Publications by authors named "Daniel D Eun"

66 Publications

A review of technical progression in the robot-assisted radical prostatectomy.

Transl Androl Urol 2021 May;10(5):2171-2177

Department of Urology, Temple University Hospital, Philadelphia, PA, USA.

Since the advent of the robotic surgery, its implementation in urology has been both wide and rapid. Particularly in extirpative surgery for prostate cancer, techniques in robotic-assisted radical prostatectomy have-and continue to-evolve to maximize functional and oncologic outcomes. In this review, we briefly present a historical perspective of the evolution of various robotic techniques, allowing us to contextualize contemporary robotic approaches to radical prostatectomy.
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http://dx.doi.org/10.21037/tau.2020.03.17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185659PMC
May 2021

Transvesical robotic excision of a Müllerian duct remnant.

Urol Case Rep 2021 Sep 19;38:101686. Epub 2021 Apr 19.

Department of Urology, Lewis Katz School of Medicine at Temple University, 3401 N. Broad St., Philadelphia, PA, 19140, USA.

Müllerian duct remnants are rare and found in patients with disorders of sexual development. Presenting symptoms vary and many parents opt for surgical management. Literature on robotic repair is limited to small series, single case reports and all were approached extravesically. We present our case of a unique transvesical approach. Perioperative parameters were favorable with no complications, suggesting robotic repair is a safe and effective treatment strategy for these unique patients.
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http://dx.doi.org/10.1016/j.eucr.2021.101686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093405PMC
September 2021

Risk Factors for Intravesical Recurrence after Minimally Invasive Nephroureterectomy for Upper Tract Urothelial Cancer (ROBUUST Collaboration).

J Urol 2021 Apr 21:101097JU0000000000001786. Epub 2021 Apr 21.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.

Purpose: Intravesical recurrence (IVR) after radical nephroureterectomy (RNU) for upper tract urothelial carcinoma (UTUC) has an incidence of approximately 20%-50%. Studies to date have been composed of mixed treatment cohorts-open, laparoscopic and robotic. The objective of this study is to assess clinicopathological risk factors for intravesical recurrence after RNU for UTUC in a completely minimally invasive cohort.

Materials And Methods: We performed a multicenter, retrospective analysis of 485 patients with UTUC without prior or concurrent bladder cancer who underwent robotic or laparoscopic RNU. Patients were selected from an international cohort of 17 institutions across the United States, Europe and Asia. Univariate and multiple Cox regression models were used to identify risk factors for bladder recurrence.

Results: A total of 485 (389 robotic, 89 laparoscopic) patients were included in analysis. Overall, 110 (22.7%) of patients developed IVR. The average time to recurrence was 15.2 months (SD 15.5 months). Hypertension was a significant risk factor on multiple regression (HR 1.99, CI 1.06; 3.71, p=0.030). Diagnostic ureteroscopic biopsy incurred a 50% higher chance of developing IVR (HR 1.49, CI 1.00; 2.20, p=0.048). Treatment specific risk factors included positive surgical margins (HR 3.36, CI 1.36; 8.33, p=0.009) and transurethral resection for bladder cuff management (HR 2.73, CI 1.10; 6.76, p=0.031).

Conclusions: IVR after minimally invasive RNU for UTUC is a relatively common event. Risk factors include a ureteroscopic biopsy, transurethral resection of the bladder cuff, and positive surgical margins. When possible, avoidance of transurethral resection of the bladder cuff and alternative strategies for obtaining biopsy tissue sample should be considered.
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http://dx.doi.org/10.1097/JU.0000000000001786DOI Listing
April 2021

Single stage Xi® robotic radical nephroureterectomy for upper tract urothelial carcinoma: surgical technique and outcomes.

Minerva Urol Nephrol 2021 Mar 29. Epub 2021 Mar 29.

Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.

Background: Radical nephroureterectomy (RNU) represents the standard of care for high grade upper tract urothelial carcinoma (UTUC). Open and laparoscopic approaches are well-established treatments, but evidence regarding robotic RANU is growing. The introduction of the Xi® system facilitates the implementation of this multi-quadrant procedure. The aim of this video-article is to describe the surgical steps and the outcomes of Xi® robotic RNU.

Methods: Single stage Xi® robotic RNU without patients repositioning and robot re-docking were done between 2015 and 2019 and collected in a large worldwide multi-institutional study, the ROBotic surgery for Upper tract Urothelial cancer STudy (ROBUUST). Institutional review board approval and data share agreement were obtained at each center. Surgical technique is described in detail in the accompanying video. Descriptive statistics of baseline characteristics and surgical, pathological, and oncological outcomes were analyzed. RESULTSː Overall, 148 patients were included in the analysis; 14% had an ECOG >1 and 68.2% ASA ≥3. Median tumor dimension was 3.0 (IQR:2.0-4.2) cm and 34.5% showed hydronephrosis at diagnosis. Forty-eight% were cT1 tumors. Bladder cuff excision and lymph node dissection were performed in 96% and 38.1% of the procedures, respectively. Median operative time and estimated blood loss were 215.5 (IQR:160.5-290.0) minutes and 100.0 (IQR: 50.0-150.0) mL, respectively. Approximately 56% of patients took opioids during hospital stay for a total morphine equivalent dose of 22.9 (IQR:16.0-60.0) milligrams equivalent. Postoperative complications were 26 (17.7%), with 4 major (15.4%). Seven patients underwent adjuvant chemotherapy, with median number of cycles of 4.0 (IQR:3.0-6.0).

Conclusions: Single stage Xi® RNU is a reproducible and safe minimally invasive procedure for treatment of UTUC. Additional potential advantages of the robot might be a wider implementation of LND with a minimally invasive approach.
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http://dx.doi.org/10.23736/S2724-6051.21.04247-8DOI Listing
March 2021

Ureteral Rest is Associated With Improved Outcomes in Patients Undergoing Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

Urology 2021 Jun 25;152:160-166. Epub 2021 Feb 25.

Lewis Katz School of Medicine at Temple University, Philadelphia, PA.

Objectives: To evaluate the effect of ureteral rest on outcomes of robotic ureteral reconstruction.

