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Post-operative Complications in the Modern-era of Robotic Partial Nephrectomy: The Impact of Experience on Arterial Malformation and Urine Leak/Urinoma
Abstract
Objectives:
To assess the incidence of post-operative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series. To evaluate risk factors for these complications.
Methods:
All RPNs were queried from IRB-approved retrospective and prospective nephrectomy databases. Demographics, peri-operative variables, and post-operative complications were collected. Differences between cohorts were analyzed using univariate analysis. Post-operative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection via drainage or aspiration. AM was identified based on post-operative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed via univariate analysis.
Results:
395 RPNs were performed by four urologists between 1/2014-10/2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p=0.01). Overall incidence of post-operative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as >= IIIa: 8/13 (61.5%) vs. 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs. 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p< 0.05). No significant predictors for AM were identified.
Conclusions:
The incidence of post-operative complications after RPN remains low (5.3% vs. 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs. 0%, 3.1% vs. 1.1%).
Studied herein are the long-term results after surgical treatment of stage cT1 kidney cancer. The study includes 278 surgeries for kidney tumors. Partial nephrectomy was performed in 199 (71.6%) cases and radical nephrectomy in 79 (28.4%). Surgeries were performed using the open, laparoscopic, and robotic approaches. Surgical treatment and long-term oncological results were studied. Open approach for partial nephrectomy was used in 2.01% of cases, laparoscopic in 27.64%, and robotic in 70.34%; and radical nephrectomy in 2.53%, 87.34%, and 10.13%, respectively. Incidence postoperative complications after partial and radical nephrectomy were 16.58% and 3.8%, respectively. Сomplications (Clavien Dindo 3) occurred in 11.56% and 3.8% cases, respectively. Positive surgical margin occurred after partial nephrectomy in 1.51%, whereas undetermined for radical nephrectomy. The 5-year disease-free survival for partial and radical nephrectomy was 94.98 1.77% vs. 86.96% 4.11%; 5-year overall survival was 96.2% 1.55% vs. 88.15% 3.96%; 10-year overall survival was 90.82% 4.19% vs. 76.32 6.1%; and 5-year cancer-specific survival was 99.16% 0.84% vs. 94.09% 2.87%, respectively. Our study demonstrates that partial nephrectomy is a safe and effective method for surgical treatment in stage cT1 kidney cancer. A minimally invasive approach is a priority. The nephron-sparring technique demonstrates superior long-term results compared with radical nephrectomy.
Context:
The European Association of Urology Renal Cell Carcinoma (RCC) Guideline Panel has prepared evidence-based guidelines and recommendations for the management of RCC.
Objective:
To provide an updated RCC guideline based on standardised methodology including systematic reviews, which is robust, transparent, reproducible, and reliable.
Evidence acquisition:
For the 2019 update, evidence synthesis was undertaken based on a comprehensive and structured literature assessment for new and relevant data. Where necessary, formal systematic reviews adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were undertaken. Relevant databases (Medline, Cochrane Libraries, trial registries, conference proceedings) were searched until June 2018, including randomised controlled trials (RCTs) and retrospective or controlled studies with a comparator arm, systematic reviews, and meta-analyses. Where relevant, risk of bias (RoB) assessment, and qualitative and quantitative syntheses of the evidence were performed. The remaining sections of the document were updated following a structured literature assessment. Clinical practice recommendations were developed and issued based on the modified GRADE framework.
Evidence synthesis:
All chapters of the RCC guidelines were updated based on a structured literature assessment, for prioritised topics based on the availability of robust data. For RCTs, RoB was low across studies. For most non-RCTs, clinical and methodological heterogeneity prevented pooling of data. The majority of included studies were retrospective with matched or unmatched cohorts, based on single- or multi-institutional data or national registries. The exception was for the treatment of metastatic RCC, for which there were several large RCTs, resulting in recommendations based on higher levels of evidence.
Conclusions:
The 2019 RCC guidelines have been updated by the multidisciplinary panel using the highest methodological standards. These guidelines provide the most reliable contemporary evidence base for the management of RCC in 2019.
Patient summary:
The European Association of Urology Renal Cell Carcinoma Guideline Panel has thoroughly evaluated the available research data on kidney cancer to establish international standards for the care of kidney cancer patients.
