Kidney Surgery Research Articles

Minimally invasive cytoreductive nephrectomy: a multi-institutional experience.

To analyze the functional and oncologic outcomes of minimally invasive cytoreductive nephrectomy (CN) in three high-volume cancer centers. Three prospectively maintained, IRB-approved kidney surgery databases were queried from three high-volume cancer centers. All patients who underwent minimally invasive surgery (laparoscopic, hand-assisted laparoscopic, or robotic) partial or radical CN with existing measurable extra-renal metastatic disease between May 2001 and May of 2013 were included in this analysis. We identified 120 patients who underwent minimally invasive CN for metastatic renal cell carcinoma. Most of the surgeries were radical (93.3%) and performed laparoscopically (96.6%). Median operative time was 210min, with a median estimated blood loss of 150cc, and 11 (9.2%) patients received blood transfusions. Four (3.3%) patients were converted to open surgery due to locally advanced disease and/or bleeding. Postoperative complications were seen in 28 (23.3%) patients, of which 20 (71.4%) were classified as minor (Clavien-Dindo I-II). The median survival of the entire cohort was 25.7months, with a 3-year survival rate of 35%. Multivariate analysis indicated that only hypertension, brain metastasis, and pT stage were independently associated with worse overall survival (HR>1). Minimally invasive cytoreductive nephrectomy is feasible and safe in experienced hands with acceptable morbidity and oncological outcomes.

MP55-14 SURGICAL SCAR LOCATION PREFERENCE FOR PEDIATRIC KIDNEY AND BLADDER SURGERY: A CROWD-SOURCED POPULATION-BASED SURVEY

You have accessJournal of UrologyPediatrics: Urinary Tract Infection and Vesicoureteral Reflux1 Apr 2016MP55-14 SURGICAL SCAR LOCATION PREFERENCE FOR PEDIATRIC KIDNEY AND BLADDER SURGERY: A CROWD-SOURCED POPULATION-BASED SURVEY Michael Garcia-Roig, Curtis Travers, Jared Kirsch, and Andrew Kirsch Michael Garcia-RoigMichael Garcia-Roig More articles by this author , Curtis TraversCurtis Travers More articles by this author , Jared KirschJared Kirsch More articles by this author , and Andrew KirschAndrew Kirsch More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.605AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgeons strive to offer minimally invasive surgery (MIS) options with evidence of a reduced length of hospital stay (LOS) & postoperative pain for pediatric urology cases. MIS in our patients often require abdominal port placement & scarring, albeit small. We aimed to evaluate the choices adult patients make for themselves & their children regarding open & MIS scar location. METHODS A survey was generated assessing patient preference for scar location/size based on surgical procedures for bladder & kidney surgery with additional questions assessing the impact of LOS & pain. The survey was posted to Amazon Mechanical Turk (www.mturk.com) with a $0.20 reward/survey. Non-identifying demographic information was assessed. RESULTS Of the 499 respondents, 150 resided outside the United States & 50 worked in the medical field & were excluded. Analysis included 290 respondents, 127 (44%) male, with the following demographics being most prevalent: age 25-35 (40%), residing in Southeast region (27.2%), white race (81.7%), bachelors or associates degree (50%), married (41%), not disabled (90.3%), & no children (56.6%). A history of surgery was reported by 199 (68.6%), & 125 (43.1%) had surgery as a child. Of these patients, surgical scar bother was present in 99 (50.0%), of which 66 (68%) would be less bothered if it were underwear-hidden. Similarly, 35 (28%) reported their child having had surgery, with 20 (57.1%) reporting the scars would be less bothersome if underwear-hidden. The following were rated as important (vs not important) when choosing surgical options for adults & for their children (adults, children): pain, 224 (77.2%), 113 (91.2%); LOS, 171 (48.3%), 85 (68.5%); scar location, 140 (48.3%), 84 (67%). For pelvic surgery scar size/location, respondents were evenly split between a pfannenstiel & standard 3-port laparoscopic port placement at 127(43.8%) each. When scar location was illustrated with respect to the underwear line, 235 (81%) preferred a larger underwear-hidden pfannenstiel, & 103 (83.1%) for their child. For kidney surgery, a dorsal lumbotomy incision was preferred by 196 (67.6%) adults & for 85 (68.6%) children based on scar size/location. When renal MIS was presented as less painful with shorter LOS, it was chosen by 125 (43.1%) adults & for 67 (54%) of children as opposed to by 18 (6.2%) adults & for 8 (6.5%) children when asked based on scar size/location alone. CONCLUSIONS Adult & parent preference for scar location does not consistently favor smaller incisions, often independent of pain or LOS. Respondents frequently chose the traditional open surgery in favor of cosmesis. Parental decisions for surgery should involve scar location preference. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e741 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael Garcia-Roig More articles by this author Curtis Travers More articles by this author Jared Kirsch More articles by this author Andrew Kirsch More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

