Collecting System Entry Research Articles

Impact of tumor contact surface area on collecting system entry in robot-assisted partial nephrectomy: a retrospective analysis

BackgroundCollecting system entry in robot-assisted partial nephrectomy may occur even in cases showing a low N factor in the R.E.N.A.L nephrometry score. Therefore, in this study, we focused on the tumor contact surface area with the adjacent renal parenchyma and attempted to construct a novel predictive model for collecting system entry.MethodsAmong 190 patients who underwent robot-assisted partial nephrectomy at our institution from 2015 to 2021, 94 patients with a low N factor (1–2) were analyzed. Contact surface was measured with three-dimensional imaging software and defined as the C factor, classified as C1, < 10 cm [2]; C2, ≥ 10 and < 15 cm [2]; and C3: ≥ 15 cm [2]. Additionally, a modified R factor (mR) was classified as mR1, < 20 mm; mR2, ≥ 20 and < 40 mm; and mR3, ≥ 40 mm. We discussed the factors influencing collecting system entry, including the C factor, and created a novel collecting system entry predictive model.ResultsCollecting system entry was observed in 32 patients with a low N factor (34%). The C factor was the only independent predictive factor for collecting system entry in multivariate regression analysis (odds ratio: 4.195, 95% CI: 2.160–8.146, p < 0.0001). Models including the C factor showed better discriminative power than the models without the C factor.ConclusionsThe new predictive model, including the C factor in N1-2 cases, may be beneficial, considering its indication for preoperative ureteral catheter placement in patients undergoing robot-assisted partial nephrectomy.

A low RENAL Nephrometry Score can avoid the need for the intraoperative insertion of a ureteral catheter in robot-assisted partial nephrectomy

BackgroundIntraoperative urinary collecting system entry (CSE) in robot-assisted partial nephrectomy (RAPN) may cause postoperative urinary leakage and extend the hospitalization. Therefore, identifying and firmly closing the entry sites are important for preventing postoperative urine leakage. In RAPN cases expected to require CSE, we insert a ureteral catheter and inject dye into the renal pelvis to identify the entry sites. We retrospectively analyzed the factors associated with intraoperative CSE in RAPN and explored the indications of intraoperative ureteral catheter indwelling in RAPN.MethodsOf 104 Japanese patients who underwent RAPN at our institution from August 2016 to March 2020, 101 were analyzed. The patients were classified into CSE and non-CSE groups. The patients’ background characteristics, RENAL Nephrometry Score (RNS), and surgical outcomes were analyzed.ResultsIntraoperative CSE was observed in 41 patients (41%). The CSE group had a significantly longer operative time, console time, ischemic time, and hospital stay than the non-CSE group. In a multivariable analysis, the N-score (odds ratio [OR] = 3.9, P < 0.05) and RNS total score excluding the L-score (OR = 3.1, P < 0.05) were associated with CSE. In a logistic regression analysis, CSE showed a moderate correlation with the RNS total score excluding the L-score (AUC 0.848, cut-off 5, sensitivity 0.83, specificity 0.73).ConclusionA ureteral catheter should not be placed in patients with an RNS total score (excluding the L-score) of ≤ 4.

1051 - Prediction of intraoperative urinary collecting system entry in patients with peripheral renal tumors undergoing partial nephrectomy: Usefulness of tumor-centered multiplanar reconstruction

1051 - Prediction of intraoperative urinary collecting system entry in patients with peripheral renal tumors undergoing partial nephrectomy: Usefulness of tumor-centered multiplanar reconstruction

Prediction of Intraoperative Urinary Collecting System Entry in Patients with Peripheral Renal Tumors Undergoing Partial Nephrectomy: Usefulness of Tumor-Centered Multiplanar Reconstruction

Objective: To assess the usefulness of tumor-centered multiplanar reconstruction (TC-MPR) for predicting intraoperative urinary collecting system (UCS) entry in patients with peripheral renal tumors undergoing partial nephrectomy (PN). Methods: Dynamic computed tomography images of 50 peripheral cT1 renal tumors treated with laparoendoscopic PN were analyzed. TC-MPR generated a digital cross-sectional image showing the tumor center and the closest calyx on a same plane. Patients and tumor characteristics including the distance from the tumor margin to the closest calyx (MPR-distance), and the angle formed by 2 tangent lines from the closest calyx to the tumor (MPR-angle) were assessed. Results: Intraoperative UCS entry was observed in 15 patients (30%). The patients who experienced intraoperative UCS entry had a higher RENAL score, wider MPR-angle, and shorter MPR-distance than those who did not (p = 0.04, p = 0.001, p < 0.001, respectively). Multivariate analysis identified MPR-angle as an independent factor for intraoperative UCS entry (p < 0.001). Conclusions: The spatial information assessed using TC-MPR serves as a predictive factor for intraoperative UCS entry during PN.

Has Sliding-Clip Renorrhaphy Eliminated the Need for Collecting System Repair During Robot-Assisted Partial Nephrectomy?

