High-grade Complication Rate Research Articles

The impact of thromboelastography on patients with penetrating abdominal trauma requiring intensive care.

Trauma-induced coagulopathy (TIC) is a complex multifaceted process which contributes to higher mortality rates in severely injured trauma patients. Thromboelastography (TEG) is effective in detecting TIC which assists in instituting goal-directed therapy as part of damage control resuscitation. This retrospective study included all adult patients over a 36-month period with penetrating abdominal trauma who required a laparotomy, blood products and admission for critical care. Analysis included demographics, admission data, 24-hour interventions, TEG parameters and 30-day outcomes. Eighty-four patients with a median age of 28 years were included. The majority (93%; 78/84) suffered from a gunshot injury, with 75% (63/84) receiving a damage control laparotomy. Forty-eight patients (57%) had a TEG. Injury severity score and total fluid and blood product administered in the first 24 hours were all significantly higher in patients who had a TEG (p < 0.05). TEG profiles were: 42% (20/48) normal, 42% (20/48) hypocoagulable, 12% (6/48) hypercoagulable and 4% (2/48) mixed parameters. Fibrinolysis profiles were: 48% (23/48) normal, 44% (21/48) fibrinolysis shutdown and 8% (4/48) hyperfibrinolysis. Mortality rate was 5% (4/84) at 24 hours and 26% (22/84) at 30 days, with no difference between the two groups. High-grade complication rates, days on a ventilator and intensive care unit length of stay were all significantly higher in patients who did not have a TEG. TIC is common in severely injured penetrating trauma patients. The usage of a thromboelastogram did not impact on 24-hour or 30-day mortality but did result in a decreased intensive care stay and a decreased high-grade complication rate.

Integration of effort for secure pancreaticoduodenectomy improved surgical outcomes: Historical observational study

To study the impact of strategies focusing attention on the safety of pancreaticoduodenectomy (PD) on postoperative outcome. Since 2012, tailored pancreaticoenterostomy, modification of stent insertion and organized drain management were applied according to risk for postoperative pancreatic fistula (POPF). Patients who performed PD after 2012 were enrolled into the prospective cohort, named experimental group (EG), and those who performed prior 2012 were enrolled into the historical control cohort (HG). Short term surgical outcomes were analyzed. HG included 90 patients and EG included 85 patients. Overall rate of Clinically relevant (CR)-POPF was 13.7% (24/175), 18.9% in HG (17/90) and 8.2% in EG (7/85), respectively (p=0.049). Postoperative delayed gastric emptying, rate of postoperative bleeding, length of hospital stay, and mortality rate did not show any difference between groups. Postoperative complications of Clavien-Dindo 3 or higher were significantly reduced in the EG (22.2% vs 8.2%, p=0.012). After the application of a new surgical policy and management, CR-POPF rate and high-grade complication rate decreased by more than half.

Inflammation-based prognostic scores in geriatric patients with rectal cancer.

Morbidity/mortality and oncologic outcomes can be worsened in geriatric rectal cancer patients due to comorbidities and frailty. The aim of this study was to compare surgical and oncological results of geriatric rectal cancer patients using inflammation-based prognostic scores. The prospectively maintained database of 991 rectal cancer patients treated at our center between 2007 and 2020 were analyzed. All conventional clinicopathologic features, and oncologic outcomes are compared between patients ≥ 65years old (geriatric patients: Group I) and < 65years old (non-geriatric patients: Group II). The modified Glasgow Prognostic Score (mGPS) and the C-reactive protein-albumin ratio (CAR), were determined. The prognostic value of mGPS and CAR as well as the well-known clinico-pathologic factors to predict surgical morbidity, mortality, local and/or distant recurrence, and overall survival was assessed. There were 567 (57.2%) patients who were ≥ 65years old (Group I; 349 males, median age 74 [range 65-9]) years) and 424 (42.8%) who were < 65years old (Group II; 252 males, median age 58 [range 20-64] years). The high-grade [Clavien-Dindo III-IV] complications rates of Group I and Group II patients sere 20% (n = 113), and 9% (n = 37), respectively. High-grade complications were related to mGPS (p < 0.001) and CAR (p < 0.001) values. The high-grade complication rate was found to be higher in Group I than in Group II, and this was statistically significant (p < 0.001). High preoperative mGPS and CAR values were significantly associated with postoperative mortality (p < 0.001). In Cox multivariate analysis, mGPS (p = 0.003) and CAR (p = 0.001) were significantly in correlation with lowered overall survival. The mGPS and CAR were found to be independent prognostic factors for overall survival. The mGPS and CAR can predict severe postoperative complications and early mortality. mGPS, and CAR have a powerful prognostic value and the potential clinical usefulness to predict decreased overall survival in both geriatric and non-geriatric rectal cancer patients.

Complications in the Early Recovery Period After Radical Cystectomy-Real Data From Impartial Inpatient Rehabilitation.

