RESUMEN
OBJECTIVE: To compare perioperative and oncologic outcomes between laparoscopic (LCA) and percutaneous cryoablation (PCA) and identify predictors of treatment failure after cryoablation. METHODS: Retrospective analysis was performed on 145 patients undergoing LCA and 118 patients undergoing PCA at our institution between July 2000 and June 2011. RESULTS: LCA and PCA were performed on 167 and 123 tumors, respectively. Perioperative complication rates were 10% for both the groups. Mean length of stay was significantly shorter for the PCA group (2.1 ± 0.5 vs 3.5 ± 3.1 days, P <.01). Both groups had a comparable decline in estimated glomerular filtration rate at most recent follow-up (LCA 3.8 ± 18.5 mL/min/1.73 m(2) vs PCA 6.6 ± 17.1 mL/min/1.73 m(2), P = .21). Mean oncologic follow-up was 71.4 ± 32.1 months for LCA and 38.6 ± 19.6 months for PCA. Kaplan-Meier estimated 5-year overall and recurrence-free survival were 79.3% and 85.5%, respectively, for LCA and 86.3% and 86.3%, respectively, for PCA. Multivariate Cox proportional hazards analysis demonstrated that cryoablation approach (LCA vs PCA) was not predictive of overall mortality or disease recurrence (P = .36 and .82, respectively). Predictors of overall mortality included age-adjusted Charlson comorbidity index ≥ 6 (P = .01) and preoperative estimated glomerular filtration rate <60 mL/min/1.73 m(2) (P = .02). Predictors of recurrence included tumor size ≥ 3 cm (P <.01), body mass index ≥ 30 kg/m(2) (P = .01), and endophytic growth (P = .04). CONCLUSION: Mean length of stay was shorter for patients undergoing PCA as compared with LCA. Complication rates and decline in renal function at most recent follow-up were similar between groups. Oncologic outcomes were influenced by baseline patient and tumor characteristics rather than the cryoablation approach.
Asunto(s)
Criocirugía , Neoplasias Renales/cirugía , Laparoscopía , Anciano , Criocirugía/métodos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function. OBJECTIVE: To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD. DESIGN, SETTING, AND PARTICIPANTS: A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15-60 ml/min per 1.73 m(2)) were identified. Perioperative results of 121 patients were compared against propensity score-matched controls without CKD (eGFR ≥60 ml/min per 1.73 m(2)). INTERVENTION: RPN in patients with or without baseline CKD. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score-matched operative and functional outcomes. RESULTS AND LIMITATIONS: After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (-5.1 vs -10.9), which remained significant at a mean follow-up of 12.6 mo (-2.8 vs -9.1, p<0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p=0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p=0.007). The retrospective analysis was the main limitation of this study. CONCLUSIONS: RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay.
Asunto(s)
Tasa de Filtración Glomerular , Nefrectomía/métodos , Tratamientos Conservadores del Órgano , Insuficiencia Renal Crónica/fisiopatología , Insuficiencia Renal Crónica/cirugía , Procedimientos Quirúrgicos Robotizados , Anciano , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Nefrectomía/efectos adversos , Periodo Posoperatorio , Periodo Preoperatorio , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
BACKGROUND AND PURPOSE: American Urological Association guidelines endorse partial nephrectomy as the preferred treatment for patients with small renal masses, while considering patients with significant comorbidities potential candidates for ablative therapy. We compared perioperative, renal functional, and oncologic outcomes of renal cryoablation and robot-assisted partial nephrectomy (RAPN) based on our long-term institutional experience. PATIENTS AND METHODS: A retrospective review evaluated 267 patients who underwent laparoscopic or percutaneous cryoablation (July 2000-June 2011) and 233 patients who underwent RAPN (June 2007-September 2012) for enhancing renal masses at Washington University. RESULTS: The perioperative complication rate was 8.6% in the cryoablation group vs 9.4% in the RAPN group (P = 0.75). There was no significant difference in complication risk between the two treatment modalities on multivariate analysis. Estimated glomerular filtration rate (eGFR) at last follow-up was 6% lower than preoperative eGFR in the cryoablation group and 13% lower in the RAPN group (P<0.01). The advantage of cryoablation in preserving renal function persisted on multivariate analysis (P = 0.02). In patients with pathologically proven renal-cell carcinoma, 5-year Kaplan-Meier disease-free survival (DFS), cancer-specific survival (CSS), and overall survival was 83.1%, 96.4%, and 77.1% in the cryoablation cohort vs 100%, 100%, and 91.7% in the RAPN group. Mean time to recurrence was 16.2 months (range 0.03-42.0 mos). Cryoablation was associated with increased recurrence risk (hazard ratio [HR] = 11.4, P = 0.01) on multivariate analysis. CONCLUSIONS: Cryoablation and RAPN are safe alternatives for managing renal masses amenable to nephron-sparing interventions, offering acceptable morbidity and excellent renal preservation. While RAPN offers improved DFS, for those willing to undergo close postoperative monitoring and accept the potential need for re-treatment of recurrent disease, cryoablation offers excellent long-term CSS.
