Low Complexity Groups Research Articles

IMPACT OF LESION COMPLEXITY ON PCI SUCCESS IN LAD DISEASE: A RETROSPECTIVE STUDY

Coronary artery disease (CAD) involving the left anterior descending (LAD) artery is a major cause of morbidity and mortality globally. The prognosis of patients with coronary artery disease depends on the extent of at-risk myocardium. LAD comparatively supplies a large percentage of the left ventricle compared to RCA or LCX. The principal indication of percutaneous coronary intervention is to improve the quality of life in patients with angina refractory to medications. There are many advancements in PCI techniques for better management of challenging lesions due to physiological, anatomical, or functional difficulties. Some of the complex lesions include ostial lesions, bifurcating lesions, calcified lesions, and chronic total occlusions. However, as lesion complexity plays a significant role in procedural success and long-term outcomes, complex lesions are often associated with increased rates of restenosis, adverse events, and procedural challenges Objective: This study aims to evaluate the impact of lesion complexity on PCI success in patients with LAD disease. Methods: This retrospective cohort study was conducted from January 1, 2021, to December 31, 2023, at a tertiary cardiovascular center. A total of 216 participants who had PCI to LAD lesions done were included. Lesion complexity was assessed using the SYNTAX score and categorised into low, intermediate, and high complexity groups. The primary outcome was restenosis at 12 months, defined as ≥50% luminal narrowing in patients requiring repeat angiography due to any indication. Secondary outcomes included procedural success, major adverse cardiac events (MACE), and rates of stent thrombosis. Data were analysed using SPSS version 24.0, with statistical significance set at p < 0.05. Results: Among the 216 participants, 72% were male, and the mean age was 61.4 ± 9.8 years. Restenosis occurred in 13.9% of participants, with higher rates observed in patients with high-complexity lesions (24.5%) compared to low-complexity lesions (7.7%) (p = 0.02). Procedural success was achieved in 92.6% of cases, though it decreased with increasing lesion complexity (97.8% for low, 93.4% for intermediate, and 85.7% for high-complexity groups). MACE occurred in 4.6% of participants, with stent thrombosis noted in 2.7%. Conclusion: Lesion complexity significantly influences PCI success and restenosis rates in LAD disease. Patients with higher complexity lesions experience worse outcomes, necessitating individualised treatment strategies to optimise procedural success.

Evolution of Complexity of Palliative Care Needs and Patient Profiles According to the PALCOM Scale (Part Two): Pooled Analysis of the Cohorts for the Development and Validation of the PALCOM Scale in Advanced Cancer Patients.

Identifying the complexity of palliative care needs is a key aspect of referral to specialized multidisciplinary early palliative care (EPC) teams. The PALCOM scale is an instrument consisting of five multidimensional assessment domains developed in 2018 and validated in 2023 to identify the level of complexity in patients with advanced cancer. (1) Objectives: The main objective of this study was to determine the degree of instability (likelihood of level change or death), health resource consumption and the survival of patients according to the level of palliative complexity assigned at the baseline visit during a 6-month follow-up. (2) Method: An observational, prospective, multicenter study was conducted using pooled data from the development and validation cohort of the PALCOM scale. The main outcome variables were as follows: (a) instability ratio (IR), defined as the probability of level change or death; (b) emergency department visits; (c) days of hospitalization; (d) hospital death; (e) survival. All the variables were analyzed monthly according to the level of complexity assigned at the baseline visit. (3) Results: A total of 607 patients with advanced cancer were enrolled. According to the PALCOM scale, 20% of patients were classified as low complexity, 50% as medium and 30% as high complexity. The overall IR was 45% in the low complexity group, 68% in the medium complexity group and 78% in the high complexity group (p < 0.001). No significant differences in mean monthly emergency department visits (0.2 visits/ patient/month) were observed between the different levels of complexity. The mean number of days spent in hospital per month was 1.5 in the low complexity group, 1.8 in the medium complexity group and 3.2 in the high complexity group (p < 0.001). The likelihood of in-hospital death was significantly higher in the high complexity group (29%) compared to the medium (16%) and low (8%) complexity groups (p < 0.001). Six-month survival was significantly lower in the high complexity group (24%) compared to the medium (37%) and low (57%) complexity groups (p < 0.001). According to the PALCOM scale, more complex cases are associated with greater instability and use of hospital resources and lower survival. The data also confirm that the PALCOM scale is a consistent and useful tool for describing complexity profiles, targeting referrals to the EPC and managing the intensity of shared care.