Methods: We retrospectively reviewed all patients who underwent robotic ureteral reconstruction of proximal and/or middle ureteral strictures in our multi-institutional database between 2/2012-03/2019 with ≥12 months follow-up. All patients were recommended to undergo ureteral rest, which we defined as the absence of hardware (ie. double-J stent or percutaneous nephroureteral tube) across a ureteral stricture ≥4 weeks prior to reconstruction. However, patients who refused percutaneous nephrostomy tube placement did not undergo ureteral rest. Perioperative outcomes were compared after grouping patients according to whether or not they underwent ureteral rest. Continuous and categorical variables were compared using Mann-Whitney U and 2-tailed chi-squared tests, respectively; P <.05 was considered significant.

Results: Of 234 total patients, 194 (82.9%) underwent ureteral rest and 40 (17.1%) did not undergo ureteral rest prior to ureteral reconstruction. Patients undergoing ureteral rest were associated with a higher success rate compared to those not undergoing ureteral rest (90.7% versus 77.5%, respectively; P = .027). Also, patients undergoing ureteral rest were associated with lower estimated blood loss (50 versus 75 milliliters, respectively; p<0.001) and less likely to undergo buccal mucosa graft ureteroplasty (20.1% versus 37.5%, respectively; p=0.023).

Conclusions: Implementing ureteral rest prior to ureteral reconstruction may allow for stricture maturation and is associated higher surgical success rates, lower estimated blood loss, and decreased utilization of buccal mucosa graft ureteroplasty.
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http://dx.doi.org/10.1016/j.urology.2021.01.058DOI Listing
June 2021

A Preoperative Nomogram to Predict Renal Function Insufficiency for Cisplatin-based Adjuvant Chemotherapy Following Minimally Invasive Radical Nephroureterectomy (ROBUUST Collaborative Group).

Eur Urol Focus 2021 Feb 3. Epub 2021 Feb 3.

OLV Hospital, Aalst, Belgium;ORSI Academy, Melle, Belgium.

Background: Postoperative renal function impairment represents a main limitation for delivering adjuvant chemotherapy after radical nephroureterectomy (RNU).

Objective: To create a model predicting renal function decline after minimally invasive RNU.

Design, Setting, And Participants: A total of 490 patients with nonmetastatic UTUC who underwent minimally invasive RNU were identified from a collaborative database including 17 institutions worldwide (February 2006 to March 2020). Renal function insufficiency for cisplatin-based regimen was defined as estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m at 3 mo after RNU. Patients with baseline eGFR >50 ml/min/1.73 m (n = 361) were geographically divided into a training set (n = 226) and an independent external validation set (n = 135) for further analysis.

Outcome Measurements And Statistical Analysis: Using transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) guidelines, a nomogram to predict postoperative eGFR <50 ml/min/1.73 m was built based on the coefficients of the least absolute shrinkage and selection operation (LASSO) logistic regression. The discrimination, calibration, and clinical use of the nomogram were investigated.

Results And Limitations: The model that incorporated age, body mass index, preoperative eGFR, and hydroureteronephrosis was developed with an area under the curve of 0.771, which was confirmed to be 0.773 in the external validation set. The calibration curve demonstrated good agreement. Besides, the model was converted into a risk score with a cutoff value of 0.583, and the difference between the low- and high-risk groups both in overall death risk (hazard ratio [HR]: 4.59, p < 0.001) and cancer-specific death risk (HR: 5.19, p < 0.001) was statistically significant. The limitation mainly lies in its retrospective design.

Conclusions: A nomogram incorporating immediately available clinical variables can accurately predict renal insufficiency for cisplatin-based adjuvant chemotherapy after minimally invasive RNU and may serve as a tool facilitating patient selection.

Patient Summary: We have developed a model for the prediction of renal function loss after radical nephroureterectomy to facilitate patient selection for perioperative chemotherapy.
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http://dx.doi.org/10.1016/j.euf.2021.01.014DOI Listing
February 2021

Robotic Ureteral Bypass Surgery with Appendiceal Graft for Management of Long-Segment Radiation-Induced Distal Ureteral Strictures: A Case Series.

J Endourol Case Rep 2020 29;6(4):305-309. Epub 2020 Dec 29.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA.

Surgical management of long-segment radiation-induced distal ureteral strictures (RIDUS) is challenging. Pelvic radiation can damage the bladder, inhibiting the utilization of typical reconstruction techniques such as a psoas hitch and/or Boari flap. Also, radiation can cause scarring that can make ureterolysis difficult. We present a case series of patients undergoing robotic ureteral bypass surgery with appendiceal graft for management of strictures in this setting. This novel procedure utilizes the patient's appendix as a bypass graft to divert urine away from the strictured portion of ureter and into the bladder; this technique does not require dissection of the strictured ureteral segment. Robotic ureteral bypass surgery can be effective for management of long-segment RIDUS.
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http://dx.doi.org/10.1089/cren.2020.0105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803247PMC
December 2020

The role of RENAL score in predicting complications after robotic partial nephrectomy.

Minerva Urol Nefrol 2021 Jan 13. Epub 2021 Jan 13.

Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA -

Background: The aim of this study is to evaluate the association between tumor complexity based on RENAL nephrometry score and complications.

Methods: We retrospectively identified 2555 patients who underwent RPN for renal cell carcinoma. Major complication was defined as clavien grade≥3. The relationship between baseline demographic, clinical characteristics, perioperative and postoperative outcomes, and tumor complexity were assessed using Chi-square test of independence, Fishers exact and Kruskal Wallis test. An unadjusted and adjusted logistic regression model was used to assess the relationship between major complication and demographic, clinical characteristics, and perioperative outcomes.

Results: There was a significant relationship between tumor complexity and WIT(p<0.001), operative time(p<0.001), estimated blood loss (p<0.001), and major complication(p=0.019). However, there was no relationship with overall complications(p=0.237) and length of stay (LOS) (p=0.085). In the unadjusted model, higher tumor complexity was associated with major complication (p=0.009). Controlling for other variables, there was no significant difference between major complication and tumor complexity (low vs. moderate, p=0.142 and high, p=0.204). LOS (p <0.001) and operative time (p=0.025) remained a significant predictor of major complication in the adjusted model.

