Open Radical Nephrectomy Research Articles

V13-09 TRICUSPID INSUFFICIENCY CAUSED BY RENAL ANGIOMYOLIPOMA WITH EXTENSION TO THE INFERIOR VENA CAVA AND RIGHT ATRIUM. A MULTIDISCIPLINARY APPROACH

You have accessJournal of UrologyCME1 May 2022V13-09 TRICUSPID INSUFFICIENCY CAUSED BY RENAL ANGIOMYOLIPOMA WITH EXTENSION TO THE INFERIOR VENA CAVA AND RIGHT ATRIUM. A MULTIDISCIPLINARY APPROACH Ruben Santiago, Omar Vieyra, Rodrigo Perez, Victor Osornio, Gerardo Garza, Roberto Lopez, and Mario Ortega Ruben SantiagoRuben Santiago More articles by this author , Omar VieyraOmar Vieyra More articles by this author , Rodrigo PerezRodrigo Perez More articles by this author , Victor OsornioVictor Osornio More articles by this author , Gerardo GarzaGerardo Garza More articles by this author , Roberto LopezRoberto Lopez More articles by this author , and Mario OrtegaMario Ortega More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal angiomyolipoma (AML) is a mesenchymal tumor benign composed by vascular, smooth muscle and adipose tissue. There are two types of AMLs: The classic variant is the most common and is characterized by thick walled vessels, spindle smooth-muscle-like cells and adipose tissue. The epithelioid variant has an epithelial cell component to it with minimal adipose tissue and has the potential to undergo malignant transformation. The objective of this video is presented the multidisciplinary approach from surgical technique to medical intensive care during and after the surgery. METHODS: A 44-year-old woman was referred by his primary care physician with symptoms characterized by shortness of breath, tachycardia, intermittent hematuria and right lumbar pain. Physical examination with holosystolic murmur. Computerized tomography (CT) scan demonstrated a 6.1x5.1cm right renal tumor, the attenuation was - 83 Hounsfield Units (HU) with tumor thrombus invasion into the inferior vena cava, which extended from renal vein ostium to right atrium. Magnetic resonance imaging (MRI) showed non-infiltration of the vena cava wall. Echocardiogram presented systolic protrusion of the thrombus towards the right ventricle, developing moderate tricuspid regurgitation. RESULTS: With multidisciplinary management (Urology, cardiology, cardiothoracic surgery, perfusionists and intensive care therapy) were performed an open right radical nephrectomy, sternotomy, cavotomy with extraction of intra-atrial thrombus and primary cavorrhaphy. With support of cellular recuperator and extracorporeal circulation pump (pump time 100 min) trans-surgical transfusions were: 3 erythrocyte concentrates, 2 fresh frozen plasmas and 1 platelet apheresis. Surgical time was 380 min. During the surgery a real-time transesophageal echocardiogram was used. Bleeding was 2500 ml and no intraoperative complications were reported. Hospital stay of 20 days, discharged without complications with serum creatinine 1.0 mg / dl and hemoglobin 11.5 g / dl. Pathology report was renal classic AML, size 8.0x6.0x4.0cm, immunohistochemistry: HMB45 (+) and smooth muscle actin (+). CONCLUSIONS: This is a rare case of a classic AML presenting with a venous tumor thrombus involving the inferior vena cava from renal vein ostium to right atrium. Radical nephrectomy with tumor thrombectomy is the most widely accepted surgical treatment following established vascular principles of venous tumor thrombectomy. Source of Funding: Non Disclousure © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1033 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ruben Santiago More articles by this author Omar Vieyra More articles by this author Rodrigo Perez More articles by this author Victor Osornio More articles by this author Gerardo Garza More articles by this author Roberto Lopez More articles by this author Mario Ortega More articles by this author Expand All Advertisement PDF DownloadLoading ...

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Comment on: "Perioperative and oncological outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution study".

Comment on: “Perioperative and oncological outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution study”

Survival after minimally invasive vs. open radical nephrectomy for stage I and II renal cell carcinoma

A recently reported phase III randomized trial comparing open and minimally invasive hysterectomy showed significantly higher rates of local recurrence after minimally invasive surgery (MIS) for cervical cancer. This raised concerns regarding patterns of recurrences and survival after MIS in general. This study aims to determine the effect of MIS on all-cause mortality among patients undergoing radical nephrectomy for Stage I and II renal cell carcinoma (RCC). We utilized the National Cancer Database to identify patients diagnosed with clinical stage I-II RCCs between 2010 and 2013. Patients for whom a laparoscopic or robotic radical nephrectomy was attempted were compared to patients who underwent open radical nephrectomy (ORN). Adjusted regression models with inverse probability propensity score weighting (IPW) were utilized to identify independent predictors of receiving MIS. All-cause mortality rates were compared using IPW survival functions and log-rank tests. Adjusted Cox proportional hazard models were fitted to determine independent predictors of OS. 27,642 patients were identified; 11,524 (41.7%) had MIS, while 16,118 (58.3%) had ORN. Kaplan-Meier survival curves in the IPW cohort showed significant OS advantage for patients who underwent MIS (p < 0.001). Furthermore, length of hospital stays (3 vs. 4days), 30day readmission rates (2.4 vs. 2.87%), 30day (0.53 vs. 0.96%) and 90day mortality rates (1.04 vs. 1.77%) were significantly higher in the ORN group (p < 0.001). MIS was associated with better OS outcomes compared to ORN for stage I and II RCC. In addition, MIS had lower post-operative readmission, 30- and 90day mortality rates.

