Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1 791 patients

Minimally invasive management of urinary fistula following robot-assisted partial nephrectomy: Case report

Urinary fistulas are a known complication that can occur after partial nephrectomy, potentially causing considerable morbidity if not properly treated. The present study examines the case of a 71-year-old male patient who developed a urinary fistula six months following a robot-assisted partial nephrectomy. Initial efforts to address the fistula through the placement of a double pigtail ureteral stent proved ineffective. Subsequent interventional radiology procedures successfully achieved fistula closure by administering adhesive fibrin directly within the fistulous tract. This case highlights the importance of a multidisciplinary approach in handling post-surgical complications like urinary fistulas.

Predicting post-surgical complications using renal scoring systems

Current surgical approaches for renal malignancies primarily rely on qualitative factors such as patient preferences, surgeon experience, and hospital capabilities. Applying a quantitative method for consistent and reliable assessment of renal lesions would significantly enhance surgical decision-making and facilitate data comparison. Nephrometry scoring (NS) systems systematically evaluate and describe renal tumors based on their anatomical features. These scoring systems, including R.E.N.A.L., PADUA, MAP scores, C-index, CSA, and T-index, aim to predict surgical complications by evaluating anatomical and patient-specific factors. In this review paper, we explore the components and methodologies of these scoring systems, compare their effectiveness and limitations, and discuss their application in advancing patient care and optimizing surgical outcomes.

SAFE: Multi-institutional study of time to complications after robot-assisted partial nephrectomy, selection of a population eligible for outpatient management (UroCCR 90)

INTRODUCTION

The average hospital length of stay after robotic-assisted partial nephrectomy (RAPN) is 3 days, with a current trend towards outpatient cases, although no population has been identified. The main objective of the study was to analyze the time to onset of post-operative complications, identify risk factors for significant early complications in order to define a population eligible for outpatient case.

MATERIAL AND METHOD

The study included 3342 patients with clinically localized renal tumors who underwent RAPN surgery between 2010 and 2021. The primary endpoint was the occurrence of significant complications (SC) (Clavien Dindo>2 [CD]). A CS-free survival analysis was performed. A multivariate logistic regression model was fitted to predict the risk of early significant complications (ESC) after RAPN.

RESULTS

The rates of total complications and SC were 14.99% and 3.59% respectively. Median time to SC was significantly longer at 3 days [3.9-5.7] versus 2 days [2.4-3] for total complications (P=0.012). The majority of complications occurred within the first 72h, and the risk factors for early SC (<72h) (ESC) were clamping time (P=0.04) and ASA>2 score (P=0.007). Analysis of survival without ESC showed a significant impact of clamping time (P=0.043) on complication-free survival.

CONCLUSION

Using standard preoperative variables, we were able to determine that the only factor influencing the occurrence of postoperative ESC was ASA score >2 and thus define it as a primary eligibility criterion for an indication of outpatient RAPN subject to a clamp time of less than 20mins.

Transcatheter renal arterial embolization for intractable urinary fistula occurring after robot-assisted partial nephrectomy: a case report

Partial nephrectomy is the standard surgical procedure for small renal tumors. Since the advent of robot-assisted partial nephrectomy (RAPN), the number of cases of renal tumors undergoing the procedure has increased exponentially. Urinary fistula is a complication of partial nephrectomy. Conservative management using ureteral stents is useful in most cases of urinary fistulas. However, some patients develop intractable urinary fistulas. Herein, we report a case in which vascular embolization was useful for treating an infected and intractable urinary fistula that developed after RAPN. A 59-year-old man was accidentally found to have a right renal tumor (approximately 3 cm in diameter) during a physical examination. Pathology was clear cell carcinoma. RAPN was performed owing to the small size of the renal tumor; however, postoperatively, an intractable urinary fistula with an isolated calyx developed, which was successfully treated with transcatheter renal arterial embolization (TAE). We encountered a rare case of infected refractory urinary fistula with an isolated calyx in which TAE was successful. TAE seems useful in treating intractable urinary fistulas with an isolated calyx occurring after RAPN.

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Urine leak and vascular complications following robotic partial nephrectomy: a contemporary single-center experience

Urine leak (UL) and vascular complications (VC), i.e., pseudoaneurysms and arteriovenous fistulas are well-described complications of robotic-assisted partial nephrectomy (RAPN). Historically, UL incidence ranges from 0.3 to 17% and VC from 0.8 to 5.6%. We report the contemporary experience of UL and VC from a single, high-volume center in cases of RAPN. 447 patients were identified from an IRB-approved Renal Tumor Database of 2174 cases who underwent RAPN from 1/2017 to 5/2023. VC occurred in 9 cases (4 pseudoaneurysms, 1 AV fistula, 4 concurrent AV fistula/pseudoaneurysm), UL occurred in 9 (2.0%), and there was one concurrent case of VC and UL. Collecting-system entry occurred in five VC cases and five UL cases. For VCs, the median nephrometry score and maximal tumor diameter was 8 (IQR 3.0) and 3.8 (0.9) cm, respectively, and 8 (3.0) and 3.7 (1.1) cm for UL cases, respectively. Most complications occurred with tumors ≤ 4 mm from the collecting system (n = 7 VC, n = 6 UL). VCs presented after 18 (6.0) days, 6 with gross hematuria; 3 required clot irrigation, 1 required continuous bladder irrigation, and 8 required embolization. No patients required postoperative transfusion. Patients with UL presented after a median of 1 (12) day, with 5 cases detected by elevated creatinine in drain fluid and the remainder detected on routine ultrasound. The duration of UL was 13 (41) days with only 2 cases requiring stenting and one case requiring a drainage catheter. No patients required kidney re-operation or removal. Our rate of VC and UL following RAPN are low and consistent with other contemporary series. Complications occurred in patients with high nephrometry scores or tumors located close to the collecting system. Both complications generally present early and can be managed without kidney re-operation or removal.