Asunto(s)
Carcinoma de Células Renales/cirugía , Criocirugía/métodos , Neoplasias Renales/cirugía , Laparoscopía/métodos , Nefrectomía/métodos , Anciano , Carcinoma de Células Renales/mortalidad , Carcinoma de Células Renales/patología , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Humanos , Incidencia , Riñón/fisiopatología , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , Missouri , Recurrencia Local de Neoplasia , Estudios Retrospectivos , Robótica , Factores de Tiempo , Resultado del TratamientoRESUMEN
Retrieval of foreign bodies from the genitourinary system, most commonly inserted for sexual satisfaction or as a result of a psychiatric illness, can pose a significant surgical challenge. Due to their breadth of size, shape, and location within the genitourinary system, endoscopic management can be difficult. Here, we review the management of four cases of foreign object insertion into the genitourinary system and their outcomes and management.
RESUMEN
Prostate cancer is a leading cause of morbidity and mortality in men and has significant treatment-associated complications. Prostate cancer chemoprevention has the potential to decrease the morbidity and mortality associated with this disease. Chemoprevention research to date has primarily focused on nutrients and 5 alpha-reductase inhibitors (5ARIs). A large randomized trial (SELECT) found no favorable effect of selenium or vitamin E on prostate cancer prevention. Two large randomized placebo controlled trials (the PCPT and REDUCE trials) have been published and have supported the role of 5ARIs in prostate cancer chemoprevention; however, these trials also have prompted concerns regarding the increase in high-grade disease seen with treatment and have not been approved by the US Food and Drug Administration (FDA) for chemoprevention. Conclusive evidence for the chemopreventive benefit of nutrients or vitamins is lacking, whereas the future role of 5ARIs remains to be clarified.
Asunto(s)
Neoplasias de la Próstata/prevención & control , Antagonistas Adrenérgicos alfa/uso terapéutico , Animales , Anticarcinógenos/uso terapéutico , Quimioprevención , Dieta , Humanos , Masculino , Ensayos Clínicos Controlados Aleatorios como Asunto , Selenio/uso terapéutico , Vitamina E/uso terapéuticoRESUMEN
PURPOSE: Expanding indications for robot-assisted partial nephrectomy raise major oncologic concerns for positive surgical margins. Previous reports showed no correlation between positive surgical margins and oncologic outcomes. We report a multi-institutional experience with the oncologic outcomes of positive surgical margins on robot-assisted partial nephrectomy. MATERIALS AND METHODS: Pathological and clinical followup data were reviewed from an institutional review board approved, prospectively maintained joint database from 5 institutions. Tumors with malignant pathology were isolated and statistically analyzed for demographics and oncologic followup. The log rank test was used to compare recurrence-free and metastasis-free survival between patients with positive and negative surgical margins. The proportional hazards method was used to assess the influence of multiple factors, including positive surgical margins, on recurrence and metastasis. RESULTS: A total of 943 robot-assisted partial nephrectomies for malignant tumors were successfully completed. Of the patients 21 (2.2%) had positive surgical margins on final pathological assessment, resulting in 2 groups, including the 21 with positive surgical margins and 922 with negative surgical margins. Positive surgical margin cases had higher recurrence and metastasis rates (p<0.001). As projected by the Kaplan-Meier method in the population as a whole at followup out to 63.6 months, 5-year recurrence-free and metastasis-free survival was 94.8% and 97.5%, respectively. There was a statistically significant difference in recurrence-free and metastasis-free survival between patients with positive and negative surgical margins (log rank test<0.001), which favored negative surgical margins. Positive surgical margins showed an 18.4-fold higher HR for recurrence when adjusted for multiple tumors, tumor size, tumor growth pattern and pathological stage. CONCLUSIONS: Positive surgical margins on final pathological evaluation increase the HR of recurrence and metastasis. In addition to pathological and molecular tumor characteristics, this should be considered to plan appropriate management.
