- Email: [email protected]
1192 ZERO-ISCHEMIA VERSUS CLAMPED ROBOTIC PARTIAL NEPHRECTOMY: INITIAL RESULTS OF 121 PATIENTS
Vol. 189, No. 4S, Supplement, Monday, May 6, 2013
THE JOURNAL OF UROLOGY姞
Pre-existing Variables Patient specific factors Estimated blood
Entire Cohort
CKD Mean (median,
De novo CKD
P
222
range) or n (%) 212
239
(100, 5-3280)
(105, 10-2200)
(95, 5-3280)
46
47
45
(45, 0-100)
(47, 0-100)
(43, 18-84)
235
242
224
(227, 126-379)
(241, 126-379)
(216, 137-377)
0.0955
Open
109 (86)
69 (88)
40 (82)
0.3055
Laparoscopic
18 (14)
9 (12)
9 (18)
loss (ml) Clamping time (min) Operative time (min)
0.7324 0.5952
Surgery type
Ischemia Cold
116 (91)
70 (90)
46 (94)
Warm
8 (6)
5 (6)
3 (6)
Zero
3 (2)
3 (4)
0
0.3782
Tumor factors 32
30.1
33.6
(29, 10-94)
(28, 10-94)
(29, 12-72)
0.3039
4-6
42 (33)
27 (35)
15 (32)
0.5731
7-9
68 (54)
43 (55)
25 (52)
10-12
8 (13)
8 (10)
8 (17)
1
94 (75)
60 (77)
34 (71)
2
28 (22)
15 (19)
13 (27)
3
4 (3)
3 (4)
1 (2)
1
51 (40)
33 (42)
18 (38)
2
59 (47)
34 (44)
25 (52)
3
16 (13)
11 (14)
5 (10)
Tumor size (mm) RENAL-NS
Radius component 0.5318
Exophytic/endophytic component 0.6233
Nearness component 1
31 (25)
21 (27)
10 (21)
2
25 (20)
14 (18)
11 (23)
3
70 (56)
43 (55)
27 (56)
1
51 (40)
35 (45)
16 (33)
2
28 (22)
17 (22)
11 (23)
0.6622
Location component
3
47 (37)
26 (33)
21 (44)
47.8
43.5
54.5
(51.7, 11.4-74.2)
(44.9, 11.4-74.2)
(56.4, 22.7-59.8)
47.8
43.4
54.8
(50.2, 8.28-70.2)
(45.0, 8.28-70.2)
(55.6, 27.4-65.6)
48.9
43.5
57.6
(51.4, 6.99-72.0)
(46.3, 6.99-72.0)
(57.8, 31.1-70.9)
0.27
(0.22, -27.3-
0.60
(0, -27.3-23.2)
23.2)
(0, -18.5-20.6)
0.3948
Postoperative eGFR 3m 6m 12m
e487
functional parenchymal volume (FPV) has been proposed as the key factor in predicting functional outcomes following nephron-sparing surgery (NSS). We reexamined the relative contribution of functional parenchymal preservation and renal ischemia following NSS. METHODS: Our prospectively maintained kidney cancer database was queried for patients who underwent NSS with warm ischemia (WIT). Patients with available cross-sectional imaging were included (n⫽188). Cylindrical volume approximation methodology was employed to calculate FPV pre- and post-operatively, accounting for the volume of tumor’s endophytic component. Percent eGFR preservation, as estimated by the CKD-EPI formula at approximately 6 months following surgery was used as the outcome metric. Spearman correlation was used to evaluate associations of WIT and percent FPV preservation with renal function preservation. Linear regression analysis was performed to control for age, BMI, weighted Charlson comorbidity index (CCI), tumor size and pre-operative eGFR. RESULTS: Of the 188 eligible patients, 36% had open and 64% minimally-invasive NSS employing WIT. Median age was 60 years with 66% of patients being male and 89% Caucasian. Median pre-operative eGFR was 88.4 (10% CKD-III or IV). Median tumor size was 2.7cm [0.9 - 10.7] with tumor complexity as captured by RENAL NS being low in 34%, intermediate in 57% and high in 9%. Median WIT was 30 minutes [10-67min], resulting in a 97.4 % FPV preservation. Median postoperative eGFR at 6.5 months was 80.4 (19% CKD-III or IV), a median 93.3% eGFR preservation. FPV demonstrated significant association with eGFR preservation (spearman correlation ⫽ 0.26, p⫽0.001), while WIT showed no statistically significant correlation (p⫽0.53). Results of the multivariable analysis are shown in Table 1. CONCLUSIONS: Residual FPV, and not WIT, appears to be the main predictor of functional outcomes following NSS. Table 1: Multivariable analysis controlling for age, BMI, weighted CCI, tumor size, pre-operative eGFR, WIT, and FPV preservation, assessing association with % eGFR outcome. Linear Regression Variable Coefficient p value Age -0.161 0.268 BMI