Robotic partial nephrectomy: Indications, patient selection, and setup for success

Robot-assisted partial nephrectomy (RAPN) has readily become the benchmark treatment of small renal masses (SRMs). The management of SRMs is focused on preserving renal function and limiting the morbidity of a traditional open operation, thus greatly impacting overall prognosis and long-term survival. Indications and techniques have evolved over the last 2 decades. In this article, we discuss the application of this nephron-sparing technique regarding its indications, surgical considerations, and functional outcomes.

Case in which percutaneous fibrin glue injection was useful for refractory urinary fistula following robot-assisted partial nephrectomy

Introduction

Urinary fistula is a rare complication following robot-assisted partial nephrectomy. For cases refractory to conservative treatment, only ureteral stent placement and percutaneous drainage are the established treatment alternatives.

Case presentation

A 44-year-old man presented with urinary fistula 3 weeks after robot-assisted partial nephrectomy for right renal cell carcinoma. Follow-up observations were conducted for 2 weeks; however, no improvements were observed. Additionally, the patient did not improve following percutaneous drainage and ureteral stent insertion. Subsequently, the patient received percutaneous injections of fibrin glue, with the urinary fistula showing significant improvements on the following day.

Conclusion

Our findings indicated that percutaneous fibrin glue injection can effectively treat refractory urinary fistula following partial nephrectomy.

Assessing the perioperative outcomes of abdominal drain omission after robot-assisted partial nephrectomy

The study aimed to evaluate the impact of abdominal drain placement (vs. omission) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN), focusing on complications, time to canalization, deambulation, and pain management. A prospectively-maintained institutional database was queried to get data of patients who underwent RAPN for renal masses between January 2018 and May 2023 at our Institution. Baseline, surgical, and postoperative data were collected. Retrieved patients were stratified based upon placement of abdominal drain (Y/N). Descriptive analyses comparing the two groups were conducted as appropriate.77 After adjusting for potential confounders, a logistic regression analysis was conducted to evaluate significant predictors of any grade and "major" complications. 342 patients were included: 192 patients in the "drain group" versus 150 patients in the "no-drain" group. Renal masses were larger (p < 0.001) and at higher complexity (RENAL score, p = 0.01), in the drain group. Procedures in the drain group had statistically significantly longer operative time, ischemia time, and higher blood loss (all p-values < 0.001). The urinary collecting system was more likely involved compared to the no-drain group (p = 0.01). At multivariate analysis, abdominal drainage was not a significant predictor of any grade (OR 0.79, 95%CI 0.33-1.87) and major postoperative complications (OR 3.62, 95%CI 0.53-9.68). Patients in the drain group experienced a statistically significantly higher hemoglobin drop (p < 0.01). Moreover, they exhibited statistically significant higher paracetamol consumption (p < 0.001) and need for additional opioids (p = 0.02). In summary, the study results suggest the safety of omitting drain placement and remark on the need for personalized decision-making, which considers patient and procedural factors.

Perioperative and oncological outcomes of robot-assisted laparoscopic partial nephrectomy for cystic and solid renal masses: Evidence from controlled trials

To evaluate the outcomes of robot-assisted partial nephrectomy (RAPN) for solid and cystic renal tumors. We systematically searched the Cochrane Library, PubMed, EMBASE, and Scopus databases up to March 2023. Review Manager 5.4 performed a pooled analysis of the data for random effects. Besides, sensitivity and subgroup analyses to explore heterogeneity, Newcastle-Ottawa scale, and GRADE to evaluate study quality and level of evidence. Five observational studies comprising 1353 patients (Cystic tumor: 183; Solid tumor: 1083) were included in this study. Compared to solid masses, cystic masses were associated with fewer major complications (odds ratio [OR] = 2.2; 95% confidence intervals [CI] = 1.17 to 4.13; p = 0.01). Additionally, no significant differences were observed between the two groups in terms of operative time, warm ischemia time, blood loss, hospital stay, intraoperative complications, postoperative complications, transfusion rate, postoperative estimated glomerular filtration rate (eGFR), eGFR preservation, positive surgical margin (PSM), recurrence, overall survival (OS), cancer-specific survival (CSS), recurrence-free survival (RFS) and trifecta achievement. RAPN can be performed in cystic renal tumors with perioperative, functional, and oncologic outcomes like those achievable in solid tumors. However, our findings need further validation in a large-sample prospective randomized study.

