Mean RENAL Score Research Articles

External validation of the ability of the mRENAL nephrometry score to identify patients at risk for major adverse events or local tumor recurrence after percutaneous renal cryoablation.

The purpose of this study was to evaluate the ability of the mRENAL score to identify patients at risk of either major adverse events (AEs) and/or local tumor recurrence (LR) after percutaneous cryoablation (PCA) in an external patient population. Patient demographic data were recorded. The RENAL and mRENAL nephrometry scores were calculated. Clinical outcomes such as AEs, LR, cancer-specific survival (CSS), and overall survival (OS) were collected. AEs were classified according to SIR criteria. Continuous variables and categorical variables were analyzed using the Wilcoxon rank sum test and chi-square test, respectively. Logistic regression analysis was performed to identify variables associated with major AEs or LR. The study included 207 patients (Males: n = 117 (56.5%)) with a mean age of 65.8 (± 11.2) years (range:27-90). Overall, the mean tumor diameter, RENAL score, and mean mRENAL score were 30.1mm (± 11.4), 6.3 (± 1.7), and 6.8 (± 1.9), respectively. 14 patients (6.8%) and 13 patients (6.3%) experienced a major AE or LR after PCA, respectively. CSS and OS were 98.6% and 90.3%, respectively. For patients with major AEs after PCA, the mean tumor diameter (p < 0.0001), mean RENAL score (p = 0.03), and mean mRENAL score (p = 0.009) were all higher than those for patients without a major AE. Multi-variate regression analysis showed that only mean tumor diameter (p = 0.005) was predictive of a major AE. There were no statistically significant differences between patients with LR and patients without LR after PCA with regards to tumor size (p = 0.07), mean RENAL score (p = 0.32), or mean mRENAL score (p = 0.07). Multi-variate regression analysis showed that only mean tumor diameter (p = 0.01) was predictive of LR. The mRENAL score did not accurately identify patients at risk for either major AEs or LR. Maximum tumor diameter alone was predictive of both major AEs and LR, and should be the primary focus during patient selection.

PD24-04 OUTCOMES OF DEFERRED CYTOREDUCTIVE NEPHRECTOMY FOLLOWING PRIMARY IMMUNOTHERAPY IN ADVANCED RENAL CELL CARCINOMA: A MULTICENTER ANALYSIS

PD24-04 OUTCOMES OF DEFERRED CYTOREDUCTIVE NEPHRECTOMY FOLLOWING PRIMARY IMMUNOTHERAPY IN ADVANCED RENAL CELL CARCINOMA: A MULTICENTER ANALYSIS

Utility of the RENAL Nephrometry Scoring System in Predicting Adverse Events and Outcomes of Percutaneous Microwave Ablation of Renal Tumors

PurposeTo assess the utility of the radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines (RENAL) nephrometry scoring system at predicting adverse events and outcomes in percutaneous microwave ablation (MWA) of renal tumors. Materials and MethodsA retrospective review of 116 patients who underwent MWA from 2004 to 2018 at 2 large university hospitals was conducted. Patient demographics and tumor characteristics were collected. The RENAL nephrometry scores were calculated, and procedure-related adverse events were stratified into minor and major (the Society of Interventional Radiology classification of class C or higher). Technical and oncologic outcomes were based on follow-up magnetic resonance imaging and computed tomography scans after ablation. ResultsThe mean RENAL score was 6.6 (range, 4–11), and the mean tumor size was 24 mm. Follow-up ranged between 16 and 161 weeks (median, 50 weeks; mean, 65 weeks). Oncologic control was achieved in 96% (n = 111) of patients. The major and minor adverse event rates were 8.6% (n = 10) and 17% (n = 19), respectively. The mean RENAL score for patients with recurrent and/or residual tumor (8.2 ± 2.7) was higher than that for patients without disease recurrence (6.5 ± 3.5, P = .05). However, in a multivariate analysis, the RENAL score was not found to be an independent predictor of oncologic outcomes (odds ratio, 1.548; P = .092). ConclusionsThe RENAL nephrometry score has minimal utility for predicting outcomes and adverse events in MWA of renal tumors. The inconsistent nature of RENAL nephrometry scoring in percutaneous ablation procedures underscores the need for an ablation-specific risk stratification system.