-0.030
Tumor Size (mm)
0.008
0.862 0.919
Weighted CCI
-0.534
0.556
Pre-Operative eGFR
-0.217
0.006*
Warm Ischemia Time (min)
-0.039
0.735
% Functional Parenchymal Volume Preservation
0.527
⬍ 0.001*
Source of Funding: Fox Chase Cancer Center Kidney Cancer Keystone Grant
0.06 % change between 3m-6m
0.7639
1192
5.56 % change between 3m-12m
1.82
-0.54
(6.18, -13.7-
(1.16, -53-40.8)
(0, -53.1-32.7)
40.8)
0.0063
CKD: chronic kidney disease eGFR: estimated glomerular filtration rate BMI: body mass index RENAL-NS: R.E.N.A.L nephrometry score
Source of Funding: None
1191 RESIDUAL FUNCTIONAL PARENCHYMAL VOLUME, NOT WARM ISCHEMIA TIME, PREDICTS FUNCTIONAL OUTCOMES FOLLOWING NEPHRON-SPARING RENAL SURGERY Serge Ginzburg*, Robert Uzzo, Christopher Miller, David Kurz, Tianyu Li, John Walton, Awad Ahmed, Anthony Corcoran, Jeffrey Tomaszevski, Reza Mehrazin, Marc Smaldone, Rosalia Viterbo, David Chen, Richard Greenberg, Alexaner Kutikov, Philadelphia, PA INTRODUCTION AND OBJECTIVES: Importance of curtailing ischemia time is coming under increasing scrutiny, while residual
ZERO-ISCHEMIA VERSUS CLAMPED ROBOTIC PARTIAL NEPHRECTOMY: INITIAL RESULTS OF 121 PATIENTS Andre Luis de Castro Abreu, Scott Leslie, Andre Berger*, Dennis Lee, Raed Azhar, Arjuna Dharmaraja, Anmol Amin, Osamu Ukimura, Monish Aron, Inderbir Gill, Mihir Desai, Los Angeles, CA INTRODUCTION AND OBJECTIVES: The objective of this study is to compare peri-operative outcomes of zero-ischemia versus clamped robotic partial nephrectomy (PN). METHODS: Prospective data on 121 patients undergoing zeroischemia (n⫽58) and clamped (n⫽63) robotic PN were retrospectively analyzed. The clamped cohort underwent hilar cross-clamping of the main renal artery. The zero-ischemia cohort underwent tumor-specific devascularization maintaining perfusion of the remnant at all times. Both groups were compared for peri-operative factors and post-operative renal function. RESULTS: Compared to the clamped group, tumors in the zero-ischemia group were more commonly hilar (24% vs 6%, p⫽0.009), larger (3.4 vs 2.6 cm, p⫽0.04) and more complex (PADUA score 10 vs 8, p⫽0.009). All 121 robotic procedures were successful,
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THE JOURNAL OF UROLOGY姞
Vol. 189, No. 4S, Supplement, Monday, May 6, 2013
all surgical margins were negative, and no kidneys were lost. The zero-ischemia group had longer operative time (301 vs 229 minutes, p⬍0.001). Both groups were similar in terms of median estimated blood loss (200 vs 150cc; p⫽0.25), peri-operative complications (15% vs 13%, P⫽0.1), and hospital stay (3 vs 3 days; p⫽0.13). The zeroischemia group had lesser decrease in eGFR at discharge (0% vs 11%, p⫽0.01) and at latest follow up (11% vs 17%, p⫽0.03). Subset analysis showed a trend towards better volume preservation in the zero-ischemia cohort (95% vs 90%, p⫽0.08) despite larger tumor volume (19 vs 8 cc, p⫽0.002). CONCLUSIONS: Robotic zero-ischemia partial nephrectomy affords the consistent opportunity to eliminate ischemic injury. Intraoperative blood loss, peri-operative complications and incidence of positive surgical margins are similar to the clamped technique. At least in the short-term, renal functional outcomes appear superior with zeroischemia robotic partial nephrectomy. Source of Funding: None
