair (buccal mucosae, lingual mucosae, appendix mucosae), Boari flap repair and ileal ureter replacement). Estimated blood loss and operative time were used as surrogate indicators of surgical complexity.ResultsThe interrater reliability of the USD score and classification system was 0.908. A linear relationship between the USD score and estimated blood loss was observed (rs =0.676, P<0.001). The USD score was also correlated with operative time (rs =0.638, P<0.001). A significant difference in USD scores was found between the high and low complexity surgery groups (4 vs. 7, P<0.001). Variability of UUTR surgery is based on USD classification system, but with regularity to conform to.ConclusionsThe USD score and classification system is a concise, easily applicable, and validated scale to delineate the clinically significant features of ureter stricture that correlate with the complexity of the UUTR surgical procedure. The use of this score and classification system can facilitate preoperative plan and comparison of USD treatments in clinical practice and urological literature. Research with large sample is needed to further examine and modify the use of the system.     

Prognostic effect of preoperative serum albumin to globulin ratio in patients treated with cytoreductive nephrectomy for metastatic renal cell carcinoma

BackgroundAccurate identification of ideal candidates for cytoreductive nephrectomy (CN) for metastatic renal cell carcinoma (mRCC) is an unmet need. We tested the association between preoperative value of systemic albumin to globulin ratio (AGR) and overall survival (OS) as well as cancer-specific survival (CSS) in mRCC patients treated with CN.MethodsmRCC patients treated with CN were included. The overall population was therefore divided into two AGR groups using cut-off of 1.43 (low, <1.43 vs. high, ≥1.43). Univariable and multivariable Cox regression analyses tested the association between AGR and OS as well as CSS. The discrimination of the model was evaluated with the Harrel’s concordance index (C-index). The clinical value of the AGR was evaluated with decision curve analysis (DCA).ResultsAmong 613 mRCC patients, 159 (26%) patients had an AGR <1.43. Median follow-up was 31 (IQR: 16–58) months. On univariable analysis, low preoperative serum AGR was significantly associated with both OS (HR: 1.55, 95% CI: 1.26–1.89, P<0.001) and CSS (HR: 1.55, 95% CI: 1.27–1.90, P<0.001). On multivariable analysis, AGR <1.43 was associated with worse OS (HR: 1.51, 95% CI: 1.23–1.85, P<0.001) and CSS (HR: 1.52, 95% CI: 1.24–1.86, P<0.001). The addition of AGR only minimally improved the discrimination of a base model that included established clinicopathologic features (C-index=0.640 vs. C-index=0.629). On DCA, the inclusion of AGR marginally improved the net benefit of the prognostic model. Low AGR remained independently associated with OS and CSS in the IMDC intermediate risk group (HR: 1.52, 95% CI: 1.16–1.99, P=0.002).ConclusionsIn our study, low AGR before CN was associated with worse OS and CSS, particularly in intermediate risk patients.     

Off-clamp robot-assisted partial nephrectomy does not benefit short-term renal function: a matched cohort analysis

In the interest of renal functional preservation, partial nephrectomy has supplanted radical nephrectomy as the preferred treatment for T1 renal masses. This procedure usually involves the induction of renal warm ischemia by clamping the hilar vessels prior to tumor excision. Performing robot-assisted partial nephrectomy (RAPN) “off-clamp” can theoretically prevent renal functional loss associated with warm ischemia. We describe our institutional experience and compare perioperative and renal functional outcomes using a propensity score matched cohort. We conducted a retrospective comparison from a prospectively maintained database of all patients who underwent RAPN from 2009 to 2015. Of those patients, 143 underwent off-clamp RAPN. Fifty off-clamp RAPN patients were propensity score matched with fifty clamped RAPN patients based on renal function, tumor size, and R.E.N.A.L. nephrometry score. The cohorts were compared across demographics, operative information, perioperative outcomes, and renal functional outcomes. For all off-clamp RAPN patients, mean nephrometry score was 7.1, mean estimated blood loss (EBL) was 236.9 mL, perioperative complication rate was 7.7%, and mean decrease in estimated glomerular filtration rate (eGFR) was 7.1% at a median follow-up of 9.2 months. In the propensity score matched cohorts, off-clamp RAPN resulted in a shorter mean operative time (172.0 versus 196.0 min, p = 0.025) and a lower mean EBL (179.7 versus 283.2 mL, p = 0.046). A lower complication rate of 6.0% in the off-clamp group compared with 20.0% in the clamped group approached significance (p = 0.071). Mean preoperative eGFR was similar in both cohorts. Importantly, there was no significant difference in decrease in eGFR between the clamped cohort (9.8%) and off-clamp cohort (11.9%) at a median follow-up of 9.0 months (p = 0.620). Off-clamp RAPN did not result in improved renal functional preservation in our experience. Surprisingly, the off-clamp cohort experienced lower intraoperative blood loss, shorter operative times, and fewer complications.     

