Publications by authors named "Ronney Abaza"

130 Publications

Impact of median lobe on urinary function after robotic prostatectomy.

Prostate 2021 Sep 14;81(12):832-837. Epub 2021 Jun 14.

Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio, USA.

Background: Enlarged median lobes (ML) can be technically challenging, particularly during bladder-neck dissection, and may affect urinary functional outcomes of robotic radical prostatectomy (RARP). If known, the impact of potentially larger bladder necks on continence and chronic obstruction on postoperative urinary symptoms might aid patient counseling. We assessed the impact of intraoperatively identified median lobes (ML) on urinary function.

Methods: We reviewed our prospective RP database from 2013 to 2020. AUA symptoms scores (AUA-SS) were assessed preoperatively and at 1, 3, and 6 months. We compared patients with and without ML (NoML). Bladder-neck sparing was routine to avoid reconstruction.

Results: Of 663 patients who completed AUA-SS questionnaires at all time points, 202 (30%) had ML. There were no significant differences in demographics, PSA, or clinical stage. Only two patients in ML and one in NoML group required bladder-neck reconstruction (1.2% and 0.2%). There was no immediate or long-term difference in continence rates between groups. Baseline mean AUA-SS was higher in ML patients and showed more improvement postoperatively (-5.5 vs. -3.6, p < .05) with greatest improvement in ML patients with severe preoperative symptoms (-15.1). There was no difference in AUA-SS between groups by 6 months.

Conclusions: The presence of enlarged ML does not increase the risk of incontinence after RARP and it appears that ML patients have greater improvements in postsurgical urinary functions. Preoperative diagnosis of ML and lower urinary tract symptoms assessment could be helpful in counseling patients undergoing RARP regarding their expected postoperative urinary outcomes.
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http://dx.doi.org/10.1002/pros.24179DOI Listing
September 2021

Salvage Robot-assisted Renal Surgery for Local Recurrence After Surgical Resection or Renal Mass Ablation: Classification, Techniques, and Clinical Outcomes.

Eur Urol 2021 Jun 1. Epub 2021 Jun 1.

Department of Urology, Vita-Salute San Raffaele University, Milan, Italy. Electronic address:

Background: Salvage treatment for local recurrence after prior partial nephrectomy (PN) or local tumor ablation (LTA) for kidney cancer is, as of yet, poorly investigated.

Objective: To classify the treatments and standardize the nomenclature of salvage robot-assisted renal surgery, to describe the surgical technique for each scenario, and to investigate complications, renal function, and oncologic outcomes.

Design, Setting, And Participants: Sixty-seven patients underwent salvage robot-assisted renal surgery from October 2010 to December 2020 at nine tertiary referral centers.

Surgical Procedure: Salvage robot-assisted renal surgery classified according to treatment type as salvage robot-assisted partial or radical nephrectomy (sRAPN or sRARN) and according to previous primary treatment (PN or LTA).

Measurements: Postoperative complications, renal function, and oncologic outcomes were assessed.

Results And Limitations: A total of 32 and 35 patients underwent salvage robotic surgery following PN and LTA, respectively. After prior PN, two patients underwent sRAPN, while ten underwent sRARN for a metachronous recurrence in the same kidney. No intra- or perioperative complication occurred. For local recurrence in the resection bed, six patients underwent sRAPN, while 14 underwent sRARN. For sRAPN, the intraoperative complication rate was 33%; there was no postoperative complication. For sRARN, there was no intraoperative complication and the postoperative complication rate was 7%. At 3 yr, the local recurrence-free rates were 64% and 82% for sRAPN and sRARN, respectively, while the 3-yr metastasis-free rates were 80% and 79%, respectively. At 33 mo, the median estimated glomerular filtration rates (eGFRs) were 57 and 45 ml/min/1.73 m for sRAPN and sRARN, respectively. After prior LTA, 35 patients underwent sRAPN and no patient underwent sRARN. There was no intraoperative complication; the overall postoperative complications rate was 20%. No local recurrence occurred. The 3-yr metastasis-free rate was 90%. At 43 mo, the median eGFR was 38 ml/min/1.73 m. The main limitations are the relatively small population and the noncomparative design of the study.

