Internal validation of the renal pelvic score: a novel marker of renal pelvic anatomy that predicts urine leak after partial nephrectomy.

OBJECTIVE: To internally validate the renal pelvic score (RPS) in an expanded cohort of patients undergoing partial nephrectomy (PN). MATERIALS AND METHODS: Our prospective institutional renal cell carcinoma database was used to identify all patients undergoing PN for localized renal cell carcinoma from 2007 to 2013. Patients were classified by RPS as having an intraparenchymal or extraparenchymal renal pelvis. Multivariate logistic regression models were used to examine the relationship between RPS and urine leak. RESULTS: Eight hundred thirty-one patients (median age, 60 ± 11.6 years; 65.1% male) undergoing PN (57.3% robotic) for low (28.9%), intermediate (56.5%), and high complexity (14.5%) localized renal tumors (median size, 3.0 ± 2.3 cm; median nephrometry score, 7.0 ± 2.6) were included. Fifty-four patients (6.5%) developed a clinically significant or radiographically identified urine leak. Seventy-two of 831 renal pelvises (8.7%) were classified as intraparenchymal. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (43.1% vs 3.0%; P <.001), major urine leak requiring intervention (23.6% vs 1.7%; P <.001), and minor urine leak (19.4% vs 1.2%; P <.001) compared with that in patients with an extrarenal pelvis. After multivariate adjustment, RPS (intraparenchymal renal pelvis; odds ratio [OR], 24.8; confidence interval [CI], 11.5-53.4; P <.001) was the most predictive of urine leak as was tumor endophyticity ("E" score of 3 [OR, 4.5; CI, 1.3-15.5; P = .018]), and intraoperative collecting system entry (OR, 6.1; CI, 2.5-14.9; P <.001). CONCLUSION: Renal pelvic anatomy as measured by the RPS best predicts urine leak after open and robotic partial nephrectomy. Although external validation of the RPS is required, preoperative identification of patients at increased risk for urine leak should be considered in perioperative management and counseling algorithms.

Renal pelvic anatomy is associated with incidence, grade, and need for intervention for urine leak following partial nephrectomy.

BACKGROUND: Although the effect of tumor complexity on perioperative outcome measures is well established, the impact of renal pelvic anatomy on perioperative outcomes remains poorly defined. OBJECTIVE: To evaluate renal pelvic anatomy as an independent predictor of urine leak in moderate- and high-complexity tumors undergoing nephron-sparing surgery. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing open partial nephrectomy (PN) for localized RCC were stratified into intermediate- and high-complexity groups using a nephrometry score (7-9 and 10-12, respectively). A renal pelvic score (RPS) was defined by the percentage of renal pelvis contained inside the volume of the renal parenchyma. On this basis, patients were categorized as having an intraparenchymal (>50%) or extraparenchymal (<50%) renal pelvis. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Characteristics of patients with and without an intraparenchymal renal pelvic anatomy were compared. RESULTS AND LIMITATIONS: Inclusion criteria were met by 255 patients undergoing PN for intermediate (73.6%) and complex (26.4%) localized renal tumors (mean size: 4.6±2.9cm). Twenty-four (9.6%) renal pelves were classified as completely intraparenchymal. Following stratification by RPS, groups differed with respect to Charlson comorbidity index, body mass index, and largest tumor size, while no differences were observed between hospital length of stay, nephrometry score, estimated blood loss, operative time, and age. Intrarenal pelvic anatomy was associated with a markedly increased risk of urine leak (75% vs 6.5%; p=0.001), secondary intervention (37.5% vs 3.9%; p<0.001), and prolonged duration of urine leak (93±62 d vs 56±29 d; p=0.025). CONCLUSIONS: Intraparenchymal renal pelvic anatomy is an uncommon anatomic variant associated with an increased rate of urine leak following PN. Elevated pressures within a small intraparenchymal renal pelvis might explain the increased risk. Preoperative imaging characteristics suggestive of increased risk for urine leak should be considered in perioperative management algorithms.

Evaluation of laparoscopic curricula in American urology residency training.

PURPOSE: The goal of this study is to evaluate the role of laparoscopic curricula and simulation technology in urology residency training from the perspectives of residents over a 2-year period. MATERIALS AND METHODS: An anonymous survey was given to urology residents attending the American Urological Association Basic Sciences Course in 2008 and 2009. We evaluated laparoscopic simulator use within a curriculum and use of simulators outside of a curriculum. Face and content validity of simulators were analyzed on a 5-point Likert scale questionnaire. Responses were compared using the unpaired Student t test and chi-square with P<0.05 considered significant. RESULTS: There were 114 surveys (81.4% response rate) and 76 surveys (43% response rate) evaluated from 2008 and 2009, respectively. Access to a surgical simulator increased from 74.6% to 78%. The percentage of programs with a laparoscopic curriculum expanded from 16.9% to 44%. In 2009, simulators were used more frequently by residents in programs with curricula compared with residents without curricula (P=0.03). In 2008, 48% of residents and in 2009 72% of residents reported using simulators as "never" or "once or twice a year." Of residents, 93% stated that urology programs should use laparoscopic curricula and 82% think simulators should be involved in the curricula. One third of residents agreed that simulators are helpful for skill acquisition, and 80% described their current laparoscopic curriculum as inadequate. CONCLUSIONS: The number of urology programs that have invested in simulators continues to expand. Despite access to laparoscopic simulators, residents rarely use them. Residents in programs with laparoscopic curricula report using surgical simulators more often than residents without curricula. Laparoscopic curricula are important, and the incorporation of simulators enhances surgical education.