Cognitive Function After Cardiopulmonary Bypass and Deep Hypothermic Circulatory Arrest in Management of Renal Cell Carcinoma With Vena Caval Thrombus

ObjectiveTo compare cognitive outcomes of patients undergoing open radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy with vs without cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. Patients and MethodsA prospective, 6-month, observational study was conducted from January 2013 to December 2019 in renal cell carcinoma patients with level II-IV IVC thrombus undergoing RN. A battery of standardized neuropsychological tests was administrated to assess multi-domain cognitive function before surgery, 1 week, and 6 months after surgery: attention, executive functions, working memory, short-term and long-term delay recall, visuomotor speed, and verbal fluency. ResultsCognitive impairment was defined as a 20% reduction in at least 20% of the main variables. The primary outcome was the incidence of cognitive impairment at 6 months postoperatively and was analyzed with general linear mixed models. Twenty-six patients treated with CPB and 39 treated with non-CPB were analyzed. There were no significant differences in cognitive impairment between the two groups. The incidence of cognitive impairment at 1 week postoperatively was 38.5% in CPB group and 30.8% in non-CPB group (P = .52), after 6 months 11.5% and 10.3% (P = 1.00). Multivariate analysis indicated that the estimated blood loss was the only risk factor associated with cognitive impairment at 1 week postoperatively. ConclusionThis study showed no significant differences in postoperative cognitive function of renal cell carcinoma patients after open RN and IVC thrombectomy with and without CPB and deep hypothermic circulatory arrest. Estimated blood loss was found to be associated with cognitive impairment at 6 months postoperatively.

328 Renal Cell Carcinoma (RCC) Metastasis to the Coracoid Process

Abstract A 51-year-old man was diagnosed with renal cell carcinoma (RCC) of the left kidney seven years ago. The tumour was staged as T2N0M0 and the patient underwent an uncomplicated open left radical nephrectomy. The RCC was classified as clear cell and he was kept on biannual renal surveillance thereafter. Six years after the nephrectomy, the patient had reported a 5-month history of worsening pain and globally restricted movement in their right shoulder. A palpable mass on the coracoid process was noted. MRI imaging had shown a 27x30x17mm lesion suggestive of an expansile osseous mass in the coracoid process. An ultrasound guided biopsy was performed for definitive characterisation. Histology had reaffirmed that the lesion was in fact metastatic clear cell carcinoma in keeping with the patient’s renal primary. CT chest/abdomen/pelvis and NM-Bone SPECT CT scanning had shown no other sites of metastasis. A marginal resection of the lesion was performed with a good macroscopic clearance. The common sites within the skeleton implicated in RCC include the spine, pelvis and femur. Tumours of the coracoid process are exceedingly rare. From the literature, only four cases of metastasis to the process have been noted: two from breast carcinoma, one from hepatocellular carcinoma and the other from basal cell carcinoma. Thus, this case denotes an extraordinary presentation for a metastasis of RCC many years after the nephrectomy. Furthermore, it emphasises the criticalness of regular follow-up and early intervention as delays could lead to systemic metastasis and a poorer prognosis.

Perioperative and oncologic outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution experience.

Scarce data are available regarding the technique and outcomes for patients with RCC and Mayo III caval thrombi. The aim of this study was to report surgical and oncological outcomes of RCC patients with Mayo III thrombi treated with radical nephrectomy and thrombectomy after liver mobilization (LM) and Pringle maneuver (PM). Retrospective analysis of surgical technique, outcomes and cancer control in 19 patients undergoing LM and PM in a single tertiary care institution were analyzed. Overall, 78% of the patients had performance status ECOG 1 and 58% had a Comorbidity Index >2. Median surgical time was 305 minutes (IQR 264-440). Intraoperative complications were reported for 39% of patients and postoperative complications for 58% (only grade 1 and 2). Intensive Care Unit support was necessary in 16% of the cases. Median length of hospital stay was 9 days (IQR: 7-11). Thirty- and 90-day mortality were 5% and 15%. Two-year overall survival and cancer-specific survival were 60% and 62%, respectively. We reported surgical techniques, intra- and perioperative complications and follow-up in the largest cohort of RCC patients requiring LM and PM.