First experience of superselective embolization of renal arteries supplying the tumor with subsequent laparoscopic kidney resection

Background. Patients with signs of tumor lesions in a single kidney or in the only one functioning kidney, with bilateral renal tumors are at high risk of functional failure or insufficiency of the kidney after surgery. Joint discussions with specialists in X-ray endovascular surgeries resulted in the development of a treatment algorithm for patients with localized kidney cancer who require organ-sparing surgery without ischemic kidney resection.Objective: to evaluation of the immediate results of two-stage surgical treatment of localized kidney cancer in patients with signs of tumor lesions in a single kidney or in the only one functioning kidney, with bilateral renal tumors, including superselective embolization of the artery supplying the tumor at the first stage, and laparoscopic kidney resection without renal ischemia parenchyma at the second stage.Materials and methods. This study included 5 patients with localized kidney cancer, who underwent two-stage treatment at Moscow Regional Oncology Dispensary between 24.03.2021 and 19.04.2021. The first stage included superselective embolization of the artery supplying the tumor; the second stage implied laparoscopic kidney resection 6-7 days following the first stage.Results. The median age of the patients was 62 years (range: 42-73 years). Four patients (80%) had unilateral kidney lesions, while 1 patient (20 %) had bilateral (synchronous) kidney cancer. The mean RENAL score was 8 (range: 6-10); patients were distributed as follows: score 4-6 in 40 %, score 7-9 in 40 %, and score &gt;10 in 20 % of patients. At the first stage, patients underwent endovascular embolization of the branches of the renal artery. Patients had superselective embolization of either middle (n = 3; 60 %), upper (n = 1; 20 %), or lower (n = 1; 20 %) segmental arteries supplying the tumor. In one of them (20 %), we identified 3 large arterial branches; in another one (20 %), we identified 2 large arterial branches.At the second stage, we performed laparoscopic kidney resection. None of the patients required renal artery clamping, because there was an excellent visualization of the demarcation zone and no significant blood loss. The resection area was sutured in 1 case (20 %). In 2 individuals (40 %), a hemostatic sponge was installed in the removed tumor bed. In the remaining 2 cases (40 %), hemostasis was ensured by coagulation. The median blood loss was 100 mL (range: 50-200 mL). The postoperative period was uneventful in all patients. None of the patients developed symptoms of acute renal failure.Conclusion. Thus, superselective embolization of arteries supplying a kidney tumor has undeniable advantages in organ-sparing surgeries for patients with localized kidney cancer and some additional kidney problems, when organ preservation is crucial for patient's life.

Clinical Value of Patient-Specific Three-Dimensional Printing of Kidney Before Partial Nephrectomy: A Qualitative Assessment.

Objectives: To qualitatively assess the clinical usefulness of patient-specific high-fidelity three-dimensional (3D) print model of kidney before partial nephrectomy (PN) and to identify subset domains where it may help in clinical terms. Materials and Methods: Thirteen 3D models were printed for tumors having RENAL nephrometry score of ≥8. Their usage for PN was assessed prospectively using a qualitative questionnaire to be answered on a Likert scale of 1-10. The questions focused on realistic resemblance, preoperative dry surgical run, intertest comparison, surgical impact, and overall beneficence domains as perceived by primary surgeons with respect to surgical conduct during PN. Results: Mean RENAL score was 9.15 (8-11). Models were rated high (9.07 ± 0.86) for realistic resemblance domain and were rated better than contrast-enhanced computed tomography (CECT) (8.38 ± 0.87) and intraoperative ultrasonography (8.07 ± 1.26) for orientation regarding resection margins. A further marginal improvement to 8.2 ± 0.84 was noted against ultrasound where surgeon did a dry cut preoperatively. Use of superselective arterial approach in four, precise awareness about dissection of a major vessel in four, retroperitoneoscopic approach in one, and surgical margin awareness in three were directly attributed to the model. Overall utility of having a model printed was rated high (8.23 ± 1.3). Conclusion: The 3D print models of complex renal tumors have high realistic resemblance to actual patient's anatomy. They were rated better than preoperative CECT or intraoperative ultrasonography for orientation regarding surgical resection margins. It may also help change or modify the surgical plan in a subset of patients with a potential to improve overall outcomes in these complex cases.

Лапароскопическая резекция почки с использованием технологии дополненной реальности: новый вектор развития оперативной урологии?

