Robotic Partial Nephrectomy In Patients Research Articles

PE078 - Three-dimensional derived volumetric and morphologic parameters to predict complications after robotic partial nephrectomy in patients with renal cancer

PE078 - Three-dimensional derived volumetric and morphologic parameters to predict complications after robotic partial nephrectomy in patients with renal cancer

Assessing the Trade-off Between the Safety and Effectiveness of Off-clamp Robotic Partial Nephrectomy for Renal Masses with a High RENAL Score: A Propensity Score–matched Comparison of Perioperative and Functional Outcomes in a Multicenter Analysis

BackgroundTumors with a high nephrometry score represent a challenging surgical scenario for which robotic partial nephrectomy (RPN) is a primary option in expert hands. ObjectiveTo compare perioperative and functional outcomes of off-clamp and on-clamp RPN in patients with renal masses with a high RENAL score (≥9). Design, setting, and participantsFor this retrospective analysis, an RPN data set including 1604 patients treated at three institutions between 2003 and 2021 was queried for cases with a RENAL score ≥9. Outcome measurements and statistical analysisWe used 1:1 propensity score matching (PSM) to select a cohort in which imbalances between the off-clamp and on-clamp groups were minimized. We used χ2 and Student t tests to compare categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare the probability of having an estimated glomerular filtration rate (eGFR) ≥45 ml/min during follow-up. Univariable and multivariable analyses were performed to identify predictors of a trifecta outcome (negative surgical margin status, no Clavien-Dindo grade ≥3 complications, eGFR decline ≤30%) and of retaining eGFR ≥45 ml/min over time. Results and limitationsFrom an overall cohort of 354 patients (142 on-clamp, 212 off-clamp), a homogeneous PSM cohort of 78 patients in each group was selected (p ≥ 0.17). In the PSM cohort, operative time was significantly shorter in the off-clamp group (p < 0.001). There were no differences between the groups in the rates of severe complications (p = 0.32) and positive surgical margins (p = 0.24). The rate of trifecta achievement was significantly higher in the off-clamp group (83.3% vs 67.9%; p = 0.03). Warm ischemia time >20 min was independently negatively associated with trifecta achievement (odds ratio 0.32, 95% confidence interval 0.14–0.74). Moreover, the off-clamp group had a significantly higher probability of retaining eGFR ≥45 ml/min over time (3 yr: 95.9% vs 81.6%; p = 0.03); every 1-min increase in warm ischemia time reduced this probability by 1.3%. ConclusionsWe found a favorable trade-off between the benefits and risks of off-clamp RPN, with similar perioperative outcomes and a net benefit in terms of trifecta achievement and long-term renal function outcomes in comparison to on-clamp RPN. Patient summaryThe complexity of surgery for kidney tumors can be assessed using the RENAL score, which is a measure of the location and size of a kidney tumor. In a multicenter series of patients with tumors with a high RENAL score, we compared outcomes between strategies with (on-clamp) and without (off-clamp) clamping of kidney blood vessels during robot-assisted removal of part of the affected kidney. We found that off-clamp surgery results in better postoperative kidney function.

