Robotic Partial Nephrectomy Cases Research Articles

PD33-04 PRIOR SURGICAL EXPERIENCE AND THE IMPACT ON PERIOPERATIVE OUTCOMES IN ROBOT-ASSISTED PARTIAL NEPHRECTOMY: A MULTICENTER ANALYSIS WITH 2,500 PATIENTS

PD33-04 PRIOR SURGICAL EXPERIENCE AND THE IMPACT ON PERIOPERATIVE OUTCOMES IN ROBOT-ASSISTED PARTIAL NEPHRECTOMY: A MULTICENTER ANALYSIS WITH 2,500 PATIENTS

V11-07 TECHNIQUES OF ROBOTIC ASSISTED PARTIAL NEPHRECTOMY WITH RENAL VEIN TUMOR THROMBECTOMY AND RECONSTRUCTION: UCSD EXPERIENCE

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-07 TECHNIQUES OF ROBOTIC ASSISTED PARTIAL NEPHRECTOMY WITH RENAL VEIN TUMOR THROMBECTOMY AND RECONSTRUCTION: UCSD EXPERIENCE Devin Patel, Daniel Holdst, Garrick Greear, Fady Ghali, Juan Javier-DesLoges, Sunil Patel, and Ithaar Derweesh Devin PatelDevin Patel More articles by this author , Daniel HoldstDaniel Holdst More articles by this author , Garrick GreearGarrick Greear More articles by this author , Fady GhaliFady Ghali More articles by this author , Juan Javier-DesLogesJuan Javier-DesLoges More articles by this author , Sunil PatelSunil Patel More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Use of partial nephrectomy for renal cell carcinoma with clinical extracortical invasion represents the frontier of the utilization of nephron sparing technique. Herein we describe our results and techniques in selected cases of robotic partial nephrectomy with renal vein tumor thrombectomy. METHODS: Robotic ports are placed in a linear configuration angled towards the kidney in a cranial to caudal direction. The case is started with bowel mobilization. In cases of left sided tumors, complete spleen, pancreatic tail and adrenal mobilization. For right sided tumors, kocherization of the 3rd segment of the duodenum to fully expose the inferior vena cava followed by adrenal mobilization. In all instances, the renal artery and main renal vein are clamped. In cases of medially located tumors and with thrombi terminating in a segmental branch, the renal vein is dissected medially to identify segmental branches. The segmental branch with tumor thrombus is isolated and clipped or stapled. In cases of more posteriorly located tumors or with tumor within the main renal vein, the tumor is resected towards the tumor thrombus. The thrombus is then identified at the point of inception and dissected proximally until complete resection. The renorrhaphy is completed in a two-layer fashion, with early hilar unclamping. RESULTS: Total operative time in three cases ranged from 264-322 minutes with an estimated blood loss in the range of 200 cc to 500 cc. The warm ischemia time ranged from 28 minutes to 37 minutes. Two patients were discharged home on post-operative day two and the third patient discharged on post-operative day three. No patients sustained an immediate post-operative complication or 30-day readmission for complication. All three patients maintained renal function >90% of baseline. Final pathology on all three specimens confirmed pT3a disease with negative margins in all cases. CONCLUSIONS: Robotic partial nephrectomy is feasible and safe for select clinical T3a renal masses, with acceptable quality outcomes. Further investigation is required to help clarify the role of minimally invasive partial nephrectomy in these advanced stage localized tumors. Source of Funding: Stephen Weissman Kidney Cancer Research Fund © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e859-e860 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Devin Patel More articles by this author Daniel Holdst More articles by this author Garrick Greear More articles by this author Fady Ghali More articles by this author Juan Javier-DesLoges More articles by this author Sunil Patel More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement Loading ...

Perioperative and Oncological Outcomes of 1,002 Consecutive Patients With Localized Renal Cell Carcinoma Treated by Robotic Partial Nephrectomy at a Single Center

Purpose: To analyze and compare the results of robotic partial nephrectomy (RPN) at a single center with the previous large-scale studies in terms of perioperative and oncological outcomes.Materials and Methods: We retrospectively evaluated 1,013 cases of RPN in our center database from December 2008 to August 2018. Total 11 cases were excluded in final analysis. We evaluated perioperative outcomes as the Trifecta achievement, which is defined as no positive surgical margin (PSM), no perioperative complications greater than Clavien-Dindo classification I and a warm ischemia time of <25 minutes. In addition, we analyzed pathological and oncological outcomes; recurrence, metastasis, all-cause deaths, cancer-specific deaths, and 5-year survival rates.Results: In 1,002 cases, the Trifecta achievement was 61.1% (n=612). The postoperative complication was 18.4% (n=184) but most were grade 2 or less (14.9%, n=145). Ninety-three cases (9.28%) had benign and 907 cases (90.5%) had malignant pathologies. A local recurrence were 14 cases (1.54%) and distant metastasis were 20 cases (2.2%) during follow-up periods. Allcause death rate was 1.2% (n=11) and cancer-specific death rate was 0.2% (n=2). The median follow-up period was 39 months. A 5-year recurrence-free survival rate, cancer-specific survival rate, and overall survival rate were 95.2%, 99.7%, and 98.4%.Conclusions: In summary, our data shows comparable perioperative outcomes to other largescale studies of RPN in terms of the Trifecta achievement with similar baseline characteristics. In terms of oncological outcomes, there was lower rate of PSM and similar recurrence free survival rate.

Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy.

ABSTRACTPurpose We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN).Patients and Methods We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI.Results Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04).Conclusion Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.

Hilar Parenchymal Oversew: a novel technique for robotic partial nephrectomy hilar tumor renorrhaphy.

ABSTRACTIntroductionA renorrhaphy technique which is effective for hemostasis but does not place undue tension on the branch vessels of the renal sinus remains one of the challenging steps after hilar tumor resection during robotic partial nephrectomy (RPN). The published V-hilar suture (VHS) technique is one option for reconstruction after an RPN involving the hilum. The objective of this video is to show a novel renorrhaphy technique, Hilar Parenchymal Oversew that has been effective for such cases.Materials and MethodsWe present two cases of RPN for renal hilar tumors. The first case depicts use of the VHS renorrhaphy technique for a tumor that abuts the renal hilum along 20% of its diameter. The second case demonstrates tumor resection and reconstruction for a tumor that has >50% involvement of the hilum along its diameter. After tumor resection, individual sinus vessels can be selectively oversewn with 2-0 Vicryl suture on SH needle. The remaining exposed parenchyma is controlled using the Hilar Parenchymal Oversew technique with a #0 Vicryl on CT-1 needle.ResultsFor the Hilar Parenchymal Oversew surgery operative time was 225 min, estimated blood loss was 140 ml, warm ischemia time was 19 minutes, and there were no intraoperative complications. Pathology was consistent with clear cell renal cancer with negative margins.ConclusionRobotic partial nephrectomy with the Hilar Parenchymal Oversew technique is a good alternative to VHS renorrhaphy in the management of renal hilar tumors “bulging” into the renal sinus with >50% of the tumor diameter abutting the hilum.

MP49-06 WHEN PARTIAL NEPHRECTOMY IS UNSUCCESSFUL: UNDERSTANDING THE REASONS FOR CONVERSION FROM ROBOTIC PARTIAL TO RADICAL NEPHRECTOMY AT A TERTIARY REFERRAL CENTER

