Inderbir S Gill

Keck School of Medicine USC, Los Ángeles, California, United States

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Publications (816)3461.48 Total impact

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    ABSTRACT: Clear cell renal cell carcinoma (ccRCC) is the most common subtype of renal cell cancer (RCC), followed by papillary RCC (pRCC). It is important to distinguish these two subtypes because of prognostic differences and possible changes in management, especially in cases undergoing active surveillance. The purpose of our study is to evaluate the use of voxel-based whole-lesion (WL) enhancement parameters on contrast enhanced computed tomography (CECT) to distinguish ccRCC from pRCC. In this institutional review board-approved study, we retrospectively queried the surgical database for post nephrectomy patients who had pathology proven ccRCC or pRCC and who had preoperative multiphase CECT of the abdomen between June 2009 and June 2011. A total of 61 patients (46 with ccRCC and 15 with pRCC) who underwent robotic assisted partial nephrectomy for clinically localized disease were included in the study. Multiphase CT acquisitions were transferred to a dedicated three-dimensional workstation, and WL regions of interest were manually segmented. Voxel-based contrast enhancement values were collected from the lesion segmentation and displayed as a histogram. Mean and median enhancement and histogram distribution parameters skewness, kurtosis, standard deviation, and interquartile range were calculated for each lesion. Comparison between ccRCC and pRCC was made using each imaging parameter. For mean and median enhancement, which had a normal distribution, independent t-test was used. For histogram distribution parameters, which were not normally distributed, Wilcoxon rank sum test was used. ccRCC had significantly higher mean and median whole WL enhancement (p < 0.01) compared to pRCC on arterial, nephrographic, and excretory phases. ccRCC had significantly higher interquartile range and standard deviation (p < 0.01) and significantly lower skewness (p < 0.01) compared to pRCC on arterial and nephrographic phases. ccRCC had significantly lower kurtosis compared to pRCC on only the arterial phase. Our study suggests that voxel-based WL enhancement parameters can be used as a quantitative tool to differentiate ccRCC from pRCC. Differentiating between the two main types of RCC would provide the patient and the treating physicians more information to formulate the initial approach to managing the patient's renal cancer.
    SpringerPlus 12/2015; 4(1). DOI:10.1186/s40064-015-0823-z
  • Toshitaka Shin · Osamu Ukimura · Inderbir S Gill
    European Urology 10/2015; DOI:10.1016/j.eururo.2015.09.024 · 13.94 Impact Factor
  • Raj Satkunasivam · Mihir Desai · Inderbir S Gill
    European Urology 09/2015; DOI:10.1016/j.eururo.2015.08.022 · 13.94 Impact Factor
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    ABSTRACT: There are distinct quantifiable features characterizing renal cell carcinomas on contrast-enhanced CT examinations, such as peak tumor enhancement, tumor heterogeneity, and percent contrast washout. While qualitative visual impressions often suffice for diagnosis, quantitative metrics if developed and validated can add to the information available from standard of care diagnostic imaging. The purpose of this study is to assess the use of quantitative enhancement metrics in predicting the Fuhrman grade of clear cell RCC. 65 multiphase CT examinations with clear cell RCCs were utilized, 44 tumors with Fuhrman grades 1 or 2 and 21 tumors with grades 3 or 4. After tumor segmentation, the following data were extracted: histogram analysis of voxel-based whole lesion attenuation in each phase, enhancement and washout using mean, median, skewness, kurtosis, standard deviation, and interquartile range. Statistically significant difference was observed in 4 measured parameters between grades 1-2 and grades 3-4: interquartile range of nephrographic attenuation values, standard deviation of absolute enhancement, as well as interquartile range and standard deviation of residual nephrographic enhancement. Interquartile range of nephrographic attenuation values was 292.86 HU for grades 1-2 and 241.19 HU for grades 3-4 (p value 0.02). Standard deviation of absolute enhancement was 41.26 HU for grades 1-2 and 34.66 HU for grades 3-4 (p value 0.03). Interquartile range was 297.12 HU for residual nephrographic enhancement for grades 1-2 and 235.57 HU for grades 3-4 (p value 0.02), and standard deviation of the same was 42.45 HU for grades 1-2 and 37.11 for grades 3-4 (p value 0.04). Our results indicate that absolute enhancement is more heterogeneous for lower grade tumors and that attenuation and residual enhancement in nephrographic phase is more heterogeneous for lower grade tumors. This represents an important step in devising a predictive non-invasive model to predict the nucleolar grade.
