Impact of Inner Layer Renorrhaphy Suture on Renal Artery Pseudoaneurysm Formation Following Robotic-assisted Partial Nephrectomy

OBJECTIVE

To report the impact of resection base inner layer renorrhaphy suture type on renal artery pseudoaneurysm (RAP) rate following robotic-assisted partial nephrectomy (RAPN).

METHODS

Five hundred and sixty-three consecutive RAPNs performed by a single surgeon were retrospectively reviewed. Patients were classified into 3 categories: (1) No base suture, (2) monofilament barbed suture (2-0 V-Loc 180 absorbable suture, Medtronic, Minneapolis, MN), (3) polyglactin 910 (2-0 Vicryl coated suture, Ethicon Inc, Cincinnati, OH). In a secondary analysis, we evaluated suturing (Vicryl and V-Loc) vs no base suture. All patients had outer cortical renorrhaphy performed with 0-Vicryl suture utilizing the standard sliding clip technique.

RESULTS

One hundred ten patients (19.5%) had V-Loc suturing, 255 patients (45.3%) had Vicryl suturing, and 198 patients (35.2%) had no base suture. Patients had a median age of 62.8years (interquartile range: 53.5-69.7) and median RENAL score was 8 (6-9). Median mass size from preoperative imaging was 3.0 cm (2.5-4.0) for V-Loc, 3.3 cm (2.5-4.2) for Vicryl, and 2.0 cm (1.8-3.0) for no base suture (P < .001). Overall, 21 patients (3.7%) developed a symptomatic postoperative RAP. The rate of RAP was 3.6% (4/110) for V-Loc, 3.9% (10/255) for 2-0 Vicryl, and 3.5% (7/198) for no base suture (P = 1.00). Similarly, the rate of RAP was 3.5% (7/198) for no base suture and 3.8% (14/365) for base suture (P = 1.00).

CONCLUSION

Utilization of base suture and type of base suture used during RAPN was not predictive of postoperative RAP development.

Analysis of Transurethral Resection of Bladder Tumor Efficiency Utilizing Nonprocedural Operating Room Times

OBJECTIVE

To analyze the contribution of nonprocedural operating room (OR) times to transurethral resection of bladder tumor (TURBT) operative efficiency.

METHODS

Over a 24-month period, all nonprocedural OR times from TURBT surgeries performed at a single institution were prospectively collected. Nonprocedural times included: in-room to anesthesia release time, anesthesia release to cut time, and close to wheels out time. Procedural OR time was cut to close time. We also analyzed the impact of time of day on TURBT efficiency (morning vs afternoon). Comparisons between groups were made using the Wilcoxon rank sum test for continuous variables.

RESULTS

We identified 777 consecutive TURBT procedures from 2019 to 2020. The median total OR time was 63 minutes (interquartile range: 50-81 minutes). The nonprocedural time occupied a median of 49.4% of the total operating time (interquartile range: 38.9%-60.4%). Median anesthesia release to cut time was slower when 1 TURBT was performed a day compared to 2 or more (13 minutes vs 12 minutes, P = .04). Median close to wheels out time was faster when there was 1 TURBT in a day (7 minutes vs 8 minutes, P = .02). Median in-room to anesthesia release time was faster in the morning than it was in the afternoon (10 minutes vs 11 minutes, P = .02).

CONCLUSION

Nonprocedural times made up roughly half of the total TURBT operating time and should be considered in OR efficiency analyses. TURBT OR efficiency may be related to the number of TURBTs performed in a day as well as the time of day of TURBT start.

Conversion to Disposable Cystoscopes Decreased Post-procedure Encounters and Infections Compared to Reusable Cystoscopes

PURPOSE

To evaluate for differences in post-procedure 30-day encounters or infections following office cystoscopy using disposable versus reusable cystoscopes.

MATERIALS AND METHODS

Cystoscopies performed from June - September 2020 and February - May 2021 in our outpatient practice were retrospectively reviewed. The 2020 cystoscopies were performed with reusable cystoscopes and the 2021 cystoscopies were performed with disposable cystoscopes (Ambu Inc., Columbia, MD, USA). The primary outcome was the number of post-procedural 30-day encounters defined as phone calls, patient portal messages, emergency department visits, hospitalizations or clinic appointments related to post-procedural complications such as dysuria, hematuria, or fever. Culture-proven urinary tract infection within 30 days of cystoscopy was evaluated as a secondary outcome.

RESULTS

We identified 1,000 cystoscopies, including 494 with disposable cystoscopes and 506 with reusable cystoscopes. Demographics were similar between groups. The most common indication for cystoscopy in both groups was suspicion of bladder cancer [disposable: 153 (30.2%) and reusable: 143 (28.9%)]. Reusable cystoscopes were associated with a higher number of 30-day encounters [35 (7.1%) vs. 11 (2.2%), P < .001], urine cultures [73 (14.8%) vs. 3 (0.6%), P = .005], and hospitalizations attributable to cystoscopy [1 (0.2%) vs. 0 (0%), P<.001] than the disposable scope group. Positive urine cultures were also significantly more likely after cystoscopy with a reusable cystoscope [17 (3.4%) vs. 1 (0.2%), P < .001].

