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Umemoto T, Hasegawa M, Yuzuriha S, Kano T, Ogawa T, Kawakami M, Nakano M, Kim H, Nitta M, Kawamura Y, Shoji S, Mizuno R, Miyajima A. Impact of tumor contact surface area on collecting system entry in robot-assisted partial nephrectomy: a retrospective analysis. BMC Urol 2023; 23:85. [PMID: 37158841 PMCID: PMC10165753 DOI: 10.1186/s12894-023-01247-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 04/13/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Collecting system entry in robot-assisted partial nephrectomy may occur even in cases showing a low N factor in the R.E.N.A.L nephrometry score. Therefore, in this study, we focused on the tumor contact surface area with the adjacent renal parenchyma and attempted to construct a novel predictive model for collecting system entry. METHODS Among 190 patients who underwent robot-assisted partial nephrectomy at our institution from 2015 to 2021, 94 patients with a low N factor (1-2) were analyzed. Contact surface was measured with three-dimensional imaging software and defined as the C factor, classified as C1, < 10 cm [2]; C2, ≥ 10 and < 15 cm [2]; and C3: ≥ 15 cm [2]. Additionally, a modified R factor (mR) was classified as mR1, < 20 mm; mR2, ≥ 20 and < 40 mm; and mR3, ≥ 40 mm. We discussed the factors influencing collecting system entry, including the C factor, and created a novel collecting system entry predictive model. RESULTS Collecting system entry was observed in 32 patients with a low N factor (34%). The C factor was the only independent predictive factor for collecting system entry in multivariate regression analysis (odds ratio: 4.195, 95% CI: 2.160-8.146, p < 0.0001). Models including the C factor showed better discriminative power than the models without the C factor. CONCLUSIONS The new predictive model, including the C factor in N1-2 cases, may be beneficial, considering its indication for preoperative ureteral catheter placement in patients undergoing robot-assisted partial nephrectomy.
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Affiliation(s)
- Tatsuya Umemoto
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Masanori Hasegawa
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan.
| | - Soichiro Yuzuriha
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Tatsuo Kano
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Takahiro Ogawa
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Masayoshi Kawakami
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Mayura Nakano
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Hakushi Kim
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Masahiro Nitta
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Yoshiaki Kawamura
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Sunao Shoji
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
| | - Ryuichi Mizuno
- Department of Urology, Keio University School of Medicine, Tokyo, Japan
| | - Akira Miyajima
- Department of Urology, Tokai University School of Medicine, 143 Shimokasuya, Isehara, 259-1193, Kanagawa, Japan
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Massouh Skorin R, Mahfouz A, Escovar la Riva P. Systematic review on active treatment for urinary fistula after partial nephrectomy. Actas Urol Esp 2022; 46:387-396. [PMID: 35780049 DOI: 10.1016/j.acuroe.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/11/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
| | - A Mahfouz
- Hospital Clinico San Borja Arriaran, Santiago, Chile
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Management of persistent urine leak after partial nephrectomy: A case series. Curr Urol 2022. [DOI: 10.1097/cu9.0000000000000136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Revisión sistemática del tratamiento activo de la fístula urinaria después de la nefrectomía parcial. Actas Urol Esp 2022. [DOI: 10.1016/j.acuro.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bosnali E, Dillioglugil O, Teke K, Yilmaz H, Yaprak Bayrak B, Uslubas AK, Avci IE, Argun OB, Kara O. Does routine intraoperative Double J stent insertion avoid urine leakage after open partial nephrectomy? Arch Ital Urol Androl 2022; 94:12-17. [PMID: 35352518 DOI: 10.4081/aiua.2022.1.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 02/10/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Efe Bosnali
- Kocaeli University, School of Medicine, Department of Urology, Kocaeli.
| | | | - Kerem Teke
- Kocaeli University, School of Medicine, Department of Urology, Kocaeli.
| | - Hasan Yilmaz
- Kocaeli University, School of Medicine, Department of Urology, Kocaeli.
| | | | - Ali Kemal Uslubas
- Kocaeli University, School of Medicine, Department of Urology, Kocaeli.
| | | | - Omer Burak Argun
- Acibadem Mehmet Ali Aydinlar University, Department of Urology, School of Medicine, Istanbul.
| | - Onder Kara
- Kocaeli University, School of Medicine, Department of Urology, Kocaeli.
