External validation of yonsei nomogram predicting chronic kidney disease development after partial nephrectomy: An international, multicenter study.

OBJECTIVE: To externally validate Yonsei nomogram. METHODS: From 2000 through 2018, 3526 consecutive patients underwent on-clamp PN for cT1 renal masses at 23 centers were included. All patients had two kidneys, preoperative eGFR ≥60 ml/min/1.73 m2, and a minimum follow-up of 12 months. New-onset CKD was defined as upgrading from CKD stage I or II into CKD stage ≥III. We obtained the CKD-free progression probabilities at 1, 3, 5, and 10 years for all patients by applying the nomogram found at https://eservices.ksmc.med.sa/ckd/. Thereafter, external validation of Yonsei nomogram for estimating new-onset CKD stage ≥III was assessed by calibration and discrimination analysis. RESULTS AND LIMITATION: Median values of patients' age, tumor size, eGFR and follow-up period were 47 years (IQR: 47-62), 3.3 cm (IQR: 2.5-4.2), 90.5 ml/min/1.73 m2 (IQR: 82.8-98), and 47 months (IQR: 27-65), respectively. A total of 683 patients (19.4%) developed new-onset CKD. The 5-year CKD-free progression rate was 77.9%. Yonsei nomogram demonstrated an AUC of 0.69, 0.72, 0.77, and 0.78 for the prediction of CKD stage ≥III at 1, 3, 5, and 10 years, respectively. The calibration plots at 1, 3, 5, and 10 years showed that the model was well calibrated with calibration slope values of 0.77, 0.83, 0.76, and 0.75, respectively. Retrospective database collection is a limitation of our study. CONCLUSIONS: The largest external validation of Yonsei nomogram showed good calibration properties. The nomogram can provide an accurate estimate of the individual risk of CKD-free progression on long-term follow-up.

Experiences of a "COVID protected" robotic surgical centre for colorectal and urological cancer in the COVID-19 pandemic.

The recent COVID-19 pandemic led to the cancellation of elective surgery across the United Kingdom. Re-establishing elective surgery in a manner that ensures patient and staff safety has been a priority. We report our experience and patient outcomes from setting up a "COVID protected" robotic unit for colorectal and renal surgery that housed both the da Vinci Si (Intuitive, Sunnyvale, CA, USA) and the Versius (CMR Surgical, Cambridge, UK) robotic systems. "COVID protected" robotic surgery was undertaken in a day-surgical unit attached to the main hospital. A standard operating procedure was developed in collaboration with the trust COVID-19 leadership team and adapted to national recommendations. 60 patients underwent elective robotic surgery in the initial 10-weeks of the study. This included 10 colorectal procedures and 50 urology procedures. Median length of stay was 4 days for rectal cancer procedures, 2 days less than prior to the COVID period, and 1 day for renal procedures. There were no instances of in-patient coronavirus transmission. Six rectal cancer patients waited more than 62 days for their surgery because of the initial COVID peak but none had an increase T-stage between pre-operative staging and post-operative histology. Robotic surgery can be undertaken in "COVID protected" units within acute hospitals in a safe way that mitigates the increased risk of undergoing major surgery in the current pandemic. Some benefits were seen such as reduced length of stay for colorectal patients that may be associated with having a dedicated unit for elective robotic surgical services.

Warm ischemia time length during on-clamp partial nephrectomy: does it really matter?

BACKGROUND: The impact of warm ischemia time (WIT) on renal functional recovery remains controversial. We examined the length of WIT>30 min on the long-term renal function following on-clamp partial nephrectomy (PN). METHODS: Data from 23 centers for patients undergoing on-clamp PN between 2000 and 2018 were analyzed. We included patients with two kidneys, single tumor, cT1, minimum 1-year follow-up, and preoperative eGFR≥60 mL/min/1.73m2. Patients were divided into two groups according to WIT length: group I "WIT≤30 min" and group II "WIT>30 min." A propensity-score matched analysis (1:1 match) was performed to eliminate potential confounding factors between groups. We compared eGFR values, eGFR (%) preservation, eGFR decline, events of chronic kidney disease (CKD) upgrading, and CKD-free progression rates between both groups. Cox regression analysis evaluated WIT impact on upgrading of CKD stages. RESULTS: The primary cohort consisted of 3526 patients: group I (N.=2868) and group II (N.=658). After matching the final cohort consisted of 344 patients in each group. At last follow-up, there were no significant differences in median eGFR values at 1, 3, 5, and 10 years (P>0.05) between the matched groups. In addition, the median eGFR (%) preservation and absolute eGFR change were similar (89% in group I vs. 87% in group II, P=0.638) and (-10 in group I vs. -11 in group II, P=0.577), respectively. The 5 years new-onset CKD-free progression rates were comparable in the non-matched groups (79% in group I vs. 81% in group II, log-rank, P=0.763) and the matched groups (78.8% in group I vs. 76.3% in group II, log-rank, P=0.905). Univariable Cox regression analysis showed that WIT>30 min was not a predictor of overall CKD upgrading (HR:0.953, 95%CI 0.829-1.094, P=0.764) nor upgrading into CKD stage ≥III (HR:0.972, 95%CI 0.805-1.173, P=0.764). Retrospective design is a limitation of our study. CONCLUSIONS: Our analysis based on a large multicenter international cohort study suggests that WIT length during PN has no effect on the long-term renal function outcomes in patients having two kidneys and preoperative eGFR≥60 mL/min/1.73m2.