A1002 - A comparative analysis of minimal invasive vs. open radical nephrectomy for stage III renal cell carcinoma

A1002 - A comparative analysis of minimal invasive vs. open radical nephrectomy for stage III renal cell carcinoma

Retrocaval ureter coexisting with renal cell carcinoma: A case report and review of literature

Background: Retrocaval Ureter (RCU) is a rare congenital anomaly that often presents with obstructive changes in the upper urinary tract which may or may not symptomatic. It arises as a result of an aberration in embryologic development of Inferior Vena Cava (IVC). Commonly occurs in isolation but can occur in association with other anomalies. Few studies have reported RCU co-existing with upper tract Transitional Cell Carcinoma (TCC) but there is no literature report so far of its co-existence with Renal Cell Carcinoma (RCC). Case summary: Hence, we report a case of a 65 year old man with right sided RCC coexisting with RCU. The anomaly was discovered intra-operatively and the patient was offered open right radical nephrectomy with a good post-operative recovery and uneventful follow-up. Conclusion: Retrocaval ureter is a rare congenital anomaly that may occur in isolation or with other associated conditions. To the best of our knowledge, we report the first case of RCU coexisting with renal cell carcinoma. Proper pre-operative evaluation will help to identify these associated anomalies so as to adopt a holistic approach to patient care in order to ensure good treatment outcome. Keywords: radical nephrectomy; renal cell carcinoma; retrocaval ureter; nephroureterectomy.

The Effect of Different Surgical Methods on the Number of Circulating Tumor Cells in the Peripheral Blood of Patients with Renal Cell Carcinoma

Objective: The objective is to explore the effects of different surgical methods-retroperitoneal laparoscopic radical nephrectomy (RLRN) and open radical nephrectomy (ORN) on the number of circulating tumor cells (CTC) in the peripheral blood of patients with renal cancer. Methods: The clinical data of 63 patients in the Department of Urology, Affiliated Hospital of Chengde Medical College who underwent radical surgery for renal cancer were divided into CTC positive group (18 cases of open surgery and 16 cases of minimally invasive surgery) and CTC negative group (14 cases of open surgery), 15 cases of minimally invasive surgery), overall group (32 cases of open surgery, 31 cases of minimally invasive surgery). Observe the changes in the number of CTC 1 week before operation and 1 week after operation. Results: In the positive group, whether it was open surgery or minimally invasive surgery, the postoperative CTC level of patients was significantly reduced (P surgery (P 0.05). In the overall group, both open and minimally invasive surgery CTC decreased significantly, and the difference was statistically significant (P Conclusion: The two different surgical methods can reduce the level of CTC, but compared with ORN, RLRN can significantly increase the number of postoperative CTC. Patients in the CTC-negative group may be less suitable for minimally invasive surgery. CTC levels have certain potential in the selection and guidance of treatment modes for patients with renal cell carcinoma (RCC).

LATERAL PARAMEDIAN OPEN RADICAL NEPHRECTOMY FOR LARGE RENAL MASS; AN UNCONVENTIONAL INCISION IN UROLOGY PRACTICE

BACKGROUND: This study aimed to retrospectively evaluate the surgical and pathological results of patients who underwent ORN (open radical nephrectomy) with an unconventional incision (lateral paramedian) applied to large renal mass in a non-academic urology clinic. SUBJECTS AND METHODS: The study included 46 patients who underwent ORN for a large renal mass between March 2014 and August 2019. The sociodemographic features of the patients, radiological features of the masses, surgical method, and pathology results were retrospectively evaluated. RESULTS: Thirteen female and 33 male patients were included in the study. Renal masses were observed in 22 patients with right side and 24 patients with left side. The mean age of the patients was 62.78±9.50 years. The mean renal mass diameter was 9.34±2.96 cm. RCC (Renal Cell Carsinom) was detected at a rate of 84.7%. The mean intraoperative bleeding was 226±121 cc and our transfusion rate was %4. The degree of early postoperative pain was medium at a rate of 89.1%. The mean operation time was 118.02±39.96 minutes. Wound infection and wound dehiscence did not occur in the early postoperative period. The mean length of hospital stay was 5.43±1.09 (4-8) days. Incisional hernia was not observed in patients. CONCLUSIONS: Lateral paramedian incision can be safely preferred in the transperitoneal radical nephrectomy of large renal tumor, providing a clear intraoperative exposure, low postoperative complication rate and the good management of postoperative pain control. Low hospitalization time was remarkable. Our pathology results were similar to the literature.