    Abdominal Imaging 08/2015; DOI:10.1007/s00261-015-0531-8 · 1.63 Impact Factor
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    ABSTRACT: Introduction: Salvage ablative therapy (SAT) has been developed as a form of localized treatment for localized recurrence of prostate cancers following radiation therapy. To better address the utility of SAT, prospective clinical trials must address the aspects of accepted standards in the initial evaluation, treatment, follow-up, and outcomes in the oncology community. We undertook this study to achieve consensus on uniform standardized trial design for SAT trials. Methods: A literature search was performed and an international multidisciplinary group of experts was identified. A questionnaire was constructed and sent out to 71 participants in 3 consecutive rounds according to the Delphi method. The project was concluded with a face-to-face meeting in which the results were reviewed and conclusions were formulated. Results: Patients with recurrent disease after radiation therapy were considered candidates for a SAT trial using any ablation scenario performed with cryotherapy or high-intensity focused ultrasound. It is feasible to compare different sources of energy or to compare with historical data on salvage radical prostatectomy outcomes. The primary objective should be to assess the efficacy of the treatment for negative biopsy rate at 12 months. Secondary objectives should include safety parameters and quality-of-life assessment. Exclusion criteria should include evidence of local or distant metastases. The optimal biopsy strategy is image-guided targeted biopsies. Follow-up includes multiparametric magnetic resonance imaging, prostate-specific antigen level, and quality of life for at least 5 years. Conclusions: A multidisciplinary board from international experts reached consensus on trial design for SAT in prostate cancer and provides a standard for designing a feasible SAT trial.
    Urologic Oncology 08/2015; DOI:10.1016/j.urolonc.2015.06.015 · 2.77 Impact Factor
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    ABSTRACT: Axl plays multiple roles in tumourigenesis in several cancers. Here we evaluated the expression and biological function of Axl in renal cell carcinoma (RCC). Axl expression was analysed in a tissue microarray of 174 RCC samples by immunostaining and a panel of 11 normal tumour pairs of human RCC tissues by western blot, as well as in RCC cell lines by both western blot and quantitative PCR. The effects of Axl knockdown in RCC cells on cell growth and signalling were investigated. The efficacy of a humanised Axl targeting monoclonal antibody hMAb173 was tested in histoculture and tumour xenograft. We have determined by immunohistochemistry (IHC) that Axl is expressed in 59% of RCC array samples with moderate to high in 20% but not expressed in normal kidney tissue. Western blot analysis of 11 pairs of tumour and adjacent normal tissue show high Axl expression in 73% of the tumours but not normal tissue. Axl is also expressed in RCC cell lines in which Axl knockdown reduces cell viability and PI3K/Akt signalling. The Axl antibody hMAb173 significantly induced RCC cell apoptosis in histoculture and inhibited the growth of RCC tumour in vivo by 78%. The hMAb173-treated tumours also had significantly reduced Axl protein levels, inhibited PI3K signalling, decreased proliferation, and induced apoptosis. Axl is highly expressed in RCC and critical for RCC cell survival. Targeting Axl is a potential approach for RCC treatment.British Journal of Cancer advance online publication, 16 July 2015; doi:10.1038/bjc.2015.237
    British Journal of Cancer 07/2015; 113(4). DOI:10.1038/bjc.2015.237 · 4.84 Impact Factor
