Same-Day Discharge After Robot-Assisted Partial Nephrectomy: Is It Worth It?

Introduction and Objective: Robot-assisted partial nephrectomy (RAPN) has traditionally been performed as an inpatient procedure; however, recent studies have suggested the feasibility of same-day discharge (SDD) after RAPN. We aimed to evaluate the safety and cost-effectiveness of SDD for RAPN. Methods: A retrospective analysis was conducted on patients undergoing RAPN between January 2015 and July 2021. Comparison before and after the implementation of an SDD protocol was assessed through differences in postanesthesia care unit (PACU) time, length of stay, 30-day readmission rate, 30-day return to emergency department (ED) rates, unplanned office visits (OVs), and need for secondary procedures. A cost-efficacy model was generated to estimate the difference in expenditure between SDD and inpatient RAPN. Results: In total, 192 patients underwent RAPN with 74 being SDD and 118 being admitted postoperatively. After SDD protocol implementation, the percentage of patients discharged from the PACU increased from 0% to 76%. The safety profile of SDD was similar to the inpatient group, with no differences in readmission rates (1.4% vs 5.1%, p = 0.18) or return to ED (5.4% vs 9.3%, p = 0.33). Compared with inpatient RAPN, SDD was associated with increased time in PACU (375 vs 251 minutes, p < 0.001), resulting in an additional expenditure of $1,622 per patient. SDD patients were more likely to return for one or more unplanned OVs (17.6% vs 6.8%, p = 0.02). Overall, the total cost of SDD was significantly lower than inpatient RAPN ($5,222 per patient vs $8,425, p < 0.001). Conclusion: Despite a shorter postoperative monitoring period, SDD appears safe, with equivalent readmission rates, return to ED, and secondary procedures. SDD for RAPN saves ∼$3,000 per patient. In implementing an SDD protocol, clinicians should be cognizant of increased demands on PACU infrastructure and be willing to provide additional support in the office setting.

Tubeless supra-costal percutaneous nephrolithotomy is associated with significantly less hydrothorax: a prospective randomized clinical study.

OBJECTIVES: To evaluate prospectively whether a tubeless (JJ stent-only) percutaneous nephrolithotomy (PCNL) might reduce the risk of hydrothorax, compared to an approach where a nephrostomy tube is left. MATERIALS AND METHODS: We conducted a two-arm open-label prospective randomized study (NCT02036398) comparing tubeless supra-costal PCNL (with a JJ stent only) to standard PCNL (with nephrostomy tube and JJ stent) using intention-to-treat (ITT) and per-protocol (PP) analyses. All patients underwent a standard single-stage prone supra-costal procedure with single-tract access. Complication data were collected according to the Clavien-Dindo grading system. The primary endpoint was the rate of hydrothorax, and secondary endpoints included stone-free rate (SFR) and complication rate. Multivariable logistic regression analysis identified factors associated with hydrothorax formation. RESULTS: Out of 101 patients approached, 75 were finally analysed. No differences were observed between the two arms with regard to baseline demographic and stone characteristics. The mean largest stone size ranged between 23 and 24.2 mm. No significant difference was seen in the mean operating time and length of hospital stay. The incidence of hydrothorax was significantly higher in the nephrostomy group in comparison to the tubeless group (37.8% vs 15.8%, P = 0.031, and 38.4% vs 13.8%, P = 0.016, in the ITT and PP analyses, respectively). The SFR and complication rate were similar in both groups using the ITT and PP analyses. Multivariable logistic regression analysis showed that nephrostomy tube placement was the only covariate associated in a statistically significant manner to hydrothorax (odds ratio 3.628, 95% confidence interval 1.073-12.265; P = 0.038). CONCLUSION: The rate of hydrothorax in supra-costal PCNL is associated with the type of postoperative drainage left. When possible, a tubeless approach should be applied as it may confer a lower risk of hydrothorax.

Prospective implementation of a nonopioid protocol for patients undergoing robot-assisted radical cystectomy with extracorporeal urinary diversion.

OBJECTIVES: To evaluate the feasibility and outcomes of a nonopioid (NOP) perioperative pain management protocol for patients undergoing robot-assisted radical cystectomy (RARC). MATERIALS AND METHODS: We prospectively included 52 consecutive patients undergoing RARC at our institution for bladder cancer. Patients received a multimodal pain management protocol, including a combination of nonopioid pain medications and regional anesthesia. For comparison, we retrospectively included 41 consecutive patients who received the same procedure before implementation of the NOP protocol. RESULTS: There was no significant difference in demographic and perioperative characteristics between the two groups. Patients included in the NOP protocol received a much lower dose of postoperative morphine milligram equivalents (2.5 [IQR: 0-23] vs. 44 [14.5-128], P < 0.001), with no difference in pain scores. In the NOP protocol, the median time to regular diet was significantly shorter (4days [IQR: 3-5] vs. 5days [IQR: 4-8], P = 0.002) and the length of stay was 2days shorter compared to the control group (5days [IQR: 4-7] vs. 7days [IQR: 6-11], P < 0.001). When evaluating the direct costs within 30days after initial surgery, the NOP protocol was associated with an 8.6% reduction as compared to the control group (P = 0.032). In multivariate analysis, the receipt of the NOP protocol was a significant predictor of a length of stay <7days after RARC (OR: 12.09; 95% CI: 1.70-140; P = 0.023). CONCLUSIONS: The prospective implementation of a NOP protocol for patients undergoing RARC is feasible, allowing for minimal narcotic usage and provides benefits to patients, institutions, and population.

Comparison of overall survival and unplanned hospital readmissions between partial and radical nephrectomy for cT1a and cT1b renal masses.