Conclusions: Salvage robot-assisted surgery has a safe complication profile in the hands of experienced surgeons at high-volume institutions, but the risk of local recurrence in this setting is non-negligible.

Patient Summary: Patients with local recurrence after partial nephrectomy or local tumor ablation should be aware that further treatment with robot-assisted surgery is not associated with a worrisome complication profile, but also that they are at risk of further recurrence.
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http://dx.doi.org/10.1016/j.eururo.2021.04.003DOI Listing
June 2021

The Case for Transperitoneal Robotic Prostatectomy.

Authors:
Ronney Abaza

J Endourol 2021 Apr 24. Epub 2021 Apr 24.

Ohio State University Medical Center, Urology, 515 Doan Hall, 410 W. 10th Avenue, Columbus, Ohio, United States, 43210.

Point/Counterpoint: Extraperitoneal vs. Intraperitoneal approach for robotic radical prostatectomy.
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http://dx.doi.org/10.1089/end.2021.0296DOI Listing
April 2021

Impact of Surgeon-Controlled Suction During Robotic Prostatectomy to Reduce Dependence on Bedside Assistance.

J Endourol 2021 Apr 13. Epub 2021 Apr 13.

Robotic Surgery, Department of Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio, USA.

Suction during robotic surgery has traditionally been performed by a bedside assistant. Adequately skilled assistants are not always available. We assessed a purpose-designed robotic surgeon-controlled suction catheter for efficiency and safety by comparing with historic cases of suction controlled by a dedicated bedside assistant using standard rigid laparoscopic suction. Beginning in February 2019, the remotely operated suction irrigation (ROSI) device was used in all robotic prostatectomy procedures, which is a flexible suction catheter manipulated by the surgeon such that a bedside assistant is never required for suction. The initial 300 consecutive cases performed with ROSI were compared with the 300 immediately previous procedures using bedside assistant suction (BAS). There were no statistically significant differences between groups in age, body mass index, American Anesthesiologist Association score, prostate specific antigen, or pathologic stage. Lymph node dissection was performed in all 600 patients. All 300 ROSI cases were completed without requiring switching to BAS. Estimated blood loss (102.7 120.2 mL,  = 0.001) and operative time (156.1 149.3 minutes,  < 0.001) were slightly lower in the ROSI group. There was no statistical difference in the 90-day complication rate (Clavien ≥III) between groups, with both having 3% of patients readmitted or seen in the emergency department within 90 days of surgery. Surgeon-controlled suction allowed more surgeon autonomy without a negative impact on efficiency or safety issues requiring "bailout" suctioning by the bedside assistant whether urgent or otherwise. Robotic surgeons without access to skilled bedside assistants should consider suctioning for themselves not unlike the norm for many laparoscopic surgeons.
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http://dx.doi.org/10.1089/end.2020.1059DOI Listing
April 2021

AUTHOR REPLY.

Urology 2021 Feb;148:165

Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, OH.

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http://dx.doi.org/10.1016/j.urology.2020.08.094DOI Listing
February 2021

Impact of the COVID-19 Crisis on Same-day Discharge After Robotic Urologic Surgery.

Urology 2021 03 19;149:40-45. Epub 2021 Jan 19.

Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, OH.

Objective: To assess the impact of the COVID-19 pandemic on the rate of same-day discharge (SDD) after robotic surgery METHODS: We reviewed our robotic surgeries during COVID-19 restrictions on surgery in Ohio between March 17 and June 5, 2020 and compared them with robotic procedures before COVID-19 and after restrictions were lifted. We followed our formerly described protocol in use since 2016 offering the option of SDD to all robotic urologic surgery patients, regardless of procedure type or patient-specific factors.

Results: During COVID-19 restrictions (COV), 89 robotic surgeries were performed and compared with 1667 of the same procedures performed previously (pre-COV) and 42 during the following month (post-COV). Among COV patients 98% (87/89 patients) opted for same-day discharge after surgery versus 52% in the historical pre-COV group (P < .00001). Post-COV, the higher rate of SDD was maintained at 98% (41/42 patients). There were no differences in 30-day complications or readmissions between SDD and overnight patients with only 2 COV (2%) and no post-COV 30-day readmissions.

