Preoperative Axial Images Research Articles

Narrated video of patient presentation, preoperative axial imaging, and intraoperative footage.

Narrated video of patient presentation, preoperative axial imaging, and intraoperative footage.

PD24-01 THE SELECTION FOR CYTOREDUCTIVE NEPHRECTOMY (SCREEN) SCORE: SURGICAL RISK STRATIFICATION INTEGRATING RADIOGRAPHIC FEATURES

You have accessJournal of UrologyCME1 Apr 2023PD24-01 THE SELECTION FOR CYTOREDUCTIVE NEPHRECTOMY (SCREEN) SCORE: SURGICAL RISK STRATIFICATION INTEGRATING RADIOGRAPHIC FEATURES Daniel Shapiro, Jose Karam, Viraj Master, Philippe Spiess, Jay Raman, Wade Sexton, Logan Zemp, Dattatraya Patil, Kate Lauer, Glenn Allen, Surena Matin, and E. Jason Abel Daniel ShapiroDaniel Shapiro More articles by this author , Jose KaramJose Karam More articles by this author , Viraj MasterViraj Master More articles by this author , Philippe SpiessPhilippe Spiess More articles by this author , Jay RamanJay Raman More articles by this author , Wade SextonWade Sexton More articles by this author , Logan ZempLogan Zemp More articles by this author , Dattatraya PatilDattatraya Patil More articles by this author , Kate LauerKate Lauer More articles by this author , Glenn AllenGlenn Allen More articles by this author , Surena MatinSurena Matin More articles by this author , and E. Jason AbelE. Jason Abel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003302.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patient selection for cytoreductive nephrectomy (CN) is critical yet few studies incorporate tumor burden into decision making. This study developed a prognostic model to improve CN selection by integrating radiologic features with known prognostic factors. METHODS: Consecutive mRCC patients treated with upfront CN at 5 institutions from 2006-2017 were included. Preoperative axial imaging was analyzed for measures of tumor burden including number of sites, total metastatic tumor burden (sum of metastatic lesions’ maximum diameter) and maximum primary tumor diameter. Univariable/multivariable Cox models were used to evaluate known prognostic variables associations with overall survival, and the SCREEN model was constructed using independently predictive preoperative variables. This model was compared to the IMDC model for predictive accuracy and clinical utility. RESULTS: A total of 914 mRCC patients were treated with upfront CN during the study period. Seven independently predictive variables used in the SCREEN score included: number of metastatic sites ≥3, total cm of metastatic tumor burden ≥5 cm, bone metastasis, systemic symptoms, low serum hemoglobin, low serum albumin, and neutrophil to lymphocyte ratio ≥4. Risk groups were created based on number of risk factors (Figure 1). The SCREEN model demonstrated improved survival discrimination compared to the IMDC risk groups. When evaluating early mortality (death ≤12 months from CN), predictive accuracy measured by the area under the ROC curve was 0.76 for SCREEN compared to 0.55 for the IMDC model. Decision curve analysis showed that the SCREEN model improved decision making beyond IMDC score for threshold probabilities of early mortality between 15-70% (Figure 2). CONCLUSIONS: The SCREEN model integrates radiographic measurements for mRCC patients, which was associated with improved predictive accuracy. These findings should be validated further in independent cohorts. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e721 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniel Shapiro More articles by this author Jose Karam More articles by this author Viraj Master More articles by this author Philippe Spiess More articles by this author Jay Raman More articles by this author Wade Sexton More articles by this author Logan Zemp More articles by this author Dattatraya Patil More articles by this author Kate Lauer More articles by this author Glenn Allen More articles by this author Surena Matin More articles by this author E. Jason Abel More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic upper lobe segmentectomy: technical pearls

: Minimally invasive approaches to segmentectomy have grown in popularity as sublobar resection has been increasingly offered as a parenchyma-sparing alternative to lobectomy for amenable lesions. Both video-assisted thoracic surgery and robotic surgery offer advantages over traditional thoracotomy, with fewer complications, shortened hospital stay, and less pain. While segmentectomy has been traditionally performed by video-assisted thoracic surgery, the robotic approach represents a growing subset of minimally invasive sublobar resections. Patient selection for robotic segmentectomy involves a standard preoperative evaluation including pulmonary function tests, cardiac evaluation, and complete staging. Preoperative axial imaging is essential in choosing patients with lesions amenable to segmentectomy, and evaluating the segmental anatomy. Safe robotic segmentectomy centers around thorough knowledge of the segmental vascular and bronchial anatomy and its variants, and preoperative imaging can help the surgeon anticipate variant anatomy intraoperatively. The operative technique generally involves a mediastinal lymph node dissection with frozen section of the N1 nodes and conversion to lobectomy if positive. The segmental resection then proceeds depending on the individual segment to be resected, but generally involves dissection and division of the vessels and bronchus, followed by division of the parenchyma along the intersegmental plane. For most patients, postoperative recovery is short and uncomplicated, with most patients being discharged on the first or second postoperative day.

