Kidney Surgery Research Articles

PD16-07 THE IMPACT OF BODY MASS INDEX ON RENAL FUNCTIONAL OUTCOMES FOLLOWING MINIMALLY INVASIVE PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized I1 Apr 2014PD16-07 THE IMPACT OF BODY MASS INDEX ON RENAL FUNCTIONAL OUTCOMES FOLLOWING MINIMALLY INVASIVE PARTIAL NEPHRECTOMY Kyle Richards, Edris Negron, Joshua Cohn, Zoe Steinberg, Scott Eggener, and Arieh Shalhav Kyle RichardsKyle Richards More articles by this author , Edris NegronEdris Negron More articles by this author , Joshua CohnJoshua Cohn More articles by this author , Zoe SteinbergZoe Steinberg More articles by this author , Scott EggenerScott Eggener More articles by this author , and Arieh ShalhavArieh Shalhav More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1152AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Partial nephrectomy is the standard of care for the management of small renal masses and is increasingly performed via minimally invasive partial nephrectomy (MIPN). Obesity is a known risk factor for kidney cancer and can make surgery more challenging. Our aim is to assess the impact of body mass index (BMI) on perioperative and renal functional outcomes in patients undergoing MIPN. Methods In our IRB-approved, prospectively maintained database, we identified 1,206 patients who underwent kidney surgery from August 2002 until March 2013. Follow up has been maintained every 6 months for 2 years, and yearly thereafter with axial imaging at the discretion of the physician. Estimated glomerular filtration rate (eGFR) was obtained at baseline and at each follow-up visit. From this group, patients that underwent MIPN with more than 12 months of follow up were selected. Exclusion criteria included missing preoperative eGFR or conversion to radical nephrectomy. Patients were separated into 4 cohorts based on BMI: 1. BMI <25 kg/m2, 2. BMI 25-30 kg/m2, 3. BMI 30-35 kg/m2, and 4. BMI >35 kg/m2. Change in eGFR was compared across variables via univariate and multivariate regression models. Results 235 patients met inclusion criteria with overall median follow-up of 17 months [IQR 7, 37]. There was no difference in follow-up, baseline demographic, clinical, perioperative, or pathologic features across BMI groups. Increasing BMI was associated with a significant absolute reduction in eGFR at 1 year on univariate analysis (0.44 mL/min/BSA reduction in GFR per 1 kg/m2 increase in BMI, p=0.008). BMI (p=0.046), CCI (p=0.007), tumor size (p=0.012), and preoperative eGFR (p<0.01) were independently associated with significant absolute reduction in eGFR in a multivariate model adjusted for gender, race, BMI, CCI, warm ischemia time, and preoperative eGFR. Controlling for the same variables, gender (p=0.05), BMI by category (p=0.035), CCI (p=0.041), and preoperative eGFR (p<0.01) were independently associated with increased odds of being chronic kidney disease stage ≥ III at 1 year Conclusions MIPN is feasible in obese patients with similar perioperative outcomes to non-obese patients. BMI is an independent risk factor for worsening kidney function following MIPN, and these patients should be counseled accordingly. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e489 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Kyle Richards More articles by this author Edris Negron More articles by this author Joshua Cohn More articles by this author Zoe Steinberg More articles by this author Scott Eggener More articles by this author Arieh Shalhav More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V7-10 ROBOTIC TRAPDOOR PARTIAL NEPHRECTOMY FOR COMPLETELY ENDOPHYTIC TUMORS

both cases, extensive adhesions were found around the kidney, making anatomical identification and dissection difficult. Intra-operative ultrasound and a doppler probe were used to facilitate identification of anatomical structures. The fourth robotic arm and robotic hook were used to help mobilize the kidney and expose important structures. RESULTS: The results of the two cases are presented in Table 1. Both cases were completed robotically with no intraoperative complications. Post-operative course was uneventful and both the patients were discharged on day three. CONCLUSIONS: Salvage robotic kidney surgery for complications of robotic partial nephrectomy is rare but challenging. Intraoperative ultrasound, intraoperative doppler, the fourth robotic arm, and robotic hook canall beuseful todefineanatomyand facilitatedissection indifficult cases.