CONCLUSIONS

Disposable cystoscopes were associated with a lower number of post-procedure encounters and positive urine cultures compared to reusable cystoscopes.

Reducing Infection Rates with Enhanced Preoperative Diabetes Mellitus Diagnosis and Optimization Processes

OBJECTIVES

Hyperglycemia and increased preoperative hemoglobin A1c (HbA1c) are associated with perioperative morbidity and death. For nonurgent operations, adequate glycemic control before surgery is recommended. Our surgical practice needed a process for preoperative diabetes mellitus (DM) diagnosis and glycemic optimization.

METHODS

Our review of the existing preoperative evaluation process found that patients without a DM diagnosis but with random plasma glucose ≥200 mg/dL received no additional screening. Patients with DM routinely receive neither preoperative HbA1c screening nor DM management when HbA1c is ≥8.0%.

RESULTS

A new preoperative evaluation process was designed. HbA1c screening was automatically performed for patients with random plasma glucose ≥200 mg/dL. For patients with a DM diagnosis, an HbA1c test was performed. Specialty consultation was prompted for patients with known DM and HbA1c ≥8.0% and those with no DM diagnosis but HbA1c ≥6.5%. In the first year postimplementation, 9320 patients received a basic metabolic panel; 263 had random plasma glucose ≥200 mg/dL that triggered an HbA1c check. In total, 123 patients (99 with and 24 without a DM diagnosis) were referred to endocrinology; 13 received a new DM diagnosis. Twenty patients had surgery delayed for DM treatment. All of the patients received individualized medication instructions for the perioperative period. Among patients with random plasma glucose ≥200 mg/dL, incidence rates for surgical site infection pre- and postimplementation were 47.8/1000 and 3.8/1000 population.

CONCLUSIONS

The implemented process benefited patients scheduled for nonurgent procedures by optimizing glucose control and lowering infection rates through earlier preoperative DM diagnosis, glycemic management, and standardized patient medication instruction.

Validation of new baseline renal function predictive model in robotic-assisted partial nephrectomy cohort

OBJECTIVE

To validate a new baseline estimated glomerular filtration rate (NB-GFR) formula in a cohort of robotic-assisted partial nephrectomies (RAPN).

METHODS

NB-GFR = 35 + preoperative GFR (× 0.65) - 18 (if radical nephrectomy) - age (× 0.25) + 3 (if tumor size >7 cm) - 2 (if diabetes). NB-GFR was calculated in 464 consecutive RAPN from a single surgeon cohort. 143 patients were excluded secondary to insufficient eGFR follow up. We analyzed NB-GFR accuracy utilizing the last observed eGFR 3-12 months post RAPN. Categorical variables were summarized with the frequency and percentage of patients. Numerical variables were summarized with the median, 25^th percentile, and 75^th percentile.

RESULTS

The mean difference between observed and predicted NB-GFR was 4.6 ml/min/1.73m² (95% CI -6.9 to 16.1 ml/min/1.73m² ). There was a pattern of higher observed NB-GFRs being underestimated by the NB-GFR equation while lower observed NB-GFRs were overestimated by the NB-GFR equation. The NB-GFR formula had a high level of accuracy with 98.8% of predicted NB-GFRs falling within 30% of the observed NB-GFR (95% CI 86.8% to 99.5%). The median and interquartile range of the difference between observed and predicted NB-GFR was 3.9 ml/min/1.73m² (IQR 0.7 to 8.2 ml/min/1.73m² ). The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of predicted NB-GFR to identify those with an observed NB-GFR <60 ml/min/1.73m² after RAPN was 98%, 92%, 88%, and 99%, respectively.

CONCLUSION

The NB-GFR equation developed with partial and radical nephrectomy cohorts is accurate in predicting post-operative eGFR 3-12 months following RAPN.

Impact of SARS-CoV-2 (COVID-19) on Fixed Operating Room Times in Urologic Surgeries

Objective

To evaluate the impact of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, on operating room (OR) efficiency for urologic procedures using the concept of fixed OR times.

Patients and Methods

Over a 24-month period, urology OR data were prospectively collected. Operations were divided into fixed and variable time points. The fixed OR times were in-roomw to anesthesia-release time, anesthesia-release to cut time, in-room to cut time, and close to wheels-out time. Data from January 1, 2019, to December 31, 2019, were pre-COVID-19 data, and data from April 1, 2020, to December 31, 2020, were post-COVID-19 data. Operations were grouped into endoscopic, implant, major open, and robotic-assisted cases. In the post-COVID-19 era, all patients had a negative polymerase chain reaction test result within 48 hours of operation. The Wilcoxon rank sum test was used to compare the fixed OR times between the pre- and post-COVID-19 eras.

