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Nguyen HN, Yamada A, Naka S, Murakami K, Tani S, Tani T. Microwave Scissors-Based Sutureless Laparoscopic Partial Nephrectomy Versus Conventional Open Partial Nephrectomy in a Porcine Model: Usefulness and Complications. Ann Surg Oncol 2024; 31:5804-5814. [PMID: 38851638 PMCID: PMC11300646 DOI: 10.1245/s10434-024-15548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/16/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND This study aimed to compare the benefits and safety of microwave scissors-based sutureless laparoscopic partial nephrectomy (MSLPN) with those of conventional open partial nephrectomy (cOPN). METHODS Each kidney in nine pigs underwent MSLPN using microwave scissors (MWS) via transperitoneal laparoscopy or cOPN via retroperitoneal open laparotomy. The kidney's lower and upper poles were resected under temporary hilar-clamping. The renal calyces exposed during renal resections were sealed and transected using MWS in MSLPN and were sutured in cOPN. For MWS, the generator's power output was 60 W. Data on procedure time (PT), ischemic time (IT), blood loss (BL), normal nephron loss (NNL), and extravasation during retrograde pyelogram were compared between the two techniques. RESULTS The authors successfully performed 22 MSLPNs and 10 cOPNs. Compared with cOPN, MSLPN was associated with significantly lower PT (median, 9.2 vs 13.0 min; p = 0.026), IT (median, 5.9 vs 9.0 min; p < 0.001), BL (median, 14.4 vs 38.3 mL; p = 0.043), and NNL (median, 7.6 vs 9.4 mm; p = 0.004). However, the extravasation rate was higher in the MSLPN group than in the cOPN group (54.5 % [n = 12] vs 30.0 % [n = 3]), albeit without a significant difference (p = 0.265). Pelvic stenosis occurred in one MSLPN procedure that involved deep lower pole resection near the kidney hilum. CONCLUSIONS The study data show that MSLPN can improve intraoperative outcomes while reducing technical demands for selected patients with non-hilar-localized renal tumors. However, renal calyces, if violated, should be additionally sutured to prevent urine leakage.
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Affiliation(s)
- Ha Ngoc Nguyen
- Department of Advanced Medical Research and Development, Shiga University of Medical Science, Shiga, Japan.
- Department of Urology, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
| | - Atsushi Yamada
- Medical Innovation Research Center, Shiga University of Medical Science, Shiga, Japan
| | - Shigeyuki Naka
- Department of Surgery, Hino Memorial Hospital, Shiga, Japan
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | | | - Soichiro Tani
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Tohru Tani
- Department of Advanced Medical Research and Development, Shiga University of Medical Science, Shiga, Japan.
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2
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Belmonte M, Frego N, Ticonosco M, Pissavini A, Balestrazzi E, Sorce G, Barletta F, Rebuffo S, Collà Ruvolo C, Morra S, Lambert E, De Groote R, De Naeyer G, Mottrie A. On-clamp vs off-clamp robot-assisted partial nephrectomy for achieving modified trifecta: inverse probability of treatment weighting analysis from a high-volume tertiary robotic center. J Robot Surg 2024; 18:327. [PMID: 39167125 DOI: 10.1007/s11701-024-02078-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
On-clamp partial nephrectomy for the surgical treatment of renal masses poses the risk of ischemia and greater post-operative renal function loss. Conversely, the off-clamp technique might enhance renal function preservation by avoiding any ischemia time. Nevertheless, the debate persists regarding the efficacy of the on- versus off-clamp partial nephrectomy in achieving better surgical, functional, and oncological outcomes. We retrospectively assessed the data from patients undergoing Robot-Assisted Partial Nephrectomy (RAPN) from 2016 and 2023 in a tertiary robotic center. Inverse probability of treatment weighting (IPTW) was used to account for selection bias in treatment allocation. The main objective of the study was assessing the achievement rates of a modified trifecta within the two groups. Multivariable logistic regression analysis (MLRA) was employed to assess the predictors of trifecta achievement. 532 patients were included in the analysis, of whom 74.1% vs. 25.9% underwent on- and off-clamp, respectively. Balancing the two groups for the main predictors of on-clamp surgery, there were no significant differences between on- and off-clamp in terms of estimated blood loss, transfusion rate, intra- and post-operative complications, positive surgical margins, and post-operative mean reduction of eGFR. Finally, no differences were found in the rate of "trifecta" achievement between on-clamp and off-clamp RAPN (24.6% vs. 21%, p = 0.82). At MLRA, off-clamp technique was not a predictor of trifecta achievement compared to the on-clamp technique (off-clamp vs. on-clamp, aOR 1.24, 95% CIs [0.65-2.36], p = 0.58). Our study revealed that clamping technique does not imply clinically relevant differences in reaching trifecta outcomes.
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Affiliation(s)
- Mario Belmonte
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium.
- ORSI Academy, Ghent, Belgium.
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Nicola Frego
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Department of Urology, Humanitas Research Hospital-IRCCS, Rozzano, Italy
| | - Marco Ticonosco
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Department of Urology, Ospedale Policlinico E Nuovo Ospedale Civile S.Agostino Estense Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandro Pissavini
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Eleonora Balestrazzi
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Gabriele Sorce
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Barletta
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Silvia Rebuffo
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Department of Urology, Policlinico San Martino Hospital, University of Genova, Genoa, Italy
| | - Claudia Collà Ruvolo
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Simone Morra
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Edward Lambert
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
| | - Ruben De Groote
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
| | - Geert De Naeyer
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
| | - Alexandre Mottrie
- Department of Urology, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
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3
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Schleef M, Roy P, Lemoine S, Paparel P, Colombel M, Badet L, Guebre-Egziabher F. Renal and major clinical outcomes and their determinants after nephrectomy in patients with pre-existing chronic kidney disease: A retrospective cohort study. PLoS One 2024; 19:e0300367. [PMID: 38696458 PMCID: PMC11065299 DOI: 10.1371/journal.pone.0300367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/23/2024] [Indexed: 05/04/2024] Open
Abstract
The consequences of partial nephrectomy (PN) compared to radical nephrectomy (RN) are less documented in patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We assessed renal outcomes, and their determinants, after PN or RN in a retrospective cohort of patients with moderate-to-severe CKD (RN-CKD and PN-CKD) or SK (PN-SK). All surgical procedures conducted between 2013 and 2018 in our institution in patients with pre-operative estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 or with SK were included. The primary outcome was a composite criterion including CKD progression or major adverse cardio-vascular events (MACE) or death, assessed one year after surgery. Predictors of the primary outcome were determined using multivariate analyses. A total of 173 procedures were included (67 RN, and 106 PN including 27 SK patients). Patients undergoing RN were older, with larger tumors. Preoperative eGFR was not significantly different between the groups. One year after surgery, PN-CKD was associated with lower rate of the primary outcome compared to RN-CKD (43% vs 71% p = 0.007). In multivariate analysis, independent risk factors for the primary outcome were postoperative AKI (stage 1 to stage 3 ranging from OR = 8.68, 95% CI 3.23-23.33, to OR = 28.87, 95% CI 4.77-167.61), larger tumor size (OR = 1.21 per cm, 95% CI 1.02-1.45), while preoperative eGFR, age, sex, diabetes mellitus, and hypertension were not. Postoperative AKI after PN or RN was the major independent determinant of worse outcomes (CKD progression, MACE, or death) one year after surgery.
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Affiliation(s)
- Maxime Schleef
- Lyon University, CarMeN laboratory, IRIS team, INSERM, INRAE, Université Claude Bernard Lyon-1, Bron, France
- Department of intensive care medicine, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Pascal Roy
- Department of biostatistics-bioinformatics, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Lemoine
- Lyon University, CarMeN laboratory, IRIS team, INSERM, INRAE, Université Claude Bernard Lyon-1, Bron, France
- Department of renal explorations, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Philippe Paparel
- Department of urology, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Marc Colombel
- Department of urology and transplantation surgery, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Lionel Badet
- Department of urology and transplantation surgery, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Fitsum Guebre-Egziabher
- Lyon University, CarMeN laboratory, IRIS team, INSERM, INRAE, Université Claude Bernard Lyon-1, Bron, France
- Department of nephrology-hypertension-dialysis, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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4
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Mastroianni R, Chiacchio G, Perpepaj L, Tuderti G, Brassetti A, Anceschi U, Ferriero M, Misuraca L, D’Annunzio S, Bove AM, Guaglianone S, Flammia RS, Proietti F, Pula M, Milanese G, Leonardo C, Galosi AB, Simone G. Comparison of Perioperative, Functional, and Oncologic Outcomes of Open vs. Robot-Assisted Off-Clamp Partial Nephrectomy: A Propensity Scored Match Analysis. SENSORS (BASEL, SWITZERLAND) 2024; 24:2822. [PMID: 38732928 PMCID: PMC11086121 DOI: 10.3390/s24092822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/15/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024]
Abstract
Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan-Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; p < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; p = 0.03), lower postoperative Clavien-Dindo ≤ 2 complications (1.3% vs. 18.3%, p < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, p = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09-4.46, p = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan-Meier analysis, no differences were observed between the two groups in terms of OS (log-rank p = 0.451), CSS (log-rank p = 0.476), DFS (log-rank p = 0.678), and MFS (log-rank p = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement.
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Affiliation(s)
- Riccardo Mastroianni
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Giuseppe Chiacchio
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
- Urology Division, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.P.); (G.M.); (A.B.G.)
| | - Leonard Perpepaj
- Urology Division, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.P.); (G.M.); (A.B.G.)
| | - Gabriele Tuderti
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Aldo Brassetti
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Umberto Anceschi
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Mariaconsiglia Ferriero
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Leonardo Misuraca
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Simone D’Annunzio
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Alfredo Maria Bove
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Salvatore Guaglianone
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Rocco Simone Flammia
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Flavia Proietti
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Marco Pula
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Giulio Milanese
- Urology Division, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.P.); (G.M.); (A.B.G.)
| | - Costantino Leonardo
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
| | - Andrea Benedetto Galosi
- Urology Division, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.P.); (G.M.); (A.B.G.)
| | - Giuseppe Simone
- Urology, IRCCS “Regina Elena” National Cancer Institute, 00128 Rome, Italy; (R.M.); (G.T.); (A.B.); (U.A.); (M.F.); (L.M.); (S.D.); (A.M.B.); (S.G.); (R.S.F.); (F.P.); (M.P.); (C.L.); (G.S.)
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5
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Flammia RS, Anceschi U, Tuderti G, Di Maida F, Grosso AA, Lambertini L, Mari A, Mastroianni R, Bove A, Capitanio U, Amparore D, Lee J, Pandolfo SD, Fiori C, Minervini A, Porpiglia F, Eun D, Autorino R, Leonardo C, Simone G. Development and internal validation of a nomogram predicting 3-year chronic kidney disease upstaging following robot-assisted partial nephrectomy. Int Urol Nephrol 2024; 56:913-921. [PMID: 37848745 DOI: 10.1007/s11255-023-03832-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE Aim of the present study was to develop and validate a nomogram to accurately predict the risk of chronic kidney disease (CKD) upstaging at 3 years in patients undergoing robot-assisted partial nephrectomy (RAPN). METHODS A multi-institutional database was queried to identify patients treated with RAPN for localized renal tumor (cT1-cT2, cN0, cM0). Significant CKD upstaging (sCKD-upstaging) was defined as development of newly onset CKD stage 3a, 3b, and 4/5. Model accuracy was calculated according to Harrell C-index. Subsequently, internal validation using bootstrapping and calibration was performed. Then nomogram was depicted to graphically calculate the 3-year sCKD-upstaging risk. Finally, regression tree analysis identified potential cut-offs in nomogram-derived probability. Based on this cut-off, four risk classes were derived with Kaplan-Meier analysis tested this classification. RESULTS Overall, 965 patients were identified. At Kaplan-Meier analysis, 3-year sCKD-upstaging rate was 21.4%. The model included baseline (estimated glomerular filtration rate) eGFR, solitary kidney status, multiple lesions, R.E.N.A.L. nephrometry score, clamping technique, and postoperative acute kidney injury (AKI). The model accurately predicted 3-year sCKD-upstaging (C-index 84%). Based on identified nomogram cut-offs (7 vs 16 vs 26%), a statistically significant increase in sCKD-upstaging rates between low vs intermediate favorable vs intermediate unfavorable vs high-risk patients (1.3 vs 9.2 vs 22 vs 54.2%, respectively, p < 0.001) was observed. CONCLUSION Herein we introduce a novel nomogram that can accurately predict the risk of sCKD-upstaging at 3 years. Based on this nomogram, it is possible to identify four risk categories. If externally validated, this nomogram may represent a useful tool to improve patient counseling and management.