Place of Open Radical Nephrectomy, in the Era of Laparoscopy in Subsaharian Africa

Introduction: Kidney cancer is discovered in Africa often at advanced or locally advanced stages. These patients could be treated by radical nephrectomy or cytoreductive nephrectomy. Open surgery still retains its place due to the technical difficulties which are linked to the stage of the tumors in this era where laparoscopy is becoming the gold standard. Through this study, we wanted to highlight the advanced stages of patients operated by open surgery in our institution rather than laparoscopy, however, with good results. Patients and Method: It was a retrospective study over a period of 5 years. Were included all patients in whom radical nephrectomy had been performed during this period. Results: Thirty-five (35) open radical nephrectomies for kidney cancer were performed. The average tumor size was 11.6 cm (±3.4 cm). The mean operating time was 169 min ± 63.4 min with extremes of 115 min (1 h 55 min) and 360 min (6 h). This duration was longer for large tumors (p = 0.002). Intraoperative incidents occurred in 4 patients (11.4%); it was a vena cava injury (02) and a spleen injury (02). Blood loss was estimated on average at 535 ml. The mean follow-up time was 19 ± 11 months. The overall survival rate was 90% at 3 months, 53% at 12 months and 35.4% at 24 months. Conclusion: The large size of kidney tumor found in Africa may constitute an obstacle to performing nephrectomies by laparoscopy. However, mastering the laparoscopic technique with appropriate equipment can help reduce operative morbidity.

Conversion to Open Radical or Partial Nephrectomy Associated with Unplanned Hospital Readmission After Attempted Minimally Invasive Approach.

Introduction/Objectives: We endeavored to explore the rates of unplanned hospital readmission (UHR) in patients who underwent minimally invasive radical or partial nephrectomy who were subsequently converted to open surgery. Patients and Methods: The National Cancer Database (NCDB) was used for this study. Patients diagnosed with renal cancer and who had minimally invasive partial or radical nephrectomy from 2004 to 2016 were included in the study. Patients were categorized as converted or not converted to open surgery. UHR was the outcome of the study and was defined as UHR within 30 days of discharge. We conducted a one-to-one nearest-neighbor propensity-score matching using baseline clinical, tumor, and facility characteristics. To evaluate the relationship between conversion to open surgery and UHR, we conducted a multivariable logistic regression on the propensity-matched cohort, a propensity score-matched model without controlling for any covariate, and a propensity score-adjusted model, controlling for only the propensity score. Results: A total of 142,040 patients were identified, with a 2.98% conversion rate. There was an overall decrease in the rate of conversion to open surgery from 2010 (4.11%) to 2016 (2.43%). Laparoscopic radical nephrectomy remained a significant contributor to the rate of conversion (at least 50% per year). In the unmatched cohort, the UHR rate was higher among those who had a conversion to open surgery (n = 710, 0.52% versus n = 44, 1.04%; P < .001). Similarly, in the propensity score-matched cohort, the UHR rate was higher among those who had a conversion to open (n = 22, 0.52% versus n = 44, 1.04%; P = .007). After controlling for other factors, conversion to open remained independently associated with UHF. Conclusion: Conversion to open radical or partial nephrectomy from a minimally invasive approach is independently associated with an increased risk of 30-day UHR.

Prediction of post radical nephrectomy complications based on patient comorbidity preoperatively.

Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, using standardized systems to grade both comorbidity and severity of postoperative complications. Clinicopathological data of 171 patients undergoing open radical nephrectomy for lesions suspected of RCC were prospectively recorded for a period of 3 years. Comorbidity was scored using the Charlson Comorbidity Index (CCI) while postoperative complications were graded according to the Clavien-Dindo system. Patients were predominantly males (59.1%); their age ranged from 35 to 88 years (mean ± SD: 63.6 ± 11.9 yrs) with 50.8% of them being ≤ 65 yrs. CCI ranged from 0 to 8 with the majority (85.3%) scoring ≤ 2. The procedure was uncomplicated in 57.3% cases; 10 patients suffered major (grade III/IV) complications and 4 patients died within the 40 days postoperative period. CCI correlated with the manifestation of any postoperative complication, Clavien ≥ 1, OR (95% CI): 1.47 (1.09-1.96), p = 0.011 and the occurrence of severe complications, Clavien > 2. OR (95% CI): 1.29 (1.01-1.63), p = 0.038. The present prospective study showed that considerable complications occur in patients with major comorbidities. CCI is easily calculated and should be incorporated in preoperative consultation especially in cases of elder patients with severe comorbidity and favorable tumor characteristics where less invasive interventions or even active surveillance could be applied.