Retroperitoneal Robotic-Assisted Laparoscopic Pyeloplasty: A 10 Year Experience in a Single Institution.

Introduction: Pelvi-ureteric junction (PUJ) obstruction was traditionally treated with open pyeloplasty. In recent decades, the development of minimally invasive techniques, including laparoscopic and later robotic surgery, has transformed treatment. The transperitoneal approach has most commonly been undertaken, with a few institutions reporting outcomes of the retroperitoneal approach. We report our 10-year experience of retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP). Methods: A prospective database of 160 patients undergoing RALP between February 2010 and November 2019 was analyzed. Data were recorded on demographics, operative details, complications, and success rate. Success was determined as symptomatic improvement and/or an unobstructed renogram. Results: One hundred fifty-two cases (95.0%) were performed by using a retroperitoneal approach, and 8 (5.0%) were performed by using a transperitoneal approach. Mean age was 45.3 ± 17.4 years. Mean operating time was 139.4 ± 45.6 minutes. A surgical drain was placed in 57 (71.3%) of the first 80 cases and 15 (18.8%) of the second 80 cases. Median hospital stay was one night (range 1-27). One case was converted to open pyeloplasty due to dense inflammatory tissue and one to robotic-assisted nephrectomy due to severe adhesions around the PUJ. There were no blood transfusions. There were six major (>grade 2 Clavien-Dindo) postoperative complications in four patients (2.5%). Two (1.3%) grade 3a complications, urine leak and pain after stent removal, required nephrostomy. There were three (1.9%) grade 3b complications: migrated stent requiring ureteroscopy, perirenal hematoma requiring open evacuation, and stent re-insertion. One (0.6%) grade 4 complication required ventilatory support on intensive care. Eighteen patients received follow-up at an alternative hospital, and 13 were lost to follow-up. Of the remaining cases, 94.5% were successful. Conclusions: R-RALP is a safe and effective treatment for PUJ obstruction allowing predictably rapid discharge from hospital without the need for a routine surgical drain. To our knowledge, our study represents the largest single institution experience on RALP using a retroperitoneal approach.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy.

OBJECTIVE: To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. RESULTS: All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677). CONCLUSION: This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

A Simple Clinical Tool for Stratifying Risk of Clinically Significant CKD after Nephrectomy: Development and Multinational Validation.

BACKGROUND: Clinically significant CKD following surgery for kidney cancer is associated with increased morbidity and mortality, but identifying patients at increased CKD risk remains difficult. Simple methods to stratify risk of clinically significant CKD after nephrectomy are needed. METHODS: To develop a tool for stratifying patients' risk of CKD arising after surgery for kidney cancer, we tested models in a population-based cohort of 699 patients with kidney cancer in Queensland, Australia (2012-2013). We validated these models in a population-based cohort of 423 patients from Victoria, Australia, and in patient cohorts from single centers in Queensland, Scotland, and England. Eligible patients had two functioning kidneys and a preoperative eGFR ≥60 ml/min per 1.73 m2. The main outcome was incident eGFR <45 ml/min per 1.73 m2 at 12 months postnephrectomy. We used prespecified predictors-age ≥65 years old, diabetes mellitus, preoperative eGFR, and nephrectomy type (partial/radical)-to fit logistic regression models and grouped patients according to degree of risk of clinically significant CKD (negligible, low, moderate, or high risk). RESULTS: Absolute risks of stage 3b or higher CKD were <2%, 3% to 14%, 21% to 26%, and 46% to 69% across the four strata of negligible, low, moderate, and high risk, respectively. The negative predictive value of the negligible risk category was 98.9% for clinically significant CKD. The c statistic for this score ranged from 0.84 to 0.88 across derivation and validation cohorts. CONCLUSIONS: Our simple scoring system can reproducibly stratify postnephrectomy CKD risk on the basis of readily available parameters. This clinical tool's quantitative assessment of CKD risk may be weighed against other considerations when planning management of kidney tumors and help inform shared decision making between clinicians and patients.

