Clavien-Dindo System Research Articles

Contemporary role of palliative cystoprostatectomy or pelvic exenteration in advanced symptomatic prostate cancer.

To access the feasibility of palliative cystoprostatectomy/pelvic exenteration in patients with bladder/rectal invasion due to prostate cancer (PC). Twenty-five men with cT4 PC were retrospectively identified in the institutional databases of six tertiary referral centers in the last decade. Local invasion was documented by CT or MRI scans and was confirmed by urethrocystoscopy. Oncological therapies, local symptoms, previous local treatments, time from diagnosis to intervention and type of surgical procedure were recorded. Patients were divided into groups: ADT group (12 pts) and 13 pts without any history of previous local/systemic treatments for PCa (nonADT groups). Perioperative complications were classified using the Clavien-Dindo system. Overall survival (OS) was defined as the time from surgery to death from any cause. A Cox regression analysis, stratified for ISUP score and previous hormonal treatment (ADT) was also performed for survival analysis. Ileal conduit was the main urinary diversion in both cohorts. For the entire cohort, complication rate was 44%. No significant differences regarding perioperative complications and complication severity between both subgroups were observed (p = 0.2). Median follow-up was 15months (range 3-41) for the entire cohort with a median survival of 15months (95% CI 10.1-19.9). In Cox regression analysis stratified for ISUP score, no statistically significant differences in OS in patients with and without previous ADT before cystectomy or exenteration were observed (HR 3.26, 95% CI 0.62-17.23, p = 0.164). Palliative cystoprostatectomy and pelvic exenteration represent viable treatment options associated with acceptable morbidity and good short-term survival outcome.

The role of surgical experience in patient selection, surgical quality, and outcomes in robot-assisted radical cystectomy

BackgroundRobot-assisted radical cystectomy (RARC) remains one of the most complex urological procedures. Due to regionalization of bladder cancer care, there is likely an imbalance in experience among urologists performing RARC. We sought to describe changes in patient selection, surgical quality surrogates and rates of complications in relation to surgical experience. MethodsWe retrospectively reviewed 409 consecutive patients with bladder cancer who underwent RARC between 2006 and 2017 by a single surgeon. The cohort was divided into 4 quartiles (Q1–Q4) according to surgical experience, based on the chronologic order at which RARC was performed. Baseline, perioperative and pathologic characteristics of patients were compared among the 4 groups. 30-day and 90-day complications were assessed using the Clavien-Dindo system. The association between surgical experience (quartile) and complications was assessed using multivariable logistic regression analyses. ResultsMedian age (interquartile range [IQR] from 70–73 years), body mass index (IQR from 25 to 27 kg/m2) and preoperative glomerular filtration rate (IQR from 59 to 65 ml/min) were similar among all quartiles (all P > 0.05). Patients in Q4 had higher rates of previous abdominopelvic surgery (46.1% vs. 30.4%, P = 0.031) and American Society of Anesthesiologists score of 3 to 4 (72.3% vs. 47.1%, P = 0.003) compared to patients in Q1. Patients who underwent RARC in Q4 compared to Q1, had less estimated blood loss (250 ml vs. 350 ml, P < 0.001), shorter operative time (346 vs. 360 minutes, P < 0.001), and higher lymph node yield (22 vs. 17 nodes, P < 0.001). The 30-day and 90-day complication rates were 53% and 62%, respectively. Thirty-day complication rates were similar among all 4 quartiles (P > 0.05), but higher among patients in Q4 compared to Q1 within 90 days (74% vs. 54%, P = 0.01). On multivariable analysis, patients in Q4 were more likely to experience any 90-day complication (OR 2.03, 95%Cl 1.11–3.70) compared to Q1. ConclusionOur results show that with surgical experience, more complex cases can be performed while continuing to improve surgical quality. Nonetheless, there appears to be a trade-off between the increase in complexity of cases performed with experience and accepting higher rates of complications.

Simultaneous bilateral laparoscopic nephrectomy with kidney transplantation in patients with ESRD due to ADPKD: A single-center experience.

Patients with autosomal dominant polycystic disease (ADPKD) may require bilateral nephrectomy (BN) in addition to kidney transplantation (KT) for symptom control. This study aims to compare simultaneous BNKT to contemporaneous controls by reviewing our cohort of ADPKD patients who underwent KT from a living donor from January 2014 to October 2019. Symptomatic patients who underwent laparoscopic BNKT were compared to KT alone. Clinical differences related to undertaking bilateral nephrectomies showed increased total kidney volumes (P<.001). We assessed operative parameters, complications, and clinical outcomes. The complications were classified according to the Clavien-Dindo system. In 148 transplant recipients, 51 underwent BNKT, and 97KT alone. There was no difference in baseline demographics. BNKT recipients had longer cold ischemia time, required more ICU care, increased blood transfusions and longer hospital stays. The kidney function was similar in the first year in both groups, with no difference in delayed graft function, readmissions or severe grade III and IV complications within 3months after surgery. Laparoscopic BNKT is safe and feasible at the time of living donor KT. Although higher acuity care is needed with a longer initial hospital stay, there are comparable posttransplant patient and allograft outcomes.

