1
|
McDonald M, Shirk JD. The Effect of Digital Three-Dimensional Reality Models on Patient Counseling for Renal Masses. JSLS 2023; 27:JSLS.2022.00084. [PMID: 36818764 PMCID: PMC9913065 DOI: 10.4293/jsls.2022.00084] [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: 02/18/2023] Open
Abstract
Background and Objectives Patient counseling for treatment of renal masses is complex. It can be difficult for patients to understand their disease and make treatment decisions when being shown standard black-and-white, two-dimensional computed tomography scans or magnetic resonance images. In a telehealth setting, the patient-physician interaction can be even more challenging. We sought to determine the impact of using digital three-dimensional (3D) models during consultation visits for patients with renal masses. Methods Forty-seven patients participating in a consultation visit for renal masses, both in-person and virtual, were shown a digital 3D model comprised of their kidney, renal mass, and key adjacent structures as part of their counseling. Patients then completed a five-question survey to assess the impact of the 3D model on their visit, with a sixth question administered to telehealth patients. Results Thirty-five patients undergoing telehealth visits and 12 patients seen in-person were shown the digital 3D model and surveyed. Survey results were universally positive, with all Likert scores > 4.7 (1 - 5 scale). There were no differences between the telehealth and in-person groups. Patients noted the digital 3D model made telehealth visits as effective as in-person visits (average Likert score 4.94). Conclusion Counseling for patients with renal masses can be augmented with patient-specific digital 3D models, leading to increased provider loyalty, lower levels of patient anxiety, and better understanding and shared decision making.
Collapse
Affiliation(s)
- Michael McDonald
- Advent Health Medical Group, University of Central Florida, Orlando, Florida
| | - Joseph D. Shirk
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, California
| |
Collapse
|
2
|
OUP accepted manuscript. Br J Surg 2022; 109:763-771. [DOI: 10.1093/bjs/znac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/24/2022] [Accepted: 03/30/2022] [Indexed: 11/14/2022]
|
3
|
Soisrithong C, Sirisreetreerux P, Sangkum P, Kijvikai K, Viseshsindh W, Kongchareonsombat W, Leenanupunth C, Kochakarn W, Jenjitranant P. Comparative Outcomes and Predictive Assessment of Trifecta in Open, Laparoscopic, and Robotic-Assisted Partial Nephrectomy Cases with Renal Cell Carcinoma: A 10-Year Experience at Ramathibodi Hospital. Res Rep Urol 2021; 13:425-435. [PMID: 34235099 PMCID: PMC8254405 DOI: 10.2147/rru.s316824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/04/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose To compare perioperative and trifecta outcomes of open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robotic-assisted laparoscopic partial nephrectomy (RPN) in patients with small renal mass at Ramathibodi Hospital, and to determine predictive factors in connection with trifecta. Methods We retrospectively reviewed 141 patients who underwent partial nephrectomy by eight experienced surgeons from January 2009 to December 2018. Baseline preoperative characteristics, postoperative and trifecta outcomes of the three treatment modalities were compared and analyzed. Univariate analysis was performed to determine predictive factors for trifecta achievement. Results A total of 70 patients had complete data available. Eighteen OPN, 11 LPN and 41 RPN cases were identified and reviewed. All preoperative and perioperative parameters were similar, except for operative time, which was significantly shorter in the OPN group compared with those undergoing LPN and RPN (135 vs 189 and 225 min, respectively; p-value = 0.001). Of these 70 patients, 59 were deemed eligible for and included in trifecta analysis, which revealed similar trifecta outcomes (64.29%, 45.45%, and 64.71% in the OPN, LPN, and RPN groups, respectively; p-value = 0.388). Univariate analysis showed that length of hospital stay was a negative associated factor for trifecta achievement (p-value = 0.007, 95% CI = 0.619 (0.44–0.88)). Conclusion Although OPN displayed the shortest operative time, the trifecta achievement rate was not significantly different among the three groups. The sole parameter, which was negatively associated with trifecta outcome achievement, was the length of hospital stay.
Collapse
Affiliation(s)
- Chaichant Soisrithong
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pokket Sirisreetreerux
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Premsant Sangkum
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Kittinut Kijvikai
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wit Viseshsindh
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wisoot Kongchareonsombat
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Charoen Leenanupunth
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wachira Kochakarn
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pocharapong Jenjitranant
- Division of Urology, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
4
|
Arroyo NA, Gessert T, Hitchcock M, Tao M, Smith CD, Greenberg C, Fernandes-Taylor S, Francis DO. What Promotes Surgeon Practice Change? A Scoping Review of Innovation Adoption in Surgical Practice. Ann Surg 2021; 273:474-482. [PMID: 33055590 PMCID: PMC10777662 DOI: 10.1097/sla.0000000000004355] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The goal of this scoping review was to summarize the literature on facilitators and barriers to surgical practice change. This information can inform research to implement best practices and evaluate new surgical innovations. BACKGROUND In an era of accelerated innovations, surgeons face the difficult decision to either acknowledge and implement or forgo new advances. Although changing surgical practice to align with evidence is an imperative of health systems, evidence-based guidelines have not translated into consistent change. The literature on practice change is limited and has largely focused on synthesizing information on methods and trials to evaluate innovative surgical interventions. No reviews to date have grounded their analysis within an implementation science framework. METHODS A systematic review of the literature on surgical practice change was performed. Abstracts and full-text articles were reviewed for relevance using inclusion and exclusion criteria and data were extracted from each article. Cited facilitators and barriers were then mapped across domains within the implementation science Theoretical Domains Framework and expanded to the Capability, Opportunity, Motivation, and Behavior model. RESULTS Components of the Capability, Opportunity, Motivation, and Behavior model were represented across the Theoretical Domains Framework domains and acted as both facilitators and barriers to practice change depending on the circumstances. Domains that most affected surgical practice change, in order, were: opportunity (environmental context and resources and social influences), capability (knowledge and skills), and motivation (beliefs about consequences and reinforcement). CONCLUSIONS Practice change is predicated on a conducive environment with adequate resources, but once that is established, the surgeon's individual characteristics, including skills, motivation, and reinforcement determine the likelihood of successful change. Deficiencies in the literature underscore the need for further study of resource interventions and the role of surgical team dynamics in the adoption of innovation. A better understanding of these areas is needed to optimize our ability to disseminate and implement best practices in surgery.
