Complex Renal Tumors Research Articles

412 Outcomes of robot-assisted partial nephrectomy in patients with complex renal tumours and pre-existing chronic kidney disease in a multi-institutional, multinational database

412 Outcomes of robot-assisted partial nephrectomy in patients with complex renal tumours and pre-existing chronic kidney disease in a multi-institutional, multinational database

V3 Is laparoscopic partial nephrectomy feasible in complex renal tumours?

V3 Is laparoscopic partial nephrectomy feasible in complex renal tumours?

Hemorrhagic complications of robot-assisted laparoscopic partial nephrectomy for renal masses.

621 Background: Partial nephrectomy is the current standard of care for T1a tumors. With advances in laparoscopy and robotic-assisted surgery, RPNx is increasingly being performed for complex renal tumors. However, significant hemorrhagic complications can occur. We review hemorrhagic complications following RPNx. Methods: At our institution 111 RPNx were performed on 110 patients (2011-2015). Demographic data and Nephrometry scores were determined. Total operating time, intraoperative blood loss, postoperative blood transfusion rate, gross hematuria, need for further procedures and mortality were collected. Pathology, including histologic diagnosis, and margin status was recorded. Results: Of 111 RPNx, 110 were done for renal masses and 112 masses were removed. Of these, 77% were malignant and most common commonly Renal Cell Carcinoma, Clear Cell pT1a (51%). Mean operative time was 245 minutes (SD 68), mean blood loss was 297 mL (SD 68), and average length of stay was 2.8 days. Hemorrhagic complications occurred in 21 patients (19%). Five had hematuria and 16 received a transfusion. Four patients required interventional radiology (IR) for angioembolization. Two patients died, one from hemorrhagic complications, and the other from septic shock related to a bowel injury. The most common Nephrometery score was 4a followed by 5a. Of those with hemorrhagic complications the most common Nephrometery score was 8, with 60% being 7 or higher. Among patients needing IR, 75% were 6 or higher and the one patient who died had a score of 11a in the setting of bilateral renal masses. Patients with hemorrhagic complications had a change in hemoglobin and hematocrit from per- to post-operation of 3.06 g/dL and 9.07% respectively compared to 2.34 g/dL and 6.28% for patients with no hemorrhagic complications. Conclusions: RPNx is a safe and nephron-sparing surgery for patients with appropriate renal masses. Significant hemorrhagic complications can occur, commonly managed with blood transfusions or angioembolization. However, catastrophic bleeding can occur in patients with high Nephrometry scores and monitoring in the ICU setting is recommended in high-risk patients.

Robot-assisted partial nephrectomy for complex renal masses.

To determine whether the approach for partial nephrectomy is influenced by tumor complexity and if the introduction of robotic techniques has allowed us to treat more complex tumors minimally invasively. Data from 292 patients who underwent partial nephrectomy for renal masses from November 1999 to July 2013 at a tertiary referral center were retrospectively reviewed. Nephrometry scores and perioperative outcomes were stratified based on when robotic techniques were introduced. Mean follow-up time was 2.6years. Preoperative RENAL nephrometry scores and perioperative outcomes were analyzed. Of the 292 patients, 31.5% underwent robot-assisted partial nephrectomy, 46.2% laparoscopic partial nephrectomy and 22.9% open partial nephrectomy. Robot-assisted partial nephrectomy mean nephrometry score was significantly higher than laparoscopic and equivalent to open. Significant perioperative differences were estimated blood loss (p=0.0001), length of stay (p=0.0001) and Clavien score (p=0.0069), all favoring robot-assisted partial nephrectomy. Limitations include retrospective design and single center data. Robot-assisted partial nephrectomy is a safe and effective surgical modality that allows for complex renal tumors that were previously reserved for open partial nephrectomy in the pure laparoscopic era to be managed with a minimally invasive approach.