PD37-03 DOES NEOADJUVANT CHEMOTHERAPY REDUCE THE COMPLEXITY OF WILMS TUMOR? AN ANALYSIS USING THE NEPHROMETRY SCORE

You have accessJournal of UrologyCME1 Apr 2023PD37-03 DOES NEOADJUVANT CHEMOTHERAPY REDUCE THE COMPLEXITY OF WILMS TUMOR? AN ANALYSIS USING THE NEPHROMETRY SCORE Catherine Nguyen, Eric Bih, Kathleen Hosek, Michelle Dai, and Niccolo Passoni Catherine NguyenCatherine Nguyen More articles by this author , Eric BihEric Bih More articles by this author , Kathleen HosekKathleen Hosek More articles by this author , Michelle DaiMichelle Dai More articles by this author , and Niccolo PassoniNiccolo Passoni More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003335.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Per the Children’s Oncology Group (COG) protocols, partial nephrectomy (PN) for Wilms tumor (WT) is reserved for bilateral tumors or lesions in solitary kidneys. Furthermore, most WTs are large masses that would not be amenable to partial nephrectomy. Unlike COG, the Societe Internationale d’Oncologie Pediatrique (SIOP) offers neoadjuvant chemotherapy (NAC) prior to surgical resection, allowing for tumor shrinkage. The Nephrometry score (NS) is a tool that was developed to assess the complexity of renal cell carcinoma, and thus the feasibility of partial nephrectomy. It relies on morphological features of tumors seen on cross-sectional imaging. The NS was however developed for renal cell carcinoma. Only one study to date has assessed Wilms tumors using the NS, showing that most are highly complex lesions not amenable to (PN). The goal of our study is to assess if NAC decreases the complexity of Wilms tumor using the NS. METHODS: We retrospectively identified patients with WT at our institution who received NAC (according to COG protocols). Pre- and post- treatment tumor volumes and NS were calculated by a single radiologist. For bilateral or multifocal tumors, the score was calculated for the most complex mass. NS was broken down into low, intermediate and high complexity groups. Rates of PN were stratified by NS score and by pre-operative variables. Statistical differences were assessed using paired t-tests and chi square tests. RESULTS: 54 patients were identified. The median pre- and post-treatment tumor volumes were 499 and 90 cm3, respectively (p<0.0001). Before NAC, NS was considered low, intermediate and high in 3.7%, 13% and 83.3% of patients, respectively. After NAC, the NS score was low, intermediate and high in 11.1%, 25.9% and 63% of patients. Fourteen tumors (26%) had their complexity downgraded. Overall rates of PN were 35% (n=19). There were statistically significant higher rates of PN for tumors with a low NS (83%) vs intermediate (64.3%) and high (14.7%) scores (p<0.0001). Among pre-operative variables such as age, sex, race, ethnicity, syndromic Wilms and stage, only female sex was statistically associated with higher rates of downgrading after NAC (36% vs 9.5% of males, p=0.028). CONCLUSIONS: The majority of WT are complex masses. Our data shows that NAC can reduce tumor complexity in 26% of cases, with more than half the patients with low or intermediate complexity WT undergoing successful PN. Further studies are needed to identify which patients with unilateral non-syndromic WT could benefit from NAC with the goal of nephron-sparing surgery. Source of Funding: Department © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e987 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catherine Nguyen More articles by this author Eric Bih More articles by this author Kathleen Hosek More articles by this author Michelle Dai More articles by this author Niccolo Passoni More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of children's cognitive load in processing and storage of their spatial working memory.

Working memory performance affects children’s learning. This study examined objective (task performance), subjective (self-report), and physiological (pupil dilation) cognitive load (CL) while children completed a spatial working memory complex span task. Frist, 80 Taiwanese 11-year-olds (40 boys) who participated in Experiment 1 confirmed the suitability of the materials. Then, 72 Taiwanese 11-year-olds (35 boys) were assigned to high and low complexity groups to participate in Experiment 2 to test the study hypothesis. Children had to recall at the end of a dual-task list and answer two questions regarding the difficulty and mental effort involved in processing and storage. Their pupil diameters were recorded using an eye-tracker. Two-way mixed ANOVA found that the processing requirements and memory load reduced storage and aggravated the subjective CL of storage; the subjective CL of processing was higher under highly complex conditions. Stepwise regression analysis indicated that subjective CL of processing predicted memory performance in low CL conditions, and physiological CL of processing predicted it in high CL conditions.

Investigating the Impact of Ultra-Radical Surgery on Survival in Advanced Ovarian Cancer Using Population-Based Data in a Multicentre UK Study.

