Kidney Surgery Research Articles

MEMORIES OF PROFESSORS OF D. IZRAEL (1848–1926) AND M. NITTS (1848–1906) (TO THE 170 ANNIVERSARY SINCE BIRTH)

The article notes that James Israel and Max Nitze have successfully developed European medicine for more than 30 years of their scientific and practical activities, enriching it with both experimental and large clinical experience. Their scientific achievements greatly contributed to the development of modern clinical urology throughout the world. Based on an analysis of the results of more than 1000 nephrectomy operations for tuberculosis, Izrael made a conclusion about the effectiveness of surgical treatment of this disease. In addition to kidney surgery, J. Israel developed questions of rhinoplasty. He participated in the International Congress of Physicians in Moscow (1897), where he reported on 191 kidney operations. He was an honorary member of the German Society of Surgeons, the Berlin Society of Urology, President of the International Congress of Urology (Paris, 1908). The main merit of M. Nitze is the invention of a cystoscope, in which for the first time an electric light source for illuminating the bladder was located at the end of a tool inserted into the bladder. The invention of the cystoscope contributed to the development of urology as an independent clinical discipline and marked the beginning of endoscopic studies of various organs and body cavities. It is analyzed the fact that the history of medicine gives rich material not only to understanding evolution, but also to the possibility to foresee its further development. The current state of clinical urology is determined by the progress of basic research in biology, physics, biochemistry, bacteriology, immunology, pharmacology. At the same time, it was noted that the personality of the scientist-physician, his observation, the non-standard view, the ability to see the opening perspectives, to bring up worthy students, to create a scientific and clinical school of urologists, is of utmost importance, at the same time, to the full compliance of the great German urologists J Israel and M. Nitze.Disclosure: The study did not have sponsorship. The author declares no conflict of interest.

Entry techniques in laparoscopic radical and partial nephrectomy: a multicenter international survey of contemporary practices.

There is no clear consensus as to the optimal method of entry in laparoscopic renal surgery and no reports have compared them in Urology. To analyze contemporary practice patterns in entry technique and port placement for laparoscopic kidney surgery. We identified 60 high volume urological laparoscopic centers. A purpose-built questionnaire was sent to surgeons. The survey included 22 questions regarding access techniques and port configuration during laparoscopic kidney surgery. Data on were collected and retrospectively analyzed. Concordance among port configurations was assessed using Cohen's Kappa statistics. The survey was sent to 60 surgeons and completed by 32 of them. Surgical procedures included were laparoscopic radical nephrectomy (1177 LRN/year) and laparoscopic partial nephrectomy (1047 LPN/year). The transperitoneal route was preferred (85%). Hasson technique was used for the access in 55% of the cases. Patient lateral recumbent position is the most frequently used during the port placement (41%). Although there is a high variability in the port positioning among the surgeons, in more than 90% of cases it was found a specific concordance in triangulation of optics and operating trocars. There were no significant differences between port configuration in LRN and LPN. Limitations include retrospective design and limited sample. A standard port configuration has not been previously reported in urological literature. Our study suggests that the transperitoneal approach, the Hasson technique and a specific triangulation of optics and operating trocars have a significant concordance in some high volume laparoscopic urologic centers.

Demographic characteristics and complications of open and minimally invasive surgeries for renal cell carcinoma: a population-based case-control study in Taiwan.

IntroductionRenal cell carcinoma (RCC) is one of the most lethal urological malignancies, and surgeries remain the mainstay for localized RCC. This study aimed to compare the selection of open surgery and minimally invasive kidney surgery for RCCs for the aspects of complication, medical costs, and patient preference.Materials and methodsWe conducted a population-based case–control study by using the National Health Insurance Research Database of Taiwan, which included data from 23 million Taiwanese residents. Patients newly diagnosed with RCC during 2006–2012 were included. We compared the general characteristics, underlying disease, complications, hospital stay, postoperative analgesic dosage, and medical costs between open group and minimally invasive group.ResultsA total of 3,172 patients who received radical nephrectomy (RN) or partial nephrectomy (PN) for RCC were included. The mean age was 61.1 years, with a male to female ratio of 1.88. In the minimally invasive groups, the mean hospital stay was significantly shorter than in open groups (12.4 days in open RN versus 10.3 days in minimally invasive RN, and 9.7 days in open PN versus 8.2 days in minimally invasive PN). There was no significant difference between the medical costs and the incidence of major bleeding complication between the open group and the minimally invasive group. Female patients and patients with higher monthly income were more likely to receive minimally invasive surgery.ConclusionDuring past decades, open RN has gradually been replaced by minimally invasive surgeries and PN. Compared to open surgeries, minimally invasive surgeries could lead to less postoperative pain and faster recovery. Economic status of the patients potentially hinders them from receiving minimally invasive surgeries, which may cost more.