To examine postoperative complications after radical cystectomy (RC) and creation of an ileum conduit (IC) or a neobladder (NB), and to identify preoperative risk factors in a contemporary series of bladder cancer patients. The study relied on prospectively collected data for 842 patients, who underwent inpatient rehabilitation (IR) after RC and urinary diversion (IC n=447, NB n=395) between April 2018 and December 2019. Postoperative complications until the end of IR were assessed according to the Clavien-Dindo classification. Uni- and multivariate analyses were performed to identify predictors for complications. A total of 2689 complications occurred in 813 patients (96.6%). High-grade complications occurred more frequently before IR onset (25.5% vs. 5.7%; P < .001), whereas a higher percentage of low-grade complications occurred during IR (89.0% vs. 77.8%; P < .001). The most common complication categories were genitourinary (60.9%), infectious (54.0%) and gastrointestinal (49.2%). Rates of high-grade complications do not differ between IC and NB patients (26.8% vs. 31.6%, P=.126). Independent predictors for overall complications were NB (odds ratio [OR] 21.520; P < .001), age ≥70 years (OR 2.522; P=.027) and higher body mass index (OR 1.153, P=.008). Risk factors for high-grade complications were NB (OR 1.448; P=.039) and Charlson Comorbidity Index ≥2 (OR 1.999; P=.001). Hospital readmission rate was 9.4%. Our study revealed significantly higher overall and high-grade complication rates after RC with IC or NB creation than previously published. A high percentage of low-grade complications occur after hospital discharge. The hospital readmission rate was lower compared to historical data.

Non-continent Urinary Diversion (Ileal Conduit) as Salvage Therapy in Patients With Refractory Lower Urinary Tract Dysfunctions due to Multiple Sclerosis: Results of a National Cohort From the French Association of Urology (AFU) Neurourology Committee and the French-speaking Neurourology Study Group (GENULF)

To describe the outcomes of ileal conduit as a salvage therapy for refractory lower urinary tract dysfunctions (LUTDs) due to multiple sclerosis (MS) in a national neurourology referral center network. A retrospective multicenter French study was carried out to identify MS patients who underwent non-continent urinary diversion for refractory LUTDs from January 2010 to December 2015. Multiple sclerosis status, urological history, surgical indication and technique, postoperative complications, renal anatomy and function at last follow-up as well as number of rehospitalizations for urinary tract infections (UTI) were collected. Preoperative and postoperative urinary-related quality of life (urQoL) through the Qualiveen short-form questionnaire (QSF) and patient global impression of improvement (PGI-I) were collected and analyzed. Overall, 10 centers identified 211 patients with a mean age of 54±11 and mean preoperative EDSS (expanded disability status scale) score of 7.3±0.9. The main indication for diversion was MS progression leading to impossible intermittent self-catheterization (55%). Cystectomy was performed either by open (34.6%), laparoscopic (39.3%) or robotic (21.8%) approach (unknown: 4.2%) with cystectomy in all cases. Early complications were reported in 42% of the patients, mainly Clavien I or II grades. There was no difference in GFR (glomerular filtration rate) after surgery. After diversion, patients had fewer hospitalizations for UTI and better urQoL on QSF confirmed by evaluation of PGI-I. This study, reporting the largest series of ileal conduit in selected MS patients with end-stage LUTDs, showed significant improvement in symptomatic UTI and quality of life with a low high-grade complication rate.