Conclusions: Tumor complexity is not associated with an increase in overall or major complication rate after RPN. Experience in high-volume centers is demonstrating a standardization of low complications rates after RPN independent of tumor complexity.
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http://dx.doi.org/10.23736/S0393-2249.20.03608-5DOI Listing
January 2021

Intermediate-term outcomes after robotic ureteral reconstruction for long-segment (≥4 centimeters) strictures in the proximal ureter: A multi-institutional experience.

Investig Clin Urol 2021 Jan 12;62(1):65-71. Epub 2020 Nov 12.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.

Purpose: To report our intermediate-term, multi-institutional experience after robotic ureteral reconstruction for the management of long-segment proximal ureteral strictures.

Materials And Methods: We retrospectively reviewed our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all patients who underwent robotic ureteral reconstruction for long-segment (≥4 centimeters) proximal ureteral strictures between August 2012 and June 2019. The primary surgeon determined the specific technique to reconstruct the ureter at time of surgery based on the patient's clinical history and intraoperative findings. Our primary outcome was surgical success, which we defined as the absence of ureteral obstruction on radiographic imaging and absence of obstructive flank pain.

Results: Of 20 total patients, 4 (20.0%) underwent robotic ureteroureterostomy (RUU) with downward nephropexy (DN), 2 (10.0%) underwent robotic ureterocalycostomy (RUC) with DN, and 14 (70.0%) underwent robotic ureteroplasty with buccal mucosa graft (RU-BMG). Median stricture length was 4 centimeters (interquartile range [IQR], 4-4; maximum, 5), 6 centimeters (IQR, 5-7; maximum, 8), and 5 centimeters (IQR, 4-5; maximum, 8) for patients undergoing RUU with DN, RUC with DN, and RU-BMG, respectively. At a median follow-up of 24 (IQR, 14-51) months, 17/20 (85.0%) cases were surgically successful. Two of four patients (50.0%) who underwent RUU with DN developed stricture recurrences within 3 months.

Conclusions: Long-segment proximal ureteral strictures may be safely and effectively managed with RUC with DN and RU-BMG. Although RUU with DN can be utilized, this technique may be associated with a higher failure rate.
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http://dx.doi.org/10.4111/icu.20200298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801167PMC
January 2021

Robotic Ureteral Reconstruction in Patients with Radiation-Induced Ureteral Strictures: Experience from the Collaborative of Reconstructive Robotic Ureteral Surgery.

J Endourol 2021 02 21;35(2):144-150. Epub 2020 Sep 21.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA.

Management of radiation-induced ureteral stricture (RIUS) is complex, requiring chronic drainage or morbid definitive open reconstruction. Herein, we report our multi-institutional comprehensive experience with robotic ureteral reconstruction (RUR) in patients with RIUSs. In a retrospective review of our multi-institutional RUR database between January 2013 and January 2020, we identified patients with RIUSs. Five major reconstruction techniques were utilized: end-to-end (anastomosing the bladder to the transected ureter) and side-to-side (anastomosing the bladder to an anterior ureterotomy proximal to the stricture without ureteral transection) ureteral reimplantation, buccal or appendiceal mucosa graft ureteroplasty, appendiceal bypass graft, and ileal ureter interposition. When necessary, adjunctive procedures were performed for mobility (i.e., psoas hitch) and improved vascularity (i.e., omental wrap). Outcomes of surgery were determined by the absence of flank pain (clinical success) and absence of obstruction on imaging (radiological success). A total of 32 patients with 35 ureteral units underwent RUR with a median stricture length of 2.5 cm (interquartile range [IQR] 2-5.5). End-to-end and side-to-side reimplantation techniques were performed in 21 (60.0%) and 8 (22.9%) RUR cases, respectively, while 4 (11.4%) underwent an appendiceal procedure. One patient (2.9%) required buccal mucosa graft ureteroplasty, while another needed an ileal ureter interposition. The median operative time was 215 minutes (IQR 177-281), estimated blood loss was 100 mL (IQR 50-150), and length of stay was 2 days (IQR 1-3). One patient required repair of a small bowel leak. Another patient died from a major cardiac event and was excluded from follow-up calculations. At a median follow-up of 13 months (IQR 9-22), 30 ureteral units (88.2%) were clinically and radiologically effective. RUR can be performed in patients with RIUSs with excellent outcomes. Surgeons must be prepared to perform adjunctive procedures for mobility and improved vascularity due to poor tissue quality. Repeat procedures for RIUSs heighten the risk of necrosis and failure.
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http://dx.doi.org/10.1089/end.2020.0643DOI Listing
February 2021

A Multi-Institutional Experience With Robotic Ureteroplasty With Buccal Mucosa Graft: An Updated Analysis of Intermediate-Term Outcomes.

Urology 2021 Jan 13;147:306-310. Epub 2020 Aug 13.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.

Objective: To update our prior multi-institutional experience with robotic ureteroplasty with buccal mucosa graft and analyze our intermediate-term outcomes. Although our previous multi-institutional report provided significant insight into the safety and efficacy associated with robotic ureteroplasty with buccal mucosa graft, it was limited by small patient numbers.

Methods: We retrospectively reviewed our multi-institutional database to identify all patients who underwent robotic ureteroplasty with buccal mucosa graft between October 2013 and March 2019 with ≥12 months follow up. Indication for surgery was a complex proximal and/or middle ureteral stricture not amenable to primary excision and anastomosis secondary to stricture length or peri-ureteral fibrosis. Surgical success was defined as the absence of obstructive flank pain and ureteral obstruction on functional imaging.

Results: Of 54 patients, 43 (79.6 %) patients underwent an onlay, and 11 (20.4%) patients underwent an augmented anastomotic robotic ureteroplasty with buccal mucosa graft. Eighteen of 54 (33.3%) patients previously failed a ureteral reconstruction. The median stricture length was 3.0 (IQR 2.0-4.0, range 1-8) centimeters. There were 3 of 54 (5.6%) major postoperative complications. The median length of stay was 1.0 (IQR 1.0-3.0) day. At a median follow-up of 27.5 (IQR 21.3-38.0) months, 47 of 54 (87.0%) cases were surgically successful. Stricture recurrences were diagnosed ≤2 months postoperatively in 3 of 7 (42.9%) patients, and ≥10 months postoperatively in 4 of 7 (57.1%) patients.