Collapse
Affiliation(s)
- Natalia A. Arroyo
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Thomas Gessert
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mary Hitchcock
- Ebling Library for the Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael Tao
- Department of Otolaryngology, The State University of New York, Syracuse, New York
| | - Cara Damico Smith
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice Greenberg
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Sara Fernandes-Taylor
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - David O. Francis
- Department of Surgery, Wisconsin Surgical Outcomes Research Program, University of Wisconsin-Madison, Madison, Wisconsin
- Division of Otolaryngology, Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
5
|
Luzzago S, Rosiello G, Pecoraro A, Deuker M, Stolzenbach F, Mistretta FA, Tian Z, Musi G, Montanari E, Shariat SF, Saad F, Briganti A, de Cobelli O, Karakiewicz PI. Contemporary rates and predictors of open conversion during minimally invasive partial nephrectomy for kidney cancer. Surg Oncol 2021; 36:131-137. [DOI: 10.1016/j.suronc.2020.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 12/31/2022]
|
6
|
McDonald M, D Shirk J. Application of Three-Dimensional Virtual Reality Models to Improve the Pre-Surgical Plan for Robotic Partial Nephrectomy. JSLS 2021; 25:JSLS.2021.00011. [PMID: 34354337 PMCID: PMC8325483 DOI: 10.4293/jsls.2021.00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and Objectives: Minimally invasive surgery for renal masses is complex and relies on two-dimensional (2D) computer tomography (CT) and magnetic resonance imaging (MRI) scans for surgical planning. We sought to determine if three-dimensional (3D) virtual reality (VR) models generated from imaging of patients undergoing robotic partial nephrectomy influenced presurgical planning approaches when compared to routine planning. Methods: The initial 15 patients underwent robotic assisted laparoscopic partial nephrectomy performed by one urologic surgeon. All patients pre-operatively underwent a CT and/or MRI scan. A pre-operative surgical plan was then recorded. 3D VR models were generated from these scans and reviewed. A second surgical plan was developed based on the 3D VR images. A comparison was made between the two studies prior to surgical intervention. All final surgical plans were implemented based on the 3D VR imaging studies. Results: Six surgical approaches were changed based on the 3D VR images. Two surgical approaches were changed from a transperitoneal to a retroperitoneal approach and two from a retroperitoneal to a transperitoneal approach. Two patients had distinctive renal vasculature related to the renal cancers which were not appreciated on routine scans but were well delineated by VR imaging studies. As a result, the surgical approach for two patients was altered to accommodate the new findings. Conclusion: Operative planning is paramount when performing robotic partial nephrectomy and developing a 3D surgical approach from 2D imaging can be difficult. Three-dimensional VR models affords the surgeon a 3D view prior to and during surgery and can ensure the selection of the appropriate surgical approach.
Collapse
Affiliation(s)
- Michael McDonald
- Department of Surgery, University of Central Florida, 400 Celebration Pl, Celebration, FL
| | - Joseph D Shirk
- UCLA Department of Urology, David Geffen School of Medicine at UCLA, 300 Stein Plaza, 3rd Floor, Los Angeles, CA
| |
Collapse
|
7
|
Flegar L, Groeben C, Koch R, Baunacke M, Borkowetz A, Kraywinkel K, Thomas C, Huber J. Trends in Renal Tumor Surgery in the United States and Germany Between 2006 and 2014: Organ Preservation Rate Is Improving. Ann Surg Oncol 2019; 27:1920-1928. [DOI: 10.1245/s10434-019-08108-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Indexed: 12/19/2022]
|
8
|
Kara Ö, Maurice MJ, Mouracade P, Malkoc E, Dagenais J, Çapraz M, Chavali JS, Kara MY, Kaouk JH. Preoperative proteinuria is associated with increased rates of acute kidney injury after partial nephrectomy. Int Braz J Urol 2019; 45:932-940. [PMID: 31268640 PMCID: PMC6844339 DOI: 10.1590/s1677-5538.ibju.2018.0776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/13/2019] [Indexed: 01/05/2023] Open
Abstract
Purpose We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN). Patients and Methods We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI. Results Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04). Conclusion Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN.
Collapse
Affiliation(s)
- Önder Kara
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.,Kocaeli University, Medical School, Kocaeli, Turkey
| | - Matthew J Maurice
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Pascal Mouracade
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ercan Malkoc
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Julien Dagenais
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jaya S Chavali
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
9
|
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.
