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Scientific Reports Sep 2023Partial nephrectomy has been demonstrated to preserve renal function compared with radical nephrectomy. Computed tomography (CT) is used to reveal localized renal cell...
Partial nephrectomy has been demonstrated to preserve renal function compared with radical nephrectomy. Computed tomography (CT) is used to reveal localized renal cell carcinoma (RCC). However, marking RCC directly and quantitatively on a patient's kidney during an operation is difficult. We fabricated and evaluated a 3D-printed kidney surgical guide (3DP-KSG) with a realistic kidney phantom. The kidney phantoms including parenchyma and three different RCC locations and 3DP-KSG were designed and fabricated based on a patient's CT image. 3DP-KSG was used to insert 16-gauge intravenous catheters into the kidney phantoms, which was scanned by CT. The catheter insertion points and angle were evaluated. The measurement errors of insertion points were 1.597 ± 0.741 mm, and cosine similarity of trajectories was 0.990 ± 0.010. The measurement errors for X-axis, Y-axis, and Z-axis in the insertion point were 0.611 ± 0.855 mm, 0.028 ± 1.001 mm, and - 0.510 ± 0.923 mm. The 3DP-KSG targeted the RCC accurately, quantitatively, and immediately on the surface of the kidney, and no significant difference was shown between the operators. Partial nephrectomy will accurately remove the RCC using 3DP-KSG in the operating room.
Topics: Humans; Carcinoma, Renal Cell; Kidney; Nephrectomy; Kidney Neoplasms; Printing, Three-Dimensional
PubMed: 37726415
DOI: 10.1038/s41598-023-42866-9 -
BJUI Compass Nov 2023This study aimed to determine if using a pre-gerotal fat patch at open partial nephrectomy (PN) as a haemostatic bolster is a viable alternative to using synthetic...
OBJECTIVE
This study aimed to determine if using a pre-gerotal fat patch at open partial nephrectomy (PN) as a haemostatic bolster is a viable alternative to using synthetic haemostatic agents.
MATERIALS AND METHODS
Human Research Ethics Committee approval was obtained for audit of a prospectively kept database from July 2012 to July 2021, which followed outcomes of patients who received a low-tension pre-gerotal fat patch renorrhaphy at open PN. Patient demographics, intraoperative measures, histological outcomes and post-operative complications were analysed. Using a retroperitoneal approach, the peritoneum was mobilised and a vascularised pedicle of pre-gerotal fat was rotated in the direction of the kidney. Routine definition of the hilum, clamping of the hilar vessels and dissection of mass followed. After watertight closure and haemostasis, the harvested pre-gerotal fat patch was placed over the defect and secured using low-tension renorrhaphy. Two-layer closure of the abdominal wall with placement of a drain was routine.
RESULTS
A total of 55 patients underwent open PN. Mean age was 60.4 (35-77) years. There were 38 men and 17 women, and 32 right and 23 left PNs. Mean mass size was 31.9 mm (10-95 mm) and collecting system was breached in 36.5% of cases. One patient (1.9%) suffered a Clavien-Dindo IIIb complication requiring return to theatre and transfusion due to a bleed from an intercostal artery. There were no renal bed bleeds, urine leaks or urine fistulas detected. Mean intraoperative blood loss was 355 mL (50-1500 mL) and mean post-operative creatinine increased by 10.7 μmol/L (51-172 μmol/L). Mean follow up was 40.2 (4-109) months.
CONCLUSION
Utilisation of an anatomical pre-gerotal fat patch to provide pressure at the renorrhaphy site during open PN is an effective technique to assist with surgical haemostasis. This simple technique avoids the costs of haemostatic agents, whilst adding minimal operating time to procedures.
PubMed: 37818025
DOI: 10.1002/bco2.264 -
Sensors (Basel, Switzerland) Apr 2024Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia... (Comparative Study)
Comparative Study
Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan-Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; = 0.03), lower postoperative Clavien-Dindo ≤ 2 complications (1.3% vs. 18.3%, < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09-4.46, = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan-Meier analysis, no differences were observed between the two groups in terms of OS (log-rank = 0.451), CSS (log-rank = 0.476), DFS (log-rank = 0.678), and MFS (log-rank = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement.
Topics: Humans; Nephrectomy; Robotic Surgical Procedures; Male; Female; Middle Aged; Kidney Neoplasms; Propensity Score; Aged; Treatment Outcome; Length of Stay; Postoperative Complications; Disease-Free Survival; Kaplan-Meier Estimate
PubMed: 38732928
DOI: 10.3390/s24092822 -
European Urology Open Science Nov 2023Repeat partial nephrectomy (PN) for tumors recurring in the ipsilateral kidney is associated with surgical complexity and a higher rate of complications.