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    ABSTRACT: To assess the impact of 3D printed models of renal tumor on patient's understanding of their conditions. Patient understanding of their medical condition and treatment satisfaction has gained increasing attention in medicine. Novel technologies such as additive manufacturing [also termed three-dimensional (3D) printing] may play a role in patient education. A prospective pilot study was conducted, and seven patients with a primary diagnosis of kidney tumor who were being considered for partial nephrectomy were included after informed consent. All patients underwent four-phase multi-detector computerized tomography (MDCT) scanning from which renal volume data were extracted to create life-size patient-specific 3D printed models. Patient knowledge and understanding were evaluated before and after 3D model presentation. Patients' satisfaction with their specific 3D printed model was also assessed through a visual scale. After viewing their personal 3D kidney model, patients demonstrated an improvement in understanding of basic kidney physiology by 16.7 % (p = 0.018), kidney anatomy by 50 % (p = 0.026), tumor characteristics by 39.3 % (p = 0.068) and the planned surgical procedure by 44.6 % (p = 0.026). Presented herein is the initial clinical experience with 3D printing to facilitate patient's pre-surgical understanding of their kidney tumor and surgery.
    World Journal of Urology 07/2015; DOI:10.1007/s00345-015-1632-2 · 2.67 Impact Factor
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    ABSTRACT: Intracorporeal orthotopic neobladder (iONB) creation following robotic radical cystectomy is an emerging procedure and robust functional data are required. To evaluate urodynamic features of iONB and bladder cancer-specific and general health-related quality-of-life (HRQOL) outcomes. We retrospectively assessed 28 men who underwent iONB creation (January 2012 to October 2013) and compared results to a previously characterized cohort of 79 of open ONB procedures. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: iONB pressure-volume properties were characterized using multichannel urodynamics (UDS). The Bladder Cancer Index (BCI) questionnaire, modified with mucus- and pad-related questions, and the Short Form Health Survey (SF-36) were used to evaluate urinary function and HRQOL. ONB cohorts were compared for functional outcomes and BCI score. Multivariable linear regression was used to assess predictors of BCI score. The median follow-up was 9.4 mo for the iONB and 62.1 mo for the open ONB group (p<0.0001); ≥2-yr follow-up had been completed for one (4%) patient in the iONB group compared to 75 (95%) patients in the open ONB group (p<0.0001). In UDS tests, the iONB group had minimal postvoid residual volume, normal compliance, and a mean capacity of 514 cm(3) (range 339-1001). BCI mean scores for urinary function (p=0.58) and urinary bother (p=0.31) were comparable between the groups. The surgical approach was not associated with the BCI score on multivariable analysis. Rates of 24-h pad use were comparable between iONB and open ONB groups (pad-free 17% vs 19%; ≤2 pads 84% vs 79%), as reflected by total pad usage (p=0.1); pad size and daytime wetness were worse in the iONB group. The clean intermittent catheterization rate was 10.7% in the iONB and 6.3% in the open ONB group. Limitations include the retrospective comparison, small number of patients and short follow-up for the iONB group. iONB had adequate UDS characteristics and comparable bladder cancer-specific HRQOL scores to open ONB. However, pad size and daytime wetness were worse for iONB, albeit over significantly shorter follow-up. We demonstrate that the volumetric and pressure characteristics are acceptable for a neobladder created using an entirely robot-assisted laparoscopic technique after bladder removal for cancer. Urinary function and quality-of-life outcomes related to the robotic technique were compared to those for neobladders created via an open surgical technique. We found that urinary function and bother indices were comparable; however, the robotic group required larger incontinence pads that were wetter during the daytime. This may be explained by the significantly shorter duration of recovery after surgery in the robotic group. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