Collapse
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
| | | |
Collapse
|
10
|
National Norwegian Practice Patterns for Surgical Treatment of Kidney Cancer Tumors ≤7cm: Adherence to Changes in Guidelines May Improve Overall Survival. Eur Urol Oncol 2019; 1:252-261. [PMID: 31102628 DOI: 10.1016/j.euo.2018.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/22/2018] [Accepted: 04/10/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Guidelines on surgical treatment for kidney cancer (KC) have changed over the last 10 yr. We present population-based data for patients with KC tumors ≤7cm from 2008 to 2013 to investigate whether surgical practice in Norway has changed according to guidelines. OBJECTIVE To assess the predictors of treatment and survival after KC surgery. DESIGN, SETTING, AND PARTICIPANTS We identified all surgically treated KC patients with tumors ≤7cm without metastasis diagnosed during 2008-2013 (2420 patients) from the Cancer Registry of Norway. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relationships with outcomes were analyzed using joinpoint regression, multivariate logistic regression, Kaplan-Meier survival estimates, Cox regression, relative survival (RS), and competing-risk analyses. RESULTS AND LIMITATIONS The mean follow-up was 5.2 yr. There was a 28% increase in the number of patients undergoing surgical treatment over the study period. Joinpoint regression revealed a significant annual increase in partial nephrectomy (PN) and a small reduction in radical nephrectomy (RN). PN increased from 43% to 66% for tumors ≤4cm and from 10% to 18% for tumors of 4.1-7cm. Minimally invasive (MI) RN increased from 53% to 72% and MI PN from 25% to 64%, of which 55% of procedures were performed with robotic assistance in 2013. The geographical distribution of treatment approaches differed significantly. Both PN and MI approaches were more frequent in high-volume hospitals. Cox regression analysis revealed that PN, age, and Fuhrman grade and stage were independent predictors of survival. There were no significant differences in cancer-specific survival (p=0.8). The 5-yr RS for T1a disease was higher after PN than after RN. CONCLUSIONS The rate of PN for tumors ≤7cm increased in the 6-yr study period. MI approaches increased for both RN and PN. This treatment shift coincides with the new guideline recommendations in 2010. The possible better survival for patients undergoing PN compared to RN indicates the importance of following evidence-based guidelines. PATIENT SUMMARY The use of partial nephrectomy and minimally invasive surgery for kidney cancer tumors increased in Norway from 2008 to 2013 according to population-based data, coinciding with guideline changes. The study illustrate that adherence to guidelines may improve patient outcomes.
Collapse
|
11
|
Retroperitoneal versus transperitoneal robotic-assisted laparoscopic partial nephrectomy: a matched-pair, bicenter analysis with cost comparison using time-driven activity-based costing. Curr Opin Urol 2019; 28:108-114. [PMID: 29278580 DOI: 10.1097/mou.0000000000000483] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW To perform a bicenter, retrospective study of perioperative outcomes of retroperitoneal versus transperitoneal robotic-assisted laparoscopic partial nephrectomy (RALPN) and assess costs using time-driven activity-based costing (TDABC). We identified 355 consecutive patients who underwent RALPN at University of California Los Angeles and the University of Michigan during 2009-2016. We matched according to RENAL nephrometry score, date, and institution for 78 retroperitoneal versus 78 transperitoneal RALPN. Unadjusted analyses were performed using McNemar's Chi-squared or paired t test, and adjusted analyses were performed using multivariable repeated measures regression analysis. From multivariable models, predicted probabilities were derived according to approach. Cost analysis was performed using TDABC. RECENT FINDINGS Patients treated with retroperitoneal versus transperitoneal RALPN were similar in age (P = 0.490), sex (P = 0.715), BMI (P = 0.273), and comorbidity (P = 0.393). Most tumors were posterior or lateral in both the retroperitoneal (92.3%) and transperitoneal (85.9%) groups. Retroperitoneal RALPN was associated with shorter operative times (167.0 versus 191.1 min, P = 0.001) and length of stay (LOS) (1.8 versus 2.7 days, P < 0.001). There were no differences in renal function preservation or cancer control. In adjusted analyses, retroperitoneal RALPN was 17.6-min shorter (P < 0.001) and had a 76% lower probability of LOS at least 2 days (P < 0.001). Utilizing TDABC, transperitoneal RALPN added $2337 in cost when factoring in disposable equipment, operative time, LOS, and personnel. SUMMARY In two high-volume, tertiary centers, retroperitoneal RALPN is associated with reduced operative times and shortened LOS in posterior and lateral tumors, whereas sharing similar clinicopathologic outcomes, which may translate into lower healthcare costs. Further investigation into anterior tumors is needed.
