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BMC Health Services Research Oct 2023Despite the wide-spread adoption of robotic-assisted surgery (RAS), the cost-benefit implications for partial (PN) and radical nephrectomy (RN) versus laparoscopic...
OBJECTIVE
Despite the wide-spread adoption of robotic-assisted surgery (RAS), the cost-benefit implications for partial (PN) and radical nephrectomy (RN) versus laparoscopic surgery (Lap) is not well established. We sought to examine the trend of adoption and 1-year healthcare expenditure of PN and RN, and compare 1-year expenditures of RAS versus Lap for PN and RN.
PATIENTS AND METHODS
This cohort study used the Merative MarketScan® Databases between 2013 and 2020. A total of 5,353 patients with kidney cancer undergoing PN (2,980, 55.7%) or RN (2,373, 44.3%). We compared open-conversion, length of stay (LOS), index expenditure, 1-year healthcare expenditure and utilization, and missed work-days between RAS and Lap for PN and RN.
RESULTS
Adoption of PN increased overtime (47.0% to 55.8%), mainly driven by robotic PN increase. Among PN, RAS had lower open-conversion, shorter LOS and lower index expenditure than Lap. Among RN, RAS had shorter LOS, and similar open-conversion and index expenditures. During 1-year post-discharge, RAS had lower hospital outpatient visits (IRR = 0.92, 95% CI = 0.85, 0.99, p = 0.029) and office-based visits (IRR = 0.91, 95% CI = 0.86, 0.96, p = 0.002) for PN, translating to a 1-day less (95% CI = 0.25, 1.75, p = 0.008) missed from work for RAS. Following RN, RAS had lower 1-year readmission than Lap (O.R = 0.72, 95% CI = 0.55, 0.94, p = 0.018). RAS and Lap had comparable 1-year post-discharge expenditures for both PN (mean difference, MD = -$475, 95% CI = -$4362, $3412, p = 0.810) and RN (MD = -$4,204, 95% CI = -$13,837, $5430, p = 0.404).
CONCLUSION
At index surgery, RAS was associated with shorter LOS for both PN and RN, and lower open-conversion and expenditures for PN. RAS and Lap had comparable 1-year total expenditures, despite lower healthcare visits for RAS.
Topics: Humans; Robotic Surgical Procedures; Cohort Studies; Aftercare; Patient Discharge; Kidney Neoplasms; Nephrectomy; Laparoscopy; Health Care Costs; Retrospective Studies; Treatment Outcome
PubMed: 37838666
DOI: 10.1186/s12913-023-10111-8 -
European Urology Jul 2023Several barriers prevent the integration and adoption of augmented reality (AR) in robotic renal surgery despite the increased availability of virtual three-dimensional...
Several barriers prevent the integration and adoption of augmented reality (AR) in robotic renal surgery despite the increased availability of virtual three-dimensional (3D) models. Apart from correct model alignment and deformation, not all instruments are clearly visible in AR. Superimposition of a 3D model on top of the surgical stream, including the instruments, can result in a potentially hazardous surgical situation. We demonstrate real-time instrument detection during AR-guided robot-assisted partial nephrectomy and show the generalization of our algorithm to AR-guided robot-assisted kidney transplantation. We developed an algorithm using deep learning networks to detect all nonorganic items. This algorithm learned to extract this information for 65 927 manually labeled instruments on 15 100 frames. Our setup, which runs on a standalone laptop, was deployed in three different hospitals and used by four different surgeons. Instrument detection is a simple and feasible way to enhance the safety of AR-guided surgery. Future investigations should strive to optimize efficient video processing to minimize the 0.5-s delay currently experienced. General AR applications also need further optimization, including detection and tracking of organ deformation, for full clinical implementation.
Topics: Humans; Robotic Surgical Procedures; Robotics; Augmented Reality; Deep Learning; Surgery, Computer-Assisted; Imaging, Three-Dimensional
PubMed: 36941148
DOI: 10.1016/j.eururo.2023.02.024 -
Cureus Jan 2024Introduction Partial nephrectomy (PN) is the current standard of care for patients with T1 renal tumors, and there has been a shift from an open and laparoscopic to a...
