Elias S. Hyams

Robotic-assisted Versus Traditional Laparoscopic Partial Nephrectomy: Comparison of Outcomes and Evaluation of Learning Curve

OBJECTIVES To examine the transition to robot-assisted laparoscopic partial nephrectomy (RALPN) from pure laparoscopic partial nephrectomy (LPN) and investigate the learning curve (LC). RALPN has emerged as a minimally invasive alternative to nephron-sparing surgery. METHODS A total of 150 consecutive patients were identified who underwent LPN or RALPN in the initial experience of a single surgeon since 2006. The perioperative data were evaluated using appropriate comparative tests. The LC was investigated by examining the operative times, warm ischemia times (WITs), and estimated blood loss (EBL) in groups of 25 consecutive patients. To account for laparoscopic LC, the outcomes of patients who underwent surgery in 2009 or later were also compared. RESULTS Of the 150 patients, 102 and 48 underwent LPN and RALPN, respectively. The patient and tumor characteristics were similar. The mean operative time (193 vs 152 minutes, P < .001), WIT (18.0 vs 14.0, P < .001), and EBL (245 vs 122 mL, P = .001) favored RALPN. Improvements in the operative time (P = .01), WIT (P = .006), and EBL (P = .01) were noted as experience increased in the LPN cohort and was most pronounced after the first 25 LPN patients. Since 2009, 55 and 44 patients underwent LPN and RALPN, respectively. Although the absolute differences were less, the operative time (182 vs 150, P < .001), WIT (15.3 vs 13.3, P < .001), and EBL (206 vs 118, P = .005) favored RALPN. CONCLUSIONS RALPN appears to have shorter operative and ischemia times and less blood loss compared with LPN. After a LC of approximately 25 cases, the transition from LPN to RALPN can be undertaken without an additional LC and can be associated with immediate benefits.

Flexible ureterorenoscopy and holmium laser lithotripsy for the management of renal stone burdens that measure 2 to 3 cm: a multi-institutional experience.

BACKGROUND AND PURPOSE Percutaneous nephrostolithotomy (PCNL) is the current standard of care for management of large renal stones (>2 cm). Recent studies have evaluated flexible ureterorenoscopy (URS)/holmium laser lithotripsy as an alternative treatment for patients with contraindications to or preference against PCNL. Stones in an intermediate size range (2-3 cm) may be most amenable to URS/laser lithotripsy as definitive treatment in a single stage. We report a multi-institutional series of URS/laser lithotripsy for renal stone burdens that measure 2 to 3 cm. PATIENTS AND METHODS Patients who underwent URS/holmium laser lithotripsy for renal stones that measured 2 to 3 cm were identified retrospectively at three tertiary care centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients with renal stone burdens of 2 to 3 cm who were treated by URS/laser lithotripsy and had at least one postoperative visit and imaging study were included. Stone clearance was evaluated using 0-2 mm and <4 mm residual stone burden on postoperative imaging. RESULTS One hundred and twenty patients underwent URS/holmium laser lithotripsy for renal stones of 2 to 3 cm. Mean stone burden was 2.4 cm, and mean body mass index was 29.3 kg/m². Indications for URS/laser lithotripsy vs PCNL included patient preference (57), technical or anatomic factors (24), patient comorbidities (17), failed shockwave lithotripsy (9), patient body habitus (3), solitary kidney (3), chronic renal insufficiency (3), and strict anticoagulation (2). Thirty-one (26%) patients had stent placement preprocedure, and 94 (78%) patients underwent outpatient surgery. A ureteral access sheath was used in 67%. One hundred and one (84%) patients underwent single-stage procedures. There was one intraoperative complication (ureteral perforation), and there were eight minor postoperative complications (6.7%). The reoperation rate through the mean 18-month follow-up was 3/120 or 2.5%. Seventy-six (63%) patients had residual stone burden of 0 to 2 mm, and 100 (83%) patients had residual burden of <4 mm. CONCLUSIONS We demonstrate that single-stage URS/holmium laser lithotripsy is effective for management of renal stones that measure 2 to 3 cm through intermediate follow-up. Staged procedures can be used selectively for technical reasons or disease factors. Although PCNL achieves superior stone clearance overall, URS/laser lithotripsy is a viable treatment option for selected patients.