Collapse
|
12
|
Xia L, Talwar R, Taylor BL, Shin MH, Berger IB, Sperling CD, Chelluri RR, Zambrano IA, Raman JD, Guzzo TJ. National trends and disparities of minimally invasive surgery for localized renal cancer, 2010 to 2015. Urol Oncol 2019; 37:182.e17-182.e27. [DOI: 10.1016/j.urolonc.2018.10.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/11/2018] [Accepted: 10/31/2018] [Indexed: 01/06/2023]
|
13
|
Johnson BA, Crivelli J, Sorokin I, Gahan J, Cadeddu JA. Surgical Outcomes of Three vs Four Arm Robotic Partial Nephrectomy: Is the Fourth Arm Necessary? Urology 2019; 123:140-145. [DOI: 10.1016/j.urology.2018.06.068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/05/2018] [Accepted: 06/14/2018] [Indexed: 01/06/2023]
|
14
|
Shirk JD, Kwan L, Saigal C. The Use of 3-Dimensional, Virtual Reality Models for Surgical Planning of Robotic Partial Nephrectomy. Urology 2018; 125:92-97. [PMID: 30597166 DOI: 10.1016/j.urology.2018.12.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/03/2018] [Accepted: 12/17/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine whether 3-dimensional virtual reality models of patient-specific anatomy improve outcomes in patients undergoing robotic partial nephrectomy. MATERIALS AND METHODS Computed tomography and magnetic resonance imaging scans for 30 patients undergoing robotic partial nephrectomy were converted to 3-dimensional virtual reality models prior to the patient's operation. These models were then viewed on the surgeon's mobile phone pre- and intraoperatively using a Google Cardboard headset to assist in surgical planning. This group was compared to 30 patients who previously underwent robotic partial nephrectomy. We compared operative time, clamp time, estimated blood loss, hospital stay, complications, and margin status between these groups. We used forward selecting multivariate regression models to create the final model controlling for significant demographic and clinical variables. RESULTS When controlling for case complexity and surgeon, patients with 3-dimensional, virtual reality-assisted surgical planning had significantly lower operative time (141 minutes vs 201 minutes, P < .0001), clamp time (13.2 minutes vs 17.4 minutes, P = .0274), and estimated blood loss (134 cc vs 259 cc, P = .0233). Patients without 3-dimensional, virtual reality-assisted surgical planning were more likely to have a hospital stay of greater than 2 days (odds ratio 5.1, 95% confidence interval 1.0, 26.4). There were no complications or positive margins noted in the VR group. CONCLUSION Use of a 3-dimensional, virtual reality model when performing robotic partial nephrectomy improves key surgical outcome parameters.
Collapse
Affiliation(s)
- Joseph D Shirk
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christopher Saigal
- Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| |
Collapse
|
15
|
Melanson TA, Hockenberry JM, Plantinga L, Basu M, Pastan S, Mohan S, Howard DH, Patzer RE. New Kidney Allocation System Associated With Increased Rates Of Transplants Among Black And Hispanic Patients. Health Aff (Millwood) 2018; 36:1078-1085. [PMID: 28583967 DOI: 10.1377/hlthaff.2016.1625] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Before the 2014 implementation of a new kidney allocation system by the United Network for Organ Sharing, white patients were more likely than black or Hispanic patients to receive a kidney transplant. To determine the effect of the new allocation system on these disparities, we examined data for 179,071 transplant waiting list events in the period June 2013-September 2016, and we calculated monthly transplantation rates (34,133 patients actually received transplants). Implementation of the new system was associated with a narrowing of the disparities in the average monthly transplantation rates by 0.29 percentage point for blacks compared to whites and by 0.24 percentage point for Hispanics compared to whites, which resulted in both disparities becoming nonsignificant after implementation of the new system.
Collapse
Affiliation(s)
- Taylor A Melanson
- Taylor A. Melanson is a doctoral student in the Laney Graduate School, Emory University, in Atlanta, Georgia
| | - Jason M Hockenberry
- Jason M. Hockenberry is an associate professor in the Department of Health Policy and Management, Rollins School of Public Health, at Emory University
| | - Laura Plantinga
- Laura Plantinga is an assistant professor in the Department of Medicine, Emory University School of Medicine
| | - Mohua Basu
- Mohua Basu is a data analyst at the Emory University School of Medicine
| | - Stephan Pastan
- Stephan Pastan is an associate professor in the Department of Medicine, Emory University School of Medicine
| | - Sumit Mohan
- Sumit Mohan is an assistant professor in the Division of Nephrology, Department of Medicine, and in the Department of Epidemiology at Columbia University Medical Center, in New York City
| | - David H Howard
- David H. Howard is an assistant professor in the Department of Health Policy and Management, Rollins School of Public Health, at Emory University
| | - Rachel E Patzer
- Rachel E. Patzer is an assistant professor in the Department of Surgery and Department of Medicine at the Emory University School of Medicine, and in the Department of Epidemiology at the Rollins School of Public Health
| |
Collapse
|
16
|
Aggarwal A, Lewis D, Mason M, Purushotham A, Sullivan R, van der Meulen J. Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery: a national, population-based study. Lancet Oncol 2017; 18:1445-1453. [PMID: 28986012 PMCID: PMC5666166 DOI: 10.1016/s1470-2045(17)30572-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/07/2017] [Accepted: 07/17/2017] [Indexed: 01/16/2023]
Abstract
Background There is a scarcity of evidence about the role of patient choice and hospital competition policies on surgical cancer services. Previous evidence has shown that patients are prepared to bypass their nearest cancer centre to receive surgery at more distant centres that better meet their needs. In this national, population-based study we investigated the effect of patient mobility and hospital competition on service configuration and technology adoption in the National Health Service (NHS) in England, using prostate cancer surgery as a model. Methods We mapped all patients in England who underwent radical prostatectomy between Jan 1, 2010, and Dec 31, 2014, according to place of residence and treatment location. For each radical prostatectomy centre we analysed the effect of hospital competition (measured by use of a spatial competition index [SCI], with a score of 0 indicating weakest competition and 1 indicating strongest competition) and the effect of being an established robotic radical prostatectomy centre at the start of 2010 on net gains or losses of patients (difference between number of patients treated in a centre and number expected based on their residence), and the likelihood of closing their radical prostatectomy service. Findings Between Jan 1, 2010, and Dec 31, 2014, 19 256 patients underwent radical prostatectomy at an NHS provider in England. Of the 65 radical prostatectomy centres open at the start of the study period, 23 (35%) had a statistically significant net gain of patients during 2010–14. Ten (40%) of these 23 were established robotic centres. 37 (57%) of the 65 centres had a significant net loss of patients, of which two (5%) were established robotic centres and ten (27%) closed their radical prostatectomy service during the study period. Radical prostatectomy centres that closed were more likely to be located in areas with stronger competition (highest SCI quartile [0·87–0·92]; p=0·0081) than in areas with weaker competition. No robotic surgery centre closed irrespective of the size of net losses of patients. The number of centres performing robotic surgery increased from 12 (18%) of the 65 centres at the beginning of 2010 to 39 (71%) of 55 centres open at the end of 2014. Interpretation Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic surgery without evidence of superior outcomes and contributed to the closure of cancer surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services' ability to deliver equitable and affordable cancer care. Funding National Institute for Health Research.