Instituting robotic pediatric urologic surgery in the Canadian healthcare system: Evaluating the feasibility and outcomes of robot-assisted pyeloplasty and ureteric reimplantation.

Robotic pediatric urologic surgery has gained wide-spread adoption over the last decade. This article describes our experience in instituting the first pediatric urologic robotic surgery program in Canada. We evaluated the feasibility and safety of instituting pediatric robot-assisted urologic surgery and report our early outcomes for robot-assisted pyeloplasty (RAP) and ureteric reimplantation (RUR). We prospectively evaluated all patients undergoing RAP and RUR by a single surgeon from June 2013 to March 2019. Demographic and clinical data were prospectively collected and included sex, age, and preoperative grade of hydronephrosis or reflux. Descriptive statistics were performed, and comparisons were made using Student's t-tests where appropriate. Success was defined as resolution or significant improvement of hydronephrosis following RAP and absence of recurrent urinary tract infection (UTI) and/or persistent vesicoureteric reflux (VUR) following RUR. Complications were described using the Clavien-Dindo system. A total of 52 RAPs and 24 RURs were performed with a minimum of six months followup. Forty-five RAP patients met criteria for success, while diagnostic imaging of success in the form of MAG-3 Lasix renograms was documented in the remaining seven for an overall success of 100%. Sixteen RUR patients met criteria for success and seven showed resolution of VUR on imaging following their first UTI, for an overall success rate of 96%. Operative times progressively improved from 204±35 minutes to 121±15 minutes in the RAP group and from 224±52 to 132±39 minutes in the RUR group. In the RAP cohort, one Clavien grade II and four Clavien grade III complications were noted, while three Clavien grade III complications were noted in the RUR cohort. Despite limited case volumes, robotic pediatric urologic surgery can be integrated into the Canadian healthcare system with success rates comparable to reported literature. However, compared to open surgery, RAP, and especially RUR, warrant further study to ensure lack of significant complications noted in our study.

The use of comprehensive complication Index® in pancreatic surgery: a comparison with the Clavien-Dindo system in a high volume center

BackgroundThe Clavien-Dindo classification (CDC) system and Comprehensive Complication Index (CCI®) are both widely used methods for reporting the burden of postoperative complications. This study aimed to compare the accuracy of the CDC and CCI® in predicting outcomes associated with pancreatic surgery. MethodsThe CCI® and CDC were applied to 668 patients who underwent pancreatic resection. Length of postoperative stay (LOS) was chosen as the primary outcome variable. The comparison between CCI® and CDC was made with the Spearman test, reporting þs with standard error (SE) and logistic regression, reporting the Odds Ratio (OR) and Area Under the Curve with SE. ResultsThe median value with the interquartile range (IQR) of CCI® was 20.9 (0–29.6). Both CCI® (þs = 0.609) and CDC (0.590) were significantly (P < 0.001) correlated to LOS. CCI (OR 1.056 and OR 1.052) and CDC (OR 1.978, and OR 1.994) predicted (P < 0.001) LOS over the median and 75th percentile. The accuracy of CCI® was superior to CDC for LOS over 50th (0.785 vs. 0.740; P = 0.004) and over 75th (0.835 vs. 0.761; P < 0.001) percentile. ConclusionThe accuracy of CCI® in measuring the complicated postoperative course was superior to CDC, correctly classifying eight patients every ten tested.

Association between postoperative complications and long-term oncologic outcomes following total laryngectomy: 10-year experience at MD Anderson Cancer Center.

Postoperative complications are an independent predictor of poor survival across several tumors. However, there is limited literature on the association between postoperative morbidity and long-term survival following total laryngectomy (TL) for cancer. We conducted a retrospective review of all TL patients at a single institution from 2008 to 2013. Demographic and clinical data were collected and analyzed, including postsurgical outcomes, which were classified using the Clavien-Dindo system. Multivariable Cox regression analyses were performed to identify factors associated with overall survival (OS) and disease-free survival (DFS). A total of 362 patients were identified. The mean age was 64 years, and the majority of patients were male (81%). The median follow-up interval was 21 months. Fifty-seven percent of patients had received preoperative radiation, and 40% had received preoperative chemotherapy. Fifty-seven percent of patients underwent salvage TL, and 60% underwent advanced reconstruction (45% free flap and 15% pedicled flap). A total of 136 patients (37.6%) developed postoperative complications, 92 (25.4%) of which were major. Multivariable modeling demonstrated that postoperative complications independently predicted shorter OS (hazard ratio [HR], 1.50; 95% CI, 1.16-1.96; P=.002) and DFS (HR, 1.36; 95% CI, 1.05-1.76; P = .021). Other independent negative predictors of OS and DFS included positive lymph node status, preoperative chemotherapy, comorbidity grade, and delayed adjuvant therapy. Severity of complication and reason for TL (salvage vs primary) were not shown to be predictive of OS or DFS. Postoperative complications are associated with worse long-term OS and DFS relative to uncomplicated cases. Patient optimization and timely management of postoperative complications may play a critical role in long-term survival.