Increased Nrf2 expression by renal cell carcinoma is associated with postoperative chronic kidney disease and an unfavorable prognosis.

Chronic kidney disease (CKD) is a worldwide health problem, and prevention of CKD is important for preservation of renal function after kidney surgery. There is evidence that transcription factor nuclear factor erythroid 2–related factor 2 (Nrf2) has a vital antioxidant and detoxifying role in protecting the kidneys against various diseases. Impaired activation of Nrf2 is associated with oxidative stress related to CKD, and Nrf2 is also a key player in the development of cancer. However, the clinical impact of Nrf2 has not been investigated in patients with renal cell carcinoma (RCC). A retrospective study was performed in 89 patients undergoing nephrectomy for RCC. The estimated glomerular filtration rate (eGFR) and serum uric acid (SUA) were investigated over time after surgery. We investigated Nrf2 protein expression in all tumors and single nucleotide polymorphisms (SNPs) of the Nrf2 gene in 7 tumors. In patients whose tumors showed higher Nrf2 expression, there was a more rapid decrease of eGFR and increase of SUA after nephrectomy. Multivariate analysis confirmed that increased Nrf2 expression was an independent poor prognostic factor related to shorter overall survival. Among the 7 tumor samples, an SNP on exon 5 of the Nrf2 gene in one tumor and three genotypes (C/C, C/A, and A/A) of rs6721961 at the promoter region of the Nrf2 gene were observed. Although the mechanisms underlying the influence of Nrf2 are still unclear, our findings suggested that elevated tumor expression of Nrf2 was associated with postoperative CKD and biologically aggressive RCC with an unfavorable prognosis.

Preoperative practice of surgical position reduces postoperative pain and discomfort in patients receiving kidney surgeries: a nonrandomized pilot study.

ObjectiveProlonged maintenance of surgical position often results in postoperative pain and discomfort in patients. The present study aimed to investigate the effect of preoperative practice of surgical position on postoperative pain and general comfort in patients receiving kidney surgeries.MethodsFor this nonrandomized pilot study, 74 patients receiving kidney surgeries were selected using the probability sampling method. Patients from ward 1 were assigned to the practice group (n=35), and those from ward 2 were assigned to the control group (n=39). The practice group were instructed to practice the surgical position for 3 days prior to the surgery. Postoperative pain and comfort were surveyed using two questionnaires for 3 days, respectively. The postoperative pain scores were compared using the Student’s t-test.ResultsThe two groups did not differ significantly in wound pain on postoperative days 1–3 (P > 0.05). However, the practice group showed significantly reduced low back pain and contralateral shoulder pain than the control group for 3 postoperative days (P < 0.05). The physical domain score was significantly higher in the practice group than in the control group (P < 0.01).ConclusionPreoperative practice of surgical position can effectively reduce postoperative low back pain and contralateral shoulder pain in patients receiving kidney surgeries and improve the physical comfort.

A Novel Dorsal Slit Approached Non-Ischemic Partial Nephrectomy Method for a Renal Tissue Regeneration in a Mouse Model.