Results

A total of 3189 procedures were evaluated: 2058 endoscopic operations (1124 in the pre-COVID-19 era and 934 in the post-COVID-19 era), 343 implant procedures (192 in the pre-COVID-19 era and 151 in the post-COVID-19 era), 222 major open procedures (119 in the pre-COVID-19 era and 103 in the post-COVID-19 era), and 566 robotic-assisted procedures (338 in the pre-COVID-19 era and 228 in the post-COVID-19 era). There were no fixed OR times in any of the examined groups that were negatively impacted by COVID-19. The percentage of the total OR time occupied by fixed OR variables in the pre-COVID-19 era was 40.6% for endoscopic operations, 41.1% for implant procedures, 29.8% for major open procedures, and 21.8% for robotic-assisted procedures.

Conclusion

A substantial portion of the total OR time includes fixed time points. Furthermore, COVID-19 did not have a negative impact on fixed OR times in a negative testing environment. Urologic OR efficiency should be maintained in the post-COVID-19 era.

Novel plasma glycoprotein biomarkers predict progression-free survival in surgically resected clear cell renal cell carcinoma

INTRODUCTION

Limited data exists on utilization of protein post-translational modifications as biomarkers for clear cell renal cell carcinoma (ccRCC). We employed high-throughput glycoproteomics to evaluate differential expression of glycoprotein-isoforms as novel markers for ccRCC progression-free survival (PFS).

METHODS

Plasma samples were obtained from 77 patients treated surgically for ccRCC. Glycoproteomic analyses were carried out after liquid chromatography tandem mass spectrometry. Age-adjusted Cox proportional hazard models were constructed to evaluate PFS. Optimized Harrell's C-index was employed to dichotomize the collective for the construction of Kaplan-Meier curves.

RESULTS

The average length of follow-up was 3.4 (range: 0.04-9.83) years. Glycoproteomic analysis identified 39 glycopeptides and 14 non-glycosylated peptides that showed statistically significant (false discovery rate P ≤ 0.05) differential expression associated with PFS. Five of the glycosylated peptides conferred continuous hazard ratio (HR) of > 6 (range 6.3-11.6). These included prothrombin A2G2S glycan motif (HR = 6.47, P = 9.53E-05), immunoglobulin J chain FA2G2S2 motif (HR = 10.69, P = 0.001), clusterin A2G2 motif (HR = 7.38, P = 0.002), complement component C8A A2G2S2 motif (HR = 11.59, P = 0.002), and apolipoprotein M glycopeptide with non-fucosylated and non-sialylated hybrid-type glycan (HR = 6.30, P = 0.003). Kaplan-Meier curves based on dichotomous expression of these five glycopeptides resulted in hazard ratios of 3.9 to 10.7, all with P-value < 0.03. Kaplan-Meyer plot using the multivariable model comprising 3 of the markers yielded HR of 11.96 (P < 0.0001).

CONCLUSION

Differential glyco-isoform abundance of plasma proteins may be a useful source of biomarkers for the clinical course and prognosis of ccRCC.

Anatomical Engineering and 3D Printing for Surgery and Medical Devices: International Review and Future Exponential Innovations

Three-dimensional printing (3DP) has recently gained importance in the medical industry, especially in surgical specialties. It uses different techniques and materials based on patients' needs, which allows bioprofessionals to design and develop unique pieces using medical imaging provided by computed tomography (CT) and magnetic resonance imaging (MRI). Therefore, the Department of Biology and Medicine and the Department of Physics and Engineering, at the Bioastronautics and Space Mechatronics Research Group, have managed and supervised an international cooperation study, in order to present a general review of the innovative surgical applications, focused on anatomical systems, such as the nervous and craniofacial system, cardiovascular system, digestive system, genitourinary system, and musculoskeletal system. Finally, the integration with augmented, mixed, virtual reality is analyzed to show the advantages of personalized treatments, taking into account the improvements for preoperative, intraoperative planning, and medical training. Also, this article explores the creation of devices and tools for space surgery to get better outcomes under changing gravity conditions.

Analysis of Operating Room (OR) Efficiency During Robotic-Assisted Urologic Surgeries Utilizing Fixed (Nonprocedural) Operative Times

Objective: To analyze operating room (OR) efficiency by evaluating fixed OR times for three common urologic robotic-assisted procedures. Methods: Over a 24-month period, we prospectively collected intraoperative data for 635-consecutive robotic-assisted surgeries. Fixed (nonprocedural) OR times were evaluated for robotic-assisted partial nephrectomy (RAPN) (n=146), robotic-assisted radical cystectomy (RARC) (n=77), and robotic-assisted radical prostatectomy (RARP) (n=412). Fixed OR times were defined as nonprocedural time in the OR, including: in room time to anesthesia release time (IRAT), anesthesia release to cut time (ARCT), in room time to cut time (IRCT; IRAT + ARCT), and close time to wheels out time (CTWO). The effects of surgery time of day and the number of anesthesia personnel (AP) present in surgery on fixed OR times were also analyzed. Results: Fixed OR times occupied 15.1% (IQR: 12.9%-17.1%) (RARC), 26.6% (22.9%-30.8%) (RAPN), and 20.1% (17.4%-23.1%) (RARP) of total OR time. Time of day did not have a negative effect on fixed OR times for robotic urologic surgeries. Median AP count was highest for RARC (median: 3, range: 1-7). We did not find any association between AP count and fixed OR times for any of the procedures (P≥0.19). Conclusions: Fixed OR times made up a significant percentage of total OR time for robotic-assisted procedures and should be incorporated into OR efficiency analyses. The number of AP per case and time of day of surgery did not negatively impact fixed OR times in urologic robotic surgeries.

