Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) Classification of Renal Tumours in Patients who are Candidates for Nephron-Sparing Surgery

Background

Besides clinical tumour size, other anatomical aspects of the renal tumour are routinely considered when evaluating the feasibility of elective nephron-sparing surgery (NSS).

Objective

To propose an original, standardised classification of renal tumours suitable for NSS based on their anatomical features and size and to evaluate the ability of this classification to predict the risk of overall complications resulting from the surgery.

Design, setting, and participants

We enrolled prospectively 164 consecutive patients who underwent NSS for renal tumours at a tertiary academic referral centre from January 2007 to December 2008.

Intervention

Open partial nephrectomy without vessel clamping.

Measurements

All tumours were classified by integrating size with the following anatomical features: anterior or posterior face, longitudinal, and rim tumour location; tumour relationships with renal sinus or urinary collecting system; and percentage of tumour deepening into the kidney. We generated an algorithm evaluating each anatomical parameter and tumour size (the preoperative aspects and dimensions used for an anatomical [PADUA] score) to predict the risk of complications.

Results and limitations

Overall rates of complication were significantly correlated to all the evaluated anatomical aspects, excluding clinical size and anterior or posterior location of the tumour. By multivariate analysis, PADUA scores were independent predictors of the occurrence of any grade complications (hazard ratio [HR] for score 8–9 vs 6–7: 14.535; HR for score ≥10 vs 6–7: 30.641). Potential limitations were the limited number of patients with T1b tumours included in the study and the lack of laparoscopically treated patients. Further external validation of the PADUA score is needed.

Conclusions

The PADUA score is a simple anatomical system that can be used to predict the risk of surgical and medical perioperative complications in patients undergoing open NSS. The use of an appropriate score can help clinicians stratify patients suitable for NSS into subgroups with different complication risks and can help researchers evaluate the real comparability among patients undergoing NSS with different surgical approaches.     

Kidney Salvage Using the Fibrinogen- and Thrombin-Coated Sponge Tachosil® During Nephron-Sparing Surgery for the Resection of Large Renal Tumours

Nephron-sparing surgery can permit functional preservation of the kidney in carefully selected patients. We report nephron-sparing surgery in two patients with renal tumours ≥ 5 cm. Both patients were successfully treated, with kidney salvage facilitated through the use of the fibrinogen- and thrombin-coated collagen sponge, TachoSil® (Nycomed UK Ltd, UK).     

Impact of the Learning Curve on Perioperative Outcomes in Patients Who Underwent Robotic Partial Nephrectomy for Parenchymal Renal Tumours

Background

Robot-assisted partial nephrectomy (RAPN) is an emerging, minimally invasive technique to treat patients with small renal masses.

Objective

To evaluate the impact of the learning curve on perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications, and renal function impairment in patients who underwent RAPN.

Design, setting, and participants

We collected prospectively the clinical and pathologic records of 62 consecutive patients who underwent RAPN between September 2006 and November 2009 for renal tumours at a nonacademic teaching institution by a single surgeon with extensive prior robotic experience.

Interventions

The surgeon used transperitoneal RAPN with excision of an adequate rim of healthy peritumour renal parenchyma.

Measurements

Perioperative parameters, pathologic outcome, and short-term outcomes for renal function were recorded. The effects of the learning curve on the previous reported perioperative and functional outcomes was studied.

Results and limitations

The mean pathologic tumour size was 2.8 ± 1.3 cm. A pelvicaliceal repair was needed in 33 cases (53%). The mean console time was 91 ± 33 min (range: 52–180), with a mean WIT of 20 ± 7 min (range: 9–40). Warm ischaemia (<20 min) and console times were optimised after the first 30 (p < 0.001) and 20 cases (p < 0.001), respectively. Pathologic results yielded a positive surgical margin (PSM) rate of 2%. Mean creatinine level changed from a baseline value of 1.02 ± 0.38 mg/dl to 1.1 ± 0.7 mg/dl 3 mo after surgery. Estimated glomerular filtration rate changed from a baseline value of 81.17 ± 29 to 80.5 ± 29 (millilitres per minute per 1.73 m²) 3 mo postoperatively.