Asunto(s)
Neoplasias Renales/patología , Neoplasias Renales/cirugía , Nefrectomía/métodos , Robótica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
PURPOSE: We evaluated the early oncological end point of recurrence-free survival in patients with renal cell carcinoma up-staged from cT1 to pT3a after partial nephrectomy. We also aimed to establish preoperative factors associated with pathological tumor up-staging. MATERIALS AND METHODS: A prospective database of robotic partial nephrectomy cases performed at 5 academic centers was queried for patients who underwent surgery for a solitary cT1 renal mass. Patients with pT1-2 renal cell carcinoma were compared to those with pT3a tumors to determine the difference in recurrence-free survival. Preoperative factors associated with cT1 to pT3a up-staging were studied using multivariate logistic regression analysis. RESULTS: A total of 1,096 patients underwent robotic partial nephrectomy for a cT1 renal mass. At final pathological evaluation 855 tumors (78.0%) were found to be renal cell carcinoma, of which 41 (4.8%) were up-staged to pT3a. The 24-month recurrence-free survival estimates for pT1-2 and pT3a tumors were 99.2% and 91.8%, respectively (p=0.003). Multivariate analysis revealed that a high vs low R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior and location relative to polar lines) nephrometry score was associated with tumor up-staging (OR 2.97, 95% CI 1.20-7.35, p=0.02). On separate multivariate analysis increasing tumor diameter (OR 1.66, 95% CI 1.32-2.08, p<0.001) and hilar location (OR 2.83, 95% CI 1.43-5.61, p=0.003) were also associated with up-staging. CONCLUSIONS: At short-term followup patients with renal cell carcinoma up-staged from cT1 to pT3a have reasonable oncological outcomes after partial nephrectomy. Factors associated with tumor up-staging include high tumor complexity, increasing tumor diameter and hilar location. Further studies are needed to determine the comparative efficacy of partial vs radical nephrectomy for small pT3a tumors.
Asunto(s)
Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Nefrectomía/métodos , Robótica , Anciano , Carcinoma de Células Renales/patología , Supervivencia sin Enfermedad , Femenino , Humanos , Neoplasias Renales/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Pronóstico , Estudios Prospectivos , Resultado del TratamientoRESUMEN
We present a case of persistent pneumaturia of one-year duration in a fifty-five-year-old male with a history of spinal cord injury. The evaluation demonstrated gas throughout the collecting system attributable to a urinary tract infection with a gas-forming organism, Klebsiella pneumoniae.