    European Urology 07/2015; DOI:10.1016/j.eururo.2015.06.041 · 13.94 Impact Factor
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    ABSTRACT: To report our 11-year experience of Active Surveillance (AS) program focusing on modern transrectal ultrasound (TRUS)-based monitoring of targeted biopsy-proven cancer lesion. Consecutive patients on AS, who had targeted biopsy-proven lesion followed by at least a repeat surveillance biopsy and three times TRUS monitoring of the identical visible lesion, were included. Doppler grade of blood flow signal within the lesion was classified from grade 0 to 3. Biopsy-proven progression was defined as upgrade of Gleason score or 25 % or greater increase in cancer core involvement. Fifty patients were included in this study. Clinical variables (median) included age (61 years), clinical stage (T1c, 42;T2, 8), PSA (4.6 ng/ml), and Gleason score (3 + 3, n = 41;3 + 4, n = 9). Of the 50 patients, 34 demonstrated pathological progression at a median follow-up of 4.4 years. In comparing between without (n = 16) and with (n = 34) pathological progression, there were significant differences in cancer core involvement at entry (p = 0.003), the major axis diameter (p = 0.001) and minor axis diameter (p = 0.001) of the visible lesion at entry, increase in the major axis diameter (p = 0.005) and minor axis diameter (p = 0.013), and upgrade of Doppler grade (p < 0.0001). In multivariate analysis for predicting pathological progression, the increase (≥25 %) in diameter of biopsy-proven lesion (hazard ratio, 15.314; p = 0.023) and upgrade of Doppler grade (hazard ratio, 37.409; p = 0.019) were significant risk factors. Longitudinal monitoring of the TRUS-visible biopsy-proven cancer provides a new opportunity to perform per-lesion-based AS. The increase in diameter and upgrade of Doppler grade of the lesion were significant risk factors for biopsy-proven progression on AS.
    World Journal of Urology 06/2015; DOI:10.1007/s00345-015-1619-z · 2.67 Impact Factor
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    ABSTRACT: To develop a robotic technique for exclusively trans-abdominal control of the supra-hepatic, infra-diaphragmatic inferior vena cava (IVC) to enable level 3 IVC tumor thrombectomy. Robotic technique was developed in 3 fresh, perfused-model cadavers. Pre-operatively, inflow (right jugular vein) and outflow (left femoral vein) cannulae were inserted and connected to a centrifugal pump to establish a 10 mmHg pressure in the IVC for the water-perfused cadaver model. Using a 5-port trans-peritoneal robotic approach, the falciform ligament was detached from the anterior abdominal wall towards its junction with the diaphragm, and tautly retracted caudally; this adequately retracted the liver caudally as well. Triangular and coronary ligaments were incised, allowing ready visualization of supra-hepatic/infra-diaphragmatic IVC and right/left main hepatic veins. Under direct robotic visualization, IVC was circumferentially mobilized, vessel-looped and controlled. All 3 robotic procedures were successfully completed trans-abdominally. Average robotic time to control the supra-hepatic IVC was 37min; in each case, the supra-hepatic IVC was circumferentially controlled with a vessel-loop. There were no intraoperative complications. Length of the mobilized supra-hepatic IVC measured between 2-3cm. Right and left supra-hepatic veins were clearly visualized in each case. Necropsy revealed no intra-abdominal/intra-thoracic visceral or vascular injuries to the supra-hepatic IVC, bilateral hepatic veins, or tributaries. We developed a novel robotic technique for trans-abdominal control of the supra-hepatic infra-diaphragmatic IVC in a perfused human cadaver model. This approach may extend the application of advanced robotic techniques for the performance of major vena caval, hepatic and level 3 IVC renal tumor thrombus surgery.