Simple SummaryOvarian cancer is treated by surgery to remove all visible cancer and chemotherapy. Cancer survival is highest when no cancer is left behind after surgery. Ultra-radical (URS) surgery or maximal effort cytoreduction surgery uses additional surgical procedures, e.g., splenectomy, diaphragm stripping, etc. to remove all visible cancer. The use of URS varies internationally with some cancer centres performing this routinely and others not. We conducted a multi-centre study investigating 1471 patients with advanced ovarian cancer (AOC) across three types of gynaecological cancer centres in the UK—those offering mainly low, intermediate or high complexity surgery and investigated survival from cancer in an operated and non-operated whole cohort of women with advanced ovarian cancer. We found that cancer survival was highest in the centres practicing more radical surgery, even after age and deprivation of patients was taken into consideration. Centres practicing mainly low complexity surgery should change practice. We investigated URS and impact on survival in whole patient cohorts with AOC treated within gynaecological cancer centres that participated in the previously presented SOCQER 2 study. National cancer registry datasets were used to identify FIGO Stage 3,4 and unknown stage patients from 11 cancer centres that had previously participated in the SOCQER2 study. Patient outcomes’ association with surgical ethos were evaluated using logistic regression and Cox proportional hazards. Centres were classified into three groups based on their surgical complexity scores (SCS); those practicing mainly low complexity, (5/11 centres with >70% low SCS procedures, 759 patients), mainly intermediate (3/11, 35–50% low SCS, 356 patients), or mainly high complexity surgery (3/11, >35% high SCS, 356 patients). Surgery rates were 43.2% vs. 58.4% vs. 60.9%. across mainly low, intermediate and high SCS centres, respectively, p < 0.001. Combined surgery and chemotherapy rates were 39.2% vs. 51.8% vs. 38.3% p < 0.000 across mainly low, intermediate and high complexity groups, respectively. Median survival was 23.1 (95% CI 19.0 to 27.2) vs. 22.0 (95% CI 17.6 to 26.3) vs. 17.9 months (95% CI 15.7 to 20.1), p = 0.043 in mainly high SCS, intermediate, and low SCS centres, respectively. In an age and deprivation adjusted model, compared to patients in the high SCS centres, patients in the low SCS group had an HR of 1.21 (95% CI 1.03 to 1.40) for death. Mainly high/intermediate SCS centres have significantly higher surgery rates and better survival at a population level. Centres that practice mainly low complexity surgery should change practice. This study provides support for the utilization of URS for patients with advanced OC.

PD33-10 NEPHROMETRY AND CUMULATIVE MORBIDITY AFTER PARTIAL NEPHRECTOMY: A STANDARDIZED ASSESSMENT OF COMPLICATIONS IN THE CONTEXT OF R.E.N.A.L. AND PADUA SCORES

You have accessJournal of UrologyCME1 May 2022PD33-10 NEPHROMETRY AND CUMULATIVE MORBIDITY AFTER PARTIAL NEPHRECTOMY: A STANDARDIZED ASSESSMENT OF COMPLICATIONS IN THE CONTEXT OF R.E.N.A.L. AND PADUA SCORES Dejan K. Filipas, Hang Yu, Clemens Spink, Michael Rink, Silke Riechardt, Philipp Gild, Phillip Marks, Margit Fisch, Roland Dahlem, Christian P. Meyer, and Malte W. Vetterlein Dejan K. FilipasDejan K. Filipas More articles by this author , Hang YuHang Yu More articles by this author , Clemens SpinkClemens Spink More articles by this author , Michael RinkMichael Rink More articles by this author , Silke RiechardtSilke Riechardt More articles by this author , Philipp GildPhilipp Gild More articles by this author , Phillip MarksPhillip Marks More articles by this author , Margit FischMargit Fisch More articles by this author , Roland DahlemRoland Dahlem More articles by this author , Christian P. MeyerChristian P. Meyer More articles by this author , and Malte W. VetterleinMalte W. Vetterlein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002584.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephrometry scores aid in clinical decision-making and improve preoperative risk assessment in patients with renal masses scheduled for surgery. However, there is a lack of knowledge whether nephrometry scores are correlated with cumulative morbidity after partial nephrectomy (PN). We aimed to evaluate the association of PADUA and R.E.N.A.L. scores with the 30-d Comprehensive Complication Index (CCI®) after PN for renal masses. METHODS: Patients undergoing PN between 01/2019-08/2020 with preoperative imaging were included. R.E.N.A.L. and PADUA scores were calculated for each patient and 30-d complications were extracted from digital charts according to both a procedure-specific predefined catalog and the EAU Guidelines on Reporting and Grading of Complications. Pearson correlation was performed to evaluate the relationship between R.E.N.A.L/PADUA scores with the CCI®, which reflects cumulative morbidity on a scale from 0-100 and is based on the validated Clavien-Dindo classification. RESULTS: Of 122 patients, 101 (83%) underwent open and 21 (17%) robot-assisted PN for renal cell carcinoma, benign lesions, or other malignancies in 85 (70%), 29 (24%), and 8 (6.6) of the cases, respectively. Median PADUA and R.E.N.A.L. scores were 9 (IQR 8-10) and 8 (IQR 6-9), respectively. Overall, 218 complications were captured in 92 patients (75%), of which 95% were classified as Clavien-Dindo ≤IIIa. Overall median CCI® was 8.7 (IQR 0.50-15). In PADUA low (score 6-7), moderate (score 8-9), and high complexity (score 10-14) groups there was a difference in median CCI® (8.7 vs. 8.7 vs. 12; p=0.002), which was not confirmed for R.E.N.A.L low (score 4-6), moderate (score 7-9), and high complexity (score 10-12) groups (8.7 vs. 12 vs. 10; p=0.074). There was a small positive correlation between PADUA or R.E.N.A.L. score with CCI® (Figure 1), explaining only 4.7% and 4.1% of the variation in CCI®, respectively. CONCLUSIONS: In a tertiary referral center, PN can be safely performed with low short-term morbidity. Increasing tumor complexity as measured by validated nephrometry scores does not negatively impact perioperative complications when employing a standardized complication assessment and using the novel CCI® to capture comprehensive, cumulative morbidity. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e556 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dejan K. Filipas More articles by this author Hang Yu More articles by this author Clemens Spink More articles by this author Michael Rink More articles by this author Silke Riechardt More articles by this author Philipp Gild More articles by this author Phillip Marks More articles by this author Margit Fisch More articles by this author Roland Dahlem More articles by this author Christian P. Meyer More articles by this author Malte W. Vetterlein More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP50-14 SINGLE PORT VS MULTI PORT ROBOTIC RENAL SURGERY: ANALYSIS OF PERIOPERATIVE OUTCOMES FOR EXCISION OF HIGH AND LOW COMPLEXITY RENAL MASSES