The impact of preoperative imaging on wait times, surgical approach and overall survival in endometrioid endometrial cancers

ObjectivesRoutine preoperative axial imaging studies (CT/MRI) are not recommended for endometrioid endometrial cancer as they are unlikely to change management and may delay surgery. This study evaluated the association of receiving preoperative imaging on various outcomes. MethodsA population-based cohort of Endometrioid Endometrial Cancer cases from 2006 to 2016 were identified from the Cancer Registry in Ontario, Canada. Wait time to surgery, type of surgery and overall survival were evaluated in patients with and without preoperative imaging. Predictive factors for wait time > 56 days and aggressive surgery (radical hysterectomy / lymphadenectomy) were determined using multivariable regression analysis. Results13,050 cases were included. 22.6% of patients received preoperative imaging, mainly CT scans. Most patients (95.9%) received no neoadjuvant treatment. Patients with preoperative imaging were more likely to have neoadjuvant treatment (11.7% vs. 1.8%) and less likely to have surgery at 180 days post diagnosis (87.9% vs 94.6%). Patients with preoperative imaging had median wait time to surgery of 64 days (47–87), compared to 53 days (36–74) than those without imaging (p < 0.001). Multivariable modeling showed preoperative imaging was associated with decreased odds of having surgery within 56 days (OR = 0.68, 95% CI = 0.62–0.75), and increased odds (OR = 1.73, 95% CI = 1.53–1.95) of having aggressive surgery. The 5-year overall survival for patients with imaging was 84.8% versus 91.1% for patients without preoperative imaging. ConclusionsPreoperative imaging was associated with longer wait times to surgery, more aggressive surgery, surgery with a gynecologic oncologist and increased use of neoadjuvant and adjuvant treatment. In early-stage disease there was no observed improvement in overall survival for patients with preoperative imaging. Further research on potential benefits of preoperative imaging in higher risk patients is required.

Parenchymal Volume Replacement by Renal Cell Carcinoma Prior to Intervention: Predictive Factors and Functional Implications

ObjectiveTo analyze predictors, extent and functional implications associated with renal parenchymal volume replacement (PVR) by renal cell carcinoma (RCC) prior to intervention. This phenomenon is well-recognized yet not adequately studied, and, if severe, can influence management. Materials and MethodsA retrospective review was performed of partial nephrectomy (PN) and radical nephrectomy (RN) patients with available preoperative nuclear-renal-scan and imaging demonstrating solitary RCC with normal contralateral kidney. Normal renal parenchymal volume of each kidney was measured by free-hand scripting from preoperative axial images. Primary endpoint was percent PVR which was estimated assuming that the contralateral-kidney serves as a control: PVR = (volume contralateral kidney – volume ipsilateral kidney) normalized by volume contralateral kidney. Multivariable linear-regression analysis assessed factors associated with preoperative PVR. Further analysis evaluated the functional effect of PVR prior to surgery. Results146 PN and 136 RN patients with necessary studies were analyzed. For RN, the median PVR was 15% and a quarter of patients had PVR ≥27%. In contrast, PVR was negligible in PN patients for whom median preoperative parenchymal volumes were nearly identical in the ipsilateral/contralateral kidneys (179/180cc, respectively). PVR inversely correlated with preoperative renal function in the ipsilateral kidney (P <.01). Tumor-size (P <.01), stage (P = .03), and endophytic properties (P = .03) associated with PVR on multivariable-analysis. ConclusionOur data suggest that substantial replacement of normal parenchyma by RCC occurs in many patients selected for RN and can contribute to preexisting renal-insufficiency. PVR prior to intervention is mainly driven by tumor characteristics in RN patients, but is negligible in most PN patients.

Open and Laparoscopic Partial Nephrectomy: Comparison and Validation of Preoperative Scoring Systems, Including PADUA, RENAL, ABC Nephrometric Scores and Perinephric Fat Evaluation with Mayo Adhesive Probability Score.