Complications after Nephron-sparing Interventions for Renal Tumors: Imaging Findings and Management

The two primary nephron-sparing interventions for treating renal masses such as renal cell carcinoma are surgical partial nephrectomy (PN) and image-guided percutaneous thermal ablation. Nephron-sparing surgery, such as PN, has been the standard of care for treating many localized renal masses. Although uncommon, complications resulting from PN can range from asymptomatic and mild to symptomatic and life-threatening. These complications include vascular injuries such as hematoma, pseudoaneurysm, arteriovenous fistula, and/or renal ischemia; injury to the collecting system causing urinary leak; infection; and tumor recurrence. The incidence of complications after any nephron-sparing surgery depends on many factors, such as the proximity of the tumor to blood vessels or the collecting system, the skill or experience of the surgeon, and patient-specific factors. More recently, image-guided percutaneous renal ablation has emerged as a safe and effective treatment option for small renal tumors, with comparable oncologic outcomes to those of PN and a low incidence of major complications. Radiologists must be familiar with the imaging findings encountered after these surgical and image-guided procedures, especially those indicative of complications. The authors review cross-sectional imaging characteristics of complications after PN and image-guided thermal ablation of kidney tumors and highlight the respective management strategies, ranging from clinical observation to interventions such as angioembolization or repeat surgery. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available in the Online Learning Center. See the invited commentary by Chung and Raman in this issue.

Radiofrequency-assisted, laparoscopic, clampless partial nephrectomy in patients with low-complexity small renal tumors: A retrospective cohort study

BACKGROUND

This single-center, retrospective study was performed to investigate the safety and efficacy of radiofrequency-assisted (RF), laparoscopic partial nephrectomy (PN) with zero ischemia in patients with low-complexity small renal tumors.

MATERIALS AND METHODS

Patients with small renal masses (SRMs) who underwent laparoscopic, clampless laparoscopic partial nephrectomy - radiofrequency assisted (LPN-RFA) between January 2016 and June 2020 were studied. Demographics, clinical and pathological characteristics, recurrence-free survival, and overall survival were recorded.

RESULTS

Fifty-two SRMs were excised from corresponding patients using RFA-LPN. The median tumor size was 2.5 cm and all specimens involved low-complexity masses according to the renal nephrometry score. No conversions to radical nephrectomy were recorded. Postoperatively, there were one patient with fever, one with hematuria, and two with urinary leakage treated endoscopically. The majority of tumors (48/52, 86.2%) were clear-cell carcinomas. According to the glomerular filtration rate postoperatively and 12 months' posttreatment, adequate renal function was preserved in all patients. There were no positive surgical margins identified postoperatively and no recurrences during a median follow-up 24 months. All patients were alive at the last follow-up.

CONCLUSIONS

This study suggests that RFA laparoscopic clampless PN represents an effective method for managing patients with low-complexity SRMs. It offers adequate intraoperative safety and excellent mid-term oncological control and functional preservation.

Comparison of robot-assisted partial nephrectomy with soft coagulation and double-layer technique for complex and non-complex tumors

OBJECTIVES

To compare the postoperative outcomes of robot-assisted partial nephrectomy when only the inner layer is sutured (single-layer technique with soft coagulation) with those when sutures are placed in the inner and outer layers (double-layer technique) in patients with and without complex renal tumors.

METHODS

This retrospective three-institution study included 371 patients with renal tumors who underwent robot-assisted partial nephrectomy with a double-layer technique or a single-layer technique with soft coagulation. Tumors that were cT1b, completely embedded, located in the renal portal, or had a RENAL score of ≥10 were considered complex. Relevant data were collected from hospital records. Propensity score matching was performed to minimize selection bias.

RESULTS

Propensity score matching created 83 patient pairs with non-complex tumors and 32 with complex tumors. Regardless of tumor complexity, there was no significant difference in operation time, console time, warm ischemia time, positive surgical margin rate, or length of hospital stay between the double-layer and single-layer groups. Although Clavien-Dindo grade I-II urinomas not requiring intervention were significantly more common in the single-layer group regardless of tumor complexity, there was no significant between-group difference in the rate of decline in renal function or grade III-IV complications.

CONCLUSION

Single-layer suturing with soft coagulation achieves renal function and perioperative outcomes comparable to those of double-layer suturing regardless of complexity.

Systematic review on active treatment for urinary fistula after partial nephrectomy

INTRODUCTION

Urinary fistula is expected to become more frequent in urological practice as a result of expanding indication of partial nephrectomy given it's oncological results equivalent to those of radical nephrectomy but at a lower risk of progression to chronic kidney disease, lower cardiovascular morbidity, and overall mortality.

OBJECTIVES

Review and compare different techniques of contemporary active management for urinary fistula after partial nephrectomy.

METHODS

A systematic literature search on the MEDLINE database was conducted in March 2020, combining the terms: "urine leak", "urine leakage", "urinary leak" and "urinary fistula", with: "partial nephrectomy", "nephron sparing surgery" and "renal sparing surgery". This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Only articles related to active treatment were eligible. Abstracts in English and Spanish from the last two decades were screened. No restriction based on study design nor the length of follow-up.

PRIMARY OUTCOMES

1) Leak resolution rate 2) Time course of leak resolution and 3) Number of interventions needed for resolution.

RESULTS

Multiple studies were found. There were no randomized controlled trials. Urinary fistula can be solved in many ways with active treatment, with a high success rate (97.5%), an average of 1.4 intervention-per-patients and a mean time for leak resolution of 11 days (median of 3 days).

CONCLUSION

There is a high risk of bias due to the study's methodology. There is a broad range of effective alternatives and various approaches to solve urinary fistula in an appropriate timing.

Does routine intraoperative Double J stent insertion avoid urine leakage after open partial nephrectomy?

OBJECTIVE

To evaluate the impact of Double J stent (DJS) insertion during open partial nephrectomy (OPN) on postoperative prolonged urinary leakage.