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II1 Apr 2017MP49-06 WHEN PARTIAL NEPHRECTOMY IS UNSUCCESSFUL: UNDERSTANDING THE REASONS FOR CONVERSION FROM ROBOTIC PARTIAL TO RADICAL NEPHRECTOMY AT A TERTIARY REFERRAL CENTER Önder Kara, Matthew J. Maurice, Pascal Mouracade, Ercan Malkoç, Julien Dagenais, Ryan J. Nelson, Jaya Sai Chavali, Robert J. Stein, Amr Fergany, and Jihad H. Kaouk Önder KaraÖnder Kara More articles by this author , Matthew J. MauriceMatthew J. Maurice More articles by this author , Pascal MouracadePascal Mouracade More articles by this author , Ercan MalkoçErcan Malkoç More articles by this author , Julien DagenaisJulien Dagenais More articles by this author , Ryan J. NelsonRyan J. Nelson More articles by this author , Jaya Sai ChavaliJaya Sai Chavali More articles by this author , Robert J. SteinRobert J. Stein More articles by this author , Amr FerganyAmr Fergany More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1508AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Given the technical advantages offered by the robotic platform, there has been an upward trend in the utilization of robotic partial nephrectomy however little information exist on conversion from robotic partial nephrectomy (RPN) to radical nephrectomy (RN). Our aim was to identify the preoperative factors associated with conversion from RPN to RN, and to report the incidence of this event. METHODS Using our institutional review board-approved database, we abstracted data on 1023 RPN cases performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics and perioperative, functional, and oncological outcomes. Logistic regression analysis was used to identify predictors of radical conversion. RESULTS The overall conversion rate was 3.1% (32/1023). The most common reasons for conversion were tumor involvement of hilar structures (n=8, 25%), Failure to achieve negative margin on frozen section (n=7, 21.8%), suspicion for advanced disease (n=5, 15.6%), and failure to progress (n=5, 15.6%). Patients requiring conversion were older (p<0.01) and had higher Charlson scores (p<0.01), including increased prevalence of CKD (p=0.02). Increasing tumor size (5 vs. 3.1 cm, p<0.01) and R.E.N.A.L score (9 vs. 8, p<0.01) also were associated with increased risk of conversion. Worse baseline renal function (OR 0.98 95% CI 0.96-0.99 p=0.04), high tumor size (OR 1.44, 95% CI 1.22-1.7, p<0.01), and increasing R.E.N.A.L score (p=0.02) were independent predictors of conversion. Compared to converted cases, standard RPN cases had similar short-term oncological outcomes but better renal functional preservation (p<0.01) at latest follow-up. CONCLUSIONS At a high-volume center, the rate of RPN conversion to RN is 3.1% including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity and poor preoperative renal function are the main predictors of conversion. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e648 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Önder Kara More articles by this author Matthew J. Maurice More articles by this author Pascal Mouracade More articles by this author Ercan Malkoç More articles by this author Julien Dagenais More articles by this author Ryan J. Nelson More articles by this author Jaya Sai Chavali More articles by this author Robert J. Stein More articles by this author Amr Fergany More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP73-19 PREOPERATIVE PROTEINURIA PREDICTS INCREASED RATES OF ACUTE KIDNEY INJURY AFTER PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Basic Research & Pathophysiology III1 Apr 2017MP73-19 PREOPERATIVE PROTEINURIA PREDICTS INCREASED RATES OF ACUTE KIDNEY INJURY AFTER PARTIAL NEPHRECTOMY Önder Kara, Matthew J. Maurice, Pascal Mouracade, Ercan Malkoç, Julien Dagenais, Ryan J. Nelson, Jaya Sai Chavali, and Jihad H. Kaouk Önder KaraÖnder Kara More articles by this author , Matthew J. MauriceMatthew J. Maurice More articles by this author , Pascal MouracadePascal Mouracade More articles by this author , Ercan MalkoçErcan Malkoç More articles by this author , Julien DagenaisJulien Dagenais More articles by this author , Ryan J. NelsonRyan J. Nelson More articles by this author , Jaya Sai ChavaliJaya Sai Chavali More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.3364AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Proteinuria reflects structural damage to glomeruli and/or renal tubules and is considered an important prognostic indicator of chronic kidney disease (CKD) and possibly acute kidney injury (AKI). We examined the significance of preoperative proteinuria on postoperative kidney function after robotic partial nephrectomy (RPN). METHODS We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (≥30 mg/dL), and groups were compared in terms of clinical and functional outcomes. The incidence of AKI was assessed using RIFLE criteria. Univariate and multivariable models were used to identify predictors of postoperative AKI. RESULTS Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.02). CONCLUSIONS Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e971-e972 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Önder Kara More articles by this author Matthew J. Maurice More articles by this author Pascal Mouracade More articles by this author Ercan Malkoç More articles by this author Julien Dagenais More articles by this author Ryan J. Nelson More articles by this author Jaya Sai Chavali More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Multiple Tumor Excisions in Ipsilateral Kidney Increase Complications After Partial Nephrectomy.

The surgical morbidity of ipsilateral synchronous multifocality (ISM) is poorly characterized. We assessed the impact of ISM on complications after robotic partial nephrectomy (RPN). We abstracted data on RPN cases performed between 2006 and 2015 at our institution. Multifocal disease was characterized by >1 renal mass on preoperative imaging or >1 mass excision during RPN. The primary outcome was the rate of overall postoperative complications. The association between multifocality and complications was evaluated using univariate and multivariable analyses. Of 1121 cases, 59 (5.3%) had >1 ipsilateral renal mass and 50 (4.5%) required >1 excision. The overall complication rate was 20.3% (230/1121). The radiographic number of ipsilateral renal masses was not significantly associated with complications (20.2% for 1 mass vs. 25.4% for >1 mass, p = 0.338). However, the actual number of ipsilateral mass excisions performed during RPN was significantly associated with complications (20.2% for ≤2 excisions vs. 42.9% for >2 excisions, p = 0.037). Major complications were higher (14.3% vs. 5.3%) for >2 versus ≤2 excision(s), but this difference was not significant (p = 0.174). The most common complications associated with multiple excisions were transfusion, urine leak, arrhythmia, venous thromboembolism, and ileus. On multivariable analysis, number of excisions independently predicted complications (OR 3.1, 95% CI 1.03-9.33, p = 0.041). Other independent predictors of complications included age, race, Charlson score, body mass index, RENAL score, and surgeon experience. ISM requiring ≥2 excisions is associated with increased morbidity after RPN. Pending external validation, this information may facilitate clinical decision-making and preoperative patient counseling.

Use of the Satinsky clamp for hilar clamping during robotic partial nephrectomy: indications, technique, and multi-center outcomes.