MP25-07 INCIDENCE OF HIGH GRADE COMPLICATIONS AND ASSOCIATED READMISSION RATES FOLLOWING COLON CONDUIT URINARY DIVERSION

You have accessJournal of UrologyCME1 May 2022MP25-07 INCIDENCE OF HIGH GRADE COMPLICATIONS AND ASSOCIATED READMISSION RATES FOLLOWING COLON CONDUIT URINARY DIVERSION Kevin Hebert, Ryan Anderson, Rano Matta, Benjamin McCormick, and Jeremy Myers Kevin HebertKevin Hebert More articles by this author , Ryan AndersonRyan Anderson More articles by this author , Rano MattaRano Matta More articles by this author , Benjamin McCormickBenjamin McCormick More articles by this author , and Jeremy MyersJeremy Myers More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002568.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Use of colon for urinary conduit diversion is often performed when there is a lack of viable ileum due to inflammatory small bowel disease, prior small bowel resection, or radiation related changes as a result of prior pelvic radiation. While short and long-term outcomes have been well studied in the ileal conduit population, there is a paucity of evidence assessing complications following colon conduit urinary diversion. Thus, we sought to elucidate the incidence and impact of high-grade complications (Clavien-Dindo IIIa-V) following colon conduit urinary diversion. METHODS: We performed a single institution, retrospective cohort study of patients undergoing colon conduit urinary diversion between April 2011 – January 2021. Perioperative characteristics were assessed including prior radiation, albumin, prealbumin, creatinine, and eGFR. Post-operative 30 and 90-day outcomes were characterized including length of stay, high-grade complication rates, readmission rates, and 90-day procedural/surgery rate. RESULTS: We identified 36 patients, median age 60 years [IQR 52,70] who underwent colon conduit urinary diversion during our study period. Colon segments utilized included transverse colon (63.8%), colon switch (19.4%), and sigmoid colon (16.7%). Active tobacco use at the time of surgery occurred in 14.8% of patients. Prior radiotherapy was common with 76.5% and 22.2% reporting prior history of external beam radiation and brachytherapy, respectively. Preoperative characteristics, median [IQR], included: body mass index 26.5 [22.9, 30.8], albumin 3.70 [3.2, 3.9], prealbumin 21.8 [17.6, 32.9], creatinine 0.9 [0.73, 1.20], and eGFR 83 [53, 101]. Median length of stay was 11 days [8, 15]. 30 and 90-day high grade complications were common, occurring in 33.3% and 52.7% of patients, respectively. Within 30-days of surgery, 27.8% of patients required readmission, which increased to 61.1% by 90 days after surgery. More than 1 readmission within 90 days of surgery occurred in 19.5%, while the incidence of a secondary procedure/surgery occurring over the same time period was 33.3%. CONCLUSIONS: In a cohort with a high prevalence of prior pelvic radiation therapy, the risk of high-grade complication, readmission within 90 days of surgery, and secondary procedure/surgery following colon conduit urinary diversion was high. The addition of multi-institutional data is necessary to better characterize the post-operative risks associated with colon conduit diversion in this patient population. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e430 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kevin Hebert More articles by this author Ryan Anderson More articles by this author Rano Matta More articles by this author Benjamin McCormick More articles by this author Jeremy Myers More articles by this author Expand All Advertisement PDF DownloadLoading ...

V05-04 ROBOTIC MANAGEMENT OF SURGICAL COMPLICATIONS AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL DIVERSION

You have accessJournal of UrologyCME1 May 2022V05-04 ROBOTIC MANAGEMENT OF SURGICAL COMPLICATIONS AFTER ROBOT-ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL DIVERSION Leonardo Misuraca, Riccardo Mastroianni, Gabriele Tuderti, Umberto Anceschi, Aldo Brassetti, Mariaconsiglia Ferriero, Alfredo Maria Bove, Salvatore Guaglianone, Michele Gallucci, and Giuseppe Simone Leonardo MisuracaLeonardo Misuraca More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002579.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: RARC is a complex and morbid procedure, even when performed in a minimally invasive fashion. It is affected by a 90-day complication of approximately 59%, with an high-grade complication rate which ranges from 15 to 30%. Many of this postoperative complications, occasionally necessitate re-exploration, which could benet in turn from a minimally invasive approach. In this video, we describe our surgical technique used to manage two relatively frequent complications. METHODS: In both cases, patient was placed in steep Trendelenburg position and a conventional 5 or 6 trocars access for pelvic surgery was adopted. The rst case is a reimplantation for uretero-ileal anastomosis stricture after RARC with orthotopic neobladder. Ureter was gently isolated and ICG near infrared uorescence imaging was used to better individuate the ischemic portion of distal ureter. Ureter was clipped with hem-o-lok, transected and spatulated. Cystostomy was performed before proceeding with a direct reimplantation with 3/0 interrupted sutures. A double J stent was placed over a guide wire, through a 5 mm trocar and cystostomy was closed with a 2/0 monocryl running suture. A water tightness test proved the suture sealing. A nal check with ICG near infrared uorescence demonstrated a normal vascularity of the re-anastomosis area.The second case is an ileal-neobladder stula in a 66-yr old male, who underwent RARC. Ports placement was particularly dicult due to multiple and extensive adhesions. A meticulous adhesiolysis was performed in order to expose the neobladder and individuate the stula location. Neobladder was irrigated with a mixture of ICG and saline solution and near infrared uorescence imaging allowed to individuate the afferent and the efferent ileum loop stulized with neobladder, which were both divided with a 60 mm laparoscopic stapler. A new latero-lateral ileal-ileal anastomosis was then performed. A 2/0 monocryl running suture was used to cover the surgical staples, in order to prevent further future adhesions. Ileal loop stulized with the neobladder was completely excluded from intestinal transit and bowel continuity restored. RESULTS: Conversion to open surgery was not necessary in any procedures. Operative time was 146 and 120 minutes, respectively, with negligible EBL. No intra- nor perioperative complications were reported and patients were discharged on 4th and 5th POD, respectively. CONCLUSIONS: In selected cases, robotic approach can be successfully used in management of surgical complication after RARC, in tertiary referral centres. ICG near infrared uorescence is a useful tool in identication of anatomical structures and allows a real-time assessment of tissue vascularity, in order to prevent complications strictly related to ischemic injuries. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e517 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leonardo Misuraca More articles by this author Riccardo Mastroianni More articles by this author Gabriele Tuderti More articles by this author Umberto Anceschi More articles by this author Aldo Brassetti More articles by this author Mariaconsiglia Ferriero More articles by this author Alfredo Maria Bove More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF DownloadLoading ...