1193 ROBOTIC PARTIAL NEPHRECTOMY WITH SELECTIVE ARTERIAL CLAMPING USING NEAR INFRARED FLUORESCENCE IMAGING: NYU INITIAL EXPERIENCE Marc Bjurlin*, James Wysock, Tyler R. McClintock, Michael Borofsky, Ganesh Sivarajan, Suzanne Sorin, Michael D. Stifelman, New York, NY INTRODUCTION AND OBJECTIVES: Near infrared fluorescence imaging (NIRF) is a technology with emerging application in urologic surgery. We evaluated our experience in robotic partial nephrectomy with selective arterial clamping using NIRF and compared renal functional status outcomes in a matched cohort of robotic partial nephrectomies without selective arterial clamping and NIRF. METHODS: A retrospective study of 58 patients, in which NIRF was utilized for partial nephrectomy, was performed. Of these 58 patients, 39 (67%) underwent successful robotic partial nephrectomies with NIRF using ICG for a total of 43 tumors. Patient demographics, peri-operative parameters, and outcomes were evaluated. This cohort was then matched by tumor size, preoperative eGFR, and functional kidney status with 39 patients who underwent robotic partial nephrectomies without selective clamping or NIRF imaging and outcomes compared. RESULTS: Table 1 demonstrates the demographics and perioperative outcomes of the NIRF selectively clamped cohort. Overall tumor size was 2.8 cm; 72% were malignant; pT1a (90%); and there was 1 positive surgical margin. Five post-operative complications occurred (14%) all Clavien grade I-III. Table 2 summarizes the early functional differences between patients undergoing partial nephrectomy with selecting clamping and their total clamp matched cohorts. Selective clamping with NIRF had a lower absolute change in eGFR (p⫽0.0473) and percent change in eGFR (p⫽0.0371) (Table 2). CONCLUSIONS: In our experience robotic partial nephrectomy with selective arterial clamping using near infrared fluorescence imaging with ICG appears safe, effective and reproducible in minimizing warm ischemia damage to the kidney. In our early experience this procedure results in a smaller overall change in eGFR and percent change in eGFR when compared to robotic partial nephrectomy without selective arterial clamping and NIRF.
Source of Funding: None
1194 ZERO-ISCHEMIA RADIOFREQUENCY ABLATION ASSISTED TUMOR ENUCLEATION FOR T1B RENAL CELL CARCINOMA Xiaozhi Zhao*, Shiwei Zhang, Guangxiang Liu, Changwei Ji, Huibo Lian, Feng Qu, Xiang Yan, Xiaogong Li, Weidong Gan, Gutian Zhang, Hongqian Guo, Nanjing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: Emerging evidence suggests that nephron sparing surgery (NSS) might be feasible and safe for renal tumors of 4-7cm. The aim of the study is to evaluate the safety and efficacy of 0-ischemia, radiofrequency ablation (RFA) assisted tumor enucleation (TE) for T1b renal cell carcinoma (RCC), reporting on the incidence of complications, positive surgical margins and shortterm followup results. METHODS: We retrospectively reviewed data for 47 patients with T1b RCC treated with 0-ischemia RFA assisted TE between March 2006 and October 2011. The mean age was 55.9 ¡À 11.0 years, and 36 (76.6%) were male. The mean greatest dimension of tumors was 5.0 ¡À 0.6 cm. Student’s t-test, chi-square test and Fisher’s exact test were used to compare operation time, bleeding and complications. Fisher’s exact test was used to analyze the association Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score and complications. Paired t test was used to compare GFR. RESULTS: We found 47 tumors with greatest dimension between 4cm to 7 cm (see Table 1). Twenty-eight patients underwent RFA assisted laparoscopic TE while 19 patients underwent open RFA