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Videourology Abstracts. J Endourol 2021. [DOI: 10.1089/end.2021.29118.vid] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ureterocalyceal Fistula: A Rare Complication of Laparoscopic Partial Nephrectomy. Case Rep Urol 2020; 2020:8827444. [PMID: 33062371 PMCID: PMC7545418 DOI: 10.1155/2020/8827444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/18/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022] Open
Abstract
Background Postoperative urinary leak is a well-documented complication following partial nephrectomy. It usually presents as persistent discharge from the retroperitoneal drain, nephrocutaneous fistula, urinary collection, systemic manifestations, or abdominal symptoms. Herein, we report for the first time on a case of urinary leak postlaparoscopic partial nephrectomy which did not heal and led to the formation of ureterocalyceal fistula. Case Presentation. A 41-year-old male presented with a coincidental renal mass at the inferiomedial aspect of the right kidney. He underwent laparoscopic partial nephrectomy. On the third postoperative day, he developed fever. CT scan showed minimal urine leak from the tumor site and a JJ stent was inserted. Due to severe bladder symptoms, the stent was removed and a perirenal drain was inserted and removed in few days. He did well initially but in two weeks, he started to develop urinary tract infections. Repeat CT scan showed ongoing urinary leak from the site of the previous surgery. Retrograde pyelography demonstrated a complete UPJ stenosis with an ureterocalyceal fistula. Trial for reanastomosis failed due to severe adhesions and small intrarenal pelvis. An ureterocalyceal anastomosis has to be performed to another calyx. Conclusion We report for the first time on an ureterocalyceal fistula following laparoscopic partial nephrectomy. This complication might be prevented by a careful dissection of the area close to the ureter or by an insertion of a JJ stent for an adequate time if a ureteric injury is suspected.
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Kyung YS, Kim N, Jeong IG, Hong JH, Kim CS. Application of 3-D Printed Kidney Model in Partial Nephrectomy for Predicting Surgical Outcomes: A Feasibility Study. Clin Genitourin Cancer 2019; 17:e878-e884. [DOI: 10.1016/j.clgc.2019.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/14/2019] [Accepted: 05/20/2019] [Indexed: 01/17/2023]
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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. J Vasc Interv Radiol 2019; 30:2002-2008. [PMID: 31420260 DOI: 10.1016/j.jvir.2019.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/18/2019] [Accepted: 05/17/2019] [Indexed: 12/16/2022] Open
Abstract
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.
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Open partial nephrectomy when a non-flank approach is required: indications and outcomes. World J Urol 2018; 37:515-522. [PMID: 30043248 DOI: 10.1007/s00345-018-2414-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/17/2018] [Indexed: 12/28/2022] Open
Abstract
PURPOSE To evaluate indications/outcomes for open partial nephrectomy (OPN) when non-flank approaches are required, with comparison to patients managed with the flank approach. Outcomes with a non-flank approach are presumed less favorable yet there have been no previous reports on this topic. METHODS 2747 OPNs were performed (1999-2015) and 76 (2.8%) required a non-flank approach. We also reviewed all traditional flank OPNs performed during odd years in this timeframe yielding 1467 patients for comparison. RESULTS Overall, median tumor size was 3.5 cm and 274 patients (18%) had a solitary kidney. Non-flank patients were younger, and tumor size and clinical/pathologic stage were significantly increased for this cohort, but the groups were otherwise comparable. Indications for non-flank OPN included large tumor size/locally advanced disease (n = 21), need for simultaneous surgery (n = 25), previous flank incision or failed thermoablation (n = 13), or congenital/vascular abnormalities (n = 9). The most common non-flank approach was anterior subcostal (n = 39, 51%). Operative times, estimated blood loss, positive margins, and functional decline were all modestly increased for non-flank patients. Intraoperative and genitourinary complications were more common in non-flank patients (p < 0.05), although all were manageable, typically with conservative measures. There were no mortalities among non-flank patients and none required long-term dialysis. CONCLUSIONS Our series, the first to address this topic, suggests that outcomes with non-flank OPN are generally less advantageous likely reflecting increased tumor/operative complexity. However, complications in this challenging patient population are manageable and final dispositions are generally favorable. Our findings should be useful for counseling regarding potential outcomes when a non-flank incision is required.