PD07-05 ASSESSING THE TRADE-OFF BETWEEN SAFETY AND EFFECTIVENESS OF OFF-CLAMP ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS WITH HIGH RENAL SCORE: A PROPENSITY SCORE-MATCHED COMPARISON OF PERIOPERATIVE AND FUNCTIONAL OUTCOMES IN A MULTICENTER ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023PD07-05 ASSESSING THE TRADE-OFF BETWEEN SAFETY AND EFFECTIVENESS OF OFF-CLAMP ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS WITH HIGH RENAL SCORE: A PROPENSITY SCORE-MATCHED COMPARISON OF PERIOPERATIVE AND FUNCTIONAL OUTCOMES IN A MULTICENTER ANALYSIS Gabriele Tuderti, Riccardo Mastroianni, Umberto Anceschi, Simone D'Annunzio, Alfredo Maria Bove, Aldo Brassetti, Mariaconsiglia Ferriero, Leonardo Misuraca, Salvatore Guaglianone, Andrea Mari, Ava Saidian, Rekha Narasimhan, Ithaar Derweesh, Riccardo Autorino, Andrea Minervini, Michele Gallucci, and Giuseppe Simone Gabriele TudertiGabriele Tuderti More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Simone D'AnnunzioSimone D'Annunzio More articles by this author , Alfredo Maria BoveAlfredo Maria Bove More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Leonardo MisuracaLeonardo Misuraca More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Andrea MariAndrea Mari More articles by this author , Ava SaidianAva Saidian More articles by this author , Rekha NarasimhanRekha Narasimhan More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Andrea MinerviniAndrea Minervini More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003231.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The potential functional benefits of Off-clamp (Off-C) robotic partial nephrectomy (RPN) should be considered cautiously, especially in challenging surgical scenarios, such as in high nephrometry score renal tumors. In this multicentric study, we aimed to compare perioperative and functional outcomes of Off-clamp (Off-C) and On-clamp (On-C) RPN in patients with a high RENAL nephrometry score (≥9). METHODS: A RPN dataset including 1604 cases treated at 3 high volume Institutions between 2003 and 2021 was queried for “RENAL score ≥ 9”. A 1:1 propensity score-matched (PSM) analysis was used to minimize imbalances between Off-C and On-C cohorts for age, gender, baseline eGFR, tumor size, diabetes, hypertension, RENAL score, ASA score. Univariable and multivariable regression analysis were performed to identify the predictors of Trifecta achievement (negative margins, no Clavien≥ 3 complications and ≤ 30% eGFR decline) and of maintaining eGFR ≥45 mL/min over time. RESULTS: From 354 patients (142 On-C,212 Off-C), two homogeneous PSM cohorts of 78 patients were selected (p≥0.17). Operative time was significantly lower in the Off-C cohort (p<0.001). No differences in terms of severe complications and positive surgical margins were detected (p=0.32 and p=0.24, respectively). Off-C approach turned into a signicantly higher Trifecta achievement (83.3% vs 67.9%, p=0.03). Prolonging Warm ischemia time (WIT) over 20 mins had an independent detrimental effect on Trifecta achievement (OR=0.32, 95%CI:0.14 –0.74). Moreover, patients receiving Off-C procedure had a significantly higher probability of maintaining an eGFR ≥ 45 mL/min over time (3yr: 95.9%vs81.6%, p=0.03), with every increasing WIT minute reducing this probability by 1.3%. CONCLUSIONS: In expert hands, Off-C RPN provides adequate cancer control, comparable perioperative complications and higher probability of achieving Trifecta. This functional benefit is maintained over time, being the risk of developing eGFR<45 ml/min significantly lower compared with On-C cohort. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e163 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriele Tuderti More articles by this author Riccardo Mastroianni More articles by this author Umberto Anceschi More articles by this author Simone D'Annunzio More articles by this author Alfredo Maria Bove More articles by this author Aldo Brassetti More articles by this author Mariaconsiglia Ferriero More articles by this author Leonardo Misuraca More articles by this author Salvatore Guaglianone More articles by this author Andrea Mari More articles by this author Ava Saidian More articles by this author Rekha Narasimhan More articles by this author Ithaar Derweesh More articles by this author Riccardo Autorino More articles by this author Andrea Minervini More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

Assessing the trade-off between safety and effectiveness of off-clamp robotic partial nephrectomy in patients with high RENAL score: A propensity score-matched comparison of perioperative and functional outcomes in a multicenter analysis

Assessing the trade-off between safety and effectiveness of off-clamp robotic partial nephrectomy in patients with high RENAL score: A propensity score-matched comparison of perioperative and functional outcomes in a multicenter analysis

3D-derived volumetric and morphologic parameters to predict complications after robotic partial nephrectomy in patients with renal cancer

3D-derived volumetric and morphologic parameters to predict complications after robotic partial nephrectomy in patients with renal cancer

SC56 - Assessing the trade-off between safety and effectiveness of off-clamp robotic partial nephrectomy in patients with high renal score: a propensity score-matched comparison of perioperative and functional outcomes in a multicenter analysis

SC56 - Assessing the trade-off between safety and effectiveness of off-clamp robotic partial nephrectomy in patients with high renal score: a propensity score-matched comparison of perioperative and functional outcomes in a multicenter analysis

