Rachid Yakoubi

Robotic Versus Laparoscopic Partial Nephrectomy for Complex Tumors: Comparison of Perioperative Outcomes

BACKGROUND Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors. OBJECTIVE To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥ 7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. INTERVENTION LPN or RPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. RESULTS AND LIMITATIONS There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m(2) compared with 30.7 kg/m(2), p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m(2), p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p<0.001) and a higher decrease in percentage of eGFR (-16.0% compared with -12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study. CONCLUSIONS RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings.

Robotic Partial Nephrectomy Versus Laparoscopic Cryoablation for the Small Renal Mass

BACKGROUND Open partial nephrectomy (OPN) remains the gold standard for treatment of small renal masses (SRMs). Laparoscopic cryoablation (LCA) has provided encouraging outcomes. Robotic partial nephrectomy (RPN) represents a new promising option but is still under evaluation. OBJECTIVE Compare the outcomes of RPN and LCA in the treatment of patients with SRMs. DESIGN, SETTING, AND PARTICIPANTS We retrospectively analyzed the medical charts of patients with SRMs (≤4cm) who underwent minimally invasive nephron-sparing surgery (RPN or LCA) in our institution from January 1998 to December 2010. INTERVENTION RPN and LCA. MEASUREMENTS Perioperative complications and functional and oncologic outcomes were analyzed. RESULTS AND LIMITATIONS A total of 446 SRMs were identified in 436 patients (RPN, n=210; LCA, n=226). Patients undergoing RPN were younger (p<0.0001), had a lower American Society of Anesthesiologists score (p<0.001), and higher baseline preoperative estimated glomerular filtration rate (eGFR) (p<0.0001). Mean tumor size was smaller in the LCA group (2.2 vs 2.4cm; p=0.004). RPN was associated with longer operative time (180 vs 165min; p=0.01), increased estimated blood loss (200 vs 75ml; p<0.0001), longer hospital stay (72 vs 48h; p<0.0001), and higher morbidity rate (20% vs 12%, p=0.015). Mean follow-ups for RPN and LCA were 4.8 mo and 44.5 mo, respectively (p<0.0001). Local recurrence rates for RPN and LCA were 0% and 11%, respectively (p<0.0001). Mean eGFR decrease after RPN and LCA was insignificant at 1 mo, at 6 mo after surgery, and during last follow-up. Limitations include retrospective study design, length of follow-up, and selection bias. CONCLUSIONS Both techniques remain viable treatment options in the management of SRMs. A higher incidence of perioperative complications was found in patients undergoing RPN. However, the technique was not predictive of the occurrence of postoperative complications. Early oncologic outcomes are promising for RPN, which also seems to be associated with better preservation of renal function. Long-term follow-up and well-designed prospective comparative studies are awaited to corroborate these findings.

Is There a Role for α-Blockers in Ureteral Stent Related Symptoms? A Systematic Review and Meta-Analysis

PURPOSE We evaluated the efficacy of α-blockers to improve ureteral stent related morbidity and quality of life. MATERIALS AND METHODS We performed a search of MEDLINE®, Embase™ and The Cochrane Library plus a hand search of conference proceedings from January 2000 to October 2010 to identify randomized, controlled trials comparing treatment for ureteral stent symptoms with α-blockers. Two reviewers independently screened studies and extracted data. Trial methodological quality was assessed by The Cochrane Collaboration quality assessment tool. Placebo randomized, controlled trials with the ureteral stent symptom questionnaire as the outcome were eligible for meta-analysis. Meta-analysis was done using the mean difference to determine the aggregate effect size. RESULTS A total of 12 randomized, controlled trials including 2 α-blockers in a total of 946 patients were eligible, including 4 (33%) presented only as an abstract at a urological meeting and 4 (33%) eligible for meta-analysis. Meta-analysis using a random effects model showed that α-blockers were associated with a significant decrease in urinary symptoms (MD -6.76, 95% CI -11.52 to -2.00, p=0.005), a significant decrease in pain (MD -3.55, 95% CI -5.51 to -1.60, p=0.0004) and significant improvement in general health (MD -1.90, 95% CI -3.05 to -0.75, p=0.001). However, they were not associated with a benefit in work (MD 2.41, 95% CI -1.62 to 6.44, p=0.24) or sexual matters (MD 0.20, 95% CI -1.06 to 1.45, p=0.33). Eight studies were not included in the meta-analysis, of which 7 showed a significant clinical decrease in urinary symptoms and pain. CONCLUSIONS Existing evidence from randomized, controlled trials shows that α-blockers are associated with improvement in ureteral stent symptoms and supports their use in routine clinical practice.

