Clinton D. Bahler

Emerging Trends in Robotic Pyeloplasty for the Management of Ureteropelvic Junction Obstruction in Adults

PURPOSE We evaluated trends and associated characteristics in the use of robotics for pyeloplasty as treatment for ureteropelvic junction obstruction. MATERIALS AND METHODS Data from the Nationwide Inpatient Sample were used to evaluate pyeloplasty trends from 2005 to 2010. Patients treated with pyeloplasty and procedure method (robotic, laparoscopic or open) were identified by ICD-9-CM codes. Coding for robotics was initiated in the fourth quarter of 2008. Multivariable analysis was performed to examine characteristics affecting the odds of undergoing robotic pyeloplasty vs other approaches to pyeloplasty. RESULTS We identified 3,947 pyeloplasties performed between 2005 and 2010, including 1,642 since the fourth quarter of 2008. There was a statistically significant increase in the number of robotic pyeloplasties (p <0.001). Mean total charges for robotic vs nonrobotic procedures were

Feasibility of omitting cortical renorrhaphy during robot-assisted partial nephrectomy: a matched analysis.

40,200 vs

Correcting the Shrinkage Effects of Formalin Fixation and Tissue Processing for Renal Tumors: toward Standardization of Pathological Reporting of Tumor Size.

37,817 (p = 0.106). Characteristics related to undergoing a robotic procedure included surgery at a teaching hospital (OR 1.29, 95% CI 1.04-1.59, p = 0.021) and in the Northeast (OR 1.54, 95% CI 1.17-2.04, p = 0.002) or Midwest (OR 1.62, 95% CI 1.23-2.12, p <0.001) compared with the South. When the primary payer was Medicaid vs private insurance, patients were 46% less likely to undergo the procedure robotically (p <0.001). There was no significant difference in charges between robotic and open pyeloplasty. CONCLUSIONS The number of robotic pyeloplasties performed quarterly in the United States is increasing, although there are disparities in the adoption of the robotic approach among geographic regions and hospital types.

The Role of R.E.N.A.L. Nephrometry Score in the Era of Robot-Assisted Partial Nephrectomy

BACKGROUND AND PURPOSE To assess the safety of omitting cortical renorrhaphy during robot-assisted partial nephrectomy and measure preliminary functional outcomes. PATIENTS AND METHODS Fifteen robot-assisted partial nephrectomies were performed with a running, base-layer suture for the collecting system and vessel hemostasis but without cortical renorrhaphy. The nonrenorrhaphy group was matched 1:2 by R.E.N.A.L. nephrometry score to a running, sliding-clip cortical renorrhaphy group retrospectively. Intraoperative blood loss, urine leaks, postoperative bleeds, and functional outcomes were evaluated. Predictors of %volume loss were evaluated using multivariable regression. RESULTS No differences were seen between renorrhaphy and nonrenorrhaphy in sex (P=0.53), age (P=0.14), body mass index (P=0.08), Charlson score (P=0.44), tumor diameter (P=0.55), nephrometry score (P=0.77), preoperative glomerular filtration rate (GFR, P=0.63), or the amount of resected healthy kidney margin (P=0.21). Warm ischemia time was less for the nonrenorrhaphy group (P<0.002). One pseudoaneurysm necessitating embolization (1/30=3%) was seen in the renorrhaphy group compared with none in the nonrenorrhaphy group. No urine leaks occurred in either group. The median %GFR loss was 8.8% for renorrhaphy and 4.4% for nonrenorrhaphy (P=0.14) at a median follow-up of 4.1 months. The median %volume loss was 17 cm(3) for renorrhaphy and 9 cm(3) for nonrenorrhaphy (P=0.003). In a multivariable model, both cortical renorrhaphy (P=0.004) and tumor diameter (P=0.004) were predictors of %volume loss. CONCLUSION Omission of cortical renorrhaphy appears feasible with no urine leaks or bleeding complications observed. The percent renal volume loss was improved by omission of cortical renorrhaphy. Reconstruction technique is important to control for when studying renal function after partial nephrectomy.

Mediastinal fibrosis in a patient with idiopathic retroperitoneal fibrosis

Given the importance of correctly staging renal cell carcinomas, specific guidelines should be in place for tumor size measurement. While a standard means of renal tumor measurement has not been established, intuitively, tumor size should be based on fresh measurements. We sought to assess the accuracy of postfixation and microscopic measurements of renal tumor size, as compared to fresh measurements and radiographic size. Thirty-four nephrectomy cases performed by a single surgeon were prospectively measured at different time points. The study cases included 23 clear cell renal cell carcinomas, 6 papillary renal cell carcinomas, and 5 other renal tumors. Radiologic tumors were 12.1% larger in diameter than fresh tumors (P<0.01). Furthermore, fresh specimens were 4.6% larger than formalin-fixed specimens (P<0.01), and postfixation measurements were 7.1% greater than microscopic measurements (P<0.01). The overall mean percentage of shrinkage between fresh and histological specimens was 11.4% (P<0.01). Histological processing would cause a tumor stage shift from pT1b to pT1a for two tumors in this study. The shrinkage effects of formalin fixation and histological processing may result in understaging of renal cell carcinomas. The shrinkage factor should be considered when reporting tumor size.