PurposeTo evaluate potential associations between 4 nephrometric scoring systems, namely the PADUA (preoperative aspects and dimensions used for anatomical classification), RENAL (radius endophytic/exophytic nearness anterior posterior location), ABC (arterial-based complexity), and MAP (Mayo adhesive probability) scores and their individual components, with surgical and oncological outcomes of patients undergoing a partial nephrectomy.Materials and MethodsA consecutive, monocentric cohort of partial nephrectomy patients was retrospectively analyzed. PADUA, RENAL, ABC and MAP nephrometry scores were determined from preoperative axial images. Unadjusted and adjusted associations between overall scores, individual components, surgical approach, complications and oncological outcomes were determined using univariate and multivariate logistic regressions.ResultsA total of 189 partial nephrectomies were performed in 181 patients, via an open or a laparoscopic approach. Among scoring systems, only the MAP classification, which assesses adherent perinephric fat, was associated with severe surgical complications as well as with operative time (p<0.05). Among all components of the PADUA and RENAL scores, only proximity of the tumor to the collecting system was associated with overall surgical complication rates, while the diameter of the tumor influenced the operative time (p<0.05). The ABC score was not relevant. Male gender, antiplatelet therapy, and a laparoscopic approach were associated with higher overall surgical complication rates (p<0.05). The number of oncologic recurrences during follow-up was too low to run statistical analyses.ConclusionNephrometry scores could be simplified to predict surgical complications after partial nephrectomy. In this framework, adherent perinephric fat seemed to be strongly associated with an increased risk of surgical complications.

The use of imaging in endometrial cancer prior to potential surgery: Are guidelines being followed?

ObjectivesClinical practice guidelines recommend against routine preoperative axial imaging studies (CT/MRI) for endometrial cancer, except for cases of locally advanced disease or aggressive histologies. This study utilized population-based data to evaluate the use of preoperative imaging and factors associated with its use. MethodsA population-based cohort of women diagnosed with endometrial cancer from 2006 to 2016 were identified from the Ontario Cancer Registry in Ontario, Canada. Patients were excluded if they had: hysterectomy prior to the date of diagnosis, non-epithelial histology or a prior cancer diagnosis within 5 years. Preoperative imaging (CT or MRI) rates were calculated over time. Predictive factors for preoperative imaging use were determined using multi-variable regression analysis. Results17,718 cases were eligible for analysis. From 2006 to 2016, the proportion of patients receiving preoperative imaging increased from 22.2% to 39.3%. In a subgroup of patients with low-risk disease (stage 1, endometrioid adenocarcinoma), imaging increased from 16.3% to 29.5%. Multivariate analysis showed an association between preoperative imaging and advanced stage, advanced grade, non-endometrioid morphology, surgery with a gynecologic oncologist, surgery at a teaching hospital and a later year of diagnosis. From 2006 to 2016, the yearly incidence of endometrial cancer increased from 22.3/100,000 to 36.1/100,000, representing a mean annual increase of 3.6% per year. ConclusionsEndometrial cancer incidence and the use of preoperative imaging are increasing. Factors most associated with preoperative imaging are high-risk features. However, preoperative imaging is still being performed in low-risk patients, indicating non-adherence to guidelines, which has implications for constrained healthcare resources.

Society for Vascular Surgery femoral runoff score is associated with limb-based patency after aortofemoral bypass

ObjectiveDespite advancements, aortofemoral bypass (AFB) remains the most durable option for aortoiliac occlusive disease. Although runoff has been shown to be associated with AFB patency, the association of the Society for Vascular Surgery (SVS) thigh runoff scoring system with patency has not been assessed. The aim of the present study was to evaluate the association between the SVS runoff scoring system and limb-based primary patency after AFB. MethodsInstitutional data for patients undergoing AFB with preoperative runoff imaging available from 2000 to 2017 were queried. Runoff scores were assigned according to the presence of occlusive disease in the superficial femoral artery and profunda femoris artery (minimum, 1; maximum, 10) as described by the 1997 SVS reporting standards for lower extremity ischemia. Limb-based patency was the primary endpoint. Kaplan-Meier analysis was used to compare the long-term limb-based patency and freedom from reintervention between limbs with runoff scores ≥6 and those with runoff scores <6. Propensity score-weighted Cox proportional hazards modeling was used to evaluate the association between a runoff score of ≥6 and primary patency loss, controlling for other factors associated with primary patency. ResultsIn 161 patients, 316 limbs had undergone revascularization. The mean patient age was 66.7 ± 11.3 years, and 51.6% were women. Most limbs had undergone revascularization for claudication (56.5%). Most (89.4%) had TransAtlantic InterSociety Consensus class D lesions, 27.3% had required suprarenal or higher clamping, and 11.2% had undergone concomitant mesenteric intervention. A femoral outflow adjunct and concurrent lower extremity bypass was required in 41.8% and 2.9% of limbs, respectively. Those with a runoff score of ≥6 had experienced greater rates of 30-day myocardial infarction (11% vs 1%; P = .005), respiratory failure (11% vs 1%; P = .005), and mortality (8% vs 0%; P ≤ .006). The median follow-up period was 4.0 years (interquartile range, 6.5 years). The 1-, 3-, and 5-year primary patency was 94.6% (95% confidence interval [CI], 91.9%-97.3%), 89.2% (95% CI, 85.4%-93.2%), and 81.4% (95% CI, 76.0%-87.1%), respectively. The 5-year primary-assisted patency, secondary patency, and freedom from reintervention were 84.9% (95% CI, 79.7%-90.5%), 91.7% (95% CI, 87.3%-96.3%), and 83.3% (95% CI, 78.3%-88.7%), respectively. Patients with a runoff score of ≥6 had lower primary (log-rank P < .01), primary-assisted (P < .01), and secondary patency (P = .01). The factors associated with the loss of primary patency included a high runoff score (runoff score of ≥6: hazard ratio [HR], 4.1; 95% CI, 2.1-8.0; P < .01), simultaneous mesenteric endarterectomy (HR, 13.5; 95% CI, 1.9-97.8; P = .01), and chronic kidney disease (HR, 4.6; 95% CI, 1.5-14.6; P = .01). Increasing age (HR, 0.94 per year; 95% CI, 0.91-0.97; P < .01) and hyperlipidemia (HR, 0.44; 95% CI, 0.23-0.85; P = .01) were protective. ConclusionsThe SVS femoral runoff score is an important factor associated with long-term AFB limb patency. Scores of ≥6 portend for worse limb outcomes and a greater incidence of operative complications. The SVS score can be determined from preoperative axial imaging studies and serve as a guide in decision-making and operative planning.