PD64-02 SURVIVAL AFTER MINIMALLY INVASIVE VERSUS OPEN RADICAL NEPHRECTOMY FOR STAGE I AND II RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (PD64)1 Sep 2021PD64-02 SURVIVAL AFTER MINIMALLY INVASIVE VERSUS OPEN RADICAL NEPHRECTOMY FOR STAGE I AND II RENAL CELL CARCINOMA Furkan Dursun, Ahmed Elshabrawy, Hanzhang Wang, Ronald Rodriguez, Dharam Kaushik, and Ahmed M. Mansour Furkan DursunFurkan Dursun More articles by this author , Ahmed ElshabrawyAhmed Elshabrawy More articles by this author , Hanzhang WangHanzhang Wang More articles by this author , Ronald RodriguezRonald Rodriguez More articles by this author , Dharam KaushikDharam Kaushik More articles by this author , and Ahmed M. MansourAhmed M. Mansour More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002108.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A phase III randomized trial comparing open and minimally invasive hysterectomy showed significantly higher rates of local recurrence after minimally invasive surgery (MIS) for cervical cancer. This raised concerns regarding patterns of recurrences after MIS in general. This study aims to determine the effect of MIS on all-cause mortality among patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC). METHODS: We utilized the National Cancer Database to identify patients diagnosed with clinical stage I and II RCCs between 2010 and 2013. Patients for whom a laparoscopic or robotic RN was attempted (including patients whose surgery was converted to open) were compared to patients who underwent open radical nephrectomy (ORN). Multivariable adjusted regression models with inverse probability propensity score weighting (IPW) were utilized to identify independent predictors of receiving MIS. All-cause mortality rates were compared using IPW survival functions and log-rank tests. Multivariable weighed Cox proportional hazard models were fitted to determine independent predictors of OS. RESULTS: Overall, 27,642 patients were identified; 11,524 (41.7%) had MIS, while 16,118 (58.3%) had an ORN. Treatment at academic centers (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.62–1.91, p<0.001) and having highest quartile median household income (OR 1.41, 95% CI 1.3–1.53, p<0.001) were associated with an increased likelihood of having MIS. Conversely, African American race (OR 0.88, CI 0.81–0.95, p=0.001) and clinical T2 disease (OR 0.58, 95% CI 0.55–0.61, p<0.001) were associated with a decreased likelihood of having MIS. At a median follow up of 44.7 months, Kaplan Meier survival curves in the propensity score weighed cohort showed OS advantage for patients who underwent MIS (HR 0.84, 95% CI 0.8–0.87, p<0.001) (Table 1). Furthermore, length of hospital stay (3 vs. 4 days), 30-day readmission rates (2.4% vs. 2.87%), 30-day mortality rates (0.53% vs. 0.96%) and 90-day mortality rates (1.04% vs. 1.77%) were significantly higher in the ORN group (p<0.001). CONCLUSIONS: After propensity score weighing, MIS was associated with better 3-year overall survival compared to ORN for stage I and II RCC. Additionally, MIS had lower post-operative readmission, 30- and 90-day mortality rates. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1143-e1144 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Furkan Dursun More articles by this author Ahmed Elshabrawy More articles by this author Hanzhang Wang More articles by this author Ronald Rodriguez More articles by this author Dharam Kaushik More articles by this author Ahmed M. Mansour More articles by this author Expand All Advertisement Loading ...

PD16-01 OBJECTIVE RISK SCORE RELIABLY PREDICTS MORTALITY AFTER RADICAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (PD16)1 Sep 2021PD16-01 OBJECTIVE RISK SCORE RELIABLY PREDICTS MORTALITY AFTER RADICAL NEPHRECTOMY Kristen Marley, Bradley Houston, Christopher Ledbetter, Robert Wake, A. Lynn Patterson, and Maurizio Buscarini Kristen MarleyKristen Marley More articles by this author , Bradley HoustonBradley Houston More articles by this author , Christopher LedbetterChristopher Ledbetter More articles by this author , Robert WakeRobert Wake More articles by this author , A. Lynn PattersonA. Lynn Patterson More articles by this author , and Maurizio BuscariniMaurizio Buscarini More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001998.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical nephrectomy (RN), with or without resection of the ureter, is the treatment of choice for patients with advanced malignancy of the kidney and/or upper urinary tract. We have previously developed and validated a mortality risk score to stratify postoperative outcomes in patients undergoing radical cystectomy. We hypothesized that this 30-day mortality risk score could be applied to patients undergoing RN for malignancy. METHODS: The National Surgical Quality Improvement Program (NSQIP) identified 16,617 patients that underwent RN for upper urinary tract or renal malignancy from 2013-2017. Patients with complete data were included in the analysis. Risk factors for 30-day mortality were identified on multivariable analysis using backward stepwise binary logistic regression. A previously developed and validated mortality risk score (Figure 1A) was calculated for each RN patient. A receiver operating characteristic (ROC) curve quantified the discriminatory ability of the risk calculator. Statistical significance was defined as p values <0.05. RESULTS: Of 9,345 patients included, laparoscopic/robotic technique was applied in 6,112 (65%) patients. The mean age was 64±12 years and most patients were male (n=5950, 64%). Postoperative 30-day mortality was 1.2% (n=116). Older age, elevated creatinine, lower albumin and hematocrit, congestive heart failure, exertional dyspnea, >10% weight loss, disseminated cancer, and open surgery as mortality risk factors. After RN, 30-day mortality increased nearly exponentially with escalating risk category (Figure 1B), p<0.00001. The ROC curve for the risk score is shown in Figure 1C; the area under the curve (AUC) was 0.794 (95% CI, 0.755-0.832; p<0.00001). Relative risk of 30-day mortality increased with escalating risk category: moderate risk=4.8 (2.5-9.1, p<0.00001), high risk=16.8 (9.0-31.5, p<0.00001), and extremely high risk=36.8 (13.4-101.2, p<0.00001). The risk score applied to minimally invasive (AUC, 0.785; 95% CI, 0.722-0.849; p<0.00001) and open RN (0.781; 0.730-0.832; p<0.00001). CONCLUSIONS: A previously established mortality risk score can be employed preoperatively in patients undergoing RN for malignancy to stratify 30-day mortality risk. This 30-day mortality risk score is reliable, accurate, and applicable to both minimally invasive and open RN. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e278-e278 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristen Marley More articles by this author Bradley Houston More articles by this author Christopher Ledbetter More articles by this author Robert Wake More articles by this author A. Lynn Patterson More articles by this author Maurizio Buscarini More articles by this author Expand All Advertisement Loading ...