Aim to evaluate the efficiency and usefulness of augmented reality (AR) technology using HoloLens glasses for laparoscopic partial nephrectomy (LPN). Materials and methods From July to December 2019, a total of 5 patients with localized kidney cancer (cT1aN0M0) underwent AR-assisted LRP. The mean RENAL score was 6 points (5-8). Preoperatively, all patients underwent contrast-enhanced multispiral computed tomography (MSCT). The three-dimensional reconstructions of the kidney, tumor, part of the abdominal aorta with the renal artery and its branches, part of the inferior vena cava with the renal vein were segmented with color coding and connected into a single virtual 3D model, which was loaded into the program in order to display image in AR glasses. The duration of surgery and thermal ischemia, type and frequency of intraoperative complications, as well as the time spent on preparing the 3D model and the Microsoft HoloLens device were evaluated. To assess the feasibility of using AR technology intraoperatively, a Likert scale was filled out by the surgeon. Results It took 10 (9-11) hours to prepare the model, including time to optimize the model and to set up its display and interactions. The setup of HoloLens required an average of 7.8 (5- 12) min. The total duration of the operation and the period of warm ischemia was 108 (90-120) and 20 (15-25) min, respectively, while intraoperative blood loss was 160 (110-250) ml. In all cases, a negative surgical margin was found. The surgeon who performed all the operations assessed the use of AR technology with the HoloLens device as highly beneficial in all clinical cases. Conclusion The use of AR technology with a HoloLens holographic device during LPN can lead to improved treatment outcomes.

Retroperitoneoscopic approach for highly complex posterior renal hilar tumors

ABSTRACTObjectives:To show our single-center experience in retroperitoneoscopic approach for highly complex posterior hilar tumors. Minimally invasive nephron sparing surgery for renal hilar tumors is extremely challenging due to their anatomic location, close to the main renal vessels and the collecting system (1). Transperitoneal approach is feasible, but highly complex because the anterior disposition of the vasculature. Retroperitoneal approach can easily provide access to the posterior hilar structures and the posterolateral surface of the kidney(2, 3).Materials and Methods:We retrospectively reviewed our hilar renal tumor database and analyzed those in which a retroperitoneoscopic approach was chosen. The RENAL score was then calculated, and operative and ischemia times were recorded. We also collected the mean hospital stay and the presence of complications. Pathology reports and follow-up were also gathered.Results:Five of our twelve highly complex hilar renal tumor patients were treated using a retroperitoneoscopic approach. Mean RENAL score was 10. Mean operative time was 135 minutes. Mean warm ischemia time was 14 minutes. Mean hospital stay was 4 days. We have recorded 2 complications. One patient required a transfusion and another presented with an urinary fistula which was treated by double J stent placement. The pathology report showed a clear cell renal cell carcinoma pT1a in most of the cases. Only one patient had a positive margin. To date, no recurrences have been noticed.Conclusions:The treatment of complex renal hilar tumors in a minimally invasive fashion is highly challenging even in experienced hands. Retroperitoneal partial nephrectomy is feasible, safe and effective for the treatment of such lesions. Long-term oncologic outcomes of this approach are awaited.

4:03 PM Abstract No. 271 Risk stratification of periprocedural complications and treatment failure for T1b renal cell carcinoma

To investigate the clinical utility of the RENAL nephrometry scoring system (which incorporates tumor Radius, Exophytic or endophytic location, Nearness to renal collecting system or sinus, Anterior or posterior location, and Location relative to polar lines) for prediction of complications and local recurrence in T1b renal cell carcinoma (RCC) following thermal ablation. A retrospective evaluation of 83 patients (M:F = 71:12, mean age =77 years) was performed between December 2008 and October 2019. T1b is defined as a biopsy-proven RCC that is between 4 and 7 cm in diameter. The RENAL scores were calculated based on the tumor morphology seen on imaging, through which tumors were stratified into high risk (RENAL = 10-12), moderate risk (RENAL = 7-9), and low risk (RENAL = 4-6) groups. The rates of residual disease and local recurrence were compared among the three groups. Of the 68 biopsy-proven T1b RCC (mean RENAL score, 7.7, SD =1.8) that were treated with percutaneous CT-guided thermal ablation, 30/79 (38%) had high RENAL scores, 30/79 (38%) had moderate RENAL scores, and 19/79 (24%) had low RENAL scores. High RENAL score was associated with a significantly elevated risk of hematoma (40%), compared to the moderate (29%) and low (10%) RENAL score groups (P = 0.0001). Similarly, a high RENAL score is associated with a significant rate of ureter injury (10%), which was not observed in the moderate and low RENAL score groups (both 0%). Local recurrence was also more prevalent in the high RENAL score group (20%) compared to the moderate (10%) and low (0%) RENAL score groups (P = 0.0001). The RENAL nephrometry scoring system is a very attractive tool for predicting the rates of complications and treatment failure in patients undergoing thermal ablation for T1b RCC. This scoring system could allow interventional radiologists and their patients to better prepare for the unique risks of complications and outcomes conferred by each tumor’s unique RENAL score.Tabled 1Analysis of Periprocedural Complications and Treatment Failure based on RENAL Nephrometry ScoreHigh RENAL RiskModerate RENAL RiskLow RENAL RiskPHematoma Yes12 (40%)9 (30%)2 (10%)0.001 No18 (60%)22 (70%)17 (90%)Ureter Injury Yes3 (10%)0 (0%)0 (0%)0.001 No27 (90%)31 (100%)9 (100%)Residual disease Yes10 (33%)3 (10%)2 (10%)0.001 No20 (67%)28 (90%)17 (90%)Local recurrence Yes6 (20%)3 (10%)0 (0%)0.001 No24 (80%)28 (90%)19 (100%) Open table in a new tab

