Jose M. Cabello

Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes

BACKGROUND Robotic partial nephrectomy (RPN) is emerging as an alternative to traditional laparoscopic partial nephrectomy (LPN). Despite the potential advantages of the robotic approach, renorrhaphy remains a challenging portion of the procedure. OBJECTIVE To present our technique and outcomes for RPN, including sliding-clip renorrhaphy. DESIGN, SETTING, AND PARTICIPANTS Between 2007 and 2008, 50 patients underwent RPN performed by a single attending surgeon. SURGICAL PROCEDURE In this paper, we describe our technique for RPN, including a sliding-clip renorrhaphy, which is distinguished by the use of Weck Hem-O-Lock clips that are slid into place under complete control of the surgeon seated at the console and secured with a LapraTy clip. For the first 13 procedures, traditional tied-suture or assistant-placed clip closures were performed; sliding-clip renorrhaphy was performed in the remaining 37 cases. RESULTS AND LIMITATIONS Mean tumor size was 2.5 cm. Mean operative time was 145.3 min, and mean overall warm ischemia time was 17.8 min. Mean estimated blood loss was 140.3 ml. The learning curve for overall operative time was 19 cases; the learning curve for portions of the case performed under warm ischemia (including tumor resection and renorrhaphy) was 26 cases. The introduction of a sliding-clip renorrhaphy produced significant reductions in overall operative time and warm ischemia time, while blood loss and hospital stay remained stable over our experience. Limitations of RPN include cost and increased reliance on the bedside assistant. CONCLUSIONS Sliding-clip renorrhaphy provides an efficient and effective repair that is under nearly complete control of the surgeon. This technique appears to contribute to significantly shorter overall operative times and, perhaps most critically, to shorter warm ischemia times. The learning curve for RPN using this technique appears to be foreshortened compared with LPN.

Does Citation Analysis Reveal Association Between h-Index and Academic Rank in Urology?

i raditionally, the world of academia has relied largely on peer review when appraising the merit of an individual faculty member, generally during eliberations for promotions or for admission into elite cademic societies. However entrenched in our academic ociety the peer-review process might be, it faces harsh riticism on the grounds of its relative secrecy and subectivity and the perceived notion that the process can be nduly influenced by politicking and gamesmanship. As uch, much interest has been generated in finding other, ore objective methods to appraise academicians’ conributions to their field. Although no single measure can ccount for every facet of an individual’s value to a rogram or department, many would agree that the prolivity to publish serves as one indicator of productivity. Although in use in the legal professions since the late 800s, the notion of incorporating bibliometric indexes nto the natural sciences was not proposed until 1955, ith Garfield’s description of the “impact factor.” Curently, databases such as the Thomson ISI Web of Scince (available from http://isiwebofknowledge.com) and he Scopus database (available from http://www.scopus. om) provide a wealth of dynamic bibliometric data that an be easily accessed through multiple search parameers, and allows for rapid scrutiny of an author’s output. Introduced in 2005 by Hirsch, the h-index has quickly ained considerable following in the academic commuity and has been adopted as the de facto metric in both he ISI and the Scopus databases because of its reliability nd ease of computation. Defined as the number of publications h that have each een cited at least h times in published reports, the -index seeks to temper the quantity of production with he perceived effect of an author’s contributions. For xample, if an author has 11 publications that have each een cited 11 times, then the h-index would be 11. The emainder of the author’s publications that do not have

Robot-assisted partial nephrectomy: Evaluation of learning curve for an experienced renal surgeon