MATERIALS AND METHODS

A retrospective study was made in consecutive cases of OPN performed between 2002 and 2020 for localized kidney tumors at our tertiary center. Urinary leakage was defined as drainage > 72 hours after surgery by biochemical analysis consistent with urine or radiographic evidence of urine leakage. The patients were divided into two groups according to intraoperative DJS placement, and compared regarding clinicopathologic characteristics, perioperative and postoperative outcomes. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with urinary leakage after the operation.

RESULTS

Review of records identified 182 patients who were included in the study. In 73 (40%) patients PN was performed without insertion of a DJS. Thus, 109 (60%) of patients had a DJS inserted. Apart from higher preoperative eGFR values among patients with DJS (96.6 vs. 94.3 mL/min/1.73 m²; p = 0.03), demographic characteristics were similar between groups. The two groups were not different regarding perioperative, postoperative and clinicopathologic outcomes. Patients with DJS had longer ischemia times (31 vs. 23 min; p = 0.02) and longer length of stay (6 vs. 5 days; p = 0.04). Urinary leakage was seen in 7.6% (n = 14) of all patients and it did not differ according to DJS placement (DJS+ 9.2 vs. DJS- 5.5%; p = 0.41). On multivariate analysis, the tumor nearness to the collecting system was the sole independently significant factor (p = 0.04) predicting postoperative urine leak.

CONCLUSIONS

Routine intraoperative DJS insertion during OPN does not appear to reduce the probability of postoperative urine leak.

Endoscopic laser treatment for urine leakage caused by an isolated calyx after robot-assisted partial nephrectomy

INTRODUCTION

An isolated calyx is a rare complication in which the renal calyx and pelvis are disconnected. The treatment is often complicated.

CASE PRESENTATION

An 81-year-old man underwent robot-assisted partial nephrectomy for the treatment of renal cell carcinoma (cT1bN0M0). Postoperatively, urine leakage was observed and did not improve with conservative measures. Retrograde pyelography and computed tomography revealed that urine leakage originated from the isolated calyx caused by infundibular stenosis. Endoscopic treatment via the transurethral approach was selected to preserve renal function. Ureteroscopy showed that the upper calyx was completely obstructed by the sutures. Therefore, we cut the suture thread using laser, and a ureteral stent was placed in the upper renal calyx. Fluid drainage immediately disappeared after the procedure, and the patient did not lose renal function.

CONCLUSION

Endoscopic management might be an option for isolated calyx after robot-assisted partial nephrectomy.

Clinical Outcomes of Robotic Assisted Partial Nephrectomy for Pathologic T3a Renal Masses with Venous Tumor Thrombus

OBJECTIVE

To evaluate the safety, efficacy, and early oncologic outcomes of pT3a renal cell carcinoma (RCC) with venous involvement treated with robotic partial nephrectomy (RPN), given that experience and outcomes in this group is limited.

METHODS

A retrospective chart review of patients undergoing RPN from 9/2009-7/2020 was performed. Outcomes were captured from patients with pathologic T3a disease with vein involvement. Clinical characteristics were analyzed using SPSS (IBM, Armonk, NY). Local recurrence-free survival (LRFS) and metastasis-free survival (MFS) at 2 years were calculated from Kaplan-Meier survival curves.

RESULTS

For 45 included patients, mean operative and warm ischemia times were 199.6 min ± 47.3 and 30.5 min ± 10.5, with mean estimated blood loss of 324.9 cc ±209.5. Rates of transfusion, embolization, re-admission, and re-operation at 30 days were 8.9% (4/45), 2.2% (1/45), 11.1% (5/45), and 6.7% (3/45; cystoscopic stent placement), respectively. All tumors were malignant on pathology, with clear cell RCC being the most common (91.0%, n=41). The positive margin rate was 6.7% (n=3). Local recurrence occurred in 4.4% (n=2) at a mean time of 5.2 months ± 2.3. Four patients (8.9%) progressed to metastatic disease at a mean of 22.2 months ± 23.0. At 2 years, LRFS was 95.4% and MFS was 95.3%.

CONCLUSIONS

We present the largest known series of patients RPN for pT3a renal masses with venous tumor involvement. We found it both feasible and safe in the appropriate hands. Short term oncologic outcomes for these patients appear more favorable than historic literature suggested. SOURCES OF FUNDING: none.

Renal artery embolization in the treatment of urinary fistula after renal duplication: A case report and review of literature

BACKGROUND

Duplicate renal malformation is a congenital disease of the urinary system, with an incidence rate of 0.8%. Surgical treatment is suitable for symptomatic patients. Urinary fistula is one of the complications of heminephrectomy. Long-term urinary fistula has a great impact on patients' lives.

CASE SUMMARY

This article mainly reports on a 47-year-old man with duplication of kidney deformity, long urinary fistula after partial nephrectomy, and no improvement after conservative treatment. We have achieved positive results in the arterial embolization treatment of the residual renal artery, indicating that selective arterial embolization is a good way to treat urinary fistula after partial nephrectomy. It is worth noting that this patient violated the Weigert-Meyer law, which also gave us more consideration.

CONCLUSION

Renal artery embolization may be a simple and safe method to treat urinary fistula inefficacy with conservative treatment.

Should a Drain Be Routinely Required After Transperitoneal Robotic Partial Nephrectomy?

