Predictive factors of complications after robot-assisted laparoscopic partial nephrectomy: a retrospective multicentre study

Radiomics and Artificial Intelligence: Renal Cell Carcinoma

There is a clinical need for accurate diagnosis and prognostication of kidney cancer using imaging. Radiomics and deep learning methods applied to imaging have shown promise in tasks such as tumor segmentation, classification, staging, and grading, as well as assessment of preoperative scores and correlation with tumor biomarkers. Artificial intelligence is also expected to play a significant role in advancing personalized medicine for the treatment of renal cell carcinoma.

Same-day discharge following minimally invasive partial and radical nephrectomy: a National Surgical Quality Improvement Program (NSQIP) analysis

PURPOSE

Minimally invasive partial nephrectomy (MIPN) and radical nephrectomy (MIRN) have successfully resulted in shorter length of stay (LOS) for patients. Using a national cohort, we compared 30-day outcomes of SDD (LOS = 0) versus standard-length discharge (SLD, LOS = 1-3) for MIRN and MIPN.

METHODS

All patients who underwent MIPN (CPT 50,543) or MIRN (CPT 50,545) in the ACS-NSQIP database from 2012 to 2019 were reviewed. SDD and SLD groups were matched 1:1 by age, sex, race, body mass index, American Society of Anesthesiologists score, and medical comorbidities. We compared baseline characteristics, 30-day Clavien-Dindo (CD) complications, reoperations, and readmissions between SDD and SLD groups. Multivariable logistic regressions were used to evaluate predictors of adverse outcomes.

RESULTS

28,140 minimally invasive nephrectomy patients were included (SDD n = 237 [0.8%], SLD n = 27,903 [99.2%]). There were no significant differences in 30-day readmissions, CD I/II, CDIII, or CD IV complications before and after matching SDD and SLD groups. On multivariate regression analysis, SDD did not confer increased risk of 30-day complications or readmissions for both MIPN and MIRN.

CONCLUSION

SDD after MIPN and MIRN did not confer increased risk of postoperative complications, reoperation, or readmission compared to SLD. Further research should explore optimal patient selection to ensure safe expansion of this initiative.

Trifecta outcomes of modified robot-assisted simple enucleation and standard robot-assisted partial nephrectomy for treating clinical T1b renal cell carcinoma

Background

To compare perioperative outcomes and Trifecta achievement of modified robot-assisted simple enucleation (MRASE) with robot-assisted partial nephrectomy (RAPN) for treating clinical T1b renal tumors.

Methods

We analyzed 203 patients who underwent MRASE or RAPN for clinical T1b renal tumors at our institution from September 2014 to June 2018. The two groups were compared regarding perioperative outcome variables. Trifecta was defined as no perioperative complications, negative surgical margin, and ischemia time ≤25 minutes.

Results

In all, 139 patients underwent MRASE and 64 underwent RAPN respectively. Patients in the MRASE group had shorter operative time (197.7 vs. 215.6 min, P=0.039) and warm ischemic time (21.2 vs. 24.1 min, P=0.004) in comparison to the RAPN group. The groups were comparable in estimated blood loss (230.5 vs. 269.8 mL, P=0.259). Tumor bed suturing was performed with a significantly lower frequency in the MRASE group than in the RAPN group (11.5% vs. 90.6%, P<0.01). The incidence of perioperative complications was similar. The rate of positive surgical margins was similar in both groups (2.2% vs. 6.3%, P=0.284). Trifecta was achieved in 61.2% and 42.2% of MRASE and RAPN patients (P=0.012). On multivariable analysis, the type of procedure, RENAL score, estimated blood loss, and operative time were positive factors for the achievement of Trifecta.

Conclusions

In this series MRASE was superior to RAPN with regard to the achievement of Trifecta in treating T1b renal tumors. Besides, MRASE had better outcomes for shorter operative time, shorter warm ischemic time, and less need for tumor bed suturing as compared with RAPN.

The value of renal score in both determining surgical strategies and predicting complications for renal cell carcinoma: A systematic review and meta-analysis

Objectives

Radical nephrectomy (RN) was the standard treatment for renal cell carcinoma (RCC). However, recent studies have found that partial nephrectomy (PN) could achieve similar effects as radical nephrectomy, and has the advantages of less bleeding and shorter hospital stay. The choice of surgical strategies has become a concern of clinicians, which could be guided by renal score introduced by Kutikov et al Therefore, we conducted this meta‐analysis to clarify the value of renal score of determining surgical strategies and predicting complications.