RESUMEN
OBJECTIVE: To review complications of robot-assisted partial nephrectomy (RAPN) at 5 centers, as classified by the Clavien system. MATERIALS AND METHODS: A multi-institutional analysis of prospectively maintained databases assessed RAPN complications. From June 2007 to November 2011, 886 patients at 5 United States centers underwent RAPN. Patient demographics, perioperative outcomes, and complications data were collected. Complication severity was classified by Clavien grade. RESULTS: Mean (standard deviation) data were patient age, 59.4 (11.4) years; age-adjusted Charlson Comorbidity Index, 3.0 (1.9); radiographic tumor size, 3.0 (1.6) cm; nephrometry score, 6.9 (2.0); and warm ischemia time, 18.8 (9.0) minutes. Median blood loss was 100 mL (interquartile range, 100-250 mL). Of the 886 patients, intraoperative complications occurred in 23 patients (2.6%) and 139 postoperative complications occurred in 115 patients (13.0%) for a total complication rate of 15.6%. Among the 139 postoperative complications, 43 (30.9%) were classified as Clavien 1, 64 (46.0%) were Clavien 2, 21 (15.1%) were Clavien 3, and 11 (7.9%) were Clavien 4. No complication-related deaths occurred. Intraoperative hemorrhage occurred in 9 patients (1.0%) and postoperative hemorrhage in 51 (5.8%). Forty-one patients (4.6%) required a perioperative blood transfusion, 10 (1.1%) required angioembolization, and 2 (0.2%) required surgical reexploration for postoperative hemorrhage. Urine leaks developed in 10 patients (1.1%): 3 (0.3%) required ureteral stenting, and 2 (0.2%) required percutaneous drainage. Acute postoperative renal insufficiency or renal failure developed in 7 patients (0.8%), 2 of whom required hemodialysis. The RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) nephrometry scoring system accurately predicted RAPN complication rates. CONCLUSION: Complication rates in this large multicenter series of RAPN appear to be acceptable and comparable with other nephron-sparing modalities. Most complications (77.0%) are Clavien 1 and 2 and can be managed conservatively.
Asunto(s)
Nefrectomía/efectos adversos , Nefrectomía/métodos , Robótica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Estados UnidosRESUMEN
BACKGROUND AND PURPOSE: Port-site metastasis (PSM) is a rare complication of laparoscopic intervention in urologic malignancies. Of the greater than 50 reported cases of PSM in the urologic oncology literature, only 9 have occurred after surgery for renal-cell carcinoma (RCC). We report a 10th instance of RCC metastasis-in this case to the camera-port site after robot-assisted partial nephrectomy (RAPN). To our knowledge, this case is the first reported PSM of RCC after RAPN. PATIENT AND METHODS: A 68-year-old man underwent an uncomplicated right RAPN for a 4-cm right renal mass (stage T1aN0M0). Five months later, he was found to have metastatic disease with an isolated peritoneal recurrence at the camera-port site. Biopsy of the lesion confirmed RCC, and the lesion was surgically resected. A comprehensive MEDLINE search for all published studies of port-site recurrences after laparoscopic renal surgery for RCC was performed. RESULTS: Nine cases of PSM after successful laparoscopic radical or partial nephrectomy for locally confined RCC have been reported. Proposed etiologic factors for port-site recurrence include biologic aggressiveness of the tumor, patient immunosuppression, local wound factors, and technique-related factors. We report an unusual case of PSM to a camera port that was not used for specimen manipulation or extraction. CONCLUSION: PSM after laparoscopic renal surgery for RCC is a rare occurrence. Our case, in which PSM occurred without specimen bag rupture or extraction through the port in question, highlights the importance of local and systemic factors in contributing to PSM occurrence. We also demonstrate that when PSM is the only site of disease recurrence, it can be successfully managed with minimally invasive surgical resection.
Asunto(s)
Carcinoma de Células Renales/secundario , Carcinoma de Células Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/cirugía , Siembra Neoplásica , Nefrectomía/efectos adversos , Nefrectomía/métodos , Robótica , Anciano , Humanos , MasculinoRESUMEN
PURPOSE: To provide a summary of the relevant literature regarding the impact of surgical cyst decortication on hypertension, renal function, and pain management in patients with autosomal dominant polycystic kidney disease (ADPKD). METHODS: Data collection was conducted via a Medline search using the subject headings autosomal dominant polycystic kidney disease, surgery, decortication, and marsupialization. Additional reports were derived from references included within these articles. RESULTS: Despite a trend for improved blood pressure control after cyst decortication in some studies, this cumulative review of the literature did not provide consistent evidence supporting the role of this procedure in blood pressure management in patients with ADPKD. Surgical cyst decortication was associated with renal deterioration in a subset of patients with compromised baseline renal function but did not otherwise appear to have a significant impact on renal function in the majority of studies reviewed. Improvement in chronic pain after this procedure was ubiquitously reported across all studies examined. CONCLUSIONS: Despite a potential role in blood pressure management in the setting of ADPKD, surgical cyst decortication has not been definitively shown to alleviate hypertension in this clinical setting. Renal function does not appear to improve following this surgery. Patients with compromised baseline renal function appear to be at increased risk for further deterioration in renal function after cyst decortication, although the role of this procedure in altering the natural trajectory of renal failure in this patient subset needs further investigation. Cyst decortication is highly effective in the management of disease-related chronic pain for the majority of patients with ADPKD, providing durable pain relief in this patient population.
