Z. Khene

Off-Clamp versus On-Clamp Robotic Partial Nephrectomy: A Multicenter Match-Paired Case-Control Study

Introduction: The aim of this study was to compare the outcomes of on-clamp and off-clamp robotic partial nephrectomy (RPN). Materials and Methods: The charts of all patients who underwent an RPN at 8 institutions between 2010 and 2014 were retrospectively reviewed. The patients who underwent an off-clamp RPN were matched to on-clamp RPN in a 1-4 fashion according to the following variables: RENAL score, tumor size and surgeons experience. Pre-, intra-, and postoperative data were compared between both groups. Results: Among 525 RPN, 26 were performed off-clamp (5%). They were matched to 104 on-clamp RPN. The complications rate (15.5 vs. 7.7%, p = 0.53), major complications rate (4.9 vs. 3.9%; p = 0.82), and transfusions rate (0 vs. 4.9%; p = 0.58) did not differ significantly between the clamped and unclamped groups. Conversely, estimated blood loss was higher in the off-clamp group (266.4 vs. 284.6 mL, p = 0.048) and so was the rate of conversion to radical nephrectomy (0 vs. 7.7%, p = 0.04). Postoperative preservation of renal function was comparable in both groups. Conclusion: Off-clamp RPN is feasible for a small subgroup of renal tumors without increased risk of postoperative complications but at the cost of higher estimated blood loss and increased risk of conversion to radical nephrectomy.

Does training of fellows affect peri-operative outcomes of robot-assisted partial nephrectomy?

To evaluate the impact of fellows’ involvement on the peri‐operative outcomes of robot‐assisted partial nephrectomy (RAPN).

Artificial Urinary Sphincter in Male Patients with Spina Bifida: Comparison of Perioperative and Functional Outcomes between Bulbar Urethra and Bladder Neck Cuff Placement

Purpose We evaluated the perioperative and long‐term functional outcomes of bladder neck and peribulbar cuff placement of an artificial urinary sphincter in a population of adult male patients with spinal dysraphism. Materials and Methods We retrospectively analyzed the French spina bifida network database. Patients who underwent implantation of an artificial urinary sphincter from January 1985 to November 2015 were selected and stratified into 2 groups according to cuff location, that is bladder neck vs bulbar urethra. Explantation‐free and revision‐free device survival was estimated by the Kaplan‐Meier method and compared with the log rank test. Cox regression models were created to assess prognostic factors of artificial urinary sphincter device failure. Results A total of 65 patients were included in study. Most patients were not wheelchair bound. The cuff was implanted around the bulbar urethra at 46 procedures (59%) and around the bladder neck in 32 (41%). In the peribulbar and bladder neck groups median revision‐free device survival was 11.7 and 14.3 years, respectively (p = 0.73). Median explantation‐free device survival was 18.5 and 24.5 years, respectively (p = 0.08). On multivariate analysis clean intermittent catheterization was the only predictor of artificial urinary sphincter device failure. Cuff location had no influence. At the last followup satisfactory continence was similar in the 2 groups (83% vs 75%, p = 0.75). Conclusions In male patients with spinal dysraphism morbidity and functional outcomes were similar for bladder neck and bulbar urethra cuff placement but with a trend toward longer survival without explantation in the bladder neck group. Clean intermittent catheterization was the only predictor of shorter device survival on multivariate analysis.