Kidney ischemia-reperfusion (IR) via laparotomy is a conventional method for kidney surgery in a mouse model. However, IR, an invasive procedure, can cause serious acute and chronic complications through apoptotic and inflammatory pathways. To avoid these adverse responses, a Non-IR and dorsal slit approach was designed for kidney surgery. Animals were divided into three groups, 1) sham-operated control; 2) IR, Kidney IR via laparotomy; and 3) Non-IR, Non-IR and dorsal slit. The effects of Non-IR method on renal surgery outcomes were verified with respect to animal viability, renal function, apoptosis, inflammation, fibrosis, renal regeneration, and systemic response using histology, immunohistochemistry, real-time polymerase chain reaction, serum chemistry, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining, and Masson's trichrome staining. The Non-IR group showed 100% viability with mild elevation of serum blood urea nitrogen and creatinine values at day 1 after surgery, whereas the IR group showed 20% viability and lethal functional abnormality. Histologically, renal tubule epithelial cell injury was evident on day 1 in the IR group, and cellular apoptosis enhanced TUNEL-positive cell number and Fas/caspase-3 and KIM-1/NGAL expression. Inflammation and fibrosis were high in the IR group, with enhanced CD4/CD8-positive T cell infiltration, inflammatory cytokine secretion, and Masson's trichrome stain-positive cell numbers. The Non-IR group showed a suitable microenvironment for renal regeneration with enhanced host cell migration, reduced immune cell influx, and increased expression of renal differentiation-related genes and anti-inflammatory cytokines. The local renal IR influenced distal organ apoptosis and inflammation by releasing circulating pro-inflammatory cytokines. The Non-IR and dorsal slit method for kidney surgery in a mouse model can be an alternative surgical approach for researchers without adverse reactions such as apoptosis, inflammation, fibrosis, functional impairment, and systemic reactions.

Robotic Pyelolithotomy, Extended Pyelolithotomy, Nephrolithotomy, and Anatrophic Nephrolithotomy.

We are a reporting on the indications, techniques, and limitations of robotic surgery in the management of renal stones disease. Robotic surgery is a good tool to manage large kidney and ureteral stones, particularly in patients with anatomic anomalies. We describe three techniques in managing staghorn kidney stones: robotic anatrophic nephrolithotomy, robotic pyelolithotomy, and robotic nephrolithotomy. Robotic pyelolithotomy (RP) is ideal for patients with large renal pelvis and partial staghorn stone with a wide extra-renal pelvis. Robotic nephrolithotomy (RN) is ideal for stones inside a calyceal diverticulum or a partial staghorn eroding into the renal parenchyma. Renal vascular control could be avoided in most of those surgeries. Robotic anatrophic nephrolithotomy (RAN) is the most complex procedure and is reserved for patients with complete staghorn stones when percutaneous approach was not successful or not feasible. Control of renal vasculature is required for RAN. For robotic kidney surgeries, patients are positioned in a lateral decubitus position. Four or five ports are placed based on the stone location and surgeon's preference. We prefer the trans-peritoneal approach as it gives us the optimal exposure. For RP and RN, hilar control is usually not required. The renal pelvis/ renal parenchyma is incised, and the stones are carefully removed. If needed intra-operative flexible nephoscopy can be used to remove residual stones fragments. The collecting system is closed using an absorbable suture. DJ stent if needed is placed in an antegrade fashion. For RAN, the kidney is fully mobilized, and hilar control is required to avoid excessive bleeding. The kidney is incised along Brodel's line and the stones are extracted. The kidney parenchyma is then closed using 1 or 2 layers. We achieved an almost 100% stone free rate with RP and RN. RAN remains a challenging procedure with a success rate around 70%. Robotic surgery is a viable option to manage large renal and ureteral stones particularly in situations where endoscopic approach is not successful or feasible.