BACKGROUND: The aim of the study was to compare overall survival (OS) and unplanned hospital readmissions (UHRs) within 30 days between partial nephrectomy (PN) and radical nephrectomy (RN) for clinically localized T1 renal tumors. METHODS: The National Cancer Database was queried to identify 51,018 patients who had undergone RN (n = 23,904; 46.9%) or PN (n = 27,114; 53.1%) for a cT1N0M0 renal mass from 2004 to 2013. OS and UHRs were compared using inverse probability of treatment weighted (IPTW)-adjusted Cox proportional hazards regression models. RESULTS: For patients with a cT1a tumor, IPTW-adjusted analysis showed PN compared with RN was associated with improved OS (hazard ratio [HR] = 0.62; 95% confidence interval [CI] = 0.56, 0.67; p < 0.001) with a 5-year and 10-year IPTW-adjusted OS of 93.0% versus 88.2% and 78.1% versus 71.7%, respectively with no difference in UHR (odds ratio [OR] = 1.02; 95% CI = 0.90, 1.16; p = 0.727). For patients with a cT1b tumor, IPTW-adjusted analysis showed PN compared with RN to be associated with marginally improved OS (HR = 0.89; 95% CI = 0.82, 0.99; p = 0.025) with a 5-year and 10-year IPTW-adjusted OS of 85.3% versus 84.3% and 70.8% versus 63.6%, respectively, with more UHRs for PN (OR = 1.43; 95% CI = 1.19, 1.72; p < 0.001). CONCLUSIONS: PN compared with RN was associated with a significant survival benefit for patients with a cT1a renal mass and a modest survival benefit for patients with a cT1b renal mass. PN should be offered over RN when feasible despite a marginal increase in UHRs for PN of cT1b tumors. Randomized controlled trials are necessary to confirm these findings.

Advances in the treatment of testicular cancer.

Germ cell tumors (GCT) are relatively uncommon, accounting for only 1% of male malignancies in the United States. It has become an important oncological disease for several reasons. It is the most common malignancy in young men 15-35 years old. GCTs are among a unique numbers of neoplasms where biochemical markers play a critical role. Finally, it is a model of curable cancer. In this review we discuss cancer epidemiology, genetics, and therapeutic principles. Recent advances in the management of stage I GCT and controversies in the management of post chemotherapy residual mass are presented.

Laparoscopic partial nephrectomy (LPN) for totally intrarenal tumours.

OBJECTIVE: To evaluate the feasibility and outcomes of laparoscopic partial nephrectomy (LPN) for totally intrarenal tumours (TIT). PATIENTS AND METHODS: TIT were defined as completely intraparenchymatic masses, without any exophytic element. Identification of such a tumour necessitates guidance of intraoperative laparoscopic ultrasonography. Data of patients with TIT who underwent LPN was collected from our Ethical Committee-approved database. Their data was compared with that of patients who underwent LPN for tumours with any degree of exophytic element. The two groups were compared for preoperative data (age, gender, tumour size and location), intraoperative variables (warm ischemia time [WIT], open conversions rate, radical nephrectomy [RN] rate, blood loss and other complications), and postoperative data (renal function, reoperation rates, pathological results, and incidence of positive surgical margins). RESULTS: Among 458 patients who underwent LPN, 41 had TIT. The mean (sd) tumour size was 2.6 (0.8) cm, mean WIT was 22.6 (13.8) min and blood loss was 279 (210) mL. The RN rate was significantly higher in the TIT group compared with the remaining cohort of LPNs (9.7% vs 5.3%). The intra- and postoperative complications, open conversion and positive margin rates were similar between the two groups. Malignant tumours were found in 84.2% and 78.2%, respectively. CONCLUSIONS: LPN for a TIT is technically feasible. TIT carry a significantly higher RN rate due to tumour involvement of vital kidney structures. This aspect should be discussed with the patient preoperatively but TIT should not be considered a definitive indication for RN.

Lymphovascular invasion in testicular germ cell tumors: clinicopathological correlates.

INTRODUCTION: We assessed clinical-pathological correlates of lymphovascular invasion in testicular germ-cell tumors. MATERIAL AND METHODS: Archived pathology specimens from 145 patients treated by radical orchiectomy for testicular germ cell tumors at our institution in 1995-2006 were reanalyzed by a dedicated urologic pathologist, and the corresponding medical records were reviewed. The association of lymphovascular invasion with clinical and pathological parameters was tested using stepwise logistic regression analysis. RESULTS: Lymphovascular invasion was identified in 38 (26%) patients and was associated with younger age, testicular pain at presentation, elevated serum tumor markers, nonseminoma histology, and advanced clinical stage. Orchalgia was indicated as the impetus for referral in 67 (46%) patients and characterized as a dull aching sensation, persistent or intermittent in nature. Among the 98 men diagnosed with clinical stage I, those presenting with testicular pain had a 1.8X-higher likelihood of lymphovascular invasion than those without pain (95% CI 1.13-14.9, p = 0.02), and patients with elevated serum tumor markers had an 8.5-fold increased probability of lymphovascular invasion than those presenting with normal tumor markers (CI 1.1-54.2, p = 0.05). Among men with nonseminoma histology, elevated tumor markers was the strongest predictor of lymphovascular invasion in both univariate and multivariate analyses (OR 5.05, 95% CI 1.16-21.8, p = 0.03). CONCLUSION: Providing pathologists with information on pre-orchiectomy tumor marker levels and, possibly, testicular pain at presentation may increase their vigilance in searching for lymphovascular invasion, potentially improving their diagnostic accuracy. Whether it may also translate into improved oncological outcomes needs further evaluation.