Contemporary assessment of the correlation between Bosniak classification and histological characteristics of surgically removed atypical renal cysts (UroCCR-12 study)

PurposeTo evaluate and compare pathological characteristics of renal cysts Bosniak IIF, III and IV in light of recent histological classification.Patients and methodsThe French research network for kidney cancer UroCCR conducted a multicentre study on patients treated surgically for a renal cyst between 2007 and 2016. Independent radiological and centralized pathological reviews were performed for every patient. Pathological characteristics were compared to the Bosniak classification.ResultsOf a total 216 patients included, 175 (81.0%) tumours (90.9% of Bosniak IV, 69.8% of Bosniak III) were malignant or had a low malignant potential, with 60% of clear cell renal cell carcinoma (CCRCC), 24% of papillary RCC (PRCC) and 6.9% of multilocular cystic renal tumour of low malignant potential (MCRTLMP). Malignancies were mostly of low pT stage (86.4% of pT1–2), and low ISUP grade (68.0% of 1–2). Bosniak III cysts had a lower rate of CCRCC (46.7 vs. 67.3%), higher rate of PRCC (30 vs. 20.9%) and MCRTLMP (18.3 vs. 0.9%) compared to Bosniak IV (p < 0.001). Low-malignant potential lesions were less likely Bosniak IV and pT3–4 stage was more frequent in Bosniak IV vs. III (15.7 vs. 3.5%; p = 0.04). There were two recurrences (1.1%) and no cancer-related death occurred during follow-up.ConclusionThese results confirmed that cystic renal malignancies have excellent prognosis. Bosniak III cysts had a low malignant potential, which suggests surveillance could be an option for these lesions.

Role of quantitative computed tomography texture analysis in the prediction of adherent perinephric fat

ObjectiveTo assess the performance of computed tomography (CT) texture analysis to predict the presence of adherent perinephric fat (APF).Materials and methodsSeventy patients with small renal tumors treated with robot-assisted partial nephrectomy were included. Patients were divided into two groups according to the presence of APF. We extracted 15 image features from unenhanced CT and contrast-enhanced CT corresponding to first-order and second-order Haralick textural features. Predictors of APF were evaluated by univariable and multivariable analysis. Receiver operating characteristic (ROC) analysis was performed and the area under the ROC curve (AUC) to predict APF was calculated for the independent predictors.ResultsAPF was observed in 26 patients (37%). We identified entropy (p = 0.01), sum entropy (p = 0.02) and difference entropy (p = 0.05) as significant independent predictors of APF. In the portal phase, we identified correlation (p = 0.03), inverse difference moment (p = 0.01), sum entropy (p = 0.02), entropy (p = 0.01), difference variance (p = 0.04) and difference entropy (p = 0.02) as significant independent predictors of APF. Combining these parameters yielded to an ROC-AUC of 0.82 (95% CI 0.65–0.86).ConclusionResults from this preliminary study suggest that CT texture analysis might be a promising quantitative imaging tool that helps urologist to identify APF.

Predicting morbidity after robotic partial nephrectomy: The effect of tumor, environment, and patient-related factors

PURPOSE To investigate the effect of tumor and nontumor related parameters on perioperative outcomes of robotic partial nephrectomy (RPN). PATIENTS AND METHODS Patients who underwent RPN for a localized renal tumor at 2 institutions between June 2010 and November 2016 were reviewed. RENAL and Mayo adhesive probability (MAP) scores were calculated and information on comorbid conditions including ASA score, performance status, Charlsons comorbidity index (CCI), and history of cardiovascular disease was collected. Correlations between each variable and warm ischemia time, estimated blood loss (EBL), operative time, change in estimated glomerular filtration rate, and length of hospital stay were assessed. Logistic regression analyses were performed to identify the best predictors of overall complications, major complications, risk of conversion, and Trifecta achievement. RESULTS A total of 500 patients were included. RENAL score was found to have a statistically significant (P<0.05) correlation with warm ischemia time, EBL, and change in estimated glomerular filtration rate. MAP score showed significant association (P<0.05) with operative time and EBL. CCI had a significant correlation (P<0.05) with length of hospital stay and postoperative complications. In multivariable analyses, MAP score as a continuous variable (OR = 7.66; P<0.001) and MAP risk group stratification (OR = 3.29; P = 0.005) were independent predictors of the risk of conversion. Major complications were significantly associated with the cardiovascular disease in both univariable (OR = 2.35; P = 0.01) and multivariable analysis (OR = 4.52, P = 0.01). Finally, the MAP score as a continuous variable was an independent factor of Trifecta achievement (OR = 0.56; P = 0.04). CONCLUSION Patients related factors were the most important determinants of postoperative complications after RPN. RENAL and MAP scores had some influence on intraoperative parameters.