MP59-09 UNPLANNED INTRAOPERATIVE CONVERSION TO OPEN DURING MINIMALLY INVASIVE KIDNEY SURGERY: THE IMPACT OF ROBOTICS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI1 Apr 2018MP59-09 UNPLANNED INTRAOPERATIVE CONVERSION TO OPEN DURING MINIMALLY INVASIVE KIDNEY SURGERY: THE IMPACT OF ROBOTICS Abhinav Khanna, Daniel Sun, Alvin Wee, and Robert Abouassaly Abhinav KhannaAbhinav Khanna More articles by this author , Daniel SunDaniel Sun More articles by this author , Alvin WeeAlvin Wee More articles by this author , and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1861AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Over the last two decades, there has been brisk adoption of minimally invasive surgical approaches (MIS) for major kidney surgery. Unplanned intraoperative conversion from MIS to open surgical approach adds patient morbidity, cost, and may mitigate the benefits of MIS. The frequency of intraoperative conversion for robotic and laparoscopic kidney surgery is unknown. We aim to compare rates of unplanned intraoperative conversion for robotic versus laparoscopic approaches among patients undergoing major kidney surgery. METHODS The National Cancer Database was used to identify patients with renal or upper urinary tract tumors who underwent robotic or laparoscopic partial nephrectomy, radical nephrectomy, or nephro-ureterectomy from 2010-2014. Baseline demographic and clinical characteristics, as well as intraoperative conversion rates to open surgery, were compared between robotic and laparoscopic approaches using chi-square. Multivariate logistic regression was used to identify predictors of intraoperative conversion. Between group differences in length of stay were analyzed using the Wilcoxon rank sum test. Propensity score 1:1 matching was performed to confirm study results. RESULTS A total of 61,191 patients underwent MIS partial nephrectomy (n=24,691), radical nephrectomy (n=33,644), or nephroureterectomy (n=2,856) during the study period. As shown in Figure 1, unplanned intraoperative conversion rates were lower for robotics than for laparoscopy across all surgery types (p<0.001). On multivariate logistic regression adjusting for clinical and sociodemographic variables, laparoscopic approach was associated with conversion from MIS to open compared to robotic approach. Median length of stay was significantly longer for patients who underwent intraoperative conversion than for those who did not (4.0 vs 3.0 days, p<0.0001). All analyses were repeated in propensity score matched cohorts, and results were confirmed. CONCLUSIONS Among patients undergoing minimally invasive major kidney surgery, robotic approach is associated with a lower rate of unplanned intraoperative conversion to open surgery than laparoscopic approach. This relative advantage should be considered when weighing the costs and benefits of robotic kidney surgery. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e784-e785 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Abhinav Khanna More articles by this author Daniel Sun More articles by this author Alvin Wee More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP59-03 A MULTICENTRE ANALYSIS OF THE ROLE OF THE G8 SCREENING TOOL IN THE ASSESSMENT OF PERI-OPERATIVE AND FUNCTIONAL OUTCOME IN ELDERLY PATIENTS WITH KIDNEY TUMOURS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI1 Apr 2018MP59-03 A MULTICENTRE ANALYSIS OF THE ROLE OF THE G8 SCREENING TOOL IN THE ASSESSMENT OF PERI-OPERATIVE AND FUNCTIONAL OUTCOME IN ELDERLY PATIENTS WITH KIDNEY TUMOURS Tommaso Silvestri, Nicola Pavan, Riccardo Boschian, Giacomo Di Cosmo, Bernardino De Concilio, Antonio Celia, Giovanni Liguori, and Carlo Trombetta Tommaso SilvestriTommaso Silvestri More articles by this author , Nicola PavanNicola Pavan More articles by this author , Riccardo BoschianRiccardo Boschian More articles by this author , Giacomo Di CosmoGiacomo Di Cosmo More articles by this author , Bernardino De ConcilioBernardino De Concilio More articles by this author , Antonio CeliaAntonio Celia More articles by this author , Giovanni LiguoriGiovanni Liguori More articles by this author , and Carlo TrombettaCarlo Trombetta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1855AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Increasing life expectancy in the general population and the fact that a disproportional burden of cancer occurs in people age ≥ 65 years old have generated great interest in delivering better cancer care for older adults. EORTC and NCCN recommend that all patients with cancer age ≥ 70 years old should undergo some form of geriatric assessment. G8 Screening Tool is a robust geriatric tool to identify a geriatric risk profile and for prediction of functional decline and prognostic information for overall survival. We evaluated the role of G8 Screening Tool in the assessment of outcome of elderly patients (≥ 70 y.o.) underwent surgery for kidney tumours. METHODS We prospectively enrolled 162 patients (≥ 70 years old at surgery date) from January 2012 to January 2016 underwent surgery at two urological institution.G8 Screening Tool was applied to each patient before surgery. We divided population into two groups (frail group vs. not-frail group) in relation to the geriatric risk profile based on G8 score (≤14 vs. > 14 respectively). The aim was to identify the role of G8 Score in predicting intraoperative, postoperative complications and functional outcomes. RESULTS A total of 70 females (34%) and 92 (46%) males were included in the analysis. 69 patients (42,6%) underwent PN, while 93 patients (57,4%) underwent RN. Mean age at surgery was 76.57 (SD±6,37). Comorbidity factors were included: mean CCI was 3.06 (SD±1,99) with CCI > 5 points in 18 patients (15,65%), mean BMI was 25,15 (SD±2,87), 55 patients (34%) with DM, 98 patients (60%) with HTN. CKD stage III was present in 73 patients (45,1%) underwent surgery. Mean ECOG PS was 1,53 (SD±0,66) with score ≥ 3 in 7 patients (6,1%). Mean ASA Score was 2,84 (SD±0,73). According to the G8 Score, 91 patients (60%) were included in the frail group and 71 (40%) in the not-frail group. 41 patients of frail group vs. 2 patients of not-frail group developed intraoperative complications (p<0,0001). 51 patients of frail group vs. 4 patients of not-frail group developed postoperative complications (p<0,0001). After a mean follow-up of 40,56 months, mean eGFR was 43,72 ml/min/1.73m2 (SD±21,49) in frail group vs. 47,53 ml/min/1.73m2 (SD±13,36) in not-frail group (p=0,015). CONCLUSIONS G8 Screening Tool seems to be an effective and useful instrument to predict the risk of complications and functional outcomes in elderly patients candidate for kidney surgery. However, further investigations should be necessary to confirm the good potential of this tool. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e782 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Tommaso Silvestri More articles by this author Nicola Pavan More articles by this author Riccardo Boschian More articles by this author Giacomo Di Cosmo More articles by this author Bernardino De Concilio More articles by this author Antonio Celia More articles by this author Giovanni Liguori More articles by this author Carlo Trombetta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V08-12 BLEEDING DISASTER MANAGEMENT DURING ROBOTIC RENAL SURGERY