Asynchronous bilateral leiomyomata of tunica vaginalis: A case report.

Leiomyomata are smooth muscle tumours that are slow growing and benign. We report a case of bilateral leiomyomata arising from tunica vaginalis. A 65 year old presented with a 5-year history of a slow growing left testicular mass and underwent radical orchidectomy. He presented again 18 months later with a slow growing right testicular mass and underwent local surgical resection. In both the cases the diagnosis of tunica vaginalis leiomyoma was determined through subsequent histopathological analysis. We hope to inform urologists to be aware of this benign rare entity as it can be cured through a simple, organ preserving surgical excision.

Retroperitoneal Robot-Assisted Partial Nephrectomy in Obese Patients.

Objectives: To report our experience with retroperitoneal robotic-assisted partial nephrectomy (RAPN) in obese patients. Patients and Methods: From April 2012 to December 2018, 127 patients with body mass index (BMI) ≥30 kg/m2 underwent RAPN, of whom 110 patients had retroperitoneal RAPN. We reviewed the patients' demographic, operative data, perioperative and postoperative complications, and postoperative histology. Results: The median BMI was 33.1 kg/m2 (interquartile range [IQR] 31.5-36.6). The median age of the patients was 59 years. The mean histological size of tumor was 32.2 mm (IQR 23.8-40). The median total surgical time was 130 minutes (IQR 110-176) with a median warm ischemia time of 22.0 minutes. The tumor was located anteriorly in 25% of the cases. The median R.E.N.A.L.* nephrometry score was 6. The median estimated blood loss was 30 mL (IQR 10-80). Three cases were converted to open partial nephrectomy because of bleeding (2.7%). Four patients and one patient returned within 30 days with postoperative complications Clavien-Dindo classification grade 2 and 3a, respectively. Two patients needed perioperative blood transfusion because of bleeding. The median length of stay was 1 day (IQR 1-2). Conclusion: Retroperitoneal RAPN is feasible in patients with high BMI and provides good surgical access to treat nonanterior renal masses. Retroperitoneal RAPN is associated with less blood loss, shorter surgical time, and warm ischemia time when compared with transperitoneal RAPN studies.

Analysis of Factors' Association with Risk of Postoperative Urosepsis in Patients Undergoing Ureteroscopy for Treatment of Stone Disease.

INTRODUCTION: To investigate which patient, stone, infective, and surgical factors were most likely to increase the risk of postoperative urosepsis within 28 days of ureteroscopy (URS) and laser stone fragmentation for ureteral or renal stones. METHODS: Data were collected prospectively in a single National Health Service institution. A logistic regression model was used to assess the association of factors with postoperative urosepsis. Two matched-pair analyses were used to assess the risk of postoperative urosepsis in patients with (a) an emergency presentation to hospital with urosepsis in the 90 days preceding URS and (b) a positive midstream sample of urine (MSSU) identified, but who were asymptomatic at preoperative assessment, who then received an appropriate course of antibiotics. RESULTS: Four hundred sixty-two consecutive patients were included in the study. Thirty-four patients (7.4%) had an episode of urosepsis within 28 days of their operation. A positive preoperative MSSU was significantly associated with postoperative urosepsis on multivariable analysis, despite appropriate treatment with a preoperative course of antibiotics: odds ratio (OR) 4.88, 95% confidence interval (CI) 2.11, 11.31, p < 0.001. The presence of diabetes mellitus, presence of ischemic heart disease, patient American Society of Anesthesiologists score, same-session bilateral URS, and stone volume were the other variables significantly associated with postoperative infection on univariable analysis, but these ceased to be significantly associated on multivariable analysis. Subgroup analysis found that a positive MSSU in both patients with a preoperative ureteral stent and those without was significantly associated with postoperative urosepsis, however, the OR was much lower for the stented group (OR 3.23 vs OR 16.67). On matched-pair analysis, patients with a positive preoperative MSSU were significantly more likely to have postoperative urosepsis compared to controls (OR 17.46, 95% CI 2.18, 139.80, p = 0.007). There was no significant difference in the OR of postoperative urosepsis in patients who had a preceding urine infection requiring hospital admission in the 90 days preceding URS (OR 0.60, 95% CI 0.19, 1.92, p = 0.39). CONCLUSIONS: Positive preoperative MSSU was significantly associated with postoperative urosepsis by logistic regression and matched-pair analysis. These higher risk patients should be counseled appropriately before surgery, and should be the focus of vigilant postoperative monitoring. The study suggests particular caution in patients with a positive preoperative MSSU without a preoperative ureteral stent.