Conclusion: Robotic ureteroplasty with buccal mucosa graft is associated with low peri-operative morbidity and excellent intermediate-term outcomes.
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http://dx.doi.org/10.1016/j.urology.2020.08.003DOI Listing
January 2021

Onlay Repair Technique for the Management of Ureteral Strictures: A Comprehensive Review.

Biomed Res Int 2020 27;2020:6178286. Epub 2020 Jul 27.

Department of Urology, Temple University School of Medicine, 255S 17th Street, 7th Floor Medical Tower, Philadelphia, PA 19103, USA.

Ureteroplasty using onlay grafts or flaps emerged as an innovative procedure for the management of proximal and midureteral strictures. Autologous grafts or flaps used commonly in ureteroplasty include the oral mucosae, bladder mucosae, ileal mucosae, and appendiceal mucosae. Oral mucosa grafts, especially buccal mucosa grafts (BMGs), have gained wide acceptance as a graft choice for ureteroplasty. The reported length of BMG ureteroplasty ranged from 1.5 to 11 cm with success rates of 71.4%-100%. However, several studies have demonstrated that ureteroplasty using lingual mucosa grafts yields better recipient site outcomes and fewer donor site complications than that using BMGs. In addition, there is no essential difference in the efficacy and complication rates of BMG ureteroplasty using an anterior approach or a posterior approach. Intestinal graft or flap ureteroplasty was also reported. And the reported length of ileal or appendiceal flap ureteroplasty ranged from 1 to 8 cm with success rates of 75%-100%. Moreover, the bladder mucosa, renal pelvis wall, and penile/preputial skin have also been reported to be used for ureteroplasty and have achieved satisfactory outcomes, but each graft or flap has unique advantages and potential problems. Tissue engineering-based ureteroplasty through the implantation of patched scaffolds, such as the small intestine submucosa, with or without cell seeding, has induced successful ureteral regeneration structurally close to that of the native ureter and has resulted in good functional outcomes in animal models.
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http://dx.doi.org/10.1155/2020/6178286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407031PMC
April 2021

Multi-institutional Experience Comparing Outcomes of Adult Patients Undergoing Secondary Versus Primary Robotic Pyeloplasty.

Urology 2020 Nov 18;145:275-280. Epub 2020 Jul 18.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.

Objective: To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP.

Methods: We retrospectively reviewed our multi-institutional, collaborative of reconstructive robotic ureteral surgery (CORRUS) database for all consecutive patients who underwent RP between April 2012 and September 2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; P < .05 was considered significant.

Results: Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 vs 50.0 milliliters, respectively; P < .01) and longer operative time (188.0 vs 136.0 minutes, respectively; P = .02). There was no difference in major (Clavien >2) complications (P = .29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% vs 92.3%, respectively; P = .44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% vs 0.0%, respectively, P < .01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% vs 40.8%, respectively; P < .01) for secondary vs primary repair.

Conclusion: Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.
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http://dx.doi.org/10.1016/j.urology.2020.07.008DOI Listing
November 2020

Should a Drain Be Routinely Required After Transperitoneal Robotic Partial Nephrectomy?

J Endourol 2020 09 25;34(9):964-968. Epub 2020 Aug 25.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Closed drains have traditionally been placed after partial nephrectomy because of risks of bleeding and urine leak. We sought to study the safety of a nonroutine drain (NRD) approach after transperitoneal robotic partial nephrectomy (RPN). From a multi-institutional database, we have analyzed the data of 904 patients who underwent RPN. Five hundred forty-six (60.40%) patients underwent RPN by a surgeon who routinely placed drains. Three hundred fifty-eight (39.60%) patients underwent RPN by a surgeon who did not routinely placed drains. Perioperative outcomes, length of stay (LOS), and readmission rates were compared between the two groups. Baseline characteristics, perioperative, and postoperative outcomes were compared using Mann-Whitney U test, chi-square test, and Fisher's exact test. Patients in the NRD group were more likely to have higher body mass index (30.10 kg/m 28.07 kg/m;  < 0.001), higher tumor size (3.0 cm 2.5 cm;  = 0.001), and higher renal score (8 7;  < 0.001). Rate of transfusion (0.00% NRD 0.56% RD;  = 0.157) and overall complication (7.33% NRD 7.82% RD;  = 0.782) were comparable. Median hospital stay is 1 day for both groups. Readmission rate was also similar (0.55% NRD 1.40% RD;  = 0.279). In a multivariable analysis, NRD approach was associated with shorter length of hospital stay (incidence rate ratio [IRR] - 0.72,  < 0.001). An NRD approach for RPN yielded a decreased LOS and similar perioperative outcomes. Placement of surgical drains should be based on individual circumstances, and not required on a routine basis.
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http://dx.doi.org/10.1089/end.2020.0325DOI Listing
September 2020

Does race impact functional outcomes in patients undergoing robotic partial nephrectomy?

Transl Androl Urol 2020 Apr;9(2):863-869

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Background: The role of race on functional outcomes after robotic partial nephrectomy (RPN) is still a matter of debate. We aimed to evaluate the clinical and pathologic characteristics of African American (AA) and Caucasian patients who underwent RPN and analyzed the association between race and functional outcomes.

Methods: Data was obtained from a multi-institutional database of patients who underwent RPN in 6 institutions in the USA. We identified 999 patients with complete clinical data. Sixty-three patients (6.3%) were AA, and each patient was matched (1:3) to Caucasian patients by age at surgery, gender, Charlson Comorbidity Index (CCI) and renal score. Bivariate and multivariate logistic regression analyses were used to evaluate predictors of acute kidney injury (AKI). Kaplan-Meier method and multivariable semiparametric Cox regression analyses were performed to assess prevalence and predictors of significant eGFR reduction during follow-up.