PD64-06 REDO ROBOTIC PARTIAL NEPHRECTOMY FOR RECURRENT RENAL MASSES: A MULTI-INSTITUTIONAL ANALYSIS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (PD64)1 Sep 2021PD64-06 REDO ROBOTIC PARTIAL NEPHRECTOMY FOR RECURRENT RENAL MASSES: A MULTI-INSTITUTIONAL ANALYSIS Alp T. Beksac, Umberto Carbonara, Mahmoud Abou Zeinab, Sij Hemal, Margaret Meagher, Alessandro Tafuri, Gabriele Tuderti, Alessandro Antonelli, Riccardo Autorino, Giuseppe Simone, Ithaar Derweesh, and Jihad Kaouk Alp T. BeksacAlp T. Beksac More articles by this author , Umberto CarbonaraUmberto Carbonara More articles by this author , Mahmoud Abou ZeinabMahmoud Abou Zeinab More articles by this author , Sij HemalSij Hemal More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , Alessandro TafuriAlessandro Tafuri More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Alessandro AntonelliAlessandro Antonelli More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Giuseppe SimoneGiuseppe Simone More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002108.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: As the experience with robotic partial nephrectomy (RPN) grows, the indications have expanded to incorporate previously operated ipsilateral kidneys with recurrent renal masses. We sought to analyze the outcomes of redo RPN in patients with a recurrent renal mass. METHODS: Using a multi-institutional series, the data of 72 patients who underwent RPN for a recurrent renal mass between 2010 and 2020 was retrospectively analyzed. Patients with familial renal cell carcinoma and multiple renal tumors were excluded. Major complication defined by Clavien grade >2. Median follow up was 28.5 months. Baseline demographics, clinical and tumor characteristics, perioperative and postoperative outcomes are reported. RESULTS: Our cohort consisted of a combination of previous thermal ablation, laparoscopic, open and robotic surgeries. Median RENAL score was 8. In our cohort, 20% had hilar tumors and 9.7% had a solitary kidney. Partial nephrectomy was completed in all cases. Two cases (2.8%) were converted to open surgery. None of the cases were converted to radical nephrectomy intraoperatively. One patient underwent radical nephrectomy postoperatively due to bleeding. Transfusion rate was 5.9% and major complication rate was 8.3%. Median length of stay was 3 days. Acute kidney injury was 35.1% at discharge, however eGFR preservation was 90.8% at one year follow up. Positive surgical margin rate was 9.5%. Recurrence was seen in 14 patients (15.2%), however only one patient had local recurrence (1.4%). CONCLUSIONS: In experienced hands, RPN is an effective approach to treat recurrent renal masses with promising perioperative and functional outcome. Patients should be carefully monitored for distant recurrence. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1145-e1146 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alp T. Beksac More articles by this author Umberto Carbonara More articles by this author Mahmoud Abou Zeinab More articles by this author Sij Hemal More articles by this author Margaret Meagher More articles by this author Alessandro Tafuri More articles by this author Gabriele Tuderti More articles by this author Alessandro Antonelli More articles by this author Riccardo Autorino More articles by this author Giuseppe Simone More articles by this author Ithaar Derweesh More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement Loading ...

Positive Surgical Margins After Robot-Assisted Partial Nephrectomy Predict Long-Term Oncologic Outcomes for Clinically Localized Renal Masses.

Introduction: For patients with clinically localized renal masses, positive surgical margins (PSMs) after robotic partial nephrectomy (RPN) have been associated with a higher risk of disease recurrence, although some studies have challenged this conclusion. Owing to inconsistent reports and a lack of long-term robotic data, the clinical impact of PSM after RPN remains uncertain. We evaluate long-term (>6 years) survival outcomes after RPN in patients with clinically localized disease with respect to surgical margin status. Methods: We conducted a retrospective review of patients who underwent RPN for clinically localized renal masses from June 2007 to December 2012 at Washington University School of Medicine. Disease recurrence and overall survival (OS) were stratified on the presence or absence of PSM. The cohort was analyzed to identify patient- and tumor-specific characteristics associated with PSM. Results: We identified 374 RPNs performed from 2007 to 2012 with a mean follow-up time of 77.7 months (SD 32.2 months). PSM was identified in 12 (3.2%) patients. Patients with PSM were at 14-fold increased risk for recurrence with no difference in OS (p < 0.001, p = 0.130, respectively). Patients with PSM had higher incidence of chronic obstructive pulmonary disease (COPD) (25% vs 6.4%) and greater blood loss (425 mL vs 203 mL). Conclusion: With an extended follow-up period of 77 months after RPN, we found that PSM substantially increased the risk of recurrence without impacting OS. Our finding that PSM may occur more frequently in older patients with COPD must be confirmed in larger studies.