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Affiliation(s)
- Rocco Simone Flammia
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy.
| | - Umberto Anceschi
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Gabriele Tuderti
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Fabrizio Di Maida
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Antonio Andrea Grosso
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Luca Lambertini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Riccardo Mastroianni
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Alfredo Bove
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Umberto Capitanio
- Division of Experimental Oncology, Urological Research Institute (URI), IRCCS Ospedale San Raffaele, Milan, Italy
| | - Daniele Amparore
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Jennifer Lee
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Cristian Fiori
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy
| | - Francesco Porpiglia
- Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy
| | - Daniel Eun
- Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Costantino Leonardo
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
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6
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Xiong L, Zou X, Luo X, Yin S, Huang Y, Ning K, Wen D, Zhou Z, Wang J, Li Z, Chen J, Li J, Peng W, Guo S, Dong P, Zhou F, Han H, Peng Y, Yu C, Zhang Z. Longitudinal changes in renal parenchymal volume and function status after partial nephrectomy: a retrospective cohort study. Int J Surg 2024; 110:984-991. [PMID: 38000077 PMCID: PMC10871623 DOI: 10.1097/js9.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND The ipsilateral renal parenchymal volume (RPV) experiences a sharp decrease shortly after partial nephrectomy (PN), mainly due to surgical remove or devascularization of kidney tissue. However, the subsequent change of RPV and its association with glomerular filtration rate (GFR) fast decline remains unknown. Our objective was to investigate the change of ipsilateral RPV and renal function status from new baseline (1-12 months after PN) to latest follow-up (≥1 year) after PN, and to explore factors associated with ipsilateral RPV decrease rate and correlation between RPV decrease and GFR fast decline. MATERIALS AND METHODS A retrospective review of 367 patients with PN was conducted. Three-dimensional reconstruction of computed tomography (CT)/MRI images was performed for RPV calculation. Spectrum score was used to assess the degree of acute kidney injury (AKI) in the operated kidney after PN. GFR decline greater than 3 ml/min/1.73 m 2 /year was defined as GFR fast decline. One hundred fourteen patients underwent abdominal surgery was used as control. Predictive factors for subsequent decrease of RPV rate and GFR fast decline were evaluated by linear and logistic regression, respectively. RESULTS With a median interval time of 21.1 (interquartile range:13.8-35.5) months, median ipsilateral RPV significantly decreased from 118.7 (interquartile range:100.7-137.1) ml at new baseline to 111.8 (IQR: 92.3-131.3) ml at latest follow-up. The interval time [β: 1.36(0.71-2.01), P <0.001] and spectrum score [β: 5.83 (2.92-8.74), P <0.001] were identified as independent predictors of ipsilateral RPV decrease rate. GFR fast decline was observed in 101 (27.5%) patients. Annual ipsilateral RPV decrease rate [odds ratio:1.67 (1.05-2.67), P =0.03] and overweight [odds ratio:1.63 (1.02-2.60), P =0.04] were independent predictors of GFR fast decline. CONCLUSIONS Ipsilateral RPV experienced a moderate but significant decrease during follow-up after PN, especially in those with severer acute kidney injury. The presence of GFR fast decline was found to be associated with reduction of ipsilateral RPV, particularly in overweight individuals.
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7
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Tuderti G, Mastroianni R, Anceschi U, Bove AM, Brassetti A, Ferriero M, Misuraca L, Guaglianone S, Costantini M, Torregiani G, Saidian A, Mari A, Narasimhan R, Derweesh I, Minervini A, Gallucci M, Simone G. Assessing the Trade-off Between the Safety and Effectiveness of Off-clamp Robotic Partial Nephrectomy for Renal Masses with a High RENAL Score: A Propensity Score-matched Comparison of Perioperative and Functional Outcomes in a Multicenter Analysis. Eur Urol Focus 2023; 9:1037-1043. [PMID: 37263828 DOI: 10.1016/j.euf.2023.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/23/2023] [Accepted: 05/23/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Tumors with a high nephrometry score represent a challenging surgical scenario for which robotic partial nephrectomy (RPN) is a primary option in expert hands. OBJECTIVE To compare perioperative and functional outcomes of off-clamp and on-clamp RPN in patients with renal masses with a high RENAL score (≥9). DESIGN, SETTING, AND PARTICIPANTS For this retrospective analysis, an RPN data set including 1604 patients treated at three institutions between 2003 and 2021 was queried for cases with a RENAL score ≥9. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We used 1:1 propensity score matching (PSM) to select a cohort in which imbalances between the off-clamp and on-clamp groups were minimized. We used χ2 and Student t tests to compare categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare the probability of having an estimated glomerular filtration rate (eGFR) ≥45 ml/min during follow-up. Univariable and multivariable analyses were performed to identify predictors of a trifecta outcome (negative surgical margin status, no Clavien-Dindo grade ≥3 complications, eGFR decline ≤30%) and of retaining eGFR ≥45 ml/min over time. RESULTS AND LIMITATIONS From an overall cohort of 354 patients (142 on-clamp, 212 off-clamp), a homogeneous PSM cohort of 78 patients in each group was selected (p ≥ 0.17). In the PSM cohort, operative time was significantly shorter in the off-clamp group (p < 0.001). There were no differences between the groups in the rates of severe complications (p = 0.32) and positive surgical margins (p = 0.24). The rate of trifecta achievement was significantly higher in the off-clamp group (83.3% vs 67.9%; p = 0.03). Warm ischemia time >20 min was independently negatively associated with trifecta achievement (odds ratio 0.32, 95% confidence interval 0.14-0.74). Moreover, the off-clamp group had a significantly higher probability of retaining eGFR ≥45 ml/min over time (3 yr: 95.9% vs 81.6%; p = 0.03); every 1-min increase in warm ischemia time reduced this probability by 1.3%. CONCLUSIONS We found a favorable trade-off between the benefits and risks of off-clamp RPN, with similar perioperative outcomes and a net benefit in terms of trifecta achievement and long-term renal function outcomes in comparison to on-clamp RPN. PATIENT SUMMARY The complexity of surgery for kidney tumors can be assessed using the RENAL score, which is a measure of the location and size of a kidney tumor. In a multicenter series of patients with tumors with a high RENAL score, we compared outcomes between strategies with (on-clamp) and without (off-clamp) clamping of kidney blood vessels during robot-assisted removal of part of the affected kidney. We found that off-clamp surgery results in better postoperative kidney function.
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Affiliation(s)
- Gabriele Tuderti
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - Riccardo Mastroianni
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alfredo Maria Bove
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Leonardo Misuraca
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Manuela Costantini
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giulia Torregiani
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Ava Saidian
- Department of Urology, University of California-San Diego Health System, La Jolla, CA, USA
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Rekha Narasimhan
- Department of Urology, University of California-San Diego Health System, La Jolla, CA, USA
| | - Ithaar Derweesh
- Department of Urology, University of California-San Diego Health System, La Jolla, CA, USA
| | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Michele Gallucci
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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8
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Zhou Z, Li Z, Ning K, Xiong L, Liu H, Huang Y, Luo X, Peng Y, Chen L, Ma B, Zou X, Wei W, Luo C, Han H, Guo S, Dong P, Zhou F, Yu C, Zhang Z. Long-term effect of acute ischemic injury on the kidney underwent clamped partial nephrectomy. iScience 2023; 26:107610. [PMID: 37664597 PMCID: PMC10474450 DOI: 10.1016/j.isci.2023.107610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/01/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023] Open
Abstract
GFR reaches a new baseline, primarily correlating with nephron-mass preservation, 1-12 months after partial nephrectomy (PN). However, does the ipsilateral GFR experience subsequent decline, and does acute ischemic injury has long-term effect on the operated kidney? 319 patients with two kidneys and unilateral clamped PN were analyzed. All had preoperative, new-baseline, and latest follow-up imaging/serum creatinine levels. Annual ipsilateral GFR decline rate (AIGDR) was defined as new-baseline GFR minus latest follow-up GFR normalized by new-baseline GFR, per year. Spectrum score was used to reflect the degree of acute ischemic injury in the operated kidney. 100 subjects searching for health screening served as controls. Predictive factors for AIGDR were assessed. The median AIGDR was 2.25%, significantly higher than controls (0.88%, p = 0.036). With some contralateral hypertrophy, the global annual GFR decline was similar to that of controls (0.81% vs. 0.88%, p = 0.7). Spectrum score correlated significantly with AIGDR (p = 0.037). These results support that acute ischemic injury has long-term effect on the operated kidney.
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Affiliation(s)
- Zhaohui Zhou
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhiyong Li
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Kang Ning
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Longbin Xiong
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Huiming Liu
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yixin Huang
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xin Luo
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yulu Peng
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Lijie Chen
- Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Binglei Ma
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiangpeng Zou
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Wensu Wei
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Cheng Luo
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Hui Han
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Shengjie Guo
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Pei Dong
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Fangjian Zhou
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Chunping Yu
- Guangdong Key Laboratory of Urology, Department of Urology, Minimally Invasive Surgery Center, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Urology, Guangzhou, China
| | - Zhiling Zhang
- Department of Urology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- State Key Laboratory of Oncology in Southern China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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9
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Cignoli D, Basile G, Fallara G, Rosiello G, Belladelli F, Cei F, Musso G, Re C, Bertini R, Karakiewicz P, Mottrie A, Dehò F, Gallina A, Montorsi F, Salonia A, Capitanio U, Larcher A. Risks and benefits of partial nephrectomy performed with limited or with zero ischaemia time. BJU Int 2023; 132:283-290. [PMID: 36932928 DOI: 10.1111/bju.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
OBJECTIVE To test the hypothesis that longer warm ischaemia time (WIT) might have a marginal impact on renal functional outcomes and might, in fact, reduce haemorrhagic risk intra-operatively. PATIENTS AND METHODS Data from 1140 patients treated with elective partial nephrectomy (PN) for a cT1-2 cN0 cM0 renal mass were prospectively collected. WIT was defined as the duration of clamping of the main renal artery with no refrigeration and was tested as a continuous variable. The primary outcome of the study was evaluation of the effect of WIT on renal function (estimated glomerular filtration rate [eGFR]) postoperatively, at 6 months and in the long term (measured between 1 and 5 years after surgery). The secondary outcome of the study was haemorrhagic risk, defined as estimated blood loss (EBL) or peri-operative transfusions. Multivariable linear, logistic and Cox regression analyses, accounting for age, Charlson comorbidity index, clinical size, preoperative eGFR and year of surgery, were used and the potential nonlinear relationship between WIT and the study outcomes was modelled using restricted cubic splines. RESULTS A total of 863 patients (76%) underwent PN with WIT and 277 (24%) without. The baseline median eGFR was 87.3 (68.8-99.2) mL/min/1.73m2 for the on-clamp population and 80.6 (63.2-95.2) mL/min/1.73m2 for the off-clamp population. The median duration of WIT was 17 (13-21) min. At multivariable analyses predicting renal function, longer WIT was associated with decreased postoperative eGFR (estimate: -0.21, 95% confidence interval [CI] -0.31; -0.11 [P < 0.001]). Conversely, no association between WIT and eGFR was recorded at 6-month or long-term follow-up (all P > 0.8). At multivariable analyses predicting haemorrhagic risk, clampless resection with no ischaemia time and PN with short WIT was associated with an increased EBL (estimate: -21.56, 95% CI -28.33; -14.79 [P < 0.001]) and peri-operative transfusion rate (estimate: -0.009, 95% CI -0.01; -0.003 [P = 0.002]). No association between WIT and positive surgical margin status was recorded (all P = 0.1). CONCLUSION Patients and clinicians should be aware that performing PN with very limited or even with zero WIT might increase bleeding and the need for peri-operative transfusion while not improving long-term renal function outcomes.