Robotic zero ischemia partial nephrectomy: step by step surgical technique with tips and tricks

Robotic zero ischemia partial nephrectomy: step by step surgical technique with tips and tricks Abdullah Erdem Canda,1 Mevlana Derya Balbay2 1Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training and Research Hospital, Department of Urology, Ankara, 2Memorial Sisli Hospital, Department of Urology, Istanbul, Turkey Abstract: Currently, most renal cell carcinoma cases are detected incidentally as small renal masses during radiologic imaging, such as abdominal ultrasound or computed tomography, and partial nephrectomy is being increasingly performed for these lesions. There has been a worldwide increase in minimally invasive surgical approaches, and robotic partial nephrectomy (RPN) in particular has the advantages of more rapid tissue dissection, reconstruction, intracorporeal suturing, three-dimensional optical magnification, dexterity in motion, and ability to perform tremor-free and delicate movements with three independent robotic arms. Renal hilar clamping during RPN decreases bleeding, but warm ischemia might negatively impact renal function. However, with sufficient surgical experience in robotic kidney surgery, zero ischemic or off-clamp RPN might be a safe and feasible minimally invasive surgical approach that has the advantage of avoiding complete renal ischemia, thus avoiding a decrease in renal function particularly in small, less complex, peripherally located, exophytic renal masses less than 3 cm in size. Currently available absorbable barbed sutures could further facilitate performing internal and external renorraphy, as could fibrin and tissue sealants that may also be used for hemostasis. This approach might be particularly important in patients with underlying kidney disease. Keywords: robotic partial nephrectomy, zero ischemia, renal cell carcinoma, small renal masses, minimally invasive surgery, surgical technique

A Novel 3-Dimensional Image Analysis System for Case-specific Kidney Anatomy and Surgical Simulation to Facilitate Clampless Partial Nephrectomy

To report our initial experience with the novel 3-dimensional (3D) image analysis system Synapse Vincent in clampless partial nephrectomy (PN), describing its advantages with regard to short-term surgical outcomes and its usefulness as an informed consent tool. Twenty-six patients with renal cell carcinoma underwent clampless PN navigated with the aid of case-specific 3D anatomic video images of the kidney, after surgical simulation using the same video system. Baseline characteristics were reviewed, and short-term surgical outcomes were recorded. Of the 26, 6 had imperative indications, and 22 were treated with a minimally invasive approach. Before tumor excision, the renal hilar vessels were meticulously dissected, and definite tumor feeders were selectively ligated. Before patients consented to PN, the surgical procedure and perioperative risks were explained to each patient using case-specific 3D video images; subsequently, surgeons asked patients whether the 3D images had helped them understand PN more clearly than 2D images would have. All operations were successfully completed without clamping, with negative surgical margins. No patients required blood transfusions. During PN, the surgeons confirmed the accuracy of the reconstructed 3D images and surgical simulations in all cases. All patients answered that the 3D images had helped them understand their disease status and surgical risks. This is the first report on the Synapse Vincent 3D image analysis system for kidney surgery. Its 3D images and surgical simulation helped not only surgeons in their performance of clampless PN but also patients in their understanding of the operation.

Surgical site infections and other healthcare related infections in cohort of urological patients, 2010-2013

Background: Surgical site infections (SSIs) and other healthcare related infections continues to be significant problem in surgical patients across the globe. Aim: To analyze and compare the surveillance data from large cohort of patients operated in Clinic for Urology, Military Medical Academy Methods: A prospective cohort study was performed to identify incidence rate and risk factors for surgical site infections (SSI) from 2010 to 2013. Infection control personal collected general and healthcare related data about patients. The microbiologic testing was performed at the Institute of Medical Microbiology by routine methods. Results: A total of 3823 surgical procedures (3288 patients) were included in the study. The lowest incidence rate was observed in kidney surgery (total nephrectomy - 2.4% and partial nephrectomy - 3.6%), and highest during bladder surgery (total cystectomy - 21.6% and partial cystectomy - 23.5%). The postoperative infections (RR: 2.018; 95%:1.111 -3.666; SE: 0.305; p: 0.021), dra inage (RR:10.417; 95%CI:4.339 - 25.011; SE: 0.447; p: 0.000), preoperative length of hospital stay (RR:0.909; 95%CI: 0.880 - 0.939; SE: 0.017; p: 0.000) and total length of hospitalization (RR:1.140; 95%CI:1.117-1.164; SE: 0.010; p:0.000), as well as contamination class (RR:1.633; CI95%:1.215 - 2.194; SE:0.151; p:0.001) are independent risk factors for SSI in this cohort of patients. Incidence rate of diarrhea caused by Clostridium difficile was 5.01 to 10 000 patient days. The most common cause of SSI and urinary tract infections was Klebsiella spp. Conclusion: The greater attention has been given to adherence to recommendations for the prevention and control of SSIs as well as management of multidrug resistant organisms in urology department.