THE JOURNAL OF UROLOGY姞
Pre-existing Variables Patient specific factors Estimated blood
Entire Cohort
CKD Mean (median,
De novo CKD
P
222
range) or n (%) 212
239
(100, 5-3280)
(105, 10-2200)
(95, 5-3280)
46
47
45
(45, 0-100)
(47, 0-100)
(43, 18-84)
235
242
224
(227, 126-379)
(241, 126-379)
(216, 137-377)
0.0955
Open
109 (86)
69 (88)
40 (82)
0.3055
Laparoscopic
18 (14)
9 (12)
9 (18)
loss (ml) Clamping time (min) Operative time (min)
0.7324 0.5952
Surgery type
Ischemia Cold
116 (91)
70 (90)
46 (94)
Warm
8 (6)
5 (6)
3 (6)
Zero
3 (2)
3 (4)
0
0.3782
Tumor factors 32
30.1
33.6
(29, 10-94)
(28, 10-94)
(29, 12-72)
0.3039
4-6
42 (33)
27 (35)
15 (32)
0.5731
7-9
68 (54)
43 (55)
25 (52)
10-12
8 (13)
8 (10)
8 (17)
1
94 (75)
60 (77)
34 (71)
2
28 (22)
15 (19)
13 (27)
3
4 (3)
3 (4)
1 (2)
1
51 (40)
33 (42)
18 (38)
2
59 (47)
34 (44)
25 (52)
3
16 (13)
11 (14)
5 (10)
Tumor size (mm) RENAL-NS
Radius component 0.5318
Exophytic/endophytic component 0.6233
Nearness component 1
31 (25)
21 (27)
10 (21)
2
25 (20)
14 (18)
11 (23)
3
70 (56)
43 (55)
27 (56)
1
51 (40)
35 (45)
16 (33)
2
28 (22)
17 (22)
11 (23)
0.6622
Location component
3
47 (37)
26 (33)
21 (44)
47.8
43.5
54.5
(51.7, 11.4-74.2)
(44.9, 11.4-74.2)
(56.4, 22.7-59.8)
47.8
43.4
54.8
(50.2, 8.28-70.2)
(45.0, 8.28-70.2)
(55.6, 27.4-65.6)
48.9
43.5
57.6
(51.4, 6.99-72.0)
(46.3, 6.99-72.0)
(57.8, 31.1-70.9)
0.27
(0.22, -27.3-
0.60
(0, -27.3-23.2)
23.2)
(0, -18.5-20.6)
0.3948
Postoperative eGFR 3m 6m 12m
e487
functional parenchymal volume (FPV) has been proposed as the key factor in predicting functional outcomes following nephron-sparing surgery (NSS). We reexamined the relative contribution of functional parenchymal preservation and renal ischemia following NSS. METHODS: Our prospectively maintained kidney cancer database was queried for patients who underwent NSS with warm ischemia (WIT). Patients with available cross-sectional imaging were included (n⫽188). Cylindrical volume approximation methodology was employed to calculate FPV pre- and post-operatively, accounting for the volume of tumor’s endophytic component. Percent eGFR preservation, as estimated by the CKD-EPI formula at approximately 6 months following surgery was used as the outcome metric. Spearman correlation was used to evaluate associations of WIT and percent FPV preservation with renal function preservation. Linear regression analysis was performed to control for age, BMI, weighted Charlson comorbidity index (CCI), tumor size and pre-operative eGFR. RESULTS: Of the 188 eligible patients, 36% had open and 64% minimally-invasive NSS employing WIT. Median age was 60 years with 66% of patients being male and 89% Caucasian. Median pre-operative eGFR was 88.4 (10% CKD-III or IV). Median tumor size was 2.7cm [0.9 - 10.7] with tumor complexity as captured by RENAL NS being low in 34%, intermediate in 57% and high in 9%. Median WIT was 30 minutes [10-67min], resulting in a 97.4 % FPV preservation. Median postoperative eGFR at 6.5 months was 80.4 (19% CKD-III or IV), a median 93.3% eGFR preservation. FPV demonstrated significant association with eGFR preservation (spearman correlation ⫽ 0.26, p⫽0.001), while WIT showed no statistically significant correlation (p⫽0.53). Results of the multivariable analysis are shown in Table 1. CONCLUSIONS: Residual FPV, and not WIT, appears to be the main predictor of functional outcomes following NSS. Table 1: Multivariable analysis controlling for age, BMI, weighted CCI, tumor size, pre-operative eGFR, WIT, and FPV preservation, assessing association with % eGFR outcome. Linear Regression Variable Coefficient p value Age -0.161 0.268 BMI
