Ryan J. Nelson

Predictors of Excisional Volume Loss in Partial Nephrectomy: Is There Still Room for Improvement?

UNLABELLED Since volume loss is the most important modifiable determinant of long-term renal function after partial nephrectomy, there is great interest in ways to reduce the loss of healthy parenchyma. We retrospectively reviewed 880 partial nephrectomies to identify predictors of excisional volume loss (EVL), based on pathologic assessment. After stepwise variable selection, we assessed age, sex, solitary kidney status, tumor size, endophytic property, estimated blood loss, surgical approach, and surgeon volume for association with EVL using multiple regression. Male sex (p<0.01), larger tumors (p<0.01), endophytic tumors (p=0.01), open approach (p<0.01), increased bleeding (p<0.01), and higher surgeon volume (p<0.01) were independently associated with greater EVL. Approach strongly influenced EVL with open surgery having 7.8 cm(3) more EVL than robotic surgery. Negative surgical margins (95.7% vs 94.1%, p=0.32) did not differ between open and robotic approaches, respectively. EVL is associated with patient, tumor, and especially provider factors, suggesting that volume preservation may be improved with surgical optimization. Lack of percent volume loss data, which precluded assessment of EVLs impact on long-term renal function, is a limitation. PATIENT SUMMARY We found that surgical approach affects the quantity of healthy kidney removed during cancer surgery, suggesting that there is room for further surgical improvement.

Comparison of robot-assisted and open partial nephrectomy for completely endophytic renal tumours: a single centre experience.

To compare outcomes between robot‐assisted partial nephrectomy (RAPN) and open PN (OPN) for completely endophytic renal tumours.

When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center

Purpose: We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. Materials and Methods: Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. Results: The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96–0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22–1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short‐term oncologic outcomes but better renal functional preservation (p <0.01). Conclusions: At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.

Perioperative morbidity, oncological outcomes and predictors of pT3a upstaging for patients undergoing partial nephrectomy for cT1 tumors

ObjectivesTo evaluate perioperative morbidity, oncological outcome and predictors of pT3a upstaging after partial nephrectomy (PN).Materials and methodsRetrospective study of 1042 patients who underwent PN for cT1N0M0 renal cell carcinoma between 2007 and 2015. A total of 113 cT1 patients were upstaged to pT3a, while 929 were staged as pT1. Demographic, perioperative and pathological variables were reviewed. We compared the clinico-pathological characteristics, perioperative morbidity and oncological outcomes between pT3a and pT1 groups. Multivariate regression evaluates variables associated with T3a upstaging. Recurrence-free survival (RFS) and overall survival analyses were performed. Survival curves were compared using log-rank test.ResultsThe pT3a tumors were high complexity tumors (median RENAL score 8 vs. 7, p < 0.01), higher hilar (h) location (27.5 vs. 14.8%, p < 0.01), higher grade (57.5 vs. 38.2%, p < 0.01), and higher positive surgical margins (18.6 vs. 5.8%, p < 0.01. Patients with pT3a had a higher estimated blood loss, transfusion rate, ischemia time and overall complications, though there were no differences in median e-GFR decline and major (Grade III-V) complications. Five-year RFS was 78.5% for pT3a group vs. 94.6% for pT1 group (log-rank p < 0.01). Male gender (OR 2.2, p < 0.01), and R.E.N.A.L. score (OR 2.3, p = 0.01) were preoperative predictors of upstaging. We acknowledge limitations in our study, most are inherent problems of retrospective studies.ConclusionPerioperative morbidity, after partial nephrectomy, is acceptable in cT1/pT3 tumors in comparison to cT1/pT1; however, upstaged patients had a worse oncological outcome. cT1/pT3a tumors are associated with adverse clinico-pathological features. Preoperative risk predictors of upstaging were higher R.E.N.A.L. score and male gender.

Patterns and Predictors of Recurrence after Partial Nephrectomy for Kidney Tumors

Purpose: We sought to identify patterns and predictors of recurrence in patients with clinically localized renal cell carcinoma managed by partial nephrectomy. Materials and Methods: We performed a retrospective study of 830 consecutive cases of partial nephrectomy done between 2007 and 2015 for clinically localized renal cell carcinoma at a single institution. Patient demographics and pathological characteristics were correlated with recurrence patterns (overall, local and distant) and overall survival using Kaplan‐Meier and Cox regression analyses. Differences in the recurrence patterns were evaluated. Results: Median patient age was 61 years and median tumor size was 3.1 cm. Overall, 11.6% of tumors were stage pT3, 39.3% were high grade, 2.9% had lymphovascular invasion and 7.1% had positive margins. Higher grade, higher stage, positive surgical margins and increased R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of deepest tumor portion to collecting system or sinus, anterior/posterior and location relative to polar line) score were associated with shorter disease‐free survival on Kaplan‐Meier analysis. On multivariable regression pT (p <0.01), grade (p <0.01) and R.E.N.A.L. score (p = 0.03) remained independent predictors of disease‐free survival. Predictors of metastasis were pT stage (HR 4.5) and grade (HR 3.9, both p <0.01), while R.E.N.A.L. score (HR 3.2, p = 0.03) was the single predictor of local recurrence. Five‐year disease‐free and overall survival probabilities were 91% and 94%, respectively. Local recurrence manifested and developed earlier than metastasis (median 13 vs 22 months, p <0.01). Conclusions: High pT stage, high grade and high R.E.N.A.L. score increase the risk of disease recurrence after partial nephrectomy. The pT stage and grade are predictors of metastasis, while R.E.N.A.L. score predicts local recurrence. Because relapse features and risk factors differ between the 2 recurrence patterns, they should be studied separately in the future.

Robot-assisted approach improves surgical outcomes in obese patients undergoing partial nephrectomy

To assess the impact of approach on surgical outcomes in otherwise healthy obese patients undergoing partial nephrectomy for small renal masses.

Optimum outcome achievement in partial nephrectomy for T1 renal masses: a contemporary analysis of open and robot-assisted cases

To compare optimum outcome achievement in open partial nephrectomy (OPN) with that in robot‐assisted partial nephrectomy (RAPN).

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Predicting complications in partial nephrectomy for T1a tumours: does approach matter?

To assess differences in complications after robot‐assisted (RAPN) and open partial nephrectomy (OPN) among experienced surgeons.

Reducing Costs for Robotic Radical Prostatectomy: Three-instrument Technique

OBJECTIVE To describe our technique for performing robotic-assisted laparoscopic prostatectomy (RALP) and pelvic lymph node dissection using only 3 robotic instruments to reduce disposable costs associated with the robotic surgical platform. METHODS The financial impact of robotic surgery is real. Whereas the initial capital investment of the robotic platform (including the cost of the device itself and the maintenance contract) is largely fixed, the cost of disposable instrumentation can vary depending on utilization. Herein we describe our technique for 3-instrument robotic radical prostatectomy that may decrease costs by limiting the use of disposable instruments. RESULTS Exclusion of the high-cost energy instruments may reduce operative costs by up to 40%. In addition, using 1 robotic needle driver vs 2 may decrease overall costs by another 12%. At our institution, we have adopted these techniques in cost-efficiency and have gone further by only using 3 instruments during robotic radical prostatectomy. The only 3 instruments necessary to perform a successful RALP are a robotic needle driver, Prograsp forceps, and monopolar scissors. CONCLUSION To improve the value of care while utilizing robotic technology, we must be cognizant of keeping operative costs to a minimum while maintaining positive patient outcomes. We demonstrate here a method to decrease disposable operating room costs while preserving the ability to successfully perform a RALP.