Warm ischemic time’ and renal function preservation in robotic partial nephrectomy -evaluating its real impact

Objective: To evaluate the effect of warm ischemic time (WIT) on future renal function (RF) after robotic partial nephrectomy (RPN) and secondarily, also to find out predictors of future RF after RPN. Method and materials: All patients who underwent RPN with normal pre-operative RF and normal contralateral kidney were included in the study except for those in whom one-year follow up was not completed. Patients were divided in four groups based on WIT (zero, &lt;20minutes, 20 minutes to 30 minutes and &gt;30 minutes). Comparison of demographic and perioperative parameters including follow-up up to one year were done. Univariable and multivariable analysis were done to detect significant correlation of RF with those parameters. Results: Total 198 RPN patients were included in the study. The four groups had comparable demographic data (age, gender, comorbidity, smoking, body mass index, pre-operative RF). Progressively increased WIT was significantly associated with increased tumour size (p=0.022), RENAL nephrometry score (p=0.003), operative time (p=0.004) and blood loss (p=0.046). Post-operatively, RF on first post-operative day (p=0.627), at one month (p=0.581) and at one year (p=0.378) had no significant difference between the four groups. Nine (4.5%) patients progressed to chronic renal disease. Pre-operative RF and perioperative complications only had significant correlation with one-year RF. Conclusion: Tumour size and RENAL nephrometry score significantly influenced WIT. Pre-operative RF and peri-operative complications were the only significant predictors of future RF and not the WIT.

SC204 - The impact of ischemia on chronic kidney disease progression after robotic partial nephrectomy in patients over 75 years old: results of a multinstitutional collaborative series (ROSULA)

SC204 - The impact of ischemia on chronic kidney disease progression after robotic partial nephrectomy in patients over 75 years old: results of a multinstitutional collaborative series (ROSULA)

96 - The impact of ischemia on chronic kidney disease progression after robotic partial nephrectomy in patients over 75 years old: Results of a multi-institutional collaborative series (ROSULA)

96 - The impact of ischemia on chronic kidney disease progression after robotic partial nephrectomy in patients over 75 years old: Results of a multi-institutional collaborative series (ROSULA)

Robotic and open partial nephrectomy for intermediate and high complexity tumors: a matched-pairs comparison of surgical outcomes at a single institution

Objective: To compare peri-operative factors and renal function following open partial nephrectomy (OPN) and robotic partial nephrectomy (RPN) for intermediate and high complexity tumors when controlling for tumor and patient complexity.Methods: A retrospective review of 222 patients undergoing partial nephrectomy was performed. Patients with intermediate (nephrometry score NS 7–9) or high (NS 10–12) complexity tumors were matched 2:1 for RPN:OPN using NS, Charlson Comorbidity Index (CCI), and BMI. Patient demographics, peri-operative values, renal function, and complication rates were analyzed and compared.Results: Seventy-four OPN patients were matched to 148 RPN patients with no difference in patient demographics. Estimated blood loss in OPN patients was significantly higher (368.5 vs 210.5 mL, p < 0.001) as was transfusion rate (17% vs 1.6%, p < 0.001). Warm ischemia time was longer in OPN (25.5 vs 19.7 min, p = 0.001) while operative time was reduced (200.5 vs 226.5 min, p = 0.010). RPN patients had significantly shorter hospitalizations (5.3 vs 3.0 days, p < 0.001). GFR decrease after one month was not statistically significant (12.9 vs 6.6 ml/min, p = 0.130). Clavien III–V complications incidence was higher for OPN compared to RPN although not significantly (20.3% vs 10.8%, p = 0.055).Conclusion: When matching for tumor and patient complexity, RPN patients had fewer high grade post-operative complications, decreased blood loss, and shorter hospitalizations. RPN is a safe option for patients with intermediate and high complexity tumors.

MP21-20 THE IMPACT OF ISCHEMIA ON CHRONIC KIDNEY DISEASE PROGRESSION AFTER ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS OVER 75 YEARS OLD: RESULTS OF A MULTI-INSTITUTIONAL COLLABORATIVE SERIES (ROSULA)