To determine whether the approach for partial nephrectomy is influenced by tumor complexity and if the introduction of robotic techniques has allowed us to treat more complex tumors minimally invasively. Data from 292 patients who underwent partial nephrectomy for renal masses from November 1999 to July 2013 at a tertiary referral center were retrospectively reviewed. Nephrometry scores and perioperative outcomes were stratified based on when robotic techniques were introduced. Mean follow-up time was 2.6 years. Preoperative RENAL nephrometry scores and perioperative outcomes were analyzed. Of the 292 patients, 31.5 % underwent robot-assisted partial nephrectomy, 46.2 % laparoscopic partial nephrectomy and 22.9 % open partial nephrectomy. Robot-assisted partial nephrectomy mean nephrometry score was significantly higher than laparoscopic and equivalent to open. Significant perioperative differences were estimated blood loss (p = 0.0001), length of stay (p = 0.0001) and Clavien score (p = 0.0069), all favoring robot-assisted partial nephrectomy. Limitations include retrospective design and single center data. Robot-assisted partial nephrectomy is a safe and effective surgical modality that allows for complex renal tumors that were previously reserved for open partial nephrectomy in the pure laparoscopic era to be managed with a minimally invasive approach.
We evaluated the incidence of perioperative complications after robotic partial nephrectomy.
We retrospectively reviewed the records of patients treated with robotic assisted partial nephrectomy across the 4 participating institutions. Demographic, blood loss, warm ischemia time, and intraoperative and postoperative complication data were collected. All complications were graded according to the Clavien classification system.
A total of 450 consecutive robotic assisted partial nephrectomies were done between June 2006 and May 2009. Overall 71 patients (15.8%) had a complication, including intraoperative and postoperative complications in 8 (1.8%) and 65 (14.4%), respectively. Hemorrhage developed in 2 patients (0.2%) intraoperatively and in 22 (4.9%) postoperatively. Seven patients (1.6%) had urine leakage. As classified by the Clavien system, complications were grade I-II in 76.1% of cases and grade III-IV in 23.9%. Robotic assisted partial nephrectomy was converted to open or conventional laparoscopic surgery in 3 patients (0.7%) and to radical nephrectomy in 7 (1.6%). There were no deaths.
Current data indicate that robotic assisted partial nephrectomy is safe. Most postoperative complications are Clavien grade I or II, or can be managed conservatively.
Urine leaks from the kidney, ureter, bladder, and urethra most commonly result from trauma. Urinomas may be occult initially and may lead to complications such as abscess formation and electrolyte imbalances if not promptly diagnosed and appropriately managed. Radiologists play a key role in diagnosing urine leaks and determining their cause and extent. Contrast material-enhanced computed tomography (CT) with delayed imaging, CT cystography, and retrograde urethrography are the diagnostic imaging studies of choice. Studies such as intravenous pyelography, antegrade and retrograde pyelography, renal scintigraphy, and imaging-guided needle aspiration may play complementary diagnostic roles. In some instances, the role of the radiologist ends with the diagnosis of urine leaks, after which patients are treated conservatively or perhaps surgically. Uncomplicated renal urine leaks, extraperitoneal urinary bladder rupture, and type 1 urethral injuries are generally managed conservatively. Urine leaks that require more extensive, imaging-guided treatment can usually be managed safely and effectively with a combination of percutaneous urinoma drainage catheters, percutaneous nephrostomy catheters, ureteral stents, and bladder drainage. In the appropriate setting, use of these management options may reduce urinoma-related complications and limit or totally eliminate the need for urologic surgery.
Objective:
Due to their size, location and proximity to the hilum, some complex renal tumours may preclude a minimally invasive approach to nephron sparing surgery. We describe our technique, illustrated with images and videos, of robotic partial nephrectomy for challenging renal tumours.
Patients and methods:
A study of 249 patients who underwent robotic partial nephrectomy (RPN) in multiple institutions was performed. Patients were identified using prospective RPN databases. A complex renal lesion was defined as a RENAL nephrometry score ≥10. Data was presented as median (interquartile range) and differences between groups were examined.