Asunto(s)
Riñón Poliquístico Autosómico Dominante/cirugía , Hepatectomía/métodos , Humanos , Hipertensión/etiología , Hipertensión/cirugía , Dolor/etiología , Dolor/cirugía , Manejo del Dolor , Riñón Poliquístico Autosómico Dominante/complicacionesRESUMEN
Robot-assisted partial nephrectomy (RAPN) has been established as a viable alternative to open and laparoscopic partial nephrectomy for small renal tumors. Multiple variations in surgical technique have been described to reduce warm ischemia time (WIT). We present our off-clamp technique for RAPN. From August 2007 to January 2012, off-clamp RAPN was performed on 47 tumors in 39 patients. WIT was 0 minutes in all cases. The mean operative time was 147 minutes (SD=58); the mean and median estimated blood loss were 219 mL (SD=253) and 150 mL (range 50-1500), respectively; the mean length of stay was 1.9 days (SD=1.1). There were no intraoperative complications, and results for all surgical margins were negative. In experienced hands, our off-clamp technique for RAPN is a safe and feasible technique that eliminates WIT.
Asunto(s)
Neoplasias Renales/cirugía , Riñón/cirugía , Nefrectomía/métodos , Robótica/métodos , Humanos , Laparoscopía , Resultado del TratamientoRESUMEN
UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: For patients who are unfit for extirpative surgery, percutaneous cryoablation (PCA) presents a minimally-invasive alternative for the treatment of renal masses. PCA has been demonstrated to be safe, with complication rates <10% being reported consistently. Studies have suggested that a minimal and insignificant decline in renal function can occur after PCA. Finally, among studies with a follow-up >20 months, treatment success rates range from 75% to 96%. However, longer-term oncological and functional results for patients treated with PCA are relatively limited. The present study profiles one of the largest reported experiences with PCA for renal masses: 129 tumours in 124 patients. Our complication rate was comparable to that observed in other reported studies. At a mean follow-up of 30 months, treatment success was achieved in 87% of tumours, which is in line with published PCA success rates. On multivariable analysis, tumour size >3.0 cm was found to be significantly associated with treatment failure. A minimal but statistically significant renal functional decline was observed, with 20% of patients experiencing a progression in National Kidney Foundation-Chronic Kidney Disease stage. On multivariable analysis, age >70 years, hilar tumour location and postoperative day 1 estimated glomerular filtration rate <60 mL/min/1.73 m(2) were found to be significantly associated with renal functional decline. The present study confirms that PCA of renal masses represents a safe alternative to surgery in patients with substantial medical comorbidities. In the present cohort, baseline patient and tumour characteristics probably impact the risk of tumour recurrence, as well as renal disease progression, after PCA. OBJECTIVE: To evaluate perioperative, oncological and functional outcomes after percutaneous cryoablation (PCA) for renal masses based on our single-centre experience. PATIENTS AND METHODS: We retrospectively identified 124 patients who underwent PCA for 129 renal tumours between March 2005 and June 2011. Patient demographics and baseline clinical characteristics, tumour features, perioperative information, and postoperative outcomes were recorded. Oncological outcomes were defined by radiographic evidence of recurrence on follow-up computed tomography or magnetic resonance imaging. Renal disease progression was defined by a change in National Kidney Foundation-Chronic Kidney Disease stage. RESULTS: Patients had mean (sd) age of 72.6 (10.2) years; mean (sd) tumour size and nephrometry score were 2.7 (1.1) cm and 6.5 (1.7), respectively. Our overall complication rate was 9% (11/124), whereas the major (greater than Clavien II) complication rate was 2% (2/124). Significant predictors of renal disease progression following PCA included age ≥ 70 years (odds ratio [OR], 4.31, P = 0.03), hilar tumour location (OR, 4.67, P = 0.04), and post operative day 1 estimated glomerular filteration rate ≤60 mL/min/1.73 m(2) (OR, 7.09, P = 0.02). Our treatment success rate was 87% (112/129) at a mean (sd) follow-up of 30.2 (18.8) months. Tumour size ≥3.0 cm was significantly associated with PCA failure (hazard ratio, 3.21, P = 0.03). CONCLUSION: PCA provides a safe and oncologically effective alternative to extirpative surgery for renal masses in patients with significant medical comorbidities.
