Feasibility of Omitting Outer Renorrhaphy During Robotic Partial Nephrectomy

Introduction: Reconstruction technique after robotic partial nephrectomy (RPN) is a modifiable factor with possible impact on ischemia time, bleeding, renal function, and incidence of pseudoaneurysms. We sought to evaluate the feasibility of omitting cortical (outer) renorrhaphy (CR) in a multi-institutional setting.Methods: We analyzed 1453 patients undergoing RPN, from 2006-2018, within the Vattikuti Collective Quality Initiative database, which captures that data from 14 centers in 9 countries. Patients having surgery for bilateral tumors(n=73) were excluded. The CR and no-CR groups were compared in terms of operative and ischemia time, blood loss, major (Clavien≥3) complications, surgical margins, hospital stay, change in estimated glomerular filtration rate (eGFR), and need of angioembolization. Inverse probability of treatment weighting (IPTW) with a Firth correction for center code was done to account for selection bias.Results: CR was omitted in 120 patients; 1260 patients underwent both inner (base) layer renorrhaphy and CR. There was no difference in intraoperative complications (7.4% in CR; 8.9% in no-CR group;p=0.6) or postoperative major complications (1% and 2.8% in the CR and no-CR groups, respectively;p=0.2). Estimated blood loss was 100 mL (IQR 50-200) in both treatment groups(p=0.6). Angioembolization was needed in 0.7% patients in CR group vs 1.4% in no-CR group(p=0.4). Additionally, there was no difference in median operative time (168 minutes and 162 minutes, respectively;p=0.2), or ischemia time (18 minutes and 17 minutes, respectively;p=0.7). Conclusions: Omission of CR did not significantly improve operative or ischemia time; however, it also had no adverse effect on perioperative outcomes after RPN in a multi-institutional setting.https://scholarlycommons.henryford.com/merf2019clinres/1003/thumbnail.jp

New multiport robotic surgical systems: a comprehensive literature review of clinical outcomes in urology

Over the past 20 years, the field of robotic surgery has largely been dominated by the da Vinci robotic platform. Nevertheless, numerous novel multiport robotic surgical systems have been developed over the past decade, and some have recently been introduced into clinical practice. This nonsystematic review aims to describe novel surgical robotic systems, their individual designs, and their reported uses and clinical outcomes within the field of urologic surgery. Specifically, we performed a comprehensive review of the literature regarding the use of the Senhance robotic system, the CMR-Versius robotic system, and the Hugo RAS in urologic procedures. Systems with fewer published uses are also described, including the Avatera, Hintori, and Dexter. Notable features of each system are compared, with a particular emphasis on factors differentiating each system from the da Vinci robotic system

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

CONTEXT: A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. OBJECTIVE: To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). EVIDENCE ACQUISITION: A literature review was conducted. EVIDENCE SYNTHESIS: Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. CONCLUSIONS: Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. PATIENT SUMMARY: In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes

Robot-assisted segmental ureterectomy with psoas hitch ureteral reimplantation: Oncological, functional and perioperative outcomes of case series of a single centre.

Introduction: According to the Urology guidelines, in selected cases of distal upper tract urothelial carcinoma (UTUC) segmental ureterectomy (SU) can be offered. There is no consensus in the surgical technique of preference. Robot-assisted SU could be an option to overcome all the limitations of open and laparoscopic techniques. We describe our first experience of robot assisted SU with psoas hitch ureteral reimplantation (RAPHUR). Materials and methods: 11 patients underwent RAPHUR for distal UTUC between 2013 and 2017 in a single centre. Pre-, intra-, and postoperative outcomes were assessed. Conventional imaging was performed after 1, 3, 6 months and 1 year from surgery as follow up protocol. We retrospectively evaluated the technical feasibility, oncological and functional outcomes. Results: Median age was 71 years (57-91). The median length of the ureteral defect was 23 mm (10-40). Median preoperative creatinine level was 1.22 mg/dl (0.7-1.85) and median eGFR was 57.5 ml/min/1.73m2 (31-80). Five (45.5%) patients were symptomatic and 7 (63.6%) had hydronephrosis. Median operative time was 185 min (120-240), with a median blood loss of 100 ml (50-300). No case required conversion to open surgery. Overall, only 1 (9%) patient developed Clavien Dindo ≥ 3 postoperative complications. Average hospital stay was 7 (2-9) days. Mean postoperative creatinine was 1.05 mg/dl (0.8-1.85) and mean postoperative eGFR was 72 (36-83). During a median follow up time of 25.5 months (12-53), 4 (36.4%) patients experienced recurrence of urothelial cancer at conventional imaging follow up and 2 (18.2%) died due to its progression. Conclusions: In our initial experience RAPHUR can be proposed to selected cases of distal ureteral carcinoma with optimal perioperative and functional outcomes. However, cancer control may be undermined compared to nephroureterectomy. Thus, further prospective studies are needed to confirm our findings