Conclusion: SDD after robotic surgery was safely applied during the COVID-19 crisis without increasing complications or readmissions. SDD may allow continuation of robotic surgery despite limited hospital beds and when minimizing hospital stay is important to protect postoperative patients from infection. Our experience suggests that patient attitude is a major factor in SDD after robotic surgery since the proportion of patients opting for SDD was much higher during COV and continued post-COV. Consideration of SDD long-term may be warranted for cost savings even in the absence of a crisis.
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http://dx.doi.org/10.1016/j.urology.2021.01.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817411PMC
March 2021

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

Randomized Controlled Comparison of Valveless Trocar (AirSeal) Standard Insufflator with Ultralow Pneuomoperitoneum During Robotic Prostatectomy.

J Endourol 2021 07 21;35(7):1020-1024. Epub 2021 Jan 21.

Department of Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio, USA.

To compare valveless insufflation (AirSeal) with a conventional insufflation system (CIS) during robotic prostatectomy (RP) and the ability to use ultralow pneumoperitoneum at 6 mm Hg with each system as well as comparison of physiologic outcomes and pain scores. We conducted a prospective study of 100 patients randomized to AirSeal or CIS during RP. The frequency of need for increasing pneumoperitoneum was assessed as well as arterial blood gases, respiratory/hemodynamic parameters, pain scores, and analgesic requirements. Quality of smoke evacuation and scope cleaning frequency were also measured. All procedures were completed at 6 mm Hg without needing to increase pressures with either insufflator. There were no statistically significant differences in partial pressure of carbon dioxide (PaCO), partial pressure of oxygen (PaO), HCO, pH, carbon dioxide (CO) elimination, or end-tidal carbon dioxide pressure (EtCO) between groups. The AirSeal group had a lower maximum peritoneal pressure (7.9 9.9 mm Hg,  < 0.001) but without differences in pain scores or analgesics. Surgeon-assessed smoke evacuation was poorer using CIS with more laparoscope cleanings in nonobese patients than with AirSeal (2.1 3.0,  = 0.026). Valveless-trocar insufflation provided more stable pressure but without benefits in physiologic or pain parameters. Previously identified benefits may have been negated by being able to complete all procedures at ultralow pressure with either insufflator, although an expert bedside assistant moderating suction may have contributed to feasibility of maintaining low pressure with CIS. A randomized trial of 6 15 mm Hg is currently underway. The ClinicalTrials.gov Identifier: NCT02114164.
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http://dx.doi.org/10.1089/end.2020.1025DOI Listing
July 2021

Single-port Robotic Surgery Allows Same-day Discharge in Majority of Cases.

Urology 2021 Feb 17;148:159-165. Epub 2020 Nov 17.

Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, OH.

Objective: To assess the influence of single-port (SP) robotic surgery on length of stay (LOS) in our initial experience using the da Vinci SP robot as compared with traditional, multiport procedures.

Methods: We evaluated our single surgeon (RA) prospective database for the initial 100 SP procedures performed between January 2019 and January 2020. Patient LOS was compared with standard multiport robotic surgery patients since we began routinely offering same-day discharge (SDD) in September 2016.

Results: Among the initial 100 SP robotic surgeries, there were 59 prostatectomies, 18 partial nephrectomies, 12 pyeloplasties, 4 nephrectomies, 4 adrenalectomies, 2 partial cystectomies, and 1 nephroureterectomy. The rate of SDD in SP procedures was higher compared to our historical SDD for multiport robotic surgeries despite uniformly offering SDD to all patients in both groups (88% vs 51%, P < .0001). Among prostatectomies, 88% of SP patients were discharged the same day versus 55% (P < .001). Among partial nephrectomies, 83% of SP patients went home the same day versus 17% (P < .001) as well as 83% of pyeloplasty patients versus 52% (P = .064). For SP adrenalectomy, nephrectomy, partial cystectomy, and nephroureterectomy, all were discharged the same day.