We evaluated whether single-layer renorrhaphy (SLR) without collecting system (CS) closure is sufficient following robot-assisted partial nephrectomy (RAPN). One hundred fifty consecutive patients underwent RAPN by a single surgeon and were prospectively labeled with regard to CS entry during surgery. Patients with CS entry were subdivided into two groups: those with classical renorrhaphy (CR) (i.e., two-layer repair) and those with SLR (i.e., without CS repair). Perioperative variables and outcomes were compared between CR and SLR groups. Ninety patients had CS entry during RAPN. Of these 90 patients, 64 had CR, and 26 had SLR, with mean ages of 62 and 59 years (p = 0.22), tumor sizes of 3.4 and 3.3 cm (p = 0.61), Mayo Adhesive Probability scores of 1.8 and 1.8 (p = 0.95), and radius, exophytic/endophytic, nearness to CS, and laterality scores of 8.5 and 8.0 (p = 0.16), respectively. Mean warm ischemia times (WITs) were 19.6 and 17.3 minutes (p = 0.04), hospital stays of 3.0 and 2.8 days (p = 0.62), and drain times of 2.9 and 2.7 days (p = 0.65), for the CR and SLR groups, respectively. Using the Clavien-Dindo classification, there were a total of six grade III or higher complications, with no difference between the CR and SLR subgroups (p = 1.0). Renal function using creatinine or glomerular filtration rate as surrogates showed no difference between groups preoperatively or up until 2 years postoperatively. Omitting CS repair during RAPN with SLR decreases WIT without altering complications, hospital stay, or drain time. Long-term renal function was not associated with CS repair.

Assessment of Perioperative Variables That Predict the Need for Surgical Drains Following Robotic Partial Nephrectomy Utilizing Quantitative Drain Creatinine Analysis.

To utilize body fluid creatinine analysis to determine which patients will require a surgical drain following robotic-assisted partial nephrectomy (RAPN). One hundred fifty consecutive RAPN performed by a single surgeon were reviewed. Postoperative day (POD) 1 drain creatinine was compared to serum creatinine to calculate the drain to serum creatinine ratio (D/S ratio). Elevated D/S ratio was defined as any value >1.2. From February 2008 to April 2015, 140 patients underwent RAPN and had a drain placed (124 had D/S ratio available on POD 1). In the 103 patients with a D/S ratio of <1.2 and the 21 with D/S ratio of >1.2, the mean tumor size was 3.0 and 3.9 cm (P = .001) and mean RENAL score was 7.6 and 8.1 (P = .270), respectively. Collecting system entry occurred in 68.2% of patients with a D/S ratio of <1.2 and 71.4% of patients with a D/S ratio of >1.2. Mean drain time was 2.4 and 4.2 days (P = .001), hospital stay was 2.7 and 3.3 days (P = .036) for the D/S ratio <1.2 and D/S ratio >1.2 groups, respectively. Those with renal mass size of 4-7 cm had increased likelihood of D/S ratio >1.2 (OR 2.78; P = .041). Most RAPN do not require a surgical drain. A POD 1 elevated D/S ratio is more likely to occur with larger masses (those approaching or greater than 4 cm) and can be associated with prolonged drain time and hospital stay.

Identifying unrecognized collecting system entry and the integrity of repair during open partial nephrectomy: comparison of two techniques

To compare retrograde dye injection through an externalized ureteral catheter with direct needle injection of dye into proximal ureter for identification of unrecognized collecting system disruption and integrity of subsequent repair during open partial nephrectomy. We retrospectively reviewed the records of 259 consecutive patients who underwent open partial nephrectomy. Externalized ureteral catheters were placed preoperatively in 110 patients (Group 1); needle injection of methylene blue directly into proximal ureter was used in 120 patients (Group 2). No assessment of the collecting system was performed in 29 patients (Group 3). We compared intraoperative parameters, tumor characteristics, collecting system entry and incidence of urine leaks among the three groups. The mean tumor diameter was 3.1 cm in Group 1, 3.6cm in Group 2, and 3.8 cm in Group 3 (p = 0.04); mean EBL 320cc, 351 cc and 376cc (p = 0.5); mean operative time 193.5 minutes, 221 minutes and 290 minutes (p < 0.001). Collecting system entry was recognized in 63%, 76% and 38% of cases in Groups 1, 2 and 3 respectively. (p = 0.07). Postoperative urine leaks requiring some form of management occurred in 11 patients from group 1 and 6 from group 2. (p = 0.2). No patient in Group 3 developed a urinary leak. Identification of unrecognized collecting system disruption as well as postoperative urine leak rate in patients undergoing partial nephrectomy were not influenced by the intraoperative technique of identifying unrecognized collecting system entry. Postoperative urine leaks are uncommon despite recognized collecting system disruption in the majority of patients.