PD29-08 RELATIONSHIP OF POST-OPERATIVE CHRONIC KIDNEY DISEASE SUBTYPE STATUS AND OUTCOMES IN PATIENTS UNDERGOING RENAL SURGERY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II1 Apr 2016PD29-08 RELATIONSHIP OF POST-OPERATIVE CHRONIC KIDNEY DISEASE SUBTYPE STATUS AND OUTCOMES IN PATIENTS UNDERGOING RENAL SURGERY miki haifler, Robert Uzzo, Tianyu Li, Ron Gor, Dan Parker, Serge Ginzburg, haseebudin mohammed, Nakhil Waingankar, Ben Ristau, David Y.T Chen, Rosalia Viterbo, Richard Greenberg, Marc Smaldone, and Alexander Kutikov miki haiflermiki haifler More articles by this author , Robert UzzoRobert Uzzo More articles by this author , Tianyu LiTianyu Li More articles by this author , Ron GorRon Gor More articles by this author , Dan ParkerDan Parker More articles by this author , Serge GinzburgSerge Ginzburg More articles by this author , haseebudin mohammedhaseebudin mohammed More articles by this author , Nakhil WaingankarNakhil Waingankar More articles by this author , Ben RistauBen Ristau More articles by this author , David Y.T ChenDavid Y.T Chen More articles by this author , Rosalia ViterboRosalia Viterbo More articles by this author , Richard GreenbergRichard Greenberg More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , and Alexander KutikovAlexander Kutikov More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.526AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Recent reports suggest that patients who experience de novo chronic kidney disease (CKD) due to surgical removal of nephrons (CKD-S) differ from patients with pre-existing CKD who undergo similar procedures (CKD-M/S). Here, we evaluate survival in these groups following kidney surgery. METHODS We queried our prospective Kidney Cancer Database for all patients who underwent radical or partial nephrectomy during January 1990 to July 2015 where survival data was available. New baseline GFR (nbGFR) was calculated 30 days after surgery. We divided the cohort into 3 groups: no post-op CKD (nbGFR >60); new onset post-op CKD (CKD-S =nbGFR< 60 with normal pre-op GFR); and persistent CKD (CKD-M/S =nbGFR and preoperative GFR both < 60). New onset CKD patients (CKD-S) patients were then further divided into 2 groups: nbGFR <45 (severe) and nbGFR>45 (mild). Kaplan-Meier estimates were used to assess overall survival (OS) and cancer specific survival (CCS). Cox proportional hazards model was fitted while controlling for age, gender and comorbidities. RESULTS 947 patients were included in the study. No CKD, new onset CKD-S and persistent CKD-M/S groups included 525 (55.4%), 267 (28.19%) and 155 (16.37%) patients respectively. 67.27% of the patients were male and 65.8% had measured comorbidities. CKD-M/S had a lower nbGFR compared with CKD-S and no CKD (40 vs. 49 vs. 81, p<0.0001). The median follow-up was 40.1 m (IQR 18.6-69.9). CKD-M/S and CKD-S groups experienced similar overall and cancer specific survival for the first 5 years after surgery, but CKD-M/S survival declined thereafter. In the multivariable analysis, gender, age and comorbidities did not affect OS and CSS in patients with CKD post-op. In this cohort, CKD-S (HR 1.8 [95%CI 1.31-2.47], p<0.003) and CKD-M/S (HR 2.01 [95%CI 1.45-3.024], p<0.0001) status did influence OS and CSS compared with no CKD. Similar results were found for cancer specific mortality. Mild and severe CKD-S groups had similar overall survival in our cohort (p=0.746), while mild CKD-S group had better mean cancer specific survival (105 m vs. 56.m, p =0.013). CONCLUSIONS Our data support the finding that post-operative CKD subtype status is associated with survival outcomes. We note that CKD-S patients demonstrated outcomes superior to CKD-M/S patients, but inferior to the no CKD group. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e709 Advertisement Copyright & Permissions© 2016MetricsAuthor Information miki haifler More articles by this author Robert Uzzo More articles by this author Tianyu Li More articles by this author Ron Gor More articles by this author Dan Parker More articles by this author Serge Ginzburg More articles by this author haseebudin mohammed More articles by this author Nakhil Waingankar More articles by this author Ben Ristau More articles by this author David Y.T Chen More articles by this author Rosalia Viterbo More articles by this author Richard Greenberg More articles by this author Marc Smaldone More articles by this author Alexander Kutikov More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP75-02 MULTIPLEX PARTIAL NEPHRECTOMY IN THE MANAGEMENT OF PATIENTS WITH MULTIFOCAL RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V1 Apr 2016MP75-02 MULTIPLEX PARTIAL NEPHRECTOMY IN THE MANAGEMENT OF PATIENTS WITH MULTIFOCAL RENAL CELL CARCINOMA Michele Fascelli, Shawna Boyle, Spencer Krane, W Marsdon Linehan, and Adam Metwalli Michele FascelliMichele Fascelli More articles by this author , Shawna BoyleShawna Boyle More articles by this author , Spencer KraneSpencer Krane More articles by this author , W Marsdon LinehanW Marsdon Linehan More articles by this author , and Adam MetwalliAdam Metwalli More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1720AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Multiplex partial nephrectomy (mPNx) involves the removal of 3 or more renal lesions. This complex subset of surgical procedures is more commonly performed in populations of patients with hereditary renal cell carcinoma (RCC). We manage a large number of families with heritary RCC and have developed an approach to management of patients with multiple renal lesions. The objective of this analysis was to determine what differences exist perioperatively and postoperatively between standard partial nephrectomy and mPNx. METHODS 546 patients underwent partial nephrectomy at the National Cancer Institute between 2003 and 2014. We compared preoperative demographics including surgical modality, intraoperative and postoperative renal functional outcomes between those patients undergoing multiplex versus non-multiplex procedures. All eGFR values were calculated using the CKD-Epi Equation. RESULTS 326 patients underwent mPNx compared with 220 patients who underwent removal of one or two lesions (Table 1). Ten patients were excluded as they underwent radical nephrectomies. Preoperative differences were limited to age alone as mPNx patients tended to be younger (p<0.001), with no difference existed in distribution of sex or ethnicity. Operative time (p<0.001) and estimated blood loss (p<0.001) were greater in the mPNx cohort. When these are calculated on a per tumor basis these differences disappear, and even favor mPNx. There was a decreased use of clamping in the multiplex kidney surgeries. The trade-off between warm ischemia and blood loss is evident in this dataset. There was an an average 5.9% reduction in GFR in the mPNx patients, which is only moderately more than the 2.3% in simpler tumor resections. On a per tumor basis, the multiplex kidneys have 10x the lesions removed but lose 2x the renal function which shows excellent preservation of renal function. CONCLUSIONS Multiplex tumor resection appears to have increased perioperative risk which is reflective of the complexity of surgical intervention. This does not translate to clinically significant decreased renal function, but the surgeon performing the procedure should counsel the patient of the increased risks associated with the surgical intervention. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e978-e979 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michele Fascelli More articles by this author Shawna Boyle More articles by this author Spencer Krane More articles by this author W Marsdon Linehan More articles by this author Adam Metwalli More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Operating from a wheelchair