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External Validation of the Arterial-Based Complexity Score and First Head-to-Head Comparison With the R.E.N.A.L. and PADUA Scores and C-index. Clin Genitourin Cancer 2018; 16:e595-e604. [DOI: 10.1016/j.clgc.2017.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/19/2017] [Accepted: 10/30/2017] [Indexed: 12/29/2022]
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Uehara S, Yoshida S, Tanaka H, Yasuda Y, Tanaka H, Kijima T, Yokoyama M, Ishioka J, Matsuoka Y, Saito K, Fujii Y. Prediction of Intraoperative Urinary Collecting System Entry in Patients with Peripheral Renal Tumors Undergoing Partial Nephrectomy: Usefulness of Tumor-Centered Multiplanar Reconstruction. Urol Int 2017; 100:85-91. [PMID: 29131130 DOI: 10.1159/000484254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/14/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To assess the usefulness of tumor-centered multiplanar reconstruction (TC-MPR) for predicting intraoperative urinary collecting system (UCS) entry in patients with peripheral renal tumors undergoing partial nephrectomy (PN). METHODS Dynamic computed tomography images of 50 peripheral cT1 renal tumors treated with laparoendoscopic PN were analyzed. TC-MPR generated a digital cross-sectional image showing the tumor center and the closest calyx on a same plane. Patients and tumor characteristics including the distance from the tumor margin to the closest calyx (MPR-distance), and the angle formed by 2 tangent lines from the closest calyx to the tumor (MPR-angle) were assessed. RESULTS Intraoperative UCS entry was observed in 15 patients (30%). The patients who experienced intraoperative UCS entry had a higher RENAL score, wider MPR-angle, and shorter MPR-distance than those who did not (p = 0.04, p = 0.001, p < 0.001, respectively). Multivariate analysis identified MPR-angle as an independent factor for intraoperative UCS entry (p < 0.001). CONCLUSIONS The spatial information assessed using TC-MPR serves as a predictive factor for intraoperative UCS entry during PN.
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Affiliation(s)
- Sho Uehara
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hiroshi Tanaka
- Department of Radiology, Ochanomizu Surugadai Clinic, Tokyo, Japan
| | - Yosuke Yasuda
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Toshiki Kijima
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Junichiro Ishioka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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Minnee RC, Kimenai HJAN, Verhagen PC, von der Thüsen JH, Dwarkasing RS, van de Wetering J, IJzermans JN. Algorithm for Bosniak 2F Cyst in Kidney Donation. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:733-738. [PMID: 28663537 PMCID: PMC5503233 DOI: 10.12659/ajcr.904045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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
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Affiliation(s)
- Robert C Minnee
- Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hendrikus J A N Kimenai
- Department of Surgery, Division of HPB and Transplant Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paul C Verhagen
- Department of Urology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jan H von der Thüsen
- Department of Pathology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Roy S Dwarkasing
- Department of Radiology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jacqueline van de Wetering
- Department of Nephrology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jan N IJzermans
- Department of Surgery, Division of Hepato-Pancreato-Biliary and Transplant Surgery, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, Netherlands
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Yoo S, You D, Jeong IG, Song C, Hong B, Hong JH, Ahn H, Kim CS. Does Ureteral Catheter Insertion Decrease the Risk of Urinary Leakage After Partial Nephrectomy in Patients With Renal Cell Carcinoma? Clin Genitourin Cancer 2017; 15:e707-e712. [PMID: 28236579 DOI: 10.1016/j.clgc.2017.01.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 01/17/2017] [Accepted: 01/28/2017] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Sangjun Yoo
- Department of Urology, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Dalsan You
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - In Gab Jeong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Cheryn Song
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bumsik Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jun Hyuk Hong
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hanjong Ahn
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Choung-Soo Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Williams RD, Snowden C, Thiel DD. Assessment of Perioperative Variables That Predict the Need for Surgical Drains Following Robotic Partial Nephrectomy Utilizing Quantitative Drain Creatinine Analysis. J Laparoendosc Adv Surg Tech A 2016; 27:43-47. [PMID: 27583580 DOI: 10.1089/lap.2016.0417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - David D Thiel
- Department of Urology, Mayo Clinic , Jacksonville, Florida
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Erlich T, Abu-Ghanem Y, Ramon J, Mor Y, Rosenzweig B, Dotan Z. Postoperative Urinary Leakage Following Partial Nephrectomy for Renal Mass: Risk Factors and a Proposed Algorithm for the Diagnosis and Management. Scand J Surg 2016; 106:139-144. [PMID: 27431979 DOI: 10.1177/1457496916659225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the current incidence, risk factors, management, and long-term follow-up of urinary leakage following partial nephrectomy, in order to propose an algorithm for diagnosis and evaluation of postoperative urinary leakage. MATERIALS AND METHODS The study included 752 patients who underwent elective partial nephrectomies for renal masses between the years 1988 and 2013. Patients' demographics, clinico-pathologic variables, and operative details were collected retrospectively. The associations between urinary leakage and patients' variables were assessed by univariate and multivariate analyses. RESULTS Of the 752 patients, 21 (2.8%) experienced urinary leakage; 4 of the 21 patients with urinary leakage had spontaneous resolution, 1 patient underwent nephrectomy, and 16 patients were treated by retrograde ureteral stents insertion. One of them necessitated insertion of an additional percutaneous nephrostomy and another one deserved concomitant percutaneous drainage of a perirenal urinoma. The average period of time that elapsed from the operation until the insertion of stent was 8.5 ± 4.5 days. Stents were removed 68 ± 20.5 days postoperatively. None of the patients had either persistent or repeated leakage. On univariate analysis, hilar renal masses (p < 0.04) and higher preoperative creatinine levels (p < 0.01) were found to be associated with higher rates of urinary leakage. None of these variables was significant on a multivariate analysis. Review of the urinary leakage rate over time revealed it has been constantly decreasing over time, from 4% in early cases to 1.3% among the most recent ones. CONCLUSION None of the preoperative variables that were examined in this study was significantly associated with increased risk of urinary leakage. However, cumulative surgical experience was associated with lower rates of urinary leakage, suggesting that the decrease in its incidence is related to the improved surgical skills, rather than to differences in tumors' or patients' characteristics.