Collapse
Affiliation(s)
- Ajay Aggarwal
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.
| | - Daniel Lewis
- Department of Social and Environment Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Jan van der Meulen
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK; Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| |
Collapse
|
17
|
Wallis CJ, Garbens A, Chopra S, Gill IS, Satkunasivam R. Robotic Partial Nephrectomy: Expanding Utilization, Advancing Innovation. J Endourol 2017; 31:348-354. [DOI: 10.1089/end.2016.0639] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Christopher J.D. Wallis
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Alaina Garbens
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| | - Sameer Chopra
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Inderbir S. Gill
- USC Institute of Urology and Norris Comprehensive Cancer Center, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Raj Satkunasivam
- Division of Urology, Department of Surgery, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Canada
| |
Collapse
|
18
|
Tan HJ, Daskivich TJ, Shirk JD, Filson CP, Litwin MS, Hu JC. Health status and use of partial nephrectomy in older adults with early-stage kidney cancer. Urol Oncol 2017; 35:153.e7-153.e14. [DOI: 10.1016/j.urolonc.2016.11.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/18/2016] [Accepted: 11/09/2016] [Indexed: 11/28/2022]
|
19
|
Bachman AG, Parker AA, Shaw MD, Cross BW, Stratton KL, Cookson MS, Patel SG. Minimally Invasive Versus Open Approach for Cystectomy: Trends in the Utilization and Demographic or Clinical Predictors Using the National Cancer Database. Urology 2017; 103:99-105. [PMID: 28214574 DOI: 10.1016/j.urology.2017.02.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/11/2017] [Accepted: 02/09/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine temporal national trends of operative approach for cystectomy and identify demographic or clinical predictive factors that influence choice of approach. METHODS We performed a retrospective cohort study of patients who underwent cystectomy for bladder cancer between 2010 and 2013 using the National Cancer Database. Approach was stratified by open vs minimally invasive (robotic or laparoscopic). Univariate Pearson chi-square and multivariate logistic regression analysis were used to assess the relationships between demographic and hospital factors and the receipt of minimally invasive or open surgical approach. RESULTS A total of 9439 patients met our inclusion criteria, of which 34.1% received a minimally invasive approach (MIA). Frequency of MIA increased from 26.3% in 2010 to 39.4% in 2013 (P < .0001). Univariate analysis identified statistically significant associations between year of diagnosis, sex, age, race, clinical T stage, insurance status, income, education, distance from hospital, facility type, geographic location, and facility cystectomy volume, and the choice of approach (all P < .01). On multivariate analysis, independent predictors of MIA included increasing year of diagnosis, male gender, lower clinical T stage, private insurance vs Medicaid, nonacademic vs academic program, northeastern geographic region, receipt of neoadjuvant chemotherapy, and lower cystectomy volume. CONCLUSION Utilization of MIA for cystectomy has increased nationally over the last several years likely due to increased surgeon familiarity with robotic laparoscopic pelvic surgery. Factors associated with MIA included male sex, locally confined disease, receipt of neoadjuvant chemotherapy, lower cystectomy volume centers, and nonacademic centers.
Collapse
Affiliation(s)
- Andrew G Bachman
- University of Oklahoma Health Science Center, Oklahoma City, OK.
| | | | - Marshall D Shaw
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | - Brian W Cross
- University of Oklahoma Health Science Center, Oklahoma City, OK
| | | | | | - Sanjay G Patel
- University of Oklahoma Health Science Center, Oklahoma City, OK
| |
Collapse
|
20
|
Kara Ö, Maurice MJ, Mouracade P, Malkoç E, Dagenais J, Nelson RJ, Chavali JSS, Stein RJ, Fergany A, Kaouk JH. When Partial Nephrectomy is Unsuccessful: Understanding the Reasons for Conversion from Robotic Partial to Radical Nephrectomy at a Tertiary Referral Center. J Urol 2017; 198:30-35. [PMID: 28087299 DOI: 10.1016/j.juro.2017.01.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2016] [Indexed: 01/20/2023]
Abstract
PURPOSE We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event. MATERIALS AND METHODS Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion. RESULTS The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01). CONCLUSIONS At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion.