Evaluation of Routine Postoperative Labs Following Robotic Assisted Partial Nephrectomy in Patients With Normal Preoperative Renal Function

OBJECTIVE

To evaluate predictors of abnormal routine postoperative day 1 (POD1) labs in patients with normal pre-operative renal function following robotic assisted partial nephrectomy (RAPN) and the associated clinical outcomes of these lab results.

METHODS

We analyzed 500 consecutive RAPN from a single surgeon series. Patients with chronic kidney disease (CKD) III or greater were excluded from the study. Three hundred ninty-three RAPN were included in the analysis. Routine POD1 lab tests including hemoglobin (Hgb), creatinine, potassium, and sodium were evaluated to determine rates of abnormal values and rates of clinical intervention. Abnormal Hgb at POD1 was defined as <8 g/dL or ≥3 g/dL decrease from the preoperative (baseline) value. Abnormal sodium (Na) preoperatively and postoperatively was defined as <135 mEq/L or >145 mEq/L. Abnormal potassium (K) was defined preoperatively and POD1 as <3.5 mEq/L or >5 mEq/L.

RESULTS

Of 37.4% (147/393) had one or more abnormal labs at POD1. Of the 101 patients with abnormal Hgb, 15 patients required blood transfusion. Twenty-six patients had abnormal sodium for which two were treated with IV fluids. Twenty-seven patients had potassium abnormalities (12/25 were hypokalemia). Acute kidney injury stage I was seen in 27 patients (6.9%) and stage II in 3 (0.8%). Patients with abnormal labs were more likely to have larger renal mass, higher R.E.N.A.L. scores, intraoperative complications, longer operative times, and higher EBL on multivariate analysis.

CONCLUSION

POD1 serum laboratory tests appear to be necessary following RAPN in patients with normal pre-operative renal function.

Statin use and association with postoperative estimated glomerular filtration rates in patients undergoing robotic-assisted partial nephrectomy

OBJECTIVE

To evaluate the association between preoperative statin use with changes in estimated glomerular filtration rate (eGFR) following robotic-assisted partial nephrectomy (RAPN).

METHODS

389 consecutive patients undergoing RAPN were evaluated. Associations of preoperative statin use with change in eGFR from pre-RAPN to POD1, 1 month, 6 months, and 12 months after RAPN were evaluated using longitudinal mixed-effects regression models with random patient-specific intercepts and slopes while accounting for imbalance of preoperative patient and tumor characteristics between groups with stabilized inverse propensity score weighting. Post-operative eGFR change from baseline was measured as total change, maintaining eGFR within 10% of baseline, and as going from eGFR > 60 ml/min/1.73m2 to < 60 ml/min/1.73m2.

RESULTS

167 (43.0%) of 389 patients were on statin therapy preoperatively. Statin patients were older (66 vs. 58 years old) and had higher rates of comorbidities including diabetes mellitus (31.7% vs. 14.9%) and hypertension (82.6% vs. 45%). Statin patients tended to have lower preoperative eGFR (mean±SD, 71.1±17.6 vs. 77.4±19.4 ml/min/1.73m2). There was no evidence of an association of preoperative statin use with changes in eGFR at any time point following RAPN (P=0.66).

CONCLUSION

Patients on pre-operative statins undergoing RAPN had lower eGFR preoperatively compared to those not taking those medications. There was no evidence of an association between preoperative statin use and change in post-RAPN eGFR in the immediate post-operative period or at 1 year following surgery.

Evaluation of Peri-operative Outcomes Associated With Resident Involvement on Tumor Resection and Renorrhaphy During Robotic-assisted Partial Nephrectomy

OBJECTIVE

To evaluate perioperative outcomes of resident trainee involvement in tumor resection and renorrhaphy during robotic assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

We analyzed 500 consecutive RAPN in a single surgeon prospectively maintained database. Cases with resident performed tumor resection and renorrhaphy (N = 71) were case matched on R.E.N.A.L. score and RAPN year using a greedy matching algorithm. Perioperative variables were compared to attending cases.

RESULTS

There were no statistically significant differences in high grade postoperative complications (resident: 3% vs attending: 6%, P = .68), positive margins (resident: 1% vs attending: 3%, P = .31), length of stay (resident: 2.0 vs attending: 2.0 days, P = .73), and 30 day readmission (resident: 7% vs attending: 11%, P = .56). However, residents had a statistically significant longer warm ischemia time (median 21 vs 15 minutes, P <.001), thus less likely to achieve trifecta (66% vs 85%, P = .02). Resident involvement had longer median operative time (197 vs 184 minutes, P = .03). No statistically significant difference in functional volume loss (P = .12) or surface intermediate base margin score (P = .66) between residents and attending was found. No difference in post-operative creatinine change was found at 1 day and 1 month (resident: 0.2 vs attending: 0.1 mg/dL, P = .4 and resident: 0.1 vs attending: 0.1 mg/dL, P = .6, respectively).

