The mayo adhesive probability score predicts postoperative fever and sepsis in retrograde intrarenal surgery.

Infectious complications are among the most common and potentially life-threatening morbidities of retrograde intrarenal surgery (RIRS). Few predictive tools on these complications include radiological signs. The Mayo adhesive probability (MAP) score is an image-based scoring system that incorporates two radiological signs: perinephric fat stranding and perinephric fat thickness. Previous studies have suggested an association between these signs and febrile urinary tract infection (UTI) following lithotripsy. This study aimed to evaluate the predictive factors, including the MAP score, for post-RIRS fever and sepsis. A total of 260 patients who underwent 306 RIRS between October 2019 to December 2023 due to renal or upper ureteral stones were included in this retrospective study. Patient demographics, perioperative characteristics, stone factors, radiological signs, and MAP scores were recorded. Multivariate logistic regression analysis was used to evaluate the risk factors associated with postoperative fever and sepsis. Postoperative fever and sepsis occurred in 20.8% and 8.5% of the patients, respectively. On multivariate analysis, female gender, history of recurrent UTI, larger maximal stone diameter, and higher MAP score were independent risk factors for postoperative fever and sepsis. Identifying the risk factors for post-RIRS infectious complications is imperative to providing the proper perioperative management. The MAP score is a promising, easily calculated, image-based scoring system that predicts post-RIRS fever and sepsis.

Relationship between influencing factors of operation time and postoperative complications in hand-assisted laparoscopic living donor nephrectomy / 器官移植

Objective To identify the influencing factors of operation time of hand-assisted laparoscopic living donor nephrectomy, and to analyze the relationship between influencing factors and the severity of postoperative complications. Methods Clinical data of 91 donors who underwent hand-assisted laparoscopic nephrectomy were retrospectively analyzed. The correlation between preoperative baseline data of donors and operation time was analyzed. The relationship between operation time and postoperative complications was assessed and the threshold of operation time was determined. Results Multiple donor renal arteries, thick perirenal and posterior renal fat, metabolic syndrome, high Mayo adhesive probability (MAP) score and Clavien-Dindo score prolonged the operation time. By analyzing the receiver operating characteristic (ROC) curve, we found that when the operation time was ≥138 min, the incidence of postoperative complications of donors was significantly increased (P<0.05). Conclusions For donors with multiple renal arteries, thick perirenal and posterior renal fat, metabolic syndrome and high MAP score and Clavien-Dindo score, experienced surgeons should be selected to make adequate preoperative preparation and pay close attention after surgery, so as to timely detect postoperative complications and reduce the severity of complications, enhance clinical prognosis of the donors.

The Mayo adhesive probability score predicts postoperative fever and intraoperative hemorrhage in mini-percutaneous nephrolithotomy.

PURPOSE: Contemporary predictive tools for miniaturized percutaneous nephrolithotomy (mPCNL) mainly focus on stone clearance but not perioperative complications, especially infection and hemorrhage. This study aimed to evaluate whether the Mayo adhesive probability (MAP) score, an index of the perinephric fat characteristics, can predict postoperative fever and intraoperative hemorrhage in mPCNL. METHODS: This is a retrospective study recruiting 159 mPCNL patients from July 2018 to January 2022. MAP scores were recorded using preoperative computed tomography. Postoperative complications included postoperative fever and intraoperative bleeding, defined as hemoglobin drop. RESULTS: Over half patients had the MAP score ≧ 3. Men, elderly, chronic kidney disease, and diabetes were associated with a higher MAP score. The patients with a higher MAP score were more likely to have postoperative fever after mPCNL. On multivariate analysis, preoperative positive urine culture (OR 2.68) and a higher MAP score (OR 2.28) were both significantly associated with postoperative fever. ROC curves analysis of the combination of these two factors on predicting postoperative fever showed AUC values were 0.731 (0.652-0.810). Moreover, a higher MAP score (OR 2.30) and longer operative time (OR 2.16) were significantly associated with higher hemoglobin drop on multivariate analysis. CONCLUSION: A high MAP score was associated with postoperative fever and intraoperative hemorrhage in patients undergoing mPCNL. The MAP score can be a novel and easy predictive tool to help endourologists improve the awareness of mPCNL safety.

Intraoperative Ultrasound Can Facilitate Laparoscopic Partial Nephrectomy in Adherent Perinephric Fat.