Asunto(s)
Carcinoma de Células Renales/cirugía , Criocirugía , Neoplasias Renales/cirugía , Nefrectomía , Factores de Edad , Anciano , Carcinoma de Células Renales/epidemiología , Carcinoma de Células Renales/patología , Carcinoma de Células Renales/fisiopatología , Criocirugía/métodos , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Hospitales Universitarios , Humanos , Neoplasias Renales/epidemiología , Neoplasias Renales/patología , Neoplasias Renales/fisiopatología , Laparoscopía , Tiempo de Internación/estadística & datos numéricos , Masculino , Análisis Multivariante , Nefrectomía/métodos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Washingtón/epidemiologíaRESUMEN
This article provides an overview of extirpative laparoscopic and robotic procedures used in the management of renal cell carcinoma, including laparoscopic radical nephrectomy, laparoscopic partial nephrectomy, and robotic-assisted partial nephrectomy. The clinical indications and principles of surgical technique for each of these procedures are discussed. The oncologic, renal functional, and perioperative outcomes of these procedures are also assessed and compared, as are complication rates.
Asunto(s)
Carcinoma de Células Renales/cirugía , Neoplasias Renales/cirugía , Laparoscopía/métodos , Nefrectomía/métodos , Robótica/métodos , Humanos , Complicaciones Posoperatorias/etiología , Resultado del TratamientoRESUMEN
The purpose of this article is to provide an update on the current literature evaluating outcomes with laparoscopic prostatectomy. The reported perioperative, oncologic, and functional outcomes with this approach are reviewed and comparisons are made to the open and robotic-assisted approaches.
Asunto(s)
Laparoscopía/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/cirugía , Pérdida de Sangre Quirúrgica , Costos y Análisis de Costo , Disfunción Eréctil/etiología , Humanos , Laparoscopía/instrumentación , Tiempo de Internación , Masculino , Recurrencia Local de Neoplasia/prevención & control , Tempo Operativo , Complicaciones Posoperatorias/etiología , Prostatectomía/instrumentación , Resultado del Tratamiento , Incontinencia Urinaria/etiologíaRESUMEN
BACKGROUND: Ongoing efforts are focused on minimizing or eliminating renal ischemia during robot-assisted partial nephrectomy (RPN). Although various techniques allowing the elimination of renal hilar clamping have been described, large multi-institutional studies assessing perioperative and functional outcomes of this approach are lacking. OBJECTIVE: To evaluate perioperative and functional outcomes of RPN without hilar clamping and to assess comparative effectiveness relative to clamped RPN. DESIGN, SETTING, AND PARTICIPANTS: A multi-institutional data analysis of prospectively collected records of 886 RPNs performed by high-volume surgeons across five academic institutions between 2007 and 2011 was carried out. A total of 66 patients who underwent RPN without hilar clamping were identified. After the exclusion of 17 patients, perioperative results of 49 patients were compared against propensity score matched clamped controls. INTERVENTION: RPN without hilar clamping. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Descriptive statistics and propensity score matching. RESULTS AND LIMITATIONS: Patients undergoing off-clamp RPN had a mean tumor size of 2.5 cm (standard deviation [SD]: ± 2.1) and a mean RENAL nephrometry score of 5.3 (SD: ± 1.5). The mean preoperative estimated glomerular filtration rate (eGFR) was 81 (SD: ± 29). The mean estimated blood loss (EBL) was 210 ml (SD: ± 212), and the mean operative time was 155 min (SD: ± 46). No Clavien 3-5 complications were recorded. The mean postoperative change in eGFR was 3% at first follow-up (1-3 mo), and no patient required postoperative dialysis. The positive surgical margin rate was 3% (n=2), with no disease recurrence reported at a mean follow-up of 21 mo. In propensity score matched analyses, the off-clamp RPN patients had a significantly shorter mean operative time (156 min compared with 185 min, p<0.001), a higher EBL (228 ml compared with 157 ml, p=0.009), and a smaller decrease in eGFR (2% compared with -6%, p=0.008). The retrospective analysis was the main limitation of this study. CONCLUSIONS: With appropriately selected patients and adequate surgeon experience, off-clamp RPN is safe and feasible. Off-clamp RPN was associated with higher EBL, shorter operative times, and smaller decrease in renal function.