R.E.N.A.L. Nephrometry Score Profile of Kidney Cancer Patients in Cipto Mangunkusumo Hospital

Background: The variation of sizes, shapes, and location of kidney cancer complicates the choices of surgical treatment.To determine which technique to use, R.E.N.A.L. nephrometry scoring systems were established. This study was conducted to evaluate R.E.N.A.L.-NS profile in kidney cancer patients at CMHMethod: The data were collected retrospectively from patients that underwent both open and laparoscopic Radical (RN) and Partial Nephrectomy (PN) procedure from 2014-2017. R.E.N.A.L.-NS was calculated based on (R)adius, (E)xophytic/ Endophytic properties, (N)earness to the collecting system, (A)nterior or Posterior position of the tumor, and (L)ocation of the tumor. It was categorized into three complexity: low (4-6 points), medium (7-9 points), and high (10-12 points). Subjects then divided based on the procedure given. Profile of R.E.N.A.L.-NS was shown based on each procedure.Result: In this study, 63 patients were included. 52 underwent RN and 11 underwent PN. In low complexity tumors, all patients received PN. In medium complexity tumors, 22 (78.5%) patients received RN and 6 (21.5%) received PN. All high complexity tumors received RN. Mean renal score in all patient 9.03 (+1.72), RN 9.59 (+1.11), PN 6.36 (+1.6). Higher (R), (N), and (L) scores mean a higher prevalence of RN.Conclusion: Higher complexity tumors were more likely to be treated with RN. Furthermore, (R), (N), and (L) score can be useful to determine RN or PN as a treatment of choice. This study could be used as a reference to another study regarding R.E.N.A.L.-NS in Indonesia.

Computed tomography-guided percutaneous cryoablation of T1b renal tumors: safety, functional and oncological outcomes

Purpose: To evaluate the safety, functional and oncological outcomes associated with percutaneous cryoablation of stage T1b renal cell carcinoma (RCC).Materials and methods: Institutional database was reviewed to identify patients treated by percutaneous CT-guidance cryoablation between 2013 and 2018 for biopsy-proven RCC tumors measuring 4.1–7.0 cm. The main outcome parameters analyzed were primary and secondary technique efficacy, progression-free survival (PFS), cancer-specific survival (CSS), loss of estimated glomerular filtration rate (eGFR) and complications. PFS and CSS were estimated by the Kaplan–Meier method. Complications were graded by the Clavien–Dindo system.Results: Twenty-three consecutive patients were included (mean tumor diameter: 45.6 ± 6.2 mm; mean RENAL score: 8.1 ± 1.8). The technical success rate was 95.7%. Primary and secondary technique efficacy rates were 86.3 and 100%, respectively. Three patients found to have incomplete ablations at 3 months were successfully treated by repeat cryoablation. Median duration follow-up was 11 months (range: 3-33). Imaging showed PFS to be 85.7% at 6 months, 66.7% at 12 months and 66.7% at 24 months. One patient with a local recurrence at 12 months was treated by radical nephrectomy. One patient died from progression of disease within 12 months. One patient reported a complication grade ≥ II (4.3%). Mean eGFR loss was 4.4 ± 8.5 ml/min/1.73m2, which was significantly higher among those treated for central tumors (p < .05).Conclusion: Cryoablation for stage T1b renal tumors is technically feasible, with favorable oncological and perioperative outcomes. Longer-term studies are needed to verify our findings.