Background: Adherent perinephric fat (APF) is one of the challenging factors of laparoscopic partial nephrectomy (LPN). The aim of this study was to investigate the effect of intraoperative laparoscopic ultrasound (ILUS) on determining renal tumor localization and dissection in patients with APF who underwent LPN. Methods: Prospectively collected data from 517 patients who underwent LPN from October 2010 to September 2020 in tertiary university hospital were evaluated retrospectively. The cohort was divided into two main groups according to the Mayo Adhesive Probability (MAP) score: Group 1 (MAP score ≤3) and Group 2 (MAP score ≥4). After implementing propensity score-matched analysis including the complexity of tumor, age, and body mass index, Group 1 consisted of 202 patients with ≤3 MAP score and Group 2 included 46 patients. Then, both groups were allocated into two subgroups according to whether ILUS was used. Demographics, perioperative features such as perirenal fatty tissue dissection, tumor excision, operation time, and perioperative outcomes accepted as trifecta, considering warm ischemia time, negative surgical margin, and complications were compared. Results: In Group 1, ILUS use did not seem to affect perioperative outcomes in both subgroups. However, ILUS has a positive effect on perirenal fatty tissue dissection (10 versus 19 minutes, P = .011), tumor excision (4 versus 7 minutes, P = .005), and operation time (78 versus 90 minutes, P = .046) in Group 2. Trifecta outcomes were also better in higher MAP scores and ultrasound-used subgroups (P = .019). Conclusions: ILUS should be considered a helpful and effective instrument in overcoming APF in LPN. It might also have a positive effect on trifecta outcomes.

Perinephric Toxic Fat: Impact on Surgical Complexity, Perioperative Outcome, and Surgical Approach in Partial Nephrectomy.

INTRODUCTION: To assess influencing factors on perinephric toxic fat (high Mayo Adhesive Probability [MAP] score) and the impact of high MAP scores on surgical complexity, perioperative outcome, and surgical approach in patients with localized renal tumors undergoing open (OPN) and robot-assisted partial nephrectomy (RAPN). METHODS: 698 patients were included in this study. Based on preoperative imaging, adherent perinephric fat (APF) was assessed to define MAP scores. Regression analyses assessed influencing parameters for high MAP scores (≥3), predictors of surgical outcome, and influencing factors on surgical approach. RESULTS: OPN was performed in 331 (47%) patients, and 367 (53%) patients underwent RAPN. Male gender (p < 0.001), age ≥65 (p < 0.001), and BMI ≥27.4 kg/m2 (p < 0.001) showed to be significantly influencing factors for the presence of APF. High MAP scores showed to be an influencing factor for a prolonged surgery duration (OR = 1.68, 95% CI 1.22-2.31, p = 0.002) and a significant predictor to rather undergo OPN than RAPN (OR = 1.5, 95% CI 1.05-2.15, p = 0.027). CONCLUSION: Older, male patients with high BMI scores have a higher risk for APF. The presence of APF increases surgery time and may have an impact on decision making regarding the preferred surgical approach.

Mayo adhesive probability score is associated with perioperative outcomes in retroperitoneal laparoscopic adrenalectomy.

BACKGROUNDS: This study aimed to determine whether the Mayo adhesive probability score (MAP), which evaluated adherent perinephric fat (APF), is useful in evaluating the difficulty of retroperitoneal laparoscopic adrenalectomy (RLA), and to analyse the correlation between MAP and perioperative parameters. METHODS: Clinical data of 104 patients with adrenal adenoma who underwent RLA were collected for retrospective analysis. According to the CT images obtained before surgery, patients were divided into two groups: High MAP group (2-5 points) and Low MAP group (0-1 points). Comparison of the general clinical characteristics and the perioperative data between the two groups was made. RESULTS: There were more male patients (73.7% versus 34.3%), more patients with a smoking history (24.3% versus 7.5%), higher BMI (25.7 versus 23.2, kg/m2 ), and bigger (23.8 versus 18.5, mm) neoplasm in the high MAP group (P < 0.05). Significant difference was observed in operative time (128.8 versus 102.3, min), estimated blood loss (47.2 versus 25.2, ml) and drainage tube removal time (4.0 versus 3.2, d) between the two groups (P < 0.05). A high MAP score (P < 0.001) and the size of tumour (P = 0.024) were independent risk factors for extended operative time. A higher BMI (OR = 1.525, P < 0.001) and larger tumour size (OR = 2.862, P = 0.004) were independent risk factors for a high MAP score. CONCLUSIONS: MAP score was associated with the perioperative outcomes of RLA. BMI and tumour size were better indicators of MAP score, which can influence the difficulty of RLA.