Conclusion: Our initial experience with SP robotic surgery suggests earlier discharge is possible with the large majority (88%) so far opting to go home the same day as surgery. Further experience will be necessary to allow analysis of pain scores and analgesic usage as potential causative factors.
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http://dx.doi.org/10.1016/j.urology.2020.08.092DOI Listing
February 2021

Adoption of Single-Port Robotic Prostatectomy: Two Alternative Strategies.

J Endourol 2020 12 15;34(12):1230-1234. Epub 2020 Oct 15.

Division of Surgery, Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

To demonstrate two distinct methods for adopting the single-port (SP) robotic surgery system for robotic-assisted laparoscopic prostatectomy (RALP) by two experienced robotic surgeons (J.D. and R.A.) and evaluate early outcomes with each strategy. The initial RALP procedures using the SP robot by two surgeons were reviewed from prospective data collection at two institutions, MD Anderson Cancer Center (MDA) and OhioHealth Dublin Methodist Hospital (DMH). Both teams adopted different strategies regarding patient selection criteria, surgical approach, use of assistant ports, performance of lymphadenectomy, postoperative discharge criteria, and having a backup robot on standby. The initial 74 consecutive patients who underwent SP-RALP at MDA and DMH ( = 34 and  = 40, respectively) were reviewed. All DMH and 24 MDA patients underwent a transperitoneal (TP) approach, whereas 10 MDA patients underwent an extraperitoneal (EP) approach. Mean operative time was similar for MDA and DMH, although it was shorter in TP patients. All MDA patients underwent nerve-sparing procedures and 12% underwent pelvic lymph node dissection (PLND); however, at DMH, all patients had PLND and 55% had nerve sparing. Mean estimated blood loss was not clinically significant for either group. Length of stay was 1.1 days (range, 1-2 days) for MDA and 0.12 days (range, 0--1 day) for DMH. No major complications occurred in either group other than two lymphoceles requiring percutaneous drainage in the EP SP-RALP group. Two significantly different strategies for SP robot adoption allowed immediately safe and equally efficacious outcomes in the initial patients treated.
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http://dx.doi.org/10.1089/end.2020.0425DOI Listing
December 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

Near-infrared fluorescence imaging for intraoperative margin assessment during robot-assisted partial nephrectomy.

BJU Int 2020 08 19;126(2):259-264. Epub 2020 May 19.

OhioHealth Robotic Urologic and Cancer Surgery, OhioHealth Dublin Methodist Hospital, Dublin, OH, USA.

Objectives: To demonstrate how using a standardised dosing strategy of indocyanine green (ICG) dye with near-infrared fluorescence (NIRF) imaging can be used to differentiate renal tumours from normal renal parenchyma during robot-assisted partial nephrectomy (RAPN).

Patients And Methods: We reviewed a prospectively collected database of 361 consecutive RAPNs using NIRF between June 2011 and March 2018, and determined the rate at which differential fluorescence was achieved. Tumour and kidney fluorescence or afluorescence were recorded intraoperatively and compared to histological results on final pathology.

Results: Of 330 tumours, after 31 exclusions for nonvisible tumours due to adherent fat, completely intrarenal location or for incomplete data, 288 (87.3%) successfully exhibited differential fluorescence. Among the predominant histologies, 249 of 277 (89.9%) renal cell carcinomas did not fluoresce, as well as 23 of 32 (71.9%) oncocytomas. Real-time gross assessment of resection margin for fluorescence yielded a positive margin rate on final pathology of 0.30%.

Conclusion: When administered with a standardised ICG-dosing strategy, NIRF successfully achieved differential fluorescence in a large majority of tumours during RAPN with an exceedingly low positive margin rate.
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http://dx.doi.org/10.1111/bju.15089DOI Listing
August 2020

Predicting intra-operative and postoperative consequential events using machine-learning techniques in patients undergoing robot-assisted partial nephrectomy: a Vattikuti Collective Quality Initiative database study.

BJU Int 2020 09 18;126(3):350-358. Epub 2020 May 18.

Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.

Objective: To predict intra-operative (IOEs) and postoperative events (POEs) consequential to the derailment of the ideal clinical course of patient recovery.