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Affiliation(s)
- T Erlich
- 1 Department of Urology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Y Abu-Ghanem
- 1 Department of Urology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - J Ramon
- 1 Department of Urology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Y Mor
- 1 Department of Urology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - B Rosenzweig
- 1 Department of Urology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Z Dotan
- 1 Department of Urology, The Chaim Sheba Medical Center, Ramat Gan, Israel.,2 Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Nohara T, Matsuyama S, Kawaguchi S, Miyagi T, Seto C, Mochizuki K. Usefulness of selective renal artery embolization for urinary fistula following partial nephrectomy: Two case reports. Mol Clin Oncol 2016; 5:158-160. [PMID: 27330790 DOI: 10.3892/mco.2016.885] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 02/26/2016] [Indexed: 12/16/2022] Open
Abstract
The present study reported two cases in which selective artery embolization were identified to assist in resolving urinary fistulae following partial nephrectomies. The first case involved a 51-year-old male who received a mini-incision partial nephrectomy with renorrhaphy. Following the operation, urine continued to discharge from the retroperitoneal drain. Selective renal artery embolization of the upper calyx at post-operation day 20 was highly effective and urine output from the drain stopped immediately. Case 2 involved a 66-year-old male, who also suffered from a urinary fistula following a partial nephrectomy. Selective renal artery embolization performed at post-operation day 21 was again effective. In each case, the upper calyx was separated from the renal pelvis. These cases demonstrated that suturing of the collecting system and renal parenchyma may result in the separation of the urine pathway, and that selective renal artery embolization appears to be a highly effective treatment in such cases.
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Affiliation(s)
- Takahiro Nohara
- Department of Urology, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
| | - Satoko Matsuyama
- Department of Urology, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
| | - Shohei Kawaguchi
- Department of Urology, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
| | - Tohru Miyagi
- Department of Urology, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
| | - Chikashi Seto
- Department of Urology, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
| | - Kentaro Mochizuki
- Department of Radiology, Toyama Prefectural Central Hospital, Toyama 930-8550, Japan
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Percutaneous Cryoablation for Successful Treatment of a Persistent Urine Leak after Robotic-Assisted Partial Nephrectomy. J Vasc Interv Radiol 2015; 26:1867-70. [DOI: 10.1016/j.jvir.2015.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/25/2015] [Accepted: 08/28/2015] [Indexed: 11/18/2022] Open
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Potretzke AM, Knight BA, Zargar H, Kaouk JH, Barod R, Rogers CG, Mass A, Stifelman MD, Johnson MH, Allaf ME, Sherburne Figenshau R, Bhayani SB. Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1 791 patients. BJU Int 2015; 117:131-7. [PMID: 26235802 DOI: 10.1111/bju.13249] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the incidence of and risk factors for a urine leak in a large multicentre, prospective database of robot-assisted partial nephrectomy (RPN). PATIENTS AND METHODS A database of 1 791 RPN from five USA centres was reviewed for urine leak as a complication of RPN. Patient and tumour characteristics were compared between patients with and those without postoperative urine leaks. 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 PN and urine leak was conducted. RESULTS Urine leak was noted in 14/1 791 (0.78%) patients who underwent RPN. The mean (sd) nephrometry score of the entire cohort was 7.2 (1.9), and 8.0 (1.9) in patients who developed urine leak. The median (range) postoperative day of presentation was 13 (3-32) days. Patients with urine leak presented in delayed fashion with fever (two of the 14 patients, 14%), gastrointestinal complaints (four patients, 29%), and pain (five patients, 36%). Eight of the 14 patients (57%) required admission, while eight (57%) and nine (64%) had a drain or stent placed, respectively. Drains and stents were removed after a median (range) of 8 (4-13) days and 21 (8-83) days, respectively. Variables associated with urine leak included tumour size (P = 0.021), hilar location (P = 0.025), operative time (P = 0.006), warm ischaemia time (P = 0.005), and pelvicalyceal repair (P = 0.018). Upon literature review, the historical incidence of urine leak ranged from 1.0% to 17.4% for open PN and 1.6-16.5% for laparoscopic PN. CONCLUSION The incidence of urine leak after RPN is very low and may be predicted by some preoperative factors, affording better patient counselling of risks. The low urinary leak rate may be attributed to the enhanced visualisation and suturing technique that accompanies the robotic approach.
