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614 ROBOTIC PARTIAL NEPHRECTOMY: PRELIMINAR ONCOLOGICAL AND FUNCTIONAL RESULTS OF A SINGLE SERIES. THE IMPACT OF THE LEARNING CURVE ON ISCHEMIA TIME
ERPF. Regression model confirmed that WIT was statistically related to ERPF and this association is evident at 3 months and 1 year postoperatively, even if the model is corrected by every misleading variable. Increasing WIT, ERPF significantly decreases (p<0.0001) such as increasing the average thickness of healthy resected parenchyma (p=0.0023) and this correlation was present 3 months and 1 year after the intervention. Concerning the cut-off for WIT, the median WIT (24 minutes) seem to well define two different Groups of patients (WIT>24’ significantly higher risk of ERPF reduction). We divided the patients on the basis of WIT quartile and we identified three categories of risk: group 1 WIT<=15’; group 2 15’28’. The risk of a ERPF reduction was more relevant for group 2 patients with respect to group 1 patients. Similarly, this risk was significantly higher for group3 patient than for group 1 patients. Conclusions: On the basis of our results, the best renal marker of renal damage in patients with a normal contralateral kidney is represented by ERPF evaluated by renal scintigraphy and best predictor for ERPF reduction is WIT. Based on WIT quartiles, we identified three groups of risk for ERPF reduction and we think that this could be helpful for clinical practice.
613
Mathematical models for estimating the appearance of postoperative acute kidney injury after radical nephrectomy
Sinescu I.1, Savu C.2, Mirvald C.1, Surcel C.1, Gingu C.1, Chibelean C.1, Cerempei V.1, Popescu F.3, Urşianu V.3, Urşianu E.4 1 Fundeni Clinical Institute of Uronephrology and Renal Transplant Ation, Dept. of Urological Surgery, Bucharest, Romania, 2Fundeni Clinical Institute of Uronephrology and Renal Transplant Ation, Dept. of ICU, Bucharest, Romania, 3 Polytechnic University of Bucharest, Dept. of Statistics, Bucharest, Romania, 4 Medical Statistic Institute, Dept. of Statistics, Bucharest, Romania Introduction & Objectives: This paper aims to identify the risk factors involved in the appearance of acute injury on the remnant kidney after anterior radical nephrectomy in patients with renal cell cancer. Materials & Methods: We conducted a prospective study between 2007-2010 on patients undergoing elective radical nephrectomy. The patients were divided into two groups depending on the progress on the development of postoperative AKI (Acute kidney injury). Study group (I) - 115 patients with postoperative AKI. The control group (II): 69 patients without postoperative AKI. We defined postoperative AKI as a 20% decrease in glomerular filtration rate assessed by measuring the creatinine clearance (Cockroft formula) between preoperative and postoperative period (postoperative D1 and D7). Considering that the parameter type of antihypertensive treatment, which was used in the preoperative period by the patient, we subdivided the patients in study group (I) in two subgroups: angiotensin-converting enzyme-inhibitor (ACEI) group = 61 patients in chronic treatment with ACEI and non-ACEI = 54 patients in chronic treatment with another antihypertensive treatment other than ACEI, in order to make the proposed statistical analysis. Since the ACEI group and non-ACEI group are heterogeneous, we used an index based on nearest neighbor algorithm in order to homogenize the study group (I). In statistical analysis, all data were performed using SAS software 9.1 (SAS Institute, Cary, NC) and Limdep (Econometric Software Inc.. Plainview, NY). Results: Preoperative variables that were significantly associated in the univariate analysis with development of AKI included age>55 yrs, diabetus mellitus (p <0.0046), chronic heart failure (CHF) with EF <30% (p <0.057), administration of contrast agent or other nephrotoxic substances (p <0.0531). Intra- and postoperative factors that were associated with postoperative AKI were hypotension during surgery, use of vasopressors, and postoperative hypotension. Multiple regression logistic model confirmed an independent and significant association of AKI and preoperative use of ACEI. This was confirmed using a bivariate probit and likelihood ratio model that adjusts for confounding by indication of use and selection bias. Conclusions: Preoperative use of ACEI is associated with a higher risk for AKI postoperatively. ACE inhibitors cause the most severe impairment of renal function compared to that in the non-ACEI medication. Age and hypotension during surgery cannot generate AKI alone but may instead worsen the prognosis of the patient postoperatively. The association of comorbidites in a patient favors the development of preoperative AKI, but do not determine AKI alone.