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III (MP21)1 Apr 2020MP21-20 THE IMPACT OF ISCHEMIA ON CHRONIC KIDNEY DISEASE PROGRESSION AFTER ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS OVER 75 YEARS OLD: RESULTS OF A MULTI-INSTITUTIONAL COLLABORATIVE SERIES (ROSULA) Umberto Anceschi*, Aldo Brassetti, Gabriele Tuderti, Andrea Minervini, Andrea Mari, Antonio Andrea Grasso, Marco Carini, Umberto Capitanio, Alessandro Larcher, Francesco Montorsi, Riccardo Autorino, Alessandro Veccia Richmond, VA, Daniele Amparore, Francesco Porpiglia, Ithar Deerwesh, Daniel Eun, Jennifer Lee, Philadelphia, PA Michele Gallucci, and Giuseppe Simone Umberto Anceschi*Umberto Anceschi* More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Gabriele TudertiGabriele Tuderti More articles by this author , Andrea MinerviniAndrea Minervini More articles by this author , Andrea MariAndrea Mari More articles by this author , Antonio Andrea GrassoAntonio Andrea Grasso More articles by this author , Marco CariniMarco Carini More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Alessandro Veccia Richmond, VAAlessandro Veccia Richmond, VA More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Francesco PorpigliaFrancesco Porpiglia More articles by this author , Ithar DeerweshIthar Deerwesh More articles by this author , Daniel EunDaniel Eun More articles by this author , Jennifer Lee, PhiladelphiaJennifer Lee, Philadelphia More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000854.020AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) in elderly patients (over 75 years) is certainly underused with concerns regarding risk of major complications and a negligible impact on renal function. The aim of this study was to compare the progression to chronic kidney disease (CKD) of purely off-clamp vs on-clamp robotic partial nephrectomy in patients ≥ 75 years in a multinstitutional series. METHODS: A collaborative multicentric renal surgery dataset (ROSULA) was queried for “partial nephrectomy” and “age≥75 years”. Between May 2008 and October 2019, a total of 207 patients who underwent robotic partial nephrectomy (RAPN) matched the inclusion criteria. Newly onset of any CKD stage (3a,3b,4,5) after surgery was computed by Kaplan-Meier curve and compared for surgical approach (purely-off clamp vs on-clamp) with the log-rank test. Univariable and multivariable Cox regression analyses were performed to identify predictors of CKD progression. For all statistical analyses, a two-sided p < 0.05 was considered significant. RESULTS: Mean age of the cohort considered was 77 years (IQR 76-81). At a median follow-up of 25 months (IQR 12-42.2) newly onset of CKD-3a and CKD-3b stages were observed in 7.2% and 8.7% of patients, respectively. At Kaplan-Meier analysis, on-clamp approach was associated with a significantly higher risk of developing a CKD progression, while a purely-off clamp approach was associated with a significantly lower risk of renal decline in patients ≥ 80 years old. (Figure 1; p=0.04 - Figure 2; p=0.03). On univariable analysis surgical approach (HR 4.22 – 95% CI 1.52-11.6; p=0.006) warm ischemia time (HR 1.05 – 95% CI 1.02-1.08; p=0.01) and tumor size (HR 1.05 -95% CI 1.01-1.09) were all significant predictors of renal function decline. On multivariable analysis warm ischemia time (HR 1.04 – 95% CI 1.01-1.08; p=0.006) was the only independent predictor of any CKD stage progression. CONCLUSIONS: Robotic partial nephrectomy in the elderly population may achieve acceptable mid-term functional outcomes. Ischemia time during robotic partial nephrectomy remains the only modifiable surgical factor to avoid a significant progression of CKD even at the oldest age. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e325-e326 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Anceschi* More articles by this author Aldo Brassetti More articles by this author Gabriele Tuderti More articles by this author Andrea Minervini More articles by this author Andrea Mari More articles by this author Antonio Andrea Grasso More articles by this author Marco Carini More articles by this author Umberto Capitanio More articles by this author Alessandro Larcher More articles by this author Francesco Montorsi More articles by this author Riccardo Autorino More articles by this author Alessandro Veccia Richmond, VA More articles by this author Daniele Amparore More articles by this author Francesco Porpiglia More articles by this author Ithar Deerwesh More articles by this author Daniel Eun More articles by this author Jennifer Lee, Philadelphia More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