Results:
31 (12.4%) RPN were performed for complex renal tumours. Median age was 57 (50.5 - 70.5) years. 21 (67.7%) were male, 10 (32.3%) were female. American Society of Anesthesiologists score was 2 (2 - 3). Median operative time was 200 (50 - 265) min, median warm ischaemia time was 23 (18.5 - 29) min, and median blood loss was 200 (50 - 265) ml. There were no intraoperative complications. 2 (6.4%) patients had post-operative complications. 1 (3.2%) patient had a positive margin. Length of stay was 3.5 (3 - 5) days. Median follow up was 12.5 (7 - 24) months. There were no recurrences. RPN did result in statistically significant changes in renal function 3 months post RPN compared to preoperative renal function, p=0.0001.
Conclusion:
RPN is a safe approach for select patients with complex renal tumours and may facilitate tumour resection and renorrhaphy for challenging cases, offering a minimally invasive surgical option for patients who may otherwise require open surgery. This article is protected by copyright. All rights reserved.
Introduction:
Urological surgeries have contributed to the increasing prevalence of minimally invasive robotic procedures. Although factors influencing the adoption of robot-assisted radical prostatectomy have previously been identified, the explanation for the rapid rise in robotic partial nephrectomies remains unknown. Using a retrospective population-based sample, we attempt to determine hospital and surgeon-specific factors influencing a surgeon's decision to utilize robotic assistance for partial nephrectomies.
Materials and methods:
A nationally representative weighted sample of all men who underwent a partial nephrectomy in the United States between 2003 and 2014 was identified within the Premier Hospital Database. Hospital, surgeon, and patient characteristics for each operation were analyzed. Descriptive statistics and a multivariate regression model stratified according to the Law of Diffusion of Innovation were performed.
Results:
A weighted sample of 14,890 nephrectomies was included in the study. Patient demographics were similar between the two groups. The adoption of robotic technology followed the Law of Diffusion of Innovation with the percentage of partial nephrectomies with robotic assistance increasing yearly, reaching 64.1% by 2013. Surgical volume was a significant factor driving the use of robotic assistance, with high volume surgeons (>5 partial nephrectomies/year) performing 23.2% more robotic partial nephrectomies per year than their low volume colleagues (< = 5 partial nephrectomies/year) from 2009 to 2013 (p < 0.001).
Conclusions:
This retrospective population-based study examines key factors influencing the diffusion of robotic technology for partial nephrectomies. Surgical volume and year of surgery were found to be the most significant factor in robotic adoption, with other patient and hospital-specific characteristics playing a minor role. Future studies are needed to correlate adoption rates with the clinical or cost-effectiveness of novel technologies within the medical field to determine whether rapid adoption is a patient-centered vs a clinician-centered decision point.
Objectives:
To determine whether use of nephron sparing surgery (NSS) for treatment of stage 1 renal cell carcinomas changed between 2009 and end 2013 in Australia.
Patients and methods:
All adult cases of renal cell carcinoma diagnosed in 2009, 2012, and 2013 were identified through the population-based Victorian Cancer Registry. For each identified patient, trained data-abstractors attended treating hospitals or clinician rooms to extract tumour and treatment data through medical record review. Multivariable logistic regression analyses examined significance of change in use of NSS over time, after adjusting for potential confounders.
Results:
A total of 1836 patients with renal cell carcinoma were identified. Of these, the proportion of cases with stage 1 tumours was 64% in 2009, 66% in 2012, and 69% in 2013. For T1a tumours, the proportion of patients residing in metropolitan areas receiving NSS increased from 43% in 2009 to 58% in 2012 (P<.05), and 69% in 2013 (P<.05). For patients residing in non-metropolitan areas, the proportion receiving NSS increased from 27% in 2009 to 49% in 2012, and 61% in 2013 (P<.01). Univariable logistic regression showed patients with moderate (OR=0.57, 95%CI 0.35-0.94) or severe comorbidities (OR=0.58, 95%CI 0.33-0.99), residing in non-metropolitan areas (OR=0.65, 95%CI 0.47-0.90), were less likely to be treated by NSS, while those attending high volume hospitals (30+ cases/year: OR=1.79, 95%CI 1.21-2.65) and those with higher socio-economic status (OR=1.45, 95%CI 1.02-2.07) were more likely to be treated by NSS. In multivariable analyses, patients with T1a tumours in 2012 (OR=2.00, 95% CI:1.34-2.97) and 2013 (OR=3.15, 95% CI: 2.13-4.68) were more likely to treated by NSS than those in 2009. For T1b tumours, use of NSS increased from 8% in 2009 to 20% in 2013 (P<.05).