BACKGROUND
Repeat partial nephrectomy (PN) for tumors recurring in the ipsilateral kidney is associated with surgical complexity and a higher rate of complications.
OBJECTIVE
To evaluate the local oncologic efficacy of thermal ablation (TA) for renal cell carcinoma (RCC) in the ipsilateral kidney following PN.
DESIGN SETTING PARTICIPATION
We included patients who underwent ablation for renal tumors in the ipsilateral kidney after PN between January 2005 and December 2019. Demographics, tumor size, procedural details, complications, pathology, local oncologic outcomes, and survival outcomes are described.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
The procedural, pathologic, and oncologic outcomes are described. Survival rates were estimated using the Kaplan-Meier method.
RESULTS AND LIMITATIONS
A total of 66 patients (46 male and 20 female) with a median age of 62 yr (interquartile range [IQR] 52-69) met our inclusion criteria. In these patients, 74 TA procedures were performed for 86 lesions (median tumor size 1.9 cm, IQR 1.6-2.5). Radiofrequency ablation and cryoablation accounted for 60 (81%) and 14 (19%) procedures, respectively. Three patients (3.7%) had Clavien-Dindo grade III complications. Of 65 lesion biopsies, 62 (95.5%) were diagnostic. The most common subtype was clear cell RCC ( = 37). The median imaging follow-up duration was 60 mo (IQR 43-88). Recurrence in the ablation zone occurred for four lesions (4.6%) at a median of 6.9 mo (IQR 6.4-10.7). The rates of overall, recurrence-free, and disease-free survival were 93.1%, 94.4%, and 65.6% at 5 yr, and 71.6%, 94.4%, and 60.1% at 10 yr, respectively. Limitations include the retrospective design and the lack of a control group.
CONCLUSIONS
TA is effective for the treatment of RCC in the ipsilateral kidney following PN.
PATIENT SUMMARY
Heat treatment to remove tumor tissue is an effective option for small kidney masses recurring after partial kidney removal for cancer. Long-term follow-up data revealed that this treatment resulted in low recurrence and complication rates.
PubMed: 38020520
DOI: 10.1016/j.euros.2023.08.005 -
Translational Andrology and Urology Apr 2024
PubMed: 38721283
DOI: 10.21037/tau-23-651 -
Clinical Medicine & Research Sep 2023Epidemiological outcomes of renal cell carcinoma (RCC) remain sparse. This study aims to compare preoperative characteristics, surgical outcomes, and oncological...
Epidemiological outcomes of renal cell carcinoma (RCC) remain sparse. This study aims to compare preoperative characteristics, surgical outcomes, and oncological outcomes of RCC patients at a urology unit in Singapore. A retrospective cohort analysis of 137 RCC patients in the National University Hospital of Singapore who had undergone partial nephrectomy between 2009 and 2020 was conducted. χ tests (Chi-Square Test, Fisher's Exact Test) and one-way analysis of variance (ANOVA) were used for comparing categorical and continuous variables respectively. Kaplan-Meier estimates were used for survival analysis. In total, 137 patients were identified (Chinese [n=82], Malay [n=19], Indian [n=15], Others [n=21]). Indian patients were diagnosed at an earlier age (52.13±10.52 years, =0.018). A larger percentage of Malay patients (78.9%, <0.001) were operated on before 2016, prior to the center's adoption of the robotic surgical technique. More Malay and Indian patients underwent laparoscopic surgery (36.8% and 46.7%, =0.008), experiencing higher rates of intra-operative conversions compared to the Chinese and other ethnicities (5.3% and 13.3% vs. 0%, =0.011). They also had longer post-operative stays compared to Chinese (7.42±6.46 days; 7.40±7.69 days vs. 4.88±2.87 days, =0.036). Malays were much less likely to undergo robotic partial nephrectomy compared to Chinese patients (OR=0.295, 95% CI=0.102-0.856) and had the highest rate of metastatic recurrence (10.5%, =0.023).