You have accessJournal of UrologyCME1 May 2022MP50-14 SINGLE PORT VS MULTI PORT ROBOTIC RENAL SURGERY: ANALYSIS OF PERIOPERATIVE OUTCOMES FOR EXCISION OF HIGH AND LOW COMPLEXITY RENAL MASSES Grant Henning, Joel Vetter, Nicholas Pickersgill, Arjun Sivaraman, R. Sherburne Figenshau, and Eric Kim Grant HenningGrant Henning More articles by this author , Joel VetterJoel Vetter More articles by this author , Nicholas PickersgillNicholas Pickersgill More articles by this author , Arjun SivaramanArjun Sivaraman More articles by this author , R. Sherburne FigenshauR. Sherburne Figenshau More articles by this author , and Eric KimEric Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002625.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is limited data on the safety and feasibility of the da Vinci Single Port (SP)® robotic surgical system (Intuitive Surgical, Sunnyvale, CA) as a minimally invasive alternative to robotic platforms requiring multiple ports. We sought to compare perioperative outcomes between SP and multi-port (MP) robotic approaches for excision of high and low complexity renal masses. METHODS: Retrospective chart review was performed for all patients undergoing robotic partial or radical nephrectomy using the SP surgical system (N=23) at our institution between its adoption in November 2019 and November 2021. Patient demographics, preoperative imaging, operative approaches, and perioperative outcomes were recorded. Renal masses were categorized into high (7+) and low complexity groups (4-6) using the RENAL nephrometry scoring system (RNS). Patients were matched using an institutionally maintained MP database by patient BMI, renal mass size, renal mass complexity, and partial or radical nephrectomy in a 2:1 (MP:SP) ratio. Perioperative outcomes were compared. RESULTS: For high complexity tumors (N=12), SP renal surgery was associated with a significantly longer average operative time compared to MP surgery (248.4 ± 75.0 min vs 188.1 ± 61.0 min, p=0.02), and tended towards higher average estimated blood loss (410.0 ± 669.9 mL vs 171.2 ± 136.0 mL, p=0.62) and a higher positive surgical margin rate (25.0% vs 12.5%, p=0.38). For low complexity tumors (N=11), there was no significant difference in operative time (177.7 ± 53.9 min vs 161.4 ± 41.9 min, p=0.53), average estimated blood loss (69.6.0 ± 33.0 mL vs 142.0 ± 168.6 mL, p=0.62) or positive margins (9.1% vs 4.5%, p=1.00) between SP and MP approaches and all patients underwent successful partial nephrectomy using the SP system. Increasing nephrometry score was associated with a greater relative increase in operative time for SP compared to MP renal surgery (p=0.07) using best of fit linear modeling (Figure 1). CONCLUSIONS: SP nephron-sparing surgery is safe and feasible for low complexity renal masses. For excision of high complexity renal masses, the SP system is associated with a significantly longer operative time when compared to a MP approach. Careful selection should be performed when planning operative approach. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e870 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Grant Henning More articles by this author Joel Vetter More articles by this author Nicholas Pickersgill More articles by this author Arjun Sivaraman More articles by this author R. Sherburne Figenshau More articles by this author Eric Kim More articles by this author Expand All Advertisement PDF DownloadLoading ...