Conclusion:
This population-based study of the management of T1 renal tumours in Australia found use of NSS increased over the period 2009 to 2013. Between 2009 and 2013 clinical practice for the treatment of small renal tumours in Australia has increasingly conformed to international guidelines. This article is protected by copyright. All rights reserved.
To determine the influence of the early unclamping technique on the risk of renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy.
From January 2013 to October 2014, 96 patients underwent robot-assisted laparoscopic partial nephrectomy for renal masses at Tokyo Women's Medical University Hospital, Tokyo, Japan. Computed tomography angiography was carried out 3-4 days after surgery. Early in the series, renal hilum was left unclamped and renorrhaphy was subsequently carried out (conventional unclamping technique). An early unclamping technique has been used since November 2013.
A total of 61 patients underwent robot-assisted laparoscopic partial nephrectomy with early unclamping, and 35 patients underwent robot-assisted laparoscopic partial nephrectomy with conventional unclamping. Ischemia time was significantly shorter in the early unclamping group (16.5 vs 23.1 min; P < 0.01). The early unclamping group showed a significantly lower incidence of asymptomatic renal artery pseudoaneurysm relative to the conventional unclamping group (11.4% vs 28.6%; P = 0.03). Multivariate analysis showed that the early unclamping technique was a significant independent factor in reducing the risk of renal artery pseudoaneurysm (hazard ratio 0.27; P = 0.01).
The present findings suggest that an early unclamping technique might reduce ischemic time and risk of renal artery pseudoaneurysm. The absence of arterial bleeding before renorrhaphy is likely to be a key step in preventing renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy.
© 2015 The Japanese Urological Association.
to evaluate the incidence of and risk factors for a urine leak in a large multicenter, prospective database of robotic partial nephrectomy (rpn).
a database of 1791 rpn from five centers was reviewed for urine leak as a complication of rpn. patients with postoperative urine leaks were compared to patients without postoperative urine leaks on a variety of patient and tumor characteristics. fisher's exact test was used for qualitative variables and wilcoxon sum-rank tests were used for quantitative variables. a review of the literature on partial nephrectomy and urine leak was conducted.
urine leak was noted in 14/1791 (0.78%) patients who underwent rpn. mean nephrometry score of the entire cohort was 7.2 ± 1.9, and 8.0 ± 1.9 in patients who developed urine leak. the median postoperative day of presentation was 13 (range 3-32). patients with urine leak presented in delayed fashion with fever (14%), gastrointestinal complaints (29%), and pain (36%). eight patients required admission (57%), while eight (57%) and nine (64%) had a drain or stent placed, respectively. drains and stents were removed after a median of eight (range 4-13) and 21 days (8-83), respectively. variables associated with urine leak included tumor size (p = 0.021), hilar location (p = 0.025), operative time (p=0.006), warm ischemia time (p = 0.005), and pelvicaliceal repair (p = 0.018). upon literature review, the historical incidence of leak ranged from 1.0-17.4% for opn and 1.6-16.5% for lpn.
the incidence of urine leak after rpn is very low and may be predicted by some preoperative factors, affording better patient counseling of risks. the low urine leak may be attributed to the enhanced visualization and suturing technique that accompanies the robotic approach. This article is protected by copyright. all rights reserved.
This article is protected by copyright. All rights reserved.
Objective:
Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time.
Patients and methods:
A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide.
Results:
The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons.
Conclusions:
The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.
