RENAL Nephrometry Score Research Articles

Limited impact of warm ischemic threshold for partial nephrectomy in the robotic surgery era: A propensity score matching study.

To evaluate the association between extended (≥30min) warm ischemic time and renal function in patients undergoing robot-assisted partial nephrectomy. This multi-institutional study retrospectively recruited 1131 patients who underwent robot-assisted partial nephrectomy. Patients were classified into shorter (<30min; n=1038) and longer (≥30min; n=92) groups based on the ischemic time required, and 1:2 propensity score matching was used to minimize selection bias. The perioperative outcomes, including acute kidney injury and trifecta attainment, and mid/long-term renal function were assessed before and after matching. Patients in the longer group had tumors with a significantly larger diameter and RENAL nephrometry score. The decline in the nadir of the estimated glomerular filtration rate was significantly greater in the longer than the shorter group in the unmatched and matched cohorts (-16.2 vs -5.5%, P<0.001; 15.5 vs -9.5%, P=0.003, respectively). A higher incidence of acute kidney injury (9.8 vs 2.6%, P=0.002) was observed in the longer group before matching, whereas the difference was comparable after matching. Before matching, the decline in estimated glomerular filtration rate at 6months postoperatively was greater (-8.2 vs -5.1%, P=0.005) and trifecta attainment was lower (50.0 vs 63.5%, P<0.001) in the longer group. However, the differences were comparable for both the parameters between the groups in the matched cohort. While extended warm ischemia during robot-assisted partial nephrectomy can be demanded in case of large and complex tumors, its impact on postoperative renal function is limited.

MP59-11 SINGLE INSTITUTION PROSPECTIVE VALIDATION AND COMPARISON OF THE SIMPLIFIED PADUA RENAL (SPARE) NEPHROMETRY SYSTEM FOR THE PREDICTION MIC ACHIEVEMENT IN ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V (MP59)1 Sep 2021MP59-11 SINGLE INSTITUTION PROSPECTIVE VALIDATION AND COMPARISON OF THE SIMPLIFIED PADUA RENAL (SPARE) NEPHROMETRY SYSTEM FOR THE PREDICTION MIC ACHIEVEMENT IN ROBOTIC PARTIAL NEPHRECTOMY Pietro Diana, Alessandro Uleri, Giovanni Lughezzani, Nicola Frego, Pier Paolo Avolio, Marco Paciotti, Davide Maffei, Rodolfo Hurle, Alberto Saita, Massimo Lazzeri, Paolo Casale, and Nicolomaria Buffi Pietro DianaPietro Diana More articles by this author , Alessandro UleriAlessandro Uleri More articles by this author , Giovanni LughezzaniGiovanni Lughezzani More articles by this author , Nicola FregoNicola Frego More articles by this author , Pier Paolo AvolioPier Paolo Avolio More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Davide MaffeiDavide Maffei More articles by this author , Rodolfo HurleRodolfo Hurle More articles by this author , Alberto SaitaAlberto Saita More articles by this author , Massimo LazzeriMassimo Lazzeri More articles by this author , Paolo CasalePaolo Casale More articles by this author , and Nicolomaria BuffiNicolomaria Buffi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002094.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The adoption of novel technologies and the increased surgical experience has pushed the adoption of nephron-sparing surgery (NSS) towards more challenging cases, potentially increasing the risk of complications. Several nephrometry score systems aimed to evaluate surgical and functional outcomes has been proposed and compared. Recently, the SPARE (The Simplified PADUA REnal) score has been proposed, with the aim of providing a simpler and more reproducible system. The aim of the current study was to prospectively validate this novel nephrometry score. METHODS: We prospectively enrolled 79 subjected to robot-assisted partial nephrectomy (RAPN) between 11/2019 and 12/2020 at our tertiary care referral center. We excluded those patients with multiple masses and those that underwent previous renal surgery on the same kidney. These patients were subjected to RAPN for clinically staged T1 and T2 kidney cancer. The renal masses were classified according to the SPARE, RENAL, and PADUA nephrometry score and correlations with intra and post-operative complications and optimal surgical outcomes defined according to the margin, ischemia, and complication (MIC) were assessed. RESULTS: Of 79 patients, 48 were male, median age was 58 (IQR: 50-65), and pre-operative tumor size was 30 mm (22.7-40.5). All RAPN were performed transperitoneally. Median warm ischemia time and estimated blood loss were 12 (9.2-17) and 60 (40-100) respectively. Clavien Dindo Complications >2 were 5 (6.3%). MIC was achieved in 63 of cases (79.7%). Patients were stratified according to the three nephrometry scores and the rates of MIC achievement was stratified accordingly as shown in table 1. In the ROC analysis, the AUC of the SPARE scoring system (0.77; CI 95% 0.65-0.89) was higher compared to those of the PADUA (0.70; 0.58-0.82) and RENAL (0.57; 0.42-0.71) scores. CONCLUSIONS: The SPARE score appears to be a promising and reliable score for the prediction of surgical outcomes of RAPN, showing higher accuracy relative to the traditional PADUA and RENAL scores. The main limitation of the study resides in the low number of patients included, which may have been limited the statistical power and will be overcome as more patients are progressively enrolled. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1034-e1034 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pietro Diana More articles by this author Alessandro Uleri More articles by this author Giovanni Lughezzani More articles by this author Nicola Frego More articles by this author Pier Paolo Avolio More articles by this author Marco Paciotti More articles by this author Davide Maffei More articles by this author Rodolfo Hurle More articles by this author Alberto Saita More articles by this author Massimo Lazzeri More articles by this author Paolo Casale More articles by this author Nicolomaria Buffi More articles by this author Expand All Advertisement Loading ...