Comparison of Perioperative and Pathologic Outcomes Between Single-port and Standard Robot-assisted Radical Prostatectomy: An Analysis of a High-volume Center and the Pooled World Experience

ObjectiveTo perform an early comparative study of outcomes between single-port and robot-assisted laparoscopic radical prostatectomy (SP-RALRP) and standard RALRP at our institution and pooled analysis of series to date. Patients and MethodsPatients with organ-confined prostate cancer undergoing SP-RALRP at a high-volume institution were identified retrospectively along with reported SP-RALRP series to date. Data were compared to a contemporary prospective cohort of men undergoing standard RALRP. Patient demographics, perioperative and postoperative data, and complications categorized by the Clavien-Dindo system were compared for the institutional and pooled SP-RALRP cohorts to standard RALRP. ResultsA total of 208 SP-RALRP cases were identified (26 from our institution) and compared to 376 standard RALRP cases. In the institutional analysis, there was no difference in operative time, length of stay, overall complications (15.4% vs 17.3%, P= 1.0), major (Clavien ≥III) complications (3.8% vs 3.7%, P = .6), inpatient opioid use, or patient-reported pain scores; median estimated blood loss (100 mL vs 150 mL, P = .02) and number of lymph nodes removed (5.5 vs 9, P = .002) were lower for SP-RALRP. In the pooled analysis, 208 patients receiving SP-RALRP had similar estimated blood loss and complication rates but fewer lymph nodes removed (P = .02) and marginally longer operating time (+16 minutes, P = .01) compared to standard RALRP. The difference in rate of positive surgical margins was not statistically significant (31.3% vs 24.5%, P = .08). ConclusionBased on an early experience with SP-RALRP at a high-volume center and a pooled analysis of SP series to date, perioperative and pathologic outcomes appear nearly equivalent compared to standard RALRP.

Single-center experience of robot-assisted radical cystectomy (RARC) and extended pelvic lymph node dissection.

To report the outcomes of robot-assisted radical cystectomy (RARC) and extended pelvic lymph node dissection (ePLND) series for bladder cancer. Between October 2016 and June 2019, overall 57 patients (50 men, 7 women) were included in the study. Patient demographics, operative data, and postoperative pathological outcomes were evaluated. Patients who had a history of pelvic or Professional surgery due to other concurrent malignancy, radiation therapy, or lacked data were excluded from the study. The mean age of the patients was 64.72±9.09 years. The mean operation time, intraoperative estimated blood loss, and hospitalization time were 418.58±85.66 minutes, 313.00±79.16mL, and 13.44±5.25 days, respectively. The postoperative pathological stages were reported as pT0 (n=8), pTis (n=4), pT1 (n=4), pT2 (n=22), pT3a (n=11), pT3b (n=2), pT4a (n=4), pT4b (n=1), and other (n=1). The mean lymph node (LN) yield was 23.45±9.43. Positive LNs were found in 16 (28.1%) patients. Surgical margins were positive in 3 (5.26%) patients. The mean follow-up period was 15.42±8.31 months. According to the modified Clavien-Dindo system, minor (Clavien 1-2) and major (Clavien 3-5) complications occurred in 18 (31.58%) and 9 (15.78%) patients during the early (0-30 days) period and in 4 (7.02%) and 5 (8.77%) patients in the late (31-90 days) period. RARC and ePLND are complex but safe procedures with acceptable morbidity and excellent surgical and oncologic outcomes in muscle-invasive or high-risk bladder tumors.

Perioperative risk factors in surgical lung biopsy for the diagnosis of interstitial lung disease: a single-centre experience.