Percutaneous Nephrostolithotomy Versus Flexible Ureteroscopy/ Holmium Laser Lithotripsy: Cost and Outcome Analysis

PURPOSE While percutaneous nephrostolithotomy is the standard of care for renal stones greater than 2 cm, recent studies have shown that staged ureteroscopy/holmium laser lithotripsy may be a reasonable option. Stones 2 to 3 cm may be amenable to ureteroscopy as well as to 1-stage treatment based on their intermediate size. We compared clinical outcomes and the estimated cost of percutaneous nephrostolithotomy vs ureteroscopy for 2 to 3 cm renal stones. MATERIALS AND METHODS We retrospectively identified patients who underwent percutaneous nephrostolithotomy and ureteroscopy at our institution from 2004 to 2008 with a maximal renal stone diameter of 2 to 3 cm. Demographic information, disease characteristics, intraoperative and postoperative data, and complications were recorded. Stone clearance was reported as a residual stone burden of 0 to 2 mm and less than 4 mm. Cost was estimated using local Medicare reimbursements for surgeon, anesthesia, hospital and outpatient services. RESULTS A total of 20 patients underwent percutaneous nephrostolithotomy and 19 underwent ureteroscopy for 2 to 3 cm renal stones. The estimated cost of percutaneous nephrostolithotomy was significantly greater than that of ureteroscopy (

Trends in Imaging Use During the Emergency Department Evaluation of Flank Pain

19,845 vs

The role of robotics for adrenal pathology

6,675, p <0.0001). There were significantly more second stage procedures among percutaneous nephrostolithotomy cases (11 vs 1, p = 0.003). Stone clearance (0 to 2 mm) was superior for percutaneous nephrostolithotomy vs ureteroscopy (89% vs 47%, p = 0.01). Using a less than 4 mm threshold stone clearance improved to 100% vs 95% (p not significant). Two patients (10.5%) with ureteroscopy required subsequent ipsilateral stone surgery. They were noncompliant with medical/dietary therapy or radiographic surveillance. CONCLUSIONS While percutaneous nephrostolithotomy achieves superior stone clearance, ureteroscopy achieves acceptable treatment outcomes with a low risk of subsequent stone related events or interventions. The lower relative cost of ureteroscopy in this population may have implications for the development of treatment guidelines.

Robot-assisted partial adrenalectomy for isolated adrenal metastasis.

PURPOSE Patients with acute flank pain or kidney pain are most commonly evaluated in the emergency department with computerized tomography. Currently our understanding of radiographic practice patterns in emergency imaging for flank pain is limited. We characterized the use of conventional radiography (x-ray), ultrasound and computerized tomography in the emergency department evaluation of patients with acute flank pain. MATERIALS AND METHODS We performed a retrospective, cross-sectional analysis of emergency department visits using data on 2000 to 2008 from the National Hospital Ambulatory Medical Care Survey. Specific visits for a complaint of flank or kidney pain were further analyzed. RESULTS During the study period there was a significant increase in computerized tomography use (p <0.0001) and a significant decrease in x-ray use (p = 0.035) while ultrasound use remained stable (p = 0.803). During that period the proportion of patients with flank pain who were diagnosed with a kidney stone remained stable at approximately 20% (p = 0.135). CONCLUSIONS Between 2000 and 2008 there was a significant increase in computerized tomography use for the emergency evaluation of patients with flank pain.

Contemporaneous comparison of open vs minimally-invasive radical prostatectomy for high-risk prostate cancer.

Purpose of review This review assesses the role of robotic surgery in management of benign and malignant adrenal disease. Recent findings Laparoscopic adrenalectomy is considered the standard of care for benign adrenal neoplasms and has been increasingly considered for malignant disease. Robotic techniques have been considered for theoretical advantages in visualizing and dissecting the adrenal and its vasculature. Series of robotic adrenalectomy and limited comparisons with laparoscopic adrenalectomy have shown that robotic adrenalectomy is well tolerated and effective with subjective advantages compared with laparoscopic adrenalectomy. There has been growing interest in adrenal sparing-surgery using minimally invasive techniques and encouraging outcomes for selected benign lesions. Summary Robotic techniques for adrenalectomy have subjective advantages compared with laparoscopic adrenalectomy, but no objective superiority has been demonstrated. Surgical outcomes have been comparable with laparoscopic adrenalectomy though there have been no randomized controlled studies. Robotic adrenalectomy will be increasingly considered in lieu of laparoscopic adrenalectomy as robotic systems further disseminate and the cost disadvantages become less prohibitive. Although laparoscopic adrenalectomy remains the standard of care, robotic adrenalectomy is an acceptable option in high volume robotic centers from standpoints of outcomes, feasibility, and cost.