Impact of a Common Clinical Pathway on Length of Hospital Stay in Patients Undergoing Open and Minimally Invasive Kidney Surgery

Clinical pathways are designed to reduce variability in patient care practices and improve clinical outcomes. We evaluated the effect of implementing a clinical care pathway on length of stay in patients undergoing kidney surgery. After receiving institutional review board approval we evaluated prospective data on consecutive cases of partial and radical nephrectomy performed at our institution from 2000 to 2011. We identified 1,775 partial nephrectomies (1,449 open and 326 minimally invasive) and 1,025 radical nephrectomies (857 open and 168 minimally invasive). We used multivariate linear regression to test for an interaction between procedure type and surgery before vs after the clinical pathway was begun. Median length of stay decreased 40% (from 5 to 3 days) for open surgery and 33% (from 3 to 2 days) for minimally invasive surgery after clinical pathway implementation. Length of stay in patients treated with minimally invasive or open partial nephrectomy and open radical nephrectomy decreased while it remained stable in those who underwent minimally invasive radical nephrectomy. The difference in length of stay between open and minimally invasive partial nephrectomy before and after implementing the clinical pathway decreased by 1.5 days (95% CI 0.56-2.5, p = 0.002). At 30 days postoperatively major complication rates remained similar. The clinical pathway resulted in a significantly shorter length ofstay in patients treated with partial and radical nephrectomy without a discernible impact on safety or quality of care. Clinical pathways for kidney surgery should be used and continually optimized to enhance efficiency, patient safety and outcomes.

Évolution des pratiques de la chirurgie rénale avant et après les recommandations de l’AFU de 2010

Compared to the 2007 edition, the 2010 French urological association onco-urology guidelines boarded the indications of partial nephrectomy (PN) as long as the procedure is technically feasible. The aim of this study was to assess national practice with respect to kidney surgery in the 2 years before and after current guidelines. The national database of the Agence Technique de l'Information sur l'Hospitalisation (ATIH) was queried for procedures performed between 2009 and 2010 (era 1) and between 2011 and 2012 (era 2). The coding system of the Classification Commune des Actes Médicaux (CCAM) was used to extract kidney related procedures. For each era, procedures were sorted into partial versus radical nephrectomy (RN), laparoscopic/robotic versus open approach, and private versus public hospital. The two eras were then compared. Overall, 28,000 and 28,907 procedures were reported in era 1 and 2 with mean 14,000 and 14,450 procedures per year respectively. PN increased from 30% to 35% (P<0.0001) between the two eras. This uptake was similar in public and private hospitals. Accordingly, laparoscopic/robotic approach has significantly increased between the two eras (35% versus 39%, P<0.0001) and even more importantly in public hospitals (P=0.0017). There was a significant increase in laparoscopic/robotic PN as well as a decrease in open RN over the years of the study period. This study showed the development of PN and the minimally invasive approach. Over the study period, minimally invasive procedure uptake was higher in public hospitals.

Prevalence of baseline chronic kidney disease in 2,769 Chinese patients with renal cancer: Nephron-sparing treatment is still underutilized

To evaluate the prevalence of baseline chronic kidney disease (CKD) in a large cohort of patients with renal masses in a single Chinese institution. Estimated glomerular filtration rate (eGFR) and CKD stage are more clinically relevant to predict the risk of morbidity and mortality in patients after nephrectomy. But, sCr reflects renal function poorly. We retrospectively identified patients undergoing kidney surgery between January 2002 and June 2012. eGFR was calculated using the modification of diet in renal disease formulas modified based on Chinese people. CKD stages I–V were defined using the National Kidney Foundation definitions. A total of 2769 patients had adequate data available to calculate a preoperative eGFR (mL/min/1.73m2) with renal cancer confirmed by pathology. Of all patients, 97.7 % awaiting surgery at our institution had a “normal” baseline sCr (≤1.4 mg/dL), and 3.2 % of patients had CKD stage III or worse. Of the 401 patients ≥70 years old, 16.7 % (67/401) had CKD stage III. Many patients with a seemingly normal sCr have CKD stage III or worse, especially in patients over 70 years old. Given the high prevalence of baseline CKD in patients with renal cancer, it is important to preserve renal parenchyma when treating them surgically.