Objectives
We systematically examined the incidence and potential implications of renal artery pseudoaneurysm occurring after partial nephrectomy detected by computed tomography screening in the early postoperative period.Methods
Between January and December 2012, 117 patients underwent enhanced screening computed tomography on the fourth postoperative day after partial nephrectomy to evaluate for renal artery pseudoaneurysm. The size of the renal artery pseudoaneurysm and follow-up imaging were utilized to decide on pre-emptive angioembolization. Patient characteristics, tumor specifics and surgical data were analyzed.ResultsA total of 17 of 117 patients (15%) were found to have renal artery pseudoaneurysm on early postoperative computed tomography. Renal artery pseudoaneurysm occurred in nine of 73 open partial nephrectomy patients (12.3%) and eight of 44 laparoscopic partial nephrectomy patients (18.2%). One early patient experienced a postoperative bleed on postoperative day 9 after diagnosis of a 3.5-mm diameter renal artery pseudoaneurysm on postoperative day 3, and this patient was successfully managed with angioembolization. There were no other postoperative bleeding episodes. Rapid growth of a renal artery pseudoaneurysm was observed in a second patient who was treated with pre-emptive angioembolization. Five patients were diagnosed with small renal artery pseudoaneurysm (2–4 mm) on postoperative day 4 and observed with follow-up imaging showing resolution of the renal artery pseudoaneurysm. Another 10 patients were diagnosed with larger renal artery pseudoaneurysm (≥4 mm) and were managed with pre-emptive angioembolization.Conclusions
Early postoperative computed tomography screening is able to detect modest rates of asymptomatic renal artery pseudoaneurysm. The rate of postoperative bleed remained low with a policy of selective angioembolization. Renal artery pseudoaneurysm size and interval enlargement might indicate the risk of rupture. Further studies are required to assess the potential role of pre-emptive angioembolization.
To identify the predictive factors of hemorrhagic complications (HC) in a contemporary cohort of patients who underwent partial nephrectomy (PN).
Records of 199 consecutive patients who underwent PN between 2008 and 2012 at our institution were retrospectively analyzed. HC was defined as a hematoma requiring transfusion, an arterio-veinous fistula, a false aneurysm or a post-operative decrease of hemoglobin >3 g/dl. Patients with or without HC were compared using Wilcoxon and Fisher exact tests for continuous and categorical variables, respectively. We performed a univariate and multivariate analysis with a logistic regression model using the occurrence of an HC as the dependent variable.
54% of the patients were male with a median age of 61 (22-86) years. Median BMI was 26 (18-47) kg/m(2). Surgery was done open, laparoscopically or with robotic assistance in 106, 54 and 39 cases, respectively. Global complication rate was 40% including 21.6% HC. There were more complex tumors (75.6% vs. 66.5%, p = 0.04) and median length of stay was increased (11 days compared to 7 days, p < 0.0001) in case of a HC. In univariate analysis, imperative indication (p = 0.08), RENAL score (p = 0.07), operating time (p = 0.07) and operative blood loss > 250 ml (p = 0.002) were statistically relevant. In multivariate analysis, only operative blood loss >250 ml was identified as a predictive factor of HC (p = 0.0007).
Patients who underwent a procedure with estimated blood loss >250 ml should be carefully monitored in the postoperative course.
To determine practice patterns and perioperative outcomes for open and minimally invasive partial nephrectomy (PN) in the United States since the introduction of a robot-assisted modifier in the Nationwide Inpatient Sample (NIS).
Relying on the NIS between October 2008-December 2010, all patients with non-metastatic disease undergoing open PN (OPN), laparoscopic PN (LPN) and robotic PN (RPN) were identified. Utilization rates were assessed according to year, patient and hospital characteristics. Peri-operative outcomes between OPN vs. RPN, and OPN vs. LPN were evaluated using binary logistic regression models adjusted for patient and hospital co-variates.
In a weighted sample of 38064 PNs, 66.9%, 23.9% and 9.2% were OPN, RPN and LPN, respectively. In 2010, the relative annual increase in the utilization of OPN, RPN and LPN was 7.9%, 45.4% and 6.1% respectively. Compared to OPN, patients undergoing minimally invasive PN were less likely to receive a blood transfusion (RPN odds ratio [OR]:0.56, p<0.001; LPN OR:0.68, p=0.016), postoperative complication (RPN OR:0.63, p<0.001; LPN OR:0.78, p<0.009), or prolonged length of stay (RPN OR:0.27, p<0.001; LPN OR:0.41, p<0.001). Only RPN patients were less likely to experience an intraoperative complication (RPN OR:0.69, p=0.014; LPN OR:0.67, p=0.069). Excess hospital charges were higher after RPN (OR:1.35, p<0.001).