-0.030
Tumor Size (mm)
0.008
0.862 0.919
Weighted CCI
-0.534
0.556
Pre-Operative eGFR
-0.217
0.006*
Warm Ischemia Time (min)
-0.039
0.735
% Functional Parenchymal Volume Preservation
0.527
⬍ 0.001*
Source of Funding: Fox Chase Cancer Center Kidney Cancer Keystone Grant
0.06 % change between 3m-6m
0.7639
1192
5.56 % change between 3m-12m
1.82
-0.54
(6.18, -13.7-
(1.16, -53-40.8)
(0, -53.1-32.7)
40.8)
0.0063
CKD: chronic kidney disease eGFR: estimated glomerular filtration rate BMI: body mass index RENAL-NS: R.E.N.A.L nephrometry score
Source of Funding: None
1191 RESIDUAL FUNCTIONAL PARENCHYMAL VOLUME, NOT WARM ISCHEMIA TIME, PREDICTS FUNCTIONAL OUTCOMES FOLLOWING NEPHRON-SPARING RENAL SURGERY Serge Ginzburg*, Robert Uzzo, Christopher Miller, David Kurz, Tianyu Li, John Walton, Awad Ahmed, Anthony Corcoran, Jeffrey Tomaszevski, Reza Mehrazin, Marc Smaldone, Rosalia Viterbo, David Chen, Richard Greenberg, Alexaner Kutikov, Philadelphia, PA INTRODUCTION AND OBJECTIVES: Importance of curtailing ischemia time is coming under increasing scrutiny, while residual
ZERO-ISCHEMIA VERSUS CLAMPED ROBOTIC PARTIAL NEPHRECTOMY: INITIAL RESULTS OF 121 PATIENTS Andre Luis de Castro Abreu, Scott Leslie, Andre Berger*, Dennis Lee, Raed Azhar, Arjuna Dharmaraja, Anmol Amin, Osamu Ukimura, Monish Aron, Inderbir Gill, Mihir Desai, Los Angeles, CA INTRODUCTION AND OBJECTIVES: The objective of this study is to compare peri-operative outcomes of zero-ischemia versus clamped robotic partial nephrectomy (PN). METHODS: Prospective data on 121 patients undergoing zeroischemia (n⫽58) and clamped (n⫽63) robotic PN were retrospectively analyzed. The clamped cohort underwent hilar cross-clamping of the main renal artery. The zero-ischemia cohort underwent tumor-specific devascularization maintaining perfusion of the remnant at all times. Both groups were compared for peri-operative factors and post-operative renal function. RESULTS: Compared to the clamped group, tumors in the zero-ischemia group were more commonly hilar (24% vs 6%, p⫽0.009), larger (3.4 vs 2.6 cm, p⫽0.04) and more complex (PADUA score 10 vs 8, p⫽0.009). All 121 robotic procedures were successful,
e488
THE JOURNAL OF UROLOGY姞
Vol. 189, No. 4S, Supplement, Monday, May 6, 2013
all surgical margins were negative, and no kidneys were lost. The zero-ischemia group had longer operative time (301 vs 229 minutes, p⬍0.001). Both groups were similar in terms of median estimated blood loss (200 vs 150cc; p⫽0.25), peri-operative complications (15% vs 13%, P⫽0.1), and hospital stay (3 vs 3 days; p⫽0.13). The zeroischemia group had lesser decrease in eGFR at discharge (0% vs 11%, p⫽0.01) and at latest follow up (11% vs 17%, p⫽0.03). Subset analysis showed a trend towards better volume preservation in the zero-ischemia cohort (95% vs 90%, p⫽0.08) despite larger tumor volume (19 vs 8 cc, p⫽0.002). CONCLUSIONS: Robotic zero-ischemia partial nephrectomy affords the consistent opportunity to eliminate ischemic injury. Intraoperative blood loss, peri-operative complications and incidence of positive surgical margins are similar to the clamped technique. At least in the short-term, renal functional outcomes appear superior with zeroischemia robotic partial nephrectomy. Source of Funding: None