The aim of this study was to evaluate mortality and morbidity after surgical lung biopsy in patients with interstitial lung diseases and to investigate perioperative risk factors for complications. A total of 132 enrolled patients were divided into three groups: group 1 (70), patients with operation scheduled before admission; group 2 (48), patients with operation determined after medical therapy; and group 3 (14), patients with emergent operation followed by steroid therapy. Complications were classified according to the Clavien-Dindo system. The 30- and 90-day mortality and complication rates were evaluated, and perioperative risk factors were investigated. Overall complication rate was 19.7%. The 30- and 90-day in-hospital mortality rates were 1.5% and 3.0%, respectively. Complication rates more than grade II were significantly different between the three groups (P = 0.045). Patients in group 1 revealed only class I or II complications and no mortalities. Elevated oxygen demand after operation was an independent risk factor for any complications, complications more than class II and any events (P < 0.001, P = 0.042 and P < 0.001, respectively). The New York Heart Association Functional Classification (NYHA) class IV was a statistically significant risk factor for any complications (P = 0.036, odds ratio 7.93). Higher NYHA class (III and IV) showed significantly higher risk in occurrence of any events after lung biopsy. Prepared surgical lung biopsy for interstitial lung disease is feasible with reasonable morbidity. Higher NYHA class and elevated oxygen demand after the surgery could imply post-operative outcomes. Alternative diagnostic methods such as transbronchial biopsy or bronchoalveolar lavage should be considered prior to surgical lung biopsy especially in high-risk patients.

Risk Factors for Postoperative Infectious Complications in Elderly Patients with Gastric Cancer.

BackgroundElderly patients with gastric cancer (GC) are at increased risk of infectious complications following gastrectomy. A limited set of risk factors has been identified to predict complications in these patients. To improve the safety of gastrectomy in this population, we investigated the incidence of infectious complications and associated clinicopathologic, nutritional and surgical risk factors in a cohort of elderly patients with GC.MethodsElderly GC patients (≥70 years) who underwent gastrectomy between January 2013 and December 2017 in Peking Union Medical College Hospital were included in the study. Clinicopathologic data were collected retrospectively. Severity of complications was classified using the Clavien–Dindo system. Infectious complications were assessed based on clinical diagnosis of health care-associated infection as defined by the US Centers for Disease Control and Prevention. Multivariate logistic regression analyses were performed to determine the risk factors for infectious complications.ResultsThree hundred thirty-one consecutive patients were included, with a median age of 74 years (range 70–88). The rate of surgical morbidity was 37.5% and the mortality rate was 1.2%. The incidence of infectious complications was 19.6%, with the most common infectious complication being pulmonary infection (11.5%). Preoperative weight loss ≥5% (odds ratio [OR] = 2.21; 95% CI, 1.15–4.28; p = 0.018), Charlson comorbidity index score ≥3 (OR = 2.83; 95% CI, 1.30–6.16; p = 0.009) and preoperative hsCRP level ≥10 mg/L (OR = 2.48; 95% CI, 1.14–5.38; p = 0.022) were independently associated with infectious complications.ConclusionPreoperative weight loss, elevated hsCRP level and comorbidity burden can be used to predict postoperative infectious complications in elderly GC patients. It is recommended to pay more attention to the treatment of elderly GC patients with these risk factors.

How Do Complications Within the First 30 days after Spinal Deformity Surgery in Children with Cerebral Palsy Affect Length of Stay?

Surgery for spinal deformity in patients with cerebral palsy is reported to have high perioperative complication rates. However, minor complications are not generally reported and the influence of the varied severity of complications on length of stay is not known. Understanding the risk factors for both minor and major perioperative complications and their effect on length of stay is important information for clinicians who seek to improve care for this group of children. (1) What is the prevalence of postoperative complications in the first 30 days after surgery for spinal deformity in a New Zealand national cohort of children with cerebral palsy using the Clavien-Dindo classification? (2) What are the patient and operative predictive risk factors for minor and major perioperative complications? (3) What is the effect of year of operation on risk of minor and major perioperative complications? (4) What is the effect of perioperative complications on length of stay? We conducted a retrospective cohort study, identifying all children in New Zealand with a confirmed diagnosis of cerebral palsy who had surgery for a spinal deformity from January 1997 to January 2018. Two hundred-three patients with cerebral palsy (102 boys) were surgically treated for a spinal deformity, at a mean age of 14 ± 3 years, at one of three centers in New Zealand. Six children had Gross Motor Function Classification System Level II or III, 66 had Gross Motor Function Classification System Level IV, and 131 had Gross Motor Function Classification System Level V. Thirty-day perioperative complications were extracted from the patients' health records and classified according to the Clavien-Dindo system. Univariate and multivariate analyses were performed to identify patient and operative risk factors for complications, and the effect on length of stay. In all, 85% of patients experienced at least one perioperative complication. There were 300 Clavien-Dindo Grade I complications in 141 patients, 156 Clavien-Dindo Grade II complications in 102 patients, 25 Clavien-Dindo Grade III complications in 22 patients, 29 Clavien-Dindo Grade IV complications in 28 patients, and one Clavien-Dindo Grade V complication (death; 0.5%). Univariate analysis showed that multiple independent factors, Gross Motor Function Classification System Level V ability (odds ratio 2.13 [95% confidence interval 1.15 to 3.95]; p = 0.02), seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01), preoperative Cobb angle of greater than 70° (OR 2.40 [95% CI 1.20 to 4.78]; p < 0.01), and anterior approach to surgery (OR 3.29 [95% CI 1.21 to 8.90]; p = 0.02), were associated with Grade I complications but, of these factors, only the presence of a seizure disorder (OR 2.27 [95% CI 1.20 to 4.32]; p < 0.01) was associated with Grade I complications on multivariate analysis. Previous recurrent respiratory infections predicted an increased risk of Clavien-Dindo Grade II complications (OR 3.6 [95% CI 1.81 to 7.0]; p = 0.03). The presence of a feeding gastrostomy was associated with an increased risk of Clavien-Dindo Grade IV complications (OR 2.6 [95% CI 1.19 to 5.87]; p = 0.02). The year of operation did not influence the frequency of any grade of complication, but the presence of any complication led to an increased length of stay. Overall, 85% of patients with cerebral palsy had at least one complication after spinal deformity surgery and 25% had major complications (Grades III, IV, and V), with proportionate increases in the postoperative length of stay. Patient-specific factors aid in the identification of complication risk. Level II, prognostic study.