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Affiliation(s)
- Daniele Cignoli
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Basile
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Fallara
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Rosiello
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Federico Belladelli
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Cei
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giacomo Musso
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiara Re
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Bertini
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Alexandre Mottrie
- Department of Urology, OLV Ziekenhuis Aalst, Aalst, Belgium
- ORSI Academy, Melle, Belgium
| | - Federico Dehò
- Department of Urology, Ospedale di Circolo e Fondazione Macchi-ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Andrea Gallina
- Department of Urology, Ospedale Regionale di Lugano, Civico USI-Università della Svizzera Italiana, Lugano, Switzerland
| | - Francesco Montorsi
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Larcher
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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10
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Munoz-Lopez C, Lewis K, Attawettayanon W, Yasuda Y, Emrich Accioly JP, Rathi N, Lone Z, Boumitri M, Campbell RA, Wood A, Kaouk JH, Haber GP, Eltemamy M, Krishnamurthi V, Abouassaly R, Haywood SC, Weight CJ, Campbell SC. Functional recovery after partial nephrectomy: next generation analysis. BJU Int 2023; 132:202-209. [PMID: 37017637 DOI: 10.1111/bju.16023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
OBJECTIVES To provide a more rigorous assessment of factors affecting functional recovery after partial nephrectomy (PN) using novel tools that allow for analysis of more patients and improved accuracy for assessment of parenchymal volume loss, thereby revealing the potential impact of secondary factors such as ischaemia. PATIENTS AND METHODS Of 1140 patients managed with PN (2012-2014), 670 (59%) had imaging and serum creatinine levels measured before and after PN necessary for inclusion. Recovery from ischaemia was defined as the ipsilateral glomerular filtration rate (GFR) saved normalised by parenchymal volume saved. Acute kidney injury was assessed through Spectrum Score, which quantifies the degree of acute ipsilateral renal dysfunction due to exposure to ischaemia that would otherwise be masked by the contralateral kidney. Multivariable regression was used to identify predictors of Spectrum Score and Recovery from Ischaemia. RESULTS In all, 409/189/72 patients had warm/cold/zero ischaemia, respectively, with median (interquartile range [IQR]) ischaemia times for cold and warm ischaemia of 30 (25-42) and 22 (18-28) min, respectively. The median (IQR) global preoperative GFR and new baseline GFR (NBGFR) were 78 (63-92) and 69 (54-81) mL/min/1.73 m2 , respectively. The median (IQR) ipsilateral preoperative GFR and NBGFR were 40 (33-47) and 31 (24-38) mL/min/1.73 m2 , respectively. Functional recovery correlated strongly with parenchymal volume preserved (r = 0.83, P < 0.01). The median (IQR) decline in ipsilateral GFR associated with PN was 7.8 (4.5-12) mL/min/1.73 m2 with loss of parenchyma accounting for 81% of this loss. The median (IQR) recovery from ischaemia was similar across the cold/warm/zero ischaemia groups at 96% (90%-102%), 95% (89%-101%), and 97% (91%-102%), respectively. Independent predictors of Spectrum Score were ischaemia time, tumour complexity, and preoperative global GFR. Independent predictors of recovery from ischaemia were insulin-dependent diabetes mellitus, refractory hypertension, warm ischaemia, and Spectrum Score. CONCLUSIONS The main determinant of functional recovery after PN is parenchymal volume preservation. A more robust and rigorous evaluation allowed us to identify secondary factors including comorbidities, increased tumour complexity, and ischaemia-related factors that are also independently associated with impaired recovery, although altogether these were much less impactful.
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Affiliation(s)
- Carlos Munoz-Lopez
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kieran Lewis
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Worapat Attawettayanon
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
- Division of Urology, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
| | - Yosuke Yasuda
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
- Tokyo Medical and Dental University, Graduate School, Tokyo, Japan
| | | | - Nityam Rathi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zaeem Lone
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Melissa Boumitri
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca A Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Wood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jihad H Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mohamad Eltemamy
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Robert Abouassaly
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samuel C Haywood
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Li KP, Chen SY, Wang CY, Yang L. Comparison between minimally invasive partial nephrectomy and open partial nephrectomy for complex renal tumors: a systematic review and meta-analysis. Int J Surg 2023; 109:1769-1782. [PMID: 37094827 PMCID: PMC10389432 DOI: 10.1097/js9.0000000000000397] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/04/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy (OPN) in patients with complex renal tumors (defined as PADUA or RENAL score ≥7). METHODS The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, Supplemental Digital Content 1, http://links.lww.com/JS9/A394 . We conducted a systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases until October 2022. MIPN and OPN-controlled trials for complex renal tumors were included. The primary outcomes were perioperative results, complications, renal function, and oncologic outcomes. RESULTS A total of 2405 patients were included in 13 studies. MIPN outperformed OPN in terms of hospital stay [weighted mean difference (WMD) -1.84 days, 95% CI -2.35 to -1.33; P <0.00001], blood loss (WMD -52.42 ml, 95% CI -71.43 to -33.41; P <0.00001), transfusion rates [odds ratio (OR) 0.34, 95% CI 0.17-0.67; P =0.002], major complications (OR 0.59, 95% CI 0.40-0.86; P =0.007) and overall complications (OR 0.43, 95% CI 0.31-0.59; P <0.0001), while operative time, warm ischemia time, conversion to radical nephrectomy rates, estimated glomerular decline, positive surgical margins, local recurrence, overall survival, recurrence-free survival, and cancer-specific survival were not significantly different. CONCLUSIONS The present study demonstrated that MIPN was associated with a shorter length of hospital stay, less blood loss, and fewer complications in treating complex renal tumors. MIPN may be considered a better treatment for patients with complex tumors when technically feasible.
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Affiliation(s)
| | | | | | - Li Yang
- Department of Urology, The Second Hospital of Lanzhou University, Lanzhou, People’s Republic of China
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12
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Wood AM, Benidir T, Campbell RA, Rathi N, Abouassaly R, Weight CJ, Campbell SC. Long-Term Renal Function Following Renal Cancer Surgery: Historical Perspectives, Current Status, and Future Considerations. Urol Clin North Am 2023; 50:239-259. [PMID: 36948670 DOI: 10.1016/j.ucl.2023.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Knowledge of functional recovery after partial (PN) and radical nephrectomy for renal cancer has advanced considerably, with PN now established as the reference standard for most localized renal masses. However, it is still unclear whether PN provides an overall survival benefit in patients with a normal contralateral kidney. While early studies seemingly demonstrated the importance of minimizing warm-ischemia time during PN, multiple new investigations over the last 10 years have proven that parenchymal mass lost is the most important predictor of new baseline renal function. Minimizing loss of parenchymal mass during resection and reconstruction is the most important controllable aspect of long-term post-operative renal function preservation.
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Affiliation(s)
- Andrew M Wood
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA.
| | - Tarik Benidir
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA
| | - Rebecca A Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA
| | - Nityam Rathi
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA
| | - Robert Abouassaly
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA
| | - Christopher J Weight
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA
| | - Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Q Building - Glickman Tower, 2050 East 96th Street, Cleveland, OH 44195, USA
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13
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Campbell SC, Campbell JA, Munoz-Lopez C, Rathi N, Yasuda Y, Attawettayanon W. Every decade counts: a narrative review of functional recovery after partial nephrectomy. BJU Int 2023; 131:165-172. [PMID: 35835519 PMCID: PMC10087004 DOI: 10.1111/bju.15848] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To provide a narrative review of the major advances regarding ischaemia and functional recovery after partial nephrectomy (PN), along with the ongoing controversies. METHODS Key articles reflecting major advances regarding ischaemia and functional recovery after PN were identified. Special emphasis was placed on contributions that changed perspectives about surgical management. Priority was also placed on randomized trials of off-clamp vs on-clamp cohorts. RESULTS A decade ago, 'Every minute counts' was published, showing strong correlations between duration of ischaemia and development of acute kidney injury (AKI) and chronic kidney disease after clamped PN. This reinforced perspectives that ischaemia was the main modifiable factor that could be addressed to improve functional outcomes and helped spur efforts towards reduced or zero ischaemia PN. These approaches were associated with strong functional recovery and some peri-operative risk, although they were generally safe in experienced hands. Further research demonstrated that, when parenchymal volume changes were incorporated into the analyses, ischaemia lost statistical significance, and percent parenchymal volume saved proved to be the main determinant. Cold ischaemia was confirmed to be highly protective, and limited warm ischaemia also proved to be safe. The reconstructive phase of PN, with avoidance of parenchymal devascularization, appears to be most important for functional outcomes. Randomized trials of on-clamp vs off-clamp PN have shown minimal impact of ischaemia on functional recovery. CONCLUSIONS The past decade has witnessed great progress regarding functional recovery after PN, with many lessons learned. However, there are still unanswered questions, including: What is the threshold of warm ischaemia at which irreversible ischaemic injury begins to develop? Are some cohorts at increased risk for AKI or irreversible ischaemic injury? and Which patients should be prioritized for zero-ischaemia PN?
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Affiliation(s)
- Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Carlos Munoz-Lopez
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Nityam Rathi
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Yosuke Yasuda
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
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Sutureless Purely Off-Clamp Robot-Assisted Partial Nephrectomy: Avoiding Renorrhaphy Does Not Jeopardize Surgical and Functional Outcomes. Cancers (Basel) 2023; 15:cancers15030698. [PMID: 36765656 PMCID: PMC9913582 DOI: 10.3390/cancers15030698] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 01/26/2023] Open
Abstract
To compare outcomes of sutureless (SL) vs. renorrhaphy (RR) off-clamp robotic partial nephrectomy (ocRPN), we retrospectively analyzed procedures performed at our center, from January 2017 to April 2021, for cT1-2N0M0 renal masses. All the patients with a minimum follow-up < 1 month were excluded from the analysis. The trifecta rate defined surgical quality. Any worsening from chronic kidney disease (CKD) I-II to ≧ IIIa (from IIIa to ≧ IIIb, and from IIIb to ≧ IV) was considered as significant stage migration (sCKDsm). A 1:1 propensity score-matched (PSM) analysis minimized baseline imbalances between SL and RR cohorts in terms of age, gender, ASA score, baseline estimated glomerular filtration rate (eGFR), tumor size, and RENAL score. Logistic regression analyses identified predictors of trifecta achievement. Kaplan-Meier (KM) analysis assessed the impact of RR on significant chronic kidney disease sCKDsm-free survival (SMFS), while Cox regression analyses identified its predictors. Overall, 531 patients were included, with a median tumor size of 3.5 cm (IQR: 2.7-5); 70 (13%) presented with a cT2 mass. An SL approach was pursued in 180 cases, but 10 needed conversion to RR. After PSM analysis, patients receiving SL showed a higher trifecta rate (94% vs. 84%; p = 0.007). SMFS probabilities were comparable at KM analysis (log-rank = 0.69). Age (OR: 0.97; 95%CI: 0.95-0.99; p = 0.01), a RENAL score ≧ 10 (OR: 0.29; 95%CI: 0.15-0.57; p < 0.001), and RR (OR: 0.34; 95%CI: 0.17-0.67; p = 0.002) were independent predictors of trifecta achievement. Age (OR: 1.04; 95%CI: 1.003-1.07; p = 0.03) and baseline eGFR (OR: 0.99; 95%CI: 0.97-0.99; p = 0.05) independently predicted sCKDsm. Compared to RR, our experience seems to show that the SL approach significantly increased the probabilities of achieving the trifecta in the observed group of cases.
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Brassetti A, Anceschi U, Bove AM, Prata F, Costantini M, Ferriero M, Mastroianni R, Misuraca L, Tuderti G, Torregiani G, Covotta M, Gallucci M, Simone G. Purely Off-Clamp Laparoscopic Partial Nephrectomy Stands the Test of Time: 15 Years Functional and Oncologic Outcomes from a Single Center Experience. Curr Oncol 2023; 30:1196-1205. [PMID: 36661741 PMCID: PMC9858317 DOI: 10.3390/curroncol30010092] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/09/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Nephron-sparing surgery represents the gold standard treatment for organ-confined renal tumors. We present 15-years of outcomes after off-clamp laparoscopic partial nephrectomy (ocLPN). METHODS a retrospective analysis was performed on patients who underwent ocLPN between May 2001 and December 2005. Baseline demographic, clinical, pathologic, surgical, functional and survival data were collected. The Kaplan-Meier method evaluated group-specific oncologic outcomes at 5, 10 and 15 years and the log rank test assessed differences between groups. The same analysis investigated the probabilities of developing a significant renal function impairment (sRFI) and achieving ROMeS. Cox analyses identified predictors of this latter tricomposite outcome. RESULTS We included 63 patients whose median tumor size was 3 cm (IQR:2-4). At 15 years, the chances of developing local recurrence, metachronous renal cancers or distant metastases were 2 ± 2%, 23 ± 6% and 17 ± 5%, respectively. Consequently, disease-free, cancer-specific and overall-survival probabilities were 68 ± 6%, 90 ± 4% and 72 ± 6%. MCRSS and UCISS well predicted oncologic outcomes. Overall, nine (14%) patients experienced an sRFI and 33 (52%) achieved ROMeS. Age (HR: 1.046; p = 0.033) and malignant histology (low-risk cancers HR: 3.233, p = 0.048) (intermediate/high risk cancers HR: 5.721, p = 0.023) were independent predictors of ROMeS non-achievement. CONCLUSIONS At 15 years from ocLPN, most of patients will experience both excellent functional and oncologic outcomes.