In 2002 Ans Khan had a paragliding accident that left him paralysed from the chest down. Despite this misfortune he continues to work as a Consultant Urological Surgeon, specialising in open kidney surgery, and is also an Associate Medical Director. In this article, he describes the uplifting story of how he came to terms with his injury and got back into the operating theatre.

A novel method for texture-mapping conoscopic surfaces for minimally invasive image-guided kidney surgery.

Organ-level registration is critical to image-guided therapy in soft tissue. This is especially important in organs such as the kidney which can freely move. We have developed a method for registration that combines three-dimensional locations from a holographic conoscope with an endoscopically obtained textured surface. By combining these data sources clear decisions as to the tissue from which the points arise can be made. By localizing the conoscope's laser dot in the endoscopic space, we register the textured surface to the cloud of conoscopic points. This allows the cloud of points to be filtered for only those arising from the kidney surface. Once a valid cloud is obtained we can use standard surface registration techniques to perform the image-space to physical-space registration. Since our methods use two distinct data sources we test for spatial accuracy and characterize temporal effects in phantoms, ex vivo porcine and human kidneys. In addition we use an industrial robot to provide controlled motion and positioning for characterizing temporal effects. Our initial surface acquisitions are hand-held. This means that we take approximately 55s to acquire a surface. At that rate we see no temporal effects due to acquisition synchronization or probe speed. Our surface registrations were able to find applied targets with submillimeter target registration errors. The results showed that the textured surfaces could be reconstructed with submillimetric mean registration errors. While this paper focuses on kidney applications, this method could be applied to any anatomical structures where a line of sight can be created via open or minimally invasive surgical techniques.

Solitary kidney - a clinical challenge for endourologist.