Clinical Implication of Adherent Perinephric Fat in Robot-Assisted Partial Nephrectomy: Validation With Video Review.

Objective: To assess the impact of adherent perinephric fat (APF) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN). Methods: A total of 562 Asian patients with kidney tumors received RAPN and their Mayo adhesive probability (MAP) scores were evaluated. APF was determined intraoperatively and confirmed by a second surgical video review and perioperative data were compared according to the MAP score. The associations of APF with clinical factors were examined using logistic regression analyses. Subgroup (classified according to who performed the surgery) analysis was conducted to assess if the perirenal dissection time is significantly correlated with APF. Results: A total of 118 consecutive patients were classified into two groups according to APF. Patients in the APF group needed significantly longer perirenal fat dissection time (p < 0.001) and longer hospital stay (p = 0.028). MAP score (Odds ratio [OR]: 2.71, 95% Confidence interval [CI]: 1.56-4.71, p < 0.001), body mass index (OR: 1.24, 95% CI: 1.04-1.47, p = 0.016), and perirenal fat dissection time (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004) were significantly associated with the presence of APF. Perirenal fat dissection time was significantly correlated with APF presence in two of three surgeon subgroups (ß = 8.117, p = 0.023; ß = 7.239, p = 0.011). Conclusions: Preoperative MAP score and perirenal fat dissection time were significantly associated with APF during RAPN.

Analysis of predictors of adherent perinephric fat and its impact on perioperative outcomes in laparoscopic partial nephrectomy: a retrospective case-control study.

BACKGROUND: Adherent perinephric fat (APF), characterized by inflammatory fat surrounding the kidney, can limit the isolation of renal tumors and increase the operative difficulty in laparoscopic partial nephrectomy (LPN). The aim of this study was to investigate the predictors of APF and its impact on perioperative outcomes during LPN. METHODS: A total of 215 consecutive patients undergoing LPN for renal cell carcinoma (RCC) from January 2017 to June 2019 at our institute were included. We divided these patients into two groups according to the presence of APF. Radiographic data were retrospectively collected from preoperative cross-sectional imaging. The perioperative clinical parameters were compared between the two groups. Univariate and multivariate analyses were performed to evaluate the predictive factors of APF. RESULTS: APF was identified in 41 patients (19.1%) at the time of LPN. Univariate analysis demonstrated that APF was significantly correlated with the male gender (P = 0.001), higher body mass index (P = 0.002), lower preoperative estimated glomerular filtration rate (P = 0.004), greater posterior perinephric fat thickness (P < 0.001), greater perinephric stranding (P < 0.001), and higher Mayo Adhesive Probability (MAP) score (P < 0.001). The MAP score (P < 0.001) was the only variable that remained an independent predictor for APF in multivariate analysis. We found that patients with APF had longer operative times (P < 0.001), warm ischemia times (P = 0.001), and greater estimated blood loss (P = 0.003) than those without APF. However, there were no significant differences in surgical approach, transfusion rate, length of postoperative stay, complication rate, or surgical margin between the two groups. CONCLUSIONS: Several specific clinical and radiographic factors including the MAP score can predict APF. The presence of APF is associated with an increased operative time, warm ischemia time, and greater estimated blood loss but has no impact on other perioperative outcomes in LPN.

Predicting Operation Time and Creating a Difficulty Scoring System in Donor Nephrectomy.

Background: To determine predictive formulas for operation time and surgical difficulty in laparoscopic living-donor kidney transplantation. Methods: We retrospectively analyzed data for 222 living donors aged >20 years and recorded factors affecting operation time from patients' CT images and medical records. We used the factors significantly affecting operation time to create a formula to predict operation time and designed a model to predict surgical difficulty based on the standardized partial regression coefficient, ß. We also analyzed the relationship between surgical difficulty (high vs low) and operation time. Results: This study involved 111 pure retroperitoneoscopic donor nephrectomies (PRDN) and 111 hand-assisted laparoscopic donor nephrectomies (HALDN). Patients' mean age was 55.7 years, and 59.5% were women; 5.0% underwent right nephrectomy, and 77.0% vs 23.0% had single- vs multiple renal arteries. The average estimated kidney graft weight was 160.0 g, and actual average graft weight was 155.3 g. The following factors were significantly correlated with operation time in the regression analysis: number of renal arteries, Mayo adhesive probability score, estimated kidney graft weight, right nephrectomy, and operation type (PRDN). These five factors were used to create the operation time prediction equation and difficulty scoring system. The multiple r2 value was 0.40 for the operation time prediction equation. Receiver operating characteristic curve analysis of the difficulty scoring system revealed the following: sensitivity: 78.0%, specificity: 64.9%, and c-statistic: 0.76 (95% confidence interval: 0.70 to 0.83). Conclusions: The equation to predict operation time and the surgical difficulty prediction model created in this study are easy to calculate and are accurate. Both may help in selecting an appropriately skilled surgeon and in improving safety in living-donor kidney transplantation.