MP22-06 TREATING ASYMPTOMATIC CONCURRENT CONTRALATERAL URINARY STONES DOES NOT IMPACT FUTURE SURGICAL INTERVENTIONS

INTRODUCTION AND OBJECTIVE: Concurrent bilateral kidney stone treatment is shown to be safe (Angerri, 2019). Whether it decreases the risk of future procedures is unknown. Treating asymptomatic contralateral stones at the time of surgery remains controversial. This study examines the need for future surgical procedures in patients with asymptomatic stones in the contralateral kidney at the time of initial stone procedure. METHODS: We conducted an IRB approved retrospective chart review. Patients were enrolled if they had bilateral stones and underwent stone surgeries (SWL, URS, PCNL) between 2009 and 2018 at a referral center. Inclusion criteria included a minimum follow-up of two years and pre-operative axial imaging. Patients were divided into two groups: bilateral (simultaneous or staged [within three months]) surgery, and unilateral surgery with asymptomatic concurrent contralateral stones. For patients who had bilateral surgery, the contralateral side was defined as the side with smaller pre-operative stone size. The primary outcome was the subsequent need for surgical treatment on the contralateral kidney. Cox regression analysis was used. RESULTS: Of the initial 3477 patients identified 614 (322 men) met our inclusion criteria. The mean age was 59.6±14.4 years, and mean BMI was 31.5±8.7. Patients’ total follow-up time was 5.2±2.2 years (range 2-11 years). Patients who had bilateral surgery and patients who had unilateral surgery with asymptomatic concurrent contralateral stones had no difference in the need for surgical treatment for contralateral stones (27.8% vs. 29.3%, p=0.838) (Figure). CONCLUSIONS: Our long-term analysis suggests that treating asymptomatic contralateral stones at the time of the stone surgery does not alter the risk for future operations.Source of Funding: None

Select early type IA endoleaks after endovascular aneurysm repair will resolve without secondary intervention

ObjectiveAlthough it is traditionally considered ominous, the natural history of early proximal attachment site endoleaks (IA) after endovascular aneurysm repair (EVAR) is not well known. Our aim was to identify risk factors for persistent type IA endoleaks and to determine their effect on long-term outcomes after EVAR. MethodsAll patients who underwent infrarenal EVAR at a single institution between 1998 and 2015 were identified. Preoperative axial imaging and intraoperative arteriograms were reviewed, and those patients with a type IA endoleak were further studied. Aneurysm features were characterized by two reviewers and were studied for predictors of persistent endoleaks at the conclusion of the case. Patient records and the Social Security Death Index were used to record 1-year and overall survival. ResultsWe identified 1484 EVARs, 122 (8%) of which were complicated by a type IA endoleak on arteriography after graft deployment, with a median follow-up of 4 years. The majority of patients underwent additional ballooning of the proximal site (52 [43%]) or placement of an aortic cuff (47 [39%]); 30 patients (25%) received a Palmaz stent, and four patients were treated with coils or anchors. At case end, only 43 (35%) of the type IA endoleaks remained; at 1 month, only 16 endoleaks persisted (13%), and only six persisted at 1 year (6%). In multivariable analysis, the only independent predictor of persistence of type IA endoleak at the conclusion of the case was the presence of extensive neck calcifications (odds ratio [OR], 9.9; 95% confidence interval [CI], 1.4-67.9; P = .02). Thirteen patients (11%) underwent reintervention for type IA endoleaks, with a time frame ranging from 3 days postoperatively to 11 years. There were three patients (2.4%) who experienced aneurysm rupture. Postoperative type IA endoleak was associated with lower survival at 1 year (79% vs 91%; relative risk, 2.5; 95% CI, 1.1-5.4; P = .02), but it did not affect long-term survival (log-rank, P = .45). Both an increase in aneurysm sac size and failure of the endoleak to resolve by case end were independent predictors of a need for reintervention (growth: OR, 8.3; 95% CI, 2.2-31.6; P < .01; persistent endoleak: OR, 7.6; 95% CI, 1.8-31.5; P < .01). A persistent type IA endoleak was not independently associated with an increase in sac size on surveillance imaging (P = .28). ConclusionsAneurysm rupture secondary to persistent type IA endoleak is rare, and most will resolve within 1 year. Extensive neck calcification is the only independent predictor of persistent type IA endoleak, and an increase in sac size warrants reintervention. These data suggest that select early persistent type IA endoleaks can be safely observed.