Collapse
Affiliation(s)
- Önder Kara
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio; Urology Department, Amasya University Medical School, Amasya, Turkey
| | - Matthew J Maurice
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Pascal Mouracade
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ercan Malkoç
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Julien Dagenais
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ryan J Nelson
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jaya Sai S Chavali
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert J Stein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amr Fergany
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
21
|
Jacobs BL, Lai JC, Seelam R, Hanley JM, Wolf JS, Hollenbeck BK, Hollingsworth JM, Dick AW, Setodji CM, Saigal CS. Variation in the Use of Open Pyeloplasty, Minimally Invasive Pyeloplasty, and Endopyelotomy for the Treatment of Ureteropelvic Junction Obstruction in Adults. J Endourol 2017; 31:210-215. [PMID: 27936909 DOI: 10.1089/end.2016.0688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Ureteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments. PATIENTS AND METHODS Using the MarketScan® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment. RESULTS Rates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13). CONCLUSIONS Over this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.
Collapse
Affiliation(s)
- Bruce L Jacobs
- 1 Department of Urology, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Julie C Lai
- 2 RAND Corporation , Santa Monica, California
| | | | | | - J Stuart Wolf
- 3 Dell Medical School of the University of Texas , Austin, Texas
| | - Brent K Hollenbeck
- 4 Department of Urology, Division of Health Services Research, University of Michigan , Ann Arbor, Michigan.,5 Department of Urology, Division of Oncology, University of Michigan , Ann Arbor, Michigan
| | - John M Hollingsworth
- 4 Department of Urology, Division of Health Services Research, University of Michigan , Ann Arbor, Michigan.,6 Department of Urology, Division of Endourology, University of Michigan , Ann Arbor, Michigan
| | | | | | - Christopher S Saigal
- 2 RAND Corporation , Santa Monica, California.,7 Department of Urology, David Geffen School of Medicine, University of California , Los Angeles, California
| |
Collapse
|
22
|
Robotic-assisted partial nephrectomy provides better operative outcomes as compared to the laparoscopic and open approaches: results from a prospective cohort study. J Robot Surg 2016; 11:333-339. [PMID: 28000016 DOI: 10.1007/s11701-016-0660-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/04/2016] [Indexed: 01/30/2023]
Abstract
The objective of this is to compare the surgical outcomes of partial nephrectomy (PN), performed via three different approaches: robot-assisted (RAPN), laparoscopic (LPN), and open (OPN), in a single non-academic regional center. The data of patients undergoing PN at our Department from 2005 to 2016 were prospectively collected. A logistic regression model adjusted for preoperative variables (age, tumor size, creatinine and hemoglobin, ASA and Padua scores) was performed to evaluate whether transfusion, conversion, and postoperative complication rate were influenced by the surgical approach. Overall 270 patients underwent PN: analysis included 253 cases (RAPN = 110, LPN = 70, OPN = 73). Preoperative variables did not differ significantly among the three groups. Shorter operative (130 vs 180 and 200') and ischaemia (12 vs 23 and 22') times and longer hospital stay (8 vs 7 and 6 days) were found in the OPN group as compared to LPN and RAPN, respectively. The RAPN group included a higher rate of pT1b (31.8 vs 14.2 and 15%) and malignant histotype (90 vs 82.9 and 68.5%) as compared to LPN and OPN, respectively. Clavien Grade III-IV complications were lower in the RAPN (7.2%) as compared to OPN (12.3%) and LPN (17.1%) groups. Multivariate analysis showed a lower risk for conversion, transfusion and overall complications in the RAPN group versus LPN and OPN. The surgical approach affects the perioperative outcomes in a regional setting. The advantages of RAPN over OPN (lower risk of conversion, transfusion, and overall complications) are extended over LPN as well, although OPN offered faster operative and ischemia times at the expense of greater blood loss and hospital stay.
Collapse
|
23
|
Kim SP, Campbell SC, Gill I, Lane BR, Van Poppel H, Smaldone MC, Volpe A, Kutikov A. Collaborative Review of Risk Benefit Trade-offs Between Partial and Radical Nephrectomy in the Management of Anatomically Complex Renal Masses. Eur Urol 2016; 72:64-75. [PMID: 27988238 DOI: 10.1016/j.eururo.2016.11.038] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 11/29/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND While partial nephrectomy (PN) is the recommended treatment for many small renal masses, anatomically complex tumors necessitate a clear understanding of the potential risks and benefits of PN and radical nephrectomy (RN). OBJECTIVE To critically review the comparative effectiveness evidence of PN versus RN; to describe key trade-offs involved in this treatment decision; and to highlight gaps in the current literature. EVIDENCE ACQUISITION A collaborative critical review of the medical literature was conducted. EVIDENCE SYNTHESIS Patients who undergo PN for an anatomically complex or large mass may be exposed to perioperative and potential oncologic risks that could be avoided if RN were performed, while patients who undergo RN may forgo long-term benefits of renal preservation. Decision-making regarding the optimal treatment with PN or RN among patients with anatomically complex or large renal mass is highly nuanced and must balance the risks and benefits of each approach. Currently, high-quality evidence on comparative effectiveness is sparse. Retrospective comparisons are plagued by selection biases, while the one existing prospective randomized trial, albeit imperfect, suggests that nephron-sparing surgery may not benefit all patients. CONCLUSIONS For anatomically complex tumors, PN preserves renal parenchyma but may expose patients to higher perioperative risks than RN. The risks and benefits of each surgical approach must be better objectified for identification of patients most suitable for complex PN. A prospective randomized trial is warranted and would help in directing patient counseling. PATIENT SUMMARY Treatment decisions for complex renal masses require shared decision-making regarding the risk trade-offs between partial and radical nephrectomy.