Internal Validation of the Renal Pelvic Score: A Novel Marker of Renal Pelvic Anatomy That Predicts Urine Leak After Partial Nephrectomy

To internally validate the renal pelvic score (RPS) in an expanded cohort of patients undergoing partial nephrectomy (PN). Our prospective institutional renal cell carcinoma database was used to identify all patients undergoing PN for localized renal cell carcinoma from 2007 to 2013. Patients were classified by RPS as having an intraparenchymal or extraparenchymal renal pelvis. Multivariate logistic regression models were used to examine the relationship between RPS and urine leak. Eight hundred thirty-one patients (median age, 60 ± 11.6years; 65.1% male) undergoing PN (57.3% robotic) for low (28.9%), intermediate (56.5%), and high complexity (14.5%) localized renal tumors (median size, 3.0 ± 2.3cm; median nephrometry score, 7.0 ± 2.6) were included. Fifty-four patients (6.5%) developed a clinically significant or radiographically identified urine leak. Seventy-two of 831 renal pelvises (8.7%) were classified as intraparenchymal. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (43.1% vs 3.0%; P<.001), major urine leak requiring intervention (23.6% vs 1.7%; P<.001), and minor urine leak (19.4% vs 1.2%; P<.001) compared with that in patients with an extrarenal pelvis. After multivariate adjustment, RPS (intraparenchymal renal pelvis; odds ratio [OR], 24.8; confidence interval [CI], 11.5-53.4; P<.001) was the most predictive of urine leak as was tumor endophyticity ("E" score of 3 [OR, 4.5; CI, 1.3-15.5; P= .018]), and intraoperative collecting system entry (OR, 6.1; CI, 2.5-14.9; P<.001). Renal pelvic anatomy as measured by the RPS best predicts urine leak after open and robotic partial nephrectomy. Although external validation of the RPS is required, preoperative identification of patients at increased risk for urine leak should be considered in perioperative management and counseling algorithms.

Anatomic Complexity Quantitated by Nephrometry Score Is Associated With Prolonged Warm Ischemia Time During Robotic Partial Nephrectomy

To assess the association between nephrometry score (NS) and prolonged warm ischemia time (WIT) in patients undergoing robotic partial nephrectomy (RPN) for clinically localized renal masses. We queried our prospectively maintained kidney cancer database to identify all patients undergoing RPN for localized tumors from 2007-2012. Patient and tumor characteristics were compared between complexity groups using analysis of variance and chi square tests. Multivariate logistic regression models were used to examine the relationship between NS complexity and warm ischemia >30minutes. Three hundred seventy-five patients (mean age, 59 ± 11years; mean Charlson comorbidity index, 1.0 ± 1.3) undergoing RPN under warm ischemia for clinically localized renal tumors (mean tumor size, 3.1 ± 1.5cm; mean NS, 6.8 ± 1.8) met inclusion criteria and had NS available. Stratified by complexity, groups differed with respect to age at surgery, tumor size, proximity to the hilum, collecting system entry, estimated blood loss, and operative time (all Pvalues≤.05). Significant differences in mean WIT were observed when comparing low (19.4 ± 12.1minutes), intermediate (28.6 ± 12.8minutes), and high (36.1 ± 13.7minutes) NS complexity groups (P<.0001). Adjusting for confounders, patients with intermediate (odds ratio, 2.1; confidence interval, 1.2-3.9) and high (odds ratio, 3.7; confidence interval, 1.1-11.8) NS complexity were more likely to require prolonged WIT when compared with patients with low complexity tumors. In our large institutional cohort, quantification of anatomic complexity using the NS is associated with WIT >30minutes in patients undergoing RPN for localized renal tumors. This provides further evidence that standardized reporting of tumor anatomic complexity affords meaningful outcome comparisons.