The dissemination of robotic surgery for PN in the U.S. has been rapid and safe. Compared to OPN, RPN had lower odds than LPN for most studied outcomes except hospital charges. RPN has now supplanted LPN as the most common minimally invasive approach for PN.
Purpose:
Partial nephrectomy is performed for renal masses as a means of preserving renal function. Renal artery pseudoaneurysm is a potential complication of partial nephrectomy. We determined the incidence of renal artery pseudoaneurysm after open and minimally invasive partial nephrectomy, and performed a comparative analysis.
Materials and methods:
We queried the Ovid Medline® and PubMed® databases to locate published reports of renal artery pseudoaneurysm after partial nephrectomy. Studies were included in comparative analysis if they were in English and showed the total number of procedures performed and perioperative complications.
Results:
Included studies represented a total of 5,229 patients, of whom 2,494 and 2,735 underwent open and minimally invasive partial nephrectomy, respectively. A total of 25 and 52 renal artery pseudoaneurysms were reported after open and minimally invasive procedures (weighted 1.00% and 1.96%, respectively). The difference between these 2 values was statistically significant (p ≤ 0.001). Patients diagnosed with renal artery pseudoaneurysm presented a mean of 14.9 days after surgery and 87.3% of them had gross hematuria at presentation. Almost all patients with renal artery pseudoaneurysm were treated with percutaneous angioembolization with 96% success.
Conclusions:
Although it is rare, the risk of renal artery pseudoaneurysm after partial nephrectomy is significant and should be high on the differential for a patient who presents postoperatively with gross hematuria. The incidence of renal artery pseudoaneurysm is higher after minimally invasive partial nephrectomy than after an open approach. Angioembolization for renal artery pseudoaneurysm after partial nephrectomy offers an excellent success rate and minimal patient morbidity.
To identify whether RENAL nephrometry score is associated with partial nephrectomy (PN) technique. RENAL nephrometry score quantifies anatomic characteristics of renal tumors. Data are limited regarding clinical utility for surgical planning.
Multicenter analysis of patients undergoing PN for renal masses from March 2003 to May 2011. Cohort was stratified by surgical modality: open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robotic-assisted laparoscopic partial nephrectomy (RALPN). Demographic and clinicopathological variables were compared between groups; RENAL score was calculated from preoperative imaging. Factors associated with choice of treatment modality and urine leak were entered into multivariable models.
One hundred fifty-three patients who underwent OPN, 100 patients who underwent LPN, and 31 patients who underwent RALPN were evaluated, the median tumor size (cm) was significantly larger for OPN (OPN 4.2 vs LPN 2.4 vs RALPN 2.0; P < .001); median operative time (minutes) and ischemia time (minutes) were shorter in OPN (OPN 190 and 25 vs LPN 200 and 29 vs RALPN 195 and 30; P = .042 and P < .001). Mean RENAL score was highest in OPN (OPN 8 vs LPN 6.3 vs RALPN 6.4; P < .001). No significant differences were noted in overall/high-grade complication rates (Clavien, P = .441/.985). On multivariate analysis, there was a 55% increased odds of undergoing OPN for each increase in RENAL score (P < .001). Higher RENAL score was associated with increased odds of urine leak (odds ratios [OR], 1.56; P = .002).
RENAL nephrometry score was associated with type of surgical approach (open vs laparoscopic/robotic) and urine leak. RENAL score may be useful as a decision-making tool in evaluation of patients for nephron-sparing surgery (NSS). Further investigation is requisite.
To our knowledge the benefit of routine drainage after partial nephrectomy has never been investigated, although a drain after partial nephrectomy can be associated with morbidity. We report our initial experience with omitting the drain in select cases of superficial renal cortical tumors.
From a surgery database we identified 512 consecutive open partial nephrectomies performed by a single surgeon between January 2005 and May 2009 using standardized technique. The study group included 75 evaluable patients (14.6%) who did not have a drain placed. Clinical data, surgical information, histological type and postoperative complications within 90 days of the procedure using the modified Clavien system were included in analysis.
Median patient age was 64 years (IQR 49, 70) and 56.8% of the patients were male. Median tumor size was 2.0 cm (IQR 1.5, 3.0) and more than 70% were malignant. A total of 38 patients (50.7%) underwent renal artery clamping and cold ischemia with a median clamp time of 30 minutes. The overall complication rate was 13.3% (10 patients). In 4 patients (5.3%) complications were related to an absent drain, including grade I urinary leak, grade II perirenal collection, grade III urinoma requiring percutaneous drainage and grade III urinary leak with urosepsis, respectively. No deaths occurred in this cohort.
