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1429 SURGICAL OUTCOMES OF RENAL CRYOABLATION WITH THE RENAL NEPHROMETRY SCORE AND ADJUSTED COMPLEXITY LEVELS
e580
THE JOURNAL OF UROLOGY姞
Risk Factor Gender Male Age (years) ⱕ 60
Category Female
Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012
Score 0
Total score 0
1
1
10.7
ⱕ50
0
2
1
3
17.8
ⱕ 70
3
4
22.7
⬎ 70
4
5
28.8
Hypertension
Absent
0
6
Present
1
7
44.6
C-Index
⬎ 1.26
0
8
ⱖ 1.26
1
9
64.1
Preoperative Estimated GFR (ml/ min/1.73m2)
⬎100
0
10
ⱕ 100
2
11
83.2
ⱕ 90
6
12
90.4
ⱕ 80
7
13
95.5
聿 70
8
14
98.3 15
Risk of CKD 肁 III 8.2
the optimal eligibility should be less than 4 cm (T1a). A model based on statistical analysis rather than ease of implementation would further improve this foundational nomogram.
13.8 Surgical Outcomes Cases
Table 1. Surgical Outcomes Moderate Low Complexity Complexity High Complexity (NS: 6-8) (NS: 6-8) p-value (NS: 4-5) 23 (21.9%) 56 (53.3%) 26 (26.0%) –
EBL, mL
25 (25-50)
50 (25-100)
50 (38-88)
0.017
36.1
ORT, min
55 (43-63)
58 (47-67)
60 (53-68)
0.416
54.1
Change in Creatinine, mg/dL
0.1 (0.0-0.2)
0.1 (0.0-0.2)
0.1 (0.0-0.2)
0.765
Hospital Length of Stay, d 74.1
99.5
2 (1-2)
Conversion to Partial Nephrectoy
0 (0.0%)
Complications
0 (0.0%)
Intra-Operative Complications
0 (0.0%)
Post-Operative Complications
0 (0.0%)
2 (1-2)
2 (2-3)
0.042
1 (1.8%)
1 (3.8%)
0.629
1 (1.8%)
5 (19.2%)
0.003
0 (0.0%)
2 (16.7%)
0.045
1 (1.8%)
3 (7.7%)
0.056
Source of Funding: None
Source of Funding: None
1429
1430
SURGICAL OUTCOMES OF RENAL CRYOABLATION WITH THE RENAL NEPHROMETRY SCORE AND ADJUSTED COMPLEXITY LEVELS
THE EFFECT OF ARTERIAL CLAMPING DURING ROBOTICALLY ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY ON RENAL FUNCTION
Alexandre Pompeo*, David Sehrt, Denver, CO; Marcelo Wroclawski, Bruno Benigno, Sao Paulo, Brazil; Garrett Pohlman, Wilson Molina, Fernando Kim, Denver, CO INTRODUCTION AND OBJECTIVES: The RENAL Nephrometry Scoring system was developed to standardize the anatomical reporting of renal masses. A secondary objective of this nomogram was to stratify masses into complexity levels pre-operatively. Presently, there is no reporting of the use of this anatomic classification system for cryoablation. This is the first evaluation of the accuracy of the RENAL Nephrometry Score (RNS), on the surgical outcomes from laparoscopic cryoablation of renal masses. METHODS: A total of 105 patients treated from November 2005 to October 2011 who undergone laparoscopic cryoablation of renal masses were reviewed by the RNS. RNS was classified as a low complexity of 4-5, intermediate 6-8 and high complexity 9-12. Surgical outcomes of estimative blood loss (EBL), operative time (ORT), change of creatinine levels, hospital length of stay, intra-operative conversions, and complications were evaluated and compared between the groups. Outcomes are presented as either occurrences with percentages or median with 1st and 3rd quartiles. RESULTS: A total of low 23 (21.9%), moderate 56 (53.3%) and high complexity 26 (26.0%) tumors (mean tumor size 2.7 cm) were found (Table 1). There were no tumors classified with a nephrometry 11 or 12 score and only 11(10.5%) tumors were larger than 4 cm. EBL, ORT and complication rates were significant between the groups (p⬍0.05). Intra-operative complications only occurred in the high complexity group which consisted of a diaphragm injury due to adhesions and a splenic