Methods

The keywords “RENAL score,” “renal nephrometry score,” or “nephrometry score” were used to retrieve electronic databases for relevant literature up to Feb 2020, including PubMed, Web of Science, and the Cochrane library. Surgical strategies and complications are outcome measures. Risk ratio (RR) with 95% confidence intervals (CI) is applied to assess the effect size.

Results

A total of 20 studies met the selection criteria for meta‐analysis. There was significant difference in RN operation rate for each subgroup (low‐moderate: RR = 3.50, 95% Cl = 2.60‐4.71, P < .001; low‐high: RR = 6.29, 95% Cl = 4.40‐9.00, P < .001; moderate‐high: RR = 1.80, 95% Cl = 1.39‐2.32, P < .001).The overall incidence of complications from high renal score group was significantly higher than that in low renal score group (low‐moderate: RR = 1.32, 95% Cl = 1.03‐1.69, P = .026; low‐high: RR = 2.45, 95% Cl = 1.48‐4.07, P = .001; moderate‐high: RR = 1.75, 95% Cl = 1.17‐2.61, P = .007).

Conclusions

This meta‐analysis indicated that renal score is an efficient tool for determining surgical strategies and predicting complications in PN. More prospective research is essential to verify the predictive value of renal score.

C-Reactive Protein Levels and Survival Following Cytoreductive Nephrectomy in 118 Patients with Metastatic Renal Cell Carcinoma Treated with Sunitinib: A Retrospective Study

Background

This study aimed to evaluate the factors associated with a survival benefit for patients with metastatic renal cell carcinoma (mRCC) treated with sunitinib, with and without cytoreductive nephrectomy (CN).

Material/Methods

This retrospective clinical study included 118 patients with mRCC who were treated with CN and sunitinib (CN-sunitinib) (N=70) and with sunitinib-alone (N=48). Categorical clinicopathological variables were compared with hypothesis tests using contingency tables and a chi-squared test. Independent indicators for progression-free survival (PFS) and overall survival (OS) were analyzed with univariate and multivariate Cox regression models. The Kaplan-Meier method and log-rank test were used to evaluate patient survival.

Results

The median PFS and OS for the 118 patients were 8.38 and 15.48 months, respectively. There were no significant differences between the CN-sunitinib group and the sunitinib-alone group for either PFS (7.2 months vs. 11.6 months; P=0.525) or OS (16.7 months vs. 15.2 months; P=0.839). Stratification of patients based on clinicopathological characteristics showed that CN was significantly associated with reduced PFS and OS for patients with lymph node metastasis (PFS, P<0.001; OS, P<0.001) and high International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk scores (PFS, P=0.003; OS, P=0.011). However, CN was associated with a significant survival benefit for patients with low levels of serum C-reactive protein (CRP<10 mg/L) (PFS, P=0.026; OS, P=0.007).

Conclusions

Sunitinib-alone without CN improved the survival of patients with mRCC who had high IMDC risk scores or lymph node metastasis. CN and sunitinib resulted in significantly improved survival in patients with low serum CRP.

May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score

Background

Although thyroidectomy is one of the most common surgical procedures performed worldwide, some permanent complications, despite the considerably reducing incidence, may affect dramatically the patients quality of life. The purpose of this study is to evaluate whether factors identified preoperatively and expressed in a score could be predictors of major surgical difficulty during total thyroidectomy and influence the incidence of complications.

Methods

A total of 164 patients who underwent total thyroidectomy were examined. For each patient we calculated a preoperative score, including seven parameters, which we evaluated to be predictors of difficulty in thyroid surgery, that is, sex, body mass index (BMI), neck length, neck extension, thyroid gland volume, thyroiditis, and increased parenchymal vascularization. The overall score was also compared with peri- and post-operative factors describing objectively the difficulty in thyroid surgery. These factors are the duration of the operation, the length of hospitalization, the incidence of complications such as hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve injuries.

Results

There was no statistically significant association between our score and either the percentage of postoperative complications or the length of hospitalization. The operative time was the only variable remarkably associated with the score value (p < 0.00001). Comparing the duration of the operation with each of the preoperative predictive factors, we found that none of the factors reached the value of statistical significance, but a close association could be noted with the thyroid volume and the BMI.