You have accessJournal of UrologyProstate & Renal Oncology II1 Apr 2018V08-12 BLEEDING DISASTER MANAGEMENT DURING ROBOTIC RENAL SURGERY Amit Patel and Craig Rogers Amit PatelAmit Patel More articles by this author and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1978AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Intraoperative complications are reported in approximately 1.8% of robotic partial nephrectomy (RPN) cases. We demonstrate examples of published algorithms for management of bleeding during robotic kidney surgery using real-life scenarios in video format. METHODS We present 8 robotic renal surgery cases (5 partial, 3 radical nephrectomy) demonstrating management of escalating vascular injuries, bleeding during renorraphy and excision of mass during RPN, management of a misfired endovasular stapler and bleeding during radical nephrectomy (missed upper pole vessel and torn parasitic vessel), one requiring open conversion. RESULTS Steps to manage vascular injuries included compression, cautery, increased pneumoperitoneum and utilization of a pre-prepared rescue suture. Techniques to avoid bleeding during excision and renorraphy included early unclamping to help visualize vessels, utilization of clips/sutures to visible vessels, additional tightening of renorraphy sutures and clamping maneuvers to avoid venous congestion while improving renal artery occlusion. Steps to manage bleeding during nephrectomy included removal of remaining attachments to control a missed vessel and a controlled conversion to open procedure. 7 cases were managed with EBL<400ml, no transfusions, and hospital stay<3 days. One patient converted to open had an EBL of 800ml with 2 units transfused and a 5 day hospital stay. CONCLUSIONS Intraoperative bleeding during robotic renal surgery, although rare, can be disasterous if not managed appropriately. Familiarity of algorithms to manage intraoperative bleeding, and preparation for these scenarios, may help prevent unnecessary patient morbity. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e823 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Amit Patel More articles by this author Craig Rogers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Adhesive Bowel Obstruction Following Urologic Surgery: Improved Outcomes with Early Intervention