Der Einfluss von Adipositas auf urologische Tumorerkrankungen

Overweight presents a growing problem in our society; therefore, there is an increasing interest to understand the influence of obesity on urological forms of cancer. In prostate cancer the development of a more aggressive phenotype seems to correlate with obesity. In renal cell cancer (RCC) obesity is both, a risk factor for occurrence -and is also associated with an improved tumour-specific survival in patients with organ-confined disease following kidney surgery as well as overall survival of patients with advanced disease receiving VEGF(R)-targeted treatment. In contrast, even though an association between body mass index (BMI) and bladder cancer has been described the role of obesity in bladder cancer remains largely unclear as published data are contradictory. An update on currently available data focusing on the relationship between obesity and genitourinary malignancies is given in this review; however, basic research which is necessary to define the biological and metabolic effects associated with obesity and which might affect the development and progression of urological cancers, is indicated.

Celastrol protects kidney against ischemia–reperfusion-induced injury in rats

BackgroundIschemia–reperfusion (IR) causes various damages in renal tissues, which is exacerbated by hypoxia-induced excessive inflammation and deteriorates the prognosis of patients after kidney surgery. Celastrol is a potent inflammation inhibitor that has little toxicity. In this report, we investigated whether celastrol protects against IR-induced renal injury in rats. Materials and methodsRenal IR injury was induced by occlusion of the bilateral renal pedicles for 45 min followed by reperfusion for 6 h. Celastrol or vehicle solution was intraperitoneally injected 30 min before renal ischemia, respectively. Renal histology, function, and pro-inflammatory cytokines and mediators were assessed. The effect of celastrol on nuclear translocation of nuclear factor kappa B (NF-κB) was also measured. ResultsCelastrol significantly suppressed elevation of the renal function markers and the lipid peroxidation level, alleviated renal tubular damage, and decreased the levels of tumor necrosis factor-α, interleukin-1β, and monocyte chemotactic protein-1 (MCP-1) messenger RNA in kidney caused by IR. Moreover, celastrol prevented IR-induced expression of pro-inflammatory mediators, which was associated with suppression of nuclear translocation of NF-κB subunit p65. ConclusionsCelastrol ameliorated the acute kidney injury caused by IR, which was associated with inhibiting local NF-κB activation and inflammation. Our findings suggest that celastrol could be useful for preventing IR-induced renal injury.

Attenuation and De-focusing During High-Intensity Focused Ultrasound Therapy Through Peri-nephric Fat

High-intensity focused ultrasound (HIFU) is an attractive therapy for kidney cancer, but its efficacy can be limited by heat deposition in the pre-focal tissues, notably in fat around the kidney (peri-nephric fat), the acoustic properties of which have not been well characterized. Measurements of attenuation were made using a modified insertion-loss technique on fresh, unfixed peri-nephric fat obtained from patients undergoing kidney surgery for cancer. The de-focusing effect of changing the position of the fat layers was also investigated using fresh subcutaneous fat from euthanized pigs. The mean attenuation of human peri-nephric fat was found to be 11.9 ± 0.9 Np/m (n = 10) at 0.8 MHz, the frequency typically used for HIFU ablation of kidney tumors, with a frequency dependence of f1.2. A typical 2- to 4-cm thickness of peri-nephric fat would result in a de-rated intensity of 3%–62% at 0.8 MHz compared with a hypothetical patient with no peri-nephric fat. Through the use of freshly excised porcine subcutaneous fat, the presence of fat 100 mm in front of the focus was found to have a de-focusing effect of approximately 1 mm in both transverse directions, which corresponds to a full HIFU beam width off-target. Peri-nephric fat may significantly affect both the intensity and accuracy of HIFU fields used for the ablation of kidney cancer.