Introduction: Closed drains have traditionally been placed after partial nephrectomy because of risks of bleeding and urine leak. We sought to study the safety of a nonroutine drain (NRD) approach after transperitoneal robotic partial nephrectomy (RPN). Patients and Methods: From a multi-institutional database, we have analyzed the data of 904 patients who underwent RPN. Five hundred forty-six (60.40%) patients underwent RPN by a surgeon who routinely placed drains. Three hundred fifty-eight (39.60%) patients underwent RPN by a surgeon who did not routinely placed drains. Perioperative outcomes, length of stay (LOS), and readmission rates were compared between the two groups. Baseline characteristics, perioperative, and postoperative outcomes were compared using Mann-Whitney U test, chi-square test, and Fisher's exact test. Results: Patients in the NRD group were more likely to have higher body mass index (30.10 kg/m² vs 28.07 kg/m²; P < 0.001), higher tumor size (3.0 cm vs 2.5 cm; P = 0.001), and higher renal score (8 vs 7; P < 0.001). Rate of transfusion (0.00% NRD vs 0.56% RD; P = 0.157) and overall complication (7.33% NRD vs 7.82% RD; P = 0.782) were comparable. Median hospital stay is 1 day for both groups. Readmission rate was also similar (0.55% NRD vs 1.40% RD; P = 0.279). In a multivariable analysis, NRD approach was associated with shorter length of hospital stay (incidence rate ratio [IRR] - 0.72, P < 0.001). Conclusion: An NRD approach for RPN yielded a decreased LOS and similar perioperative outcomes. Placement of surgical drains should be based on individual circumstances, and not required on a routine basis.

Shared decision-making for the management of small renal masses: Development and acceptability testing of a novel patient decision aid

INTRODUCTION

Shared decision-making incorporates patients' values and preferences to achieve high-quality decisions. The objective of this study was to develop an acceptable patient decision aid to facilitate shared decision-making for the management of small renal masses (SRMs).

METHODS

The International Patient Decision Aids Standards were used to guide an evidence-based development process. Management options included active surveillance, thermal ablation, partial nephrectomy, and radical nephrectomy. A literature review was performed to provide incidence rates for outcomes of each option. Once a prototype was complete, alpha-testing was performed using a 10-question survey to assess acceptability with patients, patient advocates, urologists, and methodological experts. The primary outcome was acceptability of the decision aid.

RESULTS

A novel patient decision aid was created to facilitate shared decision-making for the management of SRMs. Acceptability testing was performed with 20 patients, 10 urologists, two patient advocates, and one methodological expert. Responders indicated the decision aid was appropriate in length (82%, 27/33), well-balanced (82%, 27/33), and had language that was easy to follow (94%, 31/33). All patient responders felt the decision aid would have been helpful during their consultation and would recommend the decision aid for future patients (100%, 20/20). Most urologists reported they intend to use the decision aid (90%, 9/10).

CONCLUSIONS

A novel patient decision aid was created to facilitate shared decision-making for management of SRMs. This clinical tool was acceptable with patients, patient advocates, and urologists and is freely available at: https://decisionaid.ohri.ca/decaids.html.

Omitting Cortical Renorrhaphy in Robot-Assisted Partial Nephrectomy: Is it Safe? A Single Center Large Case Series

Introduction: Preserving renal function after robot-assisted partial nephrectomy (RAPN) is important and influenced by the technique of renal reconstruction among other parameters, including ischemia time and amount of healthy renal tissue resected. It is believed that reconstruction with a second layer of cortical renorrhaphy is necessary to prevent urinary leaks and postoperative bleeding, but this is associated with the potential loss of healthy renal parenchyma and may result in worse outcomes postoperatively. Purpose: To assess the safety of omitting cortical renorrhaphy during RAPN. Patients and Methods: A retrospective analysis of 146 consecutive patients undergoing a RAPN with single or double layer renorrhaphy at the Wirral University Teaching Hospital from 2014 to 2019. Data obtained included: Patient demographics, tumor RENAL nephrometry, Perioperative parameters; blood loss, duration, and warm ischemia time (WIT), Postop complications, change in estimated glomerular filtration rate (eGFR) (pre and 3 months postop), length of stay, and oncologic outcomes. Results: In total 146 patients were identified. One hundred-six had double renorrhaphy and 40 inner layer only renorrhaphy. No significant differences were seen between these two cohorts in terms of patient demographics, RENAL nephrometry score, tumor size, or location. Perioperative parameters showed a reduced duration of surgery in the single renorrhaphy group with a mean of 125 minutes compared to143 minutes in the double renorrhaphy (p = 0.006) and a tendency toward a shorter WIT of 12.9 minutes vs 14.0 minutes reaching borderline statistical significance (p = 0.05) but no difference in blood loss volume (p = 0.25). Postoperatively there was no statistical difference in the length of hospital stay (p = 0.85), loss in eGFR at 3 months (0.06), or complication (p = 0.56). After a median follow-up of 35 months no recurrences or deaths were observed in either group. Conclusions: Omission of cortical renorrhaphy appears feasible and safe with no urine leaks or excess complications observed.

Percutaneous Obliteration of Urinary Leakage after Partial Nephrectomy Using N-Butyl-Cyanoacrylate Obliteration of the Urinoma with or without Coil Embolization of the Fistula Tract

PURPOSE

To retrospectively evaluate the safety and efficacy of the percutaneous obliteration of urinary leakage after partial nephrectomy (PN) using coils and N-butyl-cyanoacrylate (NBCA).