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Affiliation(s)
- Aaron M Potretzke
- Division of Urology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Homayoun Zargar
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, USA
| | - Jihad H Kaouk
- Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, USA
| | - Ravi Barod
- Henry Ford Hospital, Vattikuti Urology Institute, Detroit, MI, USA
| | - Craig G Rogers
- Henry Ford Hospital, Vattikuti Urology Institute, Detroit, MI, USA
| | - Alon Mass
- Urology, NYU Medical Center, New York, NY, USA
| | | | | | | | | | - Sam B Bhayani
- Division of Urology, Washington University School of Medicine, St. Louis, MO, USA
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20
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Taneja R, Geelani IA. Role of Robotic Partial Nephrectomy in the treatment of renal cell carcinoma. APOLLO MEDICINE 2015. [DOI: 10.1016/j.apme.2015.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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21
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Chu W, Chien GW, Finley DS. Novel Ureteroscopic Technique for Treatment of Prolonged Caliceal Leak After Partial Nephrectomy. J Endourol 2015; 29:397-400. [DOI: 10.1089/end.2014.0441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- William Chu
- Department of Urology, Kaiser Permanente, Los Angeles, California
| | - Gary W. Chien
- Department of Urology, Kaiser Permanente, Los Angeles, California
| | - David S. Finley
- Department of Urology, Kaiser Permanente, Los Angeles, California
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22
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Rao SR, Moussly S, Pacheco M, Spiess PE, Sexton WJ. Identifying unrecognized collecting system entry and the integrity of repair during open partial nephrectomy: comparison of two techniques. Int Braz J Urol 2014; 40:637-43. [PMID: 25498274 DOI: 10.1590/s1677-5538.ibju.2014.05.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 01/14/2014] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To compare retrograde dye injection through an externalized ureteral catheter with direct needle injection of dye into proximal ureter for identification of unrecognized collecting system disruption and integrity of subsequent repair during open partial nephrectomy. MATERIALS AND METHODS We retrospectively reviewed the records of 259 consecutive patients who underwent open partial nephrectomy. Externalized ureteral catheters were placed preoperatively in 110 patients (Group 1); needle injection of methylene blue directly into proximal ureter was used in 120 patients (Group 2). No assessment of the collecting system was performed in 29 patients (Group 3). We compared intraoperative parameters, tumor characteristics, collecting system entry and incidence of urine leaks among the three groups. RESULTS The mean tumor diameter was 3.1 cm in Group 1, 3.6cm in Group 2, and 3.8 cm in Group 3 (p = 0.04); mean EBL 320cc, 351 cc and 376cc (p = 0.5); mean operative time 193.5 minutes, 221 minutes and 290 minutes (p < 0.001). Collecting system entry was recognized in 63%, 76% and 38% of cases in Groups 1, 2 and 3 respectively. (p = 0.07). Postoperative urine leaks requiring some form of management occurred in 11 patients from group 1 and 6 from group 2. (p = 0.2). No patient in Group 3 developed a urinary leak. CONCLUSIONS Identification of unrecognized collecting system disruption as well as postoperative urine leak rate in patients undergoing partial nephrectomy were not influenced by the intraoperative technique of identifying unrecognized collecting system entry. Postoperative urine leaks are uncommon despite recognized collecting system disruption in the majority of patients.