Mini-flank incision for open partial nephrectomy for renal tumor with Zhongshan score≥8

Objective To evaluate the effect and feasibility of mini-flank approach for open partial nephrectomy (MI-OPN) in complex renal tumors with high Zhongshan Score(ZS Score ≥8). Methods Between January 2012 and December 2014, the data from 25 patients with renal tumors, including 18 male and 7 female patients, were retrospectively reviewed.The average age was 50.2 years(range 26-75 years)and the average body mass index was 24.5 kg/m2(range 21.3-30.1 kg/m2). The initial symptom included asymptom in 17 cases, hematuria in 6 cases and other presentation in 2 cases.Bilateral renal tumors were found in 4 cases.Fifteen cases suffered with contralateral urinary stone, renal cyst or hydronephrosis.The preoperative serum creatinine level was 76.9 μmol/L(range 47-132 μmol/L) and the preoperative estimated glomerular filtration rate (eGFR) was 103.8 ml/(min·1.73 m2)(range 36.5-173.9). The ZS Score was 8 in 11 cases, 9 in 3 cases, 10 in 5 cases, 11 in 2 cases, 12 in 2 cases, and 13 in 2 cases.Mean maximum tumor size was 4.9 cm (range 2.5-8.1 cm) in CT scan.The average length of incision was 8.0 cm(7.5-10.0 cm). During the operation, the mass and around normal renal tissue were exposed after opening the Gerota fascia.Along the dorsal of kidney, the renal artery was dissected and clamped.Then, the mass was completely removed along margin of 0.5-1.0 cm normal renal tissue.The vascular end was closed by 3-0 absorbable suture.The entire wound of kidney was U shaped closed by 2-0 absorbable suture.The operative time, ischemia time, estimate blood loss, pathology parameters, operative and short-term (2-3 months) postoperative complications were recorded.Renal function was recorded 2-3 months after operation. Results MI-OPN was successfully performed in 23 cases.Radical nephrectomy was performed in 1 cases due to the tumor invasion into the renal pelvis and ureteropelvic junction.Another radical nephrectomy was performed for suspection of positive margin.Mean operative time was 100.2 min(range 75-150 min), mean warm ischemia time was 28.3 min(range 21-39 min) and mean estimated blood loss was 63.6 ml(range 10-400 ml). Only 1 case accepted blood transfusion.Mean postoperative hospital stay was 6.6 days (range 5-9 days). Postoperative complications were found in 1 patient, who was found the fluid in surgical region and relieved after the drainage. The pathological diagnosis included clear cell carcinoma in 21 cases, papillary carcinoma in 3 cases and chromophobe cell tumor in 1 case. The mean postoperative serum creatinine level was 88.9 μmol/L(range 61-189 μmol/L) and the mean postoperative eGFR was 86.3 ml/(min·1.73 m2)(range 34.0-149.6). There was significant difference between pre and postoperative renal function (P<0.01). During the average follow-up period of 13.7 months (range 6-24 months), no local recurrence or metastasis occurred. Conclusion MI-OPN is an innovation of traditional OPN and suitable for the complex renal tumors with high ZS score. Key words: Kidney neoplasms; Nephron sparing surgery; Mini-incision; Zhongshan score

ZIRK-Technique: Zero Ischemia Resection in the Kidney for High-Risk Renal Masses: Perioperative Outcome

Objectives: This study evaluates the feasibility and safety of open-partial nephrectomies in the ZIRK-technique (Zero Ischemia Resection in the Kidney) for renal masses with high-risk anatomical features - objectified by the PADUA score. Methods: We identified 40 consecutive cases of partial nephrectomies performed without clamping of the renal artery in our department of urology. Retrospective analysis of the preoperative CT or MRI scans showed 27 cases with a PADUA score ≥8, of which 15 cases had a score ≥10. Cases were in particular assessed regarding operation time (ORT), estimated blood loss (EBL), surgical margins and postoperative complications using the Clavien classification. Results: The mean age of the study population was 67.6 years with an average BMI of 26.8 kg/m². The mean ORT was 1:46 with an average EBL of 521 ml. Clavien grade II complications were observed seven times, while 3 patients had a grade IIIa complication. Despite complex and adverse location of the tumors, nephron-sparing surgery without ischemia could be performed with negative surgical margins for all cases. EBL, transfusion rate and complication were considerably more frequent in high-risk tumors. Conclusion: Highly complex renal tumors, PADUA ≥10, can be resected in ZIRK-technique with good operative outcome and a low complication rate.