From an endourologist's perspective a solitary kidney lithiasis is not a specific condition. It can be approached with all currently available endourological techniques. However, none of these methods are free of complications nor have been exclusively compared in solitary kidney patients. The question stills remains, whether the solitary kidney needs extra clinical attention. Certainly safety issues are of special concern and the priority is to protect renal function as there is no “back-up” kidney. Severe complications are potentially life-threatening and can result in renal replacement therapy. That is why an endourologist should prefer methods which are minimally invasive and associated with the lowest complication risk. Shock wave lithotripsy is considered the safest method but we should not forget its relatively low stone-free rates (SFR) and rare, but serious complications like renal hematoma or steinstrasse. Percutaneous nephrolithotomy (PNL) in the solitary kidney patients group has been extensively explored. It is well known that because of the compensatory hypertrophy, the risk of parenchymal injury and bleeding can be higher. In the CROES PNL global study in the solitary kidney group (189 patients out of a total 5745) there were higher transfusion rates and the SFR were significantly lower when compared with the bilateral kidney group [1]. Adanur et al. have claimed that PNL cannot be considered as a minimally invasive surgery in the solitary kidney due to the possible risk of complications. In their opinion, retrograde intrarenal surgery (RIRS) should be the procedure of choice, even though staged procedures are more likely to improve SFR [2]. On the contrary, ureterorenoscopy (URS) and RIRS have been merely studied. Jones et al. in the systematic review identified only four studies considering URS in the solitary kidney [3]. Nevertheless, the findings of the review confirmed that solitary kidney lithiasis can be effectively and safely managed with URS. Furthermore, Ghosh and Somani showed that URS in the solitary kidney may be performed harmless as a day-case procedure [4]. In a recent study, Kuroda et al. found that RIRS for <2 cm calculi in solitary kidney patients is as safe as in bilateral kidney patients [5]. Moreover, the preferred procedure is often implemented with the special concern to avoid any possible complications. That is why all authors report routine post-operative stenting as an approach to get extra protection against obstructive uropathy resulting from residual fragments. In the functional or anatomic solitary kidney, the risk-benefit ratio frames the treatment decision because there is much more to lose than in the bilateral kidney patient group. In case of any serious complication we cannot rely on the compensating contralateral kidney. As usual, in ambiguous clinical cases, more dedicated clinical trials are needed to find the evidence-based guided way out. Clinical expertise remains the core factor in offering the best everyday practice, as the management of the solitary kidney stones is like “living on the edge” – one false move and you fail.

The triad of kidney, obesity, and bariatric surgery.

There is an epidemic of obesity in the USA. Obesity significantly increases the risk of developing chronic kidney disease. Multiple studies have shown overall health and mortalityrelated benefits of medical and surgical weight loss. Renal benefits of bariatric surgery include decrease in proteinuria and hyperfiltration. There have only been a few small studies in patients with abnormally low glomerular filtration rate (GFR) that have shown improvements in GFR postsurgery over a short term. Long-term and larger scale studies are needed to see if renal benefits of weight loss are sustained in post-bariatric surgery patients.

Pharmacotherapies for renal cell carcinoma in Japan.

The standard treatment for advanced renal cell carcinoma has changed dramatically in the past decade, from cytokine therapy to targeted therapy. Since sorafenib was approved in April 2008, four tyrosine kinase inhibitors and two mammalian target of rapamycin inhibitors have become available in Japan. Most Japanese renal cell carcinoma patients are treated by urologists who are involved in not only kidney surgeries, but also targeted therapy using tyrosine kinase inhibitors, as well as mammalian target of rapamycin inhibitors. Optimal treatment methods are selected from theoretically-based global recommendations, such as the National Comprehensive Cancer Network and European Society for Medical Oncology guidelines; however, real-world clinical practice might be different from that in non-Asian countries. This might be because of different practical conditions; for example, different adverse events and efficacy profiles, different healthcare system, and so on. In the present review, we examine current pharmacotherapy for renal cell carcinoma from evidence-based global data, and compare the reality of Japanese clinical practice to explore the importance of individualized patient therapy.

Bilateral diaphragmatic paralysis after kidney surgery

A 57-year-old woman underwent an enucleoresection of her right kidney angiomyolipoma. Two weeks later she was admitted to our hospital because of dyspnea at rest with orthopnea. The chest x-ray showed the elevation of both hemidiaphragms and the measurement of the sniff transdiaphragmatic pressure confirmed the diagnosis of bilateral diaphragmatic paralysis. A diaphragm paralysis can be ascribed to several causes, i.e. trauma, compressive events, inflammations, neuropathies, or it can be idiopathic. In this case, it was very likely that the patient suffered from post-surgery neuralgic amyotrophy. To our knowledge, there are only a few reported cases of neuralgic amyotrophy, also known as Parsonage-Turner Syndrome, which affects only the phrenic nerve as a consequence of a surgery in an anatomically distant site.

Reconstructive kidney surgery for organ-preserving therapy of renal tumors.