614
Robotic partial nephrectomy: Preliminar oncological and functional results of a single series. The impact of the learning curve on ischemia time
Suardi N., Tosco L., Willemsen P., Pauwels E., De Wil P., De Naeyer G., Schatteman P., Ficarra V., Carpentier P., Mottrie A.M. O.L.V. Clinic, Dept. of Urology, Aalst, Belgium Introduction & Objectives: Robotic-assisted partial nephrectomy (RAPN) represents a modern surgical approach for renal cancer. The widespread use of the technique is limited by the small number of studies addressing functional and oncological outcomes after RAPN. We report the peri-operative and followup functional and oncological data and the impact of the learning curve on perioperative outcomes.
Eur Urol Suppl 2011;10(2):200
Materials & Methods: Between October 2006 and September 2010, 69 patients were submitted to RAPN by a single surgeon. All patients had pre-operative, perioperative and follow-up data. Patients were checked by accurate imaging schedule every six months after surgery. Glomerular filtration rate (GFR) was assessed the day before surgery and at last follow-up. Analyses of peri-operative outcomes, follow-up oncological and functional results were performed. The occurrence of renal insufficiency at follow-up was evaluated according to CKD stages. Finally, uni- and multivariable linear regression analyses tested the impact of the learning curve on warm ischemia time (WIT) and estimated blood loss (EBL). Results: Mean and median tumor size was 31 and 30 mm (range: 13-65). Mean and median pre-operative GFR was 78.9 and 80.5, respectively. 27.3, 54.5, 13.6 and 4.3% of patients had CKD of 0, 2, 3 and 4 respectively. Console time was 88 and 90 minutes, respectively (range:25-150). Mean ischemia time was 19.9 minutes(range: 9-40). Mean EBL was 144 ml (range: 10-900). Two patients had major complications (urosepsis and post-operative bleeding requiring transfusions, respectively). Histopathological examination revealed malignant lesions in 49 patients (71.0%). Pathological stage was pT1a, pT1b and pT3a in 43 (87.8%), 5 (10.2%) and 1 (2.0%). At a mean follow-up of 16 months (range: 1-45) no patient experienced local nor distant recurrence, and no patients died of renal cancer. Two patients died of other causes. Mean and median post-operative GFR was 70 and 75, respectively. At last follow-up, 17.6,61.8,16.2 and 4.4% of patients had CKD of 0, 2, 3 and 4 respectively. 19 patients (27.5%) had renal function deterioration by 1 or more stages according to CKD classification. Only 3 patients (4.3%) had new onset of stage 3-4 CKD. At univariable logistic regression analysis, surgical volume (β=-0.49;p<0.001) and tumor size (β=0.38;p<0.001) were associated with WIT, while tumor size were associated with EBL (β=0.33; p=0.005). At multivariable analyses surgical volume and tumor size were associated with WIT (all p<0.001). Conclusions: RAPN provides good oncological and functional results in patients with renal mass. Peri-operative morbidity is limited and this surgical approach provides highly acceptable WIT. The impact of RAPN on renal function is limited. WIT decreases during the learning curve, even after adjusting for tumor size. Oncological results will need to be evaluated at longer follow-up.