Complexity of antidiabetic medication regimen is associated with increased diabetes-related distress in persons with type 2 diabetes mellitus

IntroductionDiabetes-related distress is present in a high proportion of people with type 2 diabetes mellitus. We hypothesized that complexity of the antidiabetic medication regimen is a factor that is associated...

Validating a Patient-Reported Outcomes-Derived Algorithm for Classifying Symptom Complexity Levels Among Patients With Cancer.

The patient-reported outcomes (PROs) symptom complexity algorithm, derived from self-reported symptom scores using the Edmonton Symptom Assessment System and concerns indicated on the Canadian Problem Checklist, has not been validated extensively. This is a retrospective chart review study using data from the Alberta Cancer Registry and electronic medical records from Alberta Health Services. The sample includes patients with cancer who visited a cancer facility in Alberta, Canada, from February 2016 through November 2017 (n=1,466). The effect size (d=1.2) indicates that the magnitude of difference in health status between the severe- and low-complexity groups is large. The symptom complexity algorithm effectively classified subgroups of patients with cancer with distinct health status. Using Karnofsky performance status, the algorithm shows a sensitivity of 70.3%, specificity of 84.1%, positive predictive value of 79.1%, negative predictive value of 76.7%, and accuracy of 77.7%. An area under the receiver operating characteristic of 0.824 was found for the complexity algorithm, which is generally regarded as good, This same finding was also regarded as superior to the alternative algorithm generated by 2-step cluster analysis (area under the curve, 0.721). The validity of the PRO-derived symptom complexity algorithm is established in this study. The algorithm demonstrated satisfactory accuracy against a clinician-driven complexity assessment and a strong correlation with the known group analysis. Furthermore, the algorithm showed a higher screening capacity compared with the algorithm generated from 2-step cluster analysis, reinforcing the importance of contextualization when classifying patients' symptoms, rather than purely relying on statistical outcomes. The algorithm carries importance in clinical settings, acting as a symptom complexity flag, helping healthcare teams identify which patients may need more timely, targeted, and individualized patient symptom management.

Knowledge about Neonatal Screening among Postpartum Women and Complexity Level of Birthing Facilities.

Background: To ascertain the degree of knowledge of postpartum women about important aspects related to the neonatal screening process and whether differences of opinion exist between those who deliver in low-complexity versus high-complexity health facilities (low-risk versus high-risk pregnancies, respectively). Methods: This was a prospective, cross-sectional, questionnaire-based study. The sample consisted of postpartum women recruited from 2013 to 2015 at public maternity hospitals in the city of Niterói, Brazil. Participants were divided into two groups and completed a questionnaire consisting of Likert-scored items. Continuous variables were analyzed with the Mann-Whitney test, and categorical variables, with Fisher’s test. A confirmatory factor analysis of participants’ answers was performed. Results: Of 188 women enrolled, 54 (28.7%) had incomplete elementary education; 119 (62.2%) had attended more than six antenatal care visits. The mean age was 25.57 years. Nearly all women (n = 179, 95.2%) were roomed-in with their infants. Knowledge of neonatal screening was very similar in the high-complexity and low-complexity groups. Divergences were limited to items regarding the risks of neonatal screening. Conclusions: The degree of knowledge among postpartum women was similar among high- and low-complexity facilities. Those who attended high-complexity facilities had longer hospital stays and greater adherence to ethical issues regarding neonatal screening.

Association among the R.E.N.A.L. nephrometry score and clinical outcomes in patients with small renal masses treated with percutaneous contrast enhanced ultrasound radiofrequency ablation.