Omitting drainage after partial nephrectomy in a select group of patients without collecting system entry is feasible and safe. The decision to place a drain after partial nephrectomy for small renal cortical tumors must be made intraoperatively and should be tailored to each case.
We describe the presentation, endovascular management and functional outcomes of 15 patients with renal arterial pseudoaneurysm following open and laparoscopic partial nephrectomy.
An institutional review board approved, Health Insurance Portability and Accountability Act compliant retrospective review of a prospectively maintained database revealed that 7 of 1,160 patients who underwent open partial nephrectomy and 8 of 301 treated with laparoscopic partial nephrectomy were diagnosed with a pseudoaneurysm of a renal artery branch between 2003 and 2010. Some cases were associated with arteriovenous fistula.
Diagnosis of pseudoaneurysm was made a median of 14 days after surgery. Gross hematuria was the most frequent symptom. Median estimated glomerular filtration rate measurements at the preoperative evaluation, postoperatively, on the day the vascular lesion was diagnosed, after embolization and at the last followup were 62, 55, 55, 56 and 58 ml/minute/1.73 m(2), respectively. Median followup was 7.8 months. All patients underwent angiography and superselective coil embolization of 1 or more pseudoaneurysms with or without arteriovenous fistula. Eleven patients had immediate cessation of symptoms while 4 had persistent gross hematuria after the procedure. Of these 4 patients 2 were treated with bedside care, 1 required repeat embolization with thrombin, which was successful, and the remaining patient had coagulopathy and underwent radical nephrectomy for persistent bleeding.
Pseudoaneurysms and arteriovenous fistulas of the renal artery are rare complications of partial nephrectomy. Presentation is often delayed. Superselective coil embolization is a safe, minimally invasive treatment option that usually solves the clinical problem and preserves renal function.
• To determine if the RENAL nephrometry score is associated with urine leak after partial nephrectomy for tumours ≤ 7 cm.
• Thirty-one patients who developed urine leak after partial nephrectomy between 1998 and 2006 were identified. Each patient was individually matched (1 : 4 by age, gender and surgery date) to 124 patients who had undergone partial nephrectomy but without urine leak. • Associations of RENAL nephrometry scores and each component of the score (Radius; Endophytic; Nearness to collecting system; and Location) with urine leak were evaluated using conditional logistic regression.
• Mean tumour size for the 31 patients who developed urine leak was 3.4 cm (median 3.5; range 1.5-5.9). Mean RENAL score was 8 (median 8; range 5-11). • Each unit increase in RENAL score was associated with a 35% increased odds of urine leak (OR 1.35; 95% CI 1.08-1.69; P= 0.009). • On multivariable analysis, tumours that were <50% exophytic (OR 16.65; 95% CI 2.75-100.71; P= 0.002), completely endophytic (OR 17.02; 95% CI 2.88-100.55; P= 0.002), or located at the renal pole (OR 4.34; 95% CI 1.30-14.53; P= 0.017) were associated with urine leak. • If the score attributed to tumour location was reversed (polar location given a higher score), each unit increase in RENAL score was associated with an 89% increased odds of urine leak (OR 1.89; 95% CI 1.40-2.55; P < 0.001).
• The RENAL nephrometry score is associated with risk of urine leak after partial nephrectomy. When assessing risk of urine leak, reversal of the score attributed to tumour location may improve risk prediction.
Nephron sparing surgery has been established as a standard treatment for renal masses smaller than 4 cm in diameter. The benefit of nephron sparing surgery may be hampered by new types of complications. In particular, postoperative gross hematuria due to the formation of renal artery pseudoaneurysm (RAP) can lead to clinical significant hemorrhage. We retrospectively investigated the occurrence of postoperative RAP in our own consecutive series of open/laparoscopic partial nephrectomies requiring transarterial angioembolization.
Open partial nephrectomy (OPN) was performed in 289 patients, and laparoscopic partial nephrectomy (LPN) in 40 patients. Six patients (1.82%) developed postoperative clinical symptomatic, persistent gross hematuria from RAP. Patient files were evaluated for preoperative, operative and postoperative data.