Infrared Thermometer: an accurate tool for temperature measurement during renal surgery

To evaluate infrared thermometer (IRT) accuracy compared to standard digital thermometer in measuring kidney temperature during arterial clamping with and without renal cooling. 20 pigs weighting 20Kg underwent selective right renal arterial clamping, 10 with (Group 1 - Cold Ischemia with ice slush) and 10 without renal cooling (Group 2 - Warm Ischemia). Arterial clamping was performed without venous clamping. Renal temperature was serially measured following clamping of the main renal artery with the IRT and a digital contact thermometer (DT): immediate after clamping (T0), after 2 (T2), 5 (T5) and 10 minutes (T10). Temperature values were expressed in mean, standard deviation and range for each thermometer. We used the T student test to compare means and considered p < 0.05 to be statistically significant. In Group 1, mean DT surface temperature decrease was 12.6 ± 4.1°C (5-19°C) while deep DT temperature decrease was 15.8 ± 1.5 °C (15-18 °C). For the IRT, mean temperature decrease was 9.1 ± 3.8 °C (3-14°C). There was no statistically significant difference between thermometers. In Group 2, surface temperature decrease for DT was 2.7 ± 1.8°C (0-4°C) and mean deep temperature decrease was 0.5 ± 1.0 °C (0-3 °C). For IRT, mean temperature decrease was 3.1 ± 1.9°C (0-6°C). No statistically significant difference between thermometers was found at any time point. IRT proved to be an accurate non-invasive precise device for renal temperature monitoring during kidney surgery. External ice slush cooling confirmed to be fast and effective at cooling the pig model.

Conservative Care Best for Small Renal Cancers

Older patients with kidney tumors smaller than 1.5 cm are up to 70% less likely to die from any cause when managed by watchful waiting rather than by surgery, based on findings from a large retrospective study. Surveillance appears to be safe for these small lesions, with a renal cancer mortality of just 3% over a 5-year period. In addition, watchful waiting seems to confer a cardiovascular benefit; these patients had a 49% lower cardiac mortality risk compared with that for patients who had kidney surgery, said lead author Dr. William C. Huang of New York University Medical Center. The link between kidney surgery and heart problems is probably mediated by compromised kidney function, Dr. Huang said. “It's believed that when surgery takes excess normal kidney tissue, it hastens the acceleration of kidney failure,” leading to cardiovascular problems, he said. The study findings are going to be increasingly valuable as imaging turns up more and more incidental asymptomatic kidney tumors. Last year alone, about 65,000 of these lesions were diagnosed, most of them during a work-up for other abdominal complaints. While the trend toward surveillance of small asymptomatic lesions is growing, Dr. Huang said surgery is still the treatment mode for more than half of cases. Most procedures in the retrospective study were radical nephrectomies, with kidney removal in about half of those. “The majority of these small lesions could be removed laparoscopically, but even then you're taking out normal kidney tissue that you might really want back someday,” he said at a press briefing at the Genitourinary Cancers Symposium, sponsored by the American Society for Clinical Oncology, the American Society for Radiation Oncology, and the Society of Urologic Oncology. “Physicians can comfortably tell an elderly patient, especially a patient who is not healthy enough to tolerate general anesthesia and surgery, that the likelihood of dying of kidney cancer is low and that kidney surgery is unlikely to extend their lives,” he said. “However, since it is difficult to identify which tumors will become lethal, elderly patients who are completely healthy and have an extended life expectancy, may opt for surgery.” Editor's NoteMost of us probably are not big proponents of nephrectomies for our frail, elderly patients with renal cell carcinomas anyway, but this study – while retrospective – is large enough for us to have some decent and fairly compelling science to back up our recommendations to our patients and their families for conservative care. It's probably best not to even get a surgical consult.—Karl Steinberg, MD, CMD, Editor in Chief Most of us probably are not big proponents of nephrectomies for our frail, elderly patients with renal cell carcinomas anyway, but this study – while retrospective – is large enough for us to have some decent and fairly compelling science to back up our recommendations to our patients and their families for conservative care. It's probably best not to even get a surgical consult. —Karl Steinberg, MD, CMD, Editor in Chief The study examined mortality data in the Surveillance, Epidemiology, and End Results database for 8,317 patients, aged 66 years or older, who were diagnosed from 2002 to 2007 with kidney tumors smaller than 1.5 cm. The patients were followed for a median of 59 months; 78% were managed with surgery and 22%, with surveillance. The use of surveillance increased over the course of the study, from about 25% in 2002 to almost 40% in 2007. During the study, 2,078 (25%) of the patients died, including 277 (3%) who died of renal cancer. Cardiovascular events occurred in 24% of patients. Kidney cancer mortality rates did not vary between the treatment groups. However, surgical patients had a significantly increased risk of death from any cause. At 7-36 months, those who had surveillance were 30% less likely to have died than those managed by surgery (hazard ratio [HR], 0.70). After 36 months, patients were 63% less likely to have died if their tumors were managed by surveillance instead of surgery (HR, 0.37). Dr. Huang also demonstrated that people in the surveillance group experienced a significant cardiovascular benefit, as well. By the end of the study, 25% of the deaths were attributable to a cardiovascular event. Patients in the surveillance group had a 49% reduction in the chance of an event. Dr. Huang said he had no relevant financial conflict of interest.