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Affiliation(s)
- Aldo Brassetti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Alfredo Maria Bove
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Francesco Prata
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Manuela Costantini
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | | | - Riccardo Mastroianni
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Leonardo Misuraca
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Gabriele Tuderti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Giulia Torregiani
- Department of Anesthesiology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Marco Covotta
- Department of Anesthesiology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Michele Gallucci
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
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Cheng C, Lu M, Zhang Y, Hu X. Effect of augmented reality navigation technology on perioperative safety in partial nephrectomies: A meta-analysis and systematic review. Front Surg 2023; 10:1067275. [PMID: 37123539 PMCID: PMC10130447 DOI: 10.3389/fsurg.2023.1067275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Aim To evaluate the impact of augmented reality surgical navigation (ARSN) technology on short-term outcomes of partial nephrectomy (PN). Methods A systematic literature search was conducted in PubMed, Embase, Cochrane, and Web of Science for eligible studies published through March 28, 2022. Two researchers independently performed the article screening, data extraction and quality review. Data analysis was performed using Cochrane Review Manager software. Results A total of 583 patients from eight studies were included in the analysis, with 313 in the ARSN-assisted PN group (AR group) and 270 in the conventional PN group (NAR group). ARSN-assisted PN showed better outcomes than conventional surgery in terms of operative time, estimated blood loss, global ischemia rate, warm ischemia time, and enucleation rate. However, there were no significant differences in the rate of Conversion to radical nephrectomy (RN), postoperative estimated glomerular filtration rate (eGFR), positive margin rate, and postoperative complication rate. Conclusion The utilization of ARSN can improve the perioperative safety of PN. Compared with conventional PN, ARSN-assisted PN can reduce intraoperative blood loss, shorten operative time, and improve renal ischemia. Although direct evidence is lacking, our results still suggest a potential advantage of ARSN in improving renal recovery after PN. However, as the ARSN system is still in an exploratory stage, its relevance in PN have been poorly reported. Additional high-quality randomized controlled trial (RCT) studies will be required to confirm the effect of ARSN on PN. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=301798, identifier PROSPERO ID: CRD42022301798.
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17
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Piramide F, Duarte D, Amparore D, Piana A, De Cillis S, Volpi G, Meziere J, Fiori C, Porpiglia F, Checcucci E. Systematic Review of Comparative Studies of 3D Models for Preoperative Planning in Minimally Invasive Partial Nephrectomy. KIDNEY CANCER 2022. [DOI: 10.3233/kca-220008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: The employment of 3-dimensional (3D) virtual models of the organs and tumors, obtained from conventional 2-dimensional (2D) imaging (i.e. computed tomography scan and magnetic resonance imaging) have already demonstrated an outstanding potential in urology, especially in renal surgery. Objectives: The aim of this systematic review is to provide an updated focus on the results obtained from the preoperative employment of 3D virtual imaging reconstructions in nephron sparing oncological surgery. Methods: A systematic literature search was conducted in April 2022 using Medline (via PubMed), Embase (via Ovid), Scopus, and Web of Science. The search strategy used PICO criteria and article selection was conducted in accordance with the PRISMA guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Results: The initial electronic search identified 471 papers, of which 13 ultimately met the inclusion criteria and were included in the review. 11 studies reported outcomes of virtual models, 2 studies focused on printed 3D models. In these studies, the application of 3D models for preoperative planning has been reported to increase the selective clamping rate and reducing the opening of collecting system, blood loss and loss of renal function. Conclusions: 3D virtual models seem to provide some surgical benefits for preoperative planning especially for complex renal masses. In the next future the continuous evolution of this technology may further increase its field of application and its potential clinical benefit.
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Affiliation(s)
- Federico Piramide
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Dorival Duarte
- Department of Surgical Sciences, Federal University of Rio Grande do Sul/ Department of Urology, Moinhos deVento Hospital. Porto Alegre Rio Grande do Sul, Brazil
| | - Daniele Amparore
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Alberto Piana
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Sabrina De Cillis
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Gabriele Volpi
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Juliette Meziere
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Cristian Fiori
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Francesco Porpiglia
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Turin, Italy
| | - Enrico Checcucci
- Department of Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
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18
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Videourology Abstracts. J Endourol 2022. [DOI: 10.1089/end.2022.29127.vid] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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19
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Bianchi L, Cercenelli L, Bortolani B, Piazza P, Droghetti M, Boschi S, Gaudiano C, Carpani G, Chessa F, Lodi S, Tartarini L, Bertaccini A, Golfieri R, Marcelli E, Schiavina R, Brunocilla E. 3D renal model for surgical planning of partial nephrectomy: A way to improve surgical outcomes. Front Oncol 2022; 12:1046505. [PMID: 36338693 PMCID: PMC9634646 DOI: 10.3389/fonc.2022.1046505] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/07/2022] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVE to evaluate the impact of 3D model for a comprehensive assessment of surgical planning and quality of partial nephrectomy (PN). MATERIALS AND METHODS 195 patients with cT1-T2 renal mass scheduled for PN were enrolled in two groups: Study Group (n= 100), including patients referred to PN with revision of both 2D computed tomography (CT) imaging and 3D model; Control group (n= 95), including patients referred to PN with revision of 2D CT imaging. Overall, 20 individuals were switched to radical nephrectomy (RN). The primary outcome was the impact of 3D models-based surgical planning on Trifecta achievement (defined as the contemporary absence of positive surgical margin, major complications and ≤30% postoperative eGFR reduction). The secondary outcome was the impact of 3D models on surgical planning of PN. Multivariate logistic regressions were used to identify predictors of selective clamping and Trifecta's achievement in patients treated with PN (n=175). RESULTS Overall, 73 (80.2%) patients in Study group and 53 (63.1%) patients in Control group achieved the Trifecta (p=0.01). The preoperative plan of arterial clamping was recorded as clampless, main artery and selective in 22 (24.2%), 22 (24.2%) and 47 (51.6%) cases in Study group vs. 31 (36.9%), 46 (54.8%) and 7 (8.3%) cases in Control group, respectively (p<0.001). At multivariate logistic regressions, the use of 3D model was found to be independent predictor of both selective or super-selective clamping and Trifecta's achievement. CONCLUSION 3D-guided approach to PN increase the adoption of selective clamping and better predict the achievement of Trifecta.
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Affiliation(s)
- Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Università degli studi di Bologna, Bologna, Italy
| | - Laura Cercenelli
- eDIMES Lab - Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Barbara Bortolani
- eDIMES Lab - Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Pietro Piazza
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Droghetti
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sara Boschi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Caterina Gaudiano
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Carpani
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Chessa
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Università degli studi di Bologna, Bologna, Italy
| | - Simone Lodi
- eDIMES Lab - Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Lorenzo Tartarini
- eDIMES Lab - Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Alessandro Bertaccini
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Università degli studi di Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Emanuela Marcelli
- eDIMES Lab - Laboratory of Bioengineering, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Riccardo Schiavina
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Università degli studi di Bologna, Bologna, Italy
| | - Eugenio Brunocilla
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Università degli studi di Bologna, Bologna, Italy
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20
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The Outcome of Sutureless in Partial Nephrectomy: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5260131. [PMID: 36193318 PMCID: PMC9526602 DOI: 10.1155/2022/5260131] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/12/2022] [Indexed: 11/18/2022]
Abstract
Purpose To compare the effect of sutureless versus standard suture (double-layer suture) during renorrhaphy in laparoscopic or robotic-assisted partial nephrectomy on perioperative and renal function outcomes. Methods PubMed, Embase, and other sources were searched for randomized controlled trials or retrospective studies comparing sutureless partial nephrectomy versus standard suture partial nephrectomy. A systematic review and meta-analysis were performed by two reviewers independently. Results Five retrospective studies were included with a total of 634 patients. The results showed that there was a significant difference in the decline of estimated glomerular filtration rate (I2 = 98.5%; WMD, -4.19 ml/min; 95% CI, -7.64 to -0.73; P < 0.001) and no significant difference in postoperative complications (I2 = 0; RR, 1.31; 95% CI, 0.61 to 2.81; P = 0.623). A significant advantage in terms of operating time (I2 = 53.9%; WMD, -29.08 min; 95% CI, -33.06 to -25.10; P = 0.069) and warm ischemia time (I2 = 38.5%; WMD, -6.17 min; 95% CI, -6.99 to -5.36; P = 0.165) favored sutureless, while there was no significant difference in blood loss (I2 = 58.1%; WMD, 3.10 ml; 95% CI, -39.18 to 45.38; P = 0.049). Conclusion Sutureless during renorrhaphy is feasible and safe compared with standard suture. Sutureless can shorten the operating time and warm ischemia time without increasing postoperative complications, and thus, it protects renal function.
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Brassetti A, Cacciamani GE, Mari A, Garisto JD, Bertolo R, Sundaram CP, Derweesh I, Bindayi A, Dasgupta P, Porter J, Mottrie A, Schips L, Rah KH, Chen DYT, Zhang C, Jacobsohn K, Anceschi U, Bove AM, Costantini M, Ferriero M, Mastroianni R, Misuraca L, Tuderti G, Kutikov A, White WM, Ryan ST, Porpiglia F, Kaouk J, Minervini A, Gill I, Autorino R, Simone G. On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis. Cancers (Basel) 2022; 14:cancers14184431. [PMID: 36139591 PMCID: PMC9496892 DOI: 10.3390/cancers14184431] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 09/03/2022] [Indexed: 11/16/2022] Open
Abstract
We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.
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Affiliation(s)
- Aldo Brassetti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
- Correspondence: ; Tel.: +39-065-266-6772
| | - Giovanni E. Cacciamani
- USC Institute of Urology and Catherine, Joseph Aresty Department of Urology, Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Andrea Mari
- Department of Experimental and Clinical Medicine, Oncologic Minimally Invasive Urology and Andrology Unit, Careggi Hospital, University of Florence, 50134 Florence, Italy
| | - Juan D. Garisto
- Department of Urology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Riccardo Bertolo
- Division of Urology, San Carlo di Nancy Hospital, 00165 Rome, Italy
| | | | - Ithaar Derweesh
- Department of Urology, UCSD Health System, La Jolla, CA 92103, USA
| | - Ahmet Bindayi
- Department of Urology, UCSD Health System, La Jolla, CA 92103, USA
| | - Prokar Dasgupta
- MRC Centre for Transplantation, Guy’s Hospital, King’s College, London WC2R 2LS, UK
| | | | | | - Luigi Schips
- Department of Urology, Annunziata Hospital, G. D’Annunzio University, 66100 Chieti, Italy
| | - Koon Ho Rah
- Urological Science Institute, Yonsei University College of Medicine, Seoul 03722, Korea
| | - David Y. T. Chen
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Chao Zhang
- Department of Urology, Changhai Hospital, Shanghai 200433, China
| | - Kenneth Jacobsohn
- Department of Urology, Medical College Wisconsin, Milwaukee, WA 53226, USA
| | - Umberto Anceschi
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Alfredo M. Bove
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Manuela Costantini
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | | | - Riccardo Mastroianni
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Leonardo Misuraca
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Gabriele Tuderti
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Alexander Kutikov
- Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - Wesley M. White
- Department of Urology, University of Tennessee Medical Center, Knoxville, TN 37920, USA
| | - Stephen T. Ryan
- Department of Urology, UCSD Health System, La Jolla, CA 92103, USA
| | - Francesco Porpiglia
- Division of Urology, San Luigi Gonzaga Hospital, University of Turin, 10124 Orbassano, Italy
| | - Jihad Kaouk
- Department of Urology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Andrea Minervini
- Department of Experimental and Clinical Medicine, Oncologic Minimally Invasive Urology and Andrology Unit, Careggi Hospital, University of Florence, 50134 Florence, Italy
| | - Inderbir Gill
- USC Institute of Urology and Catherine, Joseph Aresty Department of Urology, Keck School of Medicine, Los Angeles, CA 90033, USA
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA 23298, USA
| | - Giuseppe Simone
- Department of Urology, IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
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22
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Injectable adhesive self-healing biocompatible hydrogel for haemostasis, wound healing, and postoperative tissue adhesion prevention in nephron-sparing surgery. Acta Biomater 2022; 152:157-170. [PMID: 36100176 DOI: 10.1016/j.actbio.2022.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/17/2022] [Accepted: 09/05/2022] [Indexed: 02/06/2023]
Abstract
Nephron-sparing surgery is a well-established treatment in patients with T1a renal cell carcinoma; however, the complex suturing process prolongs warm ischaemia time, affects the preservation of normal renal parenchymal function, and causes avoidable postoperative tissue adhesion complications, including chronic abdominal pain, intestinal obstruction, and female infertility. Hence, the design of multifunctional biomaterials with haemostasis, postoperative wound management, and postoperative tissue adhesion prevention properties for nephron-sparing surgeries is urgently needed. In this study, a series of injectable adhesive multifunctional biocompatible hydrogels were designed based on the free-radical polymerisation of monomers acryloyl-6-aminocaproic acid (AA) and N-acryloyl 2-glycine (NAG), and the ionic coordination between Ca2+ and the abundant carboxyl groups in AA and NAG. AA/NAG/Ca (AA, NAG, and Ca refer to acryloyl-6-aminocaproic acid, N-acryloyl 2-glycine and calcium chloride, respectively) hydrogel exhibited good mechanical properties, swelling and adhesion properties, flexibility, in vitro blood-clotting ability, and cytocompatibility. In vivo experiments on liver injury models and rat/rabbit nephron-sparing surgery models elucidated that the AA/NAG/Ca hydrogel had haemostasis performance and wound healing properties that led to short bleeding time, reduced bleeding volume, and well-organised nephron structures. An abdomen-caecum adhesion model indicated that the AA/NAG/Ca hydrogel showed excellent anti-adhesion properties. In summary, this multifunctional hydrogel exhibited potential for improving haemostasis and wound management in nephron-sparing surgeries, showing potential for clinical application. STATEMENT OF SIGNIFICANCE: Extended warm ischemia time during nephron sparing surgery negatively affected postoperative renal function due to the need for hemostasis at the wound with abundant blood supply, and postoperative wound healing and additional adhesions caused by the surgical procedure deserve attention. Based on the efficient and stable adhesion properties of hydrogels and the ability to promote wound healing. Herein, a series of adhesive self-healing biocompatible hydrogels were prepared based on free-radical polymerization of acryloyl-6-aminocaproic acid (AA) and N-acryloyl 2-glycine (NAG) and the ionic coordination between Ca2+ with the abundant carboxyl groups in AA and NAG. AA/NAG/Ca hydrogel showed hemostasis property in nephron sparing surgery model, promote kidney wound healing, and could perform anti-postoperative adhesion efficacy in an abdomen-caecum adhesion model.