    Journal of endourology / Endourological Society 06/2015; DOI:10.1089/end.2015.0081 · 1.71 Impact Factor
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    ABSTRACT: Anatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia. To report the technical feasibility of completely unclamped "minimal-margin" robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data. This study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49). Patients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy. Primary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes. Demographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up. We developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up. The technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
    European Urology 06/2015; 68(4). DOI:10.1016/j.eururo.2015.04.044 · 13.94 Impact Factor
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    ABSTRACT: To discuss the evaluation of the enhancement curve over time of the major renal cell carcinoma (RCC) subtypes, oncocytoma, and lipid-poor angiomyolipoma, to aid in the preoperative differentiation of these entities. Differentiation of these lesions is important, given the different prognoses of the subtypes, as well as the desire to avoid resecting benign lesions. We discuss findings from CT, MR, and US, but with a special emphasis on contrast-enhanced ultrasound (CEUS). CEUS technique is described, as well as time-intensity curve analysis. Examples of each of the major RCC subtypes (clear cell, papillary, and chromophobe) are shown, as well as examples of oncocytoma and lipid-poor angiomyolipoma. For each lesion, the time-intensity curve of enhancement on CEUS is reviewed, and correlated with the enhancement curve over time reported for multiphase CT and MR. Preoperative differentiation of the most common solid renal masses is important, and the time-intensity curves of these lesions show some distinguishing features that can aid in this differentiation. The use of CEUS is increasing, and as a modality it is especially well suited to the evaluation of the time-intensity curve.
    Abdominal Imaging 06/2015; 40(7). DOI:10.1007/s00261-015-0468-y · 1.63 Impact Factor
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    ABSTRACT: Amongst nephron-sparing modalities, partial nephrectomy (PN) is the standard of care in the treatment of renal cell carcinoma (RCC). Despite the increasing utilization of PN, particularly propagated by robot-assisted, minimally invasive approaches for small renal masses (SRMs), the limits of PN appear to be also evolving. In this review, we sought to address the tumour stage beyond which PN may be oncologically perilous. While the evidence supports PN in the treatment of tumours < pT2a, PN may have a role in advanced or metastatic RCC. Other scenarios wherein PN has limited utility are also explored, including anatomical or surgical factors that dictate the difficulty of the case, such as prior renal surgery. Lastly, we discuss the emerging role of molecular biomarkers, specifically epigenetics, to aid in the risk stratification of SRMs and to select tumours optimally suited for PN.
    Translational Andrology and Urology 06/2015; 4(3):294-300. DOI:10.3978/j.issn.2223-4683.2015.06.04
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    ABSTRACT: On-clamp partial nephrectomy (PN) has been considered the standard approach to minimize intraoperative bleeding and thus achieve adequate control of tumor margins. The potential negative impact of ischemia on renal function (RF) led to the development of techniques to minimize or avoid renal ischemia, such as off-clamp PN and minimally ischemic PN techniques. To review current evidence on the indications and techniques for and outcomes of minimally ischemic and off-clamp PN. A systematic review of English-language publications on PN without a main renal artery clamp from January 2005 to July 2014 was performed using the Medline, Embase, and Web of Science databases. The searches retrieved 52 papers. Off-clamp PN has been more commonly applied to small and peripheral renal tumors, while minimally ischemic PN is best suited for hilar and medially located renal tumors. These approaches are associated with increased intraoperative blood loss and perioperative transfusion rates compared to on-clamp