CONCLUSION

Supervised resident console involvement in tumor resection and renorrhaphy during RAPN is safe and does not increase rates of complications. Residents have longer median warm ischemia time compared to attending only cases, but this does not appear to impact post-operative renal function.

Posterior tibial nerve stimulation: is ultrasound guided needle placement more accurate?

INTRODUCTION To compare the accuracy of the transcutaneous ultrasound (US) in detecting the tibial nerve (TN) as opposed to digital palpation in the performance of posterior tibial nerve stimulation (PTNS).

MATERIALS AND METHODS

After Institutional Review Board (IRB) approval, 25 adults were enrolled to quantify the difference in position of the distal TN by the use of US as opposed to cutaneous palpation. The position of the TN was determined first by the palpation method and then by using a L12-4MHz high frequency Linear Array Transducer. The difference in position between the two methods was determined in both proximal-distal (PD [Knee-Sole]) and anterior-posterior planes (AP). Statistical analysis was completed with numeric variables summarized with the sample median, range, and interquartile range (IQR). Categorical variables were summarized with the number and percentage of patients. Comparisons between AP and PD distances were performed using a nonparametric Wilcoxon signed rank test. Box and whisker plots were used to display individual observations graphically. All analyses and graphics were performed using SAS statistical software (version 9.4M5, SAS Institute Inc., Cary, NC, USA).

RESULTS

Twenty-five patients were studied. The median AP distance between US and digital palpation was 2 mm (range, 0-5 mm; IQR, 2-3 mm). The median PD distance between US and digital palpation was 4 mm (range, 0-9 mm; IQR, 3-5 mm). The median difference between the AP and PD distances was 2 mm (range, -3-7 mm; IQR, 0-4 mm, p < 0.001).

CONCLUSION

The use of US identifies the nerve with statistically significant greater accuracy than palpation technique along the PD plane.

Perioperative Resumption of Direct Oral Anticoagulants: Review of the Mayo Clinic Experience

OBJECTIVE

We aimed to review recommendations for the postoperative resumption of direct oral anticoagulants (DOACs) and report complications 30 days postoperatively.

METHODS

We retrospectively reviewed patients receiving DOAC therapy who underwent preoperative evaluations from January 1, 2015 through May 30, 2018. We noted days that DOAC therapy was withheld, postoperative time until resumption of the DOAC, and complications within 30 postoperative days.

RESULTS

A total of 317 patients were included. Ten had complications. Complication rates among patients stratified by time to resumption were not significantly different, except for the deep vein thrombosis rate when DOACs were resumed after 72 hours (n = 2 [4.17%]; P = 0.02). The total time without DOACs did not affect the complication rates.

CONCLUSIONS

We suggest withholding DOACs for 48 to 72 hours before surgery and resuming them 48 to 72 hours after surgery, if safe. The interruption of therapy was not associated with an increase in thrombotic events for patients who resumed DOACs within 72 hours postoperatively. Patients who resumed DOACs after 72 hours postoperatively had a low rate of thrombotic complications.

Fat Necrosis Mimicking Renal Cell Carcinoma Recurrence Following Cryotherapy, Partial Nephrectomy, and Nephrectomy

OBJECTIVE

To present our experience with three patients surgically treated for suspected recurrent renal cell carcinoma whose final pathology was consistent with tumefactive fat necrosis.

METHODS

Three patients underwent definitive therapy for biopsy proven renal cell carcinoma (cryoablation, partial nephrectomy, and nephrectomy) and later demonstrated evidence of recurrent renal cell carcinoma on follow up imaging. All three patients underwent surgical resection of the suspected recurrences with final pathology consistent with tumefactive fat necrosis.

RESULTS

The three patients were 60, 74, and 39-years old, respectively. The previous definitive therapies for renal cell carcinoma were percutaneous ablation, RAPN, and nephrectomy. Each patient had previous surgical pathology that confirmed prior renal cell carcinoma. Signs of recurrence on diagnostic imaging occurred 2 years, 23 months, and 8 months post-definitive therapy.

CONCLUSION

In patients with a history of renal cell carcinoma, consideration of fat necrosis should be taken into account upon seeing imaging concerning for tumor recurrence. Continued analysis of cases with such a diagnosis will be beneficial in recognizing this possibility to avoid unnecessary surgery or therapy when possible.