MP42-03 COMPARISON OF SURVIVAL OUTCOMES AFTER RADICAL OR PARTIAL NEPHRECTOMY FOR COMPLEX RENAL MASS: ANALYSIS FROM THE ROSULA (ROBOTIC SURGERY FOR LARGE RENAL MASS) COLLABORATIVE GROUP

MP42-03 COMPARISON OF SURVIVAL OUTCOMES AFTER RADICAL OR PARTIAL NEPHRECTOMY FOR COMPLEX RENAL MASS: ANALYSIS FROM THE ROSULA (ROBOTIC SURGERY FOR LARGE RENAL MASS) COLLABORATIVE GROUP

MP42-01 A MATCHED ANALYSIS OF CONVENTIONAL MULTI-PORT VERSUS SP SINGLE-SITE ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III (MP42)1 Sep 2021MP42-01 A MATCHED ANALYSIS OF CONVENTIONAL MULTI-PORT VERSUS SP SINGLE-SITE ROBOTIC PARTIAL NEPHRECTOMY Joon Chae Na, Sylvia Alip, Nak-Hoon Son, Jinu Kim, Won Sik Jang, Yong Seung Lee, Koon Ho Rha, and Woong Kyu Han Joon Chae NaJoon Chae Na More articles by this author , Sylvia AlipSylvia Alip More articles by this author , Nak-Hoon SonNak-Hoon Son More articles by this author , Jinu KimJinu Kim More articles by this author , Won Sik JangWon Sik Jang More articles by this author , Yong Seung LeeYong Seung Lee More articles by this author , Koon Ho RhaKoon Ho Rha More articles by this author , and Woong Kyu HanWoong Kyu Han More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002063.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A purpose built single-site robotic SP platform has recently been introduced and our institute is currently using this novel platform conducting truly single-site robotic partial nephrectomy. In this study we aimed to compare its initial results with the conventional multi-port robotic partial nephrectomy. METHODS: Patients who underwent single-site robotic partial nephrectomy (SP group) were matched to those who underwent multi-port robotic partial nephrectomy (MP group) during the same period by the same surgeon from Dec, 2018 to Apr, 2020. Patients were matched 1:3 according to RENAL nephrometry score, horizontal location of tumor(anterior/posterior), and vertical location of tumor(upper/mid/lower), sex and BMI. RESULTS: There were 21 patients in the SP group, and 62 matched patients in the MP group. The SP group had a longer overall operation time, console time, and warm ischemic time compared to the MP group. None of the patients included in the study had a complication greater than Clavien-Dindo system grade 1, and all were recurrence free at a mean follow-up of 12.5 (SD 5.8) months. Mean changes in eGFR showed no statistically significant differences in both groups at one week, three months, six months, and one year post-operatively. CONCLUSIONS: True single-site robotic partial nephrectomy using the SP platform can be safely performed without an increase of major perioperative complication rates. Although there was an increase in operative time, especially ischemic time, the oncological and functional outcomes were equivalent to the conventional multi-port robotic approach. This maybe attributed to the precise enucleoresection made possible by the articulating instruments of the SP platform. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e770-e770 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joon Chae Na More articles by this author Sylvia Alip More articles by this author Nak-Hoon Son More articles by this author Jinu Kim More articles by this author Won Sik Jang More articles by this author Yong Seung Lee More articles by this author Koon Ho Rha More articles by this author Woong Kyu Han More articles by this author Expand All Advertisement Loading ...