capsule tear. Conversions were caused by a rupture of the tumor after the first freezing cycle in the moderate complexity level and by tumor growth into the renal vessels which was unseen from the most recent available CT in the high complexity level. CONCLUSIONS: The Nephrometry score intended to standardize reporting of renal masses and moreover predict complications rates from treatment. The Nephrometry score has shown validity in cryoablation but a model tailored more for this treatment modality would improve the predictive capability. An apparent shortcoming in the nephrometry score for cryoablation is the limitations of tumor size since
Emad Rizkala*, Shahab Hillyer, Julien Guillotreau, Riccardo Autorino, Rashid Yakoubi, Wahib Isac, Georges-Pascal Haber, Robert Stein, Jihad Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Multiple publications in recent years addressed the effect of arterial clamping on renal function during partial nephrectomy with sometimes conflicting conclusions. In this study, we aim to assess the validity of these reports in our patient population of patients who underwent robotic partial nephrectomy. METHODS: We performed a retrospective chart review of 346 patients who underwent robotically assisted laparoscopic partial nephrectomies for renal masses between February 2007 and June 2011. We specifically identified those patients with low-moderate R.E.N.A.L nephrometry scores (4-9) and we categorized their arterial clamp time into: a) unclamped, b) clamped ⬍20 min, and c) clamped ⬎20 min. Post-operative eGFR % difference in comparison to pre-operative eGFR (estimated glomerular filtration rate; calculated by the Modification of Diet in Renal Disease (MDRD) equation) was calculated for those patients with serum creatinine measured in post-operative day #3, 1 month, and 6 months. RESULTS: A total of 65 patients (9 unclamped, 37 with arterial clamp times ⬍20 min and 19 with clamp times ⬎20 min) were identified who had a nephrometry scores in the range of 4 to 9 and eGFRs measured pre-operatively, on post operative day 3, post-operative 1 month and post-operative 6 months. Results are detailed in the table below. CONCLUSIONS: Our data has illustrated that clamp time is a significant predictor of eGFR, even in those patients with a contralateral otherwise normal kidney. Patients who do not undergo renal artery clamping appear to maintain their pre-operative eGFR. However, patients who undergo arterial clamping, even in those with less than or equal to 20 minutes clamp time appear to have a statistically significant decrease in eGFR. There does not appear to be a statistically significant difference between 1 month and 6 month post-operative eGFR in patients with clamp times of ⬍20 minutes as compared to those with clamp times of ⬎20 minutes.
THE JOURNAL OF UROLOGY姞
Risk Factor Gender Male Age (years) ⱕ 60
Category Female
Vol. 187, No. 4S, Supplement, Tuesday, May 22, 2012
Score 0
Total score 0
1
1
10.7
ⱕ50
0
2
1
3
17.8
ⱕ 70
3
4
22.7
⬎ 70
4
5
28.8
Hypertension
Absent
0
6
Present
1
7
44.6
C-Index
⬎ 1.26
0
8
ⱖ 1.26
1
9
64.1
Preoperative Estimated GFR (ml/ min/1.73m2)
⬎100
0
10
ⱕ 100
2
11
83.2
ⱕ 90
6
12
90.4
ⱕ 80
7
13
95.5
聿 70
8
14
98.3 15
Risk of CKD 肁 III 8.2
the optimal eligibility should be less than 4 cm (T1a). A model based on statistical analysis rather than ease of implementation would further improve this foundational nomogram.
