Sylvia Montag

Reproducibility and fidelity of the R.E.N.A.L. nephrometry score.

BACKGROUND AND PURPOSE The R.E.N.A.L nephrometry score (NS) was developed to characterize renal tumor anatomy to facilitate standardized reporting and ultimately clinical decision making. Up to three points are assigned for each of the following criteria: Tumor size (R), exophytic vs endophytic nature (E), nearness to the collecting system (N), anterior vs posterior (A), and polar location (L), with more complex lesions receiving higher scores. There are no independent studies to date that validate the reproducibility of this scoring system. Our aim was to validate the R.E.N.A.L. NS system by assessing interobserver variability, and therefore reproducibility and fidelity of this proposed assessment tool. PATIENTS AND METHODS We reviewed our prospectively collected laparoscopic partial nephrectomy (LPN) database and identified 306 patients with available preoperative CT or MRI. Of these, 149 were independently read by two urology residents who assigned NS. The Pearson test was used to assess interobserver variability of total NS as well as each of the five components of the scoring system. RESULTS Interobserver correlation of total NS calculated by the Pearson test was found to be 0.92 (P<0.001). Concordance rates for each of the individual nephrometry components R.E.N.A.L (hilar) were 96%, 92%, 86%, 96%, 89%, and 99% respectively. A t test showed no significant difference between final NS assigned by two different observers. CONCLUSION The R.E.N.A.L. NS system is a comprehensive and reproducible tool that may aid surgeons in communicating tumor characteristics effectively. Interobserver correlation is high, rendering it a high fidelity assessment tool.

Laparoendoscopic Single-Site Surgery of the Kidney with No Accessory Trocars: An Initial Experience

BACKGROUND AND PURPOSE As laparoscopy becomes more commonplace for urologists, ongoing attempts are under way to minimize the number and size of incisions used for access. Laparoendoscopic single-site surgery (LESS) was developed and has been increasingly attempted as an extension of classic laparoscopy. Investigators hypothesize that LESS may offer a superior cosmetic result, faster recovery, and equivalent efficacy to laparoscopic surgery. Our aim is to present our experience with renal LESS. PATIENTS AND METHODS A prospective data collection was performed on all patients who were undergoing renal LESS at our institution. A total of 11 renal LESS procedures were performed between July and November 2008: four LESS donor nephrectomies, two LESS radical nephrectomies, three LESS partial nephrectomies, and two LESS pyeloplasties. All LESS procedures replicated laparoscopic techniques but were performed through a single operative site using a 5-mm flexible-tip laparoscope and flexible working instruments. RESULTS Six of the patients were men. The mean operative time was 162.4 +/- 38.5 minutes. The mean estimated blood loss was 104.5 +/- 41.6 mL, with a mean length of hospitalization of 2.4 +/- 0.8 days. There were no intraoperative complications or blood transfusions. Postoperative pain requirements were tabulated and revealed a mean in-hospital analgesic requirement of 44.8 +/- 46.7 mg (range 7-158 mg) of morphine equivalents with three patients receiving intravenous ketorolac. CONCLUSION Renal LESS is feasible as flexible laparoscopes and instruments continue to develop. In our initial experience, expert laparoscopic surgeons were able to perform these LESS procedures with equivalent efficacy without compromising perioperative measures, including operative time, blood loss, and hospital stay. Further prospective investigation through randomized studies is necessary to elucidate differences, if any, in postoperative analgesic requirements and patient satisfaction with postoperative cosmesis, and to confirm equivalent efficacy when compared with current standards.

Laparoendoscopic single-site (LESS) partial nephrectomy short-term outcomes

Laparoendoscopic single‐site (LESS) surgery has been used by urologists for a broad range of operations including LESS partial nephrectomy (LESS‐PN). To date, experiences of LESS‐PN have been presented as small series or as a subset of larger heterogeneous operative experiences, which have shown the overall feasibility and safety of this novel technique. We report our experience with LESS‐PN with complete pathological resection and excellent short‐term oncological and renal functional outcomes in the select patient population who underwent this minimally invasive approach.

Audio and Visual Analysis of Urologic Laparoscopic and Robotic Skills: Objective Criteria for Surgical Skill Evaluation

OBJECTIVE To assess intraoperative cognitive and motor skills using audio- and video-based analysis. MATERIALS AND METHODS The study enrolled 11 surgeons who were categorized into novice (n = 4), intermediate (n = 4), and expert (n = 3) groups. Categorization of skill level was based on years of experience and as determined by the lead expert surgeon. A total of 32 cases were available for analysis, including 5 robotic and 27 laparoscopic renal cases. For each procedure, video and audio components were recorded and sent for grading to 4 blinded judges. The previously validated global rating scale (GRS) and operation-specific rating scale (ORS), as well as a novel cognitive rating scale (CRS), were used to assess performances. Statistical comparisons were performed by analysis of variance. RESULTS Comparison of the 3 skill levels using analysis of variance showed that each scale was able to differentiate among the levels (P <.05). The mean scores for the before and after audio GRS, ORS, and CRS showed significant difference between the novice, intermediate, and expert groups, demonstrating construct validity. CONCLUSION The use of intraoperative audio is an innovative way to assess the cognitive ability of the surgeon. The CRS demonstrated construct validity. The addition of the CRS to the already validated GRS and ORS may serve as a reliable system to objectively evaluate laparoscopic and robotic surgical skill.