PD41-12 ACTIVE SURVEILLANCE VS. EMBOLIZATION VS. NEPHRECTOMY: RENAL OUTCOMES IN PATIENTS WITH ANGIOMYOLIPOMAS

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology II (PD41)1 Sep 2021PD41-12 ACTIVE SURVEILLANCE VS. EMBOLIZATION VS. NEPHRECTOMY: RENAL OUTCOMES IN PATIENTS WITH ANGIOMYOLIPOMAS Silvia Mora, Ithaar Derweesh, Margaret Meagher, Juan Javier-Desloges, Sabrina L. Noyes, and Brian R. Lane Silvia MoraSilvia Mora More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , Juan Javier-DeslogesJuan Javier-Desloges More articles by this author , Sabrina L. NoyesSabrina L. Noyes More articles by this author , and Brian R. LaneBrian R. Lane More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002051.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Treatment for angiomyolipomas (AML) can include active surveillance (AS), embolization, and nephrectomy. Our study investigates renal outcomes of these modalities. METHODS: Two-center (UCSD, Spectrum Health) retrospective analysis of AML patients treated with AS, embolization, or nephrectomy. Demographics and renal function were collected. Primary outcome included renal function, by treatment type, at three timepoints: diagnosis, interim (6-12 months post-diagnosis), and latest. CKD was grouped as 1 (>90), 2a (75-90), 2b (60-75), 3a (45-60), 3b (30-45), 4 (15-30), 5 (<15). RESULTS: 318 patients diagnosed with AMLs were identified with a median follow-up of 3.3 years. 184 (57.9%) underwent AS, 30 (9.4%) underwent embolization, 103 (32.4%) underwent nephrectomy, and 1 (0.3%) underwent radiofrequency ablation. Of the 103 surgical patients, 62 (60.2%) had minimally-invasive partial nephrectomy (PN), 31 (30.1%) had open PN, 3 (2.9%) had laparoscopic radical nephrectomy (RN), and 7 (6.8%) had open RN. Baseline features of AS, embolization, and nephrectomy groups were different in respect to age, sex, and race (p<0.05). The average AML size at diagnosis was 2.1cm for AS, 5.3cm for embolization, and 4.9cm for nephrectomy (p<0.001). When compared to diagnosis GFR, the interim % change in GFR showed a greater decrease for embolization (-14.0%) when compared to AS (-4.1%) and nephrectomy (-11.8%)(p=0.04). Interim CKD stage worsened in AS (26.6%), embolization (26.7%), and nephrectomy (21.4%)(p<0.001). The latest % change in GFR showed a greater decrease for nephrectomy (-14.7%) when compared to AS (-6.6%) and embolization (-14.1%)(p=0.03). Latest CKD stage worsened from diagnosis in AS (42.4%), embolization (53.3%), and nephrectomy (39.8%)(p=0.004). CONCLUSIONS: Reduced renal function is commonly observed over time in AML patients, whether managed conservatively, with embolization, or with surgery. Even so, the majority of AS and surgical patients and slightly less than half of embolization patients had no evidence of worsening CKD stage at latest follow-up. Renal functional surveillance should be obligatory for all AML patients; within the limitations of this retrospective study, surgical intervention appears an appropriate treatment option for selected AML. Source of Funding: Betz Family Endowment for Cancer Research © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e685-e686 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Silvia Mora More articles by this author Ithaar Derweesh More articles by this author Margaret Meagher More articles by this author Juan Javier-Desloges More articles by this author Sabrina L. Noyes More articles by this author Brian R. Lane More articles by this author Expand All Advertisement Loading ...