Simple enucleation for the treatment of highly complex renal tumors: Perioperative, functional and oncological results

AimTo assess the role of simple enucleation (SE) for the treatment of highly complex renal tumors. MethodsOverall, 96 Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score 10 to 13 renal tumors were treated with SE at our institution. All conventional perioperative variables, surgical, functional and oncological results were gathered in a prospectively maintained database. Survival curves were generated using a Kaplan–Meier method. Univariate analysis assessed the outcome differences. ResultsMean (±1s.d.) clinical tumor diameter was 4.8 (±1.6 cm). 70.8% of patients had ≥cT1b stage. The PADUA score was recorded as 10, 11, 12 and 13 in 57.3%, 29.2%, 11.5%, and 2.1% of tumors respectively. Overall, 76 patients were treated with an open approach and 20 robotically. Mean warm ischemia time (WIT) was 19.2 min, and WIT greater than 25 min occurred in 14.6% of cases. Positive surgical margin (PSM) rate was 3.6% and trifecta was achieved in 64.3% of patients. Postoperative surgical complications occurred in 24% of patients, with 14.6% Clavien-Dindo grade 1–2, 8.3% grade 3, and 1% grade 4. Five-year cancer specific survival (CSS), recurrent free survival (RFS), and overall survival (OS) rates resulted 96.1%, 90.8% and 88.0%, respectively. Overall, 4.2% of patients experienced progressive disease. At follow-up, the mean decrease of eGFR from preoperative value was 13.9 ml/min. This was not significantly correlated with PADUA score (p = 0.69). The surgical approach was neither a predictor of Trifecta outcome, nor of postoperative complications, WIT >25 min or PSM rate. ConclusionsSE is an effective treatment for highly-complex renal tumors, with a potential key role to widen the NSS (nephron sparing surgery) indications according to guidelines.

Mini-flank supra-12th rib incision for open partial nephrectomy for renal tumor with RENAL nephrometry score ≥10: an innovation of traditional open surgery.

The skill of supra-12th rib mini-flank approach for open partial nephrectomy (MI-OPN) provides an advanced operative method for renal tumor. Compared with laparoscopic and robotic surgery, it may be a feasible selection for the complex renal tumors. We describe our techniques and results of MI-OPN in complex renal tumors with high RENAL nephrometry score (RENAL nephrometry score ≥10).Fifty-five patients diagnosed with renal tumors between January 2009 and July 2013 were included in this study. Eligibility criteria comprised of patients with complex renal tumor (RENAL score ≥10) being candidates for partial nephrectomy (PN). All patients received MI-OPN and all surgeries were performed by a single urologist. The preoperative workup comprised of medical history, physical examination, and routine laboratory tests. Serum creatinine was recorded preoperatively and 2 to 3 months after operation. Operative time, ischemia time, blood loss, operative and postoperative complications, renal function, and pathology parameters were recorded.MI-OPN was successfully performed in all cases. Mean tumor size was 4.7 cm (range: 2.5–8.1). Mean warm ischemia time was 28.1 minutes (range: 21–39), mean operative time was 105minutes (range: 70–150) and mean estimated blood loss was 68 mL (range: 10–400). Mean postoperative hospital stay was 6.5 days (range: 5–12). Postoperative complications were found in 3 patients (5.5%). The mean pre- and postoperative serum creatinine levels were 76.2 μmol/L (range: 47–132) and 87.1 μmol/L (range: 61–189) with significant difference (P = 0.004). The mean pre- and postoperative estimated glomerular filtration rate (eGFR) were 91.5 (range: 34–133) and 82.5 (range: 22–126.5), respectively with significant difference (P = 0.024). In an average follow-up of 19.9 months (range: 8–50), no local recurrence or systemic progression occurred.In conclusion, MI-OPN can combine the benefits of both minimal invasive and traditional open partial nephrectomy (OPN) techniques with a smaller incision. It is an innovation of traditional OPN and suitable for the complex renal tumors with high RENAL nephrometry score safely and effectively.

MP57-09 COMPARISON OF THE OPEN AND ROBOTIC APPROACH IN PARTIAL NEPHRECTOMY FOR HIGHLY COMPLEX TUMORS (RENAL NEPHROMETRY SCORE ≥ 10)