MP59-05 VALIDATION OF THE RENAL PELVIC SCORE: A NOVEL MARKER OF RENAL PELVIC ANATOMY THAT PREDICTS URINE LEAK FOLLOWING PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized IV1 Apr 2014MP59-05 VALIDATION OF THE RENAL PELVIC SCORE: A NOVEL MARKER OF RENAL PELVIC ANATOMY THAT PREDICTS URINE LEAK FOLLOWING PARTIAL NEPHRECTOMY Jeffrey Tomaszewski, Marc Smaldone, Bic Cung, Tianyu Li, Reza Mehrazin, Alexander Kutikov, Rosalia Viterbo, David Chen, Richard Greenberg, and Robert Uzzo Jeffrey TomaszewskiJeffrey Tomaszewski More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Bic CungBic Cung More articles by this author , Tianyu LiTianyu Li More articles by this author , Reza MehrazinReza Mehrazin More articles by this author , Alexander KutikovAlexander Kutikov More articles by this author , Rosalia ViterboRosalia Viterbo More articles by this author , David ChenDavid Chen More articles by this author , Richard GreenbergRichard Greenberg More articles by this author , and Robert UzzoRobert Uzzo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1801AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives We previously developed a novel scoring system of renal pelvic anatomy to predict urine leak following partial nephrectomy (PN). Herein we validate the Renal Pelvic Score (RPS) in an expanded cohort of patients undergoing PN. Methods Our prospective institutional RCC database was utilized to identify all patients undergoing PN for localized RCC from 2006−2013. Patients were classified by RPS as having an intra or extraparenchymal renal pelvis. Multivariate logistic regression models were used to examine the relationship between RPS and urine leak. Results 831 patients (mean age 58±11.6 years; mean CCI 1.2±1.5; 65.1% male) undergoing PN (57.3% robotic) for low (28.9%), intermediate (56.5%), and high complexity (14.5%) localized renal tumors (mean size 3.7±2.3cm, mean NS 6.1±2.6) were included. 54 (6.5%) of patients developed a urine leak. 72 (8.7%) of renal pelvises were classified as intraparenchymal. On univariate analysis following stratification by RPS, groups differed with respect to ECOG PS, ASA class, tumor stage, collecting system entry (CSE), and procedure type (all p values < 0.05). No differences were observed between tumor grade, histologic subtype, surgical margin status, nephrometry score, race, gender, laterality, and the presence of a solitary kidney. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (57.4% vs. 3.0%, p<0.001), secondary intervention (23.6% vs. 1.7%, p<0.001), and prolonged duration of urine leak (p=0.05). After controlling for BMI, NS, procedure type, ASA status, tumor stage, EBL, and ECOG PS, intraparenchymal renal pelvis (OR 24.8 [CI 11.5-53.4]; p<0.001) and CSE (OR 6.1 [CI 2.5-14.9]; p<0.001) were associated with a significantly increased risk of urine leak. Conclusions Herein we validate the ability of the RPS to predict urine leak following open and robotic partial nephrectomy. Elevated pressures within a small intraparenchymal renal pelvis might explain the increased risk. While external validation of the RPS is required, pre-operative identification of patients at increased risk for urine leak should be considered in peri-operative management algorithms. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e651-e652 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Jeffrey Tomaszewski More articles by this author Marc Smaldone More articles by this author Bic Cung More articles by this author Tianyu Li More articles by this author Reza Mehrazin More articles by this author Alexander Kutikov More articles by this author Rosalia Viterbo More articles by this author David Chen More articles by this author Richard Greenberg More articles by this author Robert Uzzo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Higher RENAL Nephrometry Score is Predictive of Longer Warm Ischemia Time and Collecting System Entry During Laparoscopic and Robotic-assisted Partial Nephrectomy

To investigate the predictive value of the RENAL Nephrometry Score (RNS) on operative outcomes during both laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN). We reviewed 67 consecutive patients with suspicious renal lesions and available radiographic data who underwent LPN or RPN by a single surgeon. Data included operative type, body mass index (BMI), gender, age, and side of tumor. RNSs were recorded using either magnetic resonance imaging or computed tomography scans. Warm ischemia time (WIT), estimated blood loss (EBL), and collecting system entry (CSE) were the endpoints for the analyses. Total RNS entered as a continuous or dichotomous variable (<7 or ≥ 7), R-score, and N-score were independent predictors of WIT on multivariable analyses (P <.001, P = .001, P = .026, and P <.01, respectively). The total RNS and N-score were predictive of CSE in univariate analysis (P <.001). Neither total RNS nor its individual components were predictive of EBL. Total RNS, as well as the N- and R-scores, can help predict both longer WIT and CSE during LPN and RPN. The RNS and its individual components may be useful in the preoperative planning and counseling of patients undergoing LPN or RPN.

1849 PREDICTION OF POSTOPERATIVE MORBIDITY AFTER PARTIAL NEPHRECTOMY BASED ON THE EXPANDED ACCORDION SEVERITY GRADING SYSTEM