1569 NOVEL AUGMENTED REALITY VIDEO SIMULATION FOR ROBOTIC PARTIAL NEPHRECTOMY SURGERY TRAINING

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment (II)1 Apr 20131569 NOVEL AUGMENTED REALITY VIDEO SIMULATION FOR ROBOTIC PARTIAL NEPHRECTOMY SURGERY TRAINING Andrew Hung, Patrick Ramos, Jeremy Montez, and Inderbir Gill Andrew HungAndrew Hung Los Angeles, CA More articles by this author , Patrick RamosPatrick Ramos Los Angeles, CA More articles by this author , Jeremy MontezJeremy Montez Los Angeles, CA More articles by this author , and Inderbir GillInderbir Gill Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.3099AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Existing robotic virtual reality simulators have focused on basic surgical skills. Mimic Technologies and USC Urology have jointly developed a prototype training module featuring augmented reality simulation on the dV-Trainer. Users observe 3D video of robotic kidney surgery and operate augmented virtual instruments to identify anatomy, demonstrate technical skills, and learn steps of the operation. Herein, we evaluate the face, content, and construct validity of the proof-of-concept prototype. METHODS Pre-study questionnaires were used to classify participants as “novice” (no prior robotic cases as primary surgeon (n=24)) or “expert” (≥30 cases (n=12)). Participants were prospectively assessed on a training module featuring the bowel mobilization segment of a robotic partial nephrectomy. Performance metrics collected using Mimic software on the dV-Trainer were categorized as anatomy, technical, or steps. A post-study questionnaire assessed realism of simulation module (face validity), and utility as training tool (content validity). Wilcoxon nonparametric test compared performance data between cohorts (construct validity). RESULTS Novice and expert surgeons had performed a median of 0 and 200 (30-2015) robotic cases, respectively (p=0.004). Experts rated the module as “very realistic” (median 8/10 (range 4-10)) and “very useful” for resident training (9/10 (5-10)). Anatomy and steps exercises rated highly as training tools (8.5/10 (6-10) and 8/10 (5-10), respectively). Technical exercises in the prototype form received more modest scoring (5.5/10 (2-9)). Experts outperformed novices on overall attempts to correct answer (p=0.004), while they took similar time to complete all exercises (p=0.1). Expert outperformed novices on steps questions (no. attempts p<0.0001; answering time p=0.004), but performed similarly on anatomy questions (no. attempts p=0.2; time p=0.09) and technical skills exercises (no. attempts p=0.06; time p=0.7). CONCLUSIONS This proof-of-concept prototype using augmented reality simulation has face and content validity, and construct validity in teaching steps of the operation. Anatomy identification and technical skills training exercises will undergo further refinement in development. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byHung A, Shah S, Dalag L, Shin D and Gill I (2018) Development and Validation of a Novel Robotic Procedure Specific Simulation Platform: Partial NephrectomyJournal of Urology, VOL. 194, NO. 2, (520-526), Online publication date: 1-Aug-2015. Volume 189Issue 4SApril 2013Page: e643-e644 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Hung Los Angeles, CA More articles by this author Patrick Ramos Los Angeles, CA More articles by this author Jeremy Montez Los Angeles, CA More articles by this author Inderbir Gill Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V24 Complications during robot-assisted kidney surgery