Introduction Partial nephrectomy (PN) is the current standard of care for patients with T1 renal tumors, and there has been a shift from an open and laparoscopic to a robot-assisted approach. The definition of the learning curve for robot-assisted PN (RAPN) is unclear, and various studies have identified warm ischemia time (WIT), perioperative complications, and surgical margins as the defining parameters for the assessment of improvement in these outcomes over time. The objective of this study was to evaluate the learning curve of a newly trained urologist for RAPN when comparing both open and laparoscopic approaches. Methods This study included 52 patients who underwent PN by open, laparoscopic, and robotic methods performed by a single, newly trained urologist over a period of seven years. Basic demographic and perioperative data were collected, and the learning curve was compared between the three approaches. Results Baseline parameters were similar for open (n = 15), laparoscopic (n = 12), and robotic (n = 25) PN except for tumor size and nephrometry score, which were higher in the open group (p = 0.000). Operative time was significantly longer in the robotic approach (180 minutes; p = 0.05), and blood loss was greater in the open group (450 mL; p = 0.000). Median WIT was 25 minutes; significant complications (Clavien Dindo ≥II) and positive surgical margins were 12% and 0%, respectively, in the robotic arm. Preoperative imaging and final histopathology data showed larger tumors being operated on, preferably by an open method, than laparoscopic and robotic PN (6.3 cm vs. 3.4 cm; p = 0.000). More open and laparoscopic procedures (n = 12, 10) were performed during the initial 26 cases, with a later transition to robot-assisted PN (n = 21) in the next 26 cases. None of the parameters showed improvement in the latter half, while operative time showed an increase (150 vs. 180 minutes; p = 0.045). Conclusion The learning curve becomes similar across three defined parameters, i.e., WIT, perioperative complications, and positive surgical margins, after performing a minimum of 25 RAPNs when compared to open and laparoscopic approaches. However, operative duration continues to improve and may take longer to become comparable. A newly trained urologist can safely perform RAPNs even with a small number of cases, especially those who have been previously trained for open and laparoscopic cases.
PubMed: 38313876
DOI: 10.7759/cureus.51646 -
Asian Journal of Surgery Sep 2023The survival benefit of partial nephrectomy (PN) in pT3a RCC patients is controversial. Here we aimed to explore the potential benefit of PN for pT3aN0M0 renal cell...
BACKGROUND
The survival benefit of partial nephrectomy (PN) in pT3a RCC patients is controversial. Here we aimed to explore the potential benefit of PN for pT3aN0M0 renal cell carcinoma (RCC).
MATERIAL AND METHODS
Data of patients with pT3aN0M0 RCC who were diagnosed between 2010 and 2012 in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database were retrospectively collected. Overall survival (OS) and cancer specific survival (CSS) were compared using a Cox proportional hazards model between PN and radical nephrectomy (RN) in pT3aN0M0 RCC. Propensity score (-adjusted, -stratified, -weighted, and -matched) analyses were performed to control for imbalances in individual risk factors.
RESULTS
A total of 1277 patients with pT3aN0M0 RCC were identified, of whom 200 patients were treated with PN and 1077 patients were RN. PN showed favorable OS and CSS in 0-4 cm pT3aN0M0 RCC (P < 0.05), and similar OS and CSS in 4-7 cm pT3aN0M0 RCC, compared with RN using un-adjusted analyses. The Propensity score analyses further demonstrated the survival benefit of PN compared with the RN in 0-4 cm pT3aN0M0 RCC (P < 0.05).
CONCLUSIONS
In this retrospective study, PN was associated with improved survival compared with RN in 0-4 cm pT3aN0M0 RCC. Moreover, survival was comparable between PN and RN in 4-7 cm pT3aN0M0 RCC. These data provided evidence that PN could be an alternative choice for T3aN0M0 RCC less than 7 cm. Particularly, patients with 0-4 cm pT3aN0M0 RCC might benefit from PN.
Topics: Humans; Carcinoma, Renal Cell; Kidney Neoplasms; Retrospective Studies; Propensity Score; Nephrectomy; Neoplasm Staging; Treatment Outcome
PubMed: 37147255
DOI: 10.1016/j.asjsur.2023.04.058 -
Trimethylamine-N-oxide (TMAO) and predicted risk of cardiovascular events after partial nephrectomy.Asian Journal of Surgery Jan 2024Emerging evidence suggests that uremic toxins, in particular trimethylamine-N-oxide(TMAO), indoxyl-sulfate(IS), and p-cresyl-sulfate(PCS), may associate with increased...
