Browsing by Subject "partial nephrectomy"

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    Development and Validation of an Objective Scoring Tool for Robot-Assisted Partial Nephrectomy: Scoring for Partial Nephrectomy
    (Mary Ann Liebert, 2021) Iqbal, Umar; Jing, Zhe; Ahmed, Youssef; Elsayed, Ahmed S.; Rogers, Craig G.; Boris, Ronald S.; Porter, James Robert; Allaf, Mohamad E.; Badani, Ketan K.; Stifelman, Michael D.; Kaouk, Jihad; Terakawa, Tomoaki; Hinata, Nobuyuki; Aboumohamed, Ahmed; Kauffman, Eric; Li, Qiang; Abaza, Ronney; Guru, Khurshid A.; Hussein, Ahmed; Eun, Daniel; Urology, School of Medicine
    Objective: To develop a structured and objective scoring tool for assessment of robot-assisted partial nephrectomy (RAPN): Scoring for Partial Nephrectomy (SPaN). Materials and Methods:Content development: RAPN was deconstructed into 6 domains by a multi-institutional panel of 10 expert robotic surgeons. Performance on each domain was represented on a Likert scale of 1 to 5, with specific descriptions of anchors 1, 3, and 5. Content validation: The Delphi methodology was utilized to achieve consensus about the description of each anchor for each domain in terms of appropriateness of the skill assessed, objectiveness, clarity, and unambiguous wording. The content validity index (CVI) of ≥0.75 was set as cutoff for consensus. Reliability: 15 de-identified videos of RAPN were utilized to determine the inter-rater reliability using linearly weighted percent agreement, and Construct validation of SPaN was described in terms of median scores and odds ratios. Results: The expert panel reached consensus (CVI ≥0.75) after 2 rounds. Consensus was achieved for 36 (67%) statements in the first round and 18 (33%) after the second round. The final six-domain SPaN included Exposure of the kidney; Identification and dissection of the ureter and gonadal vessels; Dissection of the hilum; Tumor localization and exposure; Clamping and tumor resection; and Renorrhaphy. The linearly weighted percent agreement was >0.75 for all domains. There was no difference between median scores for any domain between attendings and trainees. Conclusion: Despite the lack of significant construct validity, SPaN is a structured, reliable, and procedure-specific tool that can objectively assesses technical proficiency for RAPN.
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    Identifying Preoperative Predictors of Operative Time and Their Impact on Outcomes in Robot-Assisted Partial Nephrectomy
    (Liebert, 2022-01) Krishnan, Naveen K.; Zappia, Jason; Calaway, Adam C.; Nagle, Ramzy T.; Sundaram, Chandru P.; Boris, Ronald S.; Urology, School of Medicine
    Objective: To identify preoperative characteristics in patients with renal masses that influence operative time during robot-assisted partial nephrectomy (RAPN) and evaluate the relationship between operative time and length of stay (LOS), complication rates, and overall outcome. Materials and Methods: We queried our institutional database to identify a cohort of patients who underwent RAPN by two experienced robotic surgeons between 2012 and 2019. A multivariable regression model was developed to analyze operative time, LOS, and any grade complication within 30 days postoperatively using the bootstrap resampling technique. Results: A total of 392 patients were included. On multivariable analyses, prior abdominal surgery (p = 0.001) was associated with 22 minutes of increase in operating room time, as well as adhesive perirenal fat (22 minutes, p = 0.001). For each one unit increase in nephrometry score, there was a 4-minute increase in operating room time (p = 0.028), and for each one-cm increase in tumor size, there was an associated 12-minute increase in operating room time (p < 0.001). For each 1 year increase in age, there was an associated 0.024-day increase in LOS [odds ratio (OR) (0.013–0.035)]; in addition, for every one-cm increase in tumor size there was a 0.18-day associated increase in LOS [OR (0.070–0.28)]. Each 1-hour increase in operating room time was associated with a 0.25-day increased LOS [OR (0.092–0.41)]. Only tumor size was found to be associated with any grade complication. Conclusions: Patients with a history of abdominal surgery, larger complex tumors, and significant Gerota's fat undergoing robotic partial nephrectomy should anticipate longer operative times. Older patients with larger tumors and longer operative times can anticipate a longer LOS. Tumor size appears to be the common determinant of all three outcomes: operative time, LOS, and any grade Clavien complication.