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Kubota M, Yamasaki T, Murata S, Abe Y, Tohi Y, Mine Y, Hagimoto H, Kokubun H, Suzuki I, Tsutsumi N, Inoue K, Kawakita M. Surgical and functional outcomes of robot-assisted versus laparoscopic partial nephrectomy with cortical renorrhaphy omission. Sci Rep 2022; 12:13000. [PMID: 35906380 PMCID: PMC9338244 DOI: 10.1038/s41598-022-17496-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 07/26/2022] [Indexed: 11/17/2022] Open
Abstract
To evaluate the surgical and functional outcomes between robot-assisted (CRO-RAPN) vs. laparoscopic (CRO-LPN) methods of cortical-renorrhaphy-omitting partial nephrectomy. Between July 2012 and June 2020, patients with localized clinical T1-2 renal masses who underwent CRO-RAPN or CRO-LPN were reviewed. The outcomes of the two groups were compared using propensity-score matching. Trifecta was defined as negative surgical margin, warm ischemic time < 25 min, and absence of complications of Clavien-Dindo grade III or more until three months postoperatively. The preservation rate of the estimated glomerular filtration rate (eGFR) was evaluated at six months postoperatively. Among 291 patients (CRO-RAPN, n = 210; CRO-LPN, n = 81) included in the study, 150 matched pairs of patients were analyzed. Compared to the CRO-LPN group, the CRO-RAPN group was associated with shorter warm ischemic time (13 min vs. 20 min, P < 0.001), shorter total operation time (162 min vs. 212 min, P < 0.001), less estimated blood loss (40 mL vs. 119 mL, P = 0.002), lower incidence of overall complications (3% vs. 16%, P = 0.001), higher preservation rate of eGFR at six months postoperatively (93% vs. 89%, P = 0.003), and higher trifecta achievement rate (84% vs. 64%, P = 0.004). CRO-RAPN contributed to shorter warm ischemic time, less blood loss, fewer complications, and higher preservation of renal function, all of which allowed this technique to achieve a higher rate of trifecta compared to CRO-LPN.
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Affiliation(s)
- Masashi Kubota
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Toshinari Yamasaki
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Shiori Murata
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yohei Abe
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yoichiro Tohi
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yuta Mine
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Hiroki Hagimoto
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Hidetoshi Kokubun
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Issei Suzuki
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Naofumi Tsutsumi
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Koji Inoue
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Mutsushi Kawakita
- Department of Urology, Kobe City Medical Centre General Hospital, 2-1-1 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
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Lee J, Hwang YC, Yoo S, Choo MS, Cho MC, Son H, Jeong H. Changes in kidney function according to ischemia type during partial nephrectomy for T1a kidney cancer. Sci Rep 2022; 12:4223. [PMID: 35273257 PMCID: PMC8913619 DOI: 10.1038/s41598-022-07919-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/28/2022] [Indexed: 11/09/2022] Open
Abstract
To compare the postoperative estimated-glomerular-filtration-rate (eGFR) and parenchymal changes between cold ischemia and zero/selective ischemia for a T1a mass. We analyzed 104 patients who underwent open partial nephrectomy with cold ischemia (53) or zero/selective ischemia (51) for T1a between 2008 and 2018 to determine postoperative renal function changes and associated factors. Postoperative renal function was expressed as (postoperative-eGFR - preoperative-eGFR)/preoperative-eGFR × 100%. Parenchymal enhancement and thicknesses of the ipsilateral kidney as tissue changes were measured on postoperative CT to identify the correlation with the renal function change. Patients with 10% or 25% decrease in eGFR were significantly more in the cold ischemia group (p = 0.032, p = 0.006). On multivariable analysis, preoperative eGFR, ischemic type, and percent change of parenchymal thickness were identified to be significantly associated with postoperative 12 months renal function (B = - 0.367, p = 0.020; B = 6.788, p = 0.042; B = 0.797, p = 0.029). Change in parenchymal thickness was negatively correlated with changes in postoperative renal function (r = - 0.277, p = 0.012). Changes in eGFR were associated with a decrease in parenchymal thickness and the type of ischemic technique. Zero/selective ischemia during partial nephrectomy may have an advantage in preserving postoperative renal function compared to cold ischemia.
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Affiliation(s)
- Junghoon Lee
- Department of Urology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Young Cheol Hwang
- Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Sangjun Yoo
- Department of Urology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Min Soo Choo
- Department of Urology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Min Chul Cho
- Department of Urology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Hwancheol Son
- Department of Urology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea
| | - Hyeon Jeong
- Department of Urology, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Korea.
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Giulioni C, Di Biase M, Marconi A, Sortino G, Diambrini M, Iacovelli V, Giannubilo W, Ferrara V. Clampless Laparoscopic Tumor Enucleation for Exophytic Masses Greater Than 4 cm: Is Renorrhaphy Necessary? J Laparoendosc Adv Surg Tech A 2022; 32:931-937. [PMID: 35443800 DOI: 10.1089/lap.2021.0815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To demonstrate the safety of clampless 3D laparoscopic tumor enucleation (cLTE) for exophytic T1b kidney masses, avoiding suture to achieve hemostasis. Methods: Between January 2010 and January 2021, 241 consecutive patients with an exophytic renal tumor underwent sutureless cLTE. Patients with predominantly endophytic growth or tumors 4 mm closer to the collecting system less were excluded. In all cases, an attempt was made to accomplish surgery without suturing kidney parenchyma. Data were obtained from a retrospective review of history and physical examinations, operative and pathology reports, anesthesia records during the hospital stay, and follow-up visits. Results: Among 241 patients who underwent cLTE, 148 had cT1a and 93 had cT1b renal tumor. The median tumor size was 32 mm, and the median R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) score was 6. Renorrhaphy was necessary in 5 cases. The median operative time (OT) was 100 minutes, and the estimated blood loss (EBL) was 150 mL. The median 24-hour decrease in hemoglobin was 1.8 g/dL. The median length of stay was 4 days. Nineteen patients had postoperative complications: 3 cases had Clavien-Dindo (CD) 3a or more, 6 had CD2, and 10 had CD1. Comparing the T1a and T1b groups, except for the median OT and the EBL, no significant differences were observed in all the other variables analyzed. In both groups, renal function was preserved after 1 year from surgery. Conclusion: Our experience showed that sutureless cLTE is safe and feasible for T1b tumors leading to radical oncological outcomes and preserving renal function.
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Affiliation(s)
- Carlo Giulioni
- Department of Urology, University Hospital "Ospedali Riuniti," Ancona, Italy
| | | | - Andrea Marconi
- Department of Urology, Hospital "Carlo Urbani," Jesi, Italy
| | | | | | - Valerio Iacovelli
- Urology Unit, San Carlo di Nancy General Hospital-GVM Care and Research, Rome, Italy
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Jin Y, Xiong H, Xia Q, Zhang Q. A Modified Two-Layer Suture Technique for Transperitoneal Laparoscopic Partial Nephrectomy: Single-Center Clinical Experience. Front Surg 2022; 8:761090. [PMID: 35178424 PMCID: PMC8843823 DOI: 10.3389/fsurg.2021.761090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Purposes This study aims to evaluate the feasibility and efficacy of a modified two-layer suture method during laparoscopic partial nephrectomy (LPN) by a comparative analysis with the traditional two-layer suture. Methods A total of 60 LPN patients were enrolled in this study, of which 30 patients received the modified two-layer suture method and the remaining 30 patients underwent the traditional two-layer suture. Then, surgical characteristics including operative time, warm ischemic time (WIT), estimated blood loss (EBL), and glomerular filtration rate (GFR) were recorded. Finally, univariable and multivariable linear regression analyses were used to evaluate the correlations of tumor characteristics, suture methods, and postoperative renal function. Results There was no significant difference between the two suture groups with respect to patient and tumor characteristics, postoperative creatinine level, and blood urea nitrogen (BUN) level. The modified suture group showed a significantly shorter clamping time and a less GFR level reduction than the traditional two-layer suture group (15 vs. 23 min; 42.32 ± 9.48 vs. 27.07 ± 7.88; p < 0.05). Additionally, the modified two-layer suture was an independent factor that influenced the clamping time and the level of GFR reduction. Conclusion The modified two-layer suture method is feasible and effective for LPN.
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Affiliation(s)
- Yang Jin
- Medical Research Center, Hospital Affiliated to Binhai University, Qingdao, China
| | - Hui Xiong
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Qinghua Xia
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Qi Zhang
- Department of Urology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- *Correspondence: Qi Zhang
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What Happens to the Preserved Renal Parenchyma After Clamped Partial Nephrectomy? Eur Urol 2022; 81:492-500. [DOI: 10.1016/j.eururo.2021.12.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/05/2021] [Accepted: 12/30/2021] [Indexed: 12/11/2022]
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Li L, Zeng X, Yang C, Un W, Hu Z. Three-dimensional (3D) reconstruction and navigation in robotic-assisted partial nephrectomy (RAPN) for renal masses in the solitary kidney: A comparative study. Int J Med Robot 2021; 18:e2337. [PMID: 34591353 DOI: 10.1002/rcs.2337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/02/2021] [Accepted: 09/22/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Numerous efforts were made to improve renal function and oncologic outcomes in surgery for patients with kidney cancer. We explored new robotic methods in solitary kidneys. MATERIALS AND METHODS We prospectively registered and included 16 patients in the 3D-robot-assisted partial nephrectomy (RAPN) group with a solitary kidney (anatomic or functional), and retrospectively identified 25 patients with a solitary kidney who received RAPN also operated by us for comparison. RESULTS The rates of global clamping reduced in the 3D-RAPN group (37.5% vs 76%)while selective rates were higher (56.2% vs 20%) (p = 0.028). The mean percentages of Scr increase (+20.2% vs +30.2%, p = 0.045) and eGFR reduction (-16.8% vs -27.1%) as well as rate of opening collecting systems (31.3% vs 72%, p = 0.010) were lower in 3D-RAPN group. CONCLUSIONS 3D-RAPN less impaired the renal function of patients with a solitary kidney and showed superiority or non-inferiority in other evaluation indexes compared to conventional RAPN.
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Affiliation(s)
- Le Li
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xing Zeng
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunguang Yang
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Waikeong Un
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiquan Hu
- Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Zhang W, Che B, Xu S, Mu Y, He J, Tang K. Comparison of Sutureless Versus Suture Partial Nephrectomy for Clinical T1 Renal Cell Carcinoma: A Meta-Analysis of Retrospective Studies. Front Oncol 2021; 11:713645. [PMID: 34540681 PMCID: PMC8445026 DOI: 10.3389/fonc.2021.713645] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022] Open
Abstract
Background Partial nephrectomy (PN) is the recommended treatment for T1 renal cell carcinoma (RCC). Compared with suture PN, sutureless PN reduces the difficulty and time of operation, but the safety and feasibility have been controversial. This meta-analysis was conducted to compare the function and perioperative outcomes of suture and sutureless PN for T1 RCC. Methods Systematic literature review was performed up to April 2021 using multiple databases to identify eligible comparative studies. According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria, identification and selection of the studies were conducted. Meta-analysis was performed for studies comparing suture to sutureless PN for both T1a and T1b RCC. In addition, subgroup analysis was performed on operation time, warm ischemia time, estimated blood loss, and postoperative complications. Sensitivity analysis was used in analysis with high heterogeneity (operation time and estimated blood loss). Results Eight retrospective studies were included with a total of 1,156 patients; of the 1,156 patients, 499 received sutureless PN and 707 received suture PN. The results showed that sutureless PN had shorter operative time (I2 = 0%, P < 0.001), warm ischemia time (I2 = 97.5%, P < 0.001), and lower clamping rate (I2 = 85.8%, P = 0.003), but estimated blood loss (I2 = 76.6%, P = 0.064) had no difference. In the comparison of perioperative outcomes, there was no significant difference in postoperative complications (I2 = 0%, P = 0.999), positive surgical margins (I2 = 0%, P = 0.356), postoperative estimated glomerular filtration rat (eGFR) (I2 = 0%, P = 0.656), and tumor recurrence (I2 = 0%, P = 0.531). Conclusions In T1a RCC with low RENAL score, sutureless PN is a feasible choice, whereas it should not be overestimated in T1b RCC.