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 20121849 PREDICTION OF POSTOPERATIVE MORBIDITY AFTER PARTIAL NEPHRECTOMY BASED ON THE EXPANDED ACCORDION SEVERITY GRADING SYSTEM Seung Jeon, Tin Ngo, Alan Thong, John Leppert, and Benjamin Chung Seung JeonSeung Jeon Seoul, Korea, Republic of More articles by this author , Tin NgoTin Ngo Stanford, CA More articles by this author , Alan ThongAlan Thong Stanford, CA More articles by this author , John LeppertJohn Leppert Stanford, CA More articles by this author , and Benjamin ChungBenjamin Chung Stanford, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1959AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy is the gold standard for the extirpative treatment of clinical T1a renal tumors. The benefits of nephron sparing approaches are numerous, but the risk of nephron sparing procedures includes a higher complication rate than that of radical nephrectomy. Analysis of complications of partial nephrectomy have been not previously been examined with the Expanded Accordion Severity Grading System (EASGS), a more stringent method to better stratify complications and their severity (Table). We sought to define the incidence of overall and severe complications after partial nephrectomy based on the EASGS, and identify the preoperative and operative risk factors for the development of complications. Expanded Accordion Severity Classification Grade 1 Mild complication Rrequires only bedside minor invasive procedures, or medications such as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. Grade 2 Moderate complication Requires pharmacologic treatment other than those allowed for minor complications, or blood transfusion, or total parenteral nutrition Grade 3 Severe complication Requires endoscopic, interventional procedure, or reoperation without general anesthesia Grade 4 Severe complication Requires operation under general anesthesia Grade 5 Severe complication Organ system failure Grade 6 Death Postoperative death METHODS A prospectively maintained retrospective database of all nephrectomies at our institution identified 251 partial nephrectomy procedures performed by any approach from 2000 to 2011. Severity of complications was graded using EASGS, which ranges on a scale from 1-6. Univariable and multivariable analyses were performed using all pre-operative and operative variables for likelihood of post-operative overall morbidity (Grades 1-6) or severe morbidity (Grades 3-6). RESULTS Of the complications, 52.5% were grade 1, 22.1% were grade 2, 15.6% were grade 3, 8.2% were grade 4, 0.4% were grade 5, and 0.4% were grade 6. On multivariable analysis, R.E.N.A.L nephrometry score (OR 1.742, 95% CI 1.32-2.28 for overall, OR 2.185 95% CI 1.51-3.15 for severe) and multiple renal arteries (OR 2.822, 95% CI 1.09-7.24 for overall, OR 4.191, 95% CI 1.54-12.54 for severe) were significant predictors of both overall and severe morbidities. Higher BMI (OR 1.057, 95% CI 1.001-1.117) predicted higher overall morbidity, while presence of a solitary kidney was a significant predictor of severe morbidity (OR 7.097, 95% CI 1.32-37.94). More recent year of surgery (OR 0.304, 95% CI 0.119-0.777) predicted for decreased overall complications. Age, sex, race, multiple tumors, smoking status, side, surgical approach, BMI, ASA score, tumor size, blood loss, operative time, preoperative serum creatinine, warm ischemia time, prior abdominal surgery, and collecting system entry did not predict for overall or severe complications. CONCLUSIONS When subjected to the more stringent EASGS, various factors predict for both overall and severe complications. These data can help stratify patients preoperatively when counseling them about the attendant risks of partial nephrectomy. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e747-e748 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Seung Jeon Seoul, Korea, Republic of More articles by this author Tin Ngo Stanford, CA More articles by this author Alan Thong Stanford, CA More articles by this author John Leppert Stanford, CA More articles by this author Benjamin Chung Stanford, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

587 DIFFERENTIATION OF NON CLEAR RENAL CELL CARCINOMA FROM CLEAR CELL RENAL CELL CARCINOMA USING CT WASHOUT FORMULA A RETROSPECTIVE STUDY

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging I1 Apr 2012587 DIFFERENTIATION OF NON CLEAR RENAL CELL CARCINOMA FROM CLEAR CELL RENAL CELL CARCINOMA USING CT WASHOUT FORMULA A RETROSPECTIVE STUDY Ryan P. Kopp, Lejla Aganovic, Kerrin L. Palazzi, and Ithaar H. Derweesh Ryan P. KoppRyan P. Kopp San Diego, CA More articles by this author , Lejla AganovicLejla Aganovic San Diego, CA More articles by this author , Kerrin L. PalazziKerrin L. Palazzi San Diego, CA More articles by this author , and Ithaar H. DerweeshIthaar H. Derweesh San Diego, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.663AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal tumor subtypes are distinct biological entities. Emerging data describe differential patterns of contrast enhancement for different renal neoplasms. We investigated the utility of application of contrast washout formula to predict renal tumor histology after 4−phase computerized tomography (CT). METHODS Two center retrospective cohort study of 163 patients with 4−phase CT for renal masses obtained 10/2002 to 7/2011. Pathology confirmed clear cell (CC−RCC; n=92), papillary (Pa−RCC; n=43), chromophobe (Ch−RCC; n=6), oncocytoma (OC; n=11), or angiomyolipoma (AML; n=11) histology. Demographics, comorbidities, disease characteristics, and preoperative creatinine were recorded. Imaging was interpreted by a radiologist (LA) who recorded tumor size, density measurements in Hounsfield Units (HU), composition, collecting system entry, necrosis, and cystic components. Data were analyzed within subgroups based on histology. Washout was calculated by the formula (Mass Nephrographic HU − Mass Delayed HU)/(Mass Nephrographic HU − Mass Noncontrast HU) and used to calculate sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS Significant differences existed in age (p<0.001), sex (P<0.001), history of diabetes (p=0.005), and preoperative creatinine (p=0.008) between histological subgroups. Tumor size was largest among CC−RCC and smallest among AML (p<0.001). Homogeneous composition was more common among Pa−RCC and Ch−RCC (p<0.001). Overall 25 (15.3%) of tumors had washout <0. Tumors with washout value <0 were Pa−RCC 24/43 (56%), and Ch−RCC 1/6 (14%). No patients with CC-RR, OC, or AML had washout value <0. Washout value <0 had a specificity of 99.2% for Pa−RCC and 100% for non−CC−RCC. Washout value ≥0 had a sensitivity and NPV of 100% for CC−RCC, OC, and AML. Washout value ≥0 had a specificity of 35.2% and a PPV of 66.7% for CC-RCC. CONCLUSIONS Washout value <0 is highly specific for Pa−RCC and non−CC−RCC. Washout value ≥0 is highly sensitive for CC−RCC, OC, and AML. These findings may provide a further tool for clinical decision making and risk stratification. Additional prospective analysis is warranted. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e239-e240 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan P. Kopp San Diego, CA More articles by this author Lejla Aganovic San Diego, CA More articles by this author Kerrin L. Palazzi San Diego, CA More articles by this author Ithaar H. Derweesh San Diego, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1434 IDENTIFYING COLLECTING SYSTEM ENTRY AND THE INTEGRITY OF REPAIR DURING OPEN PARTIAL NEPHRECTOMY: COMPARISON OF TWO TECHNIQUES