IntroductionAn association between the R.E.N.A.L. nephrometry score (RNS) and clinical outcomes in patients with a small renal mass (SRM) has been proposed. We analyzed clinical outcomes according to the RNS in patients with a SRM treated with percutaneous contrast enhanced ultrasound (CEUS) radiofrequency ablation (RFA).Material and methodsPatients with a SRM, who underwent RFA between January 2005 and March 2015, were retrospectively identified. The association between RNS and clinical outcomes was evaluated using parametric and non-parametric analysis.ResultsWe analyzed 163 SRMs in 149 consecutive patients. The mean age was 71.7 years. Mean follow-up time was 33.3 months ±20.6 (2–102). The mean RNS was 5.6 ±1.52 (4–11). A total of 121 (74.2%) cases were of low complexity and 42 (25.8%) were medium complexity. We identified 11 cases of tumor persistence (6.7%). The mean RNS was 5.58 in the cases with no persistence and 5.73 in the cases with persistence (p = 0.788). We identified 15 (9.2%) cases of recurrence. The mean RNS was 5.57 ±0.1 (4–11) in the cases without recurrence and 5.73 ±0.4 (4–9) in recurrence cases (p = 0.804). Of the 76 biopsy proven RCC cases, 8 (10.5%) cases of recurrence were observed, 5 in the low complexity group and 3 in the medium complexity group (p = 0.690). A total of 9 (5.5%) cases of complications were observed, with 5 (4.3%) in the low complexity group and 4 cases in the medium complexity group (p = 0.23). The mean length of stay was 1.5 days with a significant difference between low and medium complexity groups (1.3 vs. 2.1 days, p = 0.02). The mean difference between preoperative eGFR and estimated eGFRat 12 months was -3.08 mL / min ±13.3 (-49.4–34.1) and was significant (p = 0.008).However, this variation did not show significant differences between the low and medium complexity groups (p = 0.936). All-cause mortality was 11.7%, 14 cases (11.6%) in the low complexity group and 5 (11.9%) in the medium complexity group (p = 1.0). No cases of renal cell carcinoma (RCC) specific mortality were identified.ConclusionsThe RNS was not associated with tumor persistence, recurrence, cancer specific mortality, complications or renal function 12 months after the first treatment, showing significant difference only in length of hospital stay between low and medium complexity groups.

Tumor complexity and the impact on MIC and trifecta in robot-assisted partial nephrectomy: a multi-center study of over 500 cases.

To demonstrate the surgical feasibility of robot-assisted partial nephrectomy for complex renal masses with comparison of low/intermediate risk versus high-risk tumors according to the PADUA score. Since 2008, 538 robot-assisted partial nephrectomies were performed at three German robotic centers. Both the MIC (margin, ischemia, complications) criteria and trifecta were applied. 60.1% of the tumors were of low and intermediate complexity (PADUA score 6-9, n=326, group A), while 39.9% were highly complex (n=212, score≥10, B). Median clinical tumor size was 28 in A versus 37mm in B (p<0.001). There was no significant difference in terms of operative time (160 vs. 163min, p=0.20); ischemia time was slightly longer for B (11 vs. 12min, p<0.001). There were no significant differences for intra- (3.4%, A, vs. 6.6%, B, p=0.10) or postoperative (21.5%, A, vs. 25.5%, B, p=0.30) complication rates. There was a median eGFR decrease of -9.4 (A) versus -15.1 (B) ml/min (p<0.001) on discharge. Histopathology revealed an R1 margin rate of 3.4% for the low/intermediate versus 6.1% for the high complexity group (p=0.14). MIC criteria were fulfilled in 81.9% (A) versus 75.5% (B, p=0.11) and trifecta criteria in 74.2% (A) versus 68.93% (B, p=0.26). Complication rates, histopathology results as well as quality criteria as indicated by MIC and trifecta were similar for high and low complexity groups. Therefore, robot-assisted partial nephrectomy is a safe and feasible option also in highly complex tumors.

Brazilian Retrospective Study of Peripherally Inserted Central Catheter: 2011-2014

To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; ϕ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

The Direct and Indirect Costs of Ultrasound-Guided Peripherally Inserted Central Catheter Repositioning at a Large Academic Medical Center

BackgroundTo assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters. MethodsThis retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews. ResultsInitial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; ϕ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours. ConclusionsPICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

A Collaborative Process for Preventing Unnecessary Placement of Peripherally Inserted Central Lines for Parenteral Nutrition

To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; ϕ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

Vessel Health and Preservation: Selection Rights and Dashboard

To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; ϕ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