Partial vs. radical nephrectomy and the risk of all-cause mortality,cardiovascular, and nephrological outcomes

IntroductionThe study’s objective was to examine the effects of renal-preservation surgery on long-term mortality, cardiovascular outcomes, and renal-related outcomes.MethodsWe performed a retrospective cohort study of all partial (n=575) and radical nephrectomies (n=882) for tumors ≤7 cm in diameter between 2002 and 2010 across three academic centers in Ontario, Canada. We linked records from provincial databases to assess patient characteristics and outcomes (median seven years’ followup using retrospective data). A weighted propensity score was used to reduce confounding. The primary outcome was all-cause mortality. Secondary outcomes included hospitalization with major cardiovascular events, non-cancer related mortality, kidney cancer-related mortality, and dialysis.ResultsMean one-year postoperative estimated glomerular filtration rate (eGFR) was 71 mL/min/1.73 m² in the partial group and 52 mL/min/1.73 m² in the radical group. Partial nephrectomy was associated with a lower risk of all-cause mortality in the first five years after surgery (hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.27–0.66), which did not extend beyond five years (HR 1.01, 95% CI 0.68–1.49). Kidney cancer-related mortality was lower in the partial compared to the radical group for the first four years after surgery (HR 0.16, 95% CI 0.04–0.72). There were no significant differences between the groups for cardiovascular outcomes or non-cancer related deaths.ConclusionsOverall survival and cancer-specific survival was reduced in radical nephrectomy patients. However, despite reduced renal function in the radical nephrectomy group, non-cancer-related death, cardiovascular events, and dialysis were not significantly different between groups. Long-term benefits of partial nephrectomy may be less than previously believed.     

“Ride the Green Light”: Indocyanine Green–marked Off-clamp Robotic Partial Nephrectomy for Totally Endophytic Renal Masses

BackgroundComplexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection.ObjectiveTo detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging.Design, setting, and participantsBetween June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN.Surgical procedurePreoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN.MeasurementsClinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed.Results and limitationsMedian tumor size was 3 cm (interquartile range 2.3–3.8). The median PADUA score was 10 (9–11). Angiographic procedure was successful in all patients. Median operative time was 75 min (65–85); median estimated blood loss was 250 ml (200–350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2–3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3 g/dl (2.1–3.3) and 11% (10–20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6–20.9%) and 12.2% (5.3–13.7%), respectively.ConclusionsWe described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins.Patient summaryRobot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.     

Holographic reconstruction technology used for intraoperative real-time navigation in robot-assisted partial nephrectomy in patients with renal tumors: a single center study

BackgroundTo explore the efficacy and advantages of real-time navigation using holographic reconstruction (HR) technology combined with da VinciTM robotic system for partial nephrectomy (PN) in patients with renal tumor.MethodsThe clinical data of 41 patients with totally intrarenal tumors receiving robot-assisted partial nephrectomy (RAPN) from April 2018 to October 2020 in our department were collected and retrospectively analyzed. All operations were performed by the same surgeon. HR technology and three-dimensional (3D) reconstruction techniques were applied for real-time navigation to resect tumors using the da VinciTM robotic system. The relevant clinical parameters and surgical outcomes of the patients were recorded and analyzed.ResultsHR technology allowed accurate evaluation of tumors, renal hilus vessels, and surrounding organs during the operation. With real-time navigation HR, all cases were performed by RAPN. The mean operative time was 115.3±20.3 (range, 70–153) minutes, and the warm ischemia time (WIT) was 18.7±3.9 (range, 13–28) minutes. The estimated blood loss (EBL) was 98.8±18.7 (range, 60–141) mL. Negative surgical margins were reported in all cases. Patients with absence of grade ≤1 Clavien-Dindo complications. Compared with the clinical outcomes of standard RAPN, as reported in the literature, HR-assisted technology reduced the mean operative time, the WIT, and the EBL in patients undergoing RAPN. Therefore, combining HR with robotic abdominal surgery can enhance the efficiency of locating blood vessels and allow for more accurate resection of tumors.ConclusionsAs a novel and promising computer digital technology, HR can significantly improve the success of RAPN operations. This retrospective study demonstrated that HR-assisted operations resulted in shorter operation times and less perioperative complications and were thus safer and more effective in patients with renal tumors compared with RAPN not used HR.     

