Dinesh Samarasekera

Positive Surgical Margins in Robot-Assisted Partial Nephrectomy: A Multi-Institutional Analysis of Oncologic Outcomes (Leave No Tumor Behind)

PURPOSE Expanding indications for robot-assisted partial nephrectomy raise major oncologic concerns for positive surgical margins. Previous reports showed no correlation between positive surgical margins and oncologic outcomes. We report a multi-institutional experience with the oncologic outcomes of positive surgical margins on robot-assisted partial nephrectomy. MATERIALS AND METHODS Pathological and clinical followup data were reviewed from an institutional review board approved, prospectively maintained joint database from 5 institutions. Tumors with malignant pathology were isolated and statistically analyzed for demographics and oncologic followup. The log rank test was used to compare recurrence-free and metastasis-free survival between patients with positive and negative surgical margins. The proportional hazards method was used to assess the influence of multiple factors, including positive surgical margins, on recurrence and metastasis. RESULTS A total of 943 robot-assisted partial nephrectomies for malignant tumors were successfully completed. Of the patients 21 (2.2%) had positive surgical margins on final pathological assessment, resulting in 2 groups, including the 21 with positive surgical margins and 922 with negative surgical margins. Positive surgical margin cases had higher recurrence and metastasis rates (p<0.001). As projected by the Kaplan-Meier method in the population as a whole at followup out to 63.6 months, 5-year recurrence-free and metastasis-free survival was 94.8% and 97.5%, respectively. There was a statistically significant difference in recurrence-free and metastasis-free survival between patients with positive and negative surgical margins (log rank test<0.001), which favored negative surgical margins. Positive surgical margins showed an 18.4-fold higher HR for recurrence when adjusted for multiple tumors, tumor size, tumor growth pattern and pathological stage. CONCLUSIONS Positive surgical margins on final pathological evaluation increase the HR of recurrence and metastasis. In addition to pathological and molecular tumor characteristics, this should be considered to plan appropriate management.

Three-year Oncologic and Renal Functional Outcomes After Robot-assisted Partial Nephrectomy

BACKGROUND With the wider adoption of minimally invasive partial nephrectomy (PN), intermediate- and long-term outcomes data are needed to make firm conclusions about oncologic and functional efficacy, especially for robot-assisted PN (RPN). OBJECTIVE To report intermediate-term oncologic and renal functional outcomes of RPN. DESIGN, SETTING, AND PARTICIPANTS We performed a chart review of patients who had undergone RPN since June 2006; patients with a minimum of 2 yr of follow-up were included in this study. Length of follow-up was calculated from the date of surgery to the date of last clinical follow-up. Patients who were either lost to follow-up or who had follow-up outside of our center were sent surveys. INTERVENTION Transperitoneal RPN with or without hilar clamping. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The demographic, preoperative, and postoperative data were statistically analyzed. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), and cancer-free survival (CFS). Upstaging of chronic kidney disease (CKD) was calculated, as well. Univariate and multivariate analyses were performed to show predicting factors for the latest estimated glomerular filtration rate (eGFR). RESULTS AND LIMITATIONS Of 427 patients, 134 had a minimum follow-up of 2 yr, and 70 had a minimum of 3-6 yr of follow-up. The mean age was 59.1±12.5 yr, body mass index (BMI) was 29.8±6.2 kg/m(2), and Charlson comorbidity index (CCI) score was 4.2±1.6. The mean tumor size on computed tomography (CT) scan was 3.0±1.6 cm, RENAL score was 7.2±1.8, estimated blood loss (EBL) was 270.7±291.9 ml, operative time was 189.1±54.8 min, and warm ischemia time (WIT) was 17.9±10.3 min. A total of two intraoperative complications (1.5%) and five high-grade Clavien complications (3.7%) occurred. Patients stayed on average for 3.7±1.7 d in the hospital, and the average follow-up was 3.0±0.9 yr. OS was 97.01% at 3 yr and 90.20% at 5 yr; CFS was 98.92% at 3 yr and 98.92% at 5 yr; and CSS was 99.04%, as projected by the Kaplan-Meier method. The mean preoperative GFR was 88.2±0.8 ml/min per 1.73 m(2); the latest postoperative GFR was 80±24 ml/min per 1.73 m(2), with a 8±17.4% change. There was a 20.2% upstaging of CKD postoperatively, but no patients started dialysis. CONCLUSIONS This study reaffirms that RPN is effective in renal function preservation and oncologic control at an intermediate follow-up interval.

Robot‐assisted partial nephrectomy (RAPN) for completely endophytic renal masses: a single institution experience

To analyse the outcomes of robot‐assisted partial nephrectomy (RAPN) for completely endophytic renal tumours.

Robotic Ileal Ureter: A Completely Intracorporeal Technique

INTRODUCTION The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure. TECHNICAL CONSIDERATIONS A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m(2). Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m(2). CONCLUSION Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial.

To validate robot‐assisted surgery skills acquisition using an augmented reality (AR)‐based module for urethrovesical anastomosis (UVA).

Ipsilateral renal function preservation after robot-assisted partial nephrectomy (RAPN): an objective analysis using mercapto-acetyltriglycine (MAG3) renal scan data and volumetric assessment.

To objectively assess ipsilateral renal function (IRF) preservation and factors influencing it after robot‐assisted partial nephrectomy (RAPN).

30-Day Hospital Readmission after Robotic Partial Nephrectomy—Are We Prepared for Medicare Readmission Reduction Program?