MP75-12 MULTICENTER COMPARISON OF ROBOTIC AND OPEN PARTIAL NEPHRECTOMY FOR QUALITY MEASURES CONTROLLING FOR TUMOR COMPLEXITY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V1 Apr 2016MP75-12 MULTICENTER COMPARISON OF ROBOTIC AND OPEN PARTIAL NEPHRECTOMY FOR QUALITY MEASURES CONTROLLING FOR TUMOR COMPLEXITY Zachary Hamilton, Sean Berquist, Abd-el Rahman Hassan, Catherine Defour, Alp Tuna Beksac, Fang Wan, Maria Marquine, Brian Lane, Sean Stroup, and Ithaar Derweesh Zachary HamiltonZachary Hamilton More articles by this author , Sean BerquistSean Berquist More articles by this author , Abd-el Rahman HassanAbd-el Rahman Hassan More articles by this author , Catherine DefourCatherine Defour More articles by this author , Alp Tuna BeksacAlp Tuna Beksac More articles by this author , Fang WanFang Wan More articles by this author , Maria MarquineMaria Marquine More articles by this author , Brian LaneBrian Lane More articles by this author , Sean StroupSean Stroup More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1730AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) is now the standard therapy for small renal masses. Robotic partial nephrectomy (RPN) is being rapidly adopted in this setting. Nonetheless, concerns persist about the risks of renal functional recovery in more complex masses, given the risk of prolonged warm ischemic time in RPN. We compared RPN and open PN (OPN) utilizing a composite outcome of surgical quality which emphasized renal functional recovery in addition to technical outcomes, while controlling for tumor complexity. METHODS Multicenter retrospective analysis of OPN and RPN in patients with small renal masses performed from 2000-2015. Demographics, tumor characteristics, perioperative outcomes were reviewed. Primary outcome was Trifecta, consisting of negative surgical margin, no perioperative complications within 30 days of surgery, and return of glomerular filtration rate (GFR) to ≥80% of baseline. Secondary outcome included ΔGFR at last follow up. Patients were stratified by RENAL nephrometry scores in three complexity groups: low (4-6), intermediate (7-9), and high (10-12), and comparisons between RPN and OPN were carried out within these groups. Multi-variable analysis (MVA) was performed to identify risk factors associated with achievement of Trifecta. RESULTS 798 patients were analyzed (mean age 62.9 ± 13.78 years, tumor size 3.3 ± 2.3 cm, 54.8% RPN/44.2% OPN; 38.4% were simple (71.7% RPN/28.3% OPN), 44.5% were intermediate (63.6% RPN/36.4% OPN), and 17.1% were high complexity (37.6% RPN/62.4% OPN). ΔeGFR for RPN vs. OPN for simple, intermediate, and high complexity RENAL scores was 3.01 vs. -0.13 (p=0.3), 1.22 vs. -3.95 (p=0.105), and -4.20 vs. -0.12 (p=0.543), respectively. There was no difference in trifecta rate between RPN and OPN for low complexity (53.4% vs. 43.2%, p=0.267) or high complexity (39.3% vs. 51.0%, p=0.319) groups. For intermediate complexity masses, RPN had improved rates of trifecta (61.3% vs. 42.0%, OR 2.19, p=0.01). After adjusting for significant covariates on MVA (including age, sex, hypertension, diabetes, coronary artery disease, and estimated blood loss) RPN was associated with higher rate of trifecta (OR 1.88, p=0.002). CONCLUSIONS When controlling for renal tumor complexity using RENAL score, RPN was an independent factor associated with improved odds of achieving Trifecta. Unless surgically contraindicated, RPN may be viewed as the primary surgical option for PN regardless of tumor complexity. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e983 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Zachary Hamilton More articles by this author Sean Berquist More articles by this author Abd-el Rahman Hassan More articles by this author Catherine Defour More articles by this author Alp Tuna Beksac More articles by this author Fang Wan More articles by this author Maria Marquine More articles by this author Brian Lane More articles by this author Sean Stroup More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Anatomic Complexity Quantitated by Nephrometry Score Is Associated With Prolonged Warm Ischemia Time During Robotic Partial Nephrectomy

To assess the association between nephrometry score (NS) and prolonged warm ischemia time (WIT) in patients undergoing robotic partial nephrectomy (RPN) for clinically localized renal masses. We queried our prospectively maintained kidney cancer database to identify all patients undergoing RPN for localized tumors from 2007-2012. Patient and tumor characteristics were compared between complexity groups using analysis of variance and chi square tests. Multivariate logistic regression models were used to examine the relationship between NS complexity and warm ischemia >30minutes. Three hundred seventy-five patients (mean age, 59 ± 11years; mean Charlson comorbidity index, 1.0 ± 1.3) undergoing RPN under warm ischemia for clinically localized renal tumors (mean tumor size, 3.1 ± 1.5cm; mean NS, 6.8 ± 1.8) met inclusion criteria and had NS available. Stratified by complexity, groups differed with respect to age at surgery, tumor size, proximity to the hilum, collecting system entry, estimated blood loss, and operative time (all Pvalues≤.05). Significant differences in mean WIT were observed when comparing low (19.4 ± 12.1minutes), intermediate (28.6 ± 12.8minutes), and high (36.1 ± 13.7minutes) NS complexity groups (P<.0001). Adjusting for confounders, patients with intermediate (odds ratio, 2.1; confidence interval, 1.2-3.9) and high (odds ratio, 3.7; confidence interval, 1.1-11.8) NS complexity were more likely to require prolonged WIT when compared with patients with low complexity tumors. In our large institutional cohort, quantification of anatomic complexity using the NS is associated with WIT >30minutes in patients undergoing RPN for localized renal tumors. This provides further evidence that standardized reporting of tumor anatomic complexity affords meaningful outcome comparisons.