Benchmarking PASADENA Consensus along the Learning Curve of Robotic Radical Cystectomy with Intracorporeal Neobladder: CUSUM Based Assessment.

(1) Aim: Robot assisted radical cystectomy (RARC) with intacorporeal neobladder (iN) is a challenging procedure. There is a paucity of reports on RARC-iN, the extracorporeal approach being the most used. The aim of our study was to assess the learning curve of RARC-iN and to test its performance in benchmarking Pasadena consensus outcomes. (2) Material and methods: The single-institution learning curve of RARC-iN was retrospectively evaluated. Demographic, clinical and pathologic data of all patients were recorded. Indications to radical cystectomy included muscle invasive bladder cancer (pT ≥ 2) or recurrent high grade non muscle invasive bladder cancer. The cumulative sum (CUSUM) technique, one of the methods developed to monitor the performance and quality of the industrial sector, was adopted by the medical field in the 1970s to analyze learning curves for surgical procedures. The learning curve was evaluated using the following criteria: 1. operative time (OT) <5 h; 2. 24-h Hemoglobin (Hb) drop <2 g/dl; 3. severe complications (according to the Clavien classification system) <30%; 4. positive surgical margins <5%; and 5. complete lymph-node dissection defined as more than 16 nodes. Benchmarking of all five items on quintile analysis was tested, and a failure rate <20% for any outcome was set as threshold. (3) Results: the first 100 consecutive RARC-iN patients were included in the analysis. At CUSUM analysis, RARC required 20 cases to achieve a plateau in terms of operative time (defined as more than 3 consecutive procedures below 300 min). Hemoglobin drop, PSM and number of removed lymph-nodes did not change significantly along the learning curve. Overall, 41% of the patients presented at least one complication. Low-grade and high-grade complication rates were 30% and 17%, respectively. When assessing the benchmarks of all five Pasadena consensus outcomes on quintile analysis, a plateau was achieved after the first 60 cases. (4) Conclusions: RARC-iN is a challenging procedure. The potential impact of the learning curve on significant outcomes, such as high grade complications and positive surgical margins, has played a detrimental effect on its widespread adoption. According to this study, in tertiary referral centers, 60 procedures are sufficient to benchmark all outcomes defined in Pasadena RARC consensus.

Morbidity and mortality after robot-assisted radical cystectomy with intracorporeal urinary diversion in octogenarians: results from the European Association of Urology Robotic Urology Section Scientific Working Group.

ObjectivesTo evaluate the postoperative complication and mortality rate following laparoscopic radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) in octogenarians.Patients and MethodsWe conducted a retrospective analysis comparing postoperative complication and mortality rates depending on age in a consecutive series of 1890 patients who underwent RARC with ICUD for bladder cancer between 2004 and 2018 in 10 European centres. Outcomes of patients aged <80 years and those aged ≥80 years were compared with regard to postoperative complications (Clavien–Dindo grading) and mortality rate. Cancer‐specific mortality (CSM) and other‐cause mortality (OCM) after surgery were calculated using the non‐parametric Aalen‐Johansen estimator.ResultsA total of 1726 patients aged <80 years and 164 aged ≥80 years were included in the analysis. The 30‐ and 90‐day rate for high‐grade (Clavien–Dindo grades III–V) complications were 15% and 21% for patients aged <80 years compared to 11% and 13% for patients aged ≥80 years (P = 0.2 and P = 0.03), respectively. In a multivariable logistic regression analysis adjusting for pre‐ and postoperative variables, age ≥80 years was not an independent predictor of high‐grade complications (odds ratio 0.6, 95% confidence interval 0.3–1.1; P = 0.12). The non‐cancer‐related 90‐day mortality was 2.3% for patients aged ≥80 years and 1.8% for those aged <80 years, respectively (P = 0.7). The estimated 12‐month CSM and OCM rates for those aged <80 years were 8% and 3%, and for those aged ≥80 years, 15% and 8%, respectively (P = 0.009 and P < 0.001).ConclusionsThe minimally invasive approach to RARC with ICUD for bladder cancer in well‐selected elderly patients (aged ≥80 years) achieved a tolerable high‐grade complication rate; the 90‐day postoperative mortality rate was driven by cancer progression and the non‐cancer‐related rate was equivalent to that of patients aged <80 years. However, an increased OCM rate in this elderly group after the first year should be taken into account. These results will support clinicians and patients when balancing cancer‐related vs treatment‐related risks and benefits.

Robot-assisted intracorporeal orthotopic bladder substitution after radical cystectomy: perioperative morbidity and oncological outcomes - a single-institution experience.