A Satinsky clamp may be a backup option for hilar clamping during robotic partial nephrectomy (RPN) if there are challenges with application of bulldog clamps, but there are potential safety concerns. We evaluate outcomes of RPN using Satinsky vs. bulldog clamps, and provide tips for safe use of the Satinsky as a backup option. Using a multi-center database, we identified 1073 patients who underwent RPN between 2006 and 2013, and had information available about method of hilar clamping (bulldog clamp vs. Satinsky clamp). Patient baseline characteristics, tumor features, and perioperative outcomes were compared between the Satinsky and bulldog clamp groups. A Satinsky clamp was used for hilar clamping in 94 (8.8%) RPN cases, and bulldog clamps were used in 979 (91.2%) cases. The use of a Satinsky clamp was associated with greater operative time (198 vs. 175min, p<0.001), estimated blood loss (EBL, 200 vs. 100ml, p<0.001), warm ischemia time (WIT, 20 vs. 19min, p=0.036), transfusion rate (12.8 vs. 4.8%, p=0.001), and hospital stay (3 vs. 2days, p<0.001). Tumor characteristics and number of renal vessels were similar between groups. There were six intraoperative complications in the Satinsky clamp group, but none were directly related to the Satinsky clamp. On multivariable analysis, the use of the Satinsky clamp was not associated with increase in intraoperative or Clavien ≥3 postoperative complications, positive surgical margin rate or percentage change in estimated glomerular filtration rate. A Satinsky clamp can be a backup option for hilar clamping during challenging RPN cases, but requires careful technique, and was rarely necessary.

MP75-15 OPTIMAL OUTCOME AND TRIFECTA OF ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR T1B RENAL MASSES

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V1 Apr 2016MP75-15 OPTIMAL OUTCOME AND TRIFECTA OF ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR T1B RENAL MASSES Dae Keun Kim, Young Eun Yoon, Ibrahim Alabdulaali, Atalla Alatawi, Abulhasan Sheikh, Ali Abdel Raheem, Kyo Chul Goo, Woong Kyu Han, Byung Ha Chung, and Koon Ho Rha Dae Keun KimDae Keun Kim More articles by this author , Young Eun YoonYoung Eun Yoon More articles by this author , Ibrahim AlabdulaaliIbrahim Alabdulaali More articles by this author , Atalla AlatawiAtalla Alatawi More articles by this author , Abulhasan SheikhAbulhasan Sheikh More articles by this author , Ali Abdel RaheemAli Abdel Raheem More articles by this author , Kyo Chul GooKyo Chul Goo More articles by this author , Woong Kyu HanWoong Kyu Han More articles by this author , Byung Ha ChungByung Ha Chung More articles by this author , and Koon Ho RhaKoon Ho Rha More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1733AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The new concept of optimal outcome the pentafecta of oncology, complications and functional outcome has been proposed as a measure of effectiveness of robotic partial nephrectomy (RPN) in the treatment of small renal masses. The utility of optimal outcome for the assessment of larger renal tumors has not been studied. This study was to assess the rate of optimal outcome and trifecta in cases of RPN for T1b renal tumors, in a large tertiary center. METHODS We retrospectively reviewed the medical records of 277 cases of RPN performed from 2007 to 2015. We limited our study to RPN for clinically T1b renal masses (> 4cm and less than or equal 7 cm). Tumor complexity was investigated according to R.E.N.A.L nephrometry score. The optimal outcome was defined as achievement of Trifecta (negative surgical margin, no perioperative complications and warm ischemia time of less than or equal 25 minutes) with addition of over 90% estimated GFR preservation and no chronic kidney disease stage upgrading (postoperative 6-12 months). Logistic regression analysis for factors predicting optimal outcome (age, body mass index, operation time, EBL, tumor size, R.E.N.A.L nephrometry score, experience with RPN, preoperative GFR) was performed. RESULTS Total of 60 patients met our inclusion criteria. The median age of the cohort was 49.5 yrs. (IQR 39.8-62) and the median R.E.N.A.L. nephrometry score was 9 (IQR 7-9). The median warm ischemia time was 26.5 min (IQR 21-31.75) positive margin rate of 5%, and overall complication rate of 15%. The rate of achievement of optimal outcome was 26.7%, and trifecta rate was 43.3%. On multivariable analysis, tumor size (HR 0.42 95% CI (0.18-0.93 p=0.04), operation time (HR 0.98 95% CI(0.97-0.99) p=0.011) were predictors of achieving trifecta, and R.E.N.A.L nephrometry score (HR 0.80; 95% CI (0.67-0.97) p=0.03) was predictor of achieving optimal outcome. CONCLUSIONS Renal nephrometry score was the predictor of achieving optimal outcome for T1b tumors in our cohort. Addition of over 90 % estimated GFR preservation and no chronic kidney disease stage upgrading incorporate the long-term functional outcome of RPN, providing us with oncological and also functional surrogate for surgical quality. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e984-e985 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Dae Keun Kim More articles by this author Young Eun Yoon More articles by this author Ibrahim Alabdulaali More articles by this author Atalla Alatawi More articles by this author Abulhasan Sheikh More articles by this author Ali Abdel Raheem More articles by this author Kyo Chul Goo More articles by this author Woong Kyu Han More articles by this author Byung Ha Chung More articles by this author Koon Ho Rha More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD41-04 TRANSPERITONEAL APPROACH ACHIEVES SIMILAR OUTCOMES TO RETROPERITONEAL APPROACH FOR POSTERIOR TUMORS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV1 Apr 2016PD41-04 TRANSPERITONEAL APPROACH ACHIEVES SIMILAR OUTCOMES TO RETROPERITONEAL APPROACH FOR POSTERIOR TUMORS Matthew J. Maurice, Jihad H. Kaouk, Peter A. Caputo, Ravi Barod, Sam B. Bhayani, Mohamad E. Allaf, Craig G. Rogers, and Michael D. Stifelman Matthew J. MauriceMatthew J. Maurice More articles by this author , Jihad H. KaoukJihad H. Kaouk More articles by this author , Peter A. CaputoPeter A. Caputo More articles by this author , Ravi BarodRavi Barod More articles by this author , Sam B. BhayaniSam B. Bhayani More articles by this author , Mohamad E. AllafMohamad E. Allaf More articles by this author , Craig G. RogersCraig G. Rogers More articles by this author , and Michael D. StifelmanMichael D. Stifelman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1550AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The best approach for treating posterior renal tumors by robotic partial nephrectomy (RPN) is controversial. We sought to compare surgical outcomes for posterior tumors treated by RPN using either a transperitoneal approach (TA) or a retroperitoneal approach (RA). METHODS Using a retrospective multicenter RPN database from five high-volume surgeons, we abstracted data on consecutive patients treated between 2007 and 2015. The study cohort was limited to posterior renal masses. The primary outcomes were complication rate, transfusion rate, positive margin rate, estimated blood loss (EBL), operative time, and warm ischemia time. Other explanatory variables considered included age, sex, race, American Society of Anesthesiologists (ASA) score, body mass index, tumor size, RENAL score, and pathologic tumor stage. Univariate analysis was performed using the chi-square test or Fisher′s exact test for categorical variables, the Spearman correlation for continuous variables, and the Mann-Whitney U test for mixed variables. Multivariate analysis was performed using multiple linear regression. RESULTS Of 610 RPN cases for posterior renal masses, 87 (14.3%) were performed using a RA. Mean EBL was 190±221 ml for the TA and 149±62 ml for the RA (p=.04). After adjusting for covariates on multivariate analysis, RPN approach was no longer a significant predictor of EBL (p=.14). The rates of overall complications (16.1% vs. 10.3%, p=.17), major complications (5.0% vs. 4.6%, p=.88), transfusion (5.5% vs. 2.3%, p=.29), and positive margins (2.0% vs. 2.4%, p=.79) were not significantly different for the TA vs. the RA, respectively. Mean operative time was 180±59 for the TA and 169±58 minutes for the RA (p=.06). Warm ischemia time was 19±8.6 minutes for the TA vs. 21±6.8 minutes for the RA (p =.07). CONCLUSIONS At high-volume centers, the transperitoneal vs. retroperitoneal approach is not significantly associated with surgical outcomes after RPN for posteriorly located renal masses. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e941 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Matthew J. Maurice More articles by this author Jihad H. Kaouk More articles by this author Peter A. Caputo More articles by this author Ravi Barod More articles by this author Sam B. Bhayani More articles by this author Mohamad E. Allaf More articles by this author Craig G. Rogers More articles by this author Michael D. Stifelman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study.