Association of Ancillary Pathology Findings in Non-neoplastic Renal Parenchyma and Renal Outcomes of Robotic-Assisted Partial Nephrectomy

Background: To evaluate robotic-assisted partial nephrectomy (RAPN) renal outcomes associated with ancillary pathology findings in non-neoplastic renal parenchymal tissue. Methods: Tissue samples from 378 RAPNs were analyzed for glomerular disease (GD), vascular disease (VD), and tubulointerstitial disease (TD). One hundred and fifty-two patients were excluded due to insufficient non-neoplastic tissue for analysis and 4 patients were excluded due to calyceal diverticulum. Non-neoplastic tissue was evaluated for GD (negative, moderate, or global), VD (absent, mild, moderate, or severe), and TD (present or absent). Associations of ancillary pathology factors with patient characteristics were explored using the non-parametric Kendall tau-test and propensity score adjusted longitudinal mixed effects regression models were used to evaluate associations of these pathology factors with changes in estimated glomerular filtration rate (eGFR) following RAPN. Results: One hundred and fifty-three (68.9%) patients had hypertension and 50 (22.5%) patients had diabetes. The majority of patients did not have any GD (N = 158, 71.2%) or TD (N = 186, 83.8%) while 129 (58.1%) had VD. VD was categorized as absent (N = 93, 41.9%), mild (N = 45, 20.3%), moderate (N = 76, 34.2%), and severe (N = 8, 6.8%). Older age (P = 0.018), hypertension (P < 0.001), and high grade MAP score (P = 0.047) were associated with a higher number of ancillary pathology factors. High grade MAP score (P = 0.03, P = 0.002) and hypertension (P = 0.02, P < 0.001) were individually associated with GD severity and VD severity, respectively. Older age was also individually associated with VD severity (P = 0.002) and hypertension was associated with TD (P = 0.04). Moderate-to-severe VD was associated with a worse change in eGFR from pre-RAPN to 1-month post-RAPN compared to those with mild or no VD (difference in mean change, -3.4 ml/kg/1.73m²; 95% CI, -6.6 to -0.2 ml/kg/1.73m²; P = 0.036). Conclusions: Moderate-to-severe VD in non-neoplastic renal parenchyma is associated with post-operative changes in eGFR. Older age, hypertension, and high grade MAP scores are associated with the number of ancillary pathologies observed in RAPN specimens.

Validation of the Mayo Adhesive Probability score as a predictor of adherent perinephric fat and outcomes in open partial nephrectomy

Background

Adherent perinephric fat (APF) contributes to surgical complexity and can be associated with adverse perioperative outcomes for partial nephrectomy (PN). The Mayo Adhesive Probability (MAP) score accurately predicts the presence of APF during robotic-assisted partial nephrectomy (RAPN). Our primary aim is to validate MAP score as a predictor of APF in open partial nephrectomy (OPNx).

Methods

We reviewed 105 consecutive OPNx (100 patients) performed by a single surgeon with intraoperative determination of APF. We evaluated the ability of the MAP score to discriminate between those with APF and those without APF by estimating the area under the receiver operating characteristic curve (AUROCC). The association of perioperative outcomes with APF was evaluated as well.

Results

Forty-three patients [49%; 95% confidence interval (CI), 39–59%] had intraoperative identification of APF. The MAP score had excellent ability to predict APF in OPNx (AUROCC, 0.82; 95% CI, 0.74–0.92). APF was observed in 6% of patients with a MAP score of 0-1, 27% with score 2, 52% with score 3, 75% with score 4, and 90% with score 5. The presence of APF was associated with longer operative times (P=0.004) and higher estimated blood loss (EBL) (P=0.003). Although not statistically significant, our study did suggest that APF may be associated with postoperative complications and prolonged length of stay (LOS) (>3 days).

Conclusions

MAP score accurately predicts the presence of APF in patients undergoing OPNx. APF is associated with longer operative time and higher blood loss in OPNx.

Retrospective Evaluation of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers on Postoperative Estimated Glomerular Filtration Rates Following Robotic-Assisted Partial Nephrectomy

Objective: To evaluate the association between the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) preoperatively with changes in estimated glomerular filtration rate (eGFR) after robotic-assisted partial nephrectomy (RAPN). Methods: Patients undergoing RAPN at our institution from February 2008 through April 2019 were evaluated. ACEIs/ARBs were held on the morning of the surgery and resumed on postoperative day number one in all patients. Associations of ACEIs/ARBs use with postoperative eGFR were explored by using a linear mixed-effects regression model with random patient-specific intercepts. We included eGFR measurements at the following time points: preoperatively, postoperative day 1 (POD1), 1 month postoperative, 6 months postoperative, and 12 months postoperative. p-Values <0.05 were considered statistically significant. Results: One hundred and seventy-one (44.0%) of 389 patients were on ACEIs/ARBs therapy preoperatively. The ACEIs/ARBs patients were older and had higher rates of comorbidities, including diabetes mellitus. The ACEIs/ARBs patients tended to have lower preoperative eGFR (mean ± standard deviation, 70.4 ± 17.5 vs 78.0 ± 19.2 mL/minute/1.73 m²; p < 0.001). However, this was not significant after adjustment for potentially confounding variables (mean difference, -1.7 mL/minute/1.73 m²; 95% confidence interval, -6.4 to 3.1 mL/minute/1.73 m²; p = 0.48). There was no evidence of an association of ACEIs/ARBs use with postoperative renal function after adjustment for potentially confounding variables (adjusted mean difference in change in eGFR from baseline was -1.1, -1.2, -0.3, and -1.2 mL/minute/1.73 m² at POD1, 1, 6, and 12 months, respectively; all p ≥ 0.51). Conclusion: Continuation of ACEIs and ARBs throughout the perioperative period is not associated with change in post-RAPN eGFR.