Combined Retroperitoneoscopic and Transperitoneoscopic Accesses for Robot-Assisted Partial Nephrectomy

Abstract Objective: To demonstrate combined retroperitoneoscopic and transperitoneoscopic accesses for robot-assisted partial nephrectomy technique and outcomes. Materials and Methods: A total of 109 consecutive combined retroperitoneoscopic and transperitoneoscopic accesses for robot-assisted partial nephrectomies were performed from September 2014 to August 2016. The positive margins and cancer recurrence were both assessed after surgery. The complications, estimated blood loss, warm ischemia time (WIT), operation time, and postoperative length of stay were analyzed. Results: Totally, 109 patients (mean age: 60.45 (standard deviation [SD]: 13.79 years), mean body mass index: 24.07 kg/m2 (SD: 6.84)), were recruited in this study. Mean tumor size was 4.11 cm (SD: 1.66) and mean RENAL score was 7.76 (SD: 1.93). Mean total operative time was 111.69 minutes (SD: 26.74) and mean WIT was 13.67 minutes (SD: 3.35). Mean estimated blood loss was 63.26 mL (SD: 59.88) and mean postoperative length of stay was 6.83 ...

3:27 PM Abstract No. 243 Microwave ablation vs cryoablation in the treatment of T1a renal cell carcinoma: a single-center comparison of safety and outcomes

To compare the safety and efficacy of percutaneous ablation of T1a renal cell carcinoma (RCC) performed utilizing microwave ablation (MWA) and cryoablation (CRYO). Retrospective analysis spanning 9/2006 to 9/2014 was performed to identify RCC patients treated with MWA or CRYO. 37 patients with RCC underwent 40 percutaneous ablation procedures during the study period. 22 CRYO procedures (mean tumor diameter: 2.6 ± 0.9 cm, mean RENAL score: 7.3 [range 4-10], mean PRAC score: 8.3 [range 4-11.5]) were performed for 20 patients (age: 69.9 ± 8.1 years, male sex: 65%). 18 MWA procedures (mean tumor diameter: 2.4 ± 0.8 cm, mean RENAL score: 7.2 [range 4-10], mean PRAC score: 7.7 [range 4-11.5]) were performed for 18 patients (age: 66.8 ± 12.8 years, male sex: 61.1%). Outcomes variables included technical success, pre- and posttreatment lab values, complications, imaging response, and overall survival. Technical success was achieved in all cases. There was no significant difference in baseline renal function between MWA (BUN: 19.6 ± 7.2 mg/dl, creatinine: 1.4 ± 0.8 mg/dl) and CRYO (BUN: 24.6 ± 16.0 mg/dl, creatinine: 1.2 ± 0.5 mg/dl) groups (p = 0.238 and p = 0.465 respectively) or significant change in either BUN post-ablation for MWA and CRYO (p = 0.852 and p = 0.805 respectively) or creatinine (p = 0.355 and p = 0.599 respectively). There were 7 complications (MWA:5, Cryo:2) including 6 perinephric hematomas and an episode of urinary retention, 2 being major (SIR C) complications, without significant difference in the complication incidence between the 2 groups (p = 0.259). At median follow-up time of 3.2 years, 7 instances of disease progression (Cryo:5, MWA: 2) occurred at an average of 14.7 months post-ablation with no difference in disease progression between modalities (p = 0.205). Overall cohort survival was 5.1 (95% CI: 4.3–6.0) years with no significant difference between treatment groups (p = 0.486). There is no difference in technical success, renal function change, complication incidence, imaging outcomes, or overall survival in RCC patients treated with either microwave ablation or cryoablation. Overall survival in the present cohort was 5.1 (95% CI: 4.3–6.0) years.

Results of our laparoscopic partial nephrectomy without ischemia: the first ten cases

Laparoscopic partial nephrectomy (LPN) without ischemia is a new method that can only be performed in selected cases. We presented results of patients who underwent LPN without ischemia for renal mass in our clinic. The demographic characteristics, perioperative and postoperative surgical results, complications and renal functions were retrospectively reviewed for patients who underwent LPN without ischemia between March 2014 and September 2015. Renal function was assessed using the estimated glomerular filtration rate (GFR) calculated by the Modification of Diet in Renal Disease (MDRD) equation. Complications was assessed according to modified Clavien classification. Ten cases of LPN without ischemia were performed. The mean age was (year) 50.6 ± 8.6, the mean mass size (mm) 37.9 ± 23, the mean RENAL score was 6.4 ± 1.2. The mean operation time (minute) 110.5 ± 41, the mean bleeding amount (ml) 191 ± 198, the mean hemoglobilin (mg/dl) preoperative 13.86 ± 1.28, postoperative 12.2 ± 1.2, the mean creatinine (mg/dl) preoperative 0.95 ± 0.19, postoperative 0.85 ± 0.2, 1.Year 0,91±0,1, GFR (ml/min) preoperative 77.6, postoperative 1.day 79.6, 1.Year 81.2, hospitalization duration (day) 2.9 ± 0.7. Two patients underwent blood transfusion (According to modified Clavien classification grade 2). LPN without ischemia is a new method that can only be performed in selected cases in experienced clinics.