PD41-02 RADIOMIC-BASED “VIRTUAL BIOPSY” RELIABLY DIFFERENTIATES BENIGN FROM MALIGNANT RENAL MASSES

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology II (PD41)1 Sep 2021PD41-02 RADIOMIC-BASED “VIRTUAL BIOPSY” RELIABLY DIFFERENTIATES BENIGN FROM MALIGNANT RENAL MASSES Nima Nassiri, Marissa Maas, Giovanni Cacciamani, Bino Varghese, Darryl Hwang, Assad Oberai, Xiaomeng Lei, Mihir Desai, Monish Aron, Steven Cen, Vinay Duddalwar, and Inderbir Gill Nima NassiriNima Nassiri More articles by this author , Marissa MaasMarissa Maas More articles by this author , Giovanni CacciamaniGiovanni Cacciamani More articles by this author , Bino VargheseBino Varghese More articles by this author , Darryl HwangDarryl Hwang More articles by this author , Assad OberaiAssad Oberai More articles by this author , Xiaomeng LeiXiaomeng Lei More articles by this author , Mihir DesaiMihir Desai More articles by this author , Monish AronMonish Aron More articles by this author , Steven CenSteven Cen More articles by this author , Vinay DuddalwarVinay Duddalwar More articles by this author , and Inderbir GillInderbir Gill More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002051.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A substantial proportion of patients undergo treatment for renal masses where active surveillance or observation may be more appropriate. We sought to determine whether a radiomic-based artificial intelligence (AI) platform that incorporates clinical variables can accurately differentiate benign renal masses from renal cell carcinoma (RCC). METHODS: We performed a cross-sectional analysis of a prospectively collected and maintained registry of patients with renal masses in accordance with the STROBE Statement for observational studies. All participants had a clinically-localized renal mass visualized with multiphase computed-tomography (CT) before robotic, laparoscopic, or open partial or radical nephrectomy. Radiomic analysis of pre-operative CT scans, specifically CT shape and texture analysis, was performed. 10-fold cross-validation was performed to overcome heterogeneities in radiomic analysis. Clinical and radiomic variables of interest (VOIs) were identified through decision tree analysis and incorporated into machine-learning Random Forest and REAL Adaboost predictive models. The primary outcome was the diagnostic capacity of the predictive model to discriminate benign renal masses from RCC. Secondary outcomes included a subanalysis for small renal masses (SRMs) and for patients who underwent percutaneous renal mass biopsy. RESULTS: 684 patients with a renal mass identified on CT imaging underwent radical or partial nephrectomy. Of the patients, 76% had RCC; 57% had an SRM, of which 73% were malignant. REAL Adaboost predictive modeling differentiated benign pathology from RCC with an AUC of 0.84 (95% C.I. 0.79-0.9) (Figure 1A). In SRMs, radiomic analysis yielded a discriminatory AUC of 0.77 (95%. C.I. 0.69-0.85) (Figure 1B). When negative and non-diagnostic biopsies were supplemented with the results of radiomic analysis, accuracy increased from 83.3% to 93.4%. CONCLUSIONS: Radiomic-based predictive modeling produces a “virtual biopsy” that may discriminate benign renal masses from RCC. Enhanced diagnostic predictability may preclude surgical intervention and increase the utility of active surveillance protocols. Source of Funding: no disclosures © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e680-e681 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nima Nassiri More articles by this author Marissa Maas More articles by this author Giovanni Cacciamani More articles by this author Bino Varghese More articles by this author Darryl Hwang More articles by this author Assad Oberai More articles by this author Xiaomeng Lei More articles by this author Mihir Desai More articles by this author Monish Aron More articles by this author Steven Cen More articles by this author Vinay Duddalwar More articles by this author Inderbir Gill More articles by this author Expand All Advertisement Loading ...