Collapse
Affiliation(s)
- Simon P Kim
- University Hospital Case Medical Center, Case Western Reserve University School of Medicine, Seidman Cancer Center, Urology Institute, Center of Healthcare Outcomes and Quality, Cleveland, OH, USA; Cancer Outcomes and Public Policy Effectiveness Research Center, Yale University, New Haven, CT, USA
| | - Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Inderbir Gill
- USC Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Brian R Lane
- Spectrum Health Medical Group, Urology, Grand Rapids, MI, USA
| | - Hein Van Poppel
- Department of Urology, University Hospitals of Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marc C Smaldone
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Alessandro Volpe
- University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Alexander Kutikov
- Division of Urologic Oncology, Department of Surgical Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA.
| |
Collapse
|
24
|
Editorial Comment. J Urol 2016; 196:1377. [DOI: 10.1016/j.juro.2016.06.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
25
|
Weinberg AC, Wright JD, Whalen MJ, Paulucci DJ, Woldu SL, Berger SA, Deibert CM, Korets R, Hershman DL, Neugut AI, Badani KK. Use of Partial Nephrectomy after Acquisition of a Surgical Robot: A Population Based Study. UROLOGY PRACTICE 2016; 3:430-436. [PMID: 37592577 DOI: 10.1016/j.urpr.2015.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The advent of robotics may promote the dissemination of partial nephrectomy, and allow patients to experience survival and functional benefits compared to radical nephrectomy. Therefore, we assessed the impact of hospital acquisition of a robotic surgery platform on the rate of partial nephrectomy recorded in a nationwide database. METHODS We identified 53,364 patients with a diagnosis of localized renal cell carcinoma who underwent extirpative surgery from 2006 to 2012 using the Perspective database. Procedures were categorized based on extent of surgery (radical nephrectomy vs partial nephrectomy), approach (open, laparoscopic, robotic) and hospital ownership of a surgical robot. Changes in the proportion of partial nephrectomies performed over time and the effect of acquiring a surgical robot on the proportion of partial nephrectomies performed were assessed with multivariable logistic regression. RESULTS Overall 40,147 (75.2%) radical nephrectomies and 13,217 (24.8%) partial nephrectomies were performed between 2006 and 2012. The proportion of hospitals using a surgical robot for renal cancer surgery increased from 1.8% in the first quarter of 2006 to 47.7% by the end of 2012. Partial nephrectomy use ranged from 19.1% to 31.2%. More robotic hospitals performed partial nephrectomy than nonrobotic hospitals (29.6% vs 18.0%, p <0.001). After acquisition of a surgical robot the partial nephrectomy rate increased from 16.4% to 34.3% (p <0.001). Hospitals with a robot were more likely to use partial nephrectomy than radical nephrectomy (OR 1.464, CI 1.39-1.54, p <0.001). CONCLUSIONS While laparoscopic partial nephrectomy remains a challenging operation, this study demonstrates that hospital ownership of a surgical robot is associated with increased use of partial nephrectomy in the treatment of localized renal masses.
Collapse
Affiliation(s)
- Aaron C Weinberg
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jason D Wright
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, New York
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Michael J Whalen
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - David J Paulucci
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Solomon L Woldu
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Stephanie A Berger
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Christopher M Deibert
- Division of Urologic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ruslan Korets
- Surgical Service, Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
| | - Dawn L Hershman
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Alfred I Neugut
- Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| |
Collapse
|
26
|
Robotic and open partial nephrectomy for localized renal tumors larger than 7 cm: a single-center experience. World J Urol 2016; 35:781-787. [DOI: 10.1007/s00345-016-1937-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 09/08/2016] [Indexed: 12/30/2022] Open
|
27
|
Leppert JT, Mittakanti HR, Thomas IC, Lamberts RW, Sonn GA, Chung BI, Skinner EC, Wagner TH, Chertow GM, Brooks JD. Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind? Urology 2016; 100:65-71. [PMID: 27634733 DOI: 10.1016/j.urology.2016.08.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 08/17/2016] [Accepted: 08/30/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether patient factors, such as age and preoperative kidney function, were associated with receipt of partial nephrectomy in a national integrated healthcare system. MATERIALS AND METHODS We identified patients treated with a radical or partial nephrectomy from 2002 to 2014 in the Veterans Health Administration. We examined associations among patient age, sex, race or ethnicity, multimorbidity, baseline kidney function, tumor characteristics, and receipt of partial nephrectomy. We estimated the odds of receiving a partial nephrectomy and assessed interactions between covariates and the year of surgery to explore whether patient factors associated with partial nephrectomy changed over time. RESULTS In our cohort of 14,186 patients, 4508 (31.2%) received a partial nephrectomy. Use of partial nephrectomy increased from 17% in 2002 to 32% in 2008 and to 38% in 2014. Patient race or ethnicity, age, tumor stage, and year of surgery were independently associated with receipt of partial nephrectomy. Black veterans had significantly increased odds of receipt of partial nephrectomy, whereas older patients had significantly reduced odds. Partial nephrectomy utilization increased for all groups over time, but older patients and patients with worse baseline kidney function showed the least increase in odds of partial nephrectomy. CONCLUSION Although the utilization of partial nephrectomy increased for all groups, the greatest increase occurred in the youngest patients and those with the highest baseline kidney function. These trends warrant further investigation to ensure that patients at the highest risk of impaired kidney function are considered for partial nephrectomy whenever possible.