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 20121434 IDENTIFYING COLLECTING SYSTEM ENTRY AND THE INTEGRITY OF REPAIR DURING OPEN PARTIAL NEPHRECTOMY: COMPARISON OF TWO TECHNIQUES Sammy Moussly, Sandhya R. Rao, Michelle Pacheco, Philippe E. Spiess, and Wade J. Sexton Sammy MousslySammy Moussly TAMPA, FL More articles by this author , Sandhya R. RaoSandhya R. Rao TAMPA, FL More articles by this author , Michelle PachecoMichelle Pacheco TAMPA, FL More articles by this author , Philippe E. SpiessPhilippe E. Spiess TAMPA, FL More articles by this author , and Wade J. SextonWade J. Sexton TAMPA, FL More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1907AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephron sparing surgery is the current treatment standard for most small renal masses. The resection of deeply endophytic tumors often entails entry into the collecting system which if not recognized and repaired may lead to the development of a postoperative urinary fistula. Some investigators advocate the placement of an externalized ureteral catheter with retrograde dye injection to recognize calyceal entry and/or to test the integrity of the repair whereas others use needle injection of dye directly into the proximal ureter. This study compares the two techniques with regard to perioperative outcomes. METHODS We retrospectively reviewed the records of 259 consecutive patients who underwent open partial nephrectomy from 2005 to 2010. Patients undergoing laparoscopic or robotic assisted partial nephrectomy were not included in the review. Externalized ureteral catheters were placed preoperatively in 110 patients (Group 1) and needle injection of methylene blue was used in 120 patients (Group 2). No assessment of collecting system integrity was performed in 29 patients (Group 3). We compared intraoperative parameters including tumor size, EBL, ischemia time, operative time, recognized entry into the collecting system as well as the incidence of postoperative urinary leaks. RESULTS The average tumor size was 3.1 cm in Group 1, 3.6 cm in Group 2 and 3.8 cm in Group 3 (p=0.04 between groups 1 and 2); mean EBL was 320 cc, 351 cc and 376 cc (p =0.5); mean warm ischemia time was 19.6 mins, 27 mins and 22.5 mins (p<0.001); mean operative time was 193.5 mins, 221 mins and 290 mins (p<0.001); and the mean hospital stay was 5 days in each of the groups. Collecting system entry was recognized in 69 cases (63%) in Group 1 compared to 91 (76%) in Group 2 and 11 (38%) in Group 3 (p=0.07). Postoperative urine leak requiring any form of management (prolonged JP drain, JJ stent, Foley catheter) occurred in 11 patients from group 1 and 6 from group 2. (p=0.07). None of the patients in group 3 developed a urinary leak. CONCLUSIONS The perioperative leak rate in patients undergoing partial nephrectomy is unaffected by the intraoperative technique of identifying calyceal entry and the integrity of subsequent collecting system repair. Postoperative urine leaks are uncommon (6.6% in this series) despite recognized entry into the collecting system in the majority of patients (66%, 171 of 259). © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e582 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sammy Moussly TAMPA, FL More articles by this author Sandhya R. Rao TAMPA, FL More articles by this author Michelle Pacheco TAMPA, FL More articles by this author Philippe E. Spiess TAMPA, FL More articles by this author Wade J. Sexton TAMPA, FL More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hand-Assisted Laparoscopic Partial Nephrectomy Without Formal Collecting System Closure: Perioperative Outcomes in 104 Consecutive Patients