To report a single-institution experience with totally intracorporeal neobladder urinary diversion (UD) after robot-assisted laparoscopic radical cystectomy (RARC). A total of 158 patients underwent totally intracorporeal neobladder UD after RARC between 2003 and 2016. Patient demographics, intraoperative and pathological data, 30- and 90-day perioperative mortality and complications were recorded. Complications were classified according to the modified Clavien-Dindo classification. The 5-year overall (OS) and cancer-specific survival (CSS) rates were estimated by Kaplan-Meier plots. Most of the patients were male (84%) and had clinical T Stage ≤2 (87%). The mean operation time was 359(SD ±98)min, with a median (range) estimated blood loss of 300(50-2200)mL. Most of the men (86%) received a nerve-sparing procedure and 38% of the females an organ-sparing approach. A lymph node dissection was performed in 156 (99%) patients, with a median (range) yield of 23 (7-48)nodes. Conversion to open surgery occurred in five patients (3%). We recorded negative margins in 156 patients (99%). The median (range) follow-up was 34(1-170)months, with 30- and 90-day mortality rates of 0%. Clavien-Dindo Grade III-IV complications occurred in 29 of 158 (18%) patients at 30-days and in eight of 158 (5%) between 30-90days, resulting into a 90-day overall high-grade complication rate of 23%. The unadjusted estimated 5-years recurrence-free survival, CSS and OS rates were 70%, 72%, and 71%, respectively. In our present series the complication and oncological results were similar to open RC series, suggesting that RARC followed by totally intracorporeal neobladder UD is a safe and feasible alternative.

Simultaneous versus staged partial nephrectomies for bilateral synchronous solid renal masses

ObjectivesThe optimal management approach for synchronous bilateral renal masses is unknown, particularly regarding surgical sequencing of bilateral partial nephrectomy (PN). We evaluated the impact of simultaneous vs. staged bilateral PN on renal functional, perioperative, and oncologic outcomes. Patients and MethodsWe reviewed our institutional nephrectomy registry to identify patients who underwent simultaneous or staged (within 6 months) bilateral PN for nonmetastatic bilateral synchronous solid renal masses between 1980 and 2015. Short-term and long-term renal function changes were assessed at 3 and 12 months, respectively. Perioperative outcomes were pooled across staged surgeries by taking the sum of each outcome. Local recurrence-free, distant metastases-free, cancer-specific, and overall survival were estimated using the Kaplan-Meier method. Outcomes were compared by surgical sequencing approach. A sensitivity analysis was performed that grouped approaches by preoperative intent. ResultsAmong the 107 patients studied, 77 (72%) underwent simultaneous and 30 (28%) underwent staged PN. The majority of PN were performed by open approach. Clinicopathologic features were similar between groups. Patients who underwent simultaneous PN had lower mean short-term (−6% vs. −24%, P = 0.015) and median long-term (−4% vs. −22%, P < 0.001) reduction in eGFR vs. staged PN, respectively. Furthermore, patients with simultaneous PN had lower pooled length of stay (median 6 vs. 8 days, P < 0.001), rate of urine leak (3% vs. 17%, P = 0.018), and rate of high-grade complications (8% vs. 23%, P = 0.044), relative to staged PN, respectively. However, on sensitivity analysis, only differences in long term reduction in estimated glomerular filtration rate and length of stay remained. There were no significant differences in oncologic outcomes between groups. ConclusionsOur results suggest that when technically feasible, simultaneous PN yields comparable outcomes vs. staged PN, offering a reasonable surgical sequencing approach for patients presenting with bilateral synchronous renal masses.