Retroperitoneal Laparoscopic Nephrotomy Along the Brodel Line and Tumor Enucleation for Complete Intraparenchymal Renal Tumors: A Single Institution Experience.

To evaluate the feasibility and outcomes of retroperitoneal laparoscopic nephrotomy along the Brodel line and tumor enucleation (TE) for complete intraparenchymal renal tumors. We retrospectively analyzed the medical charts of patients with complete endophytic tumors and who underwent retroperitoneal laparoscopic nephrotomy along the Brodel line and TE between 2012 and 2015. Perioperative data, surgical technique, pathologic variables, complications, functional, and oncologic outcomes were reviewed. Twenty-one patients (mean age of 50 years; mean body mass index of 25.8 kg/m2) were treated with retroperitoneal laparoscopic TE along the Brodel line incision. The mean tumor size was 2.0 cm, and the mean RENAL score was 9.4. The main surgical outcomes were mean operative time of 94 minutes, mean estimated blood loss of 63 mL, and mean warm ischemia time of 28.4 minutes. Pathology showed clear renal cell carcinoma (n = 16), papillary renal cell carcinoma (n = 4), and reninoma (n = 1). No positive margin was found, and no perioperative complication occurred. The mean glomerular filtration rate of the affected kidney was 31.5 mL/minute/1.73 m2 three months after the surgery. In a median follow-up of 20 months (range of 4-36 months), no evidence of tumor recurrence or metastasis was found. For patients with complete intraparenchymal renal tumors, retroperitoneal laparoscopic parenchyma incision along the Brodel line and TE can be safely and effectively performed in centers with significant laparoscopic expertise.

Are renal tumour scoring systems better than clinical judgement at predicting partial nephrectomy complexity?

We aimed to determine how renal tumour scoring systems, such as RENAL, PADUA, and Centrality (C)-index, compare to clinical judgement at predicting time required for tumour removal and kidney reconstruction during partial nephrectomy. A consecutive cohort of partial nephrectomy patients treated at The Ottawa Hospital, a tertiary care uro-oncological centre, was retrospectively reviewed. Preoperative axial images were reviewed by four experienced urological oncologists who independently rated the complexity of a partial nephrectomy from 1-10 to generate a clinical judgement score. Two independent reviewers determined the RENAL, PADUA, and C-index scores. The time to complete tumour resection and renal reconstruction during partial nephrectomy was prospectively recorded. During the study period, 104 partial nephrectomies were performed. The mean partial nephrectomy complexity score based on clinical judgement was 3.4 (standard deviation [SD] 2.1) out of 10. There was good agreement between surgeons in assessing tumour complexity (intraclass correlation coefficient 0.72; 95% confidence interval [CI] 0.65, 0.78). The mean RENAL score was 6.7 (SD 1.6) out of a maximum of 12, the mean PADUA score was 8.5 (SD 1.5) out of a maximum of 14, and the mean C-index score was 3.8 (SD 2). Mean resection and reconstruction time was 24 minutes (SD 10 minutes). The correlation between clinical judgement score and time was 0.27 (p=0.005). The correlation between renal tumour scoring systems and time was 0.20 (p=0.04) for RENAL, 0.21 (p=0.03) for C-index, and 0.26 (p=0.007) for PADUA. RENAL and PADUA scores were significantly associated with surgical and total complications. The majority of variance in ischemia time is not explained by clinical judgement or renal tumour scoring systems. Renal tumour scoring systems were not better than the clinical judgement of urological oncologists at predicting ischemia time during partial nephrectomy.

Assessment of Perioperative Variables That Predict the Need for Surgical Drains Following Robotic Partial Nephrectomy Utilizing Quantitative Drain Creatinine Analysis.