Topics: Humans; Adult; Middle Aged; Carcinoma, Renal Cell; Kidney Neoplasms; Retrospective Studies; Treatment Outcome; Nephrectomy
PubMed: 37985170
DOI: 10.3121/cmr.2023.1819 -
Minerva Urology and Nephrology Apr 2024The aim of this study is to evaluate the perioperative and long-term functional outcomes of laparoscopic (LPN) and robot-assisted partial nephrectomy (RAPN) in... (Comparative Study)
Comparative Study
Minimally invasive transperitoneal partial versus radical nephrectomy in obese patients: perioperative and long-term functional outcomes from a large perspective contemporary series (RECORd2 project).
BACKGROUND
The aim of this study is to evaluate the perioperative and long-term functional outcomes of laparoscopic (LPN) and robot-assisted partial nephrectomy (RAPN) in comparison to laparoscopic radical nephrectomy (LRN) in obese patients diagnosed with renal cell carcinoma.
METHODS
Clinical data of 4325 consecutive patients from The Italian REgistry of COnservative and Radical Surgery for cortical renal tumor Disease (RECORD 2 Project) were gathered. Only patients treated with transperitoneal LPN, RAPN, or LRN with Body Mass Index (BMI) ≥30 kg/m, clinical T1 renal tumor and preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min, were included. Perioperative, and long-term functional outcomes were examined.
RESULTS
Overall, 388 patients were included, of these 123 (31.7%), 120 (30.9%) and 145 (37.4%) patients were treated with LRN, LPN, and RAPN, respectively. No significant difference was observed in preoperative characteristics. Overall, intra and postoperative complication rates were comparable among the groups. The LRN group had a significantly increased occurrence of acute kidney injury (AKI) compared to LPN and RAPN (40.6% vs. 15.3% vs. 7.6%, P=0.001). Laparoscopic RN showed a statistically significant higher renal function decline at 60-month follow-up assessment compared to LPN and RAPN. A significant renal function loss was recorded in 30.1% of patients treated with LRN compared to 16.7% and 10.3% of patients treated with LPN and RAPN (P=0.01).
CONCLUSIONS
In obese patients, both LPN and RAPN showcased comparable complication rates and higher renal function preservation than LRN. These findings highlighted the potential benefits of minimally invasive PN over radical surgery in the context of obese individuals.
Topics: Humans; Nephrectomy; Male; Kidney Neoplasms; Female; Obesity; Middle Aged; Laparoscopy; Carcinoma, Renal Cell; Aged; Treatment Outcome; Robotic Surgical Procedures; Time Factors; Postoperative Complications; Glomerular Filtration Rate
PubMed: 38742553
DOI: 10.23736/S2724-6051.24.05692-1 -
Journal of Robotic Surgery Aug 2023RAPN training usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee capacity to perform RAPN...
RAPN training usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee capacity to perform RAPN at predetermined performance levels prior to in-vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes. The authors sought to examine the reliability, construct and discriminative validity of objective intraoperative performance metrics which best characterize the optimal and suboptimal performance of a reference approach for training novice RAPN surgeons. Seven Novice and 9 Experienced RAPN surgeons video recorded one or two independently performed RAPN procedures in the human. The videos were anonymized and two experienced urology surgeons were trained to reliably score RAPN performance, using previously developed metrics. The assessors were blinded to the performing surgeon, hospital and surgeon group. They independently scored surgeon RAPN performance. Novice and Experienced group performance scores were compared for procedure steps completed and errors made. Each group was divided at the median for Total Errors score, and subgroup scores (i.e., Novice HiErrs and LoErrs, Experienced HiErrs and LoErrs) were compared. The mean inter-rater reliability (IRR) for scoring was 0.95 (range 0.84-1). Compared with Novices, Experienced RAPN surgeons made 69% fewer procedural Total Errors. This difference was accentuated when the LoErr Expert RAPN surgeon's performance was compared with the HiErrs Novice RAPN surgeon's performance with an observed 170% fewer Total Errors. GEARS showed poor reliability (Mean IRR = 0.44; range 0.0-0.8), for scoring RAPN surgical performance. The RAPN procedure metrics reliably distinguish Novice and Experienced surgeon performances. They further differentiated performance levels within a group with similar experiences. Reliable and valid metrics will underpin quality-assured novice RAPN surgical training.
Topics: Humans; Robotic Surgical Procedures; Robotics; Reproducibility of Results; Surgeons; Clinical Competence; Nephrectomy
PubMed: 36689078
DOI: 10.1007/s11701-023-01521-1 -
BMC Urology Oct 2023Acute kidney disease (AKD) is believed to be involved in the transition from acute kidney injury (AKI) to chronic kidney disease in general populations, but little is...