MATERIALS AND METHODS

Data of 10 consecutive patients who underwent percutaneous obliteration of urinary leakage after PN using coil and NBCA between February 2016 and May 2018 were retrospectively reviewed. A urinary fistulography was performed via the drainage catheter. If the fistulous tract was clearly visualized, super-selective embolization of the fistulous tract with coils and urinoma cavity sealing with NBCA was performed. In cases where the fistulous tract could not be clearly visualized, only urinoma cavity sealing was performed. Outcomes and complications were assessed by reviewing medical records and computed tomography (CT).

RESULTS

In 7 (70%) patients who showed obvious urinary fistulous tract, coil embolization of the urinary fistulous tract, followed by sealing of the urinoma cavity with NBCA, was performed. Obliteration of the urinoma without coil embolization of the fistula tract was performed in 3 patients (30%) in whom a distinct fistulous tract could not be visualized. The median number of treatment sessions required to achieve clinical success was 1 (range, 1-5). Four patients underwent multiple repeated procedure with successful results. All patients showed gradual decrease in size or complete disappearance of urinoma on follow-up CT without evidence of urinary leakage during the follow-up period (mean, 44.6 weeks; range, 11-117 weeks). There were no procedure-related complications.

CONCLUSIONS

Percutaneous obliteration of urinary leakage after PN using coils and NBCA is safe and effective.

Predictive Value of Nephrometry Scores in Nephron-sparing Surgery: A Systematic Review and Meta-analysis

CONTEXT

Over the last decade, several nephrometry scores (NSs) have been introduced with the aim of facilitating preoperative decision making, planning, and counseling in the field of nephron-sparing surgery. However, their predictive role remains controversial.

OBJECTIVE

To describe currently available nephrometry scores and to determine their predictive role for different outcomes by performing a systematic review and meta-analysis of the literature.

EVIDENCE ACQUISITION

PubMed, Embase®, and Web of Science were screened to identify eligible studies. Identification and selection of the reports were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A pooled analysis of NS predictive role of intraoperative, postoperative, oncological, and functional outcomes was performed. Odds ratio was considered the effect size. All the analyses were performed using Stata 15.0, and statistical significance was set at p≤ 0.05.

EVIDENCE SYNTHESIS

Overall, 51 studies meeting our inclusion criteria were identified and considered for the analysis. Except for one prospective randomized trial, all the studies were retrospective. All the studies were found to be of intermediate quality, except for one of high quality. Most studies assessed the predictive role of the Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) scores, mostly regarding complications after nephron-sparing surgery. RENAL was an independent predictor of an on-clamp procedure (p< 0.001). Mayo Adhesive Probability score was related to adhesive perinephric fat (p= 0.005). Continuous and high-complexity RENAL scores were predictors of warm ischemia time (WIT; p= 0.006 and p< 0.001, respectively). Continuous (p< 0.001) and high-complexity (p< 0.001) PADUA scores were related to WIT. Continuous and high-complexity RENAL scores were predictors of overall complications (p= 0.002 and p< 0.001, respectively). PADUA score was related to complications both as continuous (p< 0.001) and as a categorical value (p< 0.002). The RENAL scores R=3 (p= 0.008), E=2 (p= 0.039), and hilar location (p= 0.006) were predictors of histological malignancy. Continuous and categorical RENAL scores were independent predictors of an estimated glomerular filtration rate (eGFR) increase (p= 0.006 and p< 0.001, respectively). The Diameter-Axial-Polar score (p= 0.018) and Peritumoral Artery Scoring System (PASS; p= 0.02) were also independent predictors.

CONCLUSIONS

The literature regarding nephrometry scoring systems is sparse, and mostly focused on RENAL and PADUA, which are easy to calculate and have a good correlation with most outcomes. Renal Pelvic Score is the best predictor of pelvicalyceal entry/repair and urine leak, whereas Surgical Approach Renal Ranking and PASS strongly predict surgical approach and renal function variation, respectively. Other nephrometry scores based on mathematical models are limited by their complexity, and they lack evidence supporting their predictive value.

PATIENT SUMMARY

We reviewed the medical literature regarding the use and value of so-called "nephrometry scores," which are scoring systems based on radiological imaging and made to grade the complexity of a renal tumor. We analyzed whether these scoring systems can predict some of the outcomes of patients undergoing surgical removal of renal tumors.

Postoperative Complications After Robotic Partial Nephrectomy

Objectives: To assess the incidence of postoperative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series and to evaluate risk factors for these complications. Materials and Methods: All RPNs were queried from Institutional Review Board-approved retrospective and prospective nephrectomy databases. Demographics, perioperative variables, and postoperative complications were collected. Differences between cohorts were analyzed using univariate analysis. Postoperative 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 through drainage or aspiration. AM was identified based on postoperative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed by univariate analysis. Results: A total of 395 RPNs were performed by four urologists between January 2014 and October 2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p = 0.01). Overall incidence of postoperative 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 postoperative 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%).

A systematic management algorithm for perioperative complications after robotic assisted partial nephrectomy

Nephron-sparing surgery (NSS) is the treatment of choice for T1 renal cell carcinoma (RCC). Since the first robotic assisted partial nephrectomy (RAPN) was performed in 2004, NSS is being implemented with increasing frequency. RAPN will likely become the gold standard procedure for T1 RCC due to improved dexterity, enhanced visualization, shorter learning curve, quicker recovery time, and shortened warm ischemic time. Although RAPN appears to be the preferred treatment for select renal tumours, there are notable complications in up to 35% of cases. While complications associated with RAPN are well-described, there is a lack of literature describing appropriate management strategies. Herein, we review complications associated with RAPN and design an appropriate systematic management algorithm.