This Month in Pediatric Urology

You have accessJournal of UrologyThis Month in Pediatric Urology1 May 2020This Month in Pediatric Urology Julian Wan Julian WanJulian Wan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000784AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail The pediatric articles published in this issue of The Journal represent 2 ends of the pathological spectrum. Peycelon et al focus on the beginning in their report on in utero maternal hormone levels that may predict the risk for hypospadias.1 Aksenov and Granberg evaluate the potential complications of minimally invasive surgery to treat common conditions such as ureteropelvic junction narrowing and vesicoureteral reflux.2 Linking the articles is the acquisition, collection and analysis of large pools of data. The collection, storage, examination and commerce of personal data including medical information has expanded in the last few decades and is likely to continue to grow as greater segments of the population become associated with electronic medical record systems. Despite the many real concerns about privacy and exploitation, there are legitimate scientific applications of these larger data collections. By sampling blood collected as part of general screening, specific disease relationships can be identified and complications may emerge when gathering reports of procedures. Association of Maternal Human Chorionic Gonadotropin and Hypospadias Using a large national registry, Peycelon et al (page 1017) from France examined the association between first trimester maternal serum free beta-human chorionic gonadotropin (HCG) levels and subsequent finding of hypospadias in the newborn. It has been established that tubularization of the urethra occurs early and is usually complete by 16 to 18 weeks of gestation. This process is affected by testosterone activity which, in turn, is affected by the release of HCG from maternal placental syncytiotrophoblasts. The authors suspect that the relationship may depend more on total HCG rather than just the beta subunit. Using a large metropolitan Paris database of maternal blood samples taken as part of routine prenatal screening, they found that proximal hypospadias, but not distal hypospadias or hypospadias overall, was associated with significantly higher levels of beta-HCG. The study was controlled for age and excluded pregnancies that were initiated by artificial reproductive technologies (a known risk for hypospadias), chromosomal anomalies, twins, fetal death and terminations. However, the authors acknowledged the limitations inherent with this type of analysis, most of which relate to potential bias from underreporting of less severe forms and the small number of proximal hypospadias cases (13 of 194 hypospadias cases). Complications of Minimally Invasive Surgery in Children To assess complications in patients treated with minimally invasive surgery, Aksenov et al (page 1010) from North Carolina and Minnesota conducted a review of the existing literature.2 While the Clavien-Dindo (CD) system of classification has been widely used, it was used in only a third of the articles in their review, whereas for the remaining articles complications were adjudicated by the authors and assigned a CD grade. In particular, the authors focused on complications resulting in subsequent surgical, radiological and endoscopic interventions (CD grade IIIa without general anesthesia, CD grade IIIb with general anesthesia). They also noted conversion rates related to open surgery. A significantly lower rate of grade III complications was reported for nephrectomy than for pyeloplasty and ureteral reimplantation. Complex reconstructions, as one would expect intuitively, resulted in the highest grade III complication rate at 12%. Likewise, the complication rate was highest for conversion to open surgery, followed by partial nephrectomy, nephrectomy and ureteral reimplantation. The lowest complication rate occurred after pyeloplasty (1%) which may reflect longer experience with this procedure. The clear separation of open conversion and the need for a complication related subsequent procedure is of practical use when discussing possible risks with families, patients and referring physicians.