Laparoscopic partial nephrectomy (LPN) paralleling open techniques, particularly closure of the collecting system, can be technically challenging for the novice laparoscopist. We describe operative results and complications of a single surgeon, retrospectively reviewed series using a simplified method of hand assistance and a fibrin glue patch for hemostasis without formal collecting system closure. We identified 104 consecutive patients between September 2003 and January 2009 who underwent hand-assisted laparoscopic partial nephrectomy (HALPN). Our technique involves routine hilar clamping after isolation of the tumor and mobilization of the kidney. After resection of the mass, a fibrin glue patch is placed within the surgical defect and secured with bolstering sutures. No attempt is made to suture the collecting system, nor are ureteral catheters placed when the collecting system is entered during resection of the tumor. Mean tumor size was 2.8 cm (median 2.5 cm, range 0.7-7.0 cm). With hilar clamping, warm ischemia time averaged 24.5 minutes (range 11-39 min). Estimated blood loss averaged 220 mL (range 50-1500 mL), and five (4.8%) patients received transfusions either intraoperatively or postoperatively. Urine leak occurred in 1.9% (n=2) of patients overall and 4.3% (2/47) of patients with documented collecting system entry. Both urine leaks resolved with conservative management only. HALPN without formal collecting system closure is a safe and effective technique with similar urine leak and transfusion rates compared with other series. This technique may allow more urologists to perform minimally invasive partial nephrectomy or to do so with potentially shorter ischemia times.

Routine Drain Placement After Partial Nephrectomy is Not Always Necessary

To our knowledge the benefit of routine drainage after partial nephrectomy has never been investigated, although a drain after partial nephrectomy can be associated with morbidity. We report our initial experience with omitting the drain in select cases of superficial renal cortical tumors. From a surgery database we identified 512 consecutive open partial nephrectomies performed by a single surgeon between January 2005 and May 2009 using standardized technique. The study group included 75 evaluable patients (14.6%) who did not have a drain placed. Clinical data, surgical information, histological type and postoperative complications within 90 days of the procedure using the modified Clavien system were included in analysis. Median patient age was 64 years (IQR 49, 70) and 56.8% of the patients were male. Median tumor size was 2.0 cm (IQR 1.5, 3.0) and more than 70% were malignant. A total of 38 patients (50.7%) underwent renal artery clamping and cold ischemia with a median clamp time of 30 minutes. The overall complication rate was 13.3% (10 patients). In 4 patients (5.3%) complications were related to an absent drain, including grade I urinary leak, grade II perirenal collection, grade III urinoma requiring percutaneous drainage and grade III urinary leak with urosepsis, respectively. No deaths occurred in this cohort. Omitting drainage after partial nephrectomy in a select group of patients without collecting system entry is feasible and safe. The decision to place a drain after partial nephrectomy for small renal cortical tumors must be made intraoperatively and should be tailored to each case.

700 HIGHER R.E.N.A.L. NEPHROMETRY SCORE IS PREDICTIVE OF LONGER WARM ISCHEMIA TIME AND COLLECTING SYSTEM ENTRY DURING LAPAROSCOPIC AND ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging1 Apr 2011700 HIGHER R.E.N.A.L. NEPHROMETRY SCORE IS PREDICTIVE OF LONGER WARM ISCHEMIA TIME AND COLLECTING SYSTEM ENTRY DURING LAPAROSCOPIC AND ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY Wesley A. Mayer, Guilherme Godoy, Judy M. Choi, Alvin C. Goh, Shelly X. Bian, and Richard E. Link Wesley A. MayerWesley A. Mayer Houston, TX More articles by this author , Guilherme GodoyGuilherme Godoy Houston, TX More articles by this author , Judy M. ChoiJudy M. Choi Houston, TX More articles by this author , Alvin C. GohAlvin C. Goh Houston, TX More articles by this author , Shelly X. BianShelly X. Bian Houston, TX More articles by this author , and Richard E. LinkRichard E. Link Houston, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1667AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The RENAL Nephrometry Score (NS) was proposed as a system to describe and quantify the most surgically relevant anatomical features of solid renal masses and to provide a means to compare surgical series (Kutikov and Uzzo, J Urol, Sept 2009). Interest in NS has grown rapidly with over 15 accepted abstracts and 2 peer-reviewed publications examining the scoring system. We report the largest series to date investigating the predictive value of nephrometry score on operative outcomes during laparoscopic (LPN) and robotic-assisted partial nephrectomy (RPN). METHODS We performed a retrospective review of 67 consecutive patients with suspicious renal lesions and available NSs who underwent LPN or RPN from February 2008 to August 2010 by a single surgeon. Data included operative type, BMI, gender, age, and side of tumor. NSs were recorded using either magnetic resonance imaging or computed tomography as previously described. Operative type was classified as either RPN with enucleation, RPN by standard resection, and LPN by standard resection. Warm ischemia time (WIT), estimated blood loss (EBL), and collecting system entry (CSE) were the endpoints for the analyses. Besides comparisons of continuous variables (WIT and EBL) and proportion of CSE, we used linear and logistic regression models for analyses. RESULTS Total NS used either as a numerical or categorical variable (< 7 or ≥7), the “R” score, and the “N” score were independent predictors of WIT after controlling for operative type, BMI, age, laterality, and gender (p < 0.001, p = 0.001, p = 0.026, and p <0.01, respectively). There was no significant difference in the median WIT between the “N” scores N=2 and N=3. The “N” score was predictive of CSE in univariate analysis (p < 0.001). The total NS coded either as a numerical or categorical variable was also an independent predictor of CSE after controlling for operative type (p < 0.001 and p < 0.001, respectively). None of the individual parameters of the NS nor the total NS were predictive of EBL. There was only 1 positive margin in a patient with a NS of 7xh. CONCLUSIONS Total nephrometry score (either as a numerical value or using a cutoff of “7”) as well as the “N” score were independent predictors of both longer warm ischemia time and collecting system entry during LPN and RPN. The “R” score was also an independent predictor of longer warm ischemia time. The nephrometry score and its individual components may be useful in the preoperative evaluation and counseling of patients undergoing LPN or RPN. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e281-e282 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wesley A. Mayer Houston, TX More articles by this author Guilherme Godoy Houston, TX More articles by this author Judy M. Choi Houston, TX More articles by this author Alvin C. Goh Houston, TX More articles by this author Shelly X. Bian Houston, TX More articles by this author Richard E. Link Houston, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urinary fistulae after partial nephrectomy