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Affiliation(s)
- Wenjun Zhang
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Bangwei Che
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Shenghan Xu
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Yi Mu
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jun He
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Kaifa Tang
- Department of Urology, Affiliated Hospital of Guizhou Medical University, Guiyang, China.,Institute of Medical Science of Guizhou Medical University, Guiyang, China
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Robot-Assisted versus Laparoscopic Partial Nephrectomy for Giant Sporadic Renal Angiomyolipomas of ≥7 cm: A Propensity Score-Matched Analysis. JOURNAL OF ONCOLOGY 2021; 2021:6395876. [PMID: 34484335 PMCID: PMC8416378 DOI: 10.1155/2021/6395876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022]
Abstract
Background To compare the perioperative and functional outcomes between robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for giant sporadic renal angiomyolipomas (AMLs) of ≥7 cm. Materials and Methods Patients with sporadic renal AMLs of ≥7 cm who underwent RAPN or LPN in the First Affiliated Hospital of Nanchang University between 2015 and 2020 were retrospectively analyzed. Propensity score matching (1 : 1) was performed to adjust for potential baseline confounders. Perioperative and functional outcomes of the RAPN and LPN groups were collected and compared. Result After propensity score matching, no statistically significant differences in baseline characteristics were found between the groups (41 vs. 41). Within the matched cohort, the warm ischemia time (WIT) in the RAPN group was significantly shorter than that in the LPN group (21 vs. 27 min, p < 0.001). In addition, the RAPN group was associated with improved postoperative renal function (72.8 vs. 69.8 mL/min/1.73 m2, p=0.045). WIT and preoperative renal function are independent predictors of renal function at 6 months postoperatively, and renal score and operation method are independent predictors of WIT. Conclusion RAPN and LPN are safe and feasible minimally invasive treatments for sporadic giant renal AMLs, but RAPN is associated with shorter WIT and better postoperative renal functional preservation. WIT and preoperative renal function are independent predictors of renal function at 6 months postoperatively, while the RENAL score and surgical method are independent risk factors to WIT. For giant and complex renal AMLs, RAPN is the first choice when condition permits.
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Minimally Invasive Partial Nephrectomy: Are All Clamps Created Equal? An Ex Vivo Model Simulation of Vascular Clampage. Curr Urol Rep 2021; 22:44. [PMID: 34427767 DOI: 10.1007/s11934-021-01061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
REASON FOR REVIEW During the partial nephrectomy, clamping of the vascular pedicle before exision of the tumor is a key step in minimizing blood loss and maintaining adequate visualization. Different vascular clamping devices have been developed for minimal invasive surgery. However, there are no reports comparing them in turn of efficiency RECENT FINDINGS: We present an ex vivo experimental model, designed to demonstrate differences between the clamping devices. All clamps proved to function properly without any leakage at 90 and 120 mmHg, respectively. Our study and the ex vivo model prove that all available clamps are equally efficient at physiologic pressures.
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Inoue T, Zhang X, Kuwatsuru R, Okada S, Kato H, Ozu H, Yanagida M, Yamashiro Y. Efficacy and safety of prophylactic superselective embolization for angiomyolipoma at the renal hilum. J Int Med Res 2021; 49:3000605211016193. [PMID: 34024189 PMCID: PMC8142531 DOI: 10.1177/03000605211016193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This study investigated the efficacy and safety of superselective transcatheter arterial embolization for angiomyolipoma at the renal hilum. Methods Between August 2012 and January 2015, 13 patients with 16 angiomyolipomas at the renal hilum underwent initial, prophylactic, superselective transcatheter arterial embolization. The patients were followed by computed tomography or magnetic resonance imaging, and volume-reduction ratios after embolization were measured. Results The mean or median post-embolization volume reduction ratios were 23% (follow-up duration, 1–2 months), 55% (3–6 months), 55% (7–12 months), 66% (1–2 years), 67% (2–3 years), and 54% (>3 years). After initial embolization, none of the 16 tumors bled or required surgery; two (13%) tumors recurred; and three (19%) tumors received repeat embolization. Estimated glomerular filtration rates were not decreased at medians of 7 days (near the time of discharge) and 39 days (first clinical follow-up) post-procedure, compared with baseline. Except for post-embolization syndrome, no procedure-related complications occurred. Conclusions Superselective embolization for renal hilar angiomyolipoma is safe and kidney-preserving, with good tumor volume reduction and bleeding prevention.
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Affiliation(s)
- Tatsuro Inoue
- Department of Radiology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo Bunkyo-ku, Tokyo, Japan
| | - Xixi Zhang
- Department of Radiology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo Bunkyo-ku, Tokyo, Japan
| | - Ryohei Kuwatsuru
- Department of Radiology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo Bunkyo-ku, Tokyo, Japan.,Department of Radiology, School of Medicine, Juntendo University, Tokyo, Japan
| | - Shingo Okada
- Department of Radiology, School of Medicine, Juntendo University, Tokyo, Japan
| | - Hitomi Kato
- Department of Radiology, School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiromi Ozu
- Department of Radiology, School of Medicine, Juntendo University, Tokyo, Japan
| | - Masataka Yanagida
- Department of Radiology, School of Medicine, Juntendo University, Tokyo, Japan
| | - Yuki Yamashiro
- Department of Radiology, School of Medicine, Juntendo University, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Nephron-sparing partial nephrectomy is the state of the art for localized small renal mass and it is gaining attention also for more advanced cases. In the present narrative review, we discuss the new developments that have occurred in the advancement of this approach over the past few years. RECENT FINDINGS Off-clamp, selective/superselective clamp and early-unclamping techniques are safe and feasible approaches, with potentially superior functional outcomes, and noninferior complications rate and oncological outcomes, when compared with main artery clamping. Renorrhaphy must preserve the physiological vascularization of residual parenchyma. Running sutures, particularly using barbed wires, shorten the operating and ischemia times. A further advantage could derive from avoiding a double-layer suture. Transperitoneal robot-assisted partial nephrectomy (RAPN) and retroperitoneal RAPN can be considered equivalent in terms of perioperative morbidity, functional and oncologic outcomes, regardless of tumor's location, thus the choice of the approach should be driven by the surgeon's expertise. Future improvements should be introduced by the single-port robotic surgery, which seems to be safe and feasibly also in an off-clamp manner. SUMMARY Significant advances have recently been achieved in nephron-sparing surgery technique. However, future studies with standardized reporting of these new techniques are needed to assess the real impact of them on early and long-term functional outcomes.
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Meta grayscale adaptive network for 3D integrated renal structures segmentation. Med Image Anal 2021; 71:102055. [PMID: 33866259 DOI: 10.1016/j.media.2021.102055] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/03/2021] [Accepted: 03/26/2021] [Indexed: 11/22/2022]
Abstract
Three-dimensional (3D) integrated renal structures (IRS) segmentation targets segmenting the kidneys, renal tumors, arteries, and veins in one inference. Clinicians will benefit from the 3D IRS visual model for accurate preoperative planning and intraoperative guidance of laparoscopic partial nephrectomy (LPN). However, no success has been reported in 3D IRS segmentation due to the inherent challenges in grayscale distribution: low contrast caused by the narrow task-dependent distribution range of regions of interest (ROIs), and the networks representation preferences caused by the distribution variation inter-images. In this paper, we propose the Meta Greyscale Adaptive Network (MGANet), the first deep learning framework to simultaneously segment the kidney, renal tumors, arteries and veins on CTA images in one inference. It makes innovations in two collaborate aspects: 1) The Grayscale Interest Search (GIS) adaptively focuses segmentation networks on task-dependent grayscale distributions via scaling the window width and center with two cross-correlated coefficients for the first time, thus learning the fine-grained representation for fine segmentation. 2) The Meta Grayscale Adaptive (MGA) learning makes an image-level meta-learning strategy. It represents diverse robust features from multiple distributions, perceives the distribution characteristic, and generates the model parameters to fuse features dynamically according to image's distribution, thus adapting the grayscale distribution variation. This study enrolls 123 patients and the average Dice coefficients of the renal structures are up to 87.9%. Fine selection of the task-dependent grayscale distribution ranges and personalized fusion of multiple representations on different distributions will lead to better 3D IRS segmentation quality. Extensive experiments with promising results on renal structures reveal powerful segmentation accuracy and great clinical significance in renal cancer treatment.
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Yasuda Y, Saito K, Tanaka H, Uehara S, Kijima T, Yoshida S, Yokoyama M, Matsuoka Y, Kihara K, Fujii Y. Outcomes of gasless laparoendoscopic single-port partial nephrectomy in 356 consecutive patients: Feasibility of a clampless and sutureless technique. Int J Urol 2021; 28:302-307. [PMID: 33300187 DOI: 10.1111/iju.14452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/08/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To investigate the outcomes and feasibilities of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy. METHODS We reviewed 356 consecutive patients with primary unilateral non-metastatic renal masses who underwent gasless laparoendoscopic single-port partial nephrectomy (2011-2018), which was performed retroperitoneally using a three-dimensional flexible endoscope, without vascular clamping or renorrhaphy in principle. RESULTS The median tumor size was 2.5 cm, and 213 (60%), 105 (29%), and 38 (11%) patients had peripheral, central, and hilar tumors, respectively. Clampless and sutureless partial nephrectomy was accomplished in 337 patients (95%), while eight (2%) and 16 (4%) patients required vascular clamping and renorrhaphy, respectively. The median operative time and blood loss were 220 min and 266 mL, respectively; eight patients (2%) received blood transfusion. Clavien-Dindo grade 3a complications occurred in 27 patients (8%); all these patients had urinary leakage treated with ureteral stent placement, one of whom also developed a postoperative pseudoaneurysm. Among 324 patients diagnosed with renal cell carcinoma, six (2%) had positive surgical margins, and one (0.3%) and seven (2%) developed metastatic and local recurrences, respectively. During a median follow-up of 54 months, no patient died from kidney cancer. The median percent decrease in estimated glomerular filtration rate at 3 months after surgery was 5.7%. No patient experienced postoperative acute renal failure, while one patient with preexisting renal impairment started dialysis at 70 months after surgery. CONCLUSIONS Clampless and sutureless partial nephrectomy can be safely accomplished in most patients undergoing gasless laparoendoscopic single-port surgery, yielding favorable oncological and functional outcomes.
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Affiliation(s)
- Yosuke Yasuda
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazutaka Saito
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hajime Tanaka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Sho Uehara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshiki Kijima
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Soichiro Yoshida
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Minato Yokoyama
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoh Matsuoka
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazunori Kihara
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhisa Fujii
- Department of Urology, Tokyo Medical and Dental University, Tokyo, Japan
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Tuna MB, Doganca T, Tufek I, Argun OB, Keskin S, Obek C, Kural AR. Off-Clamp Robot-Assisted Partial Nephrectomy: Is There Something More to Achieve Optimal Trifecta Outcomes? J Endourol 2020; 35:1153-1157. [PMID: 33198502 DOI: 10.1089/end.2020.0747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: To report trifecta outcomes of our "off-clamp" partial nephrectomy (PN) patients operated without main renal artery and/or any selective/superselective clamping. Materials and Methods: Between April 2008 and March 2020, 52 patients received "off-clamp" robot-assisted partial nephrectomy. Postoperative sixth month estimated glomerular filtration rate (eGFR) and eGFR decrease were considered for renal function evaluation. Patients with negative surgical margins, <15% postoperative eGFR decrease and absence of grade ≥2 Clavien-Dindo complications were reported to achieve trifecta outcomes. Results: Mean age and body mass index of the patients were 57.51 ± 12.99 years and 27.23 ± 4.35 kg/m2, respectively. Mean preoperative hematocrit, serum creatinine, and eGFR were 42.01 ± 3.86%, 0.92 ± 0.28 mg/dL, and 85.26 ± 21.27 mL/min/1.73 m2, respectively. Mean tumor size was 30.32 ± 13.64 mm. Mean PADUA and RENAL scores were 7.63 ± 1.46 and 6.21 ± 1.63, respectively. One patient had focal surgical margin positivity. Mean console time and estimated blood loss was 82.11 ± 38.51 minutes and 280.76 ± 278.98 mL, respectively. Complications were observed in two (4%) patients (one Clavien I, one Clavien IIIB). At postoperative sixth month, serum creatinine and eGFR were 0.95 ± 0.32 mg/dL and 83.65 ± 22.44 mL/min/1.73 m2, respectively. Eventually seven patients had ≥15% postoperative eGFR decrease, one patient had grade ≥2 complication and one patient had positive surgical margin. Forty-three (83%) patients fulfilled trifecta outcomes. Conclusion: Off-clamp PN is important for optimal renal function preservation. Patient selection and additional operative measures along with experience in robotic procedure can contribute achievement of optimal trifecta outcomes.