Retzius-sparing Robotic Radical Prostatectomy for Surgeons in the Learning Curve: A Propensity Score–matching Analysis

BackgroundSeveral authors claimed that the Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) needs a prolonged learning curve, and outcomes during this phase could be suboptimal. ObjectiveTo verify the safety and outcomes of RS-RARP performed by young surgeons during the learning curve. Design, setting, and participantsWe conducted a retrospective analysis of the pre-, intra-, and postoperative features of all the patients who underwent RS-RARP from 2013 to 2017. We divided our patients into two groups: patients operated by two experienced surgeons (ESs) with >100 procedures and patients operated on by five younger surgeons in the learning curve (LCSs). LCSs had no previous experience in radical prostatectomy, and the very first RS-RARP procedures of each LCS case are included in the analysis. Outcome measurements and statistical analysisPerioperative, oncological, and functional data were analyzed. Short-term oncological results were reported as positive surgical margins (PSMs) and 1-yr disease-free survival. Complications were graded according to the Clavien-Dindo system. Potency was defined as erections sufficient for intercourse; continence was defined as no pad or one safety liner. A propensity score–matching analysis was used to adjust the difference in baseline preoperative parameters between the groups. Results and limitationsWe obtained two homogeneous groups of 256 patients each. After the matching, preoperative variables were similar in the two groups. The mean console time was longer for younger surgeons (98 vs 122 min, p < 0.001). Postoperative course, complications, and functional results were similar in the two groups; the final pathological analysis showed a worse T stage in the ES group (p = 0.017). PSMs and 1-yr disease-free survival did not differ between the groups. ConclusionsRS-RARP can be safely performed by inexperienced surgeons who have received adequate training. Patient summarySurgeons in the learning curve can perform Retzius-sparing robot-assisted radical prostatectomy safely, with similar early oncological results and functional outcomes.

3:45 PM Abstract No. 269 Long-term survival after percutaneous radiofrequency ablation of pathologically proven renal cell carcinoma in 100 patients

To determine the long-term survival of patients treated with percutaneous radiofrequency ablation (RFA) for pathologically proven renal cell carcinoma (RCC). In this single-center retrospective study, a study cohort of 100 patients with 125 RCCs (100 clear cell, 19 papillary and 6 chromophobe) ranging in size from 0.8 cm to 8 cm treated with RFA were evaluated at a single large tertiary care center between 2004 and 2015. Technical success, primary and secondary technique efficacy, pre- and postprocedural estimated glomerular filtration rate (eGFR) at 3 – 6 months and 2 – 3 years were recorded. Overall survival, cancer-specific survival, and local tumor progression-free survival by Kaplan-Meier survival curves were calculated. Complications were classified using the Clavien-Dindo system. Statistical testing was done via Chi-squared tests for proportions and the paired-t test for change in eGFR. Statistical significance was set at α = 0.05. Overall technical success was 100% and primary and secondary technique efficacy were 90% and 100%, respectively. Median follow-up was 62.8 months, ranging from 1 – 120 months. The 10-year overall, cancer-specific, and local progression-free survival rates were 32%, 86%, and 92%, respectively. The number of ablation probes used was predictive of residual unablated tumor (P < 0.001). There were no significant changes in pre procedure vs. 2 to 3 years post procedure eGFR (65.2 vs. 62.1 mL/minute/1.73 m2, P = 0.443). The overall complication rate was 9%, the majority of which were grade I. Image-guided percutaneous RFA of RCCs is effective at achieving local control and preventing cancer-specific death within 10 years from initial treatment.Tabled 1Residual TumorComplicationsTumor ProgressionTumor TypeYesNoYesNoYesNoClear cell13 (13%)87 (87%)10 (10%)90 (90%)7 (7%)93 (93%)Papillary0 (0%)19 (100%)1 (6%)18 (94%)0 (0%)19 (100%)Chromophobe0 (0%)6 (100%)0 (0%)6 (100%)1 (17%)5 (83%)P0.1630.5900.299Tumor size≤4cm11 (10%)106 (90%)10 (9%)107 (91%)7 (6%)110 (94%)>4cm2 (25%)6 (75%)1 (13%)7 (87%)1 (13%)7 (87%)P0.1620.7020.466PolarityUpper pole3 (9%)31 (91%)3 (9%)31 (91%)1 (3%)33 (97%)Mid pole5 (11%)41 (89%)3 (7%)43 (93%)6 (13%)40 (87%)Lower pole5 (11%)40 (89%)5 (11%)40 (89%)1 (2%)44 (98%)P0.9390.8330.068MorphologyExophytic7 (16%)36 (84%)4 (9%)39 (91%)3 (7%)40 (93%)Endophytic6 (7%)76 (93%)7 (9%)75 (91%)5 (6%)77 (94%)P0.1190.8850.850LocationAnterior7 (18%)31 (82%)3 (8%)35 (92%)3 (8%)35 (92%)Lateral1 (3%)31 (97%)2 (6%)30 (94%)2 (6%)30 (94%)Posterior5 (9%)50 (91%)6 (11%)49 (89%)3 (5%)52 (95%)P0.1030.7400.894LateralityLeft9 (16%)46 (84%)8 (15%)47 (85%)5 (9%)50 (91%)Right4 (6%)66 (94%)3 (4%)67 (96%)3 (4%)67 (96%)P0.0530.0440.280Ablation Probes10 (0%)65 (100%)1 (2%)64 (98%)1 (2%)64 (98%)23 (8%)36 (92%)7 (18%)32 (82%)5 (13%)34 (87%)310 (45%)11 (55%)3 (14%)18 (86%)2 (10%)19 (90%)P<0.0010.0100.061 Open table in a new tab

Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap.

The treatment of transitional ankle fractures (Tillaux and triplane) is often dictated by the amount of displacement at the articular surface. Although >2 mm is a common indication for operative management, this practice has not been strongly supported by either the pediatric or adult literature. The purpose of this study was to determine whether operative treatment of transitional fractures with 2 to 5 mm of intra-articular gap leads to superior functional outcomes compared with cast management. A retrospective review of all patients treated for distal tibial fractures at a single institution between 2009 and 2017 was conducted. Computed tomographic images obtained after closed reduction were reviewed to identify patients with 2 to 5 mm of displacement (either gap or step-off) at the articular surface of the tibial plafond. Complications were classified according to the modified Clavien-Dindo system. Only patients with functional outcome data (Foot and Ankle Ability Measure [FAAM]) at a minimum of 2 years after treatment were included. Two multivariable linear regression models were developed using backward stepwise regression with either the FAAM Sports score or the Single Assessment Numerical Evaluation (SANE) Sports score as the dependent variables. Fifty-seven patients (34 with triplane fractures and 23 with Tillaux fractures) with a mean follow-up of 4.5 years (range, 2.0 to 9.2 years) met inclusion criteria. Thirty-four patients were treated operatively, and 23 patients were treated with closed reduction and cast application. Nonoperative treatment, greater intra-articular gap, and presence of a grade-III complication were associated with worse functional outcomes in both multivariable regression models. A gap after closed reduction remained a negative predictor of functional outcome even in patients who were treated operatively. Patients who were treated nonoperatively and had ≤2.5 mm of gap had a significantly higher mean SANE Sports score at 90% than those patients with >2.5 mm of gap at 75% (p = 0.03). In Tillaux and triplane fractures with 2 to 5 mm of gap at the tibial plafond, a greater gap after closed reduction, nonoperative treatment, and complications were negative predictors of functional outcome at a mean follow-up of 4.5 years. Surgical management likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Safety of Radical Cystectomy and Pelvic Lymph Node Dissection Following Neoadjuvant Pembrolizumab in Patients with Bladder Cancer: Prospective Assessment of Perioperative Outcomes from the PURE-01 Trial

No data are available on the surgical safety of radical cystectomy (RC) and pelvic lymph node dissection (PLND) after the administration of checkpoint inhibitors. We aimed at reporting the first prospective rigorous assessment of perioperative outcomes after RC and extended PLND following neoadjuvant pembrolizumab in a contemporary cohort of patients with muscle-invasive bladder cancer (MIBC) enrolled in the PURE-01 trial. From February 2017 to June 2019, a total of 68 consecutive patients who received three courses of 200 mg pembrolizumab intravenously every 3 wk and were subsequently treated with either open or robot-assisted RC and PLND at a single high-volume tertiary referral center were identified. All men had prospectively collected data about intra- and postoperative outcomes. Postoperative complications were graded according to the Clavien-Dindo system. Perioperative data were prospectively and systematically collected during patient interviews at 90 d after surgery according to the European Association of Urology (EAU) Guidelines Panel recommendations on reporting and grading complications. Overall, 52 (77%) versus 16 (23%) patients underwent robot-assisted versus open RC, and 31 patients (46%) received an orthotopic neobladder. Median blood loss and length of stay were 150 ml and 12 d, respectively. Overall, 52 (77%), 47 (69%), and 22 (32%) patients experienced any-grade complications, grade ≥2 complications, and readmission at 90 d, respectively. High-grade complications (defined as Clavien-Dindo ≥3a) were observed in 23 patients (34%). The most frequent complications were fever (n = 35, 52%) and ileus (n = 21, 31%). None of the patients experienced perioperative mortality at 90 d. Our data represent the first prospective evidence supporting the surgical safety of RC and PLND in patients with N0M0 MIBC who received neoadjuvant immunotherapy with pembrolizumab. Patient summaryThe current study represents the first prospective evidence supporting the surgical safety of radical cystectomy and pelvic lymph node dissection in patients with nonmetastatic bladder cancer who received neoadjuvant immunotherapy with pembrolizumab.