13.8 Surgical Outcomes Cases
Table 1. Surgical Outcomes Moderate Low Complexity Complexity High Complexity (NS: 6-8) (NS: 6-8) p-value (NS: 4-5) 23 (21.9%) 56 (53.3%) 26 (26.0%) –
EBL, mL
25 (25-50)
50 (25-100)
50 (38-88)
0.017
36.1
ORT, min
55 (43-63)
58 (47-67)
60 (53-68)
0.416
54.1
Change in Creatinine, mg/dL
0.1 (0.0-0.2)
0.1 (0.0-0.2)
0.1 (0.0-0.2)
0.765
Hospital Length of Stay, d 74.1
99.5
2 (1-2)
Conversion to Partial Nephrectoy
0 (0.0%)
Complications
0 (0.0%)
Intra-Operative Complications
0 (0.0%)
Post-Operative Complications
0 (0.0%)
2 (1-2)
2 (2-3)
0.042
1 (1.8%)
1 (3.8%)
0.629
1 (1.8%)
5 (19.2%)
0.003
0 (0.0%)
2 (16.7%)
0.045
1 (1.8%)
3 (7.7%)
0.056
Source of Funding: None
Source of Funding: None
1429
1430
SURGICAL OUTCOMES OF RENAL CRYOABLATION WITH THE RENAL NEPHROMETRY SCORE AND ADJUSTED COMPLEXITY LEVELS
THE EFFECT OF ARTERIAL CLAMPING DURING ROBOTICALLY ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY ON RENAL FUNCTION
Alexandre Pompeo*, David Sehrt, Denver, CO; Marcelo Wroclawski, Bruno Benigno, Sao Paulo, Brazil; Garrett Pohlman, Wilson Molina, Fernando Kim, Denver, CO INTRODUCTION AND OBJECTIVES: The RENAL Nephrometry Scoring system was developed to standardize the anatomical reporting of renal masses. A secondary objective of this nomogram was to stratify masses into complexity levels pre-operatively. Presently, there is no reporting of the use of this anatomic classification system for cryoablation. This is the first evaluation of the accuracy of the RENAL Nephrometry Score (RNS), on the surgical outcomes from laparoscopic cryoablation of renal masses. METHODS: A total of 105 patients treated from November 2005 to October 2011 who undergone laparoscopic cryoablation of renal masses were reviewed by the RNS. RNS was classified as a low complexity of 4-5, intermediate 6-8 and high complexity 9-12. Surgical outcomes of estimative blood loss (EBL), operative time (ORT), change of creatinine levels, hospital length of stay, intra-operative conversions, and complications were evaluated and compared between the groups. Outcomes are presented as either occurrences with percentages or median with 1st and 3rd quartiles. RESULTS: A total of low 23 (21.9%), moderate 56 (53.3%) and high complexity 26 (26.0%) tumors (mean tumor size 2.7 cm) were found (Table 1). There were no tumors classified with a nephrometry 11 or 12 score and only 11(10.5%) tumors were larger than 4 cm. EBL, ORT and complication rates were significant between the groups (p⬍0.05). Intra-operative complications only occurred in the high complexity group which consisted of a diaphragm injury due to adhesions and a splenic capsule tear. Conversions were caused by a rupture of the tumor after the first freezing cycle in the moderate complexity level and by tumor growth into the renal vessels which was unseen from the most recent available CT in the high complexity level. CONCLUSIONS: The Nephrometry score intended to standardize reporting of renal masses and moreover predict complications rates from treatment. The Nephrometry score has shown validity in cryoablation but a model tailored more for this treatment modality would improve the predictive capability. An apparent shortcoming in the nephrometry score for cryoablation is the limitations of tumor size since
Emad Rizkala*, Shahab Hillyer, Julien Guillotreau, Riccardo Autorino, Rashid Yakoubi, Wahib Isac, Georges-Pascal Haber, Robert Stein, Jihad Kaouk, Cleveland, OH INTRODUCTION AND OBJECTIVES: Multiple publications in recent years addressed the effect of arterial clamping on renal function during partial nephrectomy with sometimes conflicting conclusions. In this study, we aim to assess the validity of these reports in our patient population of patients who underwent robotic partial nephrectomy. METHODS: We performed a retrospective chart review of 346 patients who underwent robotically assisted laparoscopic partial nephrectomies for renal masses between February 2007 and June 2011. We specifically identified those patients with low-moderate R.E.N.A.L nephrometry scores (4-9) and we categorized their arterial clamp time into: a) unclamped, b) clamped ⬍20 min, and c) clamped ⬎20 min. Post-operative eGFR % difference in comparison to pre-operative eGFR (estimated glomerular filtration rate; calculated by the Modification of Diet in Renal Disease (MDRD) equation) was calculated for those patients with serum creatinine measured in post-operative day #3, 1 month, and 6 months. RESULTS: A total of 65 patients (9 unclamped, 37 with arterial clamp times ⬍20 min and 19 with clamp times ⬎20 min) were identified who had a nephrometry scores in the range of 4 to 9 and eGFRs measured pre-operatively, on post operative day 3, post-operative 1 month and post-operative 6 months. Results are detailed in the table below. CONCLUSIONS: Our data has illustrated that clamp time is a significant predictor of eGFR, even in those patients with a contralateral otherwise normal kidney. Patients who do not undergo renal artery clamping appear to maintain their pre-operative eGFR. However, patients who undergo arterial clamping, even in those with less than or equal to 20 minutes clamp time appear to have a statistically significant decrease in eGFR. There does not appear to be a statistically significant difference between 1 month and 6 month post-operative eGFR in patients with clamp times of ⬍20 minutes as compared to those with clamp times of ⬎20 minutes.