PD39-08 PREOPERATIVE CHECKPOINT INHIBITORS ARE NOT ASSOCIATED WITH INCREASED SURGICAL COMPLICATIONS COMPARED TO PREOPERATIVE TYROSINE KINASE INHIBITORS OR UPFRONT CYTOREDUCTIVE NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Advanced (including Drug Therapy) II (PD39)1 Apr 2020PD39-08 PREOPERATIVE CHECKPOINT INHIBITORS ARE NOT ASSOCIATED WITH INCREASED SURGICAL COMPLICATIONS COMPARED TO PREOPERATIVE TYROSINE KINASE INHIBITORS OR UPFRONT CYTOREDUCTIVE NEPHRECTOMY Daniel Shapiro*, Mary Westerman, Nizar Tannir, Jianjun Gao, Hyunsoo Hwang, Xuemei Wang, Surena Matin, Jose Karam, and Christopher Wood Daniel Shapiro*Daniel Shapiro* More articles by this author , Mary WestermanMary Westerman More articles by this author , Nizar TannirNizar Tannir More articles by this author , Jianjun GaoJianjun Gao More articles by this author , Hyunsoo HwangHyunsoo Hwang More articles by this author , Xuemei WangXuemei Wang More articles by this author , Surena MatinSurena Matin More articles by this author , Jose KaramJose Karam More articles by this author , and Christopher WoodChristopher Wood More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000918.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Checkpoint inhibitors (CI) are increasingly utilized for metastatic renal cell carcinoma (mRCC), including in the preoperative (preop) setting. This study investigated perioperative outcomes and postoperative complications in patients who received preop CI compared to patients who received preop tyrosine kinase inhibitors (TKI) or upfront CN. METHODS: Data were analyzed from consecutive RCC patients who underwent nephrectomy for locally advanced or mRCC at a single institution from 2010-2019. Patient cohorts included those receiving either preop CI, preop TKI or upfront CN. 90-day postoperative complications according to the Clavien system were tabulated with Clavien ≥IIIa considered high grade. Clinicopathologic variables were compared with Fisher’s exact or Kruskal-Wallis test. Univariable and multivariable logistic regression evaluated associations between clinical variables and probability of complication. RESULTS: A total of 636 patients underwent nephrectomy and had complete data. 53 received preop CI therapy, 191 received preop TKI and 392 had an upfront CN. Among preop CI patients, 37 received anti-PD1, 8 received anti-CTLA4, and 8 received anti-PD1+anti-CTLA4 therapy. The median time on therapy was 1.8 and 2.8 months for CI and TKI, respectively (p=0.0001). Groups were compared by age, gender, race, Charlson comorbidity, ECOG, smoking, BMI, IMDC risk, stage, histology, grade, tumor size, and surgical approach. No differences were found except for median pathologic tumor size: 9cm for CI, 9cm for TKI, and 10cm for upfront CN (p=0.002). Surgical outcomes showed differences in duration (median 145min CI, 166min TKI, and 180min upfront CN; p=0.04), blood loss (median 250cc CI, 425cc TKI, and 510cc upfront CN; p=0.01), and number receiving a thrombectomy (28.3% CI, 25.1% TKI, and 36.2% upfront CN; p=0.02). No difference was found in the total (24.5% CI, 36.7% TKI, and 39.8% upfront CN; p=0.09) or high-grade complication rate (7.6% CI, 8.9% TKI, and 10.4% upfront CN; p=0.80). Univariable analysis identified thrombectomy and surgical approach associated with high grade complication. After MV analysis, only thrombectomy was independently associated with high grade complication (OR 3.84, 95% CI 2.21-6.61, p<0.001). Preoperative therapy was not associated with high grade complication. CONCLUSIONS: Preoperative CI therapy appears safe without increased risk of overall or high-grade complications when compared to preoperative TKI therapy or upfront CN. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e811-e812 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Shapiro* More articles by this author Mary Westerman More articles by this author Nizar Tannir More articles by this author Jianjun Gao More articles by this author Hyunsoo Hwang More articles by this author Xuemei Wang More articles by this author Surena Matin More articles by this author Jose Karam More articles by this author Christopher Wood More articles by this author Expand All Advertisement PDF downloadLoading ...

Refinement Surgical Technique, and Perioperative and Functional Outcomes in Patients With Robotic Intracorporeal Hautmann Orthotopic Neobladder

ObjectiveTo illustrate our refinement technique for robotic intracorporeal orthotopic Hautmann neobladder with adherence to open surgical principles and evaluate perioperative and functional outcomes. Patients and MethodsRobot-assisted radical cystectomy with intracorporeal Hautmann orthotopic neobladder was performed by the same surgeon in 40 patients with bladder cancer from November 2017 to March 2019. Baseline demographics, pathologic data, 90-day complications, and functional outcomes at both 6 and 12 months were evaluated with questionnaire and urodynamic analysis. ResultsMedian follow-up was 14 months (range 4-20). Median operative time was 320 (230-500) minutes, and the estimated blood loss was 300 (100-2000) mL. No conversion to the open technique was reported. The overall 90-day complication rate was 45%, and the high-grade complication rate was only 10%. The daytime satisfactory continence rate was 90% at both 6 months (30 patients) and 12 months (20 patients), while the night-time satisfactory continence rate was 76.7% and 80.0% at 6 months and 12 months, respectively. One patient underwent clean intermittent catheterization. The cohort had minimal postvoid residual volume, normal compliance, and a mean capacity of 328.7 cm3 (range 170-500) at 6 months postoperatively. ConclusionOur preliminary data indicate that robotic intracorporeal Hautmann neobladder configuration is a feasible surgical technique and can achieve a low pressure and sufficient capacity for satisfactory early voiding patterns. Refinement of the stepwise process can effectively decrease the time of the operation. Long-term functional and oncological outcomes remain to be evaluated with longer follow-up and more cases.

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: results from three high-volume robotic surgery institutions.