Urological laparoendoscopic single site surgery: Multi-institutional analysis of risk factors for conversion and postoperative complications

PURPOSE We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. MATERIALS AND METHODS The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. RESULTS Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p=0.02), pelvic surgery (p<0.001), robotic approach (p<0.001), high difficulty score (p=0.004), extended operative time (p=0.03) and an intraoperative complication (p=0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p=0.03), high difficulty score (p=0.002) and extended operative time (p=0.02) predicted high grade complications. CONCLUSIONS Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery.

Robotic single port suprapubic transvesical enucleation of the prostate (R‐STEP): initial experience

Study Type – Therapy (case series)

Natural orifice transluminal endoscopic surgery (NOTES): where are we going? A bibliometric assessment

The safe and successful development of NOTES has the potential to create a paradigm shift in minimally invasive surgery. However, anecdotal diagnostic and therapeutic NOTES procedures, many of which were strictly performed in an investigative fashion, have taught us that continued, focused translational research is imperative to address myriad, and as yet unaddressed, technical issue. This study analyses the NOTES‐related research in the medical literature over the last 5 years in an attempt to identify trends and/or progress towards its meaningful use. It shows that NOTES is still in a developmental stage and much work is still needed to refine techniques, verify safety and document efficacy. Since the first description of the concept of NOTES, >2000 clinical cases, irrespective of specialty, have been reported. NOTES remains a field of intense clinical and experimental research in various surgical specialties.

Real-Time Robotic Transrectal Ultrasound Navigation During Robotic Radical Prostatectomy: Initial Clinical Experience

OBJECTIVE To describe a novel robotic transrectal ultrasound platform for real-time navigation during robot-assisted laparoscopic radical prostatectomy (RALP) and to report its early clinical application. METHODS Five men undergoing RALPs at our Institution agreed to participate in this Institutional Review Board-approved pilot study. All of them were eligible for a bilateral nerve sparing procedure. Before docking the da Vinci robot, a transrectal ultrasound tri-plane side-fire probe was placed. A modified ViKY Endoscope Holder was used during RALPs to move the probe thanks to a remote control placed under the console surgeons control during RALPs. During each procedure, attempt was made to estimate prostate volume, define 12 reference points, and to precisely identify location of the neurovascular bundles using Doppler ultrasound. The TilePro was used during the procedures to allow real-time ultrasound imaging to guide robotic instruments during dissection. RESULTS Median robotic transrectal ultrasound probe holder (R-TRUS) setup time was 11 minutes (interquartile range [IQR], 10-14). Prostate volume calculation, reference point definition, neurovascular bundle identification, and instrument tip visualization were successful in all men. In 1 patient with a large prostate (120 mL), R-TRUS was withdrawn during recto-prostatic dissection. There were no rectal injuries. CONCLUSION R-TRUS during RALPs is feasible and safe. It allows real-time TRUS navigation and guidance. Further studies are needed to evaluate its impact on oncological and functional outcomes.

Robotic Partial Nephrectomy for Small Renal Masses in Patients With Pre-existing Chronic Kidney Disease

OBJECTIVE To assess the outcomes of robotic partial nephrectomy in patients with pre-existing chronic kidney disease (CKD). MATERIALS AND METHODS Patients who underwent robotic partial nephrectomy for renal tumors between 2007 and 2011 were identified from our prospectively maintained institutional database. Perioperative as well as short-term oncological and functional outcomes were assessed. A comparative analysis was performed between patients with pre-existing CKD (estimated glomerular filtration rate [eGFR] 15-60 mL/min, group 1, n = 52) and patients with eGFR >60 mL/min (group 2, n = 303). RESULTS Group 1 patients were older (median 68 vs 57 years, P < .001), with higher American Society of Anesthesiology (ASA) score (3 vs 2, P < .001) and a higher Charlson comorbidity index (7 vs 4, P < .001). Warm ischemia time (WIT) was similar in both groups (18 vs 18 minutes, P = .52). Group 1 had a higher postoperative complication rate (40.4% vs 21.1%, P = .003). Pathologic and oncological data were similar. After a median follow-up of 3 months (interquartile: 1-10), deterioration of eGFR was lower in group 1 patients (-5% vs -12%, P = .004). No endstage renal disease was noted in either group. There was significantly less CKD upstaging in group 1 than in group 2 (11.5% vs 33.9%, P = .001). After multivariate analysis, preoperative eGFR and WIT were independent predictors of latest eGFR. Less than 15% of patients with normal baseline renal function developed CKD stage III or higher. CONCLUSION Despite a high risk of surgical complications, robotic partial nephrectomy only marginally affects renal function in patients with pre-existing CKD.