Comparison of Perioperative Outcomes Between Laparoscopic and Open Partial Nephrectomy for Different Complexity Renal Cell Carcinoma Based on the R.E.N.A.L. Nephrometry Score.

PurposeThis study aimed to compare perioperative outcomes of open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) from a retrospective single-center dataset.Patients and MethodsA retrospective single-center analysis of 210 patients who underwent open (n=91) or laparoscopic (n =119) partial nephrectomy for RCC was conducted between 2012 and 2015. All patients were grouped into low complexity, moderate complexity, and high complexity according to the R.E.N.A.L. Nephrometry Score, respectively. The rates of intraoperative and postoperative complications estimated blood loss, warm ischemia time, operative time, conversion of laparoscopic procedure to open surgery, and postoperative length of stay were assessed for both procedures.ResultsIn low complexity group (n=93), patients undergoing LPN (n=52) under ischemia conditions had significantly longer renal artery clamp time (p < 0.001) and operative time (p = 0.001) compared with OPN (n=41). However, patients undergoing LPN had a significantly less postoperative length of stay (p=0.005) and estimated blood loss (p < 0.001) compared with OPN. There was no statistically significant difference in the rates of complications between LPN and OPN. In the moderate complexity group (n=114), 67 and 47 patients underwent LPN and OPN, respectively. LPN had notably longer warm ischemia time (p < 0.001) and operative time (p < 0.001) compared with OPN. There were no statistically significant differences in the rates of complications, estimated blood loss, and postoperative length of stay between LPN and OPN. In the high complexity group (n=3), all patients underwent OPN.ConclusionOPN and LPN procedures performed in patients with low and moderate complexity tumors based on the RENAL Nephrometry score offer acceptable and comparable results. When applied to low complexity tumors, our data suggest that laparoscopic NSS is an effective, minimally invasive therapeutic approach with the advantages of less blood loss, earlier hospital discharge, and more rapid convalescence.

MP59-10 COMPARISON OF RENAL FUNCTIONAL OUTCOMES AFTER RADICAL OR PARTIAL NEPHRECTOMY FOR COMPLEX RENAL MASS: ANALYSIS FROM THE ROSULA (ROBOTIC SURGERY FOR LARGE RENAL MASS) COLLABORATIVE GROUP

MP59-10 COMPARISON OF RENAL FUNCTIONAL OUTCOMES AFTER RADICAL OR PARTIAL NEPHRECTOMY FOR COMPLEX RENAL MASS: ANALYSIS FROM THE ROSULA (ROBOTIC SURGERY FOR LARGE RENAL MASS) COLLABORATIVE GROUP

A comparison of oncologic and functional outcomes in patients with pt3a renal cell carcinoma treated with partial and radical nephrectomy.

ABSTRACTHypothesis:Partial Nephrectomy is oncological safe in patients with pT3a RCC.Purpose:To compare the oncological and functional outcomes of patients with pT3a RCC scheduled for PN and RN.Materials and Methods:We retrospectively reviewed patients with pT3a N0 M0 RCC who underwent partial or radical nephrectomy from 2005 to 2016. Perioperative characteristics, including estimated glomerular filtration rate, tumor size, pathological histology, and RENAL nephrometry score, were compared between patients scheduled for partial or radical nephrectomy. We used multivariable Cox proportional hazards regression models to compare overall survival, cancer-specific survival, and recurrence-free survival between planned procedure type.Results:Of the 589 patients, 369 (63%) and 220 (37%) were scheduled for radical and partial nephrectomy, respectively; 26 (12%) of the scheduled partial nephrectomy cases were intraoperatively converted to radical nephrectomy. After adjusting for tumor size and histology, there were no statistically significant differences in overall survival (hazard ratio 0.66; 95% CI, 0.38–1.13), cancer-specific survival (hazard ratio 0.53; 95% CI, 0.16–1.75), or recurrence-free survival (hazard ratio 0.66; 95% CI, 0.34–1.28) between patients scheduled for partial or radical nephrectomy. Fewer patients scheduled for partial nephrectomy had estimated glomerular filtration rate reductions 3 to 9 months after surgery than patients scheduled for radical nephrectomy.Conclusion:We found no evidence that patients scheduled to undergo partial nephrectomy had poorer oncologic outcomes than patients scheduled to undergo radical nephrectomy. In select patients with pT3a renal cell carcinoma in whom partial nephrectomy is deemed feasible by the surgeon, partial nephrectomy should not be discouraged.