Precision surgery:the role of intra-operative real-time image guidance - outcomes from a multidisciplinary European consensus conference

Developments within the field of image-guided surgery are ever expanding, driven by collective involvement of clinicians, researchers, and industry. While the general conception of the potential of image-guided surgery is to improve surgical outcome, the specific motives and goals that drive can differ between the different expert groups. To establish the current and future role of intra-operative image guidance within the field of image-guided surgery a Delphi consensus survey was conducted during the 2(nd) European Congress on Image-guided surgery. This multidisciplinary survey included questions on the conceptual potential and clinical value of image-guided surgery and was aimed at defining specific areas of research and development in the field in order to stimulate further advances towards precision surgery. Obtained results based on questionnaires filled in by 56 panel experts (clinicians: N=30, researchers: N=20 and industry: N=6) were discussed during a dedicated expert discussion session during the conference. The outcome of this Delphi consensus is indicative of the potential improvements offered by image-guided surgery and of the need for further research in this emerging field, that can be enriched by the identification of reliable molecular targets

Robot-geassisteerde nefro-ureterectomie voor urotheelCa van de hogere urinewegen : resultaten van 3 high-volume robot centra

Doelstelling: Robot-geassisteerde nefro-ureterectomie (RANU) vormt een minimaal invasief alternatief voor open nefro-ureterectomie in de behandeling van urotheelcelcarcinoom van de hogere urinewegen (UTUC). Het doel van deze studie is om de perioperatieve en oncologische uitkomst na RANU te onderzoeken. Materiaal en Methoden: Tussen 2008 en 2017 ondergingen 78 patiënten RANU voor UTUC in 3 high-volume robot centra. Retrospectieve analyse met beschrijvende statistiek en Kaplan-Meier curves gebeurde om de intra- en postoperatieve complicaties te beschrijven, en de oncologische uitkomst (algeheel en gestratifieerd volgens hervaltype en pathologisch tumorstadium) te onderzoeken. Resultaten: De mediane leeftijd bij diagnose was 72jaar (IQR 65-78) met een mediane Charlson comorbidity index van 3 (IQR 1-6). Man-vrouw ratio was 2:1. De tumor bevond zich ter hoogte van het renaal/pyelo-calicieel systeem (52%), de proximale ureter (6%), midureteraal (19%), de distale ureter (2%) of multifocaal (21%). Het mediane geschatte bloedverlies was 75ml (IQR 35-180) en de mediane verblijfsduur 4dagen (IQR 4-6). Bloedtransfusies gebeurden bij 3% van de patiënten. Intraoperatieve complicaties traden op in 5% en postoperatieve complicaties in 25% van de gevallen. Clavien-Dindo graad ≥ III complicaties traden op bij 3%. Pathologisch tumorstadium betrof pTa (27%), pTis (3%), pT1 (21%), pT2 (17%), pT3 (24%), pT4 (5%) of pT0 (3%). Lymfeklierdissectie gebeurde bij 31 patiënten (40%) waarvan er bij 29% lymfeklieren waren betrokken. Bij een mediane opvolgingstijd van 15 maanden, is de geschatte algehele 2jaarsoverleving 79%. Gestratifieerd volgens hervaltype is dit respectievelijk 100% voor blaasherval en 16% voor patiënten met herval op afstand (p<0.001). Gestratifieerd volgens pT-stadium is dit 95%, 90% en 41% voor respectievelijk pTa-1, pT2 en pT3-4 tumoren (p=0.01). Peritoneale metastasering werd gezien bij 1 patiënt met pT4N2R1 UTUC. Conclusie: RANU is een veilige en doenbare chirurgische strategie als minimaal invasieve behandeling voor patiënten met UTUC. Postoperatieve morbiditeit is accepteerbaar en het aantal zware complicaties is zeer laag. Op korte termijn lijkt de oncologische uitkomst zeker aanvaardbaar zonder dat er aanwijzingen zijn op een verhoogd risico op peritoneale metastasering