Sam B. Bhayani

Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes.

PURPOSE Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. MATERIALS AND METHODS We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. RESULTS The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). CONCLUSIONS Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

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.

Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: single-surgeon analysis of >100 consecutive procedures.

OBJECTIVES To compare a single-surgeon experience of laparoscopic partial nephrectomy (LPN) and robotic-assisted partial nephrectomy (RPN) in 102 consecutive patients. METHODS The clinical, pathologic, and follow-up information from 102 consecutive procedures (40 RPNs and 62 LPNs) was reviewed. RESULTS No statistically significant differences were found between the groups with regard to age, body mass index, or American Society of Anesthesiologists score. No significant difference was found between the estimated blood loss (136 vs 173 mL), tumor size (2.5 vs 2.4 cm), need for pelvicaliceal repair (56% for both), and positive margin rate (1 vs 1 patient) between RPN and LPN, respectively. The mean total number of trocars in the robotic group was greater than the laparoscopic group (4.6 vs 3.2, P = .01). The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively. CONCLUSIONS RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed.

Mechanisms of Cardiac and Renal Dysfunction in Patients Dying of Sepsis

RATIONALE The mechanistic basis for cardiac and renal dysfunction in sepsis is unknown. In particular, the degree and type of cell death is undefined. OBJECTIVES To evaluate the degree of sepsis-induced cardiomyocyte and renal tubular cell injury and death. METHODS Light and electron microscopy and immunohistochemical staining for markers of cellular injury and stress, including connexin-43 and kidney-injury-molecule-1 (Kim-1), were used in this study. MEASUREMENTS AND MAIN RESULTS Rapid postmortem cardiac and renal harvest was performed in 44 septic patients. Control hearts were obtained from 12 transplant and 13 brain-dead patients. Control kidneys were obtained from 20 trauma patients and eight patients with cancer. Immunohistochemistry demonstrated low levels of apoptotic cardiomyocytes (<1-2 cells per thousand) in septic and control subjects and revealed redistribution of connexin-43 to lateral membranes in sepsis (P < 0.020). Electron microscopy showed hydropic mitochondria only in septic specimens, whereas mitochondrial membrane injury and autophagolysosomes were present equally in control and septic specimens. Control kidneys appeared relatively normal by light microscopy; 3 of 20 specimens showed focal injury in approximately 1% of renal cortical tubules. Conversely, focal acute tubular injury was present in 78% of septic kidneys, occurring in 10.3 ± 9.5% and 32.3 ± 17.8% of corticomedullary-junction tubules by conventional light microscopy and Kim-1 immunostains, respectively (P < 0.01). Electron microscopy revealed increased tubular injury in sepsis, including hydropic mitochondria and increased autophagosomes. CONCLUSIONS Cell death is rare in sepsis-induced cardiac dysfunction, but cardiomyocyte injury occurs. Renal tubular injury is common in sepsis but presents focally; most renal tubular cells appear normal. The degree of cell injury and death does not account for severity of sepsis-induced organ dysfunction.

A Prospective Comparison of Robotic and Laparoscopic Pyeloplasty

Objective:To determine whether robotic-assisted pyeloplasty (RLP) has any significant clinical or cost advantages over laparoscopic pyeloplasty (LP) for surgeons already facile with intracorporeal suturing. Summary Background Data:LP has become an established management approach for primary ureteropelvic junction obstruction. More recently, the da Vinci robot has been applied to this procedure (RLP) in an attempt to shorten the learning curve. Whether RLP provides any significant advantage over LP for the experienced laparoscopist remains unclear. Methods:Ten consecutive cases each of transperitoneal RLP and LP performed by a single surgeon were compared prospectively with respect to surgical times and perioperative outcomes. Cost assessment was performed by sensitivity analysis using a mathematical cost model incorporating operative time, anesthesia fees, consumables, and capital equipment depreciation. Results:The RLP and LP groups had statistically indistinguishable demographics, pathology, and similar perioperative outcomes. Mean operative and total room time for RLP was significantly longer than LP by 19.5 and 39.0 minutes, respectively. RLP was much more costly than LP (2.7 times), due to longer operative time, increased consumables costs, and depreciation of the costly da Vinci system. However, even if depreciation was eliminated, RLP was still 1.7 times as costly as LP. One-way sensitivity analysis showed that LP operative time must increase to almost 6.5 hours for it to become cost equivalent to RLP. Conclusions:For the experienced laparoscopist, application of the da Vinci robot resulted in no significant clinical advantage and added substantial cost to transperitoneal laparoscopic dismembered pyeloplasty.