Elimination of surgical drains following robotic-assisted partial nephrectomy

To prospectively evaluate outcomes of robotic-assisted partial nephrectomy (RAPN) following elimination of surgical drains. 100 consecutive drainless RAPN performed by a single surgeon were analyzed following a previously published quantitative assessment of drain creatinine/serum creatinine ratios. This cohort was compared to 100 preceding RAPN with drains. Variables analyzed included pre-operative patient/tumor characteristics and post-operative outcomes including post-operative estimated glomerular filtration rate (eGFR), length of hospital stay (LOS), and complications. There was no significant difference in median patient age, sex, body mass index, ASA score, or pre-operative eGFR between the two groups. The preceding 100 patients with drains did have larger median renal size (3.5 vs 2.6 cm, p < 0.001), higher median RENAL scores (9 vs 8, p < 0.001), and longer warm ischemia time (21 vs 18 min, p = 0.004). Patients without drains had shorter median LOS (2.0 days vs 3.0 days, p < 0.001), fewer Grade III or higher post-operative complications (4% vs 10%, p = 0.007), and no difference in 1 month percent change in eGFR (- 13% vs - 11%, p = 0.84). After adjusting for confounding variables there was no difference in LOS (OR 1.50, p = 0.31), Grade III-V complications (OR 1.49, p = 0.63), or 1 month percent change in eGFR (OR 2.3, p = 0.41) between the two groups. One patient in the drainless group required a post-operative drain for a urine leak diagnosed 10 days following RAPN. Omission of drains is safe in RAPN and does not appear to offer a clinical advantage.

Comparison of perioperative outcomes with or without renorrhaphy during open partial nephrectomy: A propensity score-matched analysis

Purpose:

Renorrhaphy in partial nephrectomy may damage intraparenchymal vessels and compress the renal parenchyma, which may lead to the formation of renal artery pseudoaneurysms or vascularized parenchymal volume reduction. Using propensity score matching, we compared surgical outcomes following non-renorrhaphy and renorrhaphy techniques for open partial nephrectomy (OPN) for T1a renal tumors.

Materials and Methods:

We retrospectively analyzed data from 159 patients with normal contralateral kidneys who underwent OPN for T1a renal tumors and pre- and postoperative enhanced computed tomography between 2012 and 2015. Patient variables were adjusted using 1:1 propensity score matching between the two Groups: renorrhaphy (inner and outer layer sutures) and non-renorrhaphy (inner layer sutures only). Postoperative complications and renal function were compared between the two groups.

Results:

We matched 43 patients per Group. Operative time, estimated blood loss, cold ischemic time, and postoperative hospital stay were not significantly different between the two Groups. Urine leakage (Clavien-Dindo grade ≥3) occurred in 0 renorrhaphy cases and 2 non-renorrhaphy cases (0% versus 4.6%, P=0.49). Renal artery pseudoaneurysm (RAP) occurred in 6 renorrhaphy cases and in 0 non-renorrhaphy cases (13% versus 0%, P=0.02).

Conclusions:

The non-renorrhaphy technique may result in a lower risk of RAP but a greater risk of urine leakage. This technique needs further refinement to become a standard procedure for OPN.

Simplified robot-assisted partial nephrectomy: step-by-step technique and perioperative outcomes

Controversies have been raised and still exist regarding several technical aspects of robot-assisted partial nephrectomy (RAPN). While the "perfect RAPN" has still to be determined, we aimed to report a simplified technique of RAPN in a step-by-step fashion and the perioperative outcomes of a single-center series. A simplified technique of RAPN was developed, refined and standardized over the past 7 years in an academic department of urology to make it as safe and as reproducible as possible, the main goal being to make it an "easy to learn" technique for fellows. This technique is presented in 12 key steps. The patients' characteristics and perioperative outcomes were prospectively collected and are reported herein. Since the first case performed in our department in 2010, 406 patients have undergone RAPN with a standardized and stable simplified technique after the first 30 cases, involving several key steps including systematic use of the transperitoneal approach, minimal visceral mobilization of the colon, systematic psoas exposure and ureter identification, minimal dissection of the perinephric fat, arterial clamping with early unclamping, no use of hemostatic agents or drain. The majority of RAPN were performed by surgeons with either low experience (i.e., < 20 procedures; 46.3%) or intermediate experience (i.e., 20-50 procedures; 17.2%). The mean warm ischemia time was 15.3 min. Conversions to an open approach and to radical nephrectomy were required in 14 (3.5%) and 21 (5.2%) cases, respectively. From 132 patients who experienced post-operative complications (32.5%), 47 experienced a major complication (11.6%). The positive surgical margin rate was 5.6%. The simplified technique of RAPN was feasible and reproducible with satisfactory perioperative outcomes. Most of the key steps have been assessed through single-center and multicenter clinical studies.

Algorithm for Bosniak 2F Cyst in Kidney Donation

Patient: Female, 54

Final Diagnosis: Multilocular cystic renal cell carcinoma with clear cells

Symptoms: None

Medication: —

Clinical Procedure: Hand-assisted retroperitoneal donor nephrectomy

Specialty: Transplantology

Complications of Renal Surgery

The incidence of the small renal mass continues to increase owing to the aging population and the ubiquity imaging. Most of these tumors are stage I tumors. Management strategies include surveillance, ablation, and extirpation. There is a wide body of literature favoring nephron-sparing approaches. Although nephron-sparing surgery may yield decreased long-term morbidity, it is not without its drawbacks, including a higher rate of complications. Urologists must be attuned to the complications of surgery and develop strategies to minimize risk. This article reviews expected complications of surgery on renal masses and risk stratification schema.