Objective: To describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes. Methods: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (2006-2011) were used to identify major urologic oncologic surgery patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis was performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, urinary tract infection, deep vein thrombosis, and pneumonia), major complications (myocardial infarction, pulmonary embolism, and sepsis), death, and postoperative length-of-stay were assessed. Results: Major urologic surgery was performed on 104,400 patients, with subsequent 5-year cumulative incidence of adhesive bowel obstruction admission of 12.4% following radical cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. During adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18 vs. 30%, p = 0.001), major complications (10 vs. 19%, p = 0.002), and median postoperative length of stay (8 vs. 11 days, p < 0.001) compared with delayed surgery. On multivariate analysis early surgery decreased the odds of minor/ moderate complications by 43% (p = 0.01), major complications by 45% (p = 0.03), and postoperative length of stay by 3.1 days (p = 0.01). Conclusion: Adhesive bowel obstruction is a significant long-term sequela of urologic surgery, for which early surgical management may be associated with improved perioperative outcomes.

Geometric techniques for robotics and HMI: Interpolation and haptics in conformal geometric algebra and control using quaternion spike neural networks

In this work, by reformulating screw theory (generalization of quaternions) in the conformal geometric algebra framework, we address the interpolation, virtual reality, graphics engineering, haptics. We derive intuitive geometric equations to handle surface operations like in kidney surgery. The interpolation can handle the interpolation and dilation in 3D of points, lines, planes, circles and spheres. With this procedure, we interpolate trajectories of surgical instrument. Using quaternions, we formulate the quaternion spike neural network for control. This new neural network structure is based on Spike Neural Networks and developed using the quaternion algebra. The real valued training algorithm was extended so that it could make adjustments of the weights according to the properties and product of the quaternion algebra. In this spike neural network, we are taking into account two relevant ideas the use of Spike neural network which is the best model for oculo-motor control and the role of geometric computing. As illustration. the quaternion spike neural network is applied for control of robot manipulator. The experimental analysis shows promising possibilities for the use of this powerful geometric language to handle multiple tasks in human–machine interaction and robotics.

UNUSUAL CAUSE OF PULMONARY HYPERTENSION

To diagnose the cause of pulmonary hypertension is sometimes challenging and may require interventional and advance imaging procedures. A 70-year-old male presented with progressive dyspnea and edema for several months. He had been stabbed at back and undergone kidney surgery in the past. Physical

Prospective evaluation of geriatric assessments as predictors of complications and functional outcome after major urologic tumor surgery in the older population.

597 Background: Old patients undergoing major urologic tumor surgery are at severe risk of functional deterioration. In this study we prospectively performed a comprehensive geriatric assessment to identify potential risk predictors for early functional outcome. Methods: Since January 2016, 75 patients undergoing elective cystectomy, prostatectomy or nephrectomy at the age of 70 or older have been enrolled prospectively. A selection of geriatric assessment tools was applied before surgery. Follow up data including standardized peri- and postoperative parameters were obtained at discharge and at day 30 and 180 after surgery (DRKS-ID: DRKS00009825). Results: 14.7% had radical cystectomy, 33.3% had radical prostatectomy and 52.0% had kidney surgery due to malignant tumor. The average age was 75.7 (70-88) years. Within hospital stay, 20.3% had major complications (Clavien-Dindo &gt; = 3) and 25% showed incomplete functional recovery at day 30 after surgery. The average reduction in activities of daily living (ADL) was -34.71. Major complications were significantly associated with impaired mobility (TUG, OR 7.350, p = 0.002), frailty (FrailScale, OR 5.007, p = 0.019) and ASA-Score (ASA, OR 4.400, p = 0.015). Incomplete functional recovery was strongly associated with preoperative impaired mobility (TUG, OR 11.524, p &lt; 0.001) but correlation with ASA-Score (ASA, OR 3.288, p = 0.070) and comorbidities (CCI, OR 3.833, p = 0.106) missed statistical significance. No correlation of functional deterioration was found with age and functional status at admission. The combination of selected assessment tools showed good prediction of early functional recovery (ErlangerIndex, OR 4.400, p = 0.019). Conclusions: Major urologic tumor surgery has a high risk of severe complications and incomplete recovery in old patients. Fast and easy-to-do preoperative assessment tools may predict functional outcome more precisely than age or preoperative functional status alone. Clinical trial information: DRKS00009825.