Reporting quality of abstracts presented at the European Association of Urology meeting: a critical assessment.

PURPOSE We assessed the reporting quality of randomized and nonrandomized, controlled trials presented in abstract form at the European Association of Urology annual meeting in a 10-year period and determined the impact on subsequent publication. MATERIALS AND METHODS Abstracts presented at the European Association of Urology annual meetings in 1998, 1999, 2008 and 2009 were retrieved and included in analysis. Two 2-year meeting periods were considered, including 1) 1998 and 1999, and 2) 2008 and 2009. Two standardized forms were constructed based on the CONSORT (Consolidated Standards of Reporting Trials) and STROBE (Strengthening the Reporting of Observational studies in Epidemiology) guidelines, each including 15 and 16 items for randomized and nonrandomized, controlled trials, respectively. Reporting quality was assessed by measuring the proportion of items respected by authors when preparing the abstract, defined as the score ratio. Subsequent full-length publication within 2 years after the meeting was also determined by a PubMed® search. Differences between the 2 periods were analyzed by the chi-square and simple t tests. Predictors of subsequent full-length publication were evaluated by multiple logistic regression using meeting period, topic, country of origin, design, multi-institutional study and the proportion of reported items (score ratio). RESULTS A total of 3,139 abstracts were included in analysis, of which 375 (11.9%) were randomized, controlled trials. Overall oncology represented the main topic (49.2% of all abstracts). The score ratio (proportion of adequately reported items in each abstract) was better for period 1 than 2 for randomized, controlled trials (63% vs 57%) but better for period 2 than 1 for nonrandomized, controlled trials (55.4% vs 53.2%, each p <0.001). Abstracts describing multi-institutional studies were more likely to be followed by full-length publication (OR 1.82, 95% CI 1.44-2.30). Other features, including reporting quality (score ratio), did not predict subsequent publication. CONCLUSIONS The reporting quality of European Association of Urology meeting abstracts did not improve in a decade. Nevertheless, this factor did not impact subsequent full-length publication. Ultimately, the reporting quality of abstracts remains to be improved by following currently available guidelines.

Does preserved kidney volume predict 1 year donor renal function after laparoscopic living donor nephrectomy

The aim of the present study was to evaluate whether preserved kidney volume predicts donor renal function at 1‐year post‐surgery. Data of patients who underwent laparoscopic living donor nephrectomy between October 2006 and September 2010 were retrospectively reviewed. All patients underwent computed tomography scan with an estimation of kidney volume by using an automated segmentation algorithm. We also calculated kidney volume adjusted for donor body surface area and donor preserved kidney volume ratio (split volume). Estimated glomerular filtration rate was estimated using the Modification of Diet in Renal Disease equation. Predictors of the estimated glomerular filtration rate at 1 year were assessed by multiple linear regression. The 1‐year estimated glomerular filtration rate was available in 140 patients. The median age was 40 years, and median adjusted preserved kidney volume was 160.5 cc/1.73 m2 (interquartile range 143.7–177.9). Median estimated glomerular filtration rate was 92.4 (interquartile range 81.9–101.2) and 61.2 mL/min/1.73 m2 (interquartile range 53.4–68.7), respectively, at baseline and at 1 year. Preserved kidney volume adjusted to body surface area (P = 0.02) with age (P = 0.002) and preoperative estimated glomerular filtration rate (P < 0.001) were independent predictors of estimated glomerular filtration rate at 1 year. However, split kidney volume was not statistically related to estimated glomerular filtration rate at 1 year (P = 0.47). In order to maximize preservation of donor renal function, the pre‐donation kidney volume adjusted to body surface area might be a useful parameter to consider when deciding on living kidney donation.