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed 'optimal outcome' for the RPN group. Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The 'optimal outcome' was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and 'optimal outcome' achievement. In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of 'optimal outcome' for the RPN group was 38.5%. In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for 'optimal outcome' might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

MP63-06 TRIFECTA OUTCOMES OF ROBOTIC PARTIAL NEPHRECTOMY FOR T1B RENAL MASSES: A MULTI-INSTITUTIONAL ANALYSIS

You have accessJournal of UrologyKidney Cancer: Surgical Therapy IV1 Apr 2015MP63-06 TRIFECTA OUTCOMES OF ROBOTIC PARTIAL NEPHRECTOMY FOR T1B RENAL MASSES: A MULTI-INSTITUTIONAL ANALYSIS Homayoun Zargar, Craig Rogers, Sam Bhayani, Mohamad Allaf, Jeffrey A. Larson, Ravi Barod, Alon Mass, Michael H. Johnson, Michael Stifelman, and Jihad H. Kaouk Homayoun ZargarHomayoun Zargar More articles by this author , Craig RogersCraig Rogers More articles by this author , Sam BhayaniSam Bhayani More articles by this author , Mohamad AllafMohamad Allaf More articles by this author , Jeffrey A. LarsonJeffrey A. Larson More articles by this author , Ravi BarodRavi Barod More articles by this author , Alon MassAlon Mass More articles by this author , Michael H. JohnsonMichael H. Johnson More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2338AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The trifecta of oncology, complications and functional outcome has been proposed as a measure of effectiveness of robotic partial nephrectomy (RPN) in the treatment of small renal masses. The utility of trifecta for the assessment of outcomes of larger renal tumors has not been well studied. Our aim was to assess the rate of trifecta of outcomes in cases of RPN for T1b renal tumors, in a large multi-institutional series. METHODS We retrospectively reviewed records of 1836 cases of RPN performed in 5 high volume centres across USA from 2000 to mid 2014. We limited our study to RPN for T1b renal masses (> 4cm and ≤ 7 cm). Tumor complexity was assigned according to R.E.N.A.L nephrometry score. Tumors were further divided into simple (4-6), intermediate (7-9) and complex (10-12) groups. We defined the Trifecta as negative surgical margin, zero perioperative complications and warm ischemia time of ≤ 25 minutes. Multivariable regression analysis of factors predicting trifecta (tumor size, R.E.N.A.L nephrometry score, experience with RPN, Charlson comorbidity score, preoperative GFR and body mass index) was performed. RESULTS Total of 319 patients met our inclusion criteria. The median age of the cohort was 61 yrs. (IQR 51-69) and the median tumor nephrometry score was 9 (IQR 7-9) with 72 (22.6%) of the tumors classified as complex. The median warm ischemia time was 23 min with overall complication rate of 17.2% and positive margin rate of 2.5%. The rate of achievement of trifecta rate was 43.6%. On multivariable analysis increase in cumulative RPN experience (OR=1.18 ;95%CI (1.01-1.39)) and increase in tumor complexity score (OR =0.80; 95%CI (0.67-0.97)) were predictors of achieving Trifecta. CONCLUSIONS The rate of trifecta for T1b renal tumors is lower than reported rate for T1a tumors. Renal nephrometry score and surgeon's experience with RPN were predictors of achieving trifecta for T1b tumors in our cohort. Although Trifecta does not incorporate the long-term functional outcome of nephron sparing surgery, it provides us with an immediate surrogate for surgical quality. Longitudinal functional and oncological follow up data is required to validate utility of trifecta as a surrogate for long-term outcomes. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e790-e791 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Homayoun Zargar More articles by this author Craig Rogers More articles by this author Sam Bhayani More articles by this author Mohamad Allaf More articles by this author Jeffrey A. Larson More articles by this author Ravi Barod More articles by this author Alon Mass More articles by this author Michael H. Johnson More articles by this author Michael Stifelman More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

V9-06 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS: ZERO ISCHEMIA OR EARLY UNCLAMPING?

You have accessJournal of UrologyRobotics – Renal1 Apr 2015V9-06 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS: ZERO ISCHEMIA OR EARLY UNCLAMPING? Benoit Peyronnet, Quentin Alimi, Tarek Fardoun, Romain Mathieu, Gregory Verhoest, and Karim Bensalah Benoit PeyronnetBenoit Peyronnet More articles by this author , Quentin AlimiQuentin Alimi More articles by this author , Tarek FardounTarek Fardoun More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , and Karim BensalahKarim Bensalah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2281AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES An arterial clamping is usually performed during partial nephrectomy in order to decrease blood loss and improve vision during tumorectomy. However, it causes warm ischemia which is potentially harmful for the kidney. The concept of “zero ischemia” robotic partially nephrectomy appeared in the early 2010's. Its aim is to avoid warm ischemia time by omitting to clamp the main renal artery. The aim of this video was to compare two managements of the renal pedicle during robotic partial nephrectomy for hilar tumors: early unclamping vs. zero ischemia. METHODS We present 2 cases of robotic partial nephrectomy for complex (RENAL NEPHROMETRY score ≥ 7) and hilar tumors. In the first case, a 6 cm tumor of the left kidney has been diagnosed in a 57 year-old male. RENAL NEPHROMETRY score was 10-ph. The main renal artery was clamped with an early unclamping (unclamping after one or two running suture in the tumor bed but before parenchymal repair). In the second case, a 4 cm totally endophytic tumor of the left kidney arised in a 66 year-old male. RENAL NEPHROMETRY score was 9-h. An off-clamp technique was chosen. RESULTS In the first case, warm ischemia time was 24 minutes and estimated blood loss was 500 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 5. Surgical margins were negative. At 1 month postoperatively, 88% of renal function was preserved. In the second case, an important bleeding occurred during tumorectomy. First, the surgeon switched to a selective arterial clamping. The bleeding continued and the surgeon had to clamp the main renal artery. Warm ischemia time was 8 minutes and estimated blood loss was 1200 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 4. Surgical margins were negative. At 1 mont postoperatively, 86% of renal function was preserved. CONCLUSIONS Hilar tumors are good candidates for the “zero ischemia” techniques during robotic partial nephrectomy. However, they could lead to important bleeding that could increase the surgical morbidity and the risk of positive margins. As recent data suggest that a limited warm ischemia time (< 30 minutes) could have no impact on renal function, the early unclamping technique, which appear safer, could be the preferred option in these patients. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e776-e777 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Quentin Alimi More articles by this author Tarek Fardoun More articles by this author Romain Mathieu More articles by this author Gregory Verhoest More articles by this author Karim Bensalah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP63-10 MINIMUM 5 YEAR FOLLOW-UP AFTER ROBOTIC PARTIAL NEPHRECTOMY : A MULTI-INSTITUTIONAL ANALYSIS