V11-02 ROBOTIC CAVECTOMY DURING ONCOLOGICAL SURGERY: TECHNICAL CONSIDERATIONS AND OUTCOMES

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-02 ROBOTIC CAVECTOMY DURING ONCOLOGICAL SURGERY: TECHNICAL CONSIDERATIONS AND OUTCOMES Wesley Yip, David Ortega, Luis Medina, Alireza Ghoreifi, Nima Nassiri, Bishoy Hanna, Akbar Ashrafi, Matthew Winter, Inderbir Gill, and Hooman Djaladat Wesley YipWesley Yip More articles by this author , David OrtegaDavid Ortega More articles by this author , Luis MedinaLuis Medina More articles by this author , Alireza GhoreifiAlireza Ghoreifi More articles by this author , Nima NassiriNima Nassiri More articles by this author , Bishoy HannaBishoy Hanna More articles by this author , Akbar AshrafiAkbar Ashrafi More articles by this author , Matthew WinterMatthew Winter More articles by this author , Inderbir GillInderbir Gill More articles by this author , and Hooman DjaladatHooman Djaladat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: An increasing proportion of renal cell carcinoma (RCC) and germ cell tumor (GCT) surgeries are being performed with a robotic-assisted laparoscopic approach. In cases of tumor and/or thrombus infiltrating the inferior vena cava (IVC) wall, adherence to the IVC endothelium, or obliteration of the IVC lumen, infra or suprarenal cavectomy may be indicated. We present our robotic cavectomy case series to demonstrate its technical feasibility and short-term outcomes. METHODS: Four patients underwent robotic cavectomy, either as adjuvant surgery (retroperitoneal lymph node dissection or radical nephrectomy) or primary procedure. Indications included: 1) post-chemotherapy retroperitoneal GCT involving the IVC, 2, 3) right-sided RCC with IVC tumor thrombus (Levels II and III), and 4) recurrent IVC tumor thrombus after previous open right radical nephrectomy and IVC thrombectomy. The post-chemotherapy retroperitoneal GCT patient underwent an infrarenal robotic cavectomy, while the RCC patients underwent suprarenal robotic cavectomies. None underwent caval reconstruction. RESULTS: All four patients tolerated intraoperative IVC clamping and subsequent cavectomy. Peri and 90-day postoperative outcomes are presented in Table 1. No patients required hemodialysis. During follow-up, there were no complications, lower extremity edema, or renal function deterioration, although the Level III IVC thrombus patient developed lung and retroperitoneal recurrences 15 months after surgery, which are planned for immunotherapy. Short-term oncological data is presented in Table 2. CONCLUSIONS: To our knowledge, this is the first case series of robotic cavectomy. We demonstrate that it can be safely performed in selected patients at experienced centers with low morbidity and complication rates. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e857-e858 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wesley Yip More articles by this author David Ortega More articles by this author Luis Medina More articles by this author Alireza Ghoreifi More articles by this author Nima Nassiri More articles by this author Bishoy Hanna More articles by this author Akbar Ashrafi More articles by this author Matthew Winter More articles by this author Inderbir Gill More articles by this author Hooman Djaladat More articles by this author Expand All Advertisement Loading ...

V11-04 ROBOTIC-ASSISTED LAPAROSCOPIC RIGHT RADICAL NEPHRECTOMY WITH RIGHT IVC THROMBECTOMY AND REPAIR WITH BOVINE GRAFT

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-04 ROBOTIC-ASSISTED LAPAROSCOPIC RIGHT RADICAL NEPHRECTOMY WITH RIGHT IVC THROMBECTOMY AND REPAIR WITH BOVINE GRAFT Rohan Sawhney, Mubashir Billah, Mutahar Ahmed, and Michael Stifelman Rohan SawhneyRohan Sawhney More articles by this author , Mubashir BillahMubashir Billah More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , and Michael StifelmanMichael Stifelman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Extension of renal cell carcinoma (RCC) into the inferior vena cava (IVC) has been reported in 3-7% of patients. Definitive treatment is surgical resection with a 5-year cancer-specific survival of 32%. Various treatment choices exist including open radical nephrectomy with IVC thrombectomy, hybrid robot-assisted laparoscopic (RAL) radical nephrectomy with limited subcostal for IVC thrombectomy and complete RAL radical nephrectomy with IVC thrombectomy. In all cases one must be prepared to reconstruct the vena cava to prevent narrowing. We present a unique case of RCC with subhepatic IVC thrombosis that was treated entirely robotically and utilized a bovine patch to reconstruct the vena cava. METHODS: A 77-year-old male presented with gross hematuria, an eGFR of 42 and MRI revealing a heterogenous ill-defined mass in the upper pole of the right kidney, level 2 IVC thrombosis, and numerous pulmonary parenchymal metastases. CT guided renal biopsy confirmed clear cell RCC and the patient was treated pre-operatively with immunotherapy. This video will review pertinent steps to performing a robotic IVC thrombectomy with bovine patch. In addition, we will review our single institution experience with complete RAL radical nephrectomy with IVC thrombectomy. RESULTS: The video outlines our technique for robotic radical nephrectomy, IVC thrombectomy and placement of bovine graft. Reviewing our retrospective and prospective data renal cancer databases, we completed 18 IVC thrombectomies, of which 3 were done completely robotically. Of the 9 requiring a bovine patch, 4 were done open, 4 were done as a hybrid technique and 1 was done robotically. Our data for complete robotic IVC thrombectomy is summarized in Table 1. CONCLUSIONS: Management of Level 1 and 2 IVC thrombus can be safely performed through a hybrid technique or completely robotically technique. No matter the technique, one must be prepared for IVC reconstruction. Our experience suggests that complete robotic IVC thrombectomy and reconstruction with bovine graft is feasible in select patients. We recommend having a vascular surgeon close by and anesthesia ready with blood products if necessary. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e858-e859 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rohan Sawhney More articles by this author Mubashir Billah More articles by this author Mutahar Ahmed More articles by this author Michael Stifelman More articles by this author Expand All Advertisement Loading ...