Background: The objective of this study was to evaluate differences in various clinical endpoints in patients with reconstructive surgery by renal partial nephrectomy for tumors up to 4 cm compared to tumors larger than 4 cm.Material and methods: A total of 170 partial renal resection patients that presented malignant tumors were included in the retrospective study. Data was analyzed retrospectively based on internal clinic files, as well as a questionnaire to enhance the follow-up clinical outcomes data obtained. The most important outcomes determined included post-operative renal function, intra- and post-operative complications, local recurrence rate and total survival time.Results: The local recurrence rate was 6.1% for tumors up to 4 cm in size, compared to 14.9% for tumors that were larger than 4 cm. Compared to results for partial resection of T1a tumors, results for partial resection of tumors larger than 4 cm are worse in terms of post-operative renal function (p=0.007), as well as in terms of a total complications rate (p=0.048). It is important to note that there was not only a higher risk of post-operative bleeding that required transfusions (p=0.012), but also a higher risk of a hypertensive episode during the post-operative period reviewed (p=0.022). In addition, the total survival time for patients presenting tumors of up to 4 cm in size was significantly better (p=0.003). Conclusion: The results of our retrospective study of 170 patients that underwent partial renal resection after the diagnosis of malignant tumors, is that partial renal resection presents an oncologicaly safe surgical solution with low local recurrence rates. Additionally, partial resection in case of tumors that are larger than 4 cm showed worse post-operative renal function, a higher complications rate and a worse survival rate.

Potential biomarkers for the early detection of acute kidney injury after percutaneous nephrolithotripsy

This study aims to investigate the role of urinary biomarkers in the determination of the potential risks of renal parenchymal tubular damage in adult patients who underwent percutaneous nephrolithotomy (PNL) with the indication of renal stone. A randomized and prospective controlled study was performed between June and December 2013. We enrolled 29 consecutive patients with renal calculi > 2 cm and who underwent PNL, as well as 47 healthy control subjects. Urine samples, including 2 h before surgery, 2 and 24 h after surgery were collected from the patient group. Freshly voided urine samples were collected from the control group. Kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), N-acetyl-glucosaminidase (NAG), and liver-type fatty acid binding protein (LFABP) levels were measured from these urine samples. The mean KIM-1/Cr value that measured 24 h after the operation was statistically significant, higher than its preoperative (preop) level (p = 0.045). A significant difference was detected between the mean preop and postoperative (postop) 24 h NAG/Cr values (p < 0.001). Also, postop 24 h NGAL/Cr levels were statistically significant, higher than its preop levels (p = 0.013). According to the comparison of preop and postop levels, an increase in LFABP/Cr values secondary to surgical intervention was observed without any statistically significant difference. Besides the LFABP/Cr levels do not change after percutaneous kidney surgery, KIM-1/Cr, NAG/Cr, and NGAL/Cr levels increase postop period, especially at 24 h. Further studies with a larger series and repeated measurements should be performed to clarify if they can be used to demonstrate renal damage after percutaneous surgery or not.

Ventricle wall dissection and vascular preservation with the pulsed water jet device: novel tissue dissector for flexible neuroendoscopic surgery.

Neuroendoscopic surgery allows minimally invasive surgery, but lacks effective methods to control bleeding. Water jet dissection with continuous flow has been used in liver and kidney surgery since the 1980s, and is effective for tissue manipulation with vascular preservation, but involves some potential risks, such as elevation of intracranial pressure during application in the ventricles. The authors previously reported the efficacy of the actuator-driven pulsed water jet device (ADPJ) to dissect soft tissue with vascular preservation in microscopic neurosurgery. This feasibility study investigated the use of the ADPJ to reduce the amount of water usage, leading to more safety with sustained efficacy. A small-diameter pulsed water jet device was developed for use with the flexible neuroendoscope. To identify the optimal conditions for the water jet, the flow rate, water pressure, and distance between the nozzle and target were analyzed in an in vitro study by using a gelatin brain phantom. A ventricle model was used to monitor the internal pressure and temperature. For ex vivo experiments the porcine brain was harvested and ventricle walls were exposed, and subsequently immersed into physiological saline. For in vivo experiments the cortex was microsurgically resected to make the small cortico-ventricle window, and then the endoscope was introduced to dissect ventricle walls. In the in vitro experiments, water pressure was approximately 6.5 bar at 0.5 mm from the ADPJ nozzle and was maintained at 1 mm, but dropped rapidly toward 50% at 2 mm, and became 10% at 3.5 mm. The ADPJ required less water to achieve the same dissection depth compared with the continuous-flow water jet. With the ventricle model, the internal pressure and temperature were well controlled at the baseline, with open water drainage. These results indicated that the ADPJ can be safely applied within the ventricles. The ADPJ was introduced into a flexible endoscope and the ventricle walls were dissected in both the ex vivo and in vivo conditions. The ventricle wall was dissected without obscuring the view, and the vascular structures were anatomically preserved under direct application. Histological examination revealed that both the vessels on the ventricle wall and the fine vessels in the parenchyma were preserved. The ADPJ can safely and effectively dissect the ventricle wall, with vascular preservation in immersed conditions. To achieve the optimal result of tissue dissection with minimal surgical risk, the ADPJ is a potential device for neuroendoscopic surgery of the ventricles.