PN. Minimally ischemic and off-clamp PN have potential functional benefits when longer ischemia time is anticipated, particularly for patients with lower baseline RF. Limitations include the lack of prospective randomized trials comparing minimally ischemic and off-clamp to on-clamp techniques, and the small sample size and short follow-up of most published series. The impact of different resection and renorrhaphy techniques on postoperative RF and its assessment via renal scintigraphy requires further investigations. Minimally ischemic and off-clamp PN are established procedures that may be particularly applicable for patients with decreased baseline RF. However, these techniques are technically demanding, with potential for increased blood loss, and require considerable experience with PN surgery. The role of ischemia in patients with a contralateral healthy kidney and consequently an indication for elective minimally ischemic or off-clamp PN remains a debatable issue. In this review we analyzed available evidence on minimally ischemic and off-clamp partial nephrectomy. These techniques, although technically demanding, may be particularly applicable for patients with decreased baseline renal function. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
    European Urology 04/2015; 68(4). DOI:10.1016/j.eururo.2015.04.020 · 13.94 Impact Factor
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    ABSTRACT: Multi-parametric MRI often under- or over-estimates the pathological cancer volume. The aim of this study was to develop a novel method to estimate prostate cancer volume using MR/US-fusion biopsy-proven cancer core-length. A total of 81 consecutive clinically localized prostate cancer patients with MR/US-fusion targeted biopsy-proven cancer who subsequently underwent radical prostatectomy were retrospectively analyzed. As 7 patients had two MRI-visible lesions, 88 lesions were analyzed. The dimensions and estimated lesion volume of MR-visible lesions were calculated using ADC maps. The modified formula for estimating cancer volume was defined as the formula of vertical stretching the AP-dimension of the MR-based 3D model in which the MR-estimated lesion-AP-dimension was replaced with MR/US-targeted biopsy-proven cancer core-length. Agreement of the pathological cancer volume (PCV) with the MR-estimated-volume (MCV) or the novel modified-volume was assessed using a Bland-Altman plot. MR/US fusion biopsy-proven cancer core-length (r=0.824, p<0.001) was a stronger predictor of the actual pathological cancer-AP-dimension than the MR-estimated lesion-AP-dimension (r=0.607, p<0.001). MR/US-targeted biopsy-proven cancer core-length was correlated with PCV (r=0.773, p<0.001). The modified formula for estimating cancer volume demonstrated a stronger correlation with PCV (r=0.824, p<0.001) than the MCV (r=0.724, p<0.001). Agreement of the modified-volume with PCV improved than that of MCV in a Bland-Altman plot analysis. The predictability was more enhanced in the subset of cancer lesions with the volume ≤2 ml (i.e., if spherical in shape, it was approximately 16 mm in diameter). Combining MRI-estimated cancer volume with MR/US-fusion biopsy-proven cancer core-length improved cancer volume predictability. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
    The Journal of urology 04/2015; DOI:10.1016/j.juro.2015.04.075 · 4.47 Impact Factor
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    ABSTRACT: A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). A literature review was conducted. Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.
    European Urology 04/2015; DOI:10.1016/j.eururo.2015.04.010 · 13.94 Impact Factor
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    ABSTRACT: To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). We utilize a four-arm robotic approach and a 5-6 port placement consisting of: 1- 12 mm camera port, 3- 8 mm robotic ports, and 1 to 2 assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. This technique has been utilized since 2010 on over 2,370 robotic urologic cases. To date, no procedure has required patient or robot positioning while maintaining 4th arm functionality with minimal robotic arm clashing. Our approach of port placement and robot docking is reproducible and feasible for pelvic and kidney surgery.