INTRODUCTION
Emerging evidence suggests that uremic toxins, in particular trimethylamine-N-oxide(TMAO), indoxyl-sulfate(IS), and p-cresyl-sulfate(PCS), may associate with increased risk of cardiovascular events(CVe). However, whether uremic toxins increase after partial nephrectomy(PN) and their correlation with risk for CVe remains unknown.
METHODS
100 patients managed with PN were retrospectively reviewed. TMAO/IS/PCS levels were examined by liquid chromatography-mass-spectrometry. Renal-parenchymal-volume-preservation(RPVP) was estimated from CT scans. Predicted risks for CVe were obtained using the Framingham score. Linear regression assessed association between uremic toxins, GFR and risk of CVe. Logistic regression evaluated factors associated with post-PN TMAO.
RESULTS
TMAO, IS and PCS increased from 1.7, 3.7 and 3.5 μmol/L before PN to 3.6, 5.4 and 7.4 μmol/L at latest follow-up, respectively, while GFR declined from 102 to 93 ml/min/1.73 m (all p<0.001). TMAO, IS and PCS levels all negatively correlated with GFR(all p<0.001). Predicted 10-year risk of CVe increased from 1.1% pre-PN to 1.7% post-PN(p<0.001), primarily due to increased age(p<0.001), blood pressure(p = 0.002) and total cholesterol(p = 0.003). TMAO(β = 0.038) and GFR (β = -0.02) were independent predictors for predicted 10-year CVe risk on multivariable-analysis. Increased TMAO was an early and sustained finding maintained through 5 years, unlike IS, PCS and eGFR. On multivariable analysis, increased pre-PN TMAO(OR = 2.79) and decreased RPVP(OR = 3.23) were identified as independent risk factors for higher post-PN TMAO, while ischemia type/duration failed to correlate.
CONCLUSION
Uremic toxin levels increased after PN correlating with reduced GFR. Higher TMAO independently associated with greater predicted 10-year CVe risk. Parenchymal mass preserved rather than ischemia time or type associated with increased TMAO.
Topics: Humans; Retrospective Studies; Uremic Toxins; Nephrectomy; Ischemia; Cardiovascular Diseases; Sulfates; Oxides
PubMed: 37673746
DOI: 10.1016/j.asjsur.2023.08.104 -
Urology Journal Oct 2023To propose a standardized scoring system of renal tumors suitable for partial nephrectomy based on mini-invasiveness and retroperitoneal approach.
PURPOSE
To propose a standardized scoring system of renal tumors suitable for partial nephrectomy based on mini-invasiveness and retroperitoneal approach.
MATERIALS AND METHODS
One-hundred and five patients in retroperitoneal group were prospectively enrolled from January 2017 to December 2018. Perioperative characteristics of all patients were collected: age, gender, BMI, preoperative blood test and imaging results, operation time (the time period starts from the skin incision to the final skin closure), estimated blood lost, clamping time, complications within 30 days, American Society of Anesthesiologists (ASA) score, pathology. An algorithm was extracted, and it was used to predict the risk of complications.
RESULTS
Symptoms, ASA score and RETRO score were significantly correlated to postoperative complications, excluding tumor size, ischemia time and operation time. Adjusted RETRO points were an independent factor to predict complication rate (p = 0.006). Limitation was that it did not analyze the relationship between the RETRO score and the long-term outcomes.
CONCLUSION
The RETRO score simplifies the risk evaluation of partial nephrectomy for patients with renal tumor, especially benefits those surgeries performed under robot-assisted laparoscope via retroperitoneal approach. The new RETRO score system that we developed is a selection criterion to perform surgery via different approaches, and an accurate system to evaluate the complexity during partial nephrectomy.
PubMed: 37312600
DOI: 10.22037/uj.v20i.7519 -
Journal of Kidney Cancer and VHL 2023This study aimed to compare the antero-lateral and posterior localized renal masses in laparoscopic partial nephrectomy with the retroperitoneal approach in terms of...