Independent external validation of a nomogram to define risk categories for a significant decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy

OBJECTIVE

To validate the Martini nomogram predicting the decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy.

METHODS

Estimated glomerular filtration rate of 406 patients from a single surgeon series was calculated before robotic-assisted partial nephrectomy and at postoperative intervals. To determine the risk group, we calculated the total score and corresponding risk of significant estimated glomerular filtration rate reduction at 15 months using the Martini nomogram. The primary outcome was a reduction in estimated glomerular filtration rate of ≥25% from preoperative levels between 1 and 12 months after surgery.

RESULTS

The median length of follow up for this study was 12 months (interquartile range 6-12 months). Overall, 134 (33%) patients were in the low-, 143 (35%) in the intermediate-, 119 (29%) in the high- and 10 (2%) in the very high-risk groups. The Kaplan-Meier estimates for the probability of significant estimated glomerular filtration rate reduction by 12 months after robotic-assisted partial nephrectomy was 12.9% in the low-risk group, 24.0% in the intermediate-risk group, 49.7% in the high-risk group and 40.0% in the very high-risk group. Harrell's C-index for discriminating between those with and without a significant reduction in estimated glomerular filtration rate 1-12 months after robotic-assisted partial nephrectomy was 0.73 (95% confidence interval 0.68-0.78).

CONCLUSIONS

The risk groups proposed by the Martini nomogram are accurate in predicting those at higher risk for a >25% decline in postoperative estimated glomerular filtration rate after robotic-assisted partial nephrectomy at 12 months.

Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review

BACKGROUND

Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes.

METHODS

Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics.

RESULTS

There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (β = - 0.16, p < 0.001) and for each specialty (GS: β = - 0.18, p < 0.001; CRS β = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

Determinants and Implications of Excised Parenchymal Mass on Robotic-Assisted Partial Nephrectomy Outcomes

OBJECTIVES

To evaluate the association between excised parenchymal mass (EPM) and postoperative renal function (eGFR) following robotic-assisted partial nephrectomy (RAPN). EPM is the amount of healthy renal parenchyma excised during partial nephrectomy in order to achieve safe surgical margins.

METHODS

We evaluated 406 consecutive RAPN performed by a single surgeon to eliminate variations in technique as a factor in EPM. EPM (mL) = (specimen volume * π/6) - (tumor volume * π/6). RENAL score was categorized as easy (4-6), moderate (7-9), or hard (10-12). EPM was grouped into four categories: ≤ 3.9 mL, 4.0-9.9 mL, 10.0-17.7 mL, and >17.7 mL. eGFR was evaluated preoperatively, postoperative day 1 (POD1), 1 month, and 6 months postoperatively.

RESULTS

Median age was 63 years (22-84 years), 252 (62.1%) were male, and median EPM was 9.9 mL (interquartile range 3.9 to 17.7 mL). The median EPM and interquartile range for each RENAL category was 3.7 mL (2.0, 7.9), 12 mL (5.7, 19.4), and 16.2 mL (7.9, 24.3), respectively. Higher EPM was associated with worse changes in eGFR at POD1 (P = 0.005) and 1 month after RAPN (P = 0.002) but was not statistically significant at the 6-month time period (P = 0.35) CONCLUSION: Increased tumor complexity is associated with an increase in EPM during RAPN. Increased EPM is associated with eGFR decline at POD1 and 1 month post RAPN but not at 6 months postoperatively.

Assessment of Advanced Perioperative Outcomes to Identify the True Learning Curve of Robotic-assisted Partial Nephrectomy

OBJECTIVES

To evaluate the learning curve of robotic-assisted partial nephrectomy as it pertains to operative time (OT) and advanced perioperative variables such as achievement of trifecta, postoperative complications, 30-day readmission rates (RR), warm ischemia time (WIT), and functional volume loss (FVL).

METHODS

We evaluated 418 consecutive robotic-assisted partial nephrectomy performed by a single surgeon between February 2008 and April 2019. Multivariable log-log regression models were used to evaluate the associations between case number and continuous outcomes (OT, WIT, and FVL). Multivariable logistic regression models were used to evaluate the association of case number with dichotomous outcomes (trifecta, postoperative complications, RR).

RESULTS

Among the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22-84), and median body mass index was 29 kg/m² (interquartile range 26-33). Surgeon experience was associated with shorter OT (-2.5% per 50% increase in case number; 95% confidence interval; P <.001) and plateaus around 77 cases performed. There was slight improvement with trifecta (odds ratio [per 50% increase in cases] = 1.08; 95% confidence interval) and the plateau was also at 77 cases, however, this was not statistically significant (P = .086). We did not find statistically significant associations of surgeon experience with FVL (P = .77), postoperative complications (P = .74), WIT (P = .73), or 30-day RR (P = .33).

CONCLUSION

There does not appear to be a relationship between surgical experience and grade 3 or higher postoperative complications, 30-day RR, WIT, or FVL. Trifecta outcomes and maximum OT performance appear to be optimized at approximately 77 cases.