A Combination of the Mayo Adhesive Probability Score and the RENAL Score to Predict Intraoperative Complications in Small Renal Masses.

INTRODUCTION: To evaluate the potential predictive value of the Mayo Adhesive Probability (MAP) score combined with the RENAL score for intraoperative outcomes in retroperitoneal laparoscopic nephron-sparing surgery (NSS) in an Eastern Asian population. METHODS: An initial of 388 patients undergoing retroperitoneal laparoscopic NSS were identified. MAP and RENAL scores were calculated according to CT and a logistic regression model was adopted as a combination of the RENAL score and the MAP score. RESULTS: A total of 293 patients were included. The overall intraoperative complication rate was 7.5% (21 cases). The MAP score was found to correlate with operation time (OT; r = 0.169), estimated blood loss (EBL; r = 0.318), and intraoperative complications (r = 0.242). The RENAL score was correlated with warm is-chemia time (r = 0.503), OT (r = 0.334), intraoperative complications (r = 0.178), and EBL (r = 0.218). The MAP score and the RENAL score were reliable predictors of overall intraoperative complications, with areas under the curve (AUC) of 0.728 and 0.759, respectively. After combination of these 2 scores, the AUC of overall intra-operative complications was improved with statistical significance (AUC = 0.847, combination vs. RENAL score: p = 0.044 < 0.05; combination vs. MAP score: p = 0.005 < 0.05). CONCLUSION: The MAP score is an important predictor of EBL, OT, and intraoperative complications in retroperitoneal laparoscopic NSS and its combination with the RENAL score showed a superior predictive value compared to a single score in overall intraoperative complications. The MAP score might be considered in preoperative radiologic aspects as regularly as the RENAL score.

Significant impact of three-dimensional volumetry of perinephric fat on the console time during robot-assisted partial nephrectomy.

BACKGROUND: To assess the impact of volumetry of perinephric fat (PNF) on the perioperative outcomes of robot-assisted partial nephrectomy (RAPN). METHODS: Between 2016 and 2019, a single surgeon performed RAPN for 128 patients with clinical T1a-b renal tumors at our institution, and the 70 most recent patients were included in this study to minimize the effects of surgical experience. PNF was defined as a fatty area around the kidney within the anatomical structures, including the lateroconal fascia, fusion fascia, psoas muscle, lumbar quadrate muscle and diaphragm, and its volume was calculated based on reconstructed three-dimensional computed tomography images using the SYNAPSE VINCENT system. RESULTS: In this series, the trifecta and MIC (margin, ischemia and complications) score system outcomes were achieved in 69 (98.6%) and 64 patients (91.4%), respectively. The median PNF volume in the 70 patients was 166.05 cm3, which was significantly correlated with both the body mass index (BMI) and Mayo adhesive probability (MAP) score (correlation coefficient = 0.68 and 0.74, respectively). There was no significant difference in the R.E.N.A.L. nephrometry score, PNF volume or console time during RAPN among 5 groups consisting of 14 consecutive patients. Of several factors examined, the console time was significantly affected by the sex, MAP score and PNF volume, and only the PNF volume was independently associated with the console time. CONCLUSION: Even if performed by an experienced robotic surgeon beyond the initial learning curve, the PNF volume may influence the console time during RAPN.

Prediction of Postoperative Risks in Laparoscopic Partial Nephrectomy Using RENAL, Mayo Adhesive Probability and Renal Pelvic Score.