To report the risk factors and natural history of urinary fistula (UF) after partial nephrectomy (PN), as their incidence has been reported to be 3-6% in large series of PN but there are few reports of the risk factors associated with the development of UF after PN, and the natural history of UF in a large group of patients. This was a retrospective review of 1118 PN at one tertiary-care institution. Most patients had a drain placed in the perinephric space after surgery. Fifty-two patients were identified as having a UF if they had persistent flank drainage for >14 days after surgery, or presented with evidence of a UF after the drain had been removed. Risk factors for development and the course of the UF are reported. Fifty-two patients developed a UF after PN (4.4%, 95% confidence interval, CI, 3.5-6.1%) The rate of a persistent urine leak (defined as drain fluid consistent with urine for >2 weeks after surgery) was 4.0 (95% CI 2.9-5.3)%. The overall rate of delayed UF presentation was only 0.4 (0.09-0.9)%. Patients who developed a UF had larger tumours (3.5 vs 2.6 cm, P= 0.03), a higher estimated blood loss (400 vs 300 mL, P < 0.001), and longer ischaemia time (50 vs 39 min, P < 0.001) than patients who did not develop a UF. Differences in tumour histology, laterality, multifocality, type of surgery (laparoscopic vs open), and intraoperative collecting system entry were not statistically different in patients who did or did not develop a UF. Patients with tumours of >2.5 cm were twice as likely to develop a UF than patients with tumours of <2.5 cm (P= 0.02). Most patients were managed conservatively with a percutaneous drain until the UF resolved, if they were asymptomatic. Overall, in 36 patients (69%) the fistula resolved with no intervention, while 16 (31%) required intervention. Stenting was the commonest intervention (15%). No patient required re-operative open surgery. The rate of development of UF after PN is low. Tumour size, blood loss and ischaemia time were all associated with the development of a UF. In most patients with a urine leak immediately after surgery the UF will resolve with no intervention, and can be managed conservatively with patience, in the absence of clinical symptoms.

Robot Assisted Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Tumors: A Multi-Institutional Analysis of Perioperative Outcomes

Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

Comparison of Intraoperative Parameters and Perioperative Complications of Retroperitoneal and Transperitoneal Approaches to Laparoscopic Partial Nephrectomy: Support for a Retroperitoneal Approach in Selected Patients

Retroperitoneal laparoscopy (RP) may have some intrinsic advantages over transperitoneal laparoscopy (TP) in certain patients undergoing partial nephrectomy. We reviewed our experience with RP and TP partial nephrectomy to identify differences in intraoperative and postoperative parameters. The records of 72 patients (45 TP, 27 RP) undergoing laparoscopic partial nephrectomy without hand assistance between January 2003 and August 2005 were reviewed. The two groups were similar demographically; tumors were smaller in RP patients (2.1 v 2.7 cm; P = 0.03), and the RP approach was used more frequently on right kidneys (70.4% v 37.8%; P = 0.01). The operative time (mean 160 v 192 minutes; P = 0.008) and length of stay (LOS; median 1.0 days [range 1-10 days] v 2.0 days [range 1-64 days]; P = 0.001) were shorter in RP patients. Rates of collecting system entry (22% v 38%), positive-margin rate (0% v 6.7%; P = 0.29), and complications (19% v 22%; P = 0.77) were similar in RP and TP patients. Hemorrhage was the most common complication in both groups. Bowel-related complications occurred in three TP patients, but in no RP patients. Overall, the median estimated blood loss (EBL) was lower in RP patients (100 mL [range 25-3500 mL] v 225 mL [range 25-1900 mL]; P = 0.06). Among patients with complications, EBL was similar in both groups (median 325 mL [50-1500 mL] v 200 mL [50-3500 mL] for RP and TP; P = 0.86). The RP approach reduces operative time, LOS, and some types of complications without compromising the quality of tumor resection. Complications in the retroperitoneal space are not associated with higher EBL. Anatomic considerations and surgeon experience may improve outcomes.