PURPOSE The learning curve for robot-assisted partial nephrectomy (RAPN) has not been extensively studied. We therefore evaluated the learning curve of RAPN for a fellowship-trained laparoscopic surgeon with extensive prior experience with laparoscopic partial nephrectomy (LPN). We also examined the potential effect of tumor size on the learning curve. PATIENTS AND METHODS We prospectively evaluated 38 consecutive patients undergoing RAPN by a single surgeon (S.B.B.). Sixteen patients had tumors <2 cm, and 22 patients had tumors >2 cm. Warm ischemia times and overall operative times were recorded as indices of learning progression. RESULTS Average operative time for tumors <2 cm was 131.9 minutes (115.3-148.5 minutes) and for tumors >2 cm was 145.8 minutes (131.1-160.5 minutes). The difference between the operative times for tumors <2 and >2 cm was not statistically significant (p = 0.23). Average warm ischemia time for tumors <2 cm was 21 minutes (16.9-25.1 minutes) and for tumors >2 cm was 24.7 minutes (21.3-28.1 minutes). This difference was also not statistically significant (p = 0.20). Defined by the overall operative time, the learning curve for RAPN was 16 cases, and by ischemic time, the learning curve was 26 cases. Tumor size did not have an effect on the learning curve. CONCLUSIONS The learning curve for RAPN is short for surgeons already experienced with LPN. The learning curve for portions performed under warm ischemia is slightly longer, implying that the critical portions of the procedure require more experience to become facile. Tumor size does not appear to have a significant impact on the learning curve for surgeons experienced with LPN.

Selective versus nonselective arterial clamping during laparoscopic partial nephrectomy: impact upon renal function in the setting of a solitary kidney in a porcine model.

INTRODUCTION Laparoscopic partial nephrectomy has emerged as a standard of care for small renal masses. Nevertheless, there remains concern over the potential for irreversible insult to the kidney as a result of exposure to warm ischemia. We aim to investigate the utility of selective segmental arterial clamping as a means to reduce the potential for ischemic damage to a solitary kidney during laparoscopic partial nephrectomy utilizing a porcine model. MATERIALS AND METHODS A total of 20 domestic swine were randomized into four equal groups. Each subject underwent laparoscopic radical nephrectomy to create the condition of a solitary kidney. On the contralateral side, a laparoscopic lower pole partial nephrectomy was performed, employing either selective or nonselective vascular clamping for either 60 or 90 minutes. Postoperatively, clinical status and serial serum studies were closely monitored for 1 week. RESULTS There were no intraoperative complications. The 90-minute nonselective clamping produced devastating effects, resulting in rapid deterioration into florid renal failure within 72 hours. The 60-minute nonselective clamping group experienced modest but significant rises in both blood urea nitrogen and creatinine. Both 60- and 90-minute selective clamping groups performed well, with no significant rises in creatinine over a 7-day period, and no instances of renal failure. CONCLUSIONS Selective arterial clamping is a safe and feasible means of vascular control during laparoscopic partial nephrectomy. In the porcine model, selective clamping appears to improve functional outcomes during prolonged periods of warm ischemic insult. Prospective evaluation of the technique in humans is necessary to determine if selective arterial control confers long-term functional benefits in patients with limited renal reserve.

Sliding-clip renorrhaphy provides superior closing tension during robot-assisted partial nephrectomy

OBJECTIVE Recently, our institution refined a technique for robot-assisted renorrhaphy utilizing sliding Weck Hem-O-Lock clips, which are tightened by the surgeon seated at the console and locked into place with a LapraTy clip. In addition to the relative ease of implementation, we believe that our technique also provides a superior strength of closure over other commonly used techniques. METHODS An in vivo porcine model was used to compare a sliding-clip technique against an assistant-placed LapraTy-only closure, and a surgeon-placed simple suture closure. A force gauge was used to record the maximum tension that could be applied during each closure method before the suture ripped through the renal parenchyma, thus illustrating the relative strength of each closure. RESULTS The simple suture closure performed relatively poorly, ripping through parenchyma at a mean force of 11.3 N. The LapraTy-only method allowed a maximum applicable mean force of 16.7 N. The sliding Weck clip with a LapraTy bolster provided the tightest closure, allowing for a mean force of 32.7 N before ripping through parenchyma. Statistical analysis reveals that a sliding-clip technique provides a significantly tighter closure than both of the other tested methods. CONCLUSION A sliding-clip technique allows for more tension to be safely applied to the closure of a partial nephrectomy defect than other commonly used methods. We believe that this is primarily attributable to the larger footprint of the Hem-O-Lock clip, which allows for the tension to be distributed over a greater surface area. The LapraTy then ensures the security of the closure by holding the Weck clip in place. Further studies are necessary to determine if this increased tension translates into appreciably better hemostasis.