Materials And Methods: The Vattikuti Collective Quality Initiative is a multi-institutional dataset of patients who underwent robot-assisted partial nephectomy for kidney tumours. Machine-learning (ML) models were constructed to predict IOEs and POEs using logistic regression, random forest and neural networks. The models to predict IOEs used patient demographics and preoperative data. In addition to these, intra-operative data were used to predict POEs. Performance on the test dataset was assessed using area under the receiver-operating characteristic curve (AUC-ROC) and area under the precision-recall curve (PR-AUC).

Results: The rates of IOEs and POEs were 5.62% and 20.98%, respectively. Models for predicting IOEs were constructed using data from 1690 patients and 38 variables; the best model had an AUC-ROC of 0.858 (95% confidence interval [CI] 0.762, 0.936) and a PR-AUC of 0.590 (95% CI 0.400, 0.759). Models for predicting POEs were trained using data from 1406 patients and 59 variables; the best model had an AUC-ROC of 0.875 (95% CI 0.834, 0.913) and a PR-AUC 0.706 (95% CI, 0.610, 0.790).

Conclusions: The performance of the ML models in the present study was encouraging. Further validation in a multi-institutional clinical setting with larger datasets would be necessary to establish their clinical value. ML models can be used to predict significant events during and after surgery with good accuracy, paving the way for application in clinical practice to predict and intervene at an opportune time to avert complications and improve patient outcomes.
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http://dx.doi.org/10.1111/bju.15087DOI Listing
September 2020

Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help?

BJU Int 2020 06 27;125(6):893-897. Epub 2020 Mar 27.

Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA.

Objectives: To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN.

Patients And Methods: Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests.

Results: Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques.

Conclusion: In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.
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http://dx.doi.org/10.1111/bju.15043DOI Listing
June 2020

Dose-Dependent Increases in Ellagitannin Metabolites as Biomarkers of Intake in Humans Consuming Standardized Black Raspberry Food Products Designed for Clinical Trials.

Mol Nutr Food Res 2020 05 17;64(10):e1900800. Epub 2020 Mar 17.

Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA.

Scope: Black raspberry (BRB) phytochemicals demonstrate anti-carcinogenic properties in experimental models, including prostate cancer. Two BRB foods, a confection and nectar, providing a consistent and reproducible product for human clinical studies are designed and characterized.

Methods And Results: Men with clinically localized prostate cancer are sequentially enrolled to a control group or one of four intervention groups (confection or nectar, 10 or 20 g dose; n = 8 per group) for 4 weeks prior to prostatectomy. Primary outcomes include: safety, adherence, and ellagitannin metabolism. Adherence to the intervention is >96%. No significant (≥grade II) toxicities are detected. Urinary urolithins (A, B, C, and D) and dimethyl ellagic acid (DMEA) quantified by Ultra high performance liquid chromatography tandem mass spectroscopy (UPLC/MS/MS) indicate a dose-dependent excretion yet heterogeneous patterns among men. Men in the BRB confection groups have greater urinary excretion of the microbial urinary metabolites urolithin A and DMEA, suggesting that this food matrix provides greater colonic microflora exposure.

Conclusion: Fully characterized BRB confections and nectar are ideal for food-based large phase III human clinical studies. BRB products provide a bioavailable source of BRB phytochemicals, however large inter individual variation in polyphenol metabolism suggests that host genetics, microflora, and other factors are critical to understanding bioactivity and metabolism.
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http://dx.doi.org/10.1002/mnfr.201900800DOI Listing
May 2020

A Multi-Institutional Analysis of the Effect of Positive Surgical Margins Following Robot-Assisted Partial Nephrectomy on Oncologic Outcomes.

J Endourol 2020 03 27;34(3):304-311. Epub 2020 Feb 27.

Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

To determine the effect of positive surgical margins (PSMs) on oncologic outcomes following robot-assisted partial nephrectomy (RAPN) and to identify factors that increase the likelihood of adverse oncologic outcomes. A multi-institutional database of patients who underwent RAPN with complete follow-up data was used to compare recurrence-free survival (RFS) and overall survival (OS) between 42 (5.1%) patients with a PSM and 797 (94.9%) patients with a negative surgical margin. Analysis was performed with univariable and multivariable Cox proportional hazard regression models adjusting for confounding variables. A Kaplan-Meier method was used to evaluate the relationship between PSM and oncologic outcomes (RFS and OS), and the equality of the curves was assessed using a log-rank test. The rate of PSM was 5.1%. RFS at 12, 24, and 36 months was 97.8%, 95.2%, and 92.9%. OS at 12, 24, and 36 months was 98.6%, 97.7%, and 93.3%. PSM was not associated with worse RFS in both univariable and multivariable analyses (hazard ratio [HR] = 1.43; 95% confidence interval [CI] = 0.37, 5.55;  = 0.607). Factors associated with worse RFS include pT3a upstaging (HR = 4.97; 95% CI = 1.63, 15.12;  = 0.005), a higher Charlson comorbidity index (HR = 1.68; 95% CI = 1.20, 2.34;  = 0.002); and advanced clinical stage (cT1a cT1b, HR = 4.22; 95% CI = 1.84, 9.68;  = 0.001 cT2a, HR = 14.09; 95% CI = 3.85, 51.53;  < 0.001). PSM was not associated with worse OS in both univariable and multivariable analyses (HR = 0.87; 95% CI = 0.26, 2.94;  = 0.821). Higher R.E.N.A.L. nephrometry score was found to be associated with worse OS (HR = 1.26; 95% CI = 1.01, 1.57;  = 0.041). Given the absence of association between PSM and worse oncologic outcomes, patients with PSM following RAPN should be carefully monitored for recurrence rather than undergo immediate secondary intervention. As advanced clinical stage (cT1b, cT2a) and pathologic upstaging (pT3a) were independently associated with disease recurrence, their presence may warrant more attentive postoperative surveillance.
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http://dx.doi.org/10.1089/end.2019.0506DOI 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

Robotic Radical Nephrectomy for Massive Renal Tumors.

J Laparoendosc Adv Surg Tech A 2020 Feb 21;30(2):196-200. Epub 2019 Nov 21.

Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio.

The role of robotic surgery in radical nephrectomy is controversial with detractors claiming no benefit over standard or hand-assisted laparoscopic nephrectomy with increased cost. We routinely offered robotic radical nephrectomy (RRN) for all renal masses not amenable to partial nephrectomy regardless of size or complexity and evaluated the success rate for massive tumors (≥15 cm) to assess whether RRN may be justifiable in such cases. We reviewed our prospective database of RRN by an experienced robotic surgeon (R.A.). All patients with massive renal tumors (≥15 cm) were included without exclusions, and no nephrectomy procedures were performed laparoscopically or open approach by the surgeon such that there was no selection bias. Fifteen patients had tumors of 15-30 cm (mean 19 cm) and underwent RRN without exclusions. Mean age was 62 years (35-78 years) with mean body mass index of 31 kg/m (21-41 kg/m). One required partial liver resection, one splenectomy and distal pancreatectomy, one had a large caval thrombus, one a large renal vein thrombus, and one invaded psoas muscle, but all were completed robotically without conversions and no transfusions, with mean operative time of 235 minutes (72-337 minutes). Midline extraction incisions were used and no patients required intravenous narcotics. Twelve were discharged on the first postoperative day (80%) with median length of stay of 1 day and no 90-day readmissions. The only complication was temporary renal insufficiency in 1 patient. RRN for massive renal tumors (>15 cm) is feasible, and can be safely performed with excellent outcomes even in the setting of locally advanced malignancies.
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http://dx.doi.org/10.1089/lap.2019.0630DOI Listing
February 2020

Complex robotic nephrectomy and inferior vena cava tumor thrombectomy: an evolving landscape.

Curr Opin Urol 2020 01;30(1):83-89

Ohio Health, Dublin Methodist Hospital, Dublin, Ohio, USA.

Purpose Of Review: Robotic nephrectomy for complex renal masses and in the setting of inferior vena cava (IVC) tumor thrombus has been shown to be a well tolerated and reproducible surgical option. Recent developments in such procedures will be discussed as they continue to evolve.