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Affiliation(s)
- Sandhya R Rao
- Department of Urology and Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Sammy Moussly
- Department of Urology and Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Michelle Pacheco
- Department of Urology and Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Philippe E Spiess
- Department of Urology and Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Wade J Sexton
- Department of Urology and Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Zargar H, Khalifeh A, Autorino R, Akca O, Brandao LF, Laydner H, Krishnan J, Samarasekera D, Haber GP, Stein RJ, Kaouk JH. Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization. Int Braz J Urol 2014; 40:763-71. [DOI: 10.1590/s1677-5538.ibju.2014.06.07] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 04/06/2014] [Indexed: 12/17/2022] Open
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24
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Tomaszewski JJ, Cung B, Smaldone MC, Mehrazin R, Kutikov A, Viterbo R, Chen DY, Greenberg RE, Uzzo RG. Renal Pelvic Anatomy Is Associated with Incidence, Grade, and Need for Intervention for Urine Leak Following Partial Nephrectomy. Eur Urol 2014; 66:949-55. [DOI: 10.1016/j.eururo.2013.10.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 10/09/2013] [Indexed: 01/20/2023]
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25
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Cleaveland P, Tang V, Pollard A, Adeyoju A. Management of a patient with a chronic nephrocutaneous fistula after partial nephrectomy using a novel technique. Int J Urol 2014; 22:232-3. [PMID: 25252217 DOI: 10.1111/iju.12641] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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26
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Russo P, Mano R. Open mini-flank partial nephrectomy: an essential contemporary operation. Korean J Urol 2014; 55:557-67. [PMID: 25237456 PMCID: PMC4165917 DOI: 10.4111/kju.2014.55.9.557] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 07/21/2014] [Indexed: 12/24/2022] Open
Abstract
Secondary to the widespread use of the modern imaging techniques of computed tomography, magnetic resonance imaging, and ultrasound, 70% of renal tumors today are detected incidentally with a median tumor size of less than 4 cm. Twenty years ago, all renal tumors, regardless of size were treated with radical nephrectomy (RN). Elective partial nephrectomy (PN) has emerged as the treatment of choice for small renal tumors. The basis of this paradigm shift is three major factors: (1) cancer specific survival is equivalent for T1 tumors (7 cm or less) whether treated by PN or RN; (2) approximately 45% of renal tumors have indolent or benign pathology; and (3) PN prevents or delays the onset of chronic kidney disease, a condition associated with increased cardiovascular morbidity and mortality. Although PN can be technically demanding and associated with potential complications of bleeding, infection, and urinary fistula, the patient derived benefits of this operation far outweigh the risks. We have developed a "mini-flank" open surgical approach that is highly effective and, coupled with rapid recovery postoperative care pathways associated with a 2-day length of hospital stay.
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Affiliation(s)
- Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roy Mano
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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27
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Tomaszewski JJ, Smaldone MC, Cung B, Li T, Mehrazin R, Kutikov A, Canter DJ, Viterbo R, Chen DYT, Greenberg RE, Uzzo RG. Internal validation of the renal pelvic score: a novel marker of renal pelvic anatomy that predicts urine leak after partial nephrectomy. Urology 2014; 84:351-7. [PMID: 24975712 DOI: 10.1016/j.urology.2014.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/21/2014] [Accepted: 05/02/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To internally validate the renal pelvic score (RPS) in an expanded cohort of patients undergoing partial nephrectomy (PN). MATERIALS AND METHODS Our prospective institutional renal cell carcinoma database was used to identify all patients undergoing PN for localized renal cell carcinoma from 2007 to 2013. Patients were classified by RPS as having an intraparenchymal or extraparenchymal renal pelvis. Multivariate logistic regression models were used to examine the relationship between RPS and urine leak. RESULTS Eight hundred thirty-one patients (median age, 60 ± 11.6 years; 65.1% male) undergoing PN (57.3% robotic) for low (28.9%), intermediate (56.5%), and high complexity (14.5%) localized renal tumors (median size, 3.0 ± 2.3 cm; median nephrometry score, 7.0 ± 2.6) were included. Fifty-four patients (6.5%) developed a clinically significant or radiographically identified urine leak. Seventy-two of 831 renal pelvises (8.7%) were classified as intraparenchymal. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (43.1% vs 3.0%; P <.001), major urine leak requiring intervention (23.6% vs 1.7%; P <.001), and minor urine leak (19.4% vs 1.2%; P <.001) compared with that in patients with an extrarenal pelvis. After multivariate adjustment, RPS (intraparenchymal renal pelvis; odds ratio [OR], 24.8; confidence interval [CI], 11.5-53.4; P <.001) was the most predictive of urine leak as was tumor endophyticity ("E" score of 3 [OR, 4.5; CI, 1.3-15.5; P = .018]), and intraoperative collecting system entry (OR, 6.1; CI, 2.5-14.9; P <.001). CONCLUSION Renal pelvic anatomy as measured by the RPS best predicts urine leak after open and robotic partial nephrectomy. Although external validation of the RPS is required, preoperative identification of patients at increased risk for urine leak should be considered in perioperative management and counseling algorithms.
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Affiliation(s)
- Jeffrey J Tomaszewski
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA.