Results: Overall, 252 patients were included. AA were more likely to have hypertension (58.7% 35.4%, P=0.001), even after 1:3 match. Overall 42 patients (16.7%) developed AKI after surgery and 35 patients (13.9%) developed significant eGFR reduction between 3 and 15 months after RAPN. On multivariate analysis, AA race did not emerge as a significant factor for predicting AKI (OR 1.10, P=0.8). On Cox multivariable analysis, only AKI was found to be associated with significant eGFR reduction between 3 and 15 months after RAPN (HR 2.49, P=0.019).

Conclusions: Although African American patients were more likely to have hypertension, renal function outcomes of robotic partial nephrectomies were not significantly different when stratified by race. However, future studies with larger cohorts are necessary to validate these findings.
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http://dx.doi.org/10.21037/tau.2019.09.31DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214979PMC
April 2020

Intermediate-term Urinary Function and Complication Outcomes After Robot-Assisted Simple Prostatectomy.

Urology 2020 Jul 22;141:89-94. Epub 2020 Apr 22.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.

Objective: To assess the incidence of delayed complications after robot-assisted simple prostatectomy and evaluate postoperative lower urinary tract symptoms (LUTS) as a function of time with intermediate-term follow-up.

Methods: We retrospectively reviewed 150 patients who underwent robot-assisted simple prostatectomy between May, 2013 and January, 2019. Indication for surgery was bothersome LUTS refractory to medical management and prostate volume ≥80 milliliters. The severity of LUTS was assessed using the International Prostate Symptom Score (IPSS) and quality of life (QOL) score. One-way analysis of variance test with post hoc Tukey's honest significant difference test was used to compare postoperative IPSS and QOL scores as a function of time; P <.05 was considered significant.

Results: At a mean ± SD follow up of 31.3 ± 18.2 months, none of the patients developed a bladder neck contracture and none of the patients required reoperation for LUTS. Postoperatively, IPSS and QOL scores decreased with an increasing duration of follow up (P <.001). Mean IPSS and QOL scores improved between 2 weeks and 3 months postoperatively (P = .027 and P = .006, respectively). After 3 months postoperatively, mean IPPS and QOL scores stabilized and remained unchanged up to 36 months of follow-up (all P >.05).

Conclusion: Robotic simple prostatectomy is associated with a low incidence of delayed complications at a mean of 31.3 months postoperatively. After robotic simple prostatectomy, urinary function outcomes improve in the early postoperative period with maximal improvement occurring at 3 months. Excellent urinary function outcomes are durable up to at least 36 months postoperatively.
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http://dx.doi.org/10.1016/j.urology.2020.04.055DOI Listing
July 2020

Utilization of a Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles After Robotic Radical Prostatectomy and Bilateral Pelvic Lymph Node Dissection.

J Endourol 2020 Aug 13;34(8):821-827. Epub 2020 May 13.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA.

The peritoneal interposition flap (PIF) has been shown to prevent postoperative symptomatic lymphocele (SL) formation after robot-assisted radical prostatectomy (RARP) and pelvic lymph node dissection (PLND). The PIF inhibits the mobilized bladder from resealing over its lateral dissection planes, which overly the lymphadenectomy beds. This creates a window for lymphatic fluid to drain into the peritoneal cavity where it can be absorbed. Herein, we externally validate its utility in preventing postoperative SL formation and assess its effect on postoperative urinary function. We retrospectively reviewed all consecutive patients who underwent RARP with bilateral PLND by a single surgeon between July 2016 and September 2019. All patients who underwent surgery before August 8, 2018 did not receive the PIF, while those who underwent surgery after August 8, 2018 received the PIF. Our PIF technique involves fixing the peritoneum overlying the lateral dome of the bladder to the ipsilateral, anterior-lateral surface of the bladder using a barbed absorbable suture. Continuous and categorical variables were compared between the two groups using independent -tests and chi-square tests, respectively;  < 0.05 was considered significant. Of 318 total patients, 201 did not undergo the PIF and 117 underwent the PIF. With regard to postoperative complications, patients undergoing the PIF had a lower incidence of SL compared with those not undergoing the PIF (0.0% 6.0%,  = 0.007). There was no difference in 30-day postoperative nonlymphocele complications (Clavien >2) between both groups ( = 0.800). With regard to urinary function, there was no difference in the rate of 3-month postoperative continence ( = 0.624), preoperative American Urological Association Symptom Score (AUASS) ( = 0.898), and postoperative AUASS ( = 0.470) between both groups. Utilization of a PIF may minimize the risk of SL formation after RARP and PLND without increasing the risk of non-SL-related complications. This technique does not adversely affect postoperative urinary function.
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http://dx.doi.org/10.1089/end.2020.0073DOI Listing
August 2020

Ureteral Reimplantation via Robotic Nontransecting Side-to-Side Anastomosis for Distal Ureteral Stricture.

J Endourol 2020 Aug 5;34(8):836-839. Epub 2020 May 5.

Department of Urology, Temple University, Philadelphia, Pennsylvania, USA.

To describe a novel technique of ureteral reimplantation through robotic nontransecting side-to-side anastomosis. Although the standard approach to ureteroneocystostomy has a high rate of success, it involves transection of the ureter that may impair vascularity and contribute to recurrent strictures. Our method seeks to maximally preserve distal ureteral blood flow that may reduce this risk. We retrospectively reviewed a multi-institutional ureteral reconstruction database to identify patients who underwent this operation between 2014 and 2018, analyzing perioperative and postoperative outcomes. Our technique was utilized in 16 patients across three U.S. academic institutions. Median operative time and estimated blood loss were 178 minutes (interquartile range [IQR] 150-204) and 50 mL (IQR 38-100), respectively. The median length of stay was 1 day (IQR 1-2). No intraoperative complications or postoperative complications with Clavien score ≥3 were reported. Postoperatively, 15 of 16 (93.8%) patients reported clinical improvement in flank pain, and all patients who underwent follow-up imaging had radiographic improvement with decrease in hydronephrosis at a median follow-up of 12.5 months. Ureteral reimplantation through a robotic nontransecting side-to-side anastomosis is a feasible and effective operation for distal ureteral stricture that may have advantages over the standard of care transecting ureteroneocystostomy.
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http://dx.doi.org/10.1089/end.2019.0877DOI Listing
August 2020

Robot-assisted distal ureteral reconstruction for benign pathology: Current state.