V24 Complications during robot-assisted kidney surgery

Cirugía de puerto único transumbilical con instrumentos laparoscópicos convencionales en riñón en herradura

IntroductionLaparoscopic surgery is following a natural course as it decreases surgical aggression on the abdominal wall without undermining the curative and functional results. Although it is still being developed, single port surgery has meant an advance in this sense. Material and methodsWe present the first single port laparoscopic pyelolithectomy surgery in horseshoe kidney, using conventional rigid instruments. The case of an 18-year old patient with BMI of 19 in whom the imaging tests (urogram and computed tomography) showed a horseshoe kidney with left coralliform lithiasis and discrete calyceal ectasia is presented. The lithiasis was extracted using umbilical access with single port device and conventional rigid instruments. ResultsThe surgery was performed without complications. Surgery time was 110minutes and bleeding 50 cc. On incision of the urinary system, there was purulent urine extravasation that conditioned fever of 38°C in the post-operatory period. During the intervention, a double J stent was placed via percutaneous approach. The patient was discharged on the third day of hospitalization. ConclusionSingle port laparoscopic access for pyelolithectomy surgery in horseshoe kidney is a reasonable alterative. The use of conventional rigid instruments facilitates the performance of this surgery with good triangulation, without conflict regarding hands and safety for the patient.

Urine Neutrophil Gelatinase-Associated Lipocalin as a Marker of Acute Kidney Injury After Kidney Surgery

We evaluated urine NGAL as a marker of acute kidney injury in patients undergoing partial nephrectomy. We sought to identify the preoperative clinical features and surgical factors during partial nephrectomy that are associated with renal injury, as measured by increased urine NGAL vs controls. Using patients treated with radical nephrectomy or thoracic surgery as controls, we prospectively collected and analyzed urine and serum samples from patients treated with partial or radical nephrectomy, or thoracic surgery between April 2010 and April 2012. Urine was collected preoperatively and at multiple time points postoperatively. Differences in urine NGAL levels were analyzed among the 3 surgical groups using a generalized estimating equation model. The partial nephrectomy group was subdivided based on a preoperative estimated glomerular filtration rate of less than 60, or 60 ml/minute/1.73 m(2) or greater. Of 162 patients included in final analysis more than 65% had cardiovascular disease. The median estimated glomerular filtration rate was greater than 60 ml/minute/1.73 m(2) in the radical and partial nephrectomy, and thoracic surgery groups (61, 78 and 84.5 ml/minute/1.73 m(2), respectively). Preoperatively, a 10 unit increase in the estimated glomerular filtration rate was associated with a 4 unit decrease in urine NGAL in the partial nephrectomy group. Postoperatively, urine NGAL in the partial nephrectomy group was not higher than in controls and did not correlate with ischemia time. Patients with partial nephrectomy with a preoperative estimated glomerular filtration rate of less than 60 ml/minute/1.73 m(2) had higher urine NGAL postoperatively than those with a higher preoperative estimated rate. Urine NGAL does not appear to be a useful marker for detecting renal injury in healthy patients treated with partial nephrectomy. However, patients with poorer preoperative renal function have higher baseline urine levels and appear more susceptible to acute kidney injury, as detected by urine levels and Acute Kidney Injury Network criteria, than those with a normal estimated glomerular filtration rate.