To utilize body fluid creatinine analysis to determine which patients will require a surgical drain following robotic-assisted partial nephrectomy (RAPN). One hundred fifty consecutive RAPN performed by a single surgeon were reviewed. Postoperative day (POD) 1 drain creatinine was compared to serum creatinine to calculate the drain to serum creatinine ratio (D/S ratio). Elevated D/S ratio was defined as any value >1.2. From February 2008 to April 2015, 140 patients underwent RAPN and had a drain placed (124 had D/S ratio available on POD 1). In the 103 patients with a D/S ratio of <1.2 and the 21 with D/S ratio of >1.2, the mean tumor size was 3.0 and 3.9 cm (P = .001) and mean RENAL score was 7.6 and 8.1 (P = .270), respectively. Collecting system entry occurred in 68.2% of patients with a D/S ratio of <1.2 and 71.4% of patients with a D/S ratio of >1.2. Mean drain time was 2.4 and 4.2 days (P = .001), hospital stay was 2.7 and 3.3 days (P = .036) for the D/S ratio <1.2 and D/S ratio >1.2 groups, respectively. Those with renal mass size of 4-7 cm had increased likelihood of D/S ratio >1.2 (OR 2.78; P = .041). Most RAPN do not require a surgical drain. A POD 1 elevated D/S ratio is more likely to occur with larger masses (those approaching or greater than 4 cm) and can be associated with prolonged drain time and hospital stay.

RENAL Nephrometry Score Is Associated With Complications After Renal Cryoablation: A Multicenter Analysis

To analyze outcomes and complications of percutaneous (PRC) and laparoscopic renal cryoablation (LRC) using the radius, endophytic, nearness to collecting system, anterior/posterior, and location (RENAL) nephrometry system. Retrospective multicenter analysis of 154 consecutive patients who underwent either ultrasound-guided LRC (n= 88) or computed tomography (CT)-guided PRC (n= 66) from March 2003 to December 2011. RENAL score and demographics were compared to postoperative complications (Clavien). Multivariable analysis was carried out for factors associated with development of postprocedure complications. Mean age was 68 years (94 men/60 women). Median follow-up was 34 months (range 23.6-45.6 months). Mean tumor size was 2.6 ± 1 cm. Mean RENAL score was 5.2 ± 1.4. Differences in (A)nterior/posterior component and (H)ilar domain of the RENAL scores were noted, with PRC favoring posterior tumors and hilar lesions compared to LRC (P< .001 and P= .044, respectively). There were 14.9% complications, all of which were low-grade (Clavien 1,2). There were no differences in complications between LRC and PRC (15.9% vs 13.6%, P= .82). Most common complication type was hemorrhagic in 9 of 154 patients (5.8%); significant increase in the hemorrhagic complication rate was noted for patients with "N" ("nearness") component score of 2 or 3 (5/36, or 13.9%), compared to patients with "N" score of 1 (4/115 or 3.5%, P= .033). multivariable analysis demonstrated that increasing RENAL score was associated with postprocedure complications (odds ratio [OR]= 1.37, P= .025). When separated into individual domains, multivariable analysis revealed that "N" score 3 was significantly associated with postoperative complications (OR 16.15, P= .027). Increasing RENAL score was associated development of postprocedure complications after renal cryotherapy. Further investigation is requisite to elucidate the role of RENAL nephrometry score in risk stratification prior to renal cryotherapy.

Factors Affecting Renal Function After Open Partial Nephrectomy—A Comparison of Clampless and Clamped Warm Ischemic Technique

To analyze factors impacting postoperative renal function after open partial nephrectomy using both the clampless and clamped warm-ischemic technique. We studied a cohort of patients who underwent clamped partial nephrectomy (n = 164) and clampless partial nephrectomy (n = 64) from March 2002 to March 2009 with ≥ 12-months follow-up. Clamped partial nephrectomy used hilar occlusion before resection. Clampless partial nephrectomy used focal radio frequency coagulation to facilitate hemostasis before resection, nonischemic dissection/resection with hydro-dissection, or sharp resection after local compression. Demographics, tumor characteristics/RENAL nephrometry scores, perioperative variables, and complications were compared between the two methods. Multivariable analysis was performed to identify factors predicting de novo estimated glomerular filtration rate <60. Patient characteristics were similar between groups. Mean RENAL score was greater in clamped (6.9) vs clampless (6.4, P = .026); complications (P = .430) and urine leaks (clampless partial nephrectomy 3.1% vs clamped-PN 7.3%, P = .360) were similar. Mean warm ischemia time (min) was 24.5 for clamped partial nephrectomy. De novo estimated glomerular filtration rate <60(%) at last follow up was 13.5 (clamped) vs 3.1 (clampless) (P = .071). Multivariable analysis of the entire cohort revealed increasing body mass index (OR 1.1, P = .042) and RENAL score (OR 1.71, P = .002) as being independently associated with development of postoperative de novo estimated glomerular filtration rate <60. Multivariable analysis of the clamped subgroup demonstrated increasing body mass index (OR 1.12, P = .028), RENAL score (OR 1.56, P = .010), and ischemia time (OR 1.15, P = .042) as independent factors associated with de novo estimated glomerular filtration rate <60. Body mass index and RENAL score were factors predictive of development of de novo estimated glomerular filtration rate <60 after partial nephrectomy, with increasing warm ischemia time also being predictive in clamped partial nephrectomy patients. Further investigation and long-term functional data are requisite.