Factors associated with complications of vaginal hysterectomy in patients with pelvic organ prolapse - a single centre's experience.

The study aimed to examine the predisposing factors that play a role in the development of complications in patients undergoing vaginal hysterectomy. This retrospective analysis was performed on data provided from 239 patients who underwent vaginal hysterectomy due to uterine prolapse at a single centre between January 2008 and August 2018. Complications were defined according to Clavien-Dindo classification of complications. The patients were divided into two groups: with and without complications. We built a model using multivariable logistic regression to examine the relationships between complications and five candidate predictors. Intra/postoperative complications developed in 30 patients, and the complication rate was found to be 12.5%. 87.2% of the reported complications were classified as Grade ≤ 2 according to Clavien-Dindo system. It was found that complications were associated with factors such as intraoperative concurrent salpingo-oophorectomy [Odds ratio (OR): 1.24 (1.1-1.4)], low preoperative haemoglobin [OR: 0.96 (0.94-0.98)], uterine weight [OR: 2.69 (2.62-2.76)], and long operation time [OR: 1.04 (1.02-1.07)]. History of pelvic surgery was not found to increase complication rate [OR: 1.11 (0.96-1.27), p = 0.13]. Our multiple logistic regression model correctly classified 74% of participants within the Receiver Operating Characteristic (ROC) curve. Preoperative anaemia, large uterus and concomitant adnexectomy were found to be factors associated with complications during and after vaginal hysterectomy for pelvic organ prolapse.

Could Chemical Composition of Stone Influence Percutaneous Nephrolithotomy in the Management of Staghorn Calculi?

The management of large renal stones is a challenging situation for the urologists. PCNL (percutaneous nephrolithotomy) represents the elective procedure and can be performed as monotherapy or combined with other techniques. This is a retrospective study on 75 patients diagnosed with staghorn calculi at Prof. Dr. Th. Burghele Clinical Hospital who underwent PCNL between 01.01.2018 to 31.06.2018. The aim of this study is to evaluate the correlations between the staghorn chemical composition, the stone free rate and the complication rate after surgery according to modified Clavien Dindo system of evaluation for urological procedures.

Could Chemical Composition of Stone Influence Percutaneous Nephrolithotomy in the Management of Staghorn Calculi?

The management of large renal stones is a challenging situation for the urologists. PCNL (percutaneous nephrolithotomy) represents the elective procedure and can be performed as monotherapy or combined with other techniques. This is a retrospective study on 75 patients diagnosed with staghorn calculi at Prof. Dr. Th. Burghele Clinical Hospital who underwent PCNL between 01.01.2018 to 31.06.2018. The aim of this study is to evaluate the correlations between the staghorn chemical composition, the stone free rate and the complication rate after surgery according to modified Clavien Dindo system of evaluation for urological procedures.

Long-Term Survival after Percutaneous Radiofrequency Ablation of Pathologically Proven Renal Cell Carcinoma in 100 Patients.

To determine the long-term survival of patients treated with percutaneous radiofrequency (RF) ablation for pathologically proven renal cell carcinoma (RCC). In this single-center retrospective study, 100 patients with 125 RCCs (100 clear-cell, 19 papillary, and 6 chromophobe) 0.8-8 cm in size treated with RF ablation were evaluated at a single large tertiary-care center between 2004 and 2015. Technical success, primary and secondary technique efficacy, and pre- and postprocedural estimated glomerular filtration rate (eGFR) at 3-6 months and 2-3 years were recorded. Overall survival, cancer-specific survival, and local tumor progression-free survival were calculated by Kaplan-Meier survival curves. Complications were classified per the Clavien-Dindo system. Statistical testing was done via χ2 tests for proportions and paired t test for changes in eGFR. Statistical significance was set at α= 0.05. Overall technical success rate was 100%, and primary and secondary technique efficacy rates were 90% and 100%, respectively. Median follow-up was 62.8 months, ranging from 1 to 120 months. The 10-year overall, cancer-specific, and local progression-free survival rates were 32%, 86%, and 92%, respectively. The number of ablation probes used was predictive of residual unablated tumor (P < .001). There were no significant changes in preprocedure vs 2-3-years postprocedure eGFR (65.2 vs 62.1 mL/min/1.73 m2; P= .443). There was a 9% overall incidence of complications, the majority of which were grade I. Image-guided percutaneous RF ablation of RCCs is effective at achieving local control and preventing cancer-specific death within 10 years from initial treatment.