Self-Reported Allergy to Thyroid Replacement Therapy: A Multicenter Retrospective Chart Review

OBJECTIVE

To determine patterns of adverse drug reactions (ADRs), including immediate drug hypersensitivity reactions (DHRs) and predictable ADRs, to thyroid replacement therapy (TRT). TRT is the treatment of choice for hypothyroidism. Levothyroxine (LT4) is among the most commonly prescribed medications in the United States, with over 70 million prescriptions annually. Documented immediate DHRs to TRT are rare, with only a few case reports.

METHODS

An 11-year (2008-2018) retrospective medical chart review of identified patients with self-reported allergy to TRT. ADRs to TRT were divided into immediate DHRs and predictable ADRs.

RESULTS

A total of 466 patients were included in our study. We found an overall incidence of ADRs to TRT of 0.3%. Median age was 61.2 years; 85.8% were women, and 94.4% were Caucasian. The principal indication for TRT was autoimmune hypothyroidism (73.6%), followed by postsurgical hypothyroidism (17.4%) and subclinical hypothyroidism (6.7%). Predictable ADR manifestations to TRT were reported more commonly than DHR manifestations (57.5% vs. 42.5%, respectively). The most frequently reported of the former were palpitations (16.4%), nausea/vomiting (9.3%), and tremor (6.3%), while rash (23.8%), hives (9.5%), and pruritus (7.1%) were the most common regarding the latter. Fifty-six percent of the patients with an ADR to TRT tolerated an alternative TRT presentation.

CONCLUSION

In our cohort, the majority of self-reported allergies to TRT were due to predictable ADRs rather than an immediate DHR.

ABBREVIATIONS

ADR = adverse drug reaction; DHR = drug hypersensitivity reaction; FDA = Food and Drug Administration; LT3 = liothyronine; LT4 = levothyroxine; SCAR = severe cutaneous adverse drug reaction; TRT = thyroid replacement therapy.

Perioperative Outcomes of Laparoscopic Radical Nephrectomy for Renal Mass in Patients on Dialysis or with Renal Transplant in Place Compared to Normal Controls

Background: The risk of renal cell carcinoma (RCC) development in the native kidney of patients on dialysis or with a renal transplant is increased compared to the general population. This study examines perioperative outcomes of laparoscopic radical nephrectomy (LN) in dialysis patients or renal transplant patients compared to normal controls. Methods: Four hundred twelve consecutive LN were evaluated (July 2007 to October 2018). Patients were divided into three groups (control, dialysis, and transplant). Perioperative outcomes, including operating room time (OT), postoperative complications, hospital length of stay, and 90-day readmission rates, were evaluated for the three groups. Results: There were 62 patients in the dialysis group, 20 renal transplants, and 330 normal controls. Dialysis patients were younger (median: 58 years versus 67 years; P = .002) and predominantly male (73% versus 59%, P = .047). Dialysis patients compared to controls had shorter total OT (median: 133 versus 149; P = .022), more papillary RCC (27% versus 10%; P < .001), and fewer high grade tumors (73% [8/11] versus 94% [100/106]; P = .038). Renal transplant patients had a higher rate of 90-day readmission (20% versus 6%; P = .034) and more papillary RCC (30% versus 10%; P = .016) compared to controls. Conclusion: LN on dialysis patients does not alter expected perioperative outcomes compared to a large cohort of control LN. LN on renal transplant patients carries a higher 90-day readmission rate than control LN.

Improving Value of Care: Cessation of Screening Urine Culture Prior to Orthopedic and Spinal Surgery

Objective

To assess the impact of cessation of screening urine cultures on surgical site infection (SSI) incidence in clinical practice.

Patients and Methods

Our study included patients undergoing hip replacement, knee replacement, spinal fusion, and laminectomy 12 months before (preintervention) and after (postintervention) cessation of preoperative screening urine cultures on June 1, 2017, at our institution. Urine cultures and urinalyses performed within 30 days before surgery during the 12 months before and after cessation were reviewed. SSI surveillance was performed in accordance with the methods of the National Healthcare Safety Network.

Results

A total of 2754 patients were included (1286 preintervention and 1468 postintervention). In the preintervention period, 1141 urine cultures were performed, compared to 153 in the postintervention period; 35 and 6 episodes of asymptomatic bacteriuria were treated, respectively. The occurrence of SSI did not differ noticeably between time periods (1.2% vs 0.7%, P=.24), and quarterly incidences of SSI were unchanged. The rate of SSI was significantly lower in the postintervention period for laminectomy (3.0% vs 0.3%, P=.02).

Conclusion

An 86.6% (153 vs 1141) reduction in screening urine cultures over a 12-month period was associated with a reduction of 988 unnecessary urine cultures, an 82.8% (6 vs 35) decline in inappropriate antibiotic treatment of asymptomatic bacteriuria, and no increase in SSI incidence after hip replacement, knee replacement, spinal fusion, or laminectomy procedures. No value of screening urine cultures before clean surgery was identified.