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.

The association between renal tumour scoring system components and complications of partial nephrectomy.

We evaluate the associations between 3 renal tumour scoring systems and their components with perioperative complications of partial nephrectomy. A consecutive cohort of partial nephrectomy patients was analyzed. Patient characteristics were abstracted from medical records. PADUA scores (preoperative aspects and dimensions used for anatomic classification), RENAL (radius exophyic/endophytic nearness anterior/posterior location scoring) nephrometry scores, and Centrality index (C-index) were determined from preoperative axial images by 2 independent reviewers. Cases were evaluated for postoperative complications up to 30 days after surgery. Pre-specified complication definitions were used for 33 potential medical and surgical complications. Unadjusted and adjusted associations between overall scores, individual components, and complications were determined using log binomial regression. In total, 118 patients were included in the study. Of these, 36 (30.5%) surgical complications occurred in 27 (22.9%) patients. Fourteen (11.9%) were Clavien grade ≥3. Overall PADUA score was significantly associated with surgical and overall complications after adjusting for potential confounders. Among all components of the 3 scoring systems, only tumour diameter and exophytic/endophytic nature of the tumour were significantly associated with complications after adjusting for the other components of the respective scoring system (p < 0.05). Renal tumour scoring systems may help predict the risk of complications after partial nephrectomy. Further refinement of current systems is required. A first step would be to include only components that are significantly associated with complications.