Does Ureteral Catheter Insertion Decrease the Risk of Urinary Leakage After Partial Nephrectomy in Patients With Renal Cell Carcinoma?

INTRODUCTION

We aimed to evaluate the impact of preoperative ureteral catheter insertion on urinary leakage after partial nephrectomy (PN) in patients with renal cell carcinoma.

METHODS

We reviewed the data of 893 patients with renal cell carcinoma who underwent PN and divided them according to ureteral catheter placement. The impact of ureteral catheter placement on postoperative urinary leakage was evaluated by using multivariate analysis.

RESULTS

Ureteral catheters were inserted in 397 (44.5%) patients. Patients with ureteral catheter insertion had larger tumors (2.4 vs. 2.6 cm; P = .031); however, the RENAL nephrometry scores were comparable (P = .131). Robotic PN was more common in patients with ureteral catheters (11.1 vs. 53.9%; P < .001). Urinary leakage did not differ according to ureteral catheter placement (3.4 vs. 3.5%; P = .936). Although tumor size (P = .002), ureteral catheter insertion (P < .001), and operative methods (P < .001) were significantly different according to surgeons, the rate of urinary leakage was similar (surgeon A: 4.0%, surgeon B: 4.6%, surgeon C: 1.5%, others: 2.9%; P = .294). In multivariate analysis of preoperative variables, age and RENAL nephrometry scores were associated with urinary leakage. In multivariate analysis of preoperative and intraoperative variables, the operative method, collecting system status, and intraoperative transfusion, but not ureteral catheter insertion, were related to urinary leakage.

CONCLUSIONS

Ureteral catheter insertion does not appear to reduce the risk of urinary leakage after PN, and visibility during PN with meticulous bleeding control is important in preventing urinary leakage after PN.

Collaborative Review of Risk Benefit Trade-offs Between Partial and Radical Nephrectomy in the Management of Anatomically Complex Renal Masses

BACKGROUND

While partial nephrectomy (PN) is the recommended treatment for many small renal masses, anatomically complex tumors necessitate a clear understanding of the potential risks and benefits of PN and radical nephrectomy (RN).

OBJECTIVE

To critically review the comparative effectiveness evidence of PN versus RN; to describe key trade-offs involved in this treatment decision; and to highlight gaps in the current literature.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

Patients who undergo PN for an anatomically complex or large mass may be exposed to perioperative and potential oncologic risks that could be avoided if RN were performed, while patients who undergo RN may forgo long-term benefits of renal preservation. Decision-making regarding the optimal treatment with PN or RN among patients with anatomically complex or large renal mass is highly nuanced and must balance the risks and benefits of each approach. Currently, high-quality evidence on comparative effectiveness is sparse. Retrospective comparisons are plagued by selection biases, while the one existing prospective randomized trial, albeit imperfect, suggests that nephron-sparing surgery may not benefit all patients.

CONCLUSIONS

For anatomically complex tumors, PN preserves renal parenchyma but may expose patients to higher perioperative risks than RN. The risks and benefits of each surgical approach must be better objectified for identification of patients most suitable for complex PN. A prospective randomized trial is warranted and would help in directing patient counseling.

PATIENT SUMMARY

Treatment decisions for complex renal masses require shared decision-making regarding the risk trade-offs between partial and radical nephrectomy.

Managing Complications Following Nephron-Sparing Procedures for Renal Masses

Small renal malignancies are commonly treated with nephron-sparing procedures including partial nephrectomy and percutaneous ablation. Although these procedures offer faster patient recovery and preserve renal function, a variety of complications can occur. Here, we review vascular and nonvascular complications associated with nephron-sparing renal mass treatments and discuss options for minimally invasive image-guided management.

Assessment of Perioperative Variables That Predict the Need for Surgical Drains Following Robotic Partial Nephrectomy Utilizing Quantitative Drain Creatinine Analysis

OBJECTIVE

To utilize body fluid creatinine analysis to determine which patients will require a surgical drain following robotic-assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

One hundred fifty consecutive RAPN performed by a single surgeon were reviewed. Postoperative day (POD) 1 drain creatinine was compared to serum creatinine to calculate the drain to serum creatinine ratio (D/S ratio). Elevated D/S ratio was defined as any value >1.2.

RESULTS

From February 2008 to April 2015, 140 patients underwent RAPN and had a drain placed (124 had D/S ratio available on POD 1). In the 103 patients with a D/S ratio of <1.2 and the 21 with D/S ratio of >1.2, the mean tumor size was 3.0 and 3.9 cm (P = .001) and mean RENAL score was 7.6 and 8.1 (P = .270), respectively. Collecting system entry occurred in 68.2% of patients with a D/S ratio of <1.2 and 71.4% of patients with a D/S ratio of >1.2. Mean drain time was 2.4 and 4.2 days (P = .001), hospital stay was 2.7 and 3.3 days (P = .036) for the D/S ratio <1.2 and D/S ratio >1.2 groups, respectively. Those with renal mass size of 4-7 cm had increased likelihood of D/S ratio >1.2 (OR 2.78; P = .041).

CONCLUSIONS

Most RAPN do not require a surgical drain. A POD 1 elevated D/S ratio is more likely to occur with larger masses (those approaching or greater than 4 cm) and can be associated with prolonged drain time and hospital stay.