RENAL Nephrometry Score is Associated With Operative Approach for Partial Nephrectomy and Urine Leak

To identify whether RENAL nephrometry score is associated with partial nephrectomy (PN) technique. RENAL nephrometry score quantifies anatomic characteristics of renal tumors. Data are limited regarding clinical utility for surgical planning. Multicenter analysis of patients undergoing PN for renal masses from March 2003 to May 2011. Cohort was stratified by surgical modality: open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robotic-assisted laparoscopic partial nephrectomy (RALPN). Demographic and clinicopathological variables were compared between groups; RENAL score was calculated from preoperative imaging. Factors associated with choice of treatment modality and urine leak were entered into multivariable models. One hundred fifty-three patients who underwent OPN, 100 patients who underwent LPN, and 31 patients who underwent RALPN were evaluated, the median tumor size (cm) was significantly larger for OPN (OPN 4.2 vs LPN 2.4 vs RALPN 2.0; P < .001); median operative time (minutes) and ischemia time (minutes) were shorter in OPN (OPN 190 and 25 vs LPN 200 and 29 vs RALPN 195 and 30; P = .042 and P < .001). Mean RENAL score was highest in OPN (OPN 8 vs LPN 6.3 vs RALPN 6.4; P < .001). No significant differences were noted in overall/high-grade complication rates (Clavien, P = .441/.985). On multivariate analysis, there was a 55% increased odds of undergoing OPN for each increase in RENAL score (P < .001). Higher RENAL score was associated with increased odds of urine leak (odds ratios [OR], 1.56; P = .002). RENAL nephrometry score was associated with type of surgical approach (open vs laparoscopic/robotic) and urine leak. RENAL score may be useful as a decision-making tool in evaluation of patients for nephron-sparing surgery (NSS). Further investigation is requisite.

Robot-assisted Laparoscopic Partial Nephrectomy: Step-by-step Contemporary Technique and Surgical Outcomes at a Single High-volume Institution

BackgroundRobotic technology is being increasingly adopted in urologic surgery. ObjectiveTo describe a contemporary surgical technique and report cumulative surgical outcomes of robot-assisted laparoscopic partial nephrectomy (RALPN) at our tertiary care institution. Design, setting, and participantsMedical charts of consecutive patients who underwent RALPN between June 2006 and November 2011 were reviewed from a prospectively maintained, institutional review board-approved database. Surgical procedureThe main steps of our current surgical technique are described in this video tutorial: patient positioning and trocar placement; bowel mobilization; hilar dissection; tumor identification and demarcation; clamping of the hilum; tumor excision; renorraphy; hilar unclamping; and tumor retrieval. Outcome measurements and statistical analysisPatients’ characteristics and main surgical outcomes were analyzed. Results and limitationsA total of 400 patients (mean age: 58.5 yr, mean body mass index: 30.7kg/m2) were included in this analysis. Mean renal tumor size was 3.17cm (standard deviation [SD]: 1.64) and mean RENAL score was 7.2 (SD: 2). Six patients (1.5%) presented with a solitary kidney. Mean total operative time was 190.3min (SD: 57), and mean warm ischemia time was 19.2min (SD: 10.72). In 36 cases (9%), an unclamped hilum technique was used. After a mean follow-up of 12.4 mo (SD: 12.2), there was a decline of −9.2ml/min per 1.73 m2 (SD: 26.56) in estimated glomerular filtration rate. Most renal masses were malignant (74.5%), and the overall mean tumor size was 3.05cm (SD: 1.66). Renal cell carcinoma with a clear cell histology represented the most frequent malignant diagnosis (64.4% of cases). A positive margin was observed in nine cases (2.25%). A total of 11 intraoperative complications (2.7%) occurred, and a conversion to open or laparoscopic PN was required in six cases (1.5%). A postoperative complication occurred in 61 cases (15.3%), the majority of them being low grade. ConclusionsThe standardization of each surgical step has allowed for optimization of RALPN and ultimately improved its outcomes and expanded its indications.