MP54-11 INCREASING PROPORTION OF PERINEPHRIC TO SUBCUTANEOUS FAT PREDICTS OPERATIVE DURATION AND COMPLICATIONS FOLLOWING MINIMALLY INVASIVE PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 2014MP54-11 INCREASING PROPORTION OF PERINEPHRIC TO SUBCUTANEOUS FAT PREDICTS OPERATIVE DURATION AND COMPLICATIONS FOLLOWING MINIMALLY INVASIVE PARTIAL NEPHRECTOMY Christopher Reynolds, Erik Lehman, Lewis Harpster, and Jay Raman Christopher ReynoldsChristopher Reynolds More articles by this author , Erik LehmanErik Lehman More articles by this author , Lewis HarpsterLewis Harpster More articles by this author , and Jay RamanJay Raman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1600AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Body mass index (BMI) is not independently associated with adverse perioperative outcomes following minimally invasive partial nephrectomy (MIPN). Several groups, however, have implicated that the distribution of fat (visceral vs. adipose) may serve as a better predictor for surgical outcomes. These data remain conflicting. We investigate the association of 1) perinephric fat thickness and 2) ratio of perinephric to subcutaneous fat thickness on outcomes following MIPN. Methods Clinical, radiographic, procedural, and pathologic data were collected for 220 consecutive patients undergoing MIPN by two surgeons via laparoscopic (n=109) or robotic (n=111) techniques. Perinephric (PF) and subcutaneous fat (SF) thickness was measured on preoperative axial imaging at the level of the renal vein and umbilicus, respectively. (Figure) The association between PF thickness and PF:SF ratio on surgical outcomes was determined by Spearman correlation and logistic regression. Results 111 men and 109 women with a median age of 55 years, BMI of 32, tumor size 2.6cm, and RENAL nephrometry score of 6 were included. On preoperative imaging, median PF thickness was 2.2 cm, SF thickness 3.1 cm, and PF:SF ratio of 0.63. Median operative duration was 212 minutes, ischemia duration 22 minutes, EBL 150 cc, and length of stay was 3 days. Seven patients had positive surgical margins, and 58 (26%) had postoperative complications including 10 with Clavien III or higher. There were statistically significant positive correlations between PF thickness (Spearman correlation coefficient = 0.26, p = 0.001) and PF:SF ratio (Spearman correlation coefficient = 0.33, p < 0.0001) with OR duration. Additionally, an increasing PF:SF ratio was associated with a greater risk of perioperative complications (OR = 1.82, 95% CI 1.1 - 3.0, p = 0.02). No association was observed with respect to ischemia time, blood loss, length of stay, margin status, or postoperative renal function. Conclusions PF thickness is associated with longer OR duration, and a greater PF:SF ratio correlated with increased OR duration and complications following MIPN. These easily measured indices of fat distribution are likely more accurate in predicting perioperative outcomes after MIPN than BMI alone. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e576 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Christopher Reynolds More articles by this author Erik Lehman More articles by this author Lewis Harpster More articles by this author Jay Raman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP54-12 DIABETES MELLITUS IS ASSOCIATED WITH AN INCREASED RISK OF CANCER-SPECIFIC MORTALITY AMONG PATIENTS WITH CLEAR CELL RENAL CELL CARCINOMA UNDERGOING NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: Body mass index (BMI) is not independently associated with adverse perioperative outcomes following minimally invasive partial nephrectomy (MIPN). Several groups, however, have implicated that the distribution of fat (visceral vs. adipose) may serve as a better predictor for surgical outcomes. These data remain conflicting. We investigate the association of 1) perinephric fat thickness and 2) ratio of perinephric to subcutaneous fat thickness on outcomes following MIPN. METHODS: Clinical, radiographic, procedural, and pathologic data were collected for 220 consecutive patients undergoing MIPN by two surgeons via laparoscopic (n1⁄4109) or robotic (n1⁄4111) techniques. Perinephric (PF) and subcutaneous fat (SF) thickness was measured on preoperative axial imaging at the level of the renal vein and umbilicus, respectively. (Figure) The association between PF thickness and PF:SF ratio on surgical outcomes was determined by Spearman correlation and logistic regression. RESULTS: 111 men and 109 women with a median age of 55 years, BMI of 32, tumor size 2.6cm, and RENAL nephrometry score of 6 were included. On preoperative imaging, median PF thickness was 2.2 cm, SF thickness 3.1 cm, and PF:SF ratio of 0.63. Median operative duration was 212 minutes, ischemia duration 22 minutes, EBL 150 cc, and length of stay was 3 days. Seven patients had positive surgical margins, and 58 (26%) had postoperative complications including 10 with Clavien III or higher. There were statistically significant positive correlations between PF thickness (Spearman correlation coefficient 1⁄4 0.26, p 1⁄4 0.001) and PF:SF ratio (Spearman correlation coefficient 1⁄4 0.33, p < 0.0001) with OR duration. Additionally, an increasing PF:SF ratio was associated with a greater risk of perioperative complications (OR 1⁄4 1.82, 95% CI 1.1 3.0, p 1⁄4 0.02). No association was observed with respect to ischemia time, blood loss, length of stay, margin status, or postoperative renal function. CONCLUSIONS: PF thickness is associated with longer OR duration, and a greater PF:SF ratio correlated with increased OR duration and complications following MIPN. These easily measured indices of fat distribution are likely more accurate in predicting perioperative outcomes after MIPN than BMI alone. Source of Funding: None

Evolution of Image-Guided Liver Surgery: Transition from Open to Laparoscopic Procedures

IntroductionIndications for liver surgery to treat primary and secondary hepatic malignancies are broadening. Utilizing data from B-mode or 2-D intraoperative ultrasound, it is often challenging to replicate the findings from preoperative CT or MRI scans. Additional data from more recently developed image-guidance technology, which registers preoperative axial imaging to a 3-D real-time model, may be used to improve operative planning, locate difficult to find hepatic tumors, and guide ablations. MethodsLaparoscopic liver procedures are often more challenging than their open counterparts. Image-guidance technology can assist in overcoming some of the obstacles to minimally invasive liver procedures by enhancing ultrasound findings and ablation guidance. This manuscript describes a protocol that evaluated an open image-guidance system, and a subsequent protocol that directly compared, for validation, a laparoscopic with an open image-guidance system. Both protocols were limited to ablations within the liver. DiscussionThe laparoscopic image-guidance system successfully creates a 3-D model at both 7 and 14 mm Hg that is similar to the open 3-D model. Ultimately, improving intraoperative image guidance can help expand the ability to perform both laparoscopic and open liver surgeries.