615
Partial nephrectomy (PN) versus radical nephrectomy (RN) for non-metastatic renal cell carcinoma (RCC): Utilization trends in the United States
Sun M.1, Abdollah F.2, Jeldres C.3, Schmitges J.4, Djahangirian O.3, Liberman D.3, Ismail S.3, Tian Z.1, Shariat S.F.5, Karakiewicz P.I.1 1 University of Montreal Health Center, Cancer Prognostics and Health Outcomes Unit, Montreal, Canada, 2Vita Salute San Raffaele University, Dept. of Urology, Milan, Italy, 3University of Montreal Health Center, Dept. of Urology, Montreal, Canada, 4Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, 5Weill Medical College of Cornell University, Dept. of Urology, New York, United States of America Introduction & Objectives: PN has several important advantages over RN in the management of RCC. The advantage hinges on the preservation of renal function and its long-term effects. Several previous investigators suggested that PN remains relatively underutilized in North America. We examined this hypothesis in a population-based analysis. Materials & Methods: We examined the Nationwide Inpatient Sample and performed a retrospective cohort analysis of 48321 patients with non-metastatic RCC treated with PN or RN between years 1998 and 2007. We examined the utilization rates of PN and RN throughout the study period, as well as the patient characteristics, in-hospital mortality, and length of stay. Finally we assessed the determinants of PN use using logistic regression models. Results: Overall, PN was performed in 8551 patients (18%). The rate of PN increased over time: from 7% in 1998 to 26% in 2007 (P<0.001). Patients treated with PN were on average younger relative to RN patients (mean: 60 vs. 63, P<0.001) and had lower baseline Charlson Comorbidity Index [CCI] (CCI 0: 64 vs. 62%, P<0.001). A higher proportion of PN patients were treated at academic (69 vs. 52%, P<0.001) and high-volume (46 vs. 31%, P<0.001) institutions. Laparoscopic procedure was performed less frequently in PN patients (6 vs. 9%, P<0.001). The rate of in-hospital mortality (0.4 vs. 0.8%, P<0.001) and the proportion of patients with a length of stay above the median (45 vs. 50%, P<0.001) was lower in PN patients. After adjusting to all variables, octogenarians (odds ratio [OR]: 0.5, P<0.001), female gender (OR: 0.9, P=0.008), Hispanic race (OR: 0.8, P=0.02), CCI≥4 (OR: 0.7, P<0.001), and non-academic institutions (OR: 0.6, P<0.001) were associated with a decreased use of PN. In contrast, intermediate- (OR: 1.2, P<0.001) and high-volume institutions (OR: 1.6, P<0.001), as well as more contemporary year of surgery (2005–2007 OR: 2.0, P<0.001) were associated with a higher odds of undergoing PN. Conclusions: The rate of PN increased nearly 4-fold over the study decade, which represents a favorable result. It is of concern that important variability in PN rates exists with respect to hospital and patient characteristics. Some of these characteristics (e.g. high hospital volume, female gender, Hispanic race) could undermine access to PN and warrant closer examination within institutions where nephrectomies are performed.
613
Mathematical models for estimating the appearance of postoperative acute kidney injury after radical nephrectomy
Sinescu I.1, Savu C.2, Mirvald C.1, Surcel C.1, Gingu C.1, Chibelean C.1, Cerempei V.1, Popescu F.3, Urşianu V.3, Urşianu E.4 1 Fundeni Clinical Institute of Uronephrology and Renal Transplant Ation, Dept. of Urological Surgery, Bucharest, Romania, 2Fundeni Clinical Institute of Uronephrology and Renal Transplant Ation, Dept. of ICU, Bucharest, Romania, 3 Polytechnic University of Bucharest, Dept. of Statistics, Bucharest, Romania, 4 Medical Statistic Institute, Dept. of Statistics, Bucharest, Romania Introduction & Objectives: This paper aims to identify the risk factors involved in the appearance of acute injury on the remnant kidney after anterior radical nephrectomy in patients with renal cell cancer. Materials & Methods: We conducted a prospective study between 2007-2010 on patients undergoing elective radical nephrectomy. The patients were divided into two groups depending on the progress on the development of postoperative AKI (Acute kidney injury). Study group (I) - 115 patients with postoperative AKI. The control group (II): 69 patients without postoperative AKI. We defined postoperative AKI as a 20% decrease in glomerular filtration rate assessed by measuring the creatinine clearance (Cockroft formula) between preoperative and postoperative period (postoperative D1 and D7). Considering that the parameter type of antihypertensive treatment, which was used in the preoperative period by the patient, we subdivided the patients in study group (I) in two subgroups: angiotensin-converting enzyme-inhibitor (ACEI) group = 61 patients in chronic treatment with ACEI and non-ACEI = 54 patients in chronic treatment with