    Journal of endourology / Endourological Society 04/2015; DOI:10.1089/end.2015.0077 · 1.71 Impact Factor
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    ABSTRACT: Level III inferior vena cava (IVC) tumor thrombectomy for renal cancer is one of the most challenging open urologic oncologic surgeries. The initial series of completely intra-corporeal robotic level III IVC tumor thrombectomy is presented. Nine patients underwent robotic level III IVC thrombectomy; additionally, 7 patients underwent level II thrombectomy. The entire operation (high intra-hepatic IVC control, caval exclusion, tumor thrombectomy, IVC repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize chances of intra-operative IVC thrombus embolization, an 'IVC-first, kidney-last' robotic technique was developed. Data were accrued prospectively. All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (n=9), median primary kidney (right=6, left=3) cancer size was 8.5 cm (5.3-10.8) and IVC thrombus length was 5.7 cm (4-7). Median operative time was 4.9 hours (4.5-6.3), estimated blood loss was 375 cc (200-7000) and hospital stay was 4.5 days. All surgical margins were negative. There was no intra- and 1 post-operative complication (Clavien 3b). Over median 7 months follow-up (1-18), all patients are alive. Compared to level II thrombi, the level III cohort trended towards greater IVC thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hrs) and blood loss (290 vs 375 cc). With appropriate patient selection, surgical planning and robotic experience, completely intra-corporeal robotic level III IVC thrombectomy is feasible and can be performed efficiently. Larger experience, longer follow-up and comparison with open surgery are needed to confirm these initial outcomes. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
    The Journal of urology 04/2015; DOI:10.1016/j.juro.2015.03.119 · 4.47 Impact Factor
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    The Journal of Urology 04/2015; 193(4):e699. DOI:10.1016/j.juro.2015.02.2089 · 4.47 Impact Factor
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    The Journal of Urology 04/2015; 193(4):e1076. DOI:10.1016/j.juro.2015.02.1913 · 4.47 Impact Factor

Publication Stats

23k Citations
3,461.48 Total Impact Points


  • 2011–2015
    • Keck School of Medicine USC
      Los Ángeles, California, United States
    • University of Texas Southwestern Medical Center
      • Department of Urology
      Dallas, Texas, United States
  • 2009–2015
    • University of Southern California
      • • Keck School of Medicine
      • • Department of Urology
      Los Ángeles, California, United States
    • University of California, Los Angeles
      Los Ángeles, California, United States
    • University Hospital Of North Staffordshire NHS Trust
      • Department of Urology
      Stoke-upon-Trent, England, United Kingdom
  • 2014
    • Istituto Regina Elena - Istituti Fisioterapici Ospitalieri
      Roma, Latium, Italy
  • 2004–2014
    • Michigan Institute of Urology
      Detroit, Michigan, United States
    • University of Cincinnati
      Cincinnati, Ohio, United States
    • Lerner Research Institute
      Cleveland, Ohio, United States
  • 2013
    • Spectrum Health
      Grand Rapids, Michigan, United States
  • 2012
    • University of Texas MD Anderson Cancer Center
      • Department of Urology
      Houston, TX, United States
  • 2010
    • Children's Hospital Los Angeles
      Los Angeles, California, United States
    • Stanford University
      Palo Alto, California, United States
  • 1994–2010
    • Cleveland Clinic
      • Department of Urology
      Cleveland, Ohio, United States
  • 2008–2009
    • Port Macquarie Base Hospital
      Порт Маккуори, New South Wales, Australia
    • Kyoto Prefectural University of Medicine
      • Department of Urology
      Kyoto, Kyoto-fu, Japan
    • Centro Médico de Caracas
      Caracas, Capital, Venezuela
    • Muljibhai Patel Urological Hospital
      Aimand, Gujarāt, India
  • 2007
    • Dokuz Eylul University
      Ismir, İzmir, Turkey
    • University of California, Davis
      • Department of Urology
      Davis, California, United States
  • 2003–2007
    • Institute for Urologic Research
      Wheeling, West Virginia, United States
    • American Physical Society
      CGS, Maryland, United States
  • 2006
    • Texas Institute for Robotic Surgery
      Austin, Texas, United States
    • Fox Chase Cancer Center
      Filadelfia, Pennsylvania, United States
  • 2001
    • Western General Hospital
      Edinburgh, Scotland, United Kingdom
    • Università Vita-Salute San Raffaele
      • Faculty of Psychology
      Milano, Lombardy, Italy
  • 1998
    • University of Innsbruck
      Innsbruck, Tyrol, Austria
  • 1996
    • University of Nebraska Medical Center
      • Department of Surgery
      Omaha, Nebraska, United States
  • 1993–1995
    • University of Kentucky
      • Department of Surgery
      Lexington, Kentucky, United States
    • Washington University in St. Louis
      • • Division of Urologic Surgery
      • • Department of Surgery
      San Luis, Missouri, United States