This study aimed to compare the antero-lateral and posterior localized renal masses in laparoscopic partial nephrectomy with the retroperitoneal approach in terms of operative, functional, and oncological outcomes. Patients who underwent retroperitoneal laparoscopic partial nephrectomy by a single surgeon between January 2013 and January 2021 were included in the study. A one-to-one propensity score matching (PSM) analysis was conducted to obtain two balanced groups. The patients were divided into two groups as posterior and antero-lateral according to the localization of the mass. A total of 239 patients were included in the PSM analysis, with 65 patients allocated to each group. The mean operative time was 79.2 ± 11.2 min in the posterior group, while it was 90.0 ± 11.6 min in the antero-lateral group (P < 0.001). Warm ischemia time was 15.9 ± 2.4 min in the posterior group and 18.6 ± 2.7 min in the antero-lateral group (P < 0.001). The median decrease in eGFR at 1 year was 4.8 (IQR, 2.9-6.9) mL/min in the posterior group and 5.0 (IQR, 2.8-11) mL/min in the antero-lateral group (P = 0.219). The warm ischemia time and clamping technique were found to be significant factors for predicting eGFR change after surgery (β:0.693, 95% CI: 0.39-0.99, P < 0.001; β:6.43, 95% CI: 1.1-11.7, P = 0.017, respectively). We report that retroperitoneal laparoscopic partial nephrectomy provided longer warm -ischemia and operative time for antero-lateral renal masses than posterior masses. However, long-term oncological and functional results were similar for both localizations.
PubMed: 37457633
DOI: 10.15586/jkcvhl.v10i3.273 -
Frontiers in Surgery 2023To compare the usefulness and safety of off-clamp microwave scissors-based sutureless partial nephrectomy (MSPN) with on-clamp conventional partial nephrectomy (cPN) in...
OBJECTIVES
To compare the usefulness and safety of off-clamp microwave scissors-based sutureless partial nephrectomy (MSPN) with on-clamp conventional partial nephrectomy (cPN) in dogs.
METHODS
We performed off-clamp MSPN using microwave scissors (MWS) in six dogs, and on-clamp cPN in three dogs, in two-stage experiments. The bilateral kidney upper poles were resected via a midline incision under general anesthesia. After 14 days of follow-up, the lower pole resections were performed. The renal calyces exposed during renal resections were sealed and transected using MWS in off-clamp MSPN and were sutured in on-clamp cPN. In the off-clamp MSPN group, the generator's power output of MWS was set as either 50 W or 60 W for each kidney side. We compared the procedure time (PT), ischemic time (IT), blood loss (BL), and normal nephron loss (NNL) between the two techniques using the Mann-Whitney -test.
RESULTS
We successfully performed 24 off-clamp MSPNs and 12 on-clamp cPNs. The off-clamp MSPN was significantly superior to on-clamp cPN in avoiding renal ischemia (median IT, 0 min vs. 8.6 min, < 0.001) and reducing PT (median PT, 5.8 min vs. 11.5 min, < 0.001) and NNL (median NNL, 5.3 mm vs. 6.0 mm, = 0.006) with comparable BL (median BL, 20.9 ml vs. 23.2 ml, = 0.804). No bleeding and major urine leakage were noted during the reoperations.
CONCLUSIONS
Off-clamp MSPN outperforms on-clamp cPN in lowering the risks of postoperative renal function impairment in dogs.
PubMed: 37795145
DOI: 10.3389/fsurg.2023.1255929 -
European Radiology Nov 2023To determine whether 3D-CT multi-level anatomical features can provide a more accurate prediction of surgical decision-making for partial or radical nephrectomy in renal...
OBJECTIVES
To determine whether 3D-CT multi-level anatomical features can provide a more accurate prediction of surgical decision-making for partial or radical nephrectomy in renal cell carcinoma.
METHODS
This is a retrospective study based on multi-center cohorts. A total of 473 participants with pathologically proved renal cell carcinoma were split into the internal training and the external testing set. The training set contains 412 cases from five open-source cohorts and two local hospitals. The external testing set includes 61 participants from another local hospital. The proposed automatic analytic framework contains the following modules: a 3D kidney and tumor segmentation model constructed by 3D-UNet, a multi-level feature extractor based on the region of interest, and a partial or radical nephrectomy prediction classifier by XGBoost. The fivefold cross-validation strategy was used to get a robust model. A quantitative model interpretation method called the Shapley Additive Explanations was conducted to explore the contribution of each feature.