You have accessJournal of UrologyKidney Cancer: Surgical Therapy II1 Apr 2015MP57-09 COMPARISON OF THE OPEN AND ROBOTIC APPROACH IN PARTIAL NEPHRECTOMY FOR HIGHLY COMPLEX TUMORS (RENAL NEPHROMETRY SCORE ≥ 10) Benoit Peyronnet, Tarek Fardoun, Thibaut Benoit, Mathieu Roumiguie, Gregory Verhoest, Jean-Baptiste Beauval, Michel Soulie, Nicolas Doumerc, and Karim Bensalah Benoit PeyronnetBenoit Peyronnet More articles by this author , Tarek FardounTarek Fardoun More articles by this author , Thibaut BenoitThibaut Benoit More articles by this author , Mathieu RoumiguieMathieu Roumiguie More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , Jean-Baptiste BeauvalJean-Baptiste Beauval More articles by this author , Michel SoulieMichel Soulie More articles by this author , Nicolas DoumercNicolas Doumerc More articles by this author , and Karim BensalahKarim Bensalah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1997AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the past few years, the robot-assisted approach has been increasingly used for partial nephrectomy (PN). However, as PN for complex tumors (RENAL SCORE ≥ 10) is considered technically challenging, the outcomes of robotic PN (RPN) for these tumors have rarely been reported and have never been compared to those of open PN (OPN). The objective of this study was to compare the outcomes of RPN and OPN for highly complex renal tumors. METHODS All patients with highly complex renal masses (RENAL SCORE ≥ 10) treated by PN between 2006 and 2013 in two academic departments were included retrospectively. Pure laparoscopic PN (LPN) were excluded. Perioperative data (surgeon's experience, tumor size, RENAL SCORE, warm ischemia time, complications, positive margins,…) were compared between the RPN and OPN groups using the χ2 test for categorical variables and student test or Mann-Whitney test for quantitative variables. RESULTS After excluding 3 LPN, 70 patients were included: 27 in the OPN group and 43 in the RPN group. Tumor size (52 vs. 52.9 mm; p = 0.85) was comparable between groups but surgeons were more experienced in the RPN group (> 50 cases: 18.5% vs. 46.5%; p <0.0001). Renal cooling was never used in the robotic group but was used in 70% of the cases during open surgery. The robotic approach was associated with a reduction in warm ischemia time (25.5 vs 17.6 min; p = 0.002) which could be due to a larger use of the early unclamping technique (26 % vs. 88 %; p<0.0001) The length of stay was also shorter in the RPN group (11.4 vs. 5.1 days; p <0.0001). In contrast, estimated blood loss was greater in the RPN group (293 vs 674mL; p = 0.009) but with no impact on the complication rate (33% vs. 21%; p = 0.25) or transfusion rate (19% vs. 12%; p = 0.42). CONCLUSIONS The robotic approach in PN for highly complex renal tumors could decrease warm ischemia time and length of stay compared to its open counterpart. However RPN is associated with higher blood loss but with no impact on complication rate and transfusion rate. Open PN N=27 Robotic PN N=43 p-value tumor size (mm) 52 53 0.85 RENAL SCORE 10.4 10.4 0.55 surgeon's experience > 50 cases 18% 47% < 0.0001 estimated blood loss (ml) 293 694 0.009 warm ischemia time 25.5 17.6 0.002 complications 33% 21% 0.25 transfusions 19% 12% 0.42 positive surgical margins 0% 5% 0.28 length of stay 11.4 5.1 < 0.0001 early unclamping 26% 88% < 0.0001 © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e693 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Tarek Fardoun More articles by this author Thibaut Benoit More articles by this author Mathieu Roumiguie More articles by this author Gregory Verhoest More articles by this author Jean-Baptiste Beauval More articles by this author Michel Soulie More articles by this author Nicolas Doumerc More articles by this author Karim Bensalah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Surgery-related outcomes and postoperative split renal function by scintigraphy evaluation in robot-assisted partial nephrectomy in complex renal tumors: an initial case series.

To assess surgery-related outcomes and split renal function evaluated by renal scintigraphy in robot-assisted partial nephrectomy (RPN) through the comparison between low and intermediate or highly complex renal tumors. In the initial 39 consecutive RPNs performed for solid renal tumors in our hospital, tumors were categorized for their complexity (low, intermediate, and high risk for partial nephrectomy) by R.E.N.A.L. (radius; exophytic/endophytic; nearness; anterior/posterior; location) nephrometry and P.A.D.U.A. (preoperative aspects and dimensions used for an anatomic) scores. The comparison between low, intermediate, and highly complex tumors according to these scoring systems were performed regarding preoperative factors, surgery-related factors, and postoperative renal function factors (split renal function at 3 months and serum creatinine level and estimated glomerular filtration rate (eGFR) at 1 week, 1, 3, 6, and 12 months postoperatively,). There was no significant difference between low and intermediate or highly complex tumors for all the categories tested in preoperative data. Especially in split renal function, the changes in mercaptoacetyltriglycine (MAG3) effective renal plasma flow (ERPF) from preoperative data were -7.00±20.2 mL/min in low complexity in R.E.N.A.L. nephrometry and -14.1±22.7 mL/min in intermediate or highly complex tumors in R.E.N.A.L. nephrometry (p=0.477), -8.21±21.3 mL/min for low complexity in P.A.D.U.A. and -13.4±22.4 in intermediate or highly complex tumors in P.A.D.U.A. (P=0.607). There was either no significant difference in the decrease of renal function (serum creatinine level and eGFR), operative time, estimated blood loss, or warm ischemia time between low and intermediate or highly complex tumors as measured by both R.E.N.A.L. nephrometry and P.A.D.U.A. scores (P>0.05). Our data showed that RPN can be performed without compromising the outcome in surgery-related factors and postoperative split renal function even in intermediate or highly complex tumors. Further studies with a larger number of cases need to be performed to confirm these findings.