Conclusions

RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. Specifically, in the hands of a surgeon with extensive robotic experience, RAPN requires a short learning curve to reach WIT <20 min, console times <100 min, limited blood loss, and acceptable overall complication rates.     

Preoperative Brain Natriuretic Peptide (BNP) Is a Better Predictor of Adverse Cardiac Events Compared to Preoperative Scoring System in Patients Who Underwent Abdominal Surgery

Background  

Cardiovascular disease is the leading cause of perioperative death in surgical patients. A variety of clinical scoring systems have been developed to predict adverse cardiovascular events. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. We present a prospective, single-center, observational cohort study of patients undergoing major abdominal surgery and evaluate the role of BNP in predicting adverse cardiac events.     

Prognostic Factors Influencing Long-Term Survival of Patients Undergoing Nephron-Sparing Surgery for Nonmetastatic Renal-Cell Carcinoma (RCC) with Imperative Indications

Background  

We assessed the effect of T stage, Fuhrman’s grade, multifocality, bilaterality, positive surgical margins, and synchronism of bilateral tumors on cancer-specific survival of patients with nonmetastatic renal-cell carcinoma (RCC) undergoing nephron-sparing surgery for imperative indications.     

MRA在亲属活体肾移植供体术前评估中的价值（附60例报告）

目的:探讨磁共振肾血管显像(MRA)在亲属活体肾移植供体术前综合评估中的临床应用价值.方法:回顾性分析60例供体术前MRA资料,并与术中肾血管解剖发现作对比,以后者作为诊断的金标准.结果:60例供体术中证实单支肾动脉54例,6例存在副肾动脉.其中2例术前MRA曾诊断供肾单支动脉.MRA供肾血管有效阳性预测值为96.6%,假阴性率为33%,多支血管敏感性为66%.无一例供体在MRA检查中发生副反应而放弃检查.结论:亲属活体肾移植供体术前应常规进行MRA作血管三维成像检查.MRA术前能够充分了解供肾体积、引流系统及实质有无畸形,帮助供体选择.确保取肾术绝对安全,提高取肾质量.     

Artificial Urinary Sphincter in Patients Following Major Pelvic Surgery and/or Radiotherapy: Are They Less Favorable Candidates?

Between January 1988 and December 1992 the AMS800^* artificial urinary sphincter was inserted in 81 men with urinary incontinence due to major pelvic surgery and/or radiation therapy. Radical retropubic prostatectomy had been performed in 38 men, radical retropubic prostatectomy with adjuvant radiation in 28, definitive radiation therapy for prostatic carcinoma in 5, abdominoperineal resection with adjuvant radiation in 1 and radical cystectomy with orthotopic urinary diversion in 8, while 1 suffered major pelvic trauma with urethral rupture. A bulbar urethral cuff was used exclusively, with pressure regulating balloons of 51 to 60 and 61 to 70 cm. water. The interval for primary activation ranged from 4 to 12 weeks (mean 7.7), with all irradiated patients waiting 12 weeks. Surgical revision was required in 38 percent of the patients totaling 43 operations. Inadequate cuff compression after presumed urethral atrophy secondary to hypovascularity accounted for 74 percent of the procedures, whereas infection with or without erosion necessitated 8 revisions, mostly attributable to improper placement elsewhere of an indwelling catheter after the artificial urinary sphincter had been activated. Mechanical malfunction was responsible for 7 percent of the revisions. Overall, socially acceptable continence was achieved in 91 percent of the study population. Despite a significantly greater need for revision in this high risk group (38 percent versus 22 percent in the literature for low risk groups) with meticulous surgical and sterile techniques as well as diligent followup, the long-term outcome in terms of continence and device survival may be excellent regardless of the underlying etiology. We conclude that use of the AMS800 artificial sphincter for significant male urinary incontinence is undoubtedly the most efficacious treatment currently available for which even the most adverse candidate should not necessarily be excluded.     