Asunto(s)
Riñón/fisiología , Nefrectomía/métodos , Tratamientos Conservadores del Órgano/métodos , Robótica , Anciano , Constricción , Femenino , Tasa de Filtración Glomerular , Humanos , Masculino , Persona de Mediana Edad , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
INTRODUCTION: We compared the impact of two-dimensional (2D) versus three-dimensional (3D) visualization on both objective and subjective measures of laparoscopic performance using the validated Fundamentals of Laparoscopic Surgery (FLS) skill set. SUBJECTS AND METHODS: Thirty-three individuals with varying laparoscopic experience completed three essential drills from the FLS skill set (peg transfer, pattern cutting, and suturing/knot tying) in both 2D and 3D. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion and number of attempts required to achieve proficiency were measured for each task. Errors were also noted. Participants completed questionnaires evaluating their experiences with both visual modalities. RESULTS: Across all tasks, greater speed was achieved in 3D versus 2D: peg transfer, 183.4 versus 245.6 seconds (P<.0001); pattern cutting, 167.7 versus 209.3 seconds (P=.004); and suturing/knot tying, 255.2 versus 329.5 seconds (P=.031). Fewer errors were committed in the peg transfer task in 3D versus 2D (P=.008). Fourteen participants required multiple attempts to achieve proficiency in one or more tasks in 2D, compared with 7 in 3D. Subjective measures of efficiency and accuracy also favored 3D visualization. The advantage of 3D vision persisted independent of participants' level of technical expertise (novice versus intermediate/expert). There were no differences in reported side effects between the two visual modalities. Overall, 87.9% of participants preferred 3D visualization. CONCLUSIONS: Three-dimensional vision appears to greatly enhance laparoscopic proficiency based on objective and subjective measures. In our experience, 3D visualization produced no more eye strain, headaches, or other side effects than 2D visualization. Participants overwhelmingly preferred 3D visualization.
Asunto(s)
Competencia Clínica , Percepción de Profundidad , Capacitación en Servicio , Laparoscopía/normas , Adulto , Femenino , Humanos , Masculino , Encuestas y Cuestionarios , Análisis y Desempeño de TareasRESUMEN
PURPOSE: Approximately 20% to 30% of suspicious small renal tumors are benign. A significant proportion of malignant tumors are low grade and potentially indolent. We evaluated whether preoperative patient and tumor characteristics are associated with adverse pathological features. MATERIALS AND METHODS: A total of 886 patients underwent robot-assisted partial nephrectomy, as done by 1 of 5 high volume surgeons. Demographic and clinical data were compared between patients with benign/malignant disease, clear cell/nonclear cell renal cell carcinoma and high/low grade tumors. Tumor complexity was quantified by R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar and location relative to polar lines) nephrometry score and described as low--4 to 6, intermediate--7 to 9 or high--10 or greater. Logistic regression analyses were performed to test the association between tumor and patient characteristics, and high grade renal cell carcinoma. Subanalyses were done for patients with renal tumors 4 cm or less. RESULTS: High grade renal cell carcinoma was larger and more likely to develop in men. Patients with malignant tumors and with clear cell histology were more likely to have intermediate or high complexity tumors. Increasing tumor complexity independently predicted malignancy, high grade malignancy and clear cell histology on multivariate regression analysis (each p <0.05). Male gender was independently associated with malignancy and high grade renal cell carcinoma. When considering tumors 4 cm or less, tumor complexity predicted malignancy but not tumor grade. CONCLUSIONS: High R.E.N.A.L nephrometry score and male gender are associated with an increased risk of malignancy and high grade malignancy in tumors treated with partial nephrectomy.