Une taille tumorale supérieure à 7 cm influence-t-elle les résultats de la néphrectomie partielle pour tumeur du rein ?

To assess the impact of a tumor size higher than 7cm on partial nephrectomy (PN) outcomes compared to a tumor size ranging between 4 and 7cm and to compare this impact to one of the RENAL score. Data from patients who underwent PN between 2006 and 2013 were retrospectively analysed. Patients with cT1b tumors and cT2 were included. Functional and oncological outcomes were compared. Analysis of the achievement of Trifecta (defined as a combination of warm ischemia time<25min, negative surgical margins and no perioperative complications) was performed according to the tumor size and the RENAL score. Among 334 PN, 57 patients were included, (41 cT1b and 16 cT2), with a median follow-up of 23.5 months (6-88). There was no difference between the groups regarding intraoperative parameters except for the conversion rate, which was higher in the cT2 group (30% vs. 4.3%; P=0.02). The cT2 group also presented higher renal function impairment at postoperative day 4 (P=0.04) which did not persist at 6 months. There was no significant difference in oncologic outcomes between the 2 groups. The rate of achievement of the Trifecta did not differ between cT1b and cT2 groups. Conversely, Trifecta rate was higher in case of low complexity renal masses (RENAL score 4-6) compared to complex renal tumors (RENAL score 7-9 and 10-12). Our results showed that a tumor size higher than 7cm had no impact on PN outcomes in selected tumors according to complexity scores such as the RENAL score. Furthermore, a lower RENAL score appeared to be significantly associated with the Trifecta achievement. 5.

Ex-vivo nephron-sparing surgery and autotransplantation for renal tumours: Revisited.

We studied the feasibility of ex-vivo nephron-sparing surgery and autotransplantation for complex renal tumours. We also studied the role of laparoscopy in these situations. All patients who underwent renal autotransplantation for renal tumour at our centre were included in this retrospective study. Patient profiles were recorded in detail. Operative and postoperative details were also recorded. Our series includes 3 patients. Two patients had complex renal cell carcinoma and 1 patient had bilateral large angiomyolipoma. In first 2 patients, laparoscopic approach was used for nephrectomy. Operative time for case 1, 2 and 3 was 5.5, 4.5, 8 (right side) and 6 (left side) hours, respectively. Cold ischemia time was 110, 90, 150 and 125 minutes, respectively. One patient required temporary postoperative hemodialysis. Ex-vivo nephron-sparing surgery and autotransplantation still remain a viable option for complex renal tumours. It offers satisfactory renal functional outcome with acceptable morbidity. The laparoscopic approach should be used whenever possible to reduce morbidity.

Early unclamping technique during robot‐assisted laparoscopic partial nephrectomy can minimise warm ischaemia without increasing morbidity