PURPOSE
Acute kidney disease (AKD) is believed to be involved in the transition from acute kidney injury (AKI) to chronic kidney disease in general populations, but little is understood about this possibility among kidney surgical populations. This study aimed to elucidate the incidence of AKD after partial nephrectomy and risk factors that promote the AKI to AKD transition.
METHODS
From January 2010 to January 2020, this study retrospectively collected a dataset of consecutive patients with renal masses undergoing partial nephrectomy in 4 urological centers. Cox proportional regression analyses were adopted to identify risk factors that promoted the AKI to AKD transition. To avoid overfitting, the results were then verified by logistic least absolute shrinkage and selection operator (LASSO) regression. A nomogram was then constructed and validated for AKI to AKD transition prediction.
RESULTS
AKI and AKD occurred in 228 (21.4%) and 42 (3.9%) patients among a total of 1062 patients, respectively. In patients with AKI, multivariable Cox regression analysis and LASSO regression identified that age (HR 1.078, 1.029-1.112, p < 0.001), baseline eGFR (HR 1.015, 1.001-1.030, p < 0.001), RENAL score (HR1.612, 1.067-2.437, p = 0.023), ischemia time > 30 min (HR 7.284, 2.210-23.999, p = 0.001), and intraoperative blood loss > 300ml (HR 8.641, 2.751-27.171, p < 0.001) were risk factors for AKD transition. These five risk factors were then integrated into a nomogram. The nomogram showed excellent discrimination, calibration, and clinical net benefit ability.
CONCLUSION
Around 3.9% patients following partial nephrectomy would transit from AKI to AKD. Intraoperative blood loss and ischemia time need to be diminished to avoid on-going functional decline. Our nomogram can accurately predict the transition from AKI to AKD.
Topics: Humans; Retrospective Studies; Blood Loss, Surgical; Acute Kidney Injury; Nephrectomy; Risk Factors; Acute Disease; Ischemia
PubMed: 37794388
DOI: 10.1186/s12894-023-01325-3 -
European Urology Open Science Aug 2023The surgical difficulty of partial nephrectomy (PN) varies depending on the operative approach. Existing nephrometry classifications for assessment of surgical...
RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned.
BACKGROUND
The surgical difficulty of partial nephrectomy (PN) varies depending on the operative approach. Existing nephrometry classifications for assessment of surgical difficulty are not specific to the robotic approach.
OBJECTIVE
To develop an international robotic-specific classification of renal masses for preoperative assessment of surgical difficulty of robotic PN.
DESIGN SETTING AND PARTICIPANTS
The RPN classification (Radius, Position of tumour, iNvasion of renal sinus) considers three parameters: tumour size, tumour position, and invasion of the renal sinus. In an international survey, 45 experienced robotic surgeons independently reviewed de-identified computed tomography images of 144 patients with renal tumours to assess surgical difficulty of robot-assisted PN using a 10-point Likert scale. A separate data set of 248 patients was used for external validation.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Multiple linear regression was conducted and a risk score was developed after rounding the regression coefficients. The RPN classification was correlated with the surgical difficulty score derived from the international survey. External validation was performed using a retrospective cohort of 248 patients. RPN classification was also compared with the RENAL (Radius; Exophytic/endophytic; Nearness; Anterior/posterior; Location), PADUA (Preoperative Aspects and Dimensions Used for Anatomic), and SPARE (Simplified PADUA REnal) scoring systems.
RESULTS AND LIMITATION
The median tumour size was 38 mm (interquartile range 27-49). The majority (81%) of renal tumours were peripheral, followed by hilar (12%) and central (7.6%) locations. Noninvasive and semi-invasive tumours accounted for 37% each, and 26% of the tumours were invasive. The mean surgical difficulty score was 5.2 (standard deviation 1.9). Linear regression analysis indicated that the RPN classification correlated very well with the surgical difficulty score (R = 0.80). The R values for the other scoring systems were: 0.66 for RENAL, 0.75 for PADUA, and 0.70 for SPARE. In an external validation cohort, the performance of all four classification systems in predicting perioperative outcomes was similar, with low R values.
CONCLUSIONS
The proposed RPN classification is the first nephrometry system to assess the surgical difficulty of renal masses for which robot-assisted PN is planned, and is a useful tool to assist in surgical planning, training and data reporting.
PATIENT SUMMARY
We describe a simple classification system to help urologists in preoperative assessment of the difficulty of robotic surgery for partial kidney removal for kidney tumours.
PubMed: 37545848
DOI: 10.1016/j.euros.2023.05.007