Browsing by Subject "Partial nephrectomy"

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    1- versus 2-Layer Renorrhaphy During Robotic Partial Nephrectomy
    (Society of Laparoscopic & Robotic Surgeons, 2025) Yong, Courtney; Sharfuddin, Asif A.; Sundaram, Chandru P.; Bahler, Clinton D.; Urology, School of Medicine
    Background and objectives: To determine whether 1- versus 2-layer renorrhaphy affects renal function after partial nephrectomy. Methods: A total of 18 patients undergoing robot-assisted partial nephrectomies for renal tumors at a single center were randomized to 1-layer or 2-layer renorrhaphy. All patients received a running base layer for hemostasis and collecting system closure. The 2-layer renorrhaphy group also underwent cortical closure with running suture, sliding clip method. Demographics and surgical outcomes were collected. Three-dimensional renal models were constructed using semiautomatic segmentation and planimetry pre- and 4 months postsurgery to determine renal volume loss. Welch's t test was used with statistical significance defined as P < .05. Results: Of the 18 patients included in the study, 10 were randomized to 1-layer and 8 to 2-layer renorrhaphy. Demographic variables were matched. There was no difference in postoperative creatinine at 1 month (P = .11), 1 year (P = .28), or 3 years (P = .28) postoperatively. However, the change from pre to postoperative creatinine favored the 1-layer group at 1 month (-0.043 vs +0.11 P = .02) and 3 years (-0.0025 vs 0.244, P = .08) follow up. The 1-layer group had a smaller mean volume loss at 4 months postoperatively compared to the 2-layer group (12% vs 22%, P = .04). Conclusion: This small, randomized trial found increased creatinine and volume loss after 2-layer cortical renorrhaphy. Omitting cortical renorrhaphy may result in better preservation of renal volume and function.
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    The learning curve and factors affecting warm ischemia time during robot-assisted partial nephrectomy
    (Wolters Kluwer, 2015-07) Dube, Hitesh; Bahler, Clinton D.; Sundaram, Chandru P.; Department of Urology, IU School of Medicine
    INTRODUCTION: The learning curve for robotic partial nephrectomy was investigated for an experienced laparoscopic surgeon and factors associated with warm ischemia time (WIT) were assessed. MATERIALS AND METHODS: Between 2007 and 2014, one surgeon completed 171 procedures. Operative time, blood loss, complications and ischemia time were examined to determine the learning curve. The learning curve was defined as the number of procedures needed to reach the targeted goal for WIT, which most recently was 20 min. Statistical analyses including multivariable regression analysis and matching were performed. RESULTS: Comparing the first 30 to the last 30 patients, mean ischemia time (23.0-15.2 min, P < 0.01) decreased while tumor size (2.4-3.4 cm, P = 0.02) and nephrometry score (5.9-7.0, P = 0.02) increased. Body mass index (P = 0.87), age (P = 0.38), complication rate (P = 0.16), operating time (P = 0.78) and estimated blood loss (P = 0.98) did not change. Decreases in ischemia time corresponded with revised goals in 2011 and early vascular unclamping with the omission of cortical renorrhaphy in selected patients. A multivariable analysis found nephrometry score, tumor diameter, cortical renorrhaphy and year of surgery to be significant predictors of WIT. CONCLUSIONS: Adoption of robotic assistance for a surgeon experienced with laparoscopic surgery was associated with low complication rates even during the initial cases of robot-assisted partial nephrectomy. Ischemia time decreased while no significant changes in blood loss, operating time or complications were seen. The largest decrease in ischemia time was associated with adopting evidence-based goals and new techniques, and was not felt to be related to a learning curve.
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    On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis
    (MDPI, 2022-09-13) Brassetti, Aldo; Cacciamani, Giovanni E.; Mari, Andrea; Garisto, Juan D.; Bertolo, Riccardo; Sundaram, Chandru P.; Derweesh, Ithaar; Bindayi, Ahmet; Dasgupta, Prokar; Porter, James; Mottrie, Alexander; Schips, Luigi; Rah, Koon Ho; Chen, David Y. T.; Zhang, Chao; Jacobsohn, Kenneth; Anceschi, Umberto; Bove, Alfredo M.; Costantini, Manuela; Ferriero, Mariaconsiglia; Mastroianni, Riccardo; Misuraca, Leonardo; Tuderti, Gabriele; Kutikov, Alexander; White, Wesley M.; Ryan, Stephen T.; Porpiglia, Francesco; Kaouk, Jihad; Minervini, Andrea; Gill, Inderbir; Autorino, Riccardo; Simone, Giuseppe; Urology, School of Medicine
    We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.
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    OTL-38-Guided Fluorescent Imaging in Renal Cell Cancer Robotic Partial Nephrectomy
    (Mary Ann Liebert, Inc., 2017-02-06) Bahler, Clinton D.; Maniar, Viraj; Marley, Kristen N.; Kheyfets, Steven V.; Shum, Cheuk Fan; Sundaram, Chandru P.; Urology, School of Medicine
    Introduction and Objective: The folate receptor (FR) protein is upregulated in numerous epithelial malignancies while having limited expression on normal tissues. This overexpression of FR in renal-cell carcinoma (RCC) can be exploited by attaching nearly any therapeutic or imaging agent for delivery to cancer cells. In one of its first applications, platinum-resistant ovarian cancer, folate was used to deliver pegylated liposomal doxorubicin (a folate-linked vinca alkaloid) and improved progression-free survival versus standard treatment. RCCs are thought to be the second highest FR-expressing cancer. OTL-38 is a folate analogue conjugated with a fluorescent dye that emits light in the near infrared spectrum. This longer wavelength allows for deeper penetration of the fluorescent light through tissues with the potential to better image tumors beneath adipose tissue or deeper into organ parenchyma. We are currently conducting a pilot, phase 2, nonrandomized study in patients with RCC, scheduled to undergo primary, partial, or radical nephrectomy. The aim is to explore the use of OTL-38 and fluorescence imaging to observe RCC at the margins of resection in partial nephrectomy and in lymph node(s) or other metastases for radical nephrectomy. Methods: Currently two patients have participated in the trial to date with an accrual target of 20 patients. The first was a 67-year-old male with an incidental 2.2 cm right-sided renal mass, and the second was a 70-year-old male with an enlarging 2 cm renal mass. Per protocol, both patients were administered OTL-38 in the preoperative area 1 hour before the procedure. Subsequently, both procedures were performed with robotic assistance as per normal routine with the use of Firefly fluorescence to aid in observation of OTL-38 uptake. Results: Intraoperative guidance through OTL-38 demonstrated minimal to no uptake of the OTL-38 as seen by Firefly fluorescence (green color). Surprisingly, the normal renal parenchyma showed strong uptake of OTL-38 as seen by Firefly fluorescence. Both pathology reports revealed conventional clear cell RCC. Immunohistochemistry slides of the tumor revealed only mild staining for folate. In contrast, immunohistochemistry slides of the normal renal parenchyma in the surgical margin revealed a strongly positive stain for folate. Conclusions: In conclusion, our first two patients' renal tumors did not stain strongly for folate; however, the normal renal parenchyma did, which served as an intraoperative guide to confirm a negative margin. Further study of patients will reveal whether folate receptors are, in fact, predominant or not in renal cell cancer.