Robotic-assisted partial nephrectomy: surgical technique using a 3-arm approach and sliding-clip renorrhaphy

INTRODUCTION For the treatment of renal tumors, minimally invasive nephron-sparing surgery has become increasingly performed due to proven efficiency and excellent functional and oncological outcomes. The introduction of robotics into urologic laparoscopic surgery has allowed surgeons to perform challenging procedures in a reliable and reproducible manner. We present our surgical technique for robotic assisted partial nephrectomy (RPN) using a 3-arm approach, including a sliding-clip renorrhaphy. MATERIALS AND METHODS Our RPN technique is presented which describes the trocar positioning, hilar dissection, tumor identification using intraoperative ultrasound for margin determination, selective vascular clamping, tumor resection, and reconstruction using a sliding-clip technique. CONCLUSION RPN using a sliding-clip renorrhaphy is a valid and reproducible surgical technique that reduces the challenge of the procedure by taking advantage of the enhanced visualization and control afforded by the robot. The renorrhaphy described is performed under complete control of the console surgeon, and has demonstrated a reduction in the warm ischemia times in our series.

Camera and trocar placement for robot-assisted radical and partial nephrectomy: which configuration provides optimal visualization and instrument mobility?

Proper camera and trocar placement is critical to the success of minimally invasive procedures. For robot-assisted renal surgery, two basic trocar configurations have been described. The medial approach, using a 30° downward-angled lens mimics a traditional transperitoneal laparoscopic configuration. An alternative configuration, using a 0° or 30° upward-angled lens approach locates the camera laterally, evoking a position sense similar to a retroperitoneal approach. Our objective is to compare the differences between these two standard approaches for robot-assisted renal surgery. After performing a review and analysis of available literature, our group tested both the medial and lateral camera approaches during robotic renal surgery performed in human patients. The medial approach provides a wide field of view, because of the relatively greater distance to the target structures and a horizon line closer to the patient’s midline. The lateral configuration offers significantly different visualization. The relative proximity to the target structures and a higher horizon line results in a comparatively restricted field of vision. Instrument mobility is comparable between the two approaches. Meta-analysis of the literature reveals that both approaches provide comparable overall operative times for both radical and partial nephrectomy, though there is a trend towards shorter overall operative times for partial nephrectomy performed through a medial approach. The medial trocar configuration provides a familiar working environment for both surgeon and assistant; the wide-angle view enables enhanced visualization of surrounding structures and tracking of the instruments inserted by the assistant. The lateral approach offers the potential advantage of a closer view of the kidney, but does so at the expense of a significantly restricted field of view. In our experience, a medial trocar configuration offers significant advantages over the lateral trocar configuration, and is, therefore, the standard approach at our high-volume center.