another antihypertensive treatment other than ACEI, in order to make the proposed statistical analysis. Since the ACEI group and non-ACEI group are heterogeneous, we used an index based on nearest neighbor algorithm in order to homogenize the study group (I). In statistical analysis, all data were performed using SAS software 9.1 (SAS Institute, Cary, NC) and Limdep (Econometric Software Inc.. Plainview, NY). Results: Preoperative variables that were significantly associated in the univariate analysis with development of AKI included age>55 yrs, diabetus mellitus (p <0.0046), chronic heart failure (CHF) with EF <30% (p <0.057), administration of contrast agent or other nephrotoxic substances (p <0.0531). Intra- and postoperative factors that were associated with postoperative AKI were hypotension during surgery, use of vasopressors, and postoperative hypotension. Multiple regression logistic model confirmed an independent and significant association of AKI and preoperative use of ACEI. This was confirmed using a bivariate probit and likelihood ratio model that adjusts for confounding by indication of use and selection bias. Conclusions: Preoperative use of ACEI is associated with a higher risk for AKI postoperatively. ACE inhibitors cause the most severe impairment of renal function compared to that in the non-ACEI medication. Age and hypotension during surgery cannot generate AKI alone but may instead worsen the prognosis of the patient postoperatively. The association of comorbidites in a patient favors the development of preoperative AKI, but do not determine AKI alone.
614
Robotic partial nephrectomy: Preliminar oncological and functional results of a single series. The impact of the learning curve on ischemia time
Suardi N., Tosco L., Willemsen P., Pauwels E., De Wil P., De Naeyer G., Schatteman P., Ficarra V., Carpentier P., Mottrie A.M. O.L.V. Clinic, Dept. of Urology, Aalst, Belgium Introduction & Objectives: Robotic-assisted partial nephrectomy (RAPN) represents a modern surgical approach for renal cancer. The widespread use of the technique is limited by the small number of studies addressing functional and oncological outcomes after RAPN. We report the peri-operative and followup functional and oncological data and the impact of the learning curve on perioperative outcomes.
Eur Urol Suppl 2011;10(2):200
Materials & Methods: Between October 2006 and September 2010, 69 patients were submitted to RAPN by a single surgeon. All patients had pre-operative, perioperative and follow-up data. Patients were checked by accurate imaging schedule every six months after surgery. Glomerular filtration rate (GFR) was assessed the day before surgery and at last follow-up. Analyses of peri-operative outcomes, follow-up oncological and functional results were performed. The occurrence of renal insufficiency at follow-up was evaluated according to CKD stages. Finally, uni- and multivariable linear regression analyses tested the impact of the learning curve on warm ischemia time (WIT) and estimated blood loss (EBL). Results: Mean and median tumor size was 31 and 30 mm (range: 13-65). Mean and median pre-operative GFR was 78.9 and 80.5, respectively. 27.3, 54.5, 13.6 and 4.3% of patients had CKD of 0, 2, 3 and 4 respectively. Console time was 88 and 90 minutes, respectively (range:25-150). Mean ischemia time was 19.9 minutes(range: 9-40). Mean EBL was 144 ml (range: 10-900). Two patients had major complications (urosepsis and post-operative bleeding requiring transfusions, respectively). Histopathological examination revealed malignant lesions in 49 patients (71.0%). Pathological stage was pT1a, pT1b and pT3a in 43 (87.8%), 5 (10.2%) and 1 (2.0%). At a mean follow-up of 16 months (range: 1-45) no patient experienced local nor distant recurrence, and no patients died of renal cancer. Two patients died of other causes. Mean and median post-operative GFR was 70 and 75, respectively. At last follow-up, 17.6,61.8,16.2 and 4.4% of patients had CKD of 0, 2, 3 and 4 respectively. 19 patients (27.5%) had renal function deterioration by 1 or more stages according to CKD classification. Only 3 patients (4.3%) had new onset of stage 3-4 CKD. At univariable logistic regression analysis, surgical volume (β=-0.49;p<0.001) and tumor size (β=0.38;p<0.001) were associated with WIT, while tumor size were associated with EBL (β=0.33; p=0.005). At multivariable analyses surgical volume and tumor size were associated with WIT (all p<0.001). Conclusions: RAPN provides good oncological and functional results in patients with renal mass. Peri-operative morbidity is limited and this surgical approach provides highly acceptable WIT. The impact of RAPN on renal function is limited. WIT decreases during the learning curve, even after adjusting for tumor size. Oncological results will need to be evaluated at longer follow-up.