Investig Clin Urol 2020 02 21;61(Suppl 1):S23-S32. Epub 2019 Nov 21.

Department of Urology, Temple University, Philadelphia, PA, USA.

Distal ureteral reconstruction for benign pathologies such as stricture disease or iatrogenic injury has posed a challenge for urologist as endoscopic procedures have poor long-term outcomes, requiring definitive open reconstruction. Over the past decade, there has been an increasing shift towards robot-assisted laparoscopy (RAL) with multiple institutions reporting their outcomes. In this article, we reviewed the current literature on RAL distal ureteral reconstruction, focusing on benign pathologies only. We present peri-operative data and outcomes on the most common technique, ureteral reimplantation, as well as adjunct procedures such as psoas hitch and Boari flap. Additionally, we present alternative techniques reported in the literature with some technical considerations. Lastly, we describe the outcomes of the comparative studies between open, laparoscopy, and RAL. Although the body of literature in this field is limited, RAL reconstruction of the distal ureter appears to be safe, feasible, and with some advantages over the traditional open approach.
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http://dx.doi.org/10.4111/icu.2020.61.S1.S23DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004836PMC
February 2020

Effect of Obesity and Overweight Status on Complications and Survival After Minimally Invasive Kidney Surgery in Patients with Clinical T Renal Masses.

J Endourol 2020 03;34(3):289-297

Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.

To evaluate the effect of obesity and overweight on surgical, functional, and survival outcomes in patients with large kidney masses after minimally invasive surgery. Within a multicenter multinational dataset, patients found to have ≥cT renal mass and treated with minimally invasive (laparoscopic or robotic) kidney surgery (radical or partial nephrectomy) during the period 2003 to 2017 were abstracted. They were stratified according to the body mass index classes as normal weight (18.5-24.9 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m). Mixed models and Cox proportional hazard regression tested differences in complication rates, estimated glomerular filtration rate (eGFR) change over time, overall mortality (OM), and disease recurrence (DR) rates. Of 812 patients, 30.6% were normal weight, 42.7% were overweight, and 26.7% obese. Overweight (odds ratio 0.82, 95% confidence interval [CI]: 0.51-1.31,  = 0.406) and obese patients (OR: 0.81, 95% CI: 0.44-1.47,  = 0.490) experienced similar complication rates than normal weight. Moreover, no statistically significant differences in eGFR were found for overweight ( = 0.129) or obese ( = 0.166) patients compared to normal weight. However, higher OM rates were recorded in overweight (hazard ratio [HR] 3.59, 95% CI: 1.03-12.51,  = 0.044), as well as in obese, patients (HR 7.83, 95% CI: 2.20-27.83,  = 0.002). Similarly, higher DR rates were recorded in obese (HR 2.76, 95% CI: 1.40-5.44,  = 0.003) patients. Obese and overweight patients do not experience higher complication rates or worse eGFR after minimally invasive kidney surgery, which therefore can be deemed feasible and safe also in this subset of patients. Nevertheless, obese and overweight patients seem to carry a higher risk of OM, and therefore, they should undergo a strict follow-up after surgery.
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http://dx.doi.org/10.1089/end.2019.0604DOI Listing
March 2020

Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy?

BJU Int 2020 03 26;125(3):442-448. Epub 2019 Dec 26.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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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http://dx.doi.org/10.1111/bju.14956DOI Listing
March 2020

A multi-institutional analysis of 263 hilar tumors during robot-assisted partial nephrectomy.

J Robot Surg 2020 Aug 26;14(4):585-591. Epub 2019 Sep 26.

Department of Urology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1272, New York, NY, 10029-5674, USA.

Hilar tumors pose unique challenges during partial nephrectomy. We present the characteristics and outcomes of 263 patients with hilar tumors undergoing robot-assisted partial nephrectomy (RPN) in the largest series to date. Perioperative, pathologic, functional, and oncological outcomes were compared between 1467 (84.8%) patients with a non-hilar tumor and 263 (15.2%) patients with a hilar tumor undergoing RPN. Variables were compared in univariable (unadjusted) analysis and using multivariable linear, logistic, poisson, cox proportional hazards and linear mixed effects regression models adjusting for tumor diameter and RENAL Nephrometry score. Hilar tumors were larger (3.7 vs. 3.0 cm, p < 0.001) and more complex (RENAL Score 9 vs. 7, p < 0.001), leading to longer operative time (186 vs. 161 min, p < 0.001), ischemia time (18 vs. 15, p < 0.001), greater blood loss (150 vs. 100 ml, p < 0.001), eGFR decline at discharge (∆ = 3.9%, p = 0.035) and eGFR decline per month up to 36 months post-RPN (β = - 0.25; p = 0.017). In multivariable analysis, hilar tumors were only associated with a 10% increase in operative time (p ≤ 0.001) and marginally worse eGFR decline over time (β = - 0.19, p = 0.076), with no differences in other outcomes analyzed including ischemia time, blood loss, complication rate, recurrence-free survival, or eGFR decline at discharge. Although hilar tumors were found to be larger and more anatomically complex, there were only marginal differences in outcome when compared to non-hilar tumors. A hilar renal tumor should be considered for partial nephrectomy when feasible without an expected increase in complications or adverse events.
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http://dx.doi.org/10.1007/s11701-019-01028-8DOI Listing
August 2020

A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications.

J Endourol 2019 12 9;33(12):1003-1008. Epub 2019 Oct 9.

OhioHealth Robotic Urologic and Cancer Surgery, Dublin Methodist Hospital, Dublin, Ohio.