Robot-Assisted NephroUreterectomy (RANU) represents a minimally invasive alternative to open NephroUreterectomy (NU) for management of Upper Tract Urothelial Carcinoma (UTUC) but its oncologic safety is still controversial. The objective of this study was to investigate the peri-operative, pathologic and oncologic outcomes of RANU for UTUC. From 2008 to 2017, 78 patients diagnosed with UTUC and elected for RANU at 3 high-volume robotic surgery centres were retrospectively assessed. Surgery was performed using da Vinci Si® and Xi® systems. RANU was done adhering to oncological principles as in open surgery. The outcomes of the study were: (1) peri-operative morbidity, namely intra- and post-operative complications, blood loss, length of hospital stay and operative time; (2) oncologic outcomes, namely overall survival (OS) and recurrence-free survival (RFS). Peri-operative overall complication rate was 24.4% and high-grade complication rate was 2.6%. Median blood loss, length of hospital stay and operative time were 124ml, 4 days and 167min. Lymphadenectomy was performed in 31 (41%) patients. Lymph-node involvement was present in 9 (29%) patients. At median follow-up of 15months, 2- and 4-year OS were 79% and 66%, respectively, and RFS was 63% and 53%. Peritoneal dissemination was recorded in 1 (1.3%) patient with pT4N2R1 UTUC. Our study is limited by the relatively small cohort of patients and its retrospective character. RANU as minimally invasive treatment for patients with UTUC is safe and feasible. Post-operative morbidity is low and major complications are rare. Oncologic outcomes are acceptable and no evidence of increased risk of peritoneal dissemination is recorded. Long-term data are needed. RANU should be regarded as an alternative to open surgery for UTUC that can offer good peri-operative and oncologic results.

Lessons learned from a single-surgeon series of paediatric robot-assisted laparoscopic urological procedures: predictors of high-grade postoperative complications.

To describe postoperative complications after robot-assisted laparoscopic urological surgery in children, and identify potential predictors of these complications by analysing the outcomes of a large-volume single-surgeon experience. We reviewed our institutional database to identify all robot-assisted laparoscopy (RAL) cases performed between December 2007 and December 2017. Patients were grouped into three cohorts based on the anatomical location of the procedure: upper urinary tract (kidney and renal pelvis); lower urinary tract (ureter); and lower urinary tract reconstruction with bowel (bladder reconstruction). A descriptive analysis of baseline characteristics, intra-operative variables and postoperative outcomes was carried out. All complications were graded using the Clavien-Dindo scale, and grouped based on type and time of occurrence (<30, 30-90, >90days). Multivariable logistic regression analysis was performed to identify predictors of high-grade complications (Clavien-Dindo grade ≥ III). We also measured complication rates based on year of surgery and surgical caseload. Our database included a total of 326 patients, of whom 57% (n = 186) underwent upper urinary tract procedures, 30% (n = 97) ureteric procedures, and 13% bladder reconstruction. The median follow-up for each procedure was 13, 11 and 57months, respectively. Of the total, 10 cases were converted to an open approach and excluded from further analysis. The most common types of complication in all groups were infections (urinary tract infections) and urinary complications (urine leaks and urolithiasis). Bladder reconstructive procedures, which require the use of bowel, presented the highest rate of high-grade complications (32%). Length of hospital stay (LOS; odds ratio [OR] 1.33, confidence interval [CI] 1.16-1.53), estimated blood loss (EBL) in surgery (OR 1.01, CI 1.002-1.019) and operating time (OR 1.004, CI 1.002-1.006) were all associatedwith increased odds of high-grade complications on multivariate analysis (P < 0.05). In this single-surgeon series, we have described the most commonly encountered complications after RAL in paediatric urology, finding rates similar to the complication rates reported in the current literature on other surgical approaches. In addition, LOS, operating time and EBL, which are probable surrogates of case complexity, were associated with increased odds of high-grade complications.

Preservation of Ejaculatory Function After Postchemotherapy Retroperitoneal Lymph Node Dissection (PC-RPLND) in Patients With Testicular Cancer: Template vs. Bilateral Resection

Background: Post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) plays a crucial role in treatment of metastatic non-seminomatous germ cell cancer.Objective: To evaluate the functional outcome regarding the preservation of ejaculatory function comparing a bilateral vs. unilateral template resection in PC-RPLND patients. In addition, oncological safety and perioperative complications of the unilateral template resection was compared to the full bilateral one.Design/Setting/Participants: Between 2003 and 2018, 504 RPLNDs have been performed in 434 patients. The database of consecutive patients was queried to identify 171 patients with PC-RPLND after 1st line chemotherapy for a non-seminoma with or without bilateral template resection. Re-Do's, late relapse, salvage patients, and thoraco-abdominal approaches were excluded. Indication for a template resection was a unilateral residual mass mainly <5 cm as published (1).Outcome, Measurement, and Statistical Analysis: Descriptive statistics were used to report preoperative features, postoperative outcomes and patterns of recurrence, on the overall population and after stratification for the type of resection (bilateral vs. unilateral). Kaplan-Meier analyses were used to describe recurrence- and cancer-specific mortality-free survival rates at different time points.Results and Limitations: Overall, 90 and 81 patients underwent unilateral and bilateral radical resection, respectively. Median size of residual mass was 7 cm for bilateral and 4 cm for unilateral template resection. Clinical stage II and III were present in 31 and 69% of patients, respectively. Median follow-up was 14.5 months (IQR 3.3–37.6). The 1- and 2-year recurrence-free survival rates were 91 and 91%, and 77 and 72% for patients treated with unilateral template and bilateral resection, respectively (p = 0.0078). Median time to recurrence was 9.5 and 9 months in template and bilateral resection group, respectively.Adjunctive procedures were performed in 56 patients (33%) and were significantly more frequent in the bilateral resection group (43 vs. 23%, p = 0.006). The overall high-grade complication rate (Clavien-Dindo ≥ III) was 6, 3, and 9% in unilateral template and bilateral resection group, respectively (p = 0.6). The rate of preservation of antegrade ejaculation was significantly higher in the unilateral group.Conclusions: Antegrade ejaculation in patients undergoing unilateral template resection with a residual mass <5 cm can be preserved at a much higher rate. Moreover, this surgical procedure is oncologically safe in terms of mid-term recurrence and CSM-free survival rates. This data undermines the growing evidence of limited PC-RPLND being justifiable in strictly unilateral residual mass <5 cm. This data has to be confirmed with a longer follow-up regarding in-field and retroperitoneal recurrences.

Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique?

Objective To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA. Materials and Methods Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis. Results Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not. Conclusions Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.

Determining the Learning Curve for Robot-Assisted Simple Prostatectomy in Surgeons Familiar with Robotic Surgery.

Robot-assisted simple prostatectomy (RASP) has excellent outcomes when treating large volume prostates and incorporates the already familiar skills to most robotic surgeons. Our objective was to determine the learning curve for RASP. A retrospective review of RASP on 120 consecutive cases performed by two experienced robotic surgeons from 2014 to 2017 was conducted. We defined "learning curve" as the point at which operative parameters transition from logarithmic to linear improvement. Scatter plots of operative outcomes were constructed and logarithmic and linear best-fit line were estimated to determine the point of transition from logarithmic to linear improvement. Surgeon 1 operated on 76 cases and surgeon 2 on 44 cases. The median age of the 120 patients who underwent RASP was 70.0 years (interquartile range [IQR] 65.0-74.0 years) and median prostate mass was 121.5 g (IQR = 102.0-149.3). Overall, high-grade complication rate was 7.5%; median hematocrit change was 5.4% (IQR = 3.2-7.7) and tissue yield was 61.2 g (IQR = 49.7-76.9). Tissue yield demonstrated logarithmic improvement over the first 12 cases and then transitioned to a linear patter for one surgeon. Operative time in the last 10 cases was statistically different from the first 10 cases (p < 0.01). Drop in hematocrit (ΔHct) for surgeon 2 demonstrated logarithmic improvement for the first 10 cases and then transitioned to a linear pattern. The learning curve for RASP varied depending on the variable examined. Blood loss (ΔHct) and tissue yield showed the greatest improvement over time, but neither showed significant improvement beyond 12 cases. We estimated the learning curve for RASP to be ∼10 to 12 cases for experienced robotic surgeons.

Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement

To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa. A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected. Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days. Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A followup study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary.

Impact of body mass index on robot-assisted radical cystectomy with intracorporeal urinary diversion.

To determine the impact of body mass index (BMI) on peri-operative and oncological outcomes after robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion. A total of 216 patients undergoing RARC, extended lymphadenectomy and intracorporeal urinary diversion, between July 2010 and December 2015, were categorized into four BMI groups according to the 2004 World Health Organization obesity classification groups: <25 kg/m2 (normal); 25-29.9 kg/m2 (pre-obese); 30-34.9 kg/m2 (obese class I); and ≥35 kg/m2 (obese class II). Pre-, intra- and postoperative characteristics, oncological outcomes, and 90-day complications were compared using sas statistical software. All 216 patients underwent intracorporeal urinary diversion, with 68 (32%) undergoing orthotopic neobladder construction. Demographics were similar among the BMI groups with regard to median (range) age (71.8 [35- 95] years), gender (80.6% men), Charlson comorbidity index (CCI) score (66.2% with CCI score 0-1), pathological stage (carcinoma in situ to T2: 55.1%, T3-T4/N0: 18.5%, Tx/N+: 26.4%), median (interquartile range) node count [41 (28, 53)] and positive soft tissue margin rate (4.2%). Obese patients had greater blood loss and longer operating time (P = 0.02 and P = 0.04, respectively). There were no significant differences in length of hospital stay, transfusion rates, readmission or 90-day overall and high-grade complication rates (P = 0.16, P = 0.96, P = 0.89, P = 0.22 and P = 0.51, respectively). At a median (range) follow-up of 13 months (15 days to 4.8 years), recurrence-free survival (P = 0.92) and overall survival (P = 0.68) were similar among the groups. The results of the present study show that RARC with intracorporeal urinary diversion is safe and feasible in obese patients with bladder cancer. BMI was not associated with significant differences in peri-operative, pathological or early oncological outcomes.