Comparison of Surgical Outcomes Between Enucleation and Standard Resection in Robot-Assisted Partial Nephrectomy for Completely Endophytic Renal Tumors Through a 1:1 Propensity Score-Matched Analysis.

Objective: Robot-assisted laparoscopic partial nephrectomy (RAPN) for completely endophytic renal tumors is challenging because of the tumor complexity. The enucleation technique is an ideal resection method to maximally preserve the renal parenchyma. In the present study, we investigated the surgical outcomes of RAPN for completely endophytic renal tumors and compared them between the enucleation and standard resection techniques. Methods: One hundred and forty-four patients who underwent RAPN for completely endophytic tumors were the subjects of this study. The subjects were divided into two groups according to the Surface-Intermediate-Base margin score (SIB score): the enucleation group (SIB score 0-2) and the standard resection group (SIB score 3-5). To minimize selection bias between the two surgical methods, patient variables such as age, sex, body mass index, American Society of Anesthesiologists score, tumor size, RENAL nephrometry score (RENAL NS), and preoperative renal function were adjusted using 1:1 propensity score matching. Results: Of the 144 patients, 72 were assigned to the enucleation group and 72 to the standard resection group. After matching, 45 patients were included in each group. The mean tumor size was 26-27 mm and the mean RENAL NS was 9.0-9.1, after matching. The enucleation group showed significantly better preservation of the estimated glomerular filtration rate in the early postoperative period (-4.9% vs -16%, p = 0.0005) and at 6-12 months after surgery (-4.9% vs -9.2%, p = 0.0327) than the standard resection group. In addition, a shorter operation time (140 vs 167 minutes, p = 0.0028) was observed in the enucleation group. Other outcomes, including estimated blood loss, positive surgical margin rate, incidence rate of complications, and length of hospital stay, were not significantly different between the two groups. Conclusion: The enucleation technique showed better surgical outcomes for completely endophytic renal tumors in terms of preservation of renal function and operation time than the standard resection technique.

Image-guided percutaneous cryoablation of T1b renal cell carcinomas in patients with comorbidities.

To investigate the influence of comorbidities and tumor characteristics on outcomes following percutaneous cryoablation (PCA) of T1b renal cell carcinoma (RCC). Age-adjusted Charlson comorbidity index (ACCI); standardized system for quantitating renal tumor size, location, and depth (RENAL nephrometry score [RNS]); and local tumor control and survival were retrospectively investigated in 28 patients who underwent PCA for stage T1b RCC. Risk factors for elevated serum creatinine levels were also investigated. Complete ablation was obtained in 27 of 28 patients. Two cases of metastasis were observed; one patient died 12months after PCA. Overall survival at 5years was 79.1%, with a mean follow-up of 42.0 ± 16.0months. Local tumor control was not correlated with the ACCI and RNS. Worsening renal function 3months after PCA was observed in ten patients, and it correlated with the presence of single kidneys (7/28 patients; p = 0.023). Significant worsening of renal function continued until 1year after PCA (p = 0.013). Having a single kidney was a risk factor for worsened renal function after PCA (odds ratio, 8.00; 95% confidence interval 1.170-54.724). PCA for T1b RCC confers positive local tumor control regardless of comorbidities and tumor characteristics.