Conclusions

In our study, predictors of difficulty in thyroidectomy did not affect morbidity rates, as suggested by previous studies, but only operative times, which were significantly increased in patients with higher score. Although our results have limited statistical significance, they allow us to confirm the fundamental role of a systematic use of optical magnification and microsurgical technique in thyroidectomy. Further studies, with a larger cohort of patients, are needed to validate our results and to formulate a universally accepted predictive score of difficulty in thyroidectomy preoperatively.

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.

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.

Value of computed tomography texture analysis for prediction of perioperative complications during laparoscopic partial nephrectomy in patients with renal cell carcinoma

Purpose

Tumorous texture is a marker for tumor tissue inhomogeneity. Based on this assumption, this study aims to evaluate the value of computed tomography texture analysis for imaging-based prediction of perioperative complications during laparoscopic partial tumor nephrectomy.

Methods

A total of 106 patients with histologically confirmed renal cell carcinoma and pre-operative CT were included and volumetric texture analysis of the tumors was performed by two readers. Texture analysis parameter ratios and differences were calculated using the kidney parenchyma as reference (“reference-corrected”). Regression analysis was performed, regarding the value of the texture analysis parameters, for assessment of the tumor nuclear grade and the prediction of peri- and postoperative complications and approximated blood loss. Moreover, the inter-rater agreement in terms of the intra-class correlation coefficient (ICC) was calculated.

Results

Regarding the reference-corrected values, the predictive value of texture analysis parameters for severe perioperative complications was highest for the standard deviation of the mean attenuation (Area under curve/AUC, .615; sensitivity, 93.8%, specificity, 30.0%), followed by the uniformity (AUC, .599; sensitivity, 62.5%, specificity, 60.0%), and the uniformity of distribution of positive pixels (AUC, .597; sensitivity, 62.5%; specificity, 61.1%).

Regarding the blood loss, the uniformity of positive pixel values (UPP; AUC, 0.638), uniformity (AUC, 0.635), and entropy (AUC, 0.633) yielded the best predictive values, whilst the tumor grade was a weaker predictor (AUC, 0.574).

The applied texture analysis parameters did not correlate with the time of surgery or the warm ischemic time. All measured parameters were better predictors for complications than the tumor diameter alone. The inter-rater agreement was almost perfect (ICC, .982).

Conclusion

CT and CT texture analysis parameters are valuable for prediction of perioperative outcome before laparoscopic partial nephrectomy in patients with renal cell carcinoma.

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.

Management of complications arising from the treatment of small renal masses

This article offers a review of the complications, and management of such complications, associated with different modalities used for the treatment of the small renal mass.

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

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.

Multidetector CT imaging of complications after laparoscopic nephron-sparing surgery

Purpose

Laparoscopic nephron-sparing surgery (L-NSS) is increasingly performed to treat localised renal lesions. However, the associated morbidity is non-negligible, with a rate of major complications approaching 10 %.

Methods and Results

This paper provides an overview of indications, surgical techniques and results of L-NSS; explains the incidence, risk factors and manifestations of postoperative complications; discusses the preferred multidetector computed tomography (CT) acquisition techniques; illustrates the appearance of normal postoperative images following L-NSS; and reviews, with example images, the most common and unusual iatrogenic complications. These include haematuria, haemorrhage, vascular injuries, infections and urinary leaks. Most emphasis is placed on CT, which provides rapid, reliable triage and follow-up of iatrogenic complications after L-NSS, identifying occurrences that require transarterial embolisation or repeated surgery.

Conclusions

Multidetector CT allows precise assessment of the surgical resection site; detection of pneumoperitoneum and subcutaneous emphysema; quantification of retroperitoneal blood; and identification of active bleeding, pseudoaneurysms, arterio-venous fistulas, abscess collections and extravasated urine.

Teaching Points

• Laparoscopic nephron-sparing surgery (NSS) is increasingly performed to treat renal lesions.

• Radiologists are increasingly requested to investigate suspected post-surgical NSS complications.

• Post-NSS complications include haemorrhage, haematuria, vascular injuries, infections and urinary leaks.

• Multidetector CT allows choice between conservative treatment, transarterial embolisation or surgery.