To compare perioperative outcomes of early unclamping (EUC) vs standard unclamping (SUC) during robot-assisted partial nephrectomy (RAPN), as early unclamping of the renal pedicle has been reported to decrease warm ischaemia time (WIT) during laparoscopic PN. A retrospective multi-institutional study was conducted at eight French academic centres between 2009 and 2013. Patients who underwent RAPN for a renal mass were included in the study. Patients without vascular clamping or for whom the decision to perform a radical nephrectomy was taken before unclamping were excluded. Perioperative outcomes were compared using the chi-squared and Fisher's exact tests for discrete variables and the Mann-Whitney test for continuous variables. Predictors of WIT and estimated blood loss (EBL) were assessed using multiple linear regression analysis. In all, there were 430 patients: 222 in the EUC group and 208 in the SUC group. Tumours were larger (35.8 vs 32.3 mm, P = 0.02) and more complex (R.E.N.A.L. nephrometry score 6.9 vs 6.1, P < 0.001) in the EUC group but surgeons were more experienced (>50 procedures 12.2% vs 1.4%, P < 0.001). The mean WIT was shorter (16.7 vs 22.3 min, P < 0.001) and EBL was higher (369.5 vs 240 mL, P = 0.001) in the EUC group with no significant difference in complications or transfusion rates. The results remained the same when analysing subgroups of complex renal tumours (R.E.N.A.L. nephrometry score ≥7) or RAPN performed by less experienced surgeons (<20 procedures). In multivariable analysis, EUC was predictive of decreased WIT (β -0.34; P < 0.001) but was not associated with EBL (β -0.09, P = 0.16). EUC can reduce WIT during RAPN without increasing morbidity even for complex renal tumours or when being performed by less experienced surgeons.

Robot-assisted partial nephrectomy: Excellent results even in more complex renal tumours

Robot-assisted partial nephrectomy: Excellent results even in more complex renal tumours

Warm ischemia time and postoperative complications after partial nephrectomy for renal cell carcinoma

ObjectiveTo evaluate the correlations between PADUA and RENAL scores, WIT and postoperative complications in a cohort of patients who underwent elective open or minimally invasive nephron sparing surgery for renal cell carcinoma. Materials and methodsWe analyzed 96 consecutive patients who underwent partial nephrectomy for renal cell carcinoma between 2004 and 2013 at our Institution. The Spearman test was used to compare categorical variables. For all statistical analyses, a two-sided p<.05 was considered statistically significant. ResultsThe median (IQR) PADUA score was 7 (7–8) and the median (IQR) RENAL score was 7 (6–8). The median (IQR) warm ischemia time was 14min (8–20). Low grade and high grade postoperative complications were found in 27 (28.1%) and 6 (6.3%) patients, respectively. PADUA risk group categories significantly correlated with WIT>20min and high grade postoperative complications, respectively (p=.04), regardless of the surgical approach. RENAL risk group categories significantly predicted longer hilar clamping time in our cohort (p=.04), but no statistically significant correlations with high grade postoperative complications were found. ConclusionsIn our retrospective series nephrometric scores demonstrated to significantly predict longer warm ischemia time and higher postoperative complications, especially in those patients with more challenging and complex renal tumors. Therefore, when planning to perform partial nephrectomy, urologists should widely use these comprehensive tools.

Tiempo de isquemia caliente y complicaciones postoperatorias después de la nefrectomía parcial por carcinoma de células renales

ObjectiveTo evaluate the correlations between PADUA and RENAL scores, WIT and postoperative complications in a cohort of patients who underwent elective open or minimally invasive nephron sparing surgery for renal cell carcinoma. Material and methodsWe analyzed 96 consecutive patients who underwent partial nephrectomy for renal cell carcinoma between 2004 and 2013 at our Institution. The Spearman test was used to compare categorical variables. For all statistical analyses, a two-sided P<.05 was considered statistically significant. ResultsThe median (IQR) PADUA score was 7 (7-8) and the median (IQR) RENAL score was 7 (6-8). The median (IQR) warm ischemia time was 14min (8-20). Low grade and high grade postoperative complications were found in 27 (28.1%) and 6 (6.3%) patients, respectively. PADUA risk group categories significantly correlated with WIT>20minutes and high grade postoperative complications, respectively (P=.04), regardless of the surgical approach. RENAL risk group categories significantly predicted longer hilar clamping time in our cohort (P=.04), but no statistically significant correlations with high grade postoperative complications were found. ConclusionsIn our retrospective series nephrometric scores demonstrated to significantly predict longer warm ischemia time and higher postoperative complications, especially in those patients with more challenging and complex renal tumors. Therefore, when planning to perform partial nephrectomy, urologists should widely use these comprehensive tools.