Laparoskopik parsiyel nefrektomi erken dönem deneyiminin, açık parsiyel nefrektomi ile klinik, onkolojik ve renal fonksiyonlar açısından karşılaştırılması

Objective: Although laparoscopic partial nephrectomy (LPN) is minimally invasive, it is also a technically challenging procedure. Currently, open partial nephrectomy (OPN) remains the only alternative in many centers for T1 kidney tumors. We reported our initial experience of LPN compared to OPN regarding clinical, oncological findings and renal functions. Material and Methods: Between 2004-2013, 81 patients who underwent OPN (n=55) or LPN (n=26) for clinically T1 renal tumors were included. Perioperative and postoperative data were compared, retrospectively. Follow-up times for OPN and LPN groups were 72.9± 41.1 and 47.6± 32.4 months, respectively (p&lt;0.05). Results: The mean tumor size and RENAL nephrometry scores were similar for both groups. Zero-ischemia was performed in all of the LPN and 15% of the OPN procedures. Estimated blood loss and perioperative transfusion rates were higher in OPN group. Complications including grade &lt; 3 and ≥ 3 did not differ significantly between the groups. The decrease in creatinine-clearance at 6th month was statistically significant in OPN group, while stable in LPN. Positive surgical margin rates were 6.6% for OPN and 17.6% for LPN, p=0.19. One patient in LPN developed local recurrence and underwent nephrectomy. In OPN group,one local recurrence and one distant metastasis were observed in two independent patients. Both patients recieved tyrosine kinase inhibitor. Conclusion: Although LPN is accepted as a technically challenging procedure, LPN provided comparable outcomes to OPN including clinical, oncological findings and renal functions, even in the early learning phase. Zero-ischemia technique for LPN was feasible and safe with favorable perioperative and renal functional outcomes. Keywords: laparoscopy; learning curve; partial nephrectomy; renal cancer; surgical margins; zero-ischemia.

Long-term renal function outcomes after renal cryoablation complicated by major hemorrhage requiring selective transarterial embolization.

To determine long-term renal function outcomes after renal cryoablation complicated by major hemorrhage requiring transarterial embolization compared to patients who underwent uncomplicated renal cryoablation without major hemorrhage. Utilizing a matched cohort study design, retrospective review identified 23 patients who underwent percutaneous image-guided renal cryoablation complicated by major hemorrhage requiring ipsilateral transarterial embolization (TAE group) and a control group of 23 patients who underwent uncomplicated renal cryoablation matched 1:1 by age, gender and RENAL Nephrometry score at a single institution from 1/1/2005 to 12/31/2019. Primary outcome parameters included change in creatinine (mg/dl) and estimated glomerular filtration rate (ml/min/1.73 m2; eGFR) from baseline and were compared between TAE and control group using a paired t-test. There was a significantly higher proportion of patients on pre-ablation anticoagulation in the TAE v. control group (30% v. 4%; p = 0.047), but all patients were off anticoagulation and with normal coagulation parameters at the time of cryoablation. Otherwise there were no significant differences in clinical, renal tumor, Charlson co-morbidity index, baseline renal function or cryoablation parameters between the TAE and control group. In the post-ablation period, there was trend toward greater increase in creatinine from baseline to worst post-ablation creatinine in the TAE v. the control group (+ 0.5 ± 0.7mg/dl v. 0.2 ± 0.1mg/dl; p = 0.056). However, at a mean follow-up of 42.7 ± 35.7months, there was no significant difference between the TAE and control group in creatinine (p = 0.68), eGFR (p = 0.60) or change from baseline in creatinine (p = 0.28), eGFR (p = 0.80) or CKD stage (p = 0.74). No patient required initiation of hemodialysis. Selective transarterial embolization for post-renal cryoablation hemorrhage does not significantly affect long-term renal function compared to cryoablation alone. Pre-ablation anticoagulation despite normal coagulation at time of ablation may be a risk factor for post-ablation hemorrhage, and warrants further evaluation when considering pre-ablation embolization.

Mixed reality models based on low-dose computed tomography technology in nephron-sparing surgery are better than models based on normal-dose computed tomography.