Recent Findings: Multiple case series have demonstrated the application of robotic surgery in the management of the most complex renal tumors and for IVC thrombi with acceptable oncologic and perioperative outcomes. Prior to the advent of robotic surgery, massive tumors, contiguous organ invasion, need for lymphadenectomy, and IVC tumor thrombus were thought by many to require open surgery. Since 2011, several studies have reported robotic nephrectomy for complex tumors with recent comparisons of robotic and open approaches finding similar oncologic and survival outcomes but with shorter length of stay (LOS) and less blood loss with robotic surgery.

Summary: Robotic surgery is a feasible and well tolerated alternative to open surgery for the management of complex renal tumors and IVC thrombi. The potential benefits of shorter LOS, less blood loss, and earlier convalescence suggest this approach should continue to be evaluated. Patient selection and surgeon experience are of paramount importance.
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http://dx.doi.org/10.1097/MOU.0000000000000690DOI Listing
January 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

Feasibility of adopting retroperitoneal robotic partial nephrectomy after extensive transperitoneal experience.

World J Urol 2020 May 12;38(5):1087-1092. Epub 2019 Sep 12.

Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, 7450 Hospital Dr., Dublin, OH, 43016, USA.

Purpose: Adoption of robotic retroperitoneal surgery has lagged behind robotic surgery adoption in general due to unique challenges of access and anatomy. We evaluated our initial results with robotic retroperitoneal robotic partial nephrectomy (RRPN) after transitioning from exclusively transperitoneal robotic partial nephrectomy (TRPN) to evaluate safety and any identifiable learning curve.

Methods: We evaluated our single-surgeon (RA) prospective partial nephrectomy database since adopting RRPN routinely for posterior tumors in 2017. The surgeon had previously performed 410 partial nephrectomies by this time. Outcomes were compared after the initial 30 RRPN.

Results: Of 137 patients since adopting RRPN, two attempted RRPN were converted to TRPN without complications due to morbid obesity affecting access, and 30 RRPN were completed (107 TRPN). There were no statistically significant differences in demographics, mean tumor size, or RENAL score between groups. Mean blood loss was lower in RRPN (53 mL vs 99 mL, P < 0.05), but there were no transfusions in either group. There was no difference in mean operative (127.8 min vs 141.2 min, P = 0.06) or ischemia time (11.1 min vs 10.8 min, P = 0.98). There were no positive margins in either group. Mean length of stay was lower in RRPN due to more same-day discharges (0.7 vs 0.9 days). There were no 90-day Clavien III-V complications. One RRPN patient was readmitted POD#8 overnight for hypoxia, and one visited the emergency room POD#7 for persistent pain. All three TRPN complications were managed as outpatients.

Conclusions: Successful adoption of RRPN can be achieved readily after experience with TRPN. Outcomes were immediately comparable without any identifiable learning curve.
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http://dx.doi.org/10.1007/s00345-019-02935-zDOI Listing
May 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

EDITORIAL COMMENT.

Authors:
Ronney Abaza

Urology 2019 08;130:209

OhioHealth Dublin Methodist Hospital, Dublin, OH 43016. Electronic address:

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http://dx.doi.org/10.1016/j.urology.2019.02.049DOI Listing
August 2019

Robotic One Access Surgery (R-1): Initial Preclinical Experience for Urological Surgeries.

Urology 2019 Nov 9;133:5-10.e1. Epub 2019 Jul 9.

Swedish Urology Group, Seattle, WA.

Laparoendoscopic single-site surgery was developed to minimize the morbidity associated with laparoscopic surgery. Application of robotics in urologic surgery has been widely adopted given the advantages it provides over standard laparoscopy including 3-dimensional vision, improved ergonomics, enhanced precision and dexterity. The real benefit of robotic laparoendoscopic single-site surgery is still unbalanced by the limitations of this approach and the sole applicability by highly skilled surgeons. The ideal robotic platform for single-port surgery should have the possibility of being deployed through a single access site restoring intracorporeal triangulation for precise instrument maneuvers. This manuscript reviews the potential applications of R-1 new surgical robot, highlighting its added value in allowing new surgical approaches.
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http://dx.doi.org/10.1016/j.urology.2019.05.045DOI Listing
November 2019

Trends and outcomes in contemporary management renal cell carcinoma and vena cava thrombus.