An Arterial Based Complexity (ABC) Scoring System to Assess the Morbidity Profile of Partial Nephrectomy

BackgroundTumor characteristics affect surgical complexity and outcomes of partial nephrectomy (PN). ObjectiveTo develop an Arterial Based Complexity (ABC) scoring system to predict morbidity of PN. Design, setting, and participantsFour readers independently scored contrast-enhanced computed tomography images of 179 patients who underwent PN. InterventionRenal cortical masses were categorized by the order of vessels needed to be transected/dissected during PN. Scores of 1, 2, 3S, or 3H were assigned to tumors requiring transection of interlobular and arcuate arteries, interlobar arteries, segmental arteries, or in close proximity of the renal hilum, respectively during PN. Outcome measurements and statistical analysisInterobserver variability was assessed with kappa values and percentage of exact matches between each pairwise combination of readers. Linear regression was used to evaluate the association between reference scores and ischemia time, estimated blood loss, and estimated glomerular filtration rates at 6 wk and 6 mo after surgery adjusted for baseline estimated glomerular filtration rate. Fisher's exact test was used to test for differences in risk of urinary fistula formation by reference category assignment. Results and limitationsPairwise comparisons of readers’ score assignments were significantly correlated (all p<0.0001); average kappa = 0.545 across all reader pairs. The average proportion of exact matches was 69%. Linear regression between the complexity score system and surgical outcomes showed significant associations between reference category assignments and ischemia time (p<0.0001) and estimated blood loss (p=0.049). Fisher's exact test showed a significant difference in risk of urinary fistula formation with higher reference category assignments (p=0.028). Limitations include use of a single institutional cohort to evaluate our system. ConclusionsThe ABC scoring system for PN is intuitive, easy to use, and demonstrated good correlation with perioperative morbidity. Patient summaryThe ABC scoring system is a novel anatomy-reproducible tool developed to help patients and doctors understand the complexity of renal masses and predict the outcomes of kidney surgery.

Retrospective Analysis of the Efficacy and Safety of Sorafenib in Chinese Patients With Metastatic Renal Cell Carcinoma and Prognostic Factors Related to Overall Survival.

Sorafenib has been recommended as first- or second-line treatment for metastatic renal cell carcinoma (mRCC) by several guidelines. The objective of this study is to evaluate the efficacy of sorafenib monotherapy in Chinese patients with mRCC and determine the prognostic clinicopathologic factors associated with survival in these patients.This is a single-arm retrospective study conducted in 2 tertiary medical centers; 140 mRCC patients were enrolled between January 2007 and June 2014. Sorafenib was administered at a dose of 400 mg twice daily, and continued until disease progression, at which point the dose was increased to 600 or 800 mg twice daily, or the onset of an intolerable adverse drug event (ADE) that required dose reduction or temporary suspension of treatment.The primary endpoint was overall survival (OS), and the secondary endpoints included progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and safety.The median follow-up time was 32 months. The median OS and PFS were 24 months (range, 3-88 months) and 16 months (range, 0-88 months), respectively. Patients with clear cell carcinoma had a greater OS (P=0.001) whereas sarcomatoid differentiation (P=0.045) and disease progression (P=0.010) negatively impacted OS; time from kidney surgery or biopsy to initiation of sorafenib treatment was associated with PFS (P=0.027). Efficacy analysis revealed that 3 (2.1%) patients achieved complete responses, 28 (20.0%) patients experienced partial responses, 88 (62.9%) patients had stable disease, and 21 (15.0%) patients developed progressive disease. Moreover, the ORR was 22.1%, and the DCR was 85.0%. Most ADEs were classified as grades 1 or 2 with only 14 (10.0%) patients experiencing a severe ADE (grade 3).Sorafenib monotherapy can achieve promising OS and PFS for Chinese patients with mRCC, especially in those with clear cell carcinoma, with manageable adverse events.