Iodine Content Analysis Using Dual-Energy Computed Tomography as a Biomarker of Transitional Cell Carcinoma, an Experience with Separation of the Clotted Blood and Tumorous Tissue.

The aim of this study was to evaluate the possibility to discriminate the blood clot from tumorous tissue in the assessment of transitional cell carcinoma (TCC), when CT data are used only from single-phase dual-energy CT (DECT). A total of 18 patients were included into the retrospective analysis of the prospectively collected data (the average age was 67.3 years, range=62-79 years, 12 males, 6 females). DECT was performed in all patients after intravenous administration of the iodinated contrast material. DECT analysis using three-material decomposition algorithm was used to discriminate blood and enhancing tumorous tissue. In all patients, TCC was detected and subsequently kidney surgery or endoscopy was performed within the next two weeks. The findings were compared with DECT results. In our cohort of patients we found 9 TCC of the renal pelvis or ureter and 7 TCC of the urinary bladder. The accuracy of the TCC detection was 94% (17/18). The presence of coagulated blood within the urinary collecting system together with a tumor was detected in 7 CT examinations. The blood coagulum without a confirmed malignant tumor was found in one case with false positive DECT finding. In other 6 cases bleeding was confirmed during surgery or endoscopy (accuracy 87%). The dual-energy data analysis enables discrimination of a blood clot from tumorous tissue. It helps in detection of UCC in cases when the excretion potential of the kidneys is decreased due to fulfillment of the collecting system with blood clots.

First robotic kidney surgeries in the UK

First robotic kidney surgeries in the UK

Laparoscopic assisted stone surgery in ectopic pelvic kidney

Laparoscopic assisted stone surgery in ectopic pelvic kidney

Perianesthetic Management of Laparoscopic Kidney Surgery.

Laparoscopic kidney surgery is commonly used for living donor, partial, and total tumor nephrectomy. The successful emergence of laparoscopic technique was justified by the many benefits offered such as reduced blood loss, tissue trauma, pain, and hospital stay. However, this comes at the expense of physiologic changes and complications secondary to pneumoperitoneum, surgical technique, and patient positioning with significant challenges in anesthetic management. A variety of laparoscopic approaches (transperitoneal, retroperitoneal, hand-assisted, robotic) are used with some having advantages over others. The kidneys are particularly sensitive to hemodynamic changes and pneumoperitoneum. Controversies in perioperative fluid administration exist. New modalities for postoperative pain control have been suggested. Laparoscopic kidney surgery is associated with multiple physiologic changes and adverse events but offers advantages of reduced postoperative pain, faster recovery, and shorter hospital stay. Understanding these physiologic changes and related anesthetic considerations is key for safe patient outcome.

Positive surgical margins are predictors of local recurrence in conservative kidney surgery for pT1 tumors.

ABSTRACTObjectives:The clinical significance of positive surgical margin (PSM) after a Nephron Sparing Surgery (NSS) is controversial. The aim of this study is to evaluate the association between PSM and the risk of disease recurrence in patients with pT1 kidney tumors who underwent NSS.Materials and Methods:Retrospective cohort study. A total of 314 patients submitted to a NSS due to stage pT1 renal tumor between January 2010 and June 2015 were included. Recurrence-free survival was estimated. The Cox model was used to adjust the tumor size, histological grade, pathological stage, age, surgical margins and type of approach.Results:Overall PSM was 6.3% (n=22). Recurrence was evidenced in 9.1% (n=2) of patients with PSM and 3.5% (n=10) for the group of negative surgical margin (NSM). The estimated local recurrence-free survival rate at 3 years was 96.4% (95% CI 91.9 to 100) for the NSM group and 87.8% (95% CI 71.9 to 100) for PSM group (p=0.02) with no difference in metastasis-free survival. The PSM and pathological high grade (Fuhrman grade III or IV) were independent predictors of local recurrence in the multivariate analysis (HR 12.9, 95%CI 1.8-94, p=0.011 / HR 38.3, 95%CI 3.1-467, p=0.004 respectively). Fuhrman grade proved to be predictor of distant recurrence (HR 8.1, 95%CI 1.6-39.7, p=0.011).Conclusions:The PSM in pT1 renal tumors showed to have higher risk of local recurrence and thus, worse oncological prognosis.