AIM: To evaluate the Mayo Adhesive Probability (MAP) score, renal pelvis score, and RENAL nephrometry score for the prediction of surgical outcome in patients with renal masses undergoing laparoscopic partial nephrectomy at a single center. PATIENTS AND METHODS: A total of 280 patients who underwent laparoscopic partial nephrectomy were identified retrospectively. Thirty-eight patients were excluded because of a lack of preoperative imaging. The outcome measures included surgical technique, patient characteristics, MAP score, renal-pelvis-score, RENAL nephrometry score, and complication rates according to the Clavien-Dindo classification. Regression analysis was performed for assessment of the predictive value of the given scores. RESULTS: Complications occurred after 32 (13%) operations. There was a significant positive association between the development of complications and RENAL nephrometry score (p=0.003). Prediction of complications was improved by the RENAL nephrometry score [area under the curve (AUC) =0.675] and the MAP score (AUC=0.655): With an increasing MAP score, there was a significantly increased operative time (p=0.033). The renal pelvis score had a minor predicitive role (AUC=0.516) and no correlation was found with postoperative urine leakage. CONCLUSION: The MAP score and RENAL nephrometry score seem to be able to predict a complex or complicated intra- and postoperative course, while the renal pelvis score is not suitable for predicting postoperative complications, especially urine leakage.

Is surgeon intuition equivalent to models of operative complexity in determining the surgical approach for nephron sparing surgery?

INTRODUCTION: The choice of approach for partial nephrectomy often depends on surgical complexity. We aimed to determine if surgeon intuition was equivalent to markers of operative complexity, such as RENAL nephrometry and Mayo adhesive probability (MAP) score, in determining the surgical approach for partial nephrectomy (PN). MATERIALS AND METHODS: We retrospectively identified 119 masses removed for suspected renal cell carcinoma from January 2012 to September 2014 by a single surgeon who intuitively chose treatment with one of three surgical approaches: Open PN (OPN), robotic-assisted transperitoneal PN (RATPN), or robotic-assisted retroperitoneal PN (RARPN). Clinicodemographic characteristics, pathological features, and postoperative outcomes were compared for each approach. Logistic regression was performed to identify independent predictors of open surgical resection, our primary endpoint. RESULTS: Fifty-four tumors (45%) were resected via OPN, 40 (34%) via RATPN, and 25 (21%) via RARPN. OPN was performed in patients with more comorbidities (P = 0.02), lower baseline renal function (P < 0.01), more solitary kidneys (P < 0.01), and more multifocal disease (P < 0.01). Patients undergoing OPN had higher median nephrometry scores compared to RATPN and RARPN patients (8 vs. 7 vs. 7, respectively; P = 0.03), but MAP scores were no different among all three groups (P = 0.36). On multivariate analysis, higher nephrometry scores (odds ratio: 1.41, 95% confidence interval: 1.10-1.81; P = 0.007) were independently associated with open surgical resection. Nephrometry score was predictive of OPN (area under curve = 0.64, P = 0.01) with a score of 6.5 having the highest sensitivity and specificity (76% and 42%, respectively). CONCLUSIONS: RENAL nephrometry score was associated with surgical approach intuitively chosen by an experienced surgeon, but the presence of adherent perinephric fat did not correlate with decision-making.

Adherent perinephric fat at minimally invasive partial nephrectomy is associated with adverse peri-operative outcomes and malignant renal histology.

OBJECTIVES: To predict adherent perinephric fat (APF) at minimally invasive partial nephrectomy (MIPN) using the Mayo adhesive probability (MAP) score and to determine the impact of MAP score and APF on MIPN outcomes. PATIENTS AND METHODS: A total of 245 patients undergoing MIPN were included in the study. The presence of APF was determined through keywords in operating notes, and radiographic data were obtained from preoperative cross-sectional imaging. Posterior fat thickness was measured between the renal capsule and the posterior abdominal wall at the level of the renal vein. Perinephric stranding was graded on a 0-3 severity scale. RESULTS: The study included 123 men and 122 women, with a median age of 55 years, body mass index of 31.7, tumour size of 2.7 cm and nephrometry score of 6. The median posterior fat thickness was 1.79 cm and MAP score 2.63. In all, 26 patients (10.6%) had evidence of APF at the time of renal surgery. Factors predictive of APF included increasing age (P = 0.001), male gender (P = 0.045), perinephric stranding (P = 0.002), posterior fat thickness (P < 0.001) and MAP score (P < 0.001). APF was associated with adverse pathological and peri-operative outcomes including malignant renal histology (P = 0.04), longer operating time (P = 0.005) and greater estimated blood loss (EBL; P = 0.025). CONCLUSIONS: Specific clinical and radiographic factors predict APF at MIPN. The presence of APF is associated with adverse peri-operative outcomes including longer operating time and greater EBL. APF was also associated with renal malignancy on final pathology, but further studies are necessary to elucidate the precise underlying mechanism.