Robotic versus open partial nephrectomy for highly complex renal masses: Comparison of perioperative,functional, and oncological outcomes

Introduction

We aimed to compare perioperative, functional and oncological outcomes between robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) for highly complex renal tumors (R.E.N.A.L. nephrometry Score > 9).

Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors

PURPOSE: Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less. MATERIALS AND METHODS: Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups. RESULTS: Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.     

Prognostic impact of paraneoplastic syndromes on patients with non-metastatic renal cell carcinoma undergoing surgery: Results from Canadian Kidney Cancer information system

IntroductionThe impact of paraneoplastic syndromes (PNS) on survival in patients with renal cell carcinoma (RCC) is uncertain. This study was conducted to analyze the association of PNS with recurrence and survival of patients with non-metastatic RCC undergoing nephrectomy.MethodsThe Canadian Kidney Cancer information system is a multi-institutional cohort of patients started in January 2011. Patients with nephrectomy for non-metastatic RCC were identified. PNS included anemia, polycythemia, hypercalcemia, and weight loss. Associations between PNS and recurrence or death were assessed using Kaplan-Meier curves and multivariable analysis.ResultsOf 4337 patients, 1314 (30.3%) had evidence of one or more PNS. Patients with PNS were older, had higher comorbidity, and had more advanced clinical and pathological tumor characteristics as compared to patients without PNS (all p<0.05). Kaplan-Meier five-year estimated recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were significantly worse in patients with PNS (63.7%, 84.3%, and 79.6%, respectively, for patients with PNS vs. 73.9%, 90.8%, and 90.1%, respectively, for patients without PNS, all p<0.005). On univariable analysis, presence of PNS increased risk of recurrence (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.48–1.90, p<0.0001) and cancer-related death (HR 1.85, 95% CI 1.34–2.54, p=0.0002). Adjusting for known prognostic factors, PNS was not associated with recurrence or survival.ConclusionsIn non-metastatic RCC patients undergoing surgery, presence of PNS is associated with older age, higher Charlson comorbidity index score, advanced tumor stage, and aggressive tumor histology. Following surgery, baseline PNS is not strongly independently associated with recurrence or death.     

Cirugía en directo: estudio de seguridad tras 17 ediciones de cirugía retroperitoneoscópica

IntroductionLive surgery has become an excellent tool for medical training. Despite this, there is controversy about the safety of the patients involved.ObjectiveTo analyze the results of live surgeries performed in 17 consecutive retroperitoneoscopy courses organized in our center. Procedures performed were partial nephrectomy (PN), radical nephrectomy (RN) and nephroureterectomy (NU).Material and methodsReview from January 2010 to October 2017 of all live surgeries carried out by an expert surgical team in the retroperitoneoscopy courses, compared with a control group of surgeries performed in standard conditions. A matching (1:1 for each RN and 1:2 for each PN and NU) according to age, body mass index and comorbidities was performed.ResultsTwenty-one live surgeries were analyzed (eight PN, seven RN and six NU) with a global median follow-up of 38 months. No significant differences were observed between both groups in terms of perioperative variables (operative time, operative bleeding and intraoperative complications) or of postoperative complications and length of hospital stay. Likewise, there were no differences between recurrence rates (PN: 0% vs. 6.3%, p = 0.47, NU: 33.3% vs. 66.7%, p = 0.180, RN: 0% vs. 28.6%, p = 0,127).ConclusionsLive surgery in the hands of expert surgeons in a suitable environment and with well-selected patients does not increase the risk of complications and allows maintaining the same oncological outcomes.     

The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation

BackgroundNo validated training program for robot-assisted partial nephrectomy (RAPN) exists.ObjectiveTo define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN).Design, setting, and participantsA modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN).Outcome measurements and statistical analysisTo define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann–Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient's outcome and the impact of trainee's experience on surgical independence.Results and limitationsConsensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p > 0.05). Conversely, operative time was longer after cRAPN (p < 0.0001). The trainee completed all phases of the curriculum and the trainee's experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p < 0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety.ConclusionsThe European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program.Patient summaryPatients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.     