703 THE ASSOCIATION BETWEEN RENAL TUMOR SCORING SYSTEMS AND PARTIAL NEPHRECTOMY COMPLICATIONS

You have accessJournal of UrologyKidney Cancer: Evaluation and Staging II1 Apr 2012703 THE ASSOCIATION BETWEEN RENAL TUMOR SCORING SYSTEMS AND PARTIAL NEPHRECTOMY COMPLICATIONS Darren J. Desantis, Luke T. Lavallée, Rodney Breau, Fadi Kamal, Brian Blew, James Watterson, Ranjeeta Mallick, Dean Ferguson, Chris Morash, and Ilias Cagiannos Darren J. DesantisDarren J. Desantis Ottawa, Canada More articles by this author , Luke T. LavalléeLuke T. Lavallée Ottawa, Canada More articles by this author , Rodney BreauRodney Breau Ottawa, Canada More articles by this author , Fadi KamalFadi Kamal Ottawa, Canada More articles by this author , Brian BlewBrian Blew Ottawa, Canada More articles by this author , James WattersonJames Watterson Ottawa, Canada More articles by this author , Ranjeeta MallickRanjeeta Mallick Ottawa, Canada More articles by this author , Dean FergusonDean Ferguson Ottawa, Canada More articles by this author , Chris MorashChris Morash Ottawa, Canada More articles by this author , and Ilias CagiannosIlias Cagiannos Ottawa, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.787AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Three renal mass scoring systems have been proposed to quantify difficulty of partial nephrectomy and risk of surgical complications. The objective of this study was to evaluate the associations between each renal tumor scoring system and post-operative complications. METHODS A consecutive cohort of partial nephrectomy patients between 2002-2009 was analyzed. Patient characteristics were abstracted from the medical record and R.E.N.A.L Nephrometry Score, PADUA score and C Index were determined from pre-operative axial images by two independent reviewers. Consensus was achieved for all reviewer discrepancies. Patients were evaluated for post-operative complications up to 30 days following surgery. Pre-specified complication definitions were used for 33 potential complications and severity of each complication was described using the Clavien classification system. Results were analyzed for significance using a Student t-test. RESULTS A total of 118 patients were included in the study. Median R.E.N.A.L. score was 7 (IQR 5-8), median PADUA score was 8 (IQR 7-9.8) and mean C index was 3.9 (SD 2.10). A total of 76 complications were recorded. There were no deaths. There were 18 Grade I, 40 Grade II, 5 Grade IIIa, 4 Grade IIIb and 9 Grade IVa complications. There were no Grade IVb or V complications. Nephrometery score was associated with overall complications (mean score 7.0 vs 6.4, p=0.04) and genitourinary specific complications (mean score 7.7 vs 6.5, p=0.003) respectively. PADUA score was also highly associated with overall (mean 8.8 vs 8.1 p=0.01) and genitourinary specific complications (mean 9.7 vs 8.2, p=0.0002). Mean C index score was not significantly associated with overall or genitourinary specific complications. CONCLUSIONS Renal tumor scoring systems are useful tools to predict risk of complications after partial nephrectomy. Tumor scores should be taken into consideration in the decision making process of partial vs. radical nephrectomy. Prospective studies are required to further evaluate if one scoring system is a superior predictor for surgical complexity. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e288 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Darren J. Desantis Ottawa, Canada More articles by this author Luke T. Lavallée Ottawa, Canada More articles by this author Rodney Breau Ottawa, Canada More articles by this author Fadi Kamal Ottawa, Canada More articles by this author Brian Blew Ottawa, Canada More articles by this author James Watterson Ottawa, Canada More articles by this author Ranjeeta Mallick Ottawa, Canada More articles by this author Dean Ferguson Ottawa, Canada More articles by this author Chris Morash Ottawa, Canada More articles by this author Ilias Cagiannos Ottawa, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Acute ventriculoperitoneal shunt malfunction following opening of the spinal subarachnoid space

Tubbs et al. present a case series of five patients who experienced ventriculoperitoneal shunt malfunction with intraspinal subarachnoid surgical manipulation implicated as the pivotal factor in conversion of a stable, suboptimally functioning, cerebrospinal fluid (CSF) shunt system into an acutely obstructed one. They conjecture a “siphoning” effect in the subarachnoid cranial–spinal subarachnoid space as causative in proximal shunt obstruction; a likely mechanism. Common intradural spinal procedures in children with hydrocephalus include spinal cord detethering and dysraphism, baclofen pump placement, Chiari and syringomyelia, and dorsal rhizotomy. Each of their patients underwent preoperative computed tomography scans confirming stable ventricular size before the spinal procedure, suggesting a preexisting clinical suspicion of this potential complication. The authors concluded that the neurosurgeon be aware that acute shunt malfunction may occur after intradural spinal procedures and recommend more careful clinical postoperative followup. Other than close postoperative clinical evaluation, should there be any additional shunt evaluation performed in these patients? Are there any maneuvers to reduce the risk of acute shunt malfunction? Other than the preoperative axial imaging, additional testing of the shunt system would likely be difficult to interpret in an asymptomatic patient (i.e., shunt tap, radionuclide shunt function study). However, repeat postoperative imaging may detect an early acute shunt malfunction prior to discharge from the hospital and might be worth considering in selected patients. Another recommendation I would make, to decrease the risk of acute shunt malfunction, is to position the patient in 10 to 20 degrees of Trendelenburg during the intradural portion of the spinal procedure to minimize loss of CSF or entrainment of air. At St. Louis Children’s Hospital, we have used this position during selective dorsal rhizotomy procedures in approximately 200 patients with hydrocephalus and preexisting shunts and have not seen any acute shunt malfunctions after the intradural spinal procedure (unpublished institutional data).