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Affiliation(s)
| | - Tunkut Doganca
- Department of Urology, Acibadem Taksim Hospital, Istanbul, Turkey
| | - Ilter Tufek
- Department of Urology, Acibadem Mehmet Ali Aydinlar University Medical Faculty, Istanbul, Turkey
| | - Omer Burak Argun
- Department of Urology, Acibadem Mehmet Ali Aydinlar University Medical Faculty, Istanbul, Turkey
| | - Selcuk Keskin
- Department of Urology, Acibadem Mehmet Ali Aydinlar University Medical Faculty, Istanbul, Turkey
| | - Can Obek
- Department of Urology, Acibadem Mehmet Ali Aydinlar University Medical Faculty, Istanbul, Turkey
| | - Ali Riza Kural
- Department of Urology, Acibadem Mehmet Ali Aydinlar University Medical Faculty, Istanbul, Turkey
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Abstract
Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.
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Affiliation(s)
- Ellen O'Connor
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Brennan Timm
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.,North Eastern Urology, Heidelberg, Australia
| | - Nathan Lawrentschuk
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Urology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph Ischia
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia
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Li M, Cheng L, Zhang H, Ma L, Wang Y, Niu W, Liu Z, Song Y, Liang P, Zhao G, Wu B, Song Y, Bu R. Laparoscopic and Robotic-Assisted Partial Nephrectomy: An Overview of Hot Issues. Urol Int 2020; 104:669-677. [PMID: 32759603 DOI: 10.1159/000508519] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/03/2020] [Indexed: 11/19/2022]
Abstract
Laparoscopic partial nephrectomy and robot-assisted partial nephrectomy are attracting increased attention from urologists. They can achieve the same effect of oncology control as radical nephrectomy; moreover, they can offer better preservation of renal function, thus obtaining long-term living benefits. The indications are also expanding, making it possible for larger and more difficult tumors. Laparoscopic partial nephrectomy and robot-assisted partial nephrectomy can be performed by transperitoneal and retroperitoneal approaches, with their individual advantages and limitations. In addition, the renal tumor scoring systems have been widely used and studied in laparoscopic partial nephrectomy and robot-assisted partial nephrectomy. In -order to better preserve renal function, the zero-ischemia technique is widely used. The application of intraoperative imaging technology provides convenience and greater benefits. Besides, whether minimal invasive partial nephrectomy can be performed without stop antiplatelet treatment is still disputed. Clinicians perform substantial exploration and practice to achieve the "trifecta" of surgery: complete resection of the tumor, maximum protection of renal function, and no complications.
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Affiliation(s)
- Ming Li
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Liang Cheng
- Departments of Pathology and Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Ying Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Wanting Niu
- Department of Orthopedics, Brigham and Women's Hospital, Harvard Medical School, Boston, Boston, Massachusetts, USA
| | - Zeqi Liu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yan Song
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Peihe Liang
- Department of Urology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guoan Zhao
- School of Network Education, Beijing University of Posts and Telecommunications, Beijing, China
| | - Bin Wu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yongsheng Song
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Renge Bu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China,
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Anceschi U, Ferriero MC, Tuderti G, Brassetti A, Bertolo R, Capitanio U, Larcher A, Garisto J, Antonelli A, Mottrie A, Minervini A, Dell'Oglio P, Veccia A, Amparore D, Mari A, Porpiglia F, Montorsi F, Kaouk J, Carini M, Autorino R, Gallucci M, Simone G. Head to Head Impact of Margin, Ischemia, Complications, Score Versus a Novel Trifecta Score on Oncologic and Functional Outcomes After Robotic-assisted Partial Nephrectomy: Results of a Multicenter Series. Eur Urol Focus 2020; 7:1391-1399. [PMID: 32675046 DOI: 10.1016/j.euf.2020.06.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/16/2020] [Accepted: 06/25/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND There is a paucity of data describing the ability of margin, ischemia, complications, score (MIC) and trifecta in predicting long-term outcomes of robotic-assisted partial nephrectomy (RAPN). OBJECTIVE To compare a novel trifecta (negative margins, no significant complications, and perioperative estimated glomerular filtration rate [eGFR] decrease ≤30%) versus standard MIC as predictors of oncologic and functional results in a large series of RAPNs. DESIGN, SETTING, AND PARTICIPANTS Between 2009 and 2019, a multicenter dataset was queried for patients with nonmetastatic renal masses who underwent RAPN at eight participating institutions. INTERVENTION RAPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS MIC and trifecta achievement were determined for the overall cohort and a subgroup undergoing off-clamp RAPN (ocRAPN), respectively. The overall survival (OS), recurrence-free survival (RFS), and new onset of end-stage renal disease (ESRD; defined as eGFR <30 ml/min) probabilities were assessed by the Kaplan-Meier method. Cox regression analyses were used to identify predictors of OS, RFS, and ESRD. For all analyses, two-sided p < 0.05 was considered significant. RESULTS AND LIMITATIONS Out of 1807 patients, MIC and trifecta were achieved in 71.1% (n = 1285) and 82.6% (n = 1492), respectively, and once restricted to the ocRAPN cohort, in 95.6% (n = 625) and 81.6% (n = 534), respectively. On Kaplan-Meier analysis, both MIC and trifecta achievement predicted higher OS and lower ESRD probabilities (all p < 0.014), while only trifecta achievement was a predictor of RFS probabilities (p = 0.009). On multivariable Cox regression, MIC did not predict any of the endpoints independently, while trifecta achievement was an independent predictor of higher OS (hazard ratio [HR] 0.4, 95% confidence interval [CI] 0.18-0.86; p = 0.019) and lower ESRD development probabilities (HR 0.32, 95% CI 0.15-0.72; p = 0.005). CONCLUSIONS Trifecta, initially described as comprehensive measures of perioperative outcomes, needs to stand the test of time. Compared with MIC, the recent trifecta was an independent predictor of clinically significant endpoints, namely, survival and ESRD development probabilities. PATIENT SUMMARY Our novel trifecta represents a reliable method for estimating survival and development of end-stage renal disease after robotic-assisted partial nephrectomy.
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Affiliation(s)
- Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy.
| | | | - Gabriele Tuderti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Riccardo Bertolo
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Alessandro Larcher
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Juan Garisto
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | | | | | - Daniele Amparore
- Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Porpiglia
- Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Francesco Montorsi
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Jihad Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marco Carini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Michele Gallucci
- Department of Urology, Policlinico Umberto I, "La Sapienza" University, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
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Anceschi U, Brassetti A, Bertolo R, Tuderti G, Ferriero MC, Mastroianni R, Flammia RS, Costantini M, Kaouk J, Leonardo C, Gallucci M, Simone G. On-clamp versus purely off-clamp robot-assisted partial nephrectomy in solitary kidneys: comparison of perioperative outcomes and chronic kidney disease progression at two high-volume centers. Minerva Urol Nephrol 2020; 73:739-745. [PMID: 32573170 DOI: 10.23736/s2724-6051.20.03795-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Minimal literature describes the impact of hilar control on the progression to chronic kidney disease (pCKD) after robotic partial nephrectomy (RPN) in solitary kidneys (SK). The aim of this study was to compare purely off-clamp (ocRPN) vs. on-clamp robotic partial nephrectomy (onRPN) in SK and to identify predictors of pCKD at two high-volume centers. METHODS Between December 2013 and October 2019, 54 patients with SK underwent ocRPN and onRPN for renal tumors at two institutions. Baseline and perioperative data were analyzed. Newly onset of CKD stage 3b,4,5 (CKD3b,4,5) was assessed by Kaplan-Meier curves and compared for warm ischemia time (WIT) with the log-rank test. Cox regression analysis was used to identify predictors of pCKD. RESULTS At a median follow-up of 13 months (IQR 6.3-34), newly onset of CKD3b and CKD 4.5 were observed in 11.1% and 7.4% of patients, respectively. onRPN was associated with a higher risk of progression to CKD 3b,4,5 stages (P=0.034) and higher rate of perioperative complications (P=0.03). On univariable analysis eGFR at discharge (eGFRd), positive surgical margins status (PSM) and WIT were predictors of newly onset of CKD3b,4,5 (each P<0.05). Multivariable analysis identified eGFRd (HR 0.88; CI 95% 0.81-0.96) and WIT (HR 1.09; CI 95% 1.02-1.16) as independent predictors of pCKD (each P<0.01). Main limitations include the retrospective nature of the study, the short-term follow-up and the lack of data adjustment for parenchymal volume loss. CONCLUSIONS eGFRd and WIT during RPN are independent predictors of pCKD in SK. In this setting a critical reduction of WIT should be achieved according to the oncologic outcome. In patients with SK, WIT represents the only surgical modifiable factor of RPN for avoiding a quicker onset of pCKD.
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Affiliation(s)
- Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy -
| | - Aldo Brassetti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Riccardo Bertolo
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gabriele Tuderti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Maria C Ferriero
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | | | | | - Manuela Costantini
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
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Robotic Partial Nephrectomy with Indocyanine Green Fluorescence Navigation. CONTRAST MEDIA & MOLECULAR IMAGING 2020; 2020:1287530. [PMID: 32410919 PMCID: PMC7204372 DOI: 10.1155/2020/1287530] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 03/26/2020] [Indexed: 01/20/2023]
Abstract
Partial nephrectomy (PN) is a recommended type of treatment of localised renal tumors. Real-time intraoperative imaging technique, such as fluorescence imaging with indocyanine green (ICG) administration helps to improve intraoperative and postoperative outcomes in patients who underwent PN. Our work presents results of patients who underwent robotic PN with ICG navigation. A total of 37 patients underwent robotic PN with application of ICG between April 2015 and May 2019. A total amount of 5 mg of ICG was applied intravenously, and then robotic PN was performed with fluorescent imaging. ICG was used by the surgeon's decision according to unfavourable anatomical properties of tumor or to high R.E.N.A.L. nephrometry score. An exact border between perfused and nonperfused tissue was detected, and exact tumor's branch of the renal artery was clamped. Robotic PN with ICG-fluorescence imaging navigation was performed in 37 cases with a preoperative average diameter of tumor of 31 mm. The mean surgery time was 133 minutes, and the mean estimated blood loss was 190 mL. Arterial clamping was performed in 35 cases. The mean duration of warm ischemia was 14 minutes. Application of ICG enabled specific tumor-supplying vessel clamping in 25 cases. Two complications of grade II according to the Clavien-Dindo classification occurred intraoperatively, and one complication of grade III was observed. Renal function changes showed favourable results for the cases with superselective clamping. Finally, an administration of ICG eases superselective clamping of tumor-specific branch of renal artery and helps to preserve normal renal function with acceptable oncological results.
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Near-infrared Fluorescence Imaging with Indocyanine Green in Robot-assisted Partial Nephrectomy: Pooled Analysis of Comparative Studies. Eur Urol Focus 2020; 6:505-512. [DOI: 10.1016/j.euf.2019.03.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 11/20/2022]
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Ferriero M, Bove AM, Tuderti G, Anceschi U, Brassetti A, Costantini M, Mastroianni R, Guaglianone S, Gallucci M, Simone G. Impact of learning curve on perioperative outcomes of off-clamp minimally invasive partial nephrectomy: propensity score matched comparison of outcomes between training versus expert series. Minerva Urol Nephrol 2020; 73:564-571. [PMID: 32182230 DOI: 10.23736/s2724-6051.20.03673-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Off-clamp robotic partial nephrectomy (Off C-RPN) is a challenging technique, hard to teach since bleeding control is not easily reproducible in training settings. We compared perioperative outcomes of two propensity score matched (PSM) cohorts of patients undergone Off C-RPN by either a training or an expert surgeon in the same Institution. METHODS The prospectively maintained "renal cancer" database was queried for "off-clamp," "robotic," "partial nephrectomy" performed between January 2017 and June 2018. Achievement of main outcomes along the learning curve of training surgeon was assessed with logistic regression and Lowess analysis. A 1:1 PSM analysis generated two populations homogeneous for demographics, ASA score, tumor size, nephrometry score, baseline hemoglobin and estimated glomerular filtration rate (eGFR). Multiple tumors, and imperative indications were excluded. Categorical and continuous variables were compared by χ2 and t-test. RESULTS Overall, 111 were treated by the expert, 51 by the training surgeon, respectively. Training surgeon experienced a significant decrease of console time (P=0.01). Patients treated by the expert surgeon had significantly larger tumors, higher PADUA and ASA scores (all P≤0.04). After applying the PSM, two cohorts of 29 patients, homogeneous for all baseline demographic and clinical variables (all P≥0.34) were selected. Hilar clamping was never necessary. Hospital stay, hemoglobin and eGFR at discharge, complication and positive surgical margins rates were comparable between the two cohorts (all P≥0.15). CONCLUSIONS Our results proved that the impact of learning curve on outcomes of Off C-RPN is negligible after completion of a proper training in minimally invasive surgery.