IJU this issue

This issue includes 12 Original Articles, two Review Articles, one Case Report and one Urological Note. In one of the Review Articles, Kageyama et al. (Shiga, Japan) traced the history of proteome research in urothelial cancers. In this review, they introduced one promising factor named C7orf24/GGCT as a good candidate target molecule for the therapy. Unfortunately, there are only a few molecules to date that are utilized in the clinical field. The other Review Article by Elsamra et al. (New York, USA) picked up a very practical topic on stenting for malignant ureteral obstruction. Taguchi et al. (Tokyo, Japan) retrospectively reviewed 200 cases of metastatic urothelial carcinoma in terms of neutrophil-to-lymphocyte ratio (NLR). They concluded that elevation of pretreatment neutrophil-to-lymphocyte ratio is a poor prognostic factor for metastatic urothelial cancers. In terms of urothelial cancer, Satake et al. (Tokyo, Japan) reported that preoperative pyuria is a good prognostic marker for non-muscle-invasive bladder cancer. They also concluded that the presence of preoperative pyuria is a useful predictor for recurrence after bacillus Calmette-Guérin therapy. These two articles suggest the important roles of the immune system in the treatment of urothelial cancer. Gershman et al. (Minnesota, USA) examined whether there is a difference in the risk of estimated glomerular filtration rate decline between continent and incontinent urinary diversion after radical cystectomy in patients with preoperative chronic kidney disease stage 2 or 3a. That study gave us very important information that there was no significant difference in long-term renal function between two types of urinary diversions. As Zapata et al. (North Carolina, USA) concluded from the Shared Equal Access Regional Cancer Hospital database, it is interesting that smoking is a predictor of extracapsular extension, positive surgical margin or larger tumor volume. They speculate that smoking might have an impact on the immunological response against prostate cancer. This issue contains two articles related to lymph node dissection. One on penile cancer, by da Costa et al. (Sao Paulo, Brazil), reported that lymphovascular invasion and lymph node ratio (the number of positive nodes/number of total resected nodes) were the independent prognostic factors. The authors successfully showed the impact of risk stratification using lymph node ratio, lymphovascular invasion and extranodal extension on the prognosis of node-positive penile cancer. In another article, Nakamura et al. (Kyoto, Japan) insisted on the importance of resecting both residual retroperitoneal lymph node mass and extraretroperitoneal masses because of the histopathological discordance. Recently, chronic kidney disease has become a serious concern in carrying out kidney surgery. Nephron-sparing surgery for small renal mass is required as much as possible in order to prevent chronic kidney disease after surgery. Lee et al. (Seoul, Korea) compared postoperative estimated glomerular filtration rate between kidney donors and radical nephrectomy patients. According to their propensity-matched study, definite estimated glomerular filtration rate recovery was observed in the donor nephrectomy group rather than the radical nephrectomy group, suggesting kidney cancer itself has an unfavorable nature. In terms of voiding dysfunction, a near-infrared spectroscopic study of interstitial cystitis patients by Matsumoto et al. (Chiba, Japan) is very unique. It sheds light on the neuromodulatory approach to interstitial cystitis. I appreciate you understanding that I cannot introduce all the issues because of the limited space. None declared.

Advanced renal cell carcinoma associated with von Hippel-Lindau disease: A case report and review of the literature.

The autosomal dominant hereditary disorder von Hippel-Lindau (VHL) disease is caused by a germline mutation in the VHL gene. The symptoms of VHL include hemangioblastoma of the central nervous system, retinal angiomas, visceral tumors and multiple visceral cysts. However, advanced renal cell carcinoma (RCC) occurs in few VHL patients at initial diagnosis; in addition, sporadic VHL disease with de novo germline mutation is rare. The current study reports the clinical case of a 33-year-old Asian male patient diagnosed with advanced bilateral multicentric renal carcinomas. The patient underwent radical nephrectomy with embolectomy of the right kidney for treatment of T3b-stage RCC and laparoscopic nephron-sparing surgery of the left kidney. Sunitinib was administered following histological diagnosis and during follow-up. Genetic analysis revealed a missense mutation, c.194C>G (p.Ser65Trp). In addition, genetic analysis of the patient's parents and brothers, who were unaffected, confirmed a diagnosis of de novo VHL disease. To the best of our knowledge, the present study reports the first known case of a sporadic de novo germline mutation of VHL at c.194C>G. Current understanding of the molecular genetics and pathophysiology of VHL disease, as well as developments in surgical and target therapies for RCC have advanced in recent years; however, early detection through genetic screening and regular clinical surveillance of VHL disease patients and their families continues to be the primary basis for managing the disease.

Primitive neuroectodermal tumour of the kidney: An unusual case mimicking renal angiomyolipoma with minimal fat.

Primitive neuroectodermal tumour (PNET) is a highly aggressive neoplasm that develops classically in the central nervous system. PNET of the kidney (rPNET) is extremely rare. Recently, a 23-year-old woman complained of left flank pain and intermittent hematuria for 3 months and was admitted to our hospital. A computed tomography (CT) scan and magnetic resonance imaging demonstrated a 5.1 × 4.4-cm heterogenous mass with unconspicuous reinforcement in the upper pole of the left kidney. F18-FDG positron emission tomography CT (PET-CT) revealed the mass as a benign lesion with internal extensive bleeding. Renal angiomyolipoma with minimal fat was diagnosed. Three months later, a CT scan showed that the mass shrank to 3.1 × 2.6 cm and nephron-sparing surgery of the left kidney was performed at the patient's request. However, histologic features and immunohistochemical analysis confirmed the diagnosis of rPNET. Five cycles of combined chemotherapy were executed. At the 11-month follow-up, the patient showed no evidence of metastasis or recurrence.