Body Mass Index,American Society of Anesthesiologists Score,and Elixhauser Comorbidity Index Predict Cost and Delay of Care During Total Knee Arthroplasty

BackgroundBody mass index (BMI), American Society of Anesthesiologists (ASA) score, and Elixhauser Comorbidity Index are measures that are utilized to predict perioperative outcomes, though little is known about their comparative predictive effects. We analyzed the effects of these indices on costs, operating room (OR) time, and length of stay (LOS) with the hypothesis that they would have a differential influence on each outcome variable.MethodsA retrospective review of the institutional database was completed on primary TKA patients from 2015 to 2018. Univariable and multivariable models were constructed to evaluate the strength of BMI, ASA, and Elixhauser comorbidities for predicting changes to total hospital and surgical costs, OR time, and LOS.ResultsIn total, 1313 patients were included. ASA score was independently predictive of all outcome variables (OR time, LOS, total hospital and surgical costs). BMI, however, was associated with intraoperative resource utilization through time and cost, but only remained predictive of OR time in an adjusted model. Total Elixhauser comorbidities were independently predictive of LOS and total hospital cost incurred outside of the operative theater, though they were not predictive of intraoperative resource consumption.ConclusionAlthough ASA, BMI, and Elixhauser comorbidities have the potential to impact outcomes and cost, there are important differences in their predictive nature. Although BMI is independently predictive of intraoperative resource utilization, other measures like Elixhauser and ASA score were more indicative of cost outside of the OR and LOS. These data highlight the differing impact of BMI, ASA, and patient comorbidities in impacting cost and time consumption throughout perioperative care.     

Commentary on “A matched comparison of perioperative outcomes of a single laparoscopic surgeon versus a multisurgeon robot-assisted cohort for partial nephrectomy.” Ellison JS,Montgomery JS,Wolf Jr JS,Hafez KS,Miller DC,Weizer AZ,Department of Urology,University of Michigan,Ann Arbor,MI, USA : J Urol 2012;188(1):45–50

PurposeMinimally invasive nephron sparing surgery is gaining popularity for small renal masses. Few groups have evaluated robot-assisted partial nephrectomy compared to other approaches using comparable patient populations. We present a matched pair analysis of a heterogeneous group of surgeons who performed robot-assisted partial nephrectomy and a single experienced laparoscopic surgeon who performed conventional laparoscopic partial nephrectomy. Perioperative outcomes and complications were compared.Materials and methodsAll 249 conventional laparoscopic and robot-assisted partial nephrectomy cases from January 2007 to June 2010 were reviewed from our prospectively maintained institutional database. Groups were matched 1:1 (108 matched pairs) by R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines) nephrometry score, transperitoneal vs retroperitoneal approach, patient age and hilar nature of the tumor. Statistical analysis was done to compare operative outcomes and complications.ResultsMatched analysis revealed that nephrometry score, age, gender, tumor side and American Society of Anesthesia physical status classification were similar. Operative time favored conventional laparoscopic partial nephrectomy. During the study period robot-assisted partial nephrectomy showed significant improvements in estimated blood loss and warm ischemia time compared to those of the experienced conventional laparoscopic group. Postoperative complication rates, and complication distributions by Clavien classification and type were similar for conventional laparoscopic and robot-assisted partial nephrectomy (41.7% and 35.0%, respectively).ConclusionsRobot-assisted partial nephrectomy has a noticeable but rapid learning curve. After it is overcome the robotic procedure results in perioperative outcomes similar to those achieved with conventional laparoscopic partial nephrectomy done by an experienced surgeon. Robot-assisted partial nephrectomy likely improves surgeon and patient accessibility to minimally invasive nephron sparing surgery.     

Impact of protruded median lobe on perioperative,urinary continence and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy

BackgroundTo investigate the effect of protruded median lobe (PML) on the perioperative, oncological, and urinary continence (UC) outcomes among patients underwent Retzius-sparing robot-assisted radical prostatectomy (RS-RARP).Methods231 consecutive patients who had undergone RS-RARP were collected and analyzed. Patients were divided into three groups based on the PML degree: PML<5 mm (n=99); 5≤ PML <10 mm (n=91); PML ≥10 mm (n=41). The perioperative outcomes, short-term oncological, and UC outcomes were compared among the three groups. Those outcomes were also compared in patients with significant PML (>10 mm) who underwent the traditional or Retzius-sparing RARP.ResultsThe median PML was significantly associated age (P<0.001) and prostate volume (P<0.001). Perioperative characteristics including console time, estimated blood loss (EBL), intraoperative transfusion rate, and complications were not statistically different among the three groups (P=0.647, 0.574, 0.231, 0.661, respectively). The rate of positive surgical margin (PSM) were not significantly different in the three groups (P=0.065). No significant difference regarding UC and biochemical recurrence (BCR) at 12-month follow-up was observed in the three groups (P>0.05). Comparison between the two approaches in men with significant PML showed better recovery of UC (HR =1.83, 95% CI: 1.117–3.01, log-rank P=0.002) and similar BCR (log-rank P=0.072) after RS-RARP.ConclusionsRS-RARP is an oncologically and functionally equivalent approach for patients with PML. Compared with the traditional approach, RS-RARP offers benefits regarding UC for cases with significant PML.