Nephron-sparing surgery has been widely applied in the treatment of renal tumors. Previous studies have confirmed the advantages of mixed reality technology in surgery. The study aimed to explore the optimization of mixed reality technology and its application value in nephron-sparing surgery. In this prospective study of 150 patients with complex renal tumors (RENAL nephrometry score ≥7) who underwent nephron-sparing surgery, patients were randomly divided into Group A (the normal-dose mixed reality group, n=50), Group B (the low-dose mixed reality group, n=50), and Group C (the traditional computed tomography image group, n=50). Group A and Group C received the normal-dose computed tomography scan protocol: 120 kVp, 400 mA, and 350 mgI/mL, while Group B received the low-dose computed tomography scan protocol: 80 kVp, automatic tube current modulation, and 320 mgI/mL. All computed tomography data were transmitted to a three-dimensional visualization workstation and underwent modeling and mixed reality imaging. Two senior surgeons evaluated mixed reality quality. Objective indexes and perioperative indexes were calculated and compared. Compared with Group A, the radiation effective dose in Group B was decreased by 39.6%. The subjective scores of mixed reality quality in Group B were significantly higher than those of Group A (Z=-4.186, P<0.001). The inter-observer agreement between the two senior surgeons in mixed reality quality was excellent (K=0.840, P<0.001). The perioperative indexes showed that the mixed reality groups were significantly different from the computed tomography image group (all P<0.017). More cases underwent nephron-sparing surgery in the mixed reality groups than in the computed tomography image group (P<0.0017). Low-dose computed tomography technology can be effectively applied to mixed reality optimization, reducing the effective dose and improving mixed reality quality. Optimized mixed reality can significantly increase the cases of successful nephron-sparing surgery and improve perioperative indexes.

Greater Renal Function Benefit from Enucleation Technique for More Complex Renal Tumors in Robot-Assisted Partial Nephrectomy

Background: Tumor enucleation technique in robot-assisted partial nephrectomy (RAPN) reportedly contributes to renal function preservation. Which tumors and which part to utilize this technique have not been determined. Patients and Methods: This multi-institutional retrospective study included patients who underwent RAPN at tertiary surgery centers. Patients were first stratified into High, Intermediate, and Low categories based on renal nephrometry score. Patients were further classified into I/B-enucleation (I/B-E, I + B ≤ 1) and I/B-resection (I/B-R, I + B ≥ 2) groups based on surface-intermediate-base margin score. Perioperative outcomes, including percentile change in estimated glomerular filtration rate (eGFR), new-onset chronic kidney disease, complication rate, surgical margin, and trifecta achievement, were compared between the I/B-E and I/B-R groups in each category. Odds ratios (ORs) and β-coefficients were also compared. Results: Overall, 704 patients were included in this study. Relative decrease in eGFR was significantly lower for the I/B-E group in all three categories, with medians of 8.1%, 4.4%, and 3.2% in the High, Intermediate, and Low, respectively. In multivariate analyses, excision technique was independently associated with eGFR change in all three. β-coefficient was higher in the High (5.06) category than in the Low (3.17) or Intermediate (3.33). Across all three categories, significantly more patients attained trifecta with a difference of 34.0%, 18.3%, and 15.1% in the High, Intermediate, and Low categories, respectively (all, p < 0.05), with a higher OR in the High (5.91) category than in the Low (3.20) or Intermediate (2.48). No significant differences were found in operation time, amount of estimated blood loss, rate of positive surgical margin, or complications. Warm ischemic time was significantly longer for the I/B-E group in the Intermediate (18.0 minutes vs 16.0 minutes, p = 0.002) and Low categories (13.0 vs 11.0, p = 0.006), but not significant in High (p = 0.344). Conclusions: I/B-enucleation in RAPN contributes to renal function preservation, and the impact was more emphasized in complex tumors.

Microwave ablation of cT1a renal cell carcinoma: oncologic and functional outcomes at a single center

PurposePercutaneous ablation is an established alternative to surgical intervention for small renal masses. Radiofrequency and cryoablation have been studied extensively in the literature. To date, series assessing the efficacy and safety of microwave ablation (MWA) are limited. We present a cohort of 110 renal tumors treated with MWA. MethodsA review of the medical record between January 2015 and July 2019 was performed, retrospectively identifying 101 patients (110 tumors). All ablations were performed by a single board-certified urologist/interventional radiologist. Demographic information, intraoperative, postoperative, and follow-up surveillance data were recorded. ResultsMedian (IQR) age was 69.7 years (60.8–77.0); 27 (24%) were female. Median (IQR) BMI was 27.0 (25.1–30.2) and Charleston Comorbidity Index was 5.0 (4.0–6.0). 82 tumors were biopsy-confirmed renal cell carcinoma/oncocytic neoplasms. Median (IQR) tumor size was 2.0 cm (1.5–2.6). Median (IQR) RENAL nephrometry score was 6.0 (5.0–8.0). Technical success was achieved in all patients and all but one patient were discharged on the same day. Median (IQR) eGFR at baseline and 1 year were 71.9 mL/min/1.73 m2 (56.5–82) and 63.0 mL/min/1.73 m2 (54.0–78.2); the difference was −5.3 (p = 0.12). Two Clavien-Dindo type-I complications, one type-II complication, and one type-III complication were experienced in this cohort. Median radiographic follow-up was 376.5 days with 2 tumors (2.4% of RCC/oncocytic neoplasms) having recurred to date. ConclusionsMWA is a safe and efficacious treatment option for small renal masses with minimal adverse events and low rates of recurrence in this cohort of 101 patients. Continued follow-up is needed to assess long-term outcomes.