RESULTS
In the prediction of partial versus radical nephrectomy, the combination of multi-level features achieved better performance than any single-level feature. For the internal validation, the AUROC was 0.93 ± 0.1, 0.94 ± 0.1, 0.93 ± 0.1, 0.93 ± 0.1, and 0.93 ± 0.1, respectively, as determined by the fivefold cross-validation. The AUROC from the optimal model was 0.82 ± 0.1 in the external testing set. The tumor shape Maximum 3D Diameter plays the most vital role in the model decision.
CONCLUSIONS
The automated surgical decision framework for partial or radical nephrectomy based on 3D-CT multi-level anatomical features exhibits robust performance in renal cell carcinoma. The framework points the way towards guiding surgery through medical images and machine learning.
CLINICAL RELEVANCE STATEMENT
We proposed an automated analytic framework that can assist surgeons in partial or radical nephrectomy decision-making. The framework points the way towards guiding surgery through medical images and machine learning.
KEY POINTS
• The 3D-CT multi-level anatomical features provide a more accurate prediction of surgical decision-making for partial or radical nephrectomy in renal cell carcinoma. • The data from multicenter study and a strict fivefold cross-validation strategy, both internal validation set and external testing set, can be easily transferred to different tasks of new datasets. • The quantitative decomposition of the prediction model was conducted to explore the contribution of each extracted feature.
Topics: Humans; Carcinoma, Renal Cell; Kidney Neoplasms; Retrospective Studies; Nephrectomy; Tomography, X-Ray Computed
PubMed: 37289245
DOI: 10.1007/s00330-023-09812-9 -
European Urology Open Science Dec 2023In partial nephrectomy for highly complex tumors with expected long ischemia time, renal hypothermia can be used to minimize ischemic parenchymal damage.
Robot-assisted Partial Nephrectomy Using Intra-arterial Renal Hypothermia for Highly Complex Endophytic or Hilar Tumors: Case Series and Description of Surgical Technique.
BACKGROUND
In partial nephrectomy for highly complex tumors with expected long ischemia time, renal hypothermia can be used to minimize ischemic parenchymal damage.
OBJECTIVE
To describe our case series, surgical technique, and early outcomes for robot-assisted partial nephrectomy (RAPN) using intra-arterial cold perfusion through arteriotomy.
DESIGN SETTING AND PARTICIPANTS
A retrospective analysis was conducted of ten patients with renal tumors (PADUA score 9-13) undergoing RAPN between March 2020 and March 2023 with intra-arterial cooling because of expected arterial clamping times longer than 25 min.
SURGICAL PROCEDURE
Multiport transperitoneal RAPN with full renal mobilization and arterial, venous, and ureteral clamping was performed. After arteriotomy and venotomy, 4°C heparinized saline is administered intravascular through a Fogarty catheter to maintain renal hypothermia while performing RAPN.
MEASUREMENTS
Demographic data, renal function, console and ischemia times, surgical margin status, hospital stay, estimated blood loss, and complications were analyzed.
RESULTS AND LIMITATIONS
The median warm and cold ischemia times were 4 min (interquartile range [IQR] 3-7 min) and 60 min (IQR 33-75 min), respectively. The median rewarming ischemia time was 10.5 min (IQR 6.5-23.75 min). The median pre- and postoperative estimated glomerular filtration rate values at least 1 mo after surgery were 90 ml/min (IQR 78.35-90 ml/min) and 86.9 ml/min (IQR 62.08-90 ml/min), respectively. Limitations include small cohort size and short median follow-up (13 [IQR 9.1-32.4] mo).
CONCLUSIONS
We demonstrate the feasibility and first case series for RAPN using intra-arterial renal hypothermia through arteriotomy. This approach broadens the scope for minimal invasive nephron-sparing surgery in highly complex renal masses.
PATIENT SUMMARY
We demonstrate a minimally invasive surgical technique that reduces kidney infarction during complex kidney tumor removal where surrounding healthy kidney tissue is spared. The technique entails arterial cold fluid irrigation, which temporarily decreases renal metabolism and allows more kidneys to be salvaged.
PubMed: 38028235
DOI: 10.1016/j.euros.2023.10.004