Long-term Outcomes of Robot-assisted Laparoscopic Pyeloplasty for Ureteropelvic Junction Obstruction

PURPOSE We studied the role of the R.E.N.A.L. nephrometry score (NS) in predicting surgical outcomes in a series of robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS Of 99 cases of minimally invasive partial nephrectomy performed by a single surgeon from 2003 to 2011, 83 were performed with robotic assistance. A trained physician investigator applied the NS to these 83 cases using the preoperative CT scans. Forty-two of these were reviewed by a urology resident to eliminate interobserver variation. Tumors were categorized into noncomplex (NS 4-6) or complex (NS 7-12) tumors, and perioperative outcomes were compared. Outcomes were also compared by each component of the NS. Perioperative outcomes were analyzed using chi-square tests and Mann-Whitney/Kruskal-Wallis tests. Univariate regression was used to analyze trends between nephrometry and outcomes. RESULTS Strong correlation was found between the two sets of NS (Spearman correlational coefficient 0.814, P<0.001). Comparing between noncomplex and complex tumors, statistical differences were found in operative time (181 min vs 215 min, P=0.028) and ischemia time (21 min vs 24 min, P=0.006). Complication rates, blood loss, conversion rate, and decrease in glomerular filtration rate were similar in both groups. On univariate regression analysis, only warm ischemia time showed a significant trend with the overall NS (P=0.007) and the location score (P=0.031). CONCLUSIONS A high NS was not associated with clinically worse outcomes during RAPN. Such renal tumors can still be excised safely with robotic assistance without adverse long-term effects.

Reducing Operating Room Costs Through Real-Time Cost Information Feedback: A Pilot Study

Combined idiopathic retroperitoneal-mediastinal fibrosis is rare. We report a case of mediastinal fibrosis that followed the onset of retroperitoneal fibrosis by six years. A 61-year-old asymptomatic woman was diagnosed with idiopathic mediastinal fibrosis in December of 2006 after discovering a 1.4 cm thick prevascular mass encasing the aortic arch. In August of 2001 the patient had been diagnosed with retroperitoneal fibrosis, which was successfully treated surgically. An axillary thoracotomy found dense adhesions that fixed the arch of the aorta to the adjacent lung. Mediastinal biopsies were consistent with idiopathic fibrosis. We describe the imaging of this case and briefly review the literature.

Management of Pain in Autosomal Dominant Polycystic Kidney Disease and Anatomy of Renal Innervation

OBJECTIVE To describe the long-term outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for the correction of ureteropelvic junction (UPJ) obstruction. METHODS A retrospective electronic medical record review of RALPs from October 2002 to July 2014 was performed, with additional follow-up for patients released from regular urological care obtained by phone. RALP success was defined as resolution of symptoms of UPJ obstruction, improved hydronephrosis radiographically, or resolution of obstruction on follow-up Tc-99m mercaptoacetyltriglycine renal scan, intravenous pyelogram, or Whitaker test. RALP failure was defined as persistence of symptoms with obstruction demonstrated on functional imaging or requirement for a subsequent UPJ procedure. RESULTS A total of 129 cases were identified, with an average patient age of 34.3 years. Stented RALP was performed in 80.6% of cases whereas 19.4% of patients underwent stentless RALP. A dismembered technique was performed in 90.7% of pyeloplasties, whereas 9.3% were nondismembered Fenger, Y-V, or flap pyeloplasties. Five intraoperative complications and 18 postoperative complications (Clavien I-IIIb) were described. One hundred twenty-nine patients received follow-up for a mean of 33.8 months (range 1-147 months). RALP was successful in 125/129 (96.9%), with an 8-year failure-free survival of 91.5%. When considering only stented pyeloplasties, the 8-year failure-free survival was 96.3%. CONCLUSION RALP is a safe and effective minimally invasive method for correction of UPJ obstruction, resulting in lasting improvement in symptoms and resolution of obstruction for most patients.

Effect of Renal Reconstruction on Renal Function After Partial Nephrectomy

PURPOSE To create a protocol for providing real-time operating room (OR) cost feedback to surgeons. We hypothesize that this protocol will reduce costs in a responsible way without sacrificing quality of care. METHODS All OR costs were obtained and recorded for robot-assisted partial nephrectomy and laparoscopic donor nephrectomy. Before the beginning of this project, costs pertaining to the 20 most recent cases were analyzed. Items were identified from previous cases as modifiable for replacement or omission. Timely feedback of total OR costs and cost of each item used was provided to the surgeon after each case, and costs were analyzed. RESULTS A cost analysis of the robot-assisted partial nephrectomy before the washout period indicates expenditures of

Changing USA national trends for adrenalectomy: the influence of surgeon and technique.

5243.04 per case. Ten recommended modifiable items were found to have an average per case cost of