PURPOSE After CMS introduced the concept of the Hospital Readmissions Reduction Program, hospitals and health care centers became financially penalized for exceeding specific readmission rates. MATERIALS AND METHODS We retrospectively reviewed our institutional review board approved database of patients undergoing robotic partial nephrectomy at our institution and included in our analysis patients who were readmitted to any hospital as an inpatient stay within 30 days from discharge home after robotic partial nephrectomy. RESULTS From March 2006 to March 2013 a total of 627 patients underwent robotic partial nephrectomy at our center and 28 (4.46%) were readmitted within 30 days of surgery. Postoperative bleeding was responsible for 8 (28.5%) readmissions. Pulmonary embolism was reported in 3 cases and retroperitoneal abscess was diagnosed in 2. Urinary leak requiring surgical intervention developed in 2 patients, pneumonia was diagnosed in 2 and 2 patients were readmitted for chest pain. Overall 9 (32.1%) patients presented with major complications requiring intervention. On multivariable analysis Charlson comorbidity index score was the only factor significantly associated with a higher 30-day readmission rate (p = 0.03). If the Charlson score was 5 or greater the chance of hospital readmission would be 2.7 times higher. CONCLUSIONS Increased comorbidity, specifically a Charlson score of 5 or greater, was the only significant predictor of a higher incidence of 30-day readmission. This information can be useful in counseling patients regarding robotic partial nephrectomy and in determining baseline rates if CMS expands the number of conditions they evaluate for excess 30-day readmissions.

Repeat robot-assisted partial nephrectomy (RAPN): feasibility and early outcomes

To demonstrate the feasibility, and to report our single‐centre perioperative outcomes of repeat robot‐assisted partial nephrectomy (RAPN).

Robot-assisted Laparoscopic Adrenalectomy: Step-by-Step Technique and Comparative Outcomes

BACKGROUND Recent evidence supports the use of robotic surgery for the minimally invasive surgical management of adrenal masses. OBJECTIVE To describe a contemporary step-by-step technique of robotic adrenalectomy (RA), to provide tips and tricks to help ensure a safe and effective implementation of the procedure, and to compare its outcomes with those of laparoscopic adrenalectomy (LA). DESIGN, SETTING, AND PARTICIPANTS We retrospectively reviewed the medical charts of consecutive patients who underwent RA performed by a single surgeon between April 2010 and October 2013. LA cases performed by the same surgeon between January 2004 and May 2010 were considered the control group. SURGICAL PROCEDURE The main steps of our current surgical technique for RA are described in this video tutorial: patient positioning, port placement, and robot docking; exposure of the adrenal gland; identification and control of the adrenal vein; circumferential dissection of the adrenal gland; and specimen retrieval and closure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Demographic parameters and main surgical outcomes were assessed. RESULTS AND LIMITATIONS A total of 76 cases (RA: 30; LA: 46) were included in the analysis. Median tumor size on computed tomography (CT) was significantly larger in the LA group (3cm [interquartile range (IQR): 3] vs 4cm [IQR: 3]; p=0.002). A significantly lower median estimated blood loss was recorded for the robotic group (50ml [IQR: 50] vs 100ml [IQR: 288]; p=0.02). The RA group presented five minor complications (16.7%) and one major (Clavien 3b) complication (3.3%), whereas four minor complications (8.7%) and one major (Clavien 3b) complication (2.3%) were observed in the LA group. No significant difference was noted between groups in terms of malignant histology (p=0.66) and positive margin rate (p=0.60). Distribution of pheochromocytomas in the LA group was significantly higher than in the RA group (43.5% vs 16.7%; p=0.02). CONCLUSIONS The standardization of each surgical step optimizes the RA procedure. The robotic approach can be applied for a wide range of adrenal indications, recapitulating the safety and effectiveness of open surgery and potentially improving the outcomes of standard laparoscopy. PATIENT SUMMARY In this report we detail our surgical technique for robotic removal of adrenal masses. This procedure has been standardized and can be offered to patients, with excellent outcomes.

Robot-assisted partial nephrectomy for ≥ 7 cm renal masses: a comparative outcome analysis.

OBJECTIVE To present our robotic partial nephrectomy (RPN) experience for renal masses ≥ 7 cm and compare the surgical outcomes in this cohort with those obtained for small (≤ 4 cm) renal masses. MATERIALS AND METHODS We retrospectively reviewed our institutional review board-approved RPN database and identified patients undergoing RPN for tumors ≥ 7 cm. Surgical technique, renal function, oncologic, and pathologic data were analyzed and compared with the RPN for renal masses ≤ 4 cm. RESULTS Overall, 441 patients were identified for the purpose of this study, including 29 cases and 412 controls. Median operative time (200 vs 180 min; P = .005), warm ischemia time (26.5 vs 19 min; P <.001), and estimated blood loss (250 mL [353] vs 150 mL [150]; P <.001) were significantly lower in the control group. Postoperative complications were significantly higher in the case group (37.9% vs 15.8%; P = .005). However, the percentages of major complications (Clavien grade ≥ III) were comparable (18.2% vs 17%; P = .57 for cases and controls respectively). Postoperative blood transfusion was higher for larger tumor group (24.1% vs 4.1%; P <.001). Positive margins were similar between groups (5.9% vs 3.3%; P = .45 for cases and controls respectively). There was no difference in estimated glomerular filtration rate decline between the two groups (12.2% vs 15.8% decline; P = .98). CONCLUSION RPN represents a feasible and safe nephron-sparing surgery approach for highly selected (mostly exophytic growth pattern, polar location, and likelihood of benign histology) renal masses ≥ 7 cm in diameter.