[show abstract][hide abstract] ABSTRACT: A 39-year-old female previously treated with shock wave lithotripsy developed extensive ureteral stricture disease. After 2 unsuccessful attempts at retrograde balloon dilatation, she was evaluated at our center for further management. Successful reconstruction was performed with laparoscopic-assisted vesicocalicostomy.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 01/2013; 16(1):163-5. · 0.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: To describe a novel robotic transrectal ultrasound platform for real-time navigation during robot-assisted laparoscopic radical prostatectomy (RALP) and to report its early clinical application.
Five men undergoing RALPs at our Institution agreed to participate in this Institutional Review Board-approved pilot study. All of them were eligible for a bilateral nerve sparing procedure. Before docking the da Vinci robot, a transrectal ultrasound tri-plane side-fire probe was placed. A modified ViKY Endoscope Holder was used during RALPs to move the probe thanks to a remote control placed under the console surgeon's control during RALPs. During each procedure, attempt was made to estimate prostate volume, define 12 reference points, and to precisely identify location of the neurovascular bundles using Doppler ultrasound. The TilePro was used during the procedures to allow real-time ultrasound imaging to guide robotic instruments during dissection.
Median robotic transrectal ultrasound probe holder (R-TRUS) setup time was 11 minutes (interquartile range [IQR], 10-14). Prostate volume calculation, reference point definition, neurovascular bundle identification, and instrument tip visualization were successful in all men. In 1 patient with a large prostate (120 mL), R-TRUS was withdrawn during recto-prostatic dissection. There were no rectal injuries.
R-TRUS during RALPs is feasible and safe. It allows real-time TRUS navigation and guidance. Further studies are needed to evaluate its impact on oncological and functional outcomes.
[show abstract][hide abstract] ABSTRACT: The R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior) and centrality index nephrometry scores enable systematic, objective assessment of anatomical tumor features. We systematically compared these systems using item analysis test theory to optimize scoring methodology.
Analysis was based on 299 patients who underwent partial nephrectomy from 2007 to 2011 and met study inclusion criteria. Percent functional volume preservation, and R.E.N.A.L. and centrality index scores were measured. Late percent glomerular filtration rate preservation was calculated as the ratio of the late to the preoperative rate. Interobserver variability analysis was done to assess measurement error. All data were statistically analyzed.
A novel scoring method termed DAP (diameter-axial-polar) nephrometry was devised using a data based approach. Mean R.E.N.A.L., centrality index and DAP scores for the cohort were 7.3, 2.5 and 6 with 84%, 90% and 95% interobserver agreement, respectively. The DAP sum score and all individual DAP scoring components were associated with the clinical outcome, including percent functional volume preservation, warm ischemia time and operative blood loss. DAP scoring criteria allowed for the normalization of score distributions and increased discriminatory power. DAP scores showed strong linear associations with percent functional volume preservation (r(2) = 0.97) and late percent glomerular filtration rate preservation (r(2) = 0.81). Each 1 unit change in DAP score equated to an average 4% change in kidney volume.
DAP nephrometry integrates the optimized attributes of the R.E.N.A.L. and centrality index scoring systems. DAP scoring was associated with simplified methodology, decreased measurement error, improved performance characteristics, improved interpretability and a clear association with volume loss and late function after partial nephrectomy.
The Journal of urology 06/2012; 188(2):384-90. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: Functional volume preservation after partial nephrectomy is a primary determinant of kidney function. We identified tumor features, including R.E.N.A.L. (radius for tumor size as maximal diameter, exophytic/endophytic tumor properties, nearness of deepest portion of tumor to collecting system or sinus, anterior/posterior descriptor and location relative to polar line) and centrality index nephrometry scores, associated with volume loss after partial nephrectomy.
A chart and imaging review was done for 237 patients who underwent partial nephrectomy from 2007 to 2010 and met study inclusion criteria. R.E.N.A.L. and centrality index nephrometry scores were measured in all patients. Percent functional volume preservation was estimated a median of 1.4 years after surgery using the cylindrical volume ratio method. Statistical analysis was done to study associations.
Independent tumor features associated with percent functional volume preservation included tumor diameter (p < 0.001) and the distance from tumor periphery to kidney center (p = 0.02). R.E.N.A.L. and centrality index scores were associated with percent functional volume preservation (each p < 0.001). Nephrometry scores were also associated with nadir and late percent glomerular filtration rate preservation. Tumors classified as highly complex, with a centrality index score of 1.5 or less and a R.E.N.A.L. score of 10 or greater, were associated with an average 28% to 30% functional parenchymal volume loss of operated kidneys. A mean 8% difference in percent functional volume preservation was observed among low, intermediate and high tumor complexity categories for R.E.N.A.L. and centrality index scores.
R.E.N.A.L. and centrality index nephrometry scores were associated with changes in the percent functional volume preservation and the perioperative functional decrease. Nephrometry scores performed better than diameter alone on statistical analysis. Nephrometry scores may be useful to estimate the likelihood of operative volume loss and by proxy the functional outcome.
The Journal of urology 05/2012; 188(1):39-44. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes.
We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations.
Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%-107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury.
In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes.
The Journal of urology 03/2012; 187(5):1667-73. · 4.02 Impact Factor
[show abstract][hide abstract] ABSTRACT: To determine the pathologic concordance rates in patients with bilateral synchronous sporadic renal tumors (BSSRT) and to determine factors predictive of concordance.
A retrospective chart review from 1985 to 2008 was completed with search criteria of all patients diagnosed with bilateral renal tumors. We included patients who had image-documented BSSRT or via reported history. We excluded patients with bilateral metachronous renal tumors, cystic renal masses, familial renal cell carcinoma (RCC) syndromes, urothelial cell carcinomas, and other variant histology. Univariate and multivariate analysis were conducted to assess for factors predictive of concordance.
We identified 297 patients eligible for analysis. RCC concordance was exhibited in 222 of 249 (89%) of patients. Benign tumor concordance, specifically oncocytoma, was found in 41 of 59 (71%) of patients. Factors such as age, gender, and tumor size on imaging did not have an association with concordance rates for bilateral RCC or bilateral oncocytoma. On multivariate analysis, multifocal tumors were associated with benign concordance (OR = 6.9, 95% CI = 1.6-29.2, P = .009).
Malignant and benign concordance rates are high for patients with BSSRT. Given the high concordance of RCC, the data support a management approach consisting of bilateral nephron-sparing surgery whenever possible. However, given the high concordance rate of oncocytoma in this population as well, less aggressive management (renal mass biopsy and surveillance) of the contralateral kidney may be considered after histologic confirmation of one side.