615
Partial nephrectomy (PN) versus radical nephrectomy (RN) for non-metastatic renal cell carcinoma (RCC): Utilization trends in the United States
Sun M.1, Abdollah F.2, Jeldres C.3, Schmitges J.4, Djahangirian O.3, Liberman D.3, Ismail S.3, Tian Z.1, Shariat S.F.5, Karakiewicz P.I.1 1 University of Montreal Health Center, Cancer Prognostics and Health Outcomes Unit, Montreal, Canada, 2Vita Salute San Raffaele University, Dept. of Urology, Milan, Italy, 3University of Montreal Health Center, Dept. of Urology, Montreal, Canada, 4Martini-Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany, 5Weill Medical College of Cornell University, Dept. of Urology, New York, United States of America Introduction & Objectives: PN has several important advantages over RN in the management of RCC. The advantage hinges on the preservation of renal function and its long-term effects. Several previous investigators suggested that PN remains relatively underutilized in North America. We examined this hypothesis in a population-based analysis. Materials & Methods: We examined the Nationwide Inpatient Sample and performed a retrospective cohort analysis of 48321 patients with non-metastatic RCC treated with PN or RN between years 1998 and 2007. We examined the utilization rates of PN and RN throughout the study period, as well as the patient characteristics, in-hospital mortality, and length of stay. Finally we assessed the determinants of PN use using logistic regression models. Results: Overall, PN was performed in 8551 patients (18%). The rate of PN increased over time: from 7% in 1998 to 26% in 2007 (P<0.001). Patients treated with PN were on average younger relative to RN patients (mean: 60 vs. 63, P<0.001) and had lower baseline Charlson Comorbidity Index [CCI] (CCI 0: 64 vs. 62%, P<0.001). A higher proportion of PN patients were treated at academic (69 vs. 52%, P<0.001) and high-volume (46 vs. 31%, P<0.001) institutions. Laparoscopic procedure was performed less frequently in PN patients (6 vs. 9%, P<0.001). The rate of in-hospital mortality (0.4 vs. 0.8%, P<0.001) and the proportion of patients with a length of stay above the median (45 vs. 50%, P<0.001) was lower in PN patients. After adjusting to all variables, octogenarians (odds ratio [OR]: 0.5, P<0.001), female gender (OR: 0.9, P=0.008), Hispanic race (OR: 0.8, P=0.02), CCI≥4 (OR: 0.7, P<0.001), and non-academic institutions (OR: 0.6, P<0.001) were associated with a decreased use of PN. In contrast, intermediate- (OR: 1.2, P<0.001) and high-volume institutions (OR: 1.6, P<0.001), as well as more contemporary year of surgery (2005–2007 OR: 2.0, P<0.001) were associated with a higher odds of undergoing PN. Conclusions: The rate of PN increased nearly 4-fold over the study decade, which represents a favorable result. It is of concern that important variability in PN rates exists with respect to hospital and patient characteristics. Some of these characteristics (e.g. high hospital volume, female gender, Hispanic race) could undermine access to PN and warrant closer examination within institutions where nephrectomies are performed.