MP83-12 EFFECTS OF A REDUCED OPIATE PRESCRIPTION PROTOCOL ON POST-DISCHARGE PILL CONSUMPTION

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety IV (MP83)1 Apr 2020MP83-12 EFFECTS OF A REDUCED OPIATE PRESCRIPTION PROTOCOL ON POST-DISCHARGE PILL CONSUMPTION Kristian Stensland*, Peter Chang, Aaron Berkenwald, Adrian Waisman Malaret, Kortney Robinson, Gabriel Brat, Sarah Hyde, Kyle McAnally, Catrina Crociani, Brian Holliday, Analeesa Baraka, Jodi Mechaber, Marc Manganiello, David Canes, Alireza Moinzadeh, and Andrew Wagner Kristian Stensland*Kristian Stensland* More articles by this author , Peter ChangPeter Chang More articles by this author , Aaron BerkenwaldAaron Berkenwald More articles by this author , Adrian Waisman MalaretAdrian Waisman Malaret More articles by this author , Kortney RobinsonKortney Robinson More articles by this author , Gabriel BratGabriel Brat More articles by this author , Sarah HydeSarah Hyde More articles by this author , Kyle McAnallyKyle McAnally More articles by this author , Catrina CrocianiCatrina Crociani More articles by this author , Brian HollidayBrian Holliday More articles by this author , Analeesa BarakaAnaleesa Baraka More articles by this author , Jodi MechaberJodi Mechaber More articles by this author , Marc ManganielloMarc Manganiello More articles by this author , David CanesDavid Canes More articles by this author , Alireza MoinzadehAlireza Moinzadeh More articles by this author , and Andrew WagnerAndrew Wagner More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000975.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prescribing fewer opiates may lead to less narcotic use and fewer excess pills in the community. We employed a multiphase opiate reduction protocol to assess baseline use, change prescribing protocols, and assess the impact of the change. METHODS: Patients prospectively recorded home pain pill use in a written log after robotic radical prostatectomy (RALP) and robotic partial nephrectomy (RPN) at 2 institutions from 7/2016 to 7/2019. Log accuracy was validated by independent phone contact in a subset of patients. We extracted in-hospital narcotic use, POD1 visual analog scale (VAS) pain scores, and patient comorbidities from our EMRs. In 7/2018, we instituted new prescribing guidelines to meet an estimated 80% of patients’ opiate requirements. RESULTS: Phone survey pill counts exactly matched written logs in 69% of patients and varied by only 1-2 pills in 93% of patients. Of the 193 RALP patients, 137 (71%) were in the pre-intervention group (20-30 pills), and 56 (29%) were in the post-intervention group (5 pills). In the pre-intervention RALP group, 64/137 (47%) patients took no opiates post-discharge, and 90/137 (66%) took <= 2 pills. In the post intervention group, 23/56 (41%) took no opiates post-discharge, and 37/56 (66%) took <= 2 pills. Of the 73 RPN patients, 56 (77%) were in the pre-intervention (20-30 pills), and 17 patients (23%) were in the post-intervention group (15 pills). In the pre-intervention PN, group, 17/56 (30%) patients took no opiates post-discharge. In the post-intervention PN group (15 pills), 3/17 (18%) of patients took no opiate pills post-discharge. After intervention, our new guidelines reduced the number of pills prescribed by 1,655 pills for these 73 patients, compared to what would have been prescribed in prior protocols. 0 and 2 additional prescriptions were filled in the pre- and post-intervention groups, respectively. CONCLUSIONS: Reducing quantity of opiates prescribed tailored by validated institutional data allowed for decreased excess pills with minimal impact on absolute number of pills taken and the number of additional requested prescriptions. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1260-e1260 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kristian Stensland* More articles by this author Peter Chang More articles by this author Aaron Berkenwald More articles by this author Adrian Waisman Malaret More articles by this author Kortney Robinson More articles by this author Gabriel Brat More articles by this author Sarah Hyde More articles by this author Kyle McAnally More articles by this author Catrina Crociani More articles by this author Brian Holliday More articles by this author Analeesa Baraka More articles by this author Jodi Mechaber More articles by this author Marc Manganiello More articles by this author David Canes More articles by this author Alireza Moinzadeh More articles by this author Andrew Wagner More articles by this author Expand All Advertisement PDF downloadLoading ...

Robotic Partial Nephrectomy in Patients with Chronic Kidney Disease: Objective Measurement of Short- and Long-Term Renal Functional Outcomes.

Minimal literature informs the use of robotic partial nephrectomy (RPN) in patients with chronic kidney disease (CKD). Therefore, we evaluated the renal functional outcomes in CKD patients undergoing RPN. We reviewed a prospective database of patients undergoing RPN 2010 to 2015 and identified 182 patients who had preoperative and postoperative nuclear renal scintigraphy (at 2 and 12 months postop). Preoperative and 12-month postoperative eGFR (mL/min/1.73 m2, by MDRD) were calculated. CKD was defined as eGFR ≤60 mL/min/1.73 m2 (CKD stages III and IV). Changes in creatinine, eGFR, and split function on mercaptoacetyltriglycine (MAG)-3 scan were compared by baseline CKD status. Correlations between pre- and postoperative eGFR were calculated. Of 182 patients, 30 (16.5%) had baseline CKD. Preoperative eGFR was 48.5 and 99.0 in CKD and non-CKD patients, respectively (p < 0.001). From preoperation to 12 months postoperation, eGFR decreased by 2.8 and 1.1 mL/min/1.73 m2, respectively (p = 0.6). On MAG-3 scan, the contribution of the surgical kidney to overall renal function decreased by 5.0% and 4.8% (p = 0.9) in the CKD and non-CKD cohorts, respectively. When comparing renal scans at 2 and 12 months postoperation, in both groups the surgical kidney significantly recovered (both p < 0.001) and the patterns of kidney function recovery was similar in both groups (CKD +2.0%, non-CKD +1.4%, p = 0.6). On long-term follow-up (>2 years), eGFR did not change significantly in either the CKD or non-CKD group (-2.8 vs -1.1 mL/min/1.73 m2, p = 0.6). On pathology, tumors were more frequently malignant in CKD vs non-CKD patients (93.3% vs 73.2%, p = 0.02) and of higher Fuhrman Grade (grade ≥3: 49.7% vs 28.1%, p < 0.001). RPN is a reasonable treatment option in patients with CKD, as it did not lead to a greater decline in renal function contributed by the surgical kidney. The patterns of kidney function recovery after surgery are similar between patients with and without CKD.