Zero ischemia robotic-assisted partial nephrectomy in Alberta: Initial results of a novel approach

INTRODUCTION

Partial nephrectomy remains the standard of care in early stage, organ-confined renal tumours. Recent evidence suggests that minimally invasive surgery can proceed without segmental vessel clamping. In this study, we review our experience at a Canadian centre with zero ischemia robotic-assisted partial nephrectomy (RAPN).

METHODS

A retrospective chart review of zero ischemia RAPN was performed. All surgeries were consecutive partial nephrectomies performed by the same surgeon at a tertiary care centre in Northern Alberta. The mean follow-up period was 28 months. These outcomes were compared against the current standards for zero ischemia (as outlined by the University of Southern California Institute of Urology [USC]).

RESULTS

We included 21 patients who underwent zero ischemia RAPN between January 2012 and June 2013. Baseline data were similar to contemporary studies. Twelve (57.1%) required no vascular clamping, 7 (33.3%) required clamping of a single segmental artery, and 2 (9.5%) required clamping of two segmental arteries. We achieved an average estimated blood loss of 158 cc, with a 9.2% average increase in creatinine postoperatively. Operating time and duration of hospital stay were short at 153 minutes and 2.2 days, respectively.

CONCLUSION

Zero ischemia partial nephrectomy was a viable option at our institution with favourable results in terms of intra-operative blood loss and postoperative creatinine change compared to results from contemporary standard zero ischemia studies (USC). To our knowledge, this is the first study to review an initial experience with the zero ischemia protocol in robotic-assisted partial nephrectomies at a Canadian hospital.

Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study

OBJECTIVE

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed 'optimal outcome' for the RPN group.

PATIENTS AND METHODS

Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The 'optimal outcome' was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and 'optimal outcome' achievement.

RESULTS

In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of 'optimal outcome' for the RPN group was 38.5%.

CONCLUSIONS

In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for 'optimal outcome' might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

Review of robot-assisted partial nephrectomy in modern practice

Partial nephrectomy (PN) is currently the standard treatment for T1 renal tumors. Minimally invasive PN offers decreased blood loss, shorter length of stay, rapid convalescence, and improved cosmesis. Due to the challenges inherent in laparoscopic partial nephrectomy, its dissemination has been stifled. Robot-assisted partial nephrectomy (RAPN) offers an intuitive platform to perform minimally invasive PN. It is one of the fastest growing robotic procedures among all surgical subspecialties. RAPN continues to improve upon the oncological and functional outcomes of renal tumor extirpative therapy. Herein, we describe the surgical technique, outcomes, and complications of RAPN.

Impact of fellowship training on robotic-assisted laparoscopic partial nephrectomy: benchmarking perioperative safety and outcomes

To provide perioperative benchmark data for surgeons entering practice from formal robotic training and performing robotic-assisted laparoscopic partial nephrectomy (RAPN). Perioperative outcomes of the first 100 RAPN from a surgeon entering into practice directly from robotic fellowship training were analyzed. Postoperative complications were categorized by Clavien-Dindo grade. Surgical "trifecta scores" and Margin, Ischemia, and Complication (MIC) scoring were utilized to assess surgical outcomes. Statistical analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, North Carolina). Median age of the cohort was 63 years (22-81 years), and 34 (34.3%) patients were over age 65. Forty-one (41.4%) patients had a BMI > 30. Thirteen (13.1%) had RENAL 10-12 tumors, 22 of which (22.2%) were >4 cm in size. Median warm ischemia time was 17 min, and 13 patients had resection without warm ischemia. Five patients were converted to open partial nephrectomy, and 1 patient was converted to laparoscopic nephrectomy. Twenty-one patients (21.2%) experienced a complication, 6 of whom had a major (Clavien grade 3 or higher) complication with one grade 5 complication. Operating room time decreased with experience, but surgical complications and hospital stay did not change with experience. MIC score of renal cell carcinoma (RCC) patients was 74.7%, while the surgical trifecta was reached in 71.3 % of RCC patients. Surgeons may enter practice directly from formal robotic training and perform RAPN with perioperative outcomes, surgical complications, surgical trifecta scores, and MIC scoring in line with those the most experienced robotic partial nephrectomists.

The association between renal tumour scoring system components and complications of partial nephrectomy

INTRODUCTION

We evaluate the associations between 3 renal tumour scoring systems and their components with perioperative complications of partial nephrectomy.