Graft Reconstruction of Inferior Vena Cava for Renal Cell Carcinoma Stage pT3b or Greater

Adrenal-sparing surgery is an effective and safe alternative to total adrenalectomy for small, benign adrenal lesions and may decrease the risk of the development of adrenal insufficiency. While series of laparoscopic partial adrenalectomy have demonstrated safety and excellent long-term outcomes, there have been no reports of a complete robot-assisted partial adrenalectomy. We believe that robotic techniques may be useful for this procedure, given the complex vascularity and small size of the adrenal gland. Furthermore, there have been no reports of minimally invasive partial adrenalectomy for management of small, isolated adrenal metastasis. We report a case of robot-assisted partial adrenalectomy in a patient with a history of renal-cell carcinoma who had previously undergone contralateral adrenalectomy for metastasis. We report our surgical technique and short-term follow-up for our patient. To our knowledge, this is the first report of a complete robot-assisted partial adrenalectomy and the first report of minimally invasive partial adrenalectomy for an isolated adrenal metastasis.

Iatrogenic vascular lesions after minimally invasive partial nephrectomy: a multi-institutional study of clinical and renal functional outcomes.

The ideal treatment for men with high‐risk prostate cancer is controversial, although most physicians agree that a multimodal approach, including radiation and hormone therapy with or without surgery, offers the best chance of cancer control. Minimally‐invasive radical prostatectomy has emerged as a treatment option for clinically localized cancer; however, critics argue that the open approach may afford advantages of tactile feedback and a better lymph node dissection. The present study demonstrates that open and minimally‐invasive radical prostatectomy offer equivalent short‐term outcomes for men with high‐risk prostate cancer at a highly experienced centre.

Renal Artery Pseudoaneurysm Following Laparoscopic Partial Nephrectomy

OBJECTIVES To review the methods and outcomes for simultaneous radical nephrectomy and inferior vena cava (IVC) graft reconstruction at our institution. Renal cell carcinoma has the potential to propagate and invade the IVC, requiring resection and/or reconstruction of the IVC concurrently with radical nephrectomy. METHODS A prospective database of patients undergoing simultaneous radical nephrectomy with IVC reconstruction for renal cell carcinoma was queried. The data were collected and analyzed for patients who had undergone IVC graft reconstruction. RESULTS A total of 17 patients were identified from 1999 to 2010, with a median age of 61 years (range 36-77). The tumor was right sided in 14 patients. The median tumor size was 12 cm (range 7.5-23), 15 tumors had clear cell histologic findings, and 16 were high grade. Seven patients had clinical metastasis found on imaging preoperatively, with another 4 having lymph node metastasis on pathologic examination. Of the 17 patients, 11 underwent patch grafting (3 expanded polytetrafluoroethylene and 8 bovine pericardium) and 6 underwent IVC interposition (3 Dacron and 3 expanded polytetrafluoroethylene). Also, 5 and 3 patients underwent cardiopulmonary and venovenous bypass, respectively. The mean estimated blood loss was 4 L, and the mean hospitalization was 7 days (range 5-16). Six patients experienced perioperative complications, with 1 perioperative mortality. Two patients overall developed graft thrombosis. Of the 6 patients initially without metastasis, the recurrence-free and overall survival rate was 50% and 83%, respectively, at a mean of 55 months. Of the 11 patients initially with metastasis, the recurrence-free and overall survival rate was 18% and 45%, respectively, at a mean of 13 months. CONCLUSIONS For selected patients with advanced renal cell carcinoma and extensive IVC thrombus, resection with patch or interposition grafting of the IVC yields acceptable patency rates, minimal complications related to the graft, and reasonable oncologic results in a high-risk patient population.