Brian Duty

The Comparison of Three Renal Tumor Scoring Systems: C-Index, P.A.D.U.A., and R.E.N.A.L. Nephrometry Scores

BACKGROUND AND PURPOSE The centrality-index (C-Index), preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification, and radius.exophyic/endophytic.nearness.anterior/posterior.location (R.E.N.A.L.) nephrometry schemes were developed as standardized scoring systems (SS) to quantify anatomic characteristics of kidney tumors. The objective of this study was to establish reliability and assess relationships between these three SS and perioperative and postoperative variables. PATIENTS AND METHODS A retrospective chart review was performed in 101 patients who underwent laparoscopic partial nephrectomy. The nephrometry schemes were correlated with intraoperative and postoperative parameters using Spearman correlations. In addition, interobserver reliability was assessed on 50 of the patients by interclass correlations comparing the scores assigned by two residents and one fellow who reviewed preoperative CT studies of these patients. RESULTS The interobserver correlation was 0.84 for the C-Index, 0.81 for the P.A.D.U.A., and 0.92 for the R.E.N.A.L. scoring systems, demonstrating excellent interobserver reliability. All three SS were significantly associated with warm ischemia time (WIT) (C-Index, P=-0.44; P.A.D.U.A., P=0.25; R.E.N.A.L., P=0.32) and percent change in creatinine level (C-Index, P=- 0.33; P.A.D.U.A., P=0.37; R.E.N.A.L., P=0.37). There were no significant associations between any of the three SS assessed and the occurrence of complications, operative time, or estimated blood loss. No significant correlation was found between the P.A.D.U.A. and R.E.N.A.L. SS and length of stay; however, C-Index did show a significant relationship for patients with lower scores having longer hospital stays (P=-0.21). CONCLUSIONS All three scoring systems demonstrated reliability among observers and represent novel methods of quantitatively describing renal tumors. They were all associated with WIT, percent change in creatinine level, and tumor size. They did not, however, correlate with any other perioperative parameters investigated. At this time, these SS provide a common language for describing renal tumors.

Anatomical Variation Between the Prone, Supine, and Supine Oblique Positions on Computed Tomography: Implications for Percutaneous Nephrolithotomy Access

OBJECTIVE To determine anatomical variations between the prone, supine, and supine oblique positions that are likely to affect percutaneous renal access. MATERIAL AND METHODS Twenty patients underwent computed tomography urograms in the supine and prone positions. Twenty patients underwent supine oblique and prone scans. Mean nephrostomy tract length, maximum access angle, and anterior-posterior renal position were calculated. RESULTS Mean nephrostomy tract length was shorter in the prone position (82.6 mm right kidney, 85.4 mm left kidney) compared with the supine position (108.3 mm right kidney, P<.001; 103.7 mm left kidney, P<.001). Prone tract length was also shorter than supine oblique tract length (86.1 mm vs 96.5 mm; P=.048). Mean maximum access angle was significantly greater (P=.018 right kidney; P=.007 left kidney) in the prone position (right kidney 99.7°, left kidney 104.0°) compared with the supine position (right kidney 87.7°, left kidney 89.4°). The same was true for the prone compared with the supine oblique position (75.8° vs 58.7°; P=.004). No difference was noted in anterior-posterior renal position between the supine and prone positions (20.3 mm vs 26.7 mm; P=.094) or supine oblique and prone positions (22.8 mm vs 15.6 mm; P=.45). CONCLUSIONS The prone position is associated with a significantly shorter nephrostomy tract length and more potential access sites, which may improve ease and safety of percutaneous renal access.

The debate over percutaneous nephrolithotomy positioning: a comprehensive review.

PURPOSE We summarized the arguments for and against prone and supine percutaneous nephrolithotomy, and determined whether any clinical characteristics warrant 1 position over the other. MATERIALS AND METHODS We searched PubMed® for articles on prone anesthesia, abdominal organ movement between the prone and supine positions, and percutaneous nephrolithotomy case series since 1998. RESULTS The prone position is associated with a decrease in the cardiac index and an increase in pulmonary functional residual capacity. An increased risk of liver and spleen injury exists for upper pole puncture with the patient supine. Potential injury to the colon is greatest during prone lower pole access. A greater surface area for percutaneous access exists with the patient prone. The supine position decreases surgeon radiation exposure and promotes spontaneous stone drainage during the procedure. Two comparative series show that the supine position is associated with significantly shorter operative time. In contrast, noncomparative case series suggest decreased operative time and blood loss when treating staghorn calculi with the patient prone. CONCLUSIONS Each position is feasible but more randomized studies are needed to accurately determine the relative efficacy and morbidity of the 2 positions.

Management of urolithiasis in patients after urinary diversions

What’s known on the subject? and What does the study add?