METHODS

A consecutive cohort of partial nephrectomy patients was analyzed. Patient characteristics were abstracted from medical records. PADUA scores (preoperative aspects and dimensions used for anatomic classification), RENAL (radius exophyic/endophytic nearness anterior/posterior location scoring) nephrometry scores, and Centrality index (C-index) were determined from preoperative axial images by 2 independent reviewers. Cases were evaluated for postoperative complications up to 30 days after surgery. Pre-specified complication definitions were used for 33 potential medical and surgical complications. Unadjusted and adjusted associations between overall scores, individual components, and complications were determined using log binomial regression.

RESULTS

In total, 118 patients were included in the study. Of these, 36 (30.5%) surgical complications occurred in 27 (22.9%) patients. Fourteen (11.9%) were Clavien grade ≥3. Overall PADUA score was significantly associated with surgical and overall complications after adjusting for potential confounders. Among all components of the 3 scoring systems, only tumour diameter and exophytic/endophytic nature of the tumour were significantly associated with complications after adjusting for the other components of the respective scoring system (p < 0.05).

CONCLUSIONS

Renal tumour scoring systems may help predict the risk of complications after partial nephrectomy. Further refinement of current systems is required. A first step would be to include only components that are significantly associated with complications.

Robotic partial nephrectomy for completely endophytic renal tumors: complications and functional and oncologic outcomes during a 4-year median period of follow-up

OBJECTIVE

To evaluate the renal functional outcome, the oncologic safety, and the occurrence of complications after robotic-assisted laparoscopic partial nephrectomy (RPN) for completely endophytic tumors.

MATERIAL AND METHODS

Data of 45 patients with completely endophytic tumors, 116 patients with mesophytic, and 64 patients with exophytic masses who underwent RPN were retrospectively analyzed. Perioperative, oncologic, and functional data were evaluated and analyzed with SPSS, version 18.

RESULTS

Demographic characteristics were similar among the groups. The median follow-up of the endophytic, the mesophytic, and the exophytic groups were 48, 43, and 38 months, respectively. Endophytic masses were more likely to be malignant and have a higher overall tumor complexity, estimated by the RENAL score (9 vs 8 vs 5.5; P <.01; P = .02). We did not detect any statistically significant differences among the groups regarding blood loss volume, transfusion rates, length of stay, and intraoperative and postoperative complications (P = .49, .25, .87, .42, and .20, respectively). There was a statistically significant difference in the estimated glomerular filtration rate percentage change on the first postoperative day (P = .02), but this significance was not observed after the first week. The patients in the endophytic group showed a tendency toward increased rates of positive surgical margins compared with the mesophytic and exophytic groups (P = .06). However, there were not any significant differences regarding the recurrence-free survival rates (P = .335) and the overall mortality rates (P = .570) according to the Kaplan-Meier analysis.

CONCLUSION

In experienced institutes, RPN for entirely intraparenchymal masses is a feasible procedure in terms of complication rates, functional and oncologic outcomes during an intermediate-term period of follow-up.

Perioperative complications of robot-assisted partial nephrectomy

The incidence of renal cell carcinoma continues to increase with utilization of diagnostic abdominal imaging with migration towards a proportionally greater detection of small renal masses (SRM). Robot-assisted partial nephrectomy (RAPN) has become an attractive minimally invasive treatment modality for SRM's due to the technical advantages and shortened learning curve compared to laparoscopic partial nephrectomy (LPN) while preserving comparable perioperative outcomes. With advances in ablative approaches for stage I renal cell carcinoma (RCC) and controversy surrounding the role of extirpative surgery for SRM's, systematic understanding of the complications associated with RAPN has become even more imperative. This review aims to summarize and evaluate the contemporary literature, compile reported intraoperative complications, describe conventional and nephron-sparing surgery (NSS) specific postoperative complications, and assess factors associated with an increased likelihood for perioperative complications following RAPN.

Anatomic complexity quantitated by nephrometry score is associated with prolonged warm ischemia time during robotic partial nephrectomy

OBJECTIVE

To assess the association between nephrometry score (NS) and prolonged warm ischemia time (WIT) in patients undergoing robotic partial nephrectomy (RPN) for clinically localized renal masses.