Off-Clamp Laparoscopic Partial Nephrectomy for Hilar Tumors: Oncologic and Renal Functional Outcomes

To present our experience demonstrating the feasibility of off-clamp laparoscopic partial nephrectomy (LPN) for hilar tumors and evaluate intermediate oncologic and renal functional outcomes. A retrospective review of LPN cases in nine patients was performed. Hilar lesions were defined as renal cortical tumors in direct physical contact with the renal artery, vein, or both as identified on preoperative imaging and confirmed intraoperatively. Although the renal hilum vasculature was isolated for possible clamping if needed, tumor extirpation was performed off-clamp, eliminating warm ischemia time (WIT). The clinicopathologic parameters, perioperative course, complications, and long-term oncologic and renal functional outcomes were analyzed. Nine patients underwent off-clamp LPN for complex hilar tumors. The mean age was 60.5 years, mean American Society of Anesthesiologists physical classification (ASA) score was 2, and mean BMI was 27.7 kg/m(2). The mean tumor size and volume were 3.2 cm and 35.8 cm(3), respectively. A greater proportion of the tumors (55.6%) were endophytic and mostly of clear cell histology (78%). The mean operative time was 131 minutes, estimated blood loss 250 cc, need for transfusion 0%, and complication rates 22%. No positive margins were present intraoperatively or on final pathology. After a median follow-up of 42.8 months, there was no evidence of clinical or radiographic recurrence in any patient. There was no change in the mean estimated glomerular filtration rate preoperatively and at a median follow-up of 32 months (97.2 mL/minute vs 81.3 mL/minute; p=0.052). Complex renal hilar tumors can be successfully managed with laparoscopic nephron-sparing surgery with elimination of WIT with preservation of perioperative, renal functional, and oncologic outcomes.

Comparison of two different renorrhaphy techniques in retroperitoneal laparoscopic partial nephrectomy for complex tumor

Background Partial nephrectomy is currently the standard treatment for clinical T1 renal neoplasms, as it can provide oncologic outcomes equivalent to radical nephrectomy. The aim was to evaluate the efficacy of self-retaining suture (SRS) in renorrhaphy technique in retroperitoneal laparoscopic partial nephrectomy (LPN) for a single renal mass of moderate or high complexity by assessing peri-operative outcomes. Methods A retrospective analysis was done of 64 patients between 2010 and 2012 for complex renal mass (RENAL score ≥7) in whom retroperitoneal LPN was performed with two layers using continuous knotless barbed suture (Quill PDO SRS group; n=34) and absorbable vicryl (non-SRS group; n=30), respectively. Cases were matched for RENAL score. All the surgical procedures were performed by the same surgeon with experience of more than 500 cases of LPN. Comparisons were made in patients and preoperative outcomes and peri-operative complications between SRS group and non-SRS group. Results Mean warm ischemia time (WIT) in SRS group was less than non-SRS group (18.0 vs. 24.8 minutes, P=0.021). Renorrhaphy suture cost in SRS group was lower than non-SRS group ($269.6 vs. $335.8, P=0.001). There were no significant differences between the two groups for postoperative changes in creatinine and estimated glomerular filtration rate and the rate of peri-operative complications. Conclusion SRS was safe for complex renal tumor with two layers, continuous and unknot suture, during LPN and would reduce the WIT and renorrhaphy suture cost significantly.

Robotic partial nephrectomy: A promising treatment option for T1b and complex renal tumors?

Robotic partial nephrectomy: A promising treatment option for T1b and complex renal tumors?

Does experience in creating a robot‐assisted partial nephrectomy (RAPN) programme in an academic centre impact outcomes or complication rate?

To evaluate the impact of increased experience in robot-assisted partial nephrectomy (RAPN) on perioperative and oncological outcomes To detail the complications encountered in establishing a RAPN programme at a tertiary referral centre and the factors associated with these complications. The initial consecutive 233 patients undergoing RAPN between March 2008 and May 2012 at our institution were identified. Patients were divided into quartiles to evaluate outcomes, and uni- and multivariate predictors of complications were calculated. In progressive quartiles, patients tended to have more complex renal tumours as evaluated by R.E.N.A.L. nephrometry (P < 0.01) or preoperative aspects and dimensions used for an anatomical classification (PADUA) scores (P = 0.003), and percentage endophytic (P = 0.01). Developing technique increased the patients undergoing unclamped PN (P < 0.01). The mean time in the operating room (from skin incision to closure) decreased significantly from 225 to 183 min (P < 0.01) and warm ischaemia time decreased from 28 to 15 min, when clamping (P < 0.01). Clavien graded complication rate (P = 0.26) and positive margin rate (P = 0.32) was unchanged by quartile. We show that increasing experience allows more complex tumours to be removed with similar outcomes in patients undergoing RAPN. The complication rates and perioperative outcomes were similar in four successive quartiles of an initial experience of RAPN.