You have accessJournal of UrologyKidney Cancer: Surgical Therapy IV1 Apr 2015MP63-10 MINIMUM 5 YEAR FOLLOW-UP AFTER ROBOTIC PARTIAL NEPHRECTOMY : A MULTI-INSTITUTIONAL ANALYSIS Homayoun Zargar, Mohamad Allaf, Craig Rogers, Michael Stifelman, Sam Bhayani, Alon Mass, Ravi Barod, Michael H. Johnson, Jeffrey A. Larson, and Jihad H. Kaouk Homayoun ZargarHomayoun Zargar More articles by this author , Mohamad AllafMohamad Allaf More articles by this author , Craig RogersCraig Rogers More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Sam BhayaniSam Bhayani More articles by this author , Alon MassAlon Mass More articles by this author , Ravi BarodRavi Barod More articles by this author , Michael H. JohnsonMichael H. Johnson More articles by this author , Jeffrey A. LarsonJeffrey A. Larson More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2342AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The utility of robotic partial nephrectomy (RPN) for the treatment of renal masses has increased in recent years. Although short to intermediate term functional and oncological data have been promising but long term data in this setting is sparse. The aim of the current study was to report the long-term outcomes of RPN in a multi-institutional cohort of patients who underwent the procedure at least 5 years ago. METHODS We retrospectively reviewed the records of 1836 cases of RPN performed in 5 high volume centres across USA from 2007 to mid 2014. We limited our study to cases where RPN was performed at least 5 years prior. Local recurrence, metastasis rate, overall survival (OS) and cancer specific survival (CSS) were assessed. Time from surgery was calculated from the time of study (November 2014) to the date of surgery. Actual follow up time was assessed as the time between latest follow up time and the date of surgery. GFR preservation was calculated as proportion of latest GFR to preoperative GFR. RESULTS Total of 369 patients met our inclusion criteria. The median time from the RPN surgery was 5 years (IQR 5-6). The median age of the cohort was 60.9 years and the median tumor nephrometry score was 7 (IQR 5-8). The median actual follow up time was 54.8 months (IQR 25.1-62.5). For the 274 patients with renal cell carcinoma the local recurrence and metastasis rates were 3.6 and 1.5% respectively. The OS and CSS were 94.2 and 98.9% respectively. The median time to latest renal function assessment was 51 months (IQR 23.5-60) with median GFR preservation of 89.6% (77.2-104). On multivariable cox regression model for identifying factors predicting overall mortality (age, comorbidities, pre-operative GFR, proportion of GFR preservation, tumor stage and surgical margin) positive surgical margin was a strong predictor of overall mortality (HR =38 (95% CI (3-474); p=0.005). CONCLUSIONS RPN in carefully selected cohort of patients provides excellent long-term oncological and functional outcomes. Positive surgical margin was a predictor of overall mortality in our series. Our results need to be validated by other RPN series as the follow up data further matures. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e792 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Homayoun Zargar More articles by this author Mohamad Allaf More articles by this author Craig Rogers More articles by this author Michael Stifelman More articles by this author Sam Bhayani More articles by this author Alon Mass More articles by this author Ravi Barod More articles by this author Michael H. Johnson More articles by this author Jeffrey A. Larson More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Cost Comparison of Open and Robotic Partial Nephrectomy Using a Short Postoperative Pathway

To compare immediate perioperative direct costs of open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN), managed under a common care pathway. Retrospective review of detailed institutional cost data for patients treated with OPN and RPN during 2011 was conducted. Cost and clinical data of OPN and RPN were compared for all patients and for patients stratified by length of stay (LOS), American Society of Anesthesiologists (ASA), and RENAL nephrometry scores. The study cohort included 190 OPN and 63 RPN cases. OPN was associated with higher ASA scores (P <.001), shorter operative times (P = .014), and higher estimated blood loss (P <.001). Median (interquartile range) LOS was 2 days (2-3 days) for OPN compared with 1 day (1-2 days) for RPN (P <.001). Median perioperative cost of OPN was lower than that of RPN with a difference of $3091 (P <.001). Although hospitalization costs were higher in OPN, surgical costs were higher in RPN ($854 and $3695 difference in median costs, respectively; P <.001 for both). The total cost of OPN for patients with an above-average LOS remained lower than that of RPN ($2680 difference in median costs; P = .001). RPN costs remained significantly higher when stratifying patients by their ASA and RENAL nephrometry scores. Despite the shorter hospital LOS associated with RPN, the immediate perioperative cost of OPN was lower than that of RPN for patients managed under a common care pathway, mainly due to high robotic purchase and maintenance costs. In light of the current health care debate, such financial disincentives may compromise the sustainability of advances in medical technology.