METHODS

We queried our prospectively maintained kidney cancer database to identify all patients undergoing RPN for localized tumors from 2007-2012. Patient and tumor characteristics were compared between complexity groups using analysis of variance and chi square tests. Multivariate logistic regression models were used to examine the relationship between NS complexity and warm ischemia >30 minutes.

RESULTS

Three hundred seventy-five patients (mean age, 59 ± 11 years; mean Charlson comorbidity index, 1.0 ± 1.3) undergoing RPN under warm ischemia for clinically localized renal tumors (mean tumor size, 3.1 ± 1.5 cm; mean NS, 6.8 ± 1.8) met inclusion criteria and had NS available. Stratified by complexity, groups differed with respect to age at surgery, tumor size, proximity to the hilum, collecting system entry, estimated blood loss, and operative time (all P values ≤.05). Significant differences in mean WIT were observed when comparing low (19.4 ± 12.1 minutes), intermediate (28.6 ± 12.8 minutes), and high (36.1 ± 13.7 minutes) NS complexity groups (P <.0001). Adjusting for confounders, patients with intermediate (odds ratio, 2.1; confidence interval, 1.2-3.9) and high (odds ratio, 3.7; confidence interval, 1.1-11.8) NS complexity were more likely to require prolonged WIT when compared with patients with low complexity tumors.

CONCLUSION

In our large institutional cohort, quantification of anatomic complexity using the NS is associated with WIT >30 minutes in patients undergoing RPN for localized renal tumors. This provides further evidence that standardized reporting of tumor anatomic complexity affords meaningful outcome comparisons.

R.E.N.A.L. Nephrometry scoring: how well correlated are urologist, radiologist, and collaborator scores?

PURPOSE

R.E.N.A.L. Nephrometry Score (NS) is an imaging-based (CT/MRI) scoring system commonly used by urologists to standardize the reporting of renal masses by enabling quantification of anatomical characteristics. We sought to examine the inter-rater correlation of NS between urologists, radiologists, and tumor-board collaborators.

METHODS

We identified adult patients undergoing partial or radical nephrectomy over 10 years (n=2450). Patients with autosomal dominant polycystic kidney disease (ADPKD), metastatic disease, masses >10 cm, and studies in which the study urologists or radiologists partook in patient care were excluded. Preoperative imaging was evaluated and patients with multiphasic CT available were included. Scans were provided to the reviewers to evaluate with a R.E.N.A.L. nephrometry questionnaire. Results were analyzed using kappa correlation coefficients.

RESULTS

One hundred twenty patients met inclusion criteria with mean age of 59.5 years. The majority of cases were partial nephrectomies (72%). Eighty-five percent of the tumors were malignant, with 26% having high-grade histology. The mean (standard deviation) overall NS was 6.8 (1.9) with fair correlation among reviewers (κ=0.222). Collaborators had the highest inter-rater correlation, ranging from 0.41 to 0.84 for NS component scores, compared with 0.42-0.85 for radiologists and 0.36-0.86 for urologists. "R" scores were best correlated (κ>0.8). NS correlation ranged between 0.16 and 0.31 for the groups while the NS complexity category correlation ranged between 0.50 and 0.61.

CONCLUSIONS

Despite being naive to NS, inter-radiologist scoring patterns were better correlated than inter-urologist. The urologist and radiologist collaborating in tumor board showed the highest agreement, suggesting that a multidisciplinary approach in the characterization of renal masses may provide benefit to patient management.

Morphometric scores for renal tumors: what does the radiologist need to know?

Numerous therapeutic options are possible in the treatment of renal carcinomas including radical nephrectomy, partial nephrectomy, cryoablation, radiofrequency, active follow-up and among surgical treatments, different approaches may be used such as laparotomy, laparoscopy, robotic-assisted intervention. The choice between these different procedures is partially based on the anatomic conditions of the tumors. Different anatomic scores determined from cross-sectional imaging have been built to predict the complexity of the surgical procedure. The goals of this article are to review the relevant morphologic pattern for management of patients with renal tumors, to know how to calculate these different scores and to understand the clinical applications of these scores.

Identifying predictors of a difficult thyroidectomy

BACKGROUND

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

METHODS

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P<0.05) variables from a univariate analysis.

RESULTS

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P=0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P=0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P=0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23-15.36, P=0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28-9.66, P=0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06-6.42, P=0.037) were independently associated with DT.

CONCLUSIONS

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.