Live Surgical Demonstrations: An Old, but Increasingly Controversial Practice

OBJECTIVE To survey a group of leading academic urologists from North America and abroad about their opinions regarding the educational value, safety, and ethics of live surgical demonstrations. MATERIALS AND METHODS An anonymous survey pertaining to live clinical demonstrations was sent to all active members of the American Association of Genitourinary Surgeons (AAGUS). RESULTS Ninety (50%) members completed the survey. Most respondents had performed at least one live surgical demonstration (93.2% at away institution, 81.5% at home institution). Overall anxiety level as a visiting professor was rated as moderate, high, and very high by 29.8%, 25.0%, and 17.9% of respondents, respectively. Anxiety while performing demonstrations at ones home institution was reported as moderate, high, and very high by 28.2%, 9.9%, and 8.5% of respondents, respectively. Excessive conversation in the operating room was cited as a major distraction by 41.3% of respondents. Concern over the appropriateness of selected cases was reported often (43.9%) and always (13.4%) of the time. Only 28.2% of AAGUS members would let a visiting faculty member operate on them or a family member. Most (70.9%) respondents felt live surgical demonstrations are morally ethical, but only 30.1% stated they should continue indefinitely in their present form. CONCLUSION No studies have been published within the urological literature about live operative demonstrations. Results from the present survey support concerns within the cardiothoracic and endoscopy literature about the continued use of live operative demonstrations. A formal review culminating in the development of an explicit policy statement by urologists should be undertaken.

The Current Role of Endourologic Management of Renal Transplantation Complications

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.

Resection of the Inferior Vena Cava Without Reconstruction for Urologic Malignancies

OBJECTIVES To present our experience with inferior vena cava (IVC) resection in 6 patients. Complete surgical excision of tumors within the retroperitoneum may afford patients their best chance at long-term disease-free survival. In rare instances, surgical therapy may require resection of the IVC. METHODS Between 2005 and 2008, a total of 6 patients underwent caval resection. The median age of the patients was 47 years (range 26-66 years). Three patients had metastatic germ cell tumors within the retroperitoneum and underwent postchemotherapy retroperitoneal lymph node dissection. Two patients had transitional cell carcinoma and 1 had renal cell carcinoma of the right kidney, which were treated by radical nephrectomy. The infrarenal IVC was removed in 5 patients and the infrahepatic cava in the remaining patient. The IVC was not reconstructed in any patient. RESULTS Mean length of stay was 10 days (range 7-17 days). Five complications were noted in 2 patients. Complications included pneumothorax, lower-extremity compartment syndrome, right upper-extremity brachial plexus stretch injury, and respiratory failure in 1 patient and atrial fibrillation in another. No complications occurred in the remaining patients. Chronic lower extremity edema was not encountered in any patient. At present, all 3 patients with testicular cancer are disease-free. Of the 3 patients with kidney cancer, 2 died of disease progression and the remaining patient has metastatic disease. CONCLUSIONS IVC resection without reconstruction is well tolerated in patients with large retroperitoneal masses because most patients have well-established collaterals before surgery due to pre-existing caval obstruction. Multiple variables have been correlated with improved prognosis in cancer patients. One of the factors most important to surgical oncologists is complete tumor resection at the time of initial extirpative surgery. Complete excision of tumors within the retroperitoneum may require resection of major vascular structures, including the IVC.

Venous resection in urological surgery.

PURPOSE Complete removal of retroperitoneal and pelvic tumors may require resection or ligation of major retroperitoneal, pelvic and mesenteric venous structures. We provide an overview of venous anatomy and collateral drainage, and review the veins that can be safely resected. MATERIALS AND METHODS We reviewed major anatomical texts, and performed a directed MEDLINE literature search of retroperitoneal, pelvic and mesenteric venous anatomy. Resection and reconstruction of these vessels were also reviewed with an emphasis on collateral blood flow and post-resection sequelae. RESULTS The infrarenal inferior vena cava, iliac veins, left renal vein, lumbar veins, inferior mesenteric vein and splenic vein may be resected or ligated without reconstruction. Resection of the right renal vein results in renal demise in the majority of instances. The portal vein may not be resected without reconstruction. Venous reconstruction may be performed with autologous or synthetic graft material. CONCLUSIONS Most major veins in the body can be safely resected or ligated with minimal sequelae. However, it is imperative to understand venous anatomy and collateral blood flow to minimize intraoperative and postoperative complications.

Medical malpractice in endourology: analysis of closed cases from the State of New York.

PURPOSE Medical malpractice indemnity payments continue to rise, resulting in increased insurance premiums. We reviewed closed malpractice claims pertaining to endourological procedures with the goal of helping urologists mitigate their risk of lawsuit. MATERIALS AND METHODS All closed malpractice claims from 2005 to 2010 pertaining to endourological procedures filed against urologists insured by the Medical Liability Mutual Insurance Company of New York were examined. Claims were reviewed for plaintiff demographics, medical history, operative details, alleged complication, clinical outcome and lawsuit disposition. RESULTS A total of 25 closed claims involved endourological operations and of these cases 10 were closed with an indemnity payment. The average payout was

Difficulties with access in percutaneous renal surgery

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