Port Placement and Docking for Robotic Surgery: The University of Southern California Approach.

To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). We use a four-arm robotic approach and a 5 to 6 port placement consisting of: One 12-mm camera port, three 8-mm robotic ports, and one to two assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. This technique has been used since 2010 on more than 2370 robotic urologic cases. To date, no procedure has needed patient or robot positioning while maintaining fourth arm functionality with minimal robotic arm clashing. Our approach of port placement and robot docking is reproducible and feasible for pelvic surgical procedures and KS.

PD49-11 SURGICAL CHRONIC KIDNEY DISEASE APPEARS TO BE A DISTINCT SUBTYPE OF CHRONIC KIDNEY DISEASE BASED ON MORTALITY RISKS FOLLOWING RENAL SURGERY

You have accessJournal of UrologyKidney Cancer: Surgical Therapy VI1 Apr 2015PD49-11 SURGICAL CHRONIC KIDNEY DISEASE APPEARS TO BE A DISTINCT SUBTYPE OF CHRONIC KIDNEY DISEASE BASED ON MORTALITY RISKS FOLLOWING RENAL SURGERY Ronak Gor, Robert Uzzo, Tianyu Li, Mohammed Haseebuddin, Nikhil Waingankar, Serge Ginzburg, Marc Smaldone, and Alexander Kutikov Ronak GorRonak Gor More articles by this author , Robert UzzoRobert Uzzo More articles by this author , Tianyu LiTianyu Li More articles by this author , Mohammed HaseebuddinMohammed Haseebuddin More articles by this author , Nikhil WaingankarNikhil Waingankar More articles by this author , Serge GinzburgSerge Ginzburg More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , and Alexander KutikovAlexander Kutikov More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2729AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Chronic kidney disease (CKD) is associated with risk of all cause mortality. Removal of nephrons, via radical nephrectomy (RN), or nephron sparing surgery (NSS), results in immediate decline in renal function. Patients with preoperative GFR greater than 60 ml/min/1.73m2 may develop CKD after RN or NSS, termed, surgical CKD (CKD-S); however, recent work suggests preexisting CKD (CKD-M) may be a stronger predictor of overall survival (OS) than CKD-S. Thus, we set out to compare overall survival of patients with CKD-S and CKD-M to patients with normal perioperative renal function (No-CKD). METHODS Surgically treated patients between 1994 and 2014 with available pre and post-operative renal function data were identified in our prospectively maintained institutional registry. Kaplan-Meier (KM) survival curves with log rank statistic were used to assess OS based on pre and post-operative renal function. Multivariable analysis (MVA) was performed using Cox proportional hazard model to evaluate variables for independent association with OS. RESULTS Of 1454 patients who met inclusion criteria, 20.4% had CKD-M, 23.3% developed CKD-S, and 56.3% had No-CKD after surgery. Median follow-up was 3.5 years. Pre and post-operative renal function predicted OS on both univariate and multivariate analysis (MVA). KM curve separation was evident immediately following surgery. On MVA, after controlling for age, gender, race, hypertension, diabetes, coronary artery disease, peripheral vascular disease, congestive heart failure, and RN vs. NSS, CKD-S was not associated with a statistically significant difference in mortality compared with No-CKD (HR 1.2, 95% CI 0.9-1.6, p=0.21). Further, when compared to CKD-M, CKD-S and No-CKD groups had significantly lower risk of mortality (HR 0.76, 95% CI 0.57-1.00, p=0.05 and HR 0.63, 95% CI 0.47-0.86, p=0.003, respectively). CONCLUSIONS Renal function before and after kidney surgery predicts OS. Survival impact appears to be immediate, suggesting CKD status is a surrogate metric of mortality risk and likely not its primary cause. At intermediate follow-up, CKD-S has an attenuated correlation with OS compared to patients with CKD-M. As such, these findings support the concept of CKD-S as a distinct subtype of CKD. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byZabell J, Demirjian S, Lane B, Derweesh I, Isharwal S, Suk-Ouichai C, Wu J, Palacios D and Campbell S (2018) Predictors of Long-Term Survival after Renal Cancer SurgeryJournal of Urology, VOL. 199, NO. 2, (384-392), Online publication date: 1-Feb-2018. Volume 193Issue 4SApril 2015Page: e975-e976 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ronak Gor More articles by this author Robert Uzzo More articles by this author Tianyu Li More articles by this author Mohammed Haseebuddin More articles by this author Nikhil Waingankar More articles by this author Serge Ginzburg More articles by this author Marc Smaldone More articles by this author Alexander Kutikov More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...