What is the feasibility of switching to 200IU OnabotulinumtoxinA in patients with detrusor overactivity who have previously received 300IU?

INTRODUCTION: To assess the feasibility of converting from 300IU to 200IU OnabotulinumtoxinA in patients diagnosed with either idiopathic detrusor overactivity (IDO) or neurogenic detrusor overactivity (NDO). MATERIAL AND METHODS: Retrospective case-notes review of patients who were converted from 300IU to 200IU OnabotulinumtoxinA. Subjective patient reported improvements at interview and bladder diary reported parameters of urgency, urgency incontinence, frequency and nocturia. RESULTS: Forty-four patients had received 300IU OnabotulinumtoxinA and were switched to 200IU after July 2008, 28 for IDO and 16 for NDO. Thirty-seven patients reported ongoing improvement with 200IU OnabotulinumtoxinA, six patients had worsening in their symptoms since down-titrating to 200IU and one patient did not attend follow-up. Improvement in urgency and urgency incontinence episodes per day were 82% and 72%, respectively, in patients who received 200IU. Of the 44 patients, 39 continued to receive 200IU, four requested up-titration to 300IU (due to decreased effect) and one did not attend after the 1st treatment. After converting from 300IU to 200IU, additional three patients were started on CISC for de novo voiding difficulty. CONCLUSIONS: Seventy-nine percent of patients were satisfied with their symptoms after switching from 300IU to 200IU OnabotulinumtoxinA. Only 9% of patients (all with NDO) reverted back to receiving 300IU. This study showed similar efficacy and longevity in the majority of patients (90%) using 200IU in both NDO and IDO.

Transurethral resection biopsy as part of a saturation biopsy protocol: a cohort study and review of the literature.

OBJECTIVE: To evaluate the prostate cancer (CaP) detection rate and morbidity of performing a transurethral resection biopsy of the prostate (TURBP) at the same time as a saturation biopsy (SBx). PATIENTS: A total of 102 men with previous negative transrectal ultrasound (TRUS) biopsies underwent a SBx under formal anaesthesia. Fifty-four [54 (52.9%)] had a combined SBx and TURBP (Group 1) and 48 (47.1%) had a SBx only (Group 2). RESULTS: The CaP detection rate in Group 1 was 38.9% (21/54), which was significantly higher than the detection rate of 27.1% (13/48) in Group 2 (P = 0.005). CaP was detected via TURBP in 12 patients (22.2%) from Group 1, including 8 (14.8%) patients who had CaP solely in their TURBP chips. According to the D'Amico classification, 66.6% (14/21) of the cancers in Group 1 were intermediate (n = 4) or high risk (n = 10). Of the 8 'TURBP only' cancers, 75% (6/8) were intermediate (n = 2) or high risk (n = 4). Seven of these eight patients went on to have a radical prostatectomy (RP) but only 2 (28.6%) were found to have a pure anterior/transition zone (TZ) tumor. The postoperative urinary retention and emergency admission rates for Groups 1 and 2 were 29.6% (16/54) vs. 16.6% (8/48) (P = 0.095) and 11.1% (6/54) vs. 5.5% (2/48) (n = 0.17). There was no difference in terms of hematuria (P = 0.54), urinary tract infection (UTI) (P = 0.22), or sepsis (P = 0.21), and patients in Group 1 spent an average of 0.5 days longer in hospital (1.9 vs. 1.4; P = 0.008). CONCLUSIONS: TURBP in association with SBx increases the detection of clinically important CaP. However, this does have to be balanced against the small increased incidence of urinary retention, emergency re-admission, and longer hospital stay.

Conservative management of pelvi-ureteric junction obstruction (PUJO): is it appropriate and if so what duration of follow-up is needed?

OBJECTIVE: • To establish whether it is safe to manage minimally symptomatic and asymptomatic pelvi-ureteric junction obstruction (PUJO) conservatively. PATIENTS AND METHODS: • In all, 50 patients with PUJO diagnosed with dynamic renography, and monitored with at least two renograms. RESULTS: • In all, 19 patients were totally asymptomatic, while 31 patients had minimal symptoms at time of diagnosis. • The mean follow-up was 53 months. • During the course of follow-up 10 of the 50 patients deteriorated. • All patients who had asymptomatic renographic deterioration, deteriorated within 2 years of diagnosis. • Eight of the 10 patients that deteriorated needed pyeloplasty and two nephrectomy. CONCLUSIONS: • Conservative management of patients with minimally symptomatic and asymptomatic PUJO is safe. • Discharging patients could be considered at 2 years from diagnosis, if they remain renographically stable and asymptomatic or minimally symptomatic.