Does the presence of hydronephrosis on preoperative axial CT imaging predict worse outcomes for patients undergoing nephroureterectomy for upper-tract urothelial carcinoma?

Objectives Hydronephrosis at the time of diagnosis of bladder cancer is associated with advanced disease and is a predictor of poorer outcomes. There is, however, limited information addressing whether a similar relationship exists for upper-tract urothelial carcinoma (UTUC). We investigate the prognostic impact of hydronephrosis on preoperative axial imaging on clinical outcomes after radical nephroureterectomy. Materials and Methods The records for 106 patients with UTUC who underwent radical nephroureterectomy at 2 medical centers were reviewed. Preoperative computed tomography (CT) images were evaluated for ipsilateral hydronephrosis by radiologists blinded to clinical outcomes. Association of hydronephrosis with pathologic features and oncologic outcomes after surgery was assessed. Results Sixty-seven men and 39 women with a median age of 69 years (range, 36 to 90) were evaluated. One-third of these patients had muscle invasive disease or greater (≥T2), 44% had high grade tumors, and 3% had lymph node (LN) metastases. At a median follow-up of 47 months (range, 1 to 164), 43% of patients experienced disease recurrence, 18% developed metastasis, and 12% died of their cancer. Thirty-nine patients (37%) had hydronephrosis on preoperative axial imaging; 35% of these patients had ureteral tumors, and 27% had multifocal disease. The presence of hydronephrosis was associated with advanced pathologic stage ( P = 0.03) and disease in the ureter (vs. renal pelvis) ( P = 0.007). Hydronephrosis was a predictor of non-organ confined disease on final pathology (hazard ratio [HR] 3.7, P = 0.01). On preoperative multivariable analysis controlling for age, gender, tumor location, ureteroscopic biopsy grade, and urinary cytology, hydronephrosis was independently associated with cancer metastasis (HR 8.2, P = 0.02) and cancer-specific death (HR 12.1, P = 0.03). Conclusions Preoperative hydronephrosis on axial imaging is associated with features of aggressive disease and predicts advanced pathologic stage for UTUC. Hydronephrosis can be a valuable prognostic tool for preoperative planning and counseling regarding disease outcomes.

Quantitative Prediction of Spinal Cord Drift After Cervical Laminectomy and Arthrodesis

Retrospective review of radiographic parameters. To identify preoperative radiographic parameters that may be quantitatively predictive of postoperative spinal cord drift after cervical laminectomy and arthrodesis. Cervical laminectomy and arthrodesis can be an effective method to treat anterior compressions of the spinal cord if there is a sufficient posterior spinal cord drift after surgery. Preoperative cervical alignment has shown some correlations to the degree of spinal cord shift, but whether this and other preoperative radiographic parameters can be used to quantitatively predict the amount of spinal cord drift is unclear. Preoperative and postoperative radiographs (radiographs, MRIs, and CT) of patients who had cervical laminectomy and arthrodesis were reviewed retrospectively. Various radiographic parameters, including sagittal alignment, longitudinal distance index, space available for the spinal cord at cephalad or caudad levels, and distance from apex of the lordosis to the C2-C7 vertical line were measured. In the first cohort of patients, these parameters were correlated with mean postoperative spinal cord shift to identify any relationships. In the second cohort of patients, the identified association was used on preoperative imaging studies to attempt quantitative prediction of the postoperative spinal cord shift. Space available for the spinal cord at the level immediately cephalad to the laminectomized segments had high correlations (R = 0.94) to the postoperative spinal cord shift. This association was used to quantitatively predict postoperative spinal cord shift within 11% +/- 6% of the measured value. If 4 mm of mean postoperative spinal cord shift is desired, the ratio to the available space and anterior posterior diameter of the spinal cord should be approximately 2.0. Relative stenosis at the level directly cephalad to the laminectomized level can affect the degree of postoperative spinal cord shift. Preoperative axial imaging studies should be closely scrutinized to ensure that adequate space is available at the cephalad adjacent level to allow sufficient cord shift after decompressive laminectomy and arthrodesis.