Prospective comparison of short-term convalescence: laparoscopic radical prostatectomy versus open radical retropubic prostatectomy

OBJECTIVES To evaluate and compare prospectively the convalescence of patients after laparoscopic radical prostatectomy (LRP) and open radical retropubic prostatectomy (RRP) in a standardized clinical care pathway at a single institution by two surgeons of equal experience and training. METHODS The study included all 60 patients undergoing LRP and RRP by two fellowship-trained surgeons in their first year of practice. The postoperative care of these patients was uniform and standardized. The medical records were reviewed and convalescence data obtained by an independent urologist and physicians assistant. RESULTS Of the 60 patients, 24 underwent RRP and 36 underwent attempted LRP; 3 patients were converted from LRP to RRP. The differences in mean age, preoperative prostate-specific antigen level, Gleason score, in-hospital morphine equivalent requirement, time to oral intake, and hospital stay were not statistically significant between the LRP and RRP groups. The operating room time was significantly longer (5.8 +/- 1.2 hours versus 2.8 +/- 0.55 hours, P <0.0001) and the estimated blood loss was significantly lower in the LRP group (533 +/- 212 mL versus 1473 +/- 768 mL, P <0.0001) than in the RRP group. Pain medication use at home was significantly less in the LRP group (9 +/- 13 versus 17 +/- 15 oxycodone tablets, P <0.04), as was the time to complete convalescence (30 +/- 18 days versus 47 +/- 21 days, P <0.002). CONCLUSIONS Although LRP took almost twice as long to complete as RRP in our initial clinical experience, the patients had a similar hospital course. LRP patients required less pain medication after discharge and had a shorter time to complete recovery than did RRP patients. Additional studies are needed to address long-term cancer control, potency, and continence outcomes to determine the precise role of LRP in the treatment of men with clinically localized prostate cancer.

Robot-Assisted Partial Nephrectomy: An International Experience

BACKGROUND Robot-assisted partial nephrectomy (RAPN) is emerging as a viable approach for nephron-sparing surgery (NSS), though many reports to date have been limited by evaluation of a relatively small number of patients. OBJECTIVE We present the largest multicenter RAPN experience to date, culling data from four high-volume centers, with focus upon functional and oncologic outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective chart review was performed for 183 patients who underwent RAPN at four centers between 2006 and 2008. SURGICAL PROCEDURE RAPN was performed using methods outlined in the supplemental video material. Though operative technique was similar across all institutions, there were minor variations in trocar placement and hilar control. MEASUREMENTS Perioperative parameters, including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. In addition, we reviewed functional and oncologic outcomes. RESULTS AND LIMITATIONS Mean age at treatment was 59.3 yr. Mean tumor size was 2.87 cm. Mean total operative time was 210 min while mean ischemic time was 23.9 min. Calyceal repair was required in 52.1% of procedures. Mean estimated blood loss was 131.5 ml. Sixty-nine percent of excised tumors were malignant, of which 2.7% exhibited positive surgical margins. The incidence of major complications was 8.2%. At up to 26 mo follow-up, there have been no documented recurrences and no significant change in serum creatinine (1.03 vs 1.04 mg/dl, p=0.84) or estimated glomerular filtration rate (eGFR) from baseline (82.2 vs 79.4 mg/ml per square meter, p=0.74). The study is limited by its retrospective nature, and the outcomes are likely influenced by the robust prior laparoscopic renal experience of each of the surgeons included in this study. CONCLUSIONS RAPN is a safe and efficacious approach for NSS, offering short ischemic times, as well as perioperative morbidity equivalent to other standard approaches. Moreover, RAPN is capable of providing patients with excellent functional and oncologic outcomes.

Predictors of warm ischemia time and perioperative complications in a multicenter, international series of robot-assisted partial nephrectomy.

BACKGROUND Warm ischemia time (WIT) and complication rates are two important parameters for evaluating the perioperative results of robot-assisted partial nephrectomy (RAPN). Few data are available about the clinical predictors of WIT and overall complications. OBJECTIVE To identify clinical predictors of WIT and perioperative complications. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective study including 347 patients who underwent RAPN for suspicious renal cell carcinoma (RCC) at four referral centers from September 2008 to September 2010. INTERVENTION All patients underwent RAPN using the da Vinci S Surgical System with hilar clamping. MEASUREMENTS WIT >20 min and overall complication rates were the main outcomes. Postoperative complications were classified according to the Clavien/Dindo system. Moreover, the following perioperative variables were considered: clinical tumor size, anatomical tumor characteristics according to Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score, surgeon experience, console time, blood loss, and upper collecting system (UCS) repair. RESULTS AND LIMITATIONS WIT >20 min was reported in 125 (36%) cases. Intraoperative and postoperative complications were observed in 10 (2.9%) and 41 (11.8%) cases, respectively. Surgeon experience (odds ratio [OR]: 6.381; 95% confidence interval [CI], 3.687-11.042; p<0.001), clinical tumor size (OR: 1.022; 95% CI, 1.002-1.044; p=0.03), the other anatomic characteristics determined by the PADUA classification score (OR: 1.294; 95% CI, 1.080-1.549; p=0.005), and the UCS repair (OR: 2.987; 95% CI, 1.728-5.165; p<0.001) turned out to be independent predictors of WIT >20 min. Similarly, surgeon experience (OR: 3.937; 95% CI, 2.011-7.705; p<0.001), clinical tumor size (OR: 1.033; 95% CI, 1.009-1.058; p=0.007), and the other anatomical characteristics determined by the PADUA classification score (OR: 1.427; 95% CI, 1.149-1.773; p<0.001) turned out to be independent predictors of overall complication rates. The retrospective design is the main limitation of this multicenter, international study. Therefore, some patient characteristics and comorbidities were not recorded. CONCLUSIONS Anatomic tumor characteristics as determined by the PADUA classification score were independent predictors of WIT and overall complications, once adjusted for the effects of surgeon experience and clinical tumor size.

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

Bladder rupture after blunt trauma: guidelines for diagnostic imaging.

PURPOSE The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.