PD16-11 LONG-TERM ONCOLOGIC OUTCOMES OF POSITIVE SURGICAL MARGINS FOLLOWING ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy III1 Apr 2018PD16-11 LONG-TERM ONCOLOGIC OUTCOMES OF POSITIVE SURGICAL MARGINS FOLLOWING ROBOTIC PARTIAL NEPHRECTOMY Michael B. Rothberg, Lily Velet, Christopher R. Reynolds, and Ashok Hemal Michael B. RothbergMichael B. Rothberg More articles by this author , Lily VeletLily Velet More articles by this author , Christopher R. ReynoldsChristopher R. Reynolds More articles by this author , and Ashok HemalAshok Hemal More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.823AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The implication of positive surgical margins (PSM) after robotic partial nephrectomy (RPN) on oncologic outcomes remain of significant interest. Previous reports detailing short and intermediate-term follow up have been inconsistent as to the impact of a PSM on oncologic outcomes. We sought to determine the effect of PSM on long-term cancer recurrence and survival outcomes. METHODS We queried our institution’s renal oncology database for RPN patients with complete follow-up data and compared recurrence free survival (RFS) and overall survival (OS) between 29 (6.7%) patients with a PSM and 403 (93.3%) patients with a negative surgical margin (NSM). Analyses were performed with Student’s t-tests and Kruskal-Wallis tests for continuous variables and Fisher’s exact tests for categorical variables. Kaplan-Meier analysis was performed for recurrence-free survival and overall survival for PSM versus NSM. RESULTS With respect to patient demographics, comorbidities, tumor characteristics, and perioperative outcomes, there were no statistically significant differences between patients with PSM versus NSM. The median lengths of follow up for patients with PSM and NSM was 60 months and 44.4 months, respectively. Of the 29 PSM, 10 (2.3%) were focally positive and 7 (1.6%) abutted the margin. Three (13.6%) patients with PSM had disease recurrence, while 14 (4.5%) with NSM had recurrence (p=0.09); of these, seven (2.2%) patients with NSM had a local recurrence, while one (4.2%) patient with PSM had a local recurrence. RFS at 24, 48, and 72 months was 95.8%, 90%, and 85.5% for patients with NSM and 96.6%, 86.6%, and 80.4% for patients with PSM, respectively (log-rank p-value for RFS curves = 0.273). OS at 24, 48, and 72 months was 98%, 93.1%, and 89.7% for patients with NSM and 96.3%, 91.2%, and 85.2% for patients with PSM, respectively (log-rank p-value for OS curves = 0.584). CONCLUSIONS PSM following RPN appear to have minimal impact on development of recurrent disease or overall survival in this large cohort of patients with long-term follow up. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e320 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Michael B. Rothberg More articles by this author Lily Velet More articles by this author Christopher R. Reynolds More articles by this author Ashok Hemal More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Functional Implications of Renal Tumor Enucleation Relative to Standard Partial Nephrectomy

To compare the surgical precision for optimizing nephron-mass preservation of tumor enucleation (TE) vs standard partial nephrectomy (SPN), with primary focus on functional outcomes. TE is presumed to optimize preservation of parenchymal mass and function but this has not yet been rigorously studied and quantified. Robotic partial nephrectomy patients who had appropriate pre- and postoperative studies for analysis of parenchymal mass preservation specific to the operated kidney were included. Computed tomography or magnetic resonance imaging and estimated glomerular filtration rate were required to be <2 months prior and 4-12 months after surgery. Parenchymal mass preservation and surgical precision were estimated for each technique, with precision defined as actual postoperative parenchymal volume or predicted postoperative parenchymal volume, presuming loss of a 5 mm rim of parenchyma associated with tumor excision and reconstruction. Analysis included 57 TE and 53 SPN. Median age, body mass index, and tumor size were comparable. Percent parenchymal mass preserved in the operated kidney with TE was 96% (interquartile range [IQR] = 90-100) vs 89% (IQR = 83-96) for SPN (P = .003). Precision of excision or reconstruction was 101% (IQR = 96-105) for TE vs 94% (IQR = 88-100) for SPN (P < .001). On multivariable analysis, only TE correlated with improved surgical precision (coefficient = 6.7, 95% confidence interval = 1.6-11.8, P = .01). Although preservation of global renal function also favored TE, the differences were marginal (96% vs 93%), and statistical significance was not observed (P = .2). Our analysis, which specifically focuses on the functional implications of TE, demonstrates that TE maximally spares normal parenchyma compared to SPN. Thus far, functional differences remain marginal and not statistically significant. Clinical significance of these findings in various clinical settings will require further investigation.