Bowel and Related Injuries in Laparoscopic Urologic Surgery

Introduction: Laparoscopy with low morbidity and rapid recovery process than open surgery is a preferred surgical technique.1,2 The aim of this video was to illustrate the points we should take care to avoid bowel injuries and treatment modalities in laparoscopic urological surgery. Materials and Methods: Bowel injuries and treatment options during two laparoscopic nephrectomies, one laparoscopic cyst decortication, and two laparoscopic prostatectomies are presented in this video. Results: In the first case, duodenal injury that occurred during laparoscopic right transperitoneal radical nephrectomy was presented. The use of scissor during the medial dissection of the kidney caused duodenal perforation, and the surgeon converted to open surgery. In the second case, serosal injury of colon that occurred during right transperitoneal laparoscopic cyst decortication was presented. To expose the cyst, dissection was performed, so medial from the white-line, close to the bowel, under poor image using bipolar energy and serosal injury of colon was occurred. Primer suturation of the lesion was performed laparoscopically. In the third case, colon injury during transperitoneal nephrectomy of nonfunctioned kidney with the history of multiple pyelonephritis and fistula to the skin was presented. Dissection was performed, so medial from the white-line and bipolar energy was used close to the bowel. This caused colon injury, which has not been noticed peroperatively. Open surgery was needed because of the ileus at postoperative 3rd day. Colon perforation was detected and repaired by primer suturing and temporary ileostomy. In the fourth case, injury of denonviller during laparoscopic retroperitoneal ascending radical prostatectomy was presented. While performing the dissection of right neurovascular bundle, denonviller injury occurred with right-angled forceps. Prostatectomy was completed, and then denonviller injury was repaired with two-layer continuous suture laparoscopically. In the last case, rectal injury during laparoscopic radical prostatectomy was presented. Bleeding occurred during the dissection of posterior urethra. Without identifying the source of bleeding, multiple bipolar coagulations were performed over denonviller that was close to the rectum. Rectal injury was detected after observing the air bubbles those insuflated from the rectal tube. Rectal injury was repaired with double-layer suturation laparoscopically. Conclusion: The surgeon must take care with the duodenum at right transperitoneal approaches, which is close to the kidney, and should not use sharp instruments during dissection. Dissection should be initiated at the layer of white-line, not medial to it, in transperitoneal laparoscopic kidney surgeries. We should avoid using bipolar energy close to the bowel and not forget the importance of clear image in laparoscopic surgery. When making dissection over denonviller, the surgeon must take care that he is at the true layer. In laparoscopic radical prostatectomy, we should avoid using electrosurgical energy over denonviller fascia, which can cause rectal injuries as well as rectal necrosis and fistulas at postoperative period. If there is any doubt about rectal injury, air insuflation through the rectal tube can show us any rectal injury, and can be repaired with double-layer suturation. Different preventions of these complications can be performed by surgeons, depending on their experience. Runtime of video: 9 mins 55 secs No competing financial interests exist.

Kidney surgery

Ureteronephrectomy is the most commonly performed surgical procedure of the kidney. It is indicated when one of the kidneys is detrimental to the animal's health whilst the function of the contralateral one is adequate to sustain life. This frequently occurs in cases of advanced hydronephrosis – usually secondary to obstruction of the ureter or the renal pelvis. Whenever possible the kidney is spared, and alternative procedures are performed to resolve the obstruction. Nephrotomy and pyelotomy are rarely performed, and recently have been associated with or superseded by ureteral stenting. All the latter procedures are technically challenging, and require advanced expertise and facilities.

Adolescent Obesity and Paternal Country of Origin Predict Renal Cell Carcinoma: A Cohort Study of 1.1 Million 16 to 19-Year-Old Males

The incidence of renal cell carcinoma has increased in recent decades, particularly among middle-aged adults. Early precursors of renal cancer remain unclear. We evaluated the association of body mass index and height determined in late adolescence, and paternal or grandpaternal country of origin with the risk of renal cell carcinoma. Health related data on 1,110,835 males at ages 16 to 19 years who were examined for fitness for military service between 1967 and 2005 were linked to the Israel National Cancer Registry in this nationwide, population based cohort study. We used Cox proportional hazards modeling to estimate the HR of renal cell carcinoma associated with birth year, body mass index, height, father country of origin and socioeconomic indicators. During 19,576,635 person-years of followup renal cancer developed in 274 examinees. Substantial excess risk was conferred by a body mass index of greater than 27.5 kg/m(2) compared to less than 22.5 kg/m(2) (HR 2.43, 95% CI 1.54-3.83, p <0.0001). Asian or African origin was protective compared to European origin (African origin HR 0.67, 95% CI 0.49-0.92). Overweight in late adolescence is a substantial risk factor for renal cell carcinoma. European origin is independently associated with excess risk and it persists among Israeli born males. Preventing childhood obesity may be a promising target for decreasing the burden of renal cancer.