Intraoperative Cyst Rupture at Partial Nephrectomy of Cystic Renal Masses: Does It Increase the Risk of Recurrence?

Purpose: Our objective was to assess the prevalence of intraoperative cyst rupture and its impact on oncologic outcomes. Materials and Methods: All patients who underwent partial nephrectomy for a cystic renal mass via an open or robot‐assisted approach at a total of 8 academic institutions were included in this retrospective study. All operative reports were carefully reviewed and any description of cyst rupture, cyst effraction or local spillage intraoperatively was recorded as cyst rupture. Multivariate logistic regression analysis was done to assess the variables associated with cyst rupture. Recurrence‐free, cancer specific and overall survival was estimated by the Kaplan‐Meier method and compared with the log rank test. Results: Overall 268 patients were included in study. There were 50 intraoperative cyst ruptures (18.7%) in the whole cohort. No preoperative parameter was significantly associated with a risk of intraoperative cyst rupture on univariate or multivariate analysis. Of the cystic renal masses 75% were malignant on the final pathology report. At a median followup of 32 months 5 patients (2.5%) had local recurrence while progression to metastasis was observed in 2%. There were no peritoneal carcinomatosis nor port site metastasis. There was also no local or metastatic recurrence in the subgroup with intraoperative cyst rupture. Estimated recurrence‐free survival did not differ significantly between patients with vs without intraoperative cyst rupture at 100% vs 92.7% at 5 years (p = 0.20). Conclusions: Intraoperative cyst rupture during partial nephrectomy is a relatively common occurrence but with few oncologic implications.

Risk of prolapse and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor using clean intermittent catheterization versus Valsalva voiding

To assess the relative risks of pelvic organ prolapse (POP) and urinary complications in adult spina bifida patients with neurogenic acontractile detrusor voiding with Valsalva versus those using clean‐intermittent catheterization (CIC).

The Learning Curve for Robot-assisted Partial Nephrectomy: Impact of Surgical Experience on Perioperative Outcomes

Robot-assisted partial nephrectomy (RAPN) outcomes might be importantly affected by increasing surgical experience (EXP). The aim of the study is to investigate the effect of EXP on warm ischemia time (WIT), presence of at least one Clavien-Dindo ≥2 postoperative complication (CD ≥ 2), and positive surgical margins (PSMs) to define the learning curve for RAPN. We evaluated 457 consecutive patients diagnosed with a cT1-T2 renal mass were evaluated. EXP was defined as the total number of RAPNs performed by each surgeon before each patients operation. Median WIT was 14min and the rate of CD ≥ 2 and PSMs was 15% and 4%, respectively. At multivariable regression analyses adjusted for case mix, EXP resulted associated with shorter WIT (p<0.0001) and higher probability of CD ≥ 2-free postoperative course (p=0.001), but not with PSMs (p=0.7). The relationship between EXP and WIT emerged as nonlinear, with a steep slope reduction within the first 100 cases and a plateau observed after 150 cases. Conversely, the relationship between EXP and CD ≥ 2-free course resulted linear, without reaching a plateau, even after 300 cases. Patient summary: Perioperative outcomes after robot-assisted partial nephrectomy (RAPN) are importantly and individually affected by surgeons experience. After 150 RAPNs, no further improvement is observed with respect to ischemia time, but the learning curve appears endless with respect to complications.

Peri-operative and local control outcomes of robot-assisted partial nephrectomy vs percutaneous cryoablation for renal masses: comparison after matching on radiological stage and renal score

To compare the oncological outcomes of percutaneous cryoablation (PCA) vs robot‐assisted partial nephrectomy (RAPN) for the treatment of T1 renal tumours.