| | - Marc C Smaldone
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Bic Cung
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Tianyu Li
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Reza Mehrazin
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Daniel J Canter
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Rosalia Viterbo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - David Y T Chen
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Richard E Greenberg
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Robert G Uzzo
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
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Pierorazio PM, Mullins JK, Ross AE, Hyams ES, Partin AW, Han M, Walsh PC, Schaeffer EM, Pavlovich CP, Allaf ME, Bivalacqua TJ. Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): a 20-year institutional experience. BJU Int 2013; 112:45-53. [PMID: 23759008 DOI: 10.1111/j.1464-410x.2012.11767.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Standard clinical care pathways to discharge have been established for a number of operations including radical prostatectomy (RP). The pathway after RP has changed dramatically over the past two decades due to improvements in surgical technique, anaesthesia and most recently, the introduction of minimally invasive RP (MIRP). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. OBJECTIVE To investigate the development of the clinical care pathway to discharge after radical prostatectomy (RP) at a large, academic medical centre over the past 20 years, focusing on the rates and reasons for deviation. PATIENTS AND METHODS In all, 18 049 men were identified from the Johns Hopkins RP database who had undergone surgery since 1991. Patients in whom the length of stay (LOS) was ≤95th percentile, defined the clinical care pathway to discharge and those in whom LOS was ≥98th percentile were termed 'off-pathway'. RESULTS The mean LOS decreased from 7.7 days in 1991 to 1.6 days in 2010. Of 7126 patients undergoing RP since 2005, 1803(25.3%), 4881(68.5%) and 312 (4.4%) were discharged on postoperative day (POD) 1, 2 and 3, respectively; 126 (1.8%) patients, discharged on POD4-21 were 'off-pathway'. The most common reasons for delay of discharge were ileus (44, 0.615%), urine leak (12, 0.17%), anaemia requiring blood transfusion (nine, 0.126%) and bleeding requiring re-exploration (six, 0.08%). The proportion of patients 'off-pathway' was 1.20%, 1.06% and 4.01% for retropubic RP (RRP), laparoscopic RP (LRP) and robot-assisted laparoscopic RP (RALRP), respectively (P < 0.001). Ileus delayed discharge in 0.28%, 0.37% and 1.9% of patients undergoing RRP, LRP and RALRP, respectively (P < 0.001). CONCLUSIONS The clinical care pathway to discharge after RP has changed dramatically at our institution over the past 20 years. RALRP appears to result in a higher proportion of 'off-pathway' patients, primarily due to ileus, compared with RRP and LRP. However, very few patients were discharged 'off-pathway'.
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Affiliation(s)
- Phillip M Pierorazio
- The James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD, USA
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Wang L, Lee BR. Robotic partial nephrectomy: current technique and outcomes. Int J Urol 2013; 20:848-59. [PMID: 23635467 DOI: 10.1111/iju.12177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Accepted: 03/21/2013] [Indexed: 01/20/2023]
Abstract
Over the past decade, management of the T1 renal mass has focused on nephron-sparing surgery. Robotic partial nephrectomy has played an increasing role in the technique of preserving renal function by decreasing warm ischemia time, as well as optimizing outcomes of hemorrhage and fistula. Robot-assisted partial nephrectomy is designed to provide a minimally-invasive nephron-sparing surgical option utilizing reconstructive capability, decreasing intracorporeal suturing time, technical feasibility and safety. Ultimately, its benefits are resulting in its dissemination across institutions. Articulated instrumentation and three-dimensional vision facilitate resection, collecting system reconstruction and renorrhaphy, leading to decreased warm ischemia time while preserving oncological outcomes. The aim of the present review was to present our surgical sequence and technique, as well as review the current status of robot-assisted partial nephrectomy.
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Affiliation(s)
- Liang Wang
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
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30
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Mayer WA, Godoy G, Choi JM, Goh AC, Bian SX, Link RE. Higher RENAL Nephrometry Score is predictive of longer warm ischemia time and collecting system entry during laparoscopic and robotic-assisted partial nephrectomy. Urology 2012; 79:1052-6. [PMID: 22546382 DOI: 10.1016/j.urology.2012.01.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 01/15/2012] [Accepted: 01/27/2012] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the predictive value of the RENAL Nephrometry Score (RNS) on operative outcomes during both laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN). METHODS We reviewed 67 consecutive patients with suspicious renal lesions and available radiographic data who underwent LPN or RPN by a single surgeon. Data included operative type, body mass index (BMI), gender, age, and side of tumor. RNSs were recorded using either magnetic resonance imaging or computed tomography scans. Warm ischemia time (WIT), estimated blood loss (EBL), and collecting system entry (CSE) were the endpoints for the analyses. RESULTS Total RNS entered as a continuous or dichotomous variable (<7 or ≥ 7), R-score, and N-score were independent predictors of WIT on multivariable analyses (P <.001, P = .001, P = .026, and P <.01, respectively). The total RNS and N-score were predictive of CSE in univariate analysis (P <.001). Neither total RNS nor its individual components were predictive of EBL. CONCLUSION Total RNS, as well as the N- and R-scores, can help predict both longer WIT and CSE during LPN and RPN. The RNS and its individual components may be useful in the preoperative planning and counseling of patients undergoing LPN or RPN.
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Affiliation(s)
- Wesley A Mayer
- Scott Department of Urology, Baylor College of Medicine, Houston, TX 77030, USA.