First symptom presentation was observed at a median of 12.5 days (range 6-36) after surgery. Symptoms were flank pain, gross hematuria, dizziness/syncope and/or fever. Median postoperative blood transfusion rate was 3 units (range 0-8). RAP was proven with angiography in all patients. RAP was sufficiently occluded in all patients by using microcoils in a supraselective approach. Median follow-up was 23 months (range 10-37) without any episodes of hemorrhage/flank pain in each patient.
RAP is a rare, but typical complication after partial nephrectomy. The clinical symptoms present with delay. Angiography identifies the origin of the bleeding and provides successful minimally invasive treatment.
Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons.
We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes.
The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%).
Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.
Research electronic data capture (REDCap) is a novel workflow methodology and software solution designed for rapid development and deployment of electronic data capture tools to support clinical and translational research. We present: (1) a brief description of the REDCap metadata-driven software toolset; (2) detail concerning the capture and use of study-related metadata from scientific research teams; (3) measures of impact for REDCap; (4) details concerning a consortium network of domestic and international institutions collaborating on the project; and (5) strengths and limitations of the REDCap system. REDCap is currently supporting 286 translational research projects in a growing collaborative network including 27 active partner institutions.
Open nephron sparing surgery (NSS) is now the standard of care for small renal tumors irrespective of overall renal function. More recently laparoscopic NSS with hilar clamping has emerged, albeit with relatively longer ischemic times. We reviewed our experience with contemporary open NSS, comparing complication rates to those of historical controls and updating data for comparison with minimally invasive procedures.
From 1985 to 2001, 823 open NSSs were performed at our institution. Early (within 30 days of NSS) and late (30 days to 1 year) complications were compared using the chi-square and Wilcoxon rank sum tests between procedures performed in 1985 to 1995 (control group of 343 patients) and 1996 to 2001 (contemporary group of 480).
In the control vs the contemporary group there were significant decreases in intraoperative blood loss (median 550 vs 350 cc, p <0.001), chronic renal insufficiency/failure (14.6% vs 8.1%, p = 0.003), dialysis need (7.0% vs 2.1%, p <0.001) and any early (13.4% vs 6.9%, p = 0.002) or late (32.4% vs 24.6%, p = 0.014) complication. In the contemporary group 50% of patients did not require pedicle clamping, 32% underwent warm ischemia (median 12 minutes) and 18% underwent cold ischemia (median 27 minutes). In addition, patients with a warm ischemia time of 20 minutes or less had fewer early complications than patients with greater than 20 minutes of ischemia, although this did not attain statistical significance (3.8% vs 13.6%, p = 0.063).
Complications resulting from open NSS have significantly decreased with time. Contemporary open NSS is associated with minimal morbidity, and decreases the need for pedicle clamping and overall ischemia time.
We describe the presentation, evaluation and management of hemorrhage due to renal artery pseudoaneurysm following laparoscopic partial nephrectomy.
Of the 345 laparoscopic partial nephrectomies performed by us during a 5-year period 6 patients (1.7%) had postoperative hemorrhage from a renal artery pseudoaneurysm. Patient charts were reviewed to identify pertinent preoperative, intraoperative and postoperative data.
Median tumor size was 3.5 cm (range 2.2 to 5), intraoperative blood loss was 175 cc (range 50 to 500), warm ischemia time was 32 minutes (range 30 to 45) and operative time was 3.8 hours (range 2.5 to 5). The mean percent of kidney excised was 31% and pelvicaliceal system entry was suture repaired in all 6 patients. No patient required blood transfusion perioperatively. Average hospital stay was 3.4 days (range 2.5 to 6). Delayed postoperative hemorrhage occurred at a median of 12 days (range 8 to 15). Angiography revealed a renal artery pseudoaneurysm most commonly at a third or fourth order branch (4 and 2 patients, respectively). Percutaneous embolization was successful in each patient.
Renal artery pseudoaneurysm is an uncommon complication following laparoscopic partial nephrectomy. These patients often present in delayed fashion. Selective angiographic embolization is the initial treatment of choice.
Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less.
Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups.
Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively.
Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.
Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors.
Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3).
Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence.
Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.