Asunto(s)
Carcinoma de Células Renales/patología , Neoplasias Renales/patología , Riñón/patología , Carcinoma de Células Renales/cirugía , Femenino , Humanos , Riñón/cirugía , Neoplasias Renales/cirugía , Modelos Logísticos , Masculino , Nefrectomía , Pronóstico , Factores de Riesgo , Factores SexualesRESUMEN
PURPOSE: We elucidate the role of endopyelotomy as a primary and secondary intervention for ureteropelvic junction obstruction in children. MATERIALS AND METHODS: We retrospectively identified 79 pediatric patients who underwent endopyelotomy for ureteropelvic junction obstruction between 1986 and 2011. Eleven patients were lost to followup and were excluded from analysis. Patient demographics, operative information, complications and success rates were reviewed for the remaining 68 patients. Treatment success was defined as the absence of symptom recurrence and improved radiographic features on ultrasound, computerized tomography, diuretic renogram or excretory urogram at most recent followup. RESULTS: Primary endopyelotomy data were analyzed in 37 patients with a median age of 11.1 years. The success rate was 65% at a median followup of 34 months (range 1.5 to 242). Treatment failure occurred in 13 patients with a median time to failure of 8 months (range 1.5 to 131). There were 8 cases of failure during 12 months of surgery. Secondary endopyelotomy data were analyzed in 31 patients with a median age of 6.5 years. The success rate was 94% at a median followup of 61 months (range 1 to 204). Treatment failure occurred in 2 patients at 1 and 6 months. Approximately two-thirds of all procedures used an antegrade approach. CONCLUSIONS: Primary endopyelotomy is significantly less successful than pyeloplasty in the treatment of ureteropelvic junction obstruction in pediatric patients. However, secondary endopyelotomy following failed pyeloplasty represents a viable alternative to redo pyeloplasty.
Asunto(s)
Pelvis Renal/cirugía , Obstrucción Ureteral/cirugía , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Estudios Retrospectivos , Ureteroscopía , Procedimientos Quirúrgicos Urológicos/métodosRESUMEN
PURPOSE: Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with adult dominant polycystic kidney disease presenting with refractory pain. MATERIALS AND METHODS: Between 1994 and 2003, 37 patients with adult dominant polycystic kidney disease underwent laparoscopic cyst decortication at Barnes-Jewish Hospital. A total of 19 patients (4 male, 15 female) with at least 3-year followup were included in the study. Renal function was evaluated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated glomerular filtration rate formula. End stage renal disease was defined as progression to transplant, dialysis or stage 5 chronic kidney disease. Hypertension was evaluated using the antihypertensive therapeutic index. Pain assessment was based primarily on a telephone questionnaire. RESULTS: At a mean followup of 10.9 years (range 6.4 to 16.9), 67% of evaluable patients reported more than 50% improvement in pain. Ten patients had progression to end stage renal disease--3 dialysis, 6 transplant, and 1 chronic kidney disease stage 5. Two patients had stage 5 chronic kidney disease at initial presentation. A comparison of preoperative estimated glomerular filtration rate between patients with and those without end stage renal disease revealed a lower preoperative estimated glomerular filtration rate in the former group (43.4 vs 75.4 ml/minute/1.73 m(2), p = 0.01). Of the patients 53% had an improved or stable antihypertensive therapeutic index at last followup, although no improvement in mean overall antihypertensive therapeutic index was noted (4.7 pre-laparoscopic cyst decortications vs 7.0 post-laparoscopic cyst decortications, p = 0.28). CONCLUSIONS: Durable pain relief but not hypertension control was seen at 10-year followup. Preoperative estimated glomerular filtration rate is a strong predictor of post-laparoscopic cyst decortication progression to end stage renal disease. A cautious approach with laparoscopic cyst decortication should be taken in patients with poor preoperative renal function.