Concurrent Robotic Kidney and General Surgery Procedures

Introduction: When kidney tumors are found incidentally during evaluation of a general surgery condition, patients may request concurrent robotic surgeries to address both issues simultaneously.1,2 This video shows two such cases: first a concurrent robotic nephrectomy and cholecystectomy and second a concurrent robotic partial nephrectomy with partial gastrectomy. Methods: Robotic nephrectomy and cholecystectomy: A 46-year-old woman with right upper quadrant pain was found to have cholelithiasis and a 7.1 cm right renal mass. The procedure was performed with the daVinci Si system with a four-arm approach and flank position with no redocking. Ports were placed for robotic kidney surgery with a 5 mm subxiphoid port for a liver retractor. The upper pole attachments of the kidney were mobilized, facilitating cranial retraction of the liver and exposure of the gallbladder. The nephrectomy was done first and hilar vessels were ligated with specimen being placed in a retrieval bag. Attention was turned to the cholecystectomy, and the cystic duct and artery were dissected and ligated with robotic hemlock clips. The remaining gallbladder attachments were freed and the specimen was removed through retrieval bag. Robotic partial nephrectomy and partial gastrectomy: A 66-year-old woman with gastrointestinal symptoms was found to have a 3.1 cm enhancing mass off the gastric fundus consistent with a gastrointestinal stromal tumor (GIST) and an incidental 4 cm renal mass of the left lower pole. The procedure was performed with the daVinci Si system with a four-arm transabdominal approach in flank position and no redocking. Ports were placed for robotic kidney surgery with a Gelpoint for the assistant port to allow intraoperative assessment of the specimens. The partial gastrectomy was performed first, using the robotic vessel sealer to expose the gastric fundus. The endoGIA stapler was used to remove the lesion at its base with negative margins, which was removed through a retrieval bag through the Gelpoint. Partial nephrectomy was performed next. The colon was mobilized and the renal hilar vessels were dissected. Intraoperative ultrasound was used to delineate tumor margins and the tumor was excised through sharp and blunt dissection. Results: Robotic nephrectomy and cholecystectomy: operating room (OR) time was 170 minutes, estimated blood loss (EBL) was 30 mL, and hospital stay was 1 day. Final pathology report confirmed a 7.1 cm chromophobe renal-cell carcinoma (RCC) with sarcomatoid differentiation (pT2a). Gallbladder pathology report showed acute cholecystitis and cholelithiasis. Robotic partial nephrectomy and partial gastrectomy: OR time was 150 minutes, EBL was 200 mL, and hospital stay was 3 days. Final pathology report confirmed a 4 cm papillary RCC type 1 (pT1a), grade 3. Partial gastrectomy pathology report confirmed a 3.1 cm GIST tumor. An additional two cases were performed, including a nephrectomy showing clear RCC (pT4) with partial hepatectomy caused by RCC extension into the liver. The second case involved a nephrectomy demonstrating clear RCC (pT1b) alongside a right hemicolectomy because of tubulovillous adenoma. All procedures documented had negative margins and no complications. Conclusion: This video demonstrates the feasibility of concurrent robotic kidney procedures in conjunction with robotic general surgery procedures. With careful planning and proper technique, robotic kidney and robotic general surgery procedures may be performed simultaneously with favorable outcomes. No competing financial interests exist. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 7 mins 47 secs This video was presented at the North American Robotic Urology Symposium, February 2017, in Las Vegas, Nevada.