To evaluate the feasibility of postoperative day 1 (POD1) discharge after robotic partial nephrectomy (RPN) and to determine whether a protocol targeting a shorter length of stay (LOS) is associated with any difference in the rate of postoperative complications. We reviewed a prospectively maintained, multi-institutional database of patients who underwent RPN from September 2013 to September 2016. Three of the six participating surgeons used a protocol that targeted discharge on POD1, whereas three surgeons did not. Patient characteristics and postoperative complication rates between the two groups were compared. A total of 665 patients were included, 455 of whom were treated by surgeons utilizing a POD1 discharge protocol, whereas 210 were not. The mean LOS for those in the POD1 protocol group was 1.13 days 2.02 days in the non-protocol group. Between groups, there were no differences in age ( = 0.098), body mass index ( = 0.164), tumor size ( = 0.502), or R.E.N.A.L. Nephrometry score ( = 0.974), but POD1 discharge protocol patients had higher age-adjusted Charlson comorbidity score (4 2,  = 0.033), were less likely to have a hilar tumor (15.9% 23.1%,  = 0.03), and had a larger percent decrease in discharge estimated glomerular filtration rate (-15.9% -7.1%,  < 0.001). There were no differences in the rates of overall ( = 0.715), major ( = 0.164), medical ( = 0.089), or surgical complications ( = 0.301) or in complications by the Clavien-Dindo category ( = 0.13). Discharge on POD1 after RPN is feasible, reproducible by different surgeons, and not associated with an increased risk of postoperative complications.
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http://dx.doi.org/10.1089/end.2019.0218DOI Listing
December 2019

Defining Risk Categories for a Significant Decline in Estimated Glomerular Filtration Rate After Robotic Partial Nephrectomy: Implications for Patient Follow-up.

Eur Urol Oncol 2021 Jun 30;4(3):498-501. Epub 2019 Jul 30.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Following partial nephrectomy (PN), it is important to prevent any deterioration in estimated glomerular filtration rate (eGFR). At present there are no evidence-based recommendations on when a nephrology consultation should be requested and how to adjust postoperative management when the risk of renal function decline is high. In an effort to address this void, we used our previously published nomogram to define risk groups for a significant decline in eGFR at 3-15 mo after PN. We used the nomogram-derived probability as the independent variable for the classification and regression tree and identified four risk groups: low (0-10%), intermediate (10-21%), high (21-65%), and very high (65-100%). Overall, 336 (34%), 386 (39%), 243 (24%), and 34 (4%) patients fell in the low, intermediate, high, and very high risk groups, respectively. The rates of significant eGFR decline across the low, intermediate, high, and very high risk groups were 4%, 14%, 29%, and 79%. With the low risk category as a reference, the hazard ratio for eGFR decline was 3.21 (95% confidence interval [CI] 1.83-5.64) for the intermediate, 7.80 (95% CI 4.52-13.48) for the high, and 27.24 (95% CI 13.8-53.8) for the very high risk group (all p<0.001). These prognostic risk categories can be used to design postoperative follow-up schedules. A multidisciplinary approach can be considered for patients at high and very high risk of eGFR decline. PATIENT SUMMARY: We propose a new stratification system to identify individuals at high risk of a decline in renal function after robotic partial nephrectomy.
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http://dx.doi.org/10.1016/j.euo.2019.07.001DOI Listing
June 2021

Association of Low Socioeconomic Status With Adverse Prostate Cancer Pathology Among African American Men Who Underwent Radical Prostatectomy.

Clin Genitourin Cancer 2019 10 20;17(5):e1054-e1059. Epub 2019 Jun 20.

Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA. Electronic address:

Background: We tested for associations between socioeconomic status (SES) and adverse prostate cancer pathology in a population of African American (AA) men treated with radical prostatectomy (RP).

Patients And Methods: We retrospectively reviewed data from 2 institutions for AA men who underwent RP between 2010 and 2015. Household incomes were estimated using census tract data, and patients were stratified into income groups relative to the study population median. Pathologic outcomes after RP were assessed, including the postsurgical Cancer of the Prostate Risk Assessment (CAPRA-S) score and a definition of adverse pathology (stage ≥ pT3, Gleason score ≥ 4+3, or positive lymph nodes), and compared between income groups.

Results: We analyzed data of 347 AA men. Median household income was $37,954. Low-SES men had significantly higher prostate-specific antigen values (mean 10.2 vs. 7.3; P < .01) and CAPRA-S scores (mean 3.4 vs. 2.5; P < .01), more advanced pathologic stage (T3-T4 31.8% vs. 21.5%; P = .03), and higher rates of seminal vesicle invasion (17.3% vs. 8.2%; P < .01), positive surgical margins (35.3% vs. 22.1%; P < .01), and adverse pathology (41.4% vs. 30.1%; P = .03). Linear and logistic regression showed significant inverse associations of SES with CAPRA-S score (P < .01) and adverse pathology (P = .03).

Conclusion: In a population of AA men who underwent RP, we observed an independent association of low SES with advanced stage or aggressive prostate cancer. By including only patients in a single racial demographic group, we eliminated the potential confounding effect of race on the association between SES and prostate cancer risk. These findings suggest that impoverished populations might benefit from more intensive screening and early, aggressive treatment of prostatic malignancies.
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http://dx.doi.org/10.1016/j.clgc.2019.06.006DOI Listing
October 2019

Management of high complexity renal masses in partial nephrectomy: A multicenter analysis.

Urol Oncol 2019 07 16;37(7):437-444. Epub 2019 May 16.

Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address:

Objective: To determine the safety and efficacy of performing partial nephrectomy (PN) on patients with high nephrometry score tumors.

Patients And Methods: We used a prospectively maintained multi-institutional kidney cancer database to identify 144 patients with R.E.N.A.L. nephrometry score ≥10 who underwent PN for a cT1-cT2 renal mass. Baseline demographics and clinical characteristics, tumor characteristics, perioperative, and pathological outcomes were analyzed and reported. Trifecta achievement, defined by warm ischemia time <25 minutes, no perioperative complications, and negative surgical margins, was the primary outcome. We assessed the relationship of baseline clinical and tumor characteristics data to trifecta achievement and perioperative complications.

Results: Baseline median eGFR was 84.57 ml/min/1.73 m, with 119 (84.39%) patients having normal baseline kidney function. The median clinical tumor size was 4.95 cm, with 74 (51.75%) being completely endophytic and 58 (41.73%) located on the hilum. The median ischemia time was 20 minutes. Median estimated blood loss was 150 ml. Twelve patients (8.33%) had intraoperative complications. No patient had a conversion to open surgery. Postoperative, perioperative, and major complication rate were 10.42%, 17.3%, and 2.34% respectively. Thirty-six patients (37.89%) developed postoperative acute kidney injury and 28 (20.90%) developed new-onset CKD at a median follow-up of 6 months. Eight patients (5.56%) had a positive surgical margin. Trifecta was achieved in 89 (61.81%) patients. There was no significant difference in baseline, clinical, and tumor characteristics between those that achieved trifecta and in those where trifecta was not. Pathologic tumor stage was the only factor significantly associated with trifecta achievement (P = 0.025).