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Wang P, Xia D, Wang S. Multiple Factor Analysis of Urine Leaks after Retroperitoneal Laparoscopic Partial Nephrectomy. Urol Int 2011; 87:411-5. [DOI: 10.1159/000331905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 08/13/2011] [Indexed: 12/15/2022]
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Clements T, Raman JD. Surgery: is perinephric drainage essential after partial nephrectomy? Nat Rev Urol 2011; 8:594-5. [PMID: 22009416 DOI: 10.1038/nrurol.2011.152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Thomas Clements
- Division of Urology, Penn State Milton S. Hershey Medical Center, 500 University Drive, H055, Hershey, PA 17033-0850, USA
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Godoy G, Katz DJ, Adamy A, Jamal JE, Bernstein M, Russo P. Routine Drain Placement After Partial Nephrectomy is Not Always Necessary. J Urol 2011; 186:411-5. [DOI: 10.1016/j.juro.2011.03.151] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Indexed: 11/17/2022]
Affiliation(s)
- Guilherme Godoy
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Darren J. Katz
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ari Adamy
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Joseph E. Jamal
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Melanie Bernstein
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Paul Russo
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy. Eur Urol 2011; 60:724-30. [PMID: 21621910 DOI: 10.1016/j.eururo.2011.05.030] [Citation(s) in RCA: 207] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 05/15/2011] [Indexed: 01/20/2023]
Abstract
BACKGROUND The association between tumor complexity and postoperative complications after partial nephrectomy (PN) has not been well characterized. OBJECTIVE We evaluated whether increasing renal tumor complexity, quantitated by nephrometry score (NS), is associated with increased complication rates following PN using the Clavien-Dindo classification system (CCS). DESIGN, SETTING, AND PARTICIPANTS We queried our prospectively maintained kidney cancer database for patients undergoing PN from 2007 to 2010 for whom NS was available. INTERVENTIONS All patients underwent PN. MEASUREMENTS Tumors were categorized into low- (NS: 4-6), moderate- (NS: 7-9), and high-complexity (NS: 10-12) lesions. Complication rates within 30 d were graded (CCS: I-5), stratified as minor (CCS: I or 2) or major (CCS: 3-5), and compared between groups. RESULTS AND LIMITATIONS A total of 390 patients (mean age: 58.0 ± 11.9 yr; 66.9% male) undergoing PN (44.6% open, 55.4% robotic) for low- (28%), moderate- (55.6%), and high-complexity (16.4%) tumors (mean tumor size: 3.74 ± 2.4 cm; median: 3.2 cm) from 2007 to 2010 were identified. Tumor size, estimated blood loss, and ischemia time all significantly differed (p<0.0001) between groups; patient age, body mass index (BMI), and operative time were comparable. When stratified by CCS, minor and major complication rates for all patients were 26.7% and 11.5%, respectively. Minor complication rates were comparable (26.6 vs. 24.9 vs 32.8%; p=0.45), whereas major complication rates differed (6.4 vs. 11.1 vs. 21.9%; p=0.009) among tumor complexity groups. Controlling for age, gender, BMI, type of surgical approach, operative duration, and tumor complexity, prolonged operative time (odds ratio [OR]: 1.01; confidence interval [CI], 1.0-1.02) and high tumor complexity (OR: 5.4; CI, 1.2-24.2) were associated with the postoperative development of a major complication. Lack of external validation is a limitation of this study. CONCLUSIONS Increasing tumor complexity is associated with the development of major complications after PN. This association should be validated externally and integrated into the decision-making process when counseling patients with complex renal tumors.
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Rogers A, Thiel DD, Brisson TE, Igel TC. Use of the Habib 4 × Radiofrequency-Assisted Bipolar Hemostatic Device to Avoid Warm Ischemia in Select Large Partial Nephrectomies: Description and Video of Technique. J Laparoendosc Adv Surg Tech A 2011; 21:153-6. [DOI: 10.1089/lap.2010.0347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alexandra Rogers
- Department of Urology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - David D. Thiel
- Department of Urology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | | | - Todd C. Igel
- Department of Urology, Mayo Clinic Jacksonville, Jacksonville, Florida
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Bruner B, Breau RH, Lohse CM, Leibovich BC, Blute ML. Renal nephrometry score is associated with urine leak after partial nephrectomy. BJU Int 2010; 108:67-72. [PMID: 21087391 DOI: 10.1111/j.1464-410x.2010.09837.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE • To determine if the RENAL nephrometry score is associated with urine leak after partial nephrectomy for tumours ≤ 7 cm. PATIENTS AND METHODS • 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. RESULTS • 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). CONCLUSION • 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.
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Affiliation(s)
- Bryan Bruner
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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