Collapse
Affiliation(s)
- John T Leppert
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford Kidney Cancer Research Program, Stanford, CA.
| | | | - I-Chun Thomas
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Remy W Lamberts
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Geoffrey A Sonn
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Stanford Kidney Cancer Research Program, Stanford, CA
| | - Benjamin I Chung
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Stanford Kidney Cancer Research Program, Stanford, CA
| | - Eila C Skinner
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Stanford Kidney Cancer Research Program, Stanford, CA
| | - Todd H Wagner
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Stanford Kidney Cancer Research Program, Stanford, CA
| | - Glenn M Chertow
- Stanford Kidney Cancer Research Program, Stanford, CA; Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - James D Brooks
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Stanford Kidney Cancer Research Program, Stanford, CA
| |
Collapse
|
28
|
Ramirez D, Maurice MJ, Caputo PA, Nelson RJ, Kara Ö, Malkoç E, Kaouk JH. Predicting complications in partial nephrectomy for T1a tumours: does approach matter? BJU Int 2016; 118:940-945. [DOI: 10.1111/bju.13583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Daniel Ramirez
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| | - Matthew J. Maurice
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| | - Peter A. Caputo
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| | - Ryan J. Nelson
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| | - Önder Kara
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| | - Ercan Malkoç
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| | - Jihad H. Kaouk
- Department of Urology; Glickman Urological and Kidney Institute; Cleveland Clinic; Cleveland OH USA
| |
Collapse
|
29
|
Single-Institution Experience with Robotic Partial Nephrectomy for Renal Masses Greater Than 4 cm. J Endourol 2016; 30:384-9. [DOI: 10.1089/end.2015.0254] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
|
30
|
Abstract
The diagnosis and management of renal cell carcinoma have changed remarkably rapidly. Although the incidence of renal cell carcinoma has been increasing, survival has improved substantially. As incidental diagnosis of small indolent cancers has become more frequent, active surveillance, robot-assisted nephron-sparing surgical techniques, and minimally invasive procedures, such as thermal ablation, have gained popularity. Despite progression in cancer control and survival, locally advanced disease and distant metastases are still diagnosed in a notable proportion of patients. An integrated management strategy that includes surgical debulking and systemic treatment with well established targeted biological drugs has improved the care of patients. Nevertheless, uncertainties, controversies, and research questions remain. Further advances are expected from translational and clinical studies.
Collapse
Affiliation(s)
- Umberto Capitanio
- Department of Urology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Francesco Montorsi
- Division of Experimental Oncology, URI, Urological Research Institute, Renal Cancer Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
31
|
Tan HJ. Survival benefit of partial nephrectomy: Reconciling experimental and observational data. Urol Oncol 2015; 33:505.e21-4. [DOI: 10.1016/j.urolonc.2015.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/03/2015] [Accepted: 08/03/2015] [Indexed: 01/30/2023]
|
32
|
The Effect of the Diffusion of the Surgical Robot on the Hospital-level Utilization of Partial Nephrectomy. Med Care 2015. [DOI: 10.1097/mlr.0000000000000333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
33
|
Olvera-Posada D, Pautler SE. Editorial comment. Urology 2015; 85:849. [PMID: 25681248 DOI: 10.1016/j.urology.2014.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel Olvera-Posada
- Division of Urology, Department of Surgery, The University of Western Ontario, London, Canada
| | - Stephen E Pautler
- Division of Urology, Department of Surgery, The University of Western Ontario, London, Canada; Division of Surgical Oncology, Department of Oncology, The University of Western Ontario, London, Canada
| |
Collapse
|
34
|
Chandra A, Snider JT, Wu Y, Jena A, Goldman DP. Robot-Assisted Surgery For Kidney Cancer Increased Access To A Procedure That Can Reduce Mortality And Renal Failure. Health Aff (Millwood) 2015; 34:220-8. [DOI: 10.1377/hlthaff.2014.0986] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Amitabh Chandra
- Amitabh Chandra ( ) is a professor of public policy at the John F. Kennedy School of Government, Harvard University, in Cambridge, Massachusetts
| | - Julia Thornton Snider
- Julia Thornton Snider is a senior research economist at Precision Health Economics in Los Angeles, California
| | - Yanyu Wu
- Yanyu Wu is an associate research economist, health analytics, at Precision Health Economics in Boston, Massachusetts
| | - Anupam Jena
- Anupam Jena is an assistant professor of health care policy and medicine at Harvard Medical School and a physician at Massachusetts General Hospital, both in Boston; and a faculty research fellow at the National Bureau of Economic Research in Cambridge, Massachusetts
| | - Dana P. Goldman
- Dana P. Goldman is the Leonard D. Schaeffer Chair and director of the Schaeffer Center for Health Policy and Economics at the University of Southern California, in Los Angeles
| |
Collapse
|