Off-clamp robotic partial nephrectomy: Technique and outcome.

Introduction:Robotic partial nephrectomy (RPN) is a technically challenging procedure. Advanced skills are needed to accomplish tumor resection, hemostasis, and renorrhaphy within short ischemia time in RPN. Off-clamp RPN with zero ischemia may decrease the risk of ischemic reperfusion injury to the kidney. However, the off-clamp technique has been associated with an increased risk of blood loss. The purpose of this study was to evaluate the outcome of our modified off-clamp technique utilized in certain RPN cases.Patients and Methods:A total of 81 patients underwent RPN between September 2009 and July 2013 for renal masses. We studied a subgroup of patients who underwent off-clamp RPN with zero ischemia time. The off-clamp technique was utilized for exophytic, nonhilar tumors that have a base of 2 cm or less. We developed a novel technique to avoid ischemia reperfusion renal injury while minimizing blood loss in certain cases of RPN.Results:Of the 81 cases of RPN, we reviewed and adopted the off-clamp technique in 34 patients (41.98%). Utilizing off-clamp RPN resulted in an average blood loss of 96.29 ml and 1.56 days (range: 1-3 days) of hospital stay and minimal change in serum creatinine.Conclusions:Off-clamp RPN is safe and feasible approach to excise certain kidney tumors. It carries the benefits of RPN and prevents ischemia reperfusion renal injury.

Evaluation of Renal Mass Biopsy Risk Stratification Algorithm for Robotic Partial Nephrectomy—Could a Biopsy Have Guided Management?

We evaluated a published biopsy directed small renal mass management algorithm using a large cohort of patients who underwent robotic partial nephrectomy for tumors 4 cm or smaller. A simplified algorithm of biopsy directed small renal mass management previously reported using risk stratified biopsies was applied to 1,175 robotic partial nephrectomy cases from 5 academic centers. A theoretical assumption was made of perfect biopsies that were feasible for all patients and had 100% concordance to final pathology. Pathology risk groups were benign, favorable, unfavorable and intermediate. The algorithm assigned favorable or intermediate tumors smaller than 2 cm to active surveillance and unfavorable or intermediate 2 to 4 cm tumors to treatment. Higher surgical risk patients were defined as ASA® 3 or greater and age 70 years or older. Patients were assigned to the pathology risk groups of benign (23%), favorable (13%), intermediate (51%) and unfavorable (12%). Patients were alsoassigned to the management groups of benign pathology (275, 23%), activesurveillance (336, 29%) and treatment (564, 48%). Most of the 611 (52%) patients in the benign or active surveillance groups were low surgical risk andhad safe treatment (2.6% high grade complications). A biopsy may not havebeen feasible or accurate in some tumors that were anterior (378, 32%), hilar (93,7.9%) or less than 2 cm (379, 32%). Of 129 (11%) high surgical risk patients the biopsy algorithm assigned 70 (54%) to benign or active surveillance groups. The theoretical application of a biopsy driven, risk stratified smallrenal mass management algorithm to a large robotic partial nephrectomy database suggests that about half of the patients might have avoided surgery. Despite the obvious limitations of a theoretical assumption of all patients receiving a perfect biopsy, the data support the emerging role of renal mass biopsies to guide management, particularly in high surgical risk patients.

PD16-11 COMPARISON OF PERI-OPERATIVE OUTCOMES OF ROBOTIC PARTIAL NEPHRECTOMY AND OPEN PARTIAL NEPHRECTOMY IN IN PATIENTS WITH SOLITARY KIDNEYS

PD16-11 COMPARISON OF PERI-OPERATIVE OUTCOMES OF ROBOTIC PARTIAL NEPHRECTOMY AND OPEN PARTIAL NEPHRECTOMY IN IN PATIENTS WITH SOLITARY KIDNEYS

MP59-14 CLINICAL VALUES OF ZERO ISCHEMIA TECHNIQUE IN PARTIAL NEPHRECTOMY: POSTOPERATIVE FUNCTIONAL PRESERVATION AND WIDE INDICATION FOR TUMOR COMPLEXITY.

MP59-14 CLINICAL VALUES OF ZERO ISCHEMIA TECHNIQUE IN PARTIAL NEPHRECTOMY: POSTOPERATIVE FUNCTIONAL PRESERVATION AND WIDE INDICATION FOR TUMOR COMPLEXITY.