PD35-11 NEW DIGITAL SINGLE-USE FLEXIBLE URETEROSCOPE (PUSEN TM): FIRST CLINICAL EXPERIENCE

INTRODUCTION AND OBJECTIVES: We report the clinical results of flexible ureteroscopy using the new digital single-use flexible ureteroscope from PUSEN (New South Wales, Australia). This device has an outer diameter of 9 Fr, with a working channel of 3,6 Fr. The deflection system has both options of standart and reverse modes with maximum deflection of 270 in both directions. METHODS: Between August and October 2016 we performed flexibleureteroscopy (FUR)using thenewdevice.Theprimaryoutcomewas stone free rates, secondary outcomeswere total time of the procedure, total time of fluoroscopy and perioperative complications. The tertiary outcome was the behavior of the instrument during and at the end of the procedure RESULTS: A total of eleven FUR were performed. The present study included eight male patients and three female patients, with an average age of 39 years (range 23-65 years). All the patient were treated using a 12 Fr access sheath and holmium laser lithotripsy(260 mm fiber). The average stone size was 6 mm (range 4-10 mm), and stones were located as follow: 3 in proximal ureter, 6 in renal pelvis and 2 in lower calix. Total time taken to complete the surgery was 45 minutes (range 25-85 min). The number of stones treated per patient varied between 1 and 4. Mean fluoroscopy time was 50 seconds. We achieved 100% stone free rate in eight cases and 80% in the remaining three. One patient present an ureteral wall injury, with mucosal erosion at time of ureteral access sheath placement. A double J stent was placed in all patients. The device behaves properly during and at the end of the procedure, there was no loss in image quality or deflection capacity, being able to safely finish all the cases carried out. CONCLUSIONS: With respect to outcomes evaluated in this study with the PUSEN digital single use flexible ureteroscope seems to be similar in comparison to reusable flexible ureteroscope. The clinical results achieved in the present study suggest that this device could be considered a valid method to treat endoscopically renal and proximal ureteral stones reducing maintenance costs.

V5-10 RIGHT RADICAL NEPHRECTOMY WITH DISSECTION OF THROMBUS IN THE INFERIOR VENA CAVA LEVEL III

INTRODUCTION AND OBJECTIVES: The renal cell carcinoma has a known tendency to spread forming tumor thrombus to the renal vein or inferior vena cava (4-10%) The level that reach the tumor, it’s in direct relation with the 5-years survival METHODS: We show a case of a male 58 years old patient with history of diabetes and smoking. The patient complains of hematuria that started ten months ago. In the general lab work, the patient was anemic with a hemoglobin of 8 gr/dL and a serum creatinine of 1.1 mg/mL. The CT-Scan showed an 18 cm right kidney tumor with a thrombus in the inferior vena cava up to the diaphragm (Level III) with no seen metastatic disease or malignant lymphnodes Anterior open nephrectomy was performed, followed by control of inferior vena cava which it’s open entirely to perform the thrombectomy. RESULTS: The estimated operative time was 260 minutes, with a bleeding of 1600ml, requiring 3 units of blood during the surgery. No complications was reported. The post-op management was in the ICU for only 24 hours, with a total of length of stay of 5 days. The patient evolved without any complication, showing in the control lab, a serum creatinine of 1.3 mg/dL. To the date there is no evidence of residual disease, clinical nor in the images. CONCLUSIONS: The radical nephrectomy it’s the standard of care in the, level III inferior vena cava thrombus, in the setting of kidney cancer. It should be done in patients in conditions to have surgery.

Renal tumor models: Evaluation of ease of implementation, quality of composition, and imaging characteristics

BACKGROUND AND PURPOSE With the rise in detection of small renal masses that are amenable to nephron-sparing surgical approaches, there has been an increasing need for renal tumor models that create discrete lesions suitable for training exercises. We aim to investigate a handful of commonly used compounds, subjectively evaluating their ease of implementation and imaging characteristics. MATERIALS AND METHODS After an initial ex vivo study, we selected five compounds for an in vivo porcine investigation. These compounds included metagel with barium, Smooth-Cast 320, Silfome with and without barium, and Kromopan. The compounds were injected under laparoscopic guidance with the aim of creating discrete renal tumors. The kidneys were then imaged under ultrasonography and CT. The animals were euthanized, and nephrectomy was performed. Handling characteristics were noted. RESULTS All compounds were relatively easy to inject. Most of the compounds were susceptible to some degree of subcapsular spread. Kromopan had a high propensity for infiltration of the collecting system. On imaging, metagel was clearly distinguishable from normal renal parenchyma on both CT and ultrasonography. Silfome and Smooth-Cast were difficult to resolve on ultrasonography. Metagel was prone to rupture during surgical manipulation. CONCLUSIONS No single compound provided the ideal combination of ease of implementation, resistance to extravasation, ease of resolution on imaging, and resistance to rupture. Therefore, compound selection should be dictated by the particular aims of a training simulation.