Urol Oncol 2019 09 5;37(9):576.e17-576.e23. Epub 2019 Jun 5.

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

Introduction: We sought to analyze the safety, efficacy, and national trends in the use of robotic radical nephrectomy (RN) and inferior vena cava thrombectomy in patients with renal cell carcinoma.

Patients And Methods: We analyzed 872 patients from the National Cancer Database dataset who underwent open (n = 838, 96.1%) or robotic (n = 34, 3.9%) radical nephrectomy with inferior vena cava thrombectomy for cT3b renal cell carcinoma between 2010 and 2014. Length of stay (LOS), 30-day readmissions and 30-day mortality were compared between the 2 groups. As internal validation, we performed a multi-institutional analysis of 20 patients (9 open [45%] vs. 11 robotic [55%]) undergoing RN with a level II thrombus. Patients were compared in terms of baseline characteristics, peri- and postoperative outcomes. Uni- and multivariable models were used adjusting for clinical and tumor characteristics.

Results: Baseline characteristics were similar between the 2 groups in both datasets. In the National Cancer Database, robotic approach was associated with 26% reduction in LOS (P < 0.001) but no difference in readmissions (odds ratio [OR] = 0.91; 95% confidence interval [CI] = 0.05, 4.50; P = 0.925) or 30-day mortality (OR = 2.72; 95% CI = 0.40, 10.86; P = 0.211). In multicenter database, open group had significantly greater blood loss (600 vs. 100.0 mL, P = 0.020). The rate of blood transfusion was higher in the open group, but was not significant (44.4% vs. 18.2%, P = 0.336). Robotic group had a shorter LOS (1 vs. 5 days; P = 0.026). No difference was seen between the open and robotic groups in terms of operative time (226 vs. 260 minutes, P = 0.922) and postoperative complications (P > 0.999).

Conclusion: In select cases and experienced hands, robotic approach offers a reasonable alternative to open surgery without an increased complication rate.
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http://dx.doi.org/10.1016/j.urolonc.2019.05.010DOI Listing
September 2019

Identifying tumor-related risk factors for simultaneous adrenalectomy in patients with cT1-cT2 kidney cancer during robotic assisted laparoscopic radical nephrectomy.

Minerva Urol Nephrol 2021 Feb 4;73(1):72-77. Epub 2019 Jun 4.

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

Background: In some cases, preservation of adrenal gland could be at risk in patients with cT1 and cT2 RCC. The aim of this study was to evaluate tumor-related factors that can potentially increase the risk of simultaneous adrenalectomy during robotic-assisted laparoscopic radical nephrectomy (RALRN) in patients with cT1-cT2 disease and the impact of performing such procedure on recurrence-free survival (RFS) and complication rates.

Methods: We used a multi-institutional kidney cancer database where we identified patients who underwent RALRN with or without adrenalectomy. We evaluated the tumor-related characteristics that could potentially increase the risk of adrenal gland resection of these patients. We also reported RFS at 12-24 months of follow-up, which was compared with an inverse probability of treatment weighted (IPTW) multivariable cox proportional hazards regression model and postoperative complications, which was compared with an IPTW multivariable logistic regression model.

Results: Tumor size, cT stage, pT stage, histologic subtype, sarcomatoid differentiation, BMI, lymph node involvement, metastatic disease, Fuhrman grade do not increase the risk of simultaneous adrenalectomy during RALRN. Moreover, RALRN with adrenalectomy had no significant benefit in RFS. No differences in post-operative complications were noted.

Conclusions: Our evaluated tumor-related characteristics did not show to impact the incidence of simultaneous adrenalectomy. Adrenal gland resection T does not provide significant benefit in recurrence-free survival. We consider that RALRN with adrenalectomy should be reserved only for patients with adrenal compromise as stated previously regardless that it has shown to be a safe procedure.
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http://dx.doi.org/10.23736/S0393-2249.19.03440-4DOI Listing
February 2021
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