1193 ROBOTIC PARTIAL NEPHRECTOMY WITH SELECTIVE ARTERIAL CLAMPING USING NEAR INFRARED FLUORESCENCE IMAGING: NYU INITIAL EXPERIENCE Marc Bjurlin*, James Wysock, Tyler R. McClintock, Michael Borofsky, Ganesh Sivarajan, Suzanne Sorin, Michael D. Stifelman, New York, NY INTRODUCTION AND OBJECTIVES: Near infrared fluorescence imaging (NIRF) is a technology with emerging application in urologic surgery. We evaluated our experience in robotic partial nephrectomy with selective arterial clamping using NIRF and compared renal functional status outcomes in a matched cohort of robotic partial nephrectomies without selective arterial clamping and NIRF. METHODS: A retrospective study of 58 patients, in which NIRF was utilized for partial nephrectomy, was performed. Of these 58 patients, 39 (67%) underwent successful robotic partial nephrectomies with NIRF using ICG for a total of 43 tumors. Patient demographics, peri-operative parameters, and outcomes were evaluated. This cohort was then matched by tumor size, preoperative eGFR, and functional kidney status with 39 patients who underwent robotic partial nephrectomies without selective clamping or NIRF imaging and outcomes compared. RESULTS: Table 1 demonstrates the demographics and perioperative outcomes of the NIRF selectively clamped cohort. Overall tumor size was 2.8 cm; 72% were malignant; pT1a (90%); and there was 1 positive surgical margin. Five post-operative complications occurred (14%) all Clavien grade I-III. Table 2 summarizes the early functional differences between patients undergoing partial nephrectomy with selecting clamping and their total clamp matched cohorts. Selective clamping with NIRF had a lower absolute change in eGFR (p⫽0.0473) and percent change in eGFR (p⫽0.0371) (Table 2). CONCLUSIONS: In our experience robotic partial nephrectomy with selective arterial clamping using near infrared fluorescence imaging with ICG appears safe, effective and reproducible in minimizing warm ischemia damage to the kidney. In our early experience this procedure results in a smaller overall change in eGFR and percent change in eGFR when compared to robotic partial nephrectomy without selective arterial clamping and NIRF.
Source of Funding: None
1194 ZERO-ISCHEMIA RADIOFREQUENCY ABLATION ASSISTED TUMOR ENUCLEATION FOR T1B RENAL CELL CARCINOMA Xiaozhi Zhao*, Shiwei Zhang, Guangxiang Liu, Changwei Ji, Huibo Lian, Feng Qu, Xiang Yan, Xiaogong Li, Weidong Gan, Gutian Zhang, Hongqian Guo, Nanjing, China, People’s Republic of INTRODUCTION AND OBJECTIVES: Emerging evidence suggests that nephron sparing surgery (NSS) might be feasible and safe for renal tumors of 4-7cm. The aim of the study is to evaluate the safety and efficacy of 0-ischemia, radiofrequency ablation (RFA) assisted tumor enucleation (TE) for T1b renal cell carcinoma (RCC), reporting on the incidence of complications, positive surgical margins and shortterm followup results. METHODS: We retrospectively reviewed data for 47 patients with T1b RCC treated with 0-ischemia RFA assisted TE between March 2006 and October 2011. The mean age was 55.9 ¡À 11.0 years, and 36 (76.6%) were male. The mean greatest dimension of tumors was 5.0 ¡À 0.6 cm. Student’s t-test, chi-square test and Fisher’s exact test were used to compare operation time, bleeding and complications. Fisher’s exact test was used to analyze the association Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score and complications. Paired t test was used to compare GFR. RESULTS: We found 47 tumors with greatest dimension between 4cm to 7 cm (see Table 1). Twenty-eight patients underwent RFA assisted laparoscopic TE while 19 patients underwent open RFA