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Affiliation(s)
| | - Alfredo Maria Bove
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Gabriele Tuderti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Aldo Brassetti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Manuela Costantini
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | | | | | | | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
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Borojeni S, Borojeni A, Panayotopoulos P, Bouvier A, Aubé C, Azzouzi AR, Bigot P. Study of Renal and Kidney Tumor Vascularization Using Data from Preoperative Three-dimensional Arteriography Prior to Partial Nephrectomy. Eur Urol Focus 2020; 6:112-121. [PMID: 30078544 DOI: 10.1016/j.euf.2018.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 06/24/2018] [Accepted: 07/18/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND In a cadaveric model with healthy kidneys, it has recently been highlighted that a single renal segment could be supplied by one or more arterial branches originating from an artery supplying another segment. OBJECTIVE To demonstrate occurrences of anatomical variations of renal vascularization and to analyze vascularization of renal tumors. DESIGN, SETTING, AND PARTICIPANTS This prospective monocentric study included all patients treated for a renal tumor between May 2015 and June 2017 by laparoscopic partial nephrectomy after superselective tumor embolization in a hybrid operating room. INTERVENTION Three-dimensional renal and tumoral arteriography with cone-beam computed tomography scan was performed, coupled with preoperative cross-sectional imaging. This procedure provided an accurate vascular anatomical mapping of the kidney and allowed further analysis of tumor vascularization. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relation between anatomical variations of the vascularization and perioperative data was assessed. A χ2 test or Fisher's test was used for qualitative variables, and a Student t test was used for quantitative variables. RESULTS AND LIMITATIONS Out of the 60 patients included, only 25 (42%) presented a standard vascular subdivision. In 26 patients (43%), tumors were supplied by more than one branch and in 20 patients (33%), there was a branch supplying the tumor from another segment. In these cases of multiple or multi-segmental tumor vascularization, tumor size, operative duration, and duration of embolization were significantly higher than in the case of standard vascularization. These complex tumors were more often located at the upper pole of the kidney or at the junction of the anterior and posterior vascular territories of the kidney. Limitations of this study include the low number of patients and its monocentricity. CONCLUSIONS This study confirms that renal vascularization frequently differs from Graves' reference model and that tumor vascularization can depend on several segmental branches. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy. PATIENT SUMMARY We studied renal and tumor vascularization using three-dimensional preoperative arteriography data on tumor kidneys. We have shown that there is great variability in renal vascularization and that tumors can be vascularized branches that originate from an artery leading to another segment. This vascular complexity explains surgical difficulties and must be taken into consideration when segmental arterial clamping is considered during partial nephrectomy.
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Affiliation(s)
- Shahed Borojeni
- Urology Department, Angers University Hospital, Angers, France
| | | | | | - Antoine Bouvier
- Radiology Department, Angers University Hospital, Angers, France
| | - Christophe Aubé
- Radiology Department, Angers University Hospital, Angers, France
| | | | - Pierre Bigot
- Urology Department, Angers University Hospital, Angers, France.
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Brassetti A, Anceschi U, Bertolo R, Ferriero M, Tuderti G, Capitanio U, Larcher A, Garisto J, Antonelli A, Mottire A, Minervini A, Dell'oglio P, Veccia A, Amparore D, Flammia RS, Mari A, Porpiglia F, Montorsi F, Kaouk J, Autorino R, Carini M, Gallucci M, Simone G. Surgical quality, cancer control and functional preservation: introducing a novel trifecta for robot-assisted partial nephrectomy. MINERVA UROL NEFROL 2019; 72:82-90. [PMID: 31833720 DOI: 10.23736/s0393-2249.19.03570-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND In order to improve standard reporting of outcomes after partial nephrectomy, different "trifecta" systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes. METHODS A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo ≥3 complications and ≤30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage ≥IIIa, recurrence-free and overall survival. RESULTS Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation. CONCLUSIONS This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality.
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Affiliation(s)
- Aldo Brassetti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy -
| | - Umberto Anceschi
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Riccardo Bertolo
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Gabriele Tuderti
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
| | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Alessandro Larcher
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Juan Garisto
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Andrea Minervini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | | | | | - Daniele Amparore
- Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Rocco S Flammia
- Department of Urology, Umberto I Polyclinic, Sapienza University, Rome, Italy
| | - Andrea Mari
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Francesco Porpiglia
- Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Francesco Montorsi
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy
| | - Jihad Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Marco Carini
- Department of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Michele Gallucci
- Department of Urology, Umberto I Polyclinic, Sapienza University, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, Regina Elena National Cancer Institute, Rome, Italy
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Beksac AT, Okhawere KE, Rosen DC, Elbakry A, Dayal BD, Daza J, Sfakianos JP, Ronney A, Eun DD, Bhandari A, Hemal AK, Porter J, Stifelman MD, Badani KK. Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy? BJU Int 2019; 125:442-448. [PMID: 31758657 DOI: 10.1111/bju.14956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD). PATIENTS AND METHODS The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24 months, were included in the model for analysis. The median follow-up was 12.0 months (interquartile range 6.7-16.5; range 3.0-24.0 months). RESULTS In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β = -1.20, 95% confidence interval [CI] -5.45, 3.06; P = 0.582) and OC and MAC RPN (β = -1.57, 95% CI -5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. CONCLUSION SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.
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Affiliation(s)
- Alp Tuna Beksac
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel C Rosen
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amr Elbakry
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bheesham D Dayal
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jorge Daza
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abaza Ronney
- Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Columbus, OH, USA
| | - Daniel D Eun
- Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Akshay Bhandari
- Division of Urology, Columbia University at Mount Sinai, Miami Beach, FL, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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47
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Mastroianni R, Brassetti A, Costantini M, Simone G. Predicting biological behaviour of newly diagnosed renal masses: a possible role of cell proliferation biomarkers? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S143. [PMID: 31576350 DOI: 10.21037/atm.2019.06.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Aldo Brassetti
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Manuela Costantini
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
| | - Giuseppe Simone
- Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy
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48
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Simone G, Capitanio U, Tuderti G, Presicce F, Leonardo C, Ferriero M, Misuraca L, Costantini M, Larcher A, Minisola F, Guaglianone S, Anceschi U, Muttin F, Nini A, Trevisani F, Montorsi F, Bertini R, Gallucci M. On‐clamp versus off‐clamp partial nephrectomy: Propensity score‐matched comparison of long‐term functional outcomes. Int J Urol 2019; 26:985-991. [DOI: 10.1111/iju.14079] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Giuseppe Simone
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
| | - Umberto Capitanio
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Gabriele Tuderti
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
| | | | | | | | - Leonardo Misuraca
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
| | - Manuela Costantini
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
| | - Alessandro Larcher
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Francesco Minisola
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
| | | | - Umberto Anceschi
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
| | - Fabio Muttin
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Alessandro Nini
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Francesco Trevisani
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Francesco Montorsi
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Roberto Bertini
- Department of Urology Hospital San Raffaele University Vita Salute MilanItaly
| | - Michele Gallucci
- Department of Urology “Regina Elena” National Cancer Institute RomeItaly
- Department of Urology Sapienza University Rome Italy
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49
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Mazzeo A, Sincos APWB, Leite KRM, Góes MA, Dos Pavão OFS, Kaufmann OG. Study of kidney morphologic and structural changes related to different ischemia times and types of clamping of the renal vascular pedicle. Int Braz J Urol 2019; 45:754-762. [PMID: 31184454 PMCID: PMC6837590 DOI: 10.1590/s1677-5538.ibju.2018.0559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 04/14/2019] [Indexed: 02/07/2023] Open
Abstract
Purpose This study aimed to study morphological and renal structural changes in relation to different ischemic times and types of renal vascular pedicle clamping. Methods Sixteen pigs were divided into two groups (n = 8): Group AV - unilateral clamping of the renal artery and vein and Group A - unilateral clamping of the renal artery only, both with the contralateral kidney used as control. Serial biopsies were performed at 0, 10, 20, 30, 40, 50, 60, 70, 80, and 90 minutes after clamping. Results there is a correlation between the occurrence of renal damage as a function of time (p <0.001), with a higher frequency of Group A lesions for cellular alterations (vascular congestion and edema, interstitial inflammatory infiltrate, interstitial hemorrhage and cell degeneration), with the exception of in the formation of pigmented cylinders that were evidenced only in the AV Group. Conclusion the number of lesions derived from ischemia is associated with the duration of the insult, there is a significant difference between the types of clamping, and the AV Group presented a lower frequency of injuries than Group A. The safety time found for Group A was 10 minutes and for Group AV 20 minutes.
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Affiliation(s)
- Angela Mazzeo
- Hospital Israelita Albert Einstein, São Paulo, Brasil
| | | | | | - Miguel Angelo Góes
- Hospital Israelita Albert Einstein, São Paulo, Brasil.,Disciplina de Nefrologia, Escola Paulista de Medicina, Universidade Federal de São Paulo - Unifesp, SP, Brasil
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50
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Shirk JD, Thiel DD, Wallen EM, Linehan JM, White WM, Badani KK, Porter JR. Effect of 3-Dimensional Virtual Reality Models for Surgical Planning of Robotic-Assisted Partial Nephrectomy on Surgical Outcomes: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1911598. [PMID: 31532520 PMCID: PMC6751754 DOI: 10.1001/jamanetworkopen.2019.11598] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Planning complex operations such as robotic-assisted partial nephrectomy requires surgeons to review 2-dimensional computed tomography or magnetic resonance images to understand 3-dimensional (3-D), patient-specific anatomy. OBJECTIVE To determine surgical outcomes for robotic-assisted partial nephrectomy when surgeons reviewed 3-D virtual reality (VR) models during operative planning. DESIGN, SETTING, AND PARTICIPANTS A single-blind randomized clinical trial was performed. Ninety-two patients undergoing robotic-assisted partial nephrectomy performed by 1 of 11 surgeons at 6 large teaching hospitals were prospectively enrolled and randomized. Enrollment and data collection occurred from October 2017 through December 2018, and data analysis was performed from December 2018 through March 2019. INTERVENTIONS Patients were assigned to either a control group undergoing usual preoperative planning with computed tomography and/or magnetic resonance imaging only or an intervention group where imaging was supplemented with a 3-D VR model. This model was viewed on the surgeon's smartphone in regular 3-D format and in VR using a VR headset. MAIN OUTCOMES AND MEASURES The primary outcome measure was operative time. It was hypothesized that the operations performed using the 3-D VR models would have shorter operative time than those performed without the models. Secondary outcomes included clamp time, estimated blood loss, and length of hospital stay. RESULTS Ninety-two patients (58 men [63%]) with a mean (SD) age of 60.9 (11.6) years were analyzed. The analysis included 48 patients randomized to the control group and 44 randomized to the intervention group. When controlling for case complexity and other covariates, patients whose surgical planning involved 3-D VR models showed differences in operative time (odds ratio [OR], 1.00; 95% CI, 0.37-2.70; estimated OR, 2.47), estimated blood loss (OR, 1.98; 95% CI, 1.04-3.78; estimated OR, 4.56), clamp time (OR, 1.60; 95% CI, 0.79-3.23; estimated OR, 11.22), and length of hospital stay (OR, 2.86; 95% CI, 1.59-5.14; estimated OR, 5.43). Estimated ORs were calculated using the parameter estimates from the generalized estimating equation model. Referent group values for each covariate and the corresponding nephrometry score were summed across the covariates and nephrometry score, and the sum was exponentiated to obtain the OR. A mean of the estimated OR weighted by sample size for each nephrometry score strata was then calculated. CONCLUSIONS AND RELEVANCE This large, randomized clinical trial demonstrated that patients whose surgical planning involved 3-D VR models had reduced operative time, estimated blood loss, clamp time, and length of hospital stay. TRIAL REGISTRATION ClinicalTrials.gov identifiers (1 registration per site): NCT03334344, NCT03421418, NCT03534206, NCT03542565, NCT03556943, and NCT03666104.
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Affiliation(s)
- Joseph D. Shirk
- David Geffen School of Medicine, Department of Urology, University of California, Los Angeles
| | - David D. Thiel
- Department of Urology, Mayo Clinic Florida, Jacksonville
| | - Eric M. Wallen
- Chapel Hill School of Medicine, Department of Urology, University of North Carolina, Chapel Hill
| | - Jennifer M. Linehan
- John Wayne Cancer Institute, Providence St John’s Health Center, Santa Monica, California
| | - Wesley M. White
- Department of Urology, The University of Tennessee Medical Center, Knoxville
| | - Ketan K. Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
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