Transitioning to robotic partial nephrectomy with a team-based proctorship achieves the desired improved outcomes over open and laparoscopic partial nephrectomy.

Proctoring may facilitate a safe transition to robotic-assisted partial nephrectomy (RAPN) for centres performing open (OPN) and laparoscopic partial nephrectomies (LPN). This study compared the 5-year outcomes of RAPN, initiated with a team-based proctorship, with OPN and LPN. Following an observation course at the proctor's institution and a 3-surgeon performance of proctored RAPN in August 2014, a review of 90 RAPN, 29 LPN and 43 OPN consecutively performed by the same team from 2013 to 2019 at National University Hospital, Singapore was conducted. Peri-operative data, functional and oncological outcomes were compared amongst the three groups. Most cases were performed robotically after 2015 with comparable baseline characteristics in all groups. Median RENAL Nephrometry Score was not significantly different between RAPN (8 [IQR 6, 9]) and OPN (9 [IQR 7, 10]) (P = 0.12) but was significantly lower for LPN (7 [IQR 5, 8]) compared to RAPN (P = 0.002). RAPN achieved the lowest blood loss (226ml vs.348ml and 263ml for OPN and LPN respectively, P = 0.02), transfusion rate (3% vs.21% and 17% respectively, P = 0.003) and median length of stay after surgery (4 vs.6 and 5days respectively, P = 0.001). Complication rates, warm ischemic times were similar between the three approaches with no differences in 1-year and long-term renal function. The rate of positive surgical margin was 8%, 8% and 3% for RAPN, LPN and OPN, respectively (P = 0.76), with a single recurrence in each arm. Despite modest hospital volume, a team-based proctorship facilitated the transition to the Da Vinci robotic platform to perform partial nephrectomies of equivalent complexities as open surgery, achieving improved perioperative outcomes, while maintaining oncological and kidney functional results.

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.

Surgical innovation revisited: A historical narrative of the minimally invasive "Agarwal sliding-clip renorrhaphy" technique for partial nephrectomy and its application to an Australian cohort.

ObjectiveTo evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy.MethodsWe reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding‐clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post‐operative outcomes, including Clavien‐Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90‐day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank‐sum test for continuous variables and the Chi‐squared or Fisher's exact test, for binary and categorical variables, respectively.ResultsOpen surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre‐ and post‐operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any‐grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals.ConclusionThe sliding‐clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present‐day emergence as a routine standard of practice.

Comparison of Sutureless and Conventional Laparoscopic Partial Nephrectomy: A Propensity Score-Matching Analysis