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

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

MP75-04 OFF-CLAMP TECHNIQUE OFFERS IMPROVED RENAL FUNCTION OUTCOMES AFTER ROBOTIC PARTIAL NEPHRECTOMY IN LOW AND INTERMEDIATE COMPLEXITY TUMORS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy V1 Apr 2016MP75-04 OFF-CLAMP TECHNIQUE OFFERS IMPROVED RENAL FUNCTION OUTCOMES AFTER ROBOTIC PARTIAL NEPHRECTOMY IN LOW AND INTERMEDIATE COMPLEXITY TUMORS Daniel C. Rosen, David J. Paulucci, Ronney Abaza, Daniel D. Eun, Ashok K. Hemal, Louis S. Krane, and Ketan K. Badani Daniel C. RosenDaniel C. Rosen More articles by this author , David J. PaulucciDavid J. Paulucci More articles by this author , Ronney AbazaRonney Abaza More articles by this author , Daniel D. EunDaniel D. Eun More articles by this author , Ashok K. HemalAshok K. Hemal More articles by this author , Louis S. KraneLouis S. Krane More articles by this author , and Ketan K. BadaniKetan K. Badani More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1722AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Several arterial clamping techniques have been reported to reduce the deleterious effects of warm ischemia time (WIT) on renal function following partial nephrectomy (PN). Since there is a paucity of comparative data on each technique, the present study compared renal function and surgical outcomes between selective arterial (SAC), main artery (MAC), and off-clamp (OC) techniques in patients undergoing robotic PN (RPN) with low and intermediate complexity tumors. METHODS The present study identified 1,145 patients from 4 medical institutions who underwent RPN from January 2008 to June 2015. Patients with two kidneys, a RENAL score < 10, follow up > 3 months, and a tumor not abutting the main renal artery or vein were included for analysis providing 346 (78.3%) MAC, 37 (8.4%) SAC and 59 (13.3%) OC patients. The percentage change in eGFR was compared between groups using an analysis of covariance. Positive surgical margins (PSM), estimated blood loss (EBL), length of stay (LOS), complications and non-neoplastic parenchymal volume (NNPV) removed were also compared. RESULTS R.E.N.A.L. score (5.8 vs. 6.9 vs. 6.5, p=.001), tumor size (2.2 cm vs. 2.9 vs. 3.1, p<.001) and median follow-up (15.9 months vs. 6 vs. 14.6, p=.002) differed between OC vs. SAC vs. MAC RPN patients respectively. The percentage reduction in eGFR at 13.9 months was significantly lower in OC vs. SAC or MAC RPN (2.5% vs. -7.0 % vs. -9.9%, p=.001) adjusting for R.E.N.A.L. score, American Society of Anesthesiologists score (ASA), body mass index (BMI) and baseline eGFR (Figure 1). In a multivariable cox proportional hazards model, the risk of CKD upstaging was not different in patients undergoing OC vs SAC or MAC (HR= 0.51, p=.260). A trend towards greater EBL (178.0 cc vs. 130.3 vs. 117.1, p=.051) was seen in OC vs. SAC RPN. There were no differences in NNPV removed (p=.586), PSM (p=.849) or complications (p=.693). CONCLUSIONS This study suggests that there may be a renal function advantage to OC RPN. No difference in NNPV removed between groups suggests that the lack of ischemic damage underlies the renal function benefit of OC RPN. Improved renal function without increased risk of PSM or complications suggests that when technically feasible, OC RPN is a consideration in patients with low and intermediate complexity tumors. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e979-e980 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Daniel C. Rosen More articles by this author David J. Paulucci More articles by this author Ronney Abaza More articles by this author Daniel D. Eun More articles by this author Ashok K. Hemal More articles by this author Louis S. Krane More articles by this author Ketan K. Badani More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

644 Medical risk factors for chronic kidney disease are not independent predictors of worse renal function outcome following robotic partial nephrectomy in patients with a normal baseline kidney function

644 Medical risk factors for chronic kidney disease are not independent predictors of worse renal function outcome following robotic partial nephrectomy in patients with a normal baseline kidney function