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    Impact of positive surgical margins on overall survival after partial nephrectomy—A matched comparison based on the National Cancer Database
    (Elsevier, 2018-03) Shum, Cheuk Fan; Bahler, Clinton D.; Sundaram, Chandru P.; Urology, School of Medicine
    Introduction The impact of positive surgical margins (PSM) in partial nephrectomy (PN) has been a controversy. Previous studies on the relationship between PSM and overall survival (OS) were either underpowered or had highly dissimilar groups. We used the National Cancer Database with propensity score matching to determine the association between PSM and OS after PN. Materials and methods We identified patients with T1/T2 N0M0 renal cancer treated with PN between 2004 and 2009, and divided them into 2 groups based on their margin status. We used propensity score matching to ensure similarities in age, comorbidity score (CCI), tumor size, histology, and grade between groups. Covariates were compared by χ2 test. Cox multiple regression was used to estimate the hazard ratios (HR) for all-cause mortality. OS between matched groups were compared by log-rank, Breslow and Tarone-Ware tests. Results After excluding those with missing data on margin or survival status, 20,762 patients were eligible for matching. Each matched group had 1,265 patients, similar in age, sex, race, CCI, tumor size, histology, and grade. There were 386 recorded all-cause mortalities over a median follow-up duration of 72.6 months. Cox multiple regression showed a higher risk of all-cause mortality among cases with PSM (HR: 1.393, P = 0.001). Old age, high CCI, and large tumors had higher risks, while papillary and chromophore histologic subtypes had lower risks. PSM was associated with significantly worse OS by log-rank, Breslow, and Tarone-Ware tests. Conclusion PSM is associated with significantly worse OS after PN.
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    Novel Use of Folate-Targeted Intraoperative Fluorescence, OTL38, in Robot-Assisted Laparoscopic Partial Nephrectomy: Report of the First Three Cases
    (Mary Ann Liebert, 2016) Shum, Cheuk Fan; Bahler, Clinton D.; Low, Philip S.; Ratliff, Timothy L.; Kheyfets, Steven V.; Natarajan, Jay P.; Sandusky, George E.; Sundaram, Chandru P.; Department of Urology, IU School of Medicine
    Partial nephrectomy is now the preferred surgical option for small renal tumors because it allows nephron preservation without compromising oncologic clearance. Its outcomes depend on the surgeon's ability to continuously identify the edges of the tumor during resection, thus leaving an adequate margin around the tumor without excessive removal of normal parenchyma, as well as keeping a short ischemic time. Folate receptors are highly abundant in the normal kidney, and there is a difference in folate receptor expression between malignant and normal renal tissues. Thus, the use of fluorescent agents that target folate receptors should result in differential fluorescence between the tumor and surrounding parenchyma during partial nephrectomy, which, in turn, helps tumor demarcation for identification and resection. A phase 2 study on the novel use of OTL38 in robot-assisted laparoscopic partial nephrectomy is currently in progress in our institution. The outcomes of the first three cases have shown the possible advantages of OTL38 in intraoperative tumor identification before resection and recognition of residual disease in the surrounding parenchyma after resection. The tumors typically appeared dark while the surrounding parenchyma showed brighter fluorescence. Immediately after tumor resection, the margins of all the specimens appeared to have a uniformly bright fluorescence, suggestive of an intact margin of normal renal parenchyma along the plane of excision. The pattern of intraoperative fluorescence correlates well with immunohistochemistry. No OTL38-related adverse effects have been seen among these three patients. We present the outcomes of these three cases, illustrated with intraoperative and immunohistochemistry images.
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    Renal Volume Loss During Partial Nephrectomy Due to Resected Healthy Parenchyma: A Tool for Quick Estimation
    (Liebert, 2020) Plattner, Haley S.; Sundaram, Chandru P.; Cheng, Liang; Bahler, Clinton D.; Urology, School of Medicine
    Purpose: Our objective is to evaluate a technique for estimating the amount of healthy margin resected during partial nephrectomy (PN). Materials and Methods: The resected healthy margin volume was determined by planimetry (gold standard), which was performed in a prospective manner on 30 freshly resected renal masses by cross-sectional slicing every ∼5 mm. A single cross-sectional slice containing the largest tumor diameter (bivalved tumor) was chosen to build a model for estimating the amount of healthy kidney removed. This single-slice technique was then applied to a second series of patients (n = 39) status post PN. Three-dimensional models were created using pre- and postoperative CT scans to determine the overall volume loss following PN. Results: The median (range) for tumor diameter and tumor volume was 3.2 cm (1–6.1) and 10.7 cm3 (0.5–101.9), respectively, for the 30 PN specimens used to build the single-slice estimation equation. The median (range) healthy margin volume calculated by planimetry and single slice technique was 9.0 cm3 (1.0–22.1) and 7.8 cm3 (1.0–31.0), respectively (p = 0.37). The Pearson correlation was 0.84, and the median (range) percent difference between the planimetry and single slice techniques was −0.5% (−39% to 57%). For the 39 PN patients, the median (range) total renal volume loss, 25.8 cm3 (3–79), was significantly greater than the volume of healthy margin removed during resection, 5.7 cm3 (1–22), p < 0.001. Conclusions: The healthy margin resected during PN differs widely and can be estimated from a single cross-section. The healthy margin resected accounted for <50% of the total volume loss seen during PN.