Application of R.E.N.A.L. scoring system in robotic laparoscopic partial nephrectomy

Objective To evaluate the clinical value of R.E.N.A.L.scoring system in analyzing the tumor anatomical feature and indication characteristics of patients undergoing robotic laparoscopic partial nephrectomy(RPN).Methods The clinical data of 70consecutive RPN cases done between March 2012and September 2013by the same surgeon at our institutionwere analyzed in this study.The 70patients(47males and 23females)had a mean age of(52.8±10.3)years,a mean body mass index(BMI)of(24.8±3.25)kg/m2,a mean ASA score of 2.0±0.4,and a mean age-weighted Charlson comorbidity index of(0.7±1.03).There were 38cases on the left(with 1case of solitary kidney)and 32cases on the right(also with 1case of solitary kidney).All the tumors were solitary ones,with the maximal diameter being(3.7±1.31)cm and a mean R.E.N.A.L.score of(8.1±1.31).The patients were divided into three groups according to the R.E.N.A.L.scores,and the clinical variables were compared between groups.Results One patient was transferred to open surgery due to intraoperative hemorrhage and the rest were successfully completed.The operative time was(230±48.3)min,estimated blood loss was(154±135.9)mL,renal ischemia time was(23.0±9.30)min,and the mean postoperative hospital stay was(11.4±4.44)days.The overall transfusion rate was 8.57%(6/70)and the complication rate was 17.1%(12/70).Pathological examination revealed no positive surgical margin;there were 58cases with renal carcinoma,4with angiomyolipoma and 8with other benign renal lesions.All patients were alive and had no local recurrence or distant metastasis at the latest follow-up.Nevertheless,the estimated glomerular filtration rate(eGFR)was significantly different before and after operation(P=0.003).Significant differences were also found among the low,moderate and high tumor complexity groups(according to R.E.N.A.L.scores)regarding the cases finished in the first ten cases(50.0% vs 10.9% vs 11.1%,P=0.033),operative time([213±35.5]vs[225±48.9]vs[269±31.7]min,P=0.008),estimated blood loss([86±31.3]vs[158±148.5]vs[172.0±66.7]mL,P=0.032),and renal ischemia time([18.9±7.54]vs[22.2±8.88]vs[30.4±9.76]min,P=0.019).Conclusion R.E.N.A.L.nephrometry score is closely correlated with the surgical outcomes of RPN.Preoperative application of R.E.N.A.L.scoring system to identify tumor complexity can help to guide the clinical use of da Vinci surgical system for partial nephrectomy.

Can the R.E.N.A.L Nephrometry Score Preoperatively Predict Postoperative Clinical Outcomes in Patients Undergoing Open and Laparoscopic Partial Nephrectomy?

Aim: We evaluate whether the preoperative R.E.N.A.L Nephrometry Score (RNS) can predict the postoperative outcomes in patients undergoing either an open or laparoscopic partial nephrectomy. Patients and Methods: We retrospectively calculated the RNS of 128 patients who underwent either an open partial nephrectomy (OPN) (n = 38) or laparoscopic partial nephrectomy (LPN) (n = 90) between 2003 and 2011. Patients were categorized into low, moderate or high complexity groups based on RNSs. Intra-operative warm ischemic time (WIT), peri-operative surgical outcomes using the Clavien-Dindo classification, postoperative histology, positive surgical margin rates were correlated to the RNS. Results: The RNS was associated with the length of the WIT in OPN (low vs. moderate vs. high: 11.4 vs. 13.1 vs. 23.4 minutes, p = 0.025) and blood loss in LPN (low vs. moderate 319 vs. 498 ml, p = 0.009). The positive surgical margins were greater in high versus moderate RNS lesions (40 vs. 7.4%, p = 0.045). No differences were seen in complications, hospital stay or transfusion rates. The RNS was significantly higher in OPN versus LPN (7.45 vs. 6.2, p = 0.0002). Conclusion: An Increasing RNS was associated with increased WIT in OPN and blood loss in LPN, supporting RNS relationship to tumor complexity. A higher RNS in OPN indicate it may corroborate procedure choice. RNS should allow comparisons between treatment modalities for similar complexity lesions and with further research could aid stratification of individual risk preoperatively.