Objective: To compare the functional outcome, safety and efficacy of sutureless and conventional laparoscopic partial nephrectomy.Methods: After the inclusion and exclusion criteria were applied, our study reviewed 379 patients with T1 stage renal tumors. We applied propensity score matching (PSM) to limit potential baseline confusion. Perioperative and functional outcomes between sutureless laparoscopic partial nephrectomy (sLPN) and conventional laparoscopic partial nephrectomy (cLPN) groups were compared and analyzed before and after PSM.Results: Of our 379 patients with T1 stage renal tumors, 199 and 180 were identified in the cLPN and sLPN groups, respectively. After applying PSM with preoperative features, 116 patients in the cLNP group were paired to 116 patients in the sLNP group. We found that all differences in preoperative baseline characteristics disappeared. All the preoperative characteristics (age, gender, tumor diameter, RENAL nephrometry score, side, preoperative eGFR, hypertension, diabetes mellitus, ASA score) were not statistically different between the two groups. The operative time (OT) (p < 0.001) and warm ischemia time (WIT) (p < 0.001) of the sLPN group were of shorter duration than that of the cLPN group. The eGFR baseline was almost equal, but there was a statistically smaller decrease in eGFR in the sLPN than in the cLPN group 1 week after surgery (14.3 vs. 7.4, p < 0.001) and after 6 months (11.9 vs. 5.0, p < 0.001). After both preoperative features and WIT were included in PSM, fifty-one pairs of patients were identified between the groups, the WIT difference between them disappeared, while the decrease in eGFR between the groups remained as it was previously at 1 week (15.4 vs. 8.6, p < 0.001) and at 6 months (13.0 vs. 6.2, p < 0.001).Conclusion: Sutureless laparoscopic partial nephrectomy is as safe and effective as conventional laparoscopic partial nephrectomy, and compared to cLPN, sLPN can effectively reduce the WIT, retain more renal parenchyma and protect renal function.

Comfortable suture angle with optimized trocar position aids renorrhaphy during retroperitoneal laparoscopic partial nephrectomy.

BackgroundThis study investigated a comfortable suture angle (CSA) with optimized trocar position for closing the defect during renorrhaphy in retroperitoneal laparoscopic partial nephrectomy (LPN). The feasibility, usefulness, and safety of achieving the CSA with modified trocar position were determined for different tumor types.MethodsTwo optimized trocar positions were introduced for different tumor types. A suture angle was based on the tumor plane of the superficial parenchyma defect and the line formed by the needle holder. Preliminary surgical simulations determined a CSA that combined the least suture time with the greatest ease of performance. Achieving the CSA was attempted during renorrhaphy of 106 enrolled patients undergoing retroperitoneal LPN. Patients’ characteristics, operative features, and follow-up information were collected and analyzed.ResultsFor 89 (83.96%) patients, a CSA was successfully reached and parenchyma recovered. The remaining 17 patients were successfully sutured, but the attempt to achieve a CSA failed. For the CSA group, the suture, clamping, and overall operative times were significantly less than that of the non-CSA patients. The groups were similar regarding estimated blood loss, positive surgical margin, and rates of glomerular filtration reduction and complications. Univariable analyses determined that tumor location, growth pattern, and R.E.N.A.L. nephrometry score (RNS) may influence the success of this approach. Multivariable analyses indicated that only tumor location and RNS were independent factors affecting successful achievement of the CSA.ConclusionsThrough different kidney position changes, the CSA could be used to ease the suture process. It is feasible and safe to perform a CSA with optimized trocar position during LPN. Tumor location and RNS may influence the approach to get a CSA.

Total robotic surgical volume influences outcomes of low-volume robotic-assisted partial nephrectomy over an extended duration

Introduction: The objective of this study was to examine the surgeon’s experience of low-volume robotic-assisted partial nephrectomy (RAPN) over an extended duration, and whether a high-volume fellowship-training influenced the outcomes.&#x0D; Methods: Data on all RAPN at a tertiary center performed by a uro-oncologist were retrospectively collected. The surgeon experience was assessed by examining perioperative outcomes among three groups of consecutive patients (first=14, second=14, third=15 patients, respectively).&#x0D; Results: Between February 2014 and February 2020, 45 RAPNs were performed out of a total of 200 robotic procedures. The median tumor size was 3 cm, and 28 (65%) patients had a R.E.N.A.L nephrometry score (RNS) ≥7. The median operative time and warm ischemia time (WIT) were 190 and 16 minutes, respectively. The median estimated blood loss (EBL) was 100 mL. Two (4%) patients had a positive surgical margin (PSM). Overall, five (12%) complications were recorded. All except one were minor (Clavien I–II). The median followup was 26.2 months. Trifecta and pentafecta were achieved in 40 (93%) and 27 (81.8%) patients, respectively. Increased surgeon experience was significantly associated with a shorter operative time and less EBL. Furthermore, there was an independent association between surgeon experience and operative time and EBL, and between RNS and operative time and WIT.&#x0D; Conclusions: With fellowship training and subsequent adequate total number of robotic procedures during practice, it is possible to perform RAPN with favorable perioperative outcomes in the setting of low-volume of cases over an extended duration.