Conclusion: In treating complex renal tumors, PN should be performed when possible. Although this remains a challenging procedure, with experience and appropriate case selection, the trifecta outcome can be achieved in a significant number of patients with high renal score lesions.
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http://dx.doi.org/10.1016/j.urolonc.2019.04.019DOI Listing
July 2019

Predicting acute kidney injury after robot-assisted partial nephrectomy: Implications for patient selection and postoperative management.

Urol Oncol 2019 07 8;37(7):445-451. Epub 2019 May 8.

Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY.

Background: Acute Kidney Injury (AKI) is a common occurrence after partial nephrectomy and is a significant risk factor for chronic kidney disease. We aimed to create a model that predicts postoperative AKI in patients undergoing robot-assisted partial nephrectomy (RAPN).

Methods: We identified 1,190 patients who underwent RAPN between 2008 and 2017 from a multicenter database. AKI was defined as a >25% reduction in eGFR from pre-RAPN to discharge. A nomogram was built based on a binary logistic regression that ultimately included age, sex, BMI, diabetes, baseline eGFR, and RENAL Nephrometry score. Internal validation was performed using the leave-one-out cross validation. Calibration was graphically investigated. The decision curve analysis was used to evaluate the net clinical benefit; a classification tree was used to identify risk categories. The same model was fit adding ischemia time during RAPN.

Results: Median (IQR) age at surgery was 61 (50, 68) years; 505 (42%) patients were female, while 685 (58%) were male. Median (IQR) ischemia time during RAPN was 14 (10, 18) min. postoperative AKI occurred in 274 (23%) patients. All variables fitted in the model emerged as predictors of AKI (all P ≤ 0.005) and all were considered to build a nomogram. After internal validation, the area under the curve was 73%. The model demonstrated excellent calibration and improved clinical risk prediction at the decision curve analysis. In the low, intermediate, and high-risk groups the postoperative AKI rates were: 10%, 30%, and 48%, respectively. Adding ischemia time to the preoperative model fit the data better (likelihood ratio test: P < 0.001) and yielded an incremental area under the curve of 3% (95% confidence interval: 1, 5%) CONCLUSION: We developed a nomogram that accurately predicts AKI in patients undergoing RAPN. This model might serve (1) in the preoperative setting: for counsel patients according to their preoperative AKI risk (2) in the immediate postoperative: for identifying patients who would benefit from an early multidisciplinary evaluation, when considering also ischemia time.
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http://dx.doi.org/10.1016/j.urolonc.2019.04.018DOI Listing
July 2019

The Impact of Obesity in Patients Undergoing Robotic Partial Nephrectomy.

J Endourol 2019 06;33(6):431-437

1 Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York.

As the prevalence of obesity increases worldwide, an increasing proportion of surgical candidates have an elevated body mass index (BMI), with associated metabolic syndrome. Yet there exists limited evidence regarding the effect of elevated BMI on surgical outcomes in robotic surgeries. We examined whether obese patients had worse perioperative outcomes and postoperative renal function after robotic partial nephrectomies (RPNs). We performed a multi-institutional analysis of 1770 patients who underwent RPNs between 2008 and 2015, allowing time for the data set to mature. Associations between BMI, as a continuous and categorical variable, and perioperative outcomes, acute kidney injury (AKI, >25% reduction in estimated glomerular filtration rate [eGFR]) at discharge, and change in eGFR per month were analyzed. AKI and eGFR were evaluated using multivariable logistic and linear regression models adjusted for confounders, including age, Charlson comorbidity index, tumor size, and the identity of the surgeon. In total 45.2% ( = 529) of patients were found to be obese, with a greater prevalence of hypertension and diabetes in overweight and obese patients. Obese patients were more likely to have malignant tumors (>77% 68%,  < 0.001) and trended toward having larger tumors (3.0 cm 2.8 cm;  = 0.061). Heavier patients required longer operative times (166-196 minutes 155 minutes;  < 0.001), although equivalent warm ischemia times ( = 0.873). Obesity did not correlate with an increased complication rate ( > 0.05). On multivariable analysis, obesity (odds ratio [OR] = 1.81;  = 0.031), male sex (OR = 1.54;  = 0.028), and larger tumor size (OR = 1.23;  < 0.001) were associated with a significant increase in the likelihood of AKI at discharge. BMI above normal weight was not associated with greater eGFR decline per month post-RPN. Obesity was associated with equivalent perioperative outcomes and long-term renal function. Further research is warranted into how obesity and metabolic syndrome may foster a more aggressive tumor environment. RPN appears to be an equally safe operative option for patients regardless of obesity status.
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http://dx.doi.org/10.1089/end.2019.0018DOI Listing
June 2019

Renal Endometriosis: The Case of an Endometrial Implant Mimicking a Renal Mass.

J Endourol Case Rep 2018 29;4(1):176-178. Epub 2018 Oct 29.

Department of Urology, Temple University Hospital, Philadelphia, Pennsylvania.

Endometriosis is a multifactorial benign disorder characterized by the abnormal presence of endometrial tissue in an extraendometrial site. Although extrapelvic endometriosis is uncommon, symptomatic involvement of the kidney is exceedingly rare. This benign disease can mimic several urologic processes, but because of its scarcity in clinical practice, it is seldom considered in the differential. In this report, we describe the case of a 45-year-old woman with flank pain and hematuria, who was found to have a left renal mass on cross-sectional imaging. After robotic partial nephrectomy, pathologic analysis revealed an endometrial implant within the renal parenchyma. This case of renal endometriosis highlights how this benign disease process can mimic several more sinister urologic processes.
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http://dx.doi.org/10.1089/cren.2018.0070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206897PMC
October 2018
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