Preoperative Prediction of Growth Hormone (GH)/Insulin-Like Growth Factor-1 (IGF-1) Axis Modification and Postoperative Changes in Candidates for Bariatric Surgery

Background

Several factors alter the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis in obese patients, but GH/IGF-1 correlation with anthropometric parameters and lipid metabolism is still unclear. We evaluated this relationship and the postoperative axis modifications in candidates for bariatric surgery.

Methods

Eighty-eight patients (males/females (M/F), 34/54) scheduled for bariatric surgery (biliopancreatic diversion or laparoscopic-adjustable gastric banding) between 2008 and 2010 were included in this observational, open, prospective study.

Results

Preoperative serum GH concentrations were found near the lowest limit of normal range in both sexes, with males showing the lowest values (130 vs. 1,405 pg/ml; p?<?0.01). Serum concentrations of IGF-1 were within the normal range (M/F, 179/168.5 ng/ml), whereas IGF-binding protein (BP)1 and 3 values were at the lowest limits of normal range in both sexes (M/F 1.8/3.1 μg/ml and M/F 4.1/4.2 μg/ml, respectively). A statistically significant inverse correlation was found between GH, IGF-1, and IGF-BP1-3 values and total cholesterol, LDL-cholesterol, and triglycerides values in both sexes. GH and IGF-BP1-3 values were also inversely related to waist circumference and waist/hip ratio (WHR). GH, IGF-1, and IGF-BP1 and 3 values (35 cases) increased 1 year postoperatively in both sexes, mainly after malabsorptive procedures.

Conclusions

Our results support the hypothesis that GH deficiency associated with low levels of binding proteins in obese patients may be an endocrine response to visceral fat and high levels of non-esterified fatty acids, assessable in daily clinical practice by WHR, total and LDL-cholesterol, and triglycerides. In these patients, malabsorptive procedures might be the treatment of choice due to the metabolic adaptations induced.     

Evaluation of Appropriate Short-Term Mammographic Surveillance in Patients Who Undergo Breast-Conserving Surgery (BCS)

Background

Mammography is an important surveillance tool for detecting ipsilateral breast tumor recurrence (IBTR) after BCS. Although IBTR is rare in the first 2?years, various organizations have established protocols for postoperative mammographic surveillance. Currently there is no consensus on the optimal interval for imaging evaluation of patients following BCS.

Methods

We conducted a retrospective review of patients who underwent BCS at Aultman Hospital between 1/06 and 12/08. To be included in the study, patients had to be diagnosed with invasive primary breast carcinoma or ductal carcinoma in situ (DCIS), treated with BCS (with or without postoperative breast radiation), and have had at least one postoperative surveillance mammogram at our Breast Care Center. Our mammographic surveillance protocol for patients undergoing BCS consists of ipsilateral mammograms (affected side) around 6 and 18?months and bilateral mammograms around 12 and 24?months. All mammograms that were Breast Imaging-Reporting and Data System (BIRADS) 0 or 4 were reviewed by a single radiologist (T.B.P.).

Results

A total of 375 patients constituted the core group for this study. Each interval mammographic screening (6- and 18-month mammograms) resulted in additional imaging in 3?C4 % of patients. There was a very low yield for identifying IBTR: 1/266 (0.4 %) for the 5?C10-month postoperative mammogram and 1/286 (0.3 %) for the 16?C21-month postoperative mammogram.

Conclusions

Based on our data and the low expected yield of IBTR in the first 2?years, annual mammographic surveillance appears adequate following BCS and interval ipsilateral mammograms at 6 and 18?months do not provide additional clinical benefit.