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773 PATIENT-REPORTED COSMESIS OUTCOMES FOLLOWING UROLOGIC SURGERY: LESS VS. LAPAROSCOPIC VS. OPEN SURGERY
Vol. 185, No. 4S, Supplement, Monday, May 16, 2011
772 FACTORS PREDICTING EARLY AND LATE RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY Livia Lee*, Toronto, Canada; Jeff Warren, Ottawa, Canada; Yves Caumartin, Laval, Canada; Andrew A House, Patrick P. W Luke, London, Canada INTRODUCTION AND OBJECTIVES: We prospectively assessed the impact of multiple factors affecting early, intermediate and late renal function after LPN. METHODS: Between 2004 –2009, sixty-eight patients with 2 functioning renal units undergoing LPN were prospectively analysed. MDRD and Cockcroft Gault-calculated glomerular filtration rates (GFR), MAG-3 renograms with GFR and differential function were obtained at 1) preoperatively 2) immediately post-op (⬍3 days) 3) intermediate post-op (6 –12wks) and late post-op (one year). The impact of patient demographics, tumour characteristics and surgical factors on functional renal outcomes were assessed. Correlation analysis was first performed using Spearman correlation to elucidate factors correlated with GFR decline. Subsequent multivariate analysis was performed at each of the postop periods. Paired t-test was used to compare baseline GFR and renograms to these outcomes at each of the postoperative time periods. RESULTS: Spearman correlation determined that age, weight, pre-operative GFR, piece size and warm ischemia time (WIT) were correlated with early decline in GFR. However, multivariate analysis showed that in the immediate time period, only tumor weight and WIT were predictive of decreased renal function (p⬍0.01). As well, in the late post-op period, only the degree of early/intermediate reduction in renal function was predictive of persistent impaired renal function (p⬍0.00001). Paired t-test analysis showed that there was significant decline in renal function in the immediate and intermediate time points (p⬍0.001); this decline did not persist at one year, indicating capacity for late renal recovery (p⫽NS). However, paired t-test using nuclear renogram studies showed that there was persistent dysfunction of the affected kidney at one year postop (41.7% vs 49.4% preop; p⬍0.001). Taken together, this indicates that late renal recovery may occur as a result of compensation from the contralateral renal unit. CONCLUSIONS: This study confirms the negative impact of warm ishemic time upon early renal function post-LPN. Importantly, this is the first study to show that the degree of initial renal functional loss is a key determinant to renal recovery at one year. Additionally, the function of the affected kidney remains compromised at one year, and recovery of renal function is primarily by compensation from the contralateral kidney. Source of Funding: None
773 PATIENT-REPORTED COSMESIS OUTCOMES FOLLOWING UROLOGIC SURGERY: LESS VS. LAPAROSCOPIC VS. OPEN SURGERY Samuel Park*, Ephrem Olweny, Sara Best, Saad Mir, Dallas, TX; Chad Tracy, Iowa City, IA; Jeffrey Cadeddu, Dallas, TX INTRODUCTION AND OBJECTIVES: Laparoendoscopic single site surgery (LESS) continues to gain popularity in urology, with reported equivalent perioperative outcomes and superior cosmesis to conventional laparoscopy. To date, cosmesis outcomes following LESS have been touted or criticized solely based on subjective surgeon assessment. We investigated patients’ attitudes towards cosmesis following LESS urologic surgery, using a questionnaire and photographic-based survey adapted from Dunker et al. (Surg Endosc (1998) 12: 1334). METHODS: As of August 2009, consenting patients who underwent LESS (n⫽10), laparoscopic (lap) (n⫽23) or open (n⫽6) urologic surgery at our institution were asked to complete a questionnaire and photographic-based survey pertaining to: demographics; self scar assessment before and after viewing photographs of LESS, laparoscopic, and
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open surgical scars; body image; and willingness to undergo future LESS procedures at varying levels of surgical risk. Surveys were administered ⫽/⬎ 3 months after surgery. Scars were rated on a Likert scale ranging from 1 (revolting) to 10 (beautiful). Survey responses were grouped into “upper” (7–10), “mid” (5– 6) or “lower” (1– 4) tiers for comparison. RESULTS: For LESS vs. Lap vs. Open, “upper” tier responses for overall scar satisfaction were recorded by 67%, 43%, and 40% of patients respectively. For the overall cohort, “upper” tier ratings for cosmetic appeal of photographs of LESS vs. lap vs. open scars were recorded by 69%, 46%, and 23% respectively. When asked to re-evaluate their own scars after viewing the photographs, “upper” tier scar satisfaction ratings increased to 80% vs. 57% vs. 50% for the LESS vs. lap vs. open groups respectively. Lastly, when the overall cohort was queried on desire to undergo LESS in the future, assuming equivalent operative risk, 5% greater risk, or 10% greater risk, preference for LESS decreased from 33%, to 31%, to 15%, while preference for laparoscopy increased from 41%, to 49%, to 54% respectively. CONCLUSIONS: Preliminary data suggest that patients value the cosmetic advantage provided by LESS surgery. Patient-reported cosmesis outcomes following LESS are superior to those for conventional laparoscopy or open surgery. Desire to undergo future LESS declined in proportion to theoretical increases in surgical risk, suggesting that LESS may be offered as a surgical alternative to willing patients provided that perioperative risks are not increased. Ongoing assessment pending further patient accrual is underway. Source of Funding: None
774 TRANSGASTRIC NOTESTM PARTIAL CYSTECTOMY: A PROSPECTIVE CHRONIC PORCINE STUDY Mark D. Sawyer*, Irma Lengu, Matthew Steinway, Jeffrey Marks, Wenbin Xiao, Gregory MacLennan, Steve Schomisch, Joseph Trunzo, Lee E. Ponsky, Cleveland, OH INTRODUCTION AND OBJECTIVES: Natural Orifice Translumenal Endoscopic Surgery (NOTESTM) uses a natural orifice to access the peritoneum. Clinical transgastric NOTES procedures have been described, but not in Urology. After demonstrating feasibility of transgastric NOTES partial cystectomy in an acute model, our group initiated a prospective chronic porcine study to evaluate outcomes and pathologic healing of the bladder closure. METHODS: This IACUC approved study was intended to include ten animals for a two week survival period. All procedures were performed under anesthesia with antibiotics administered prior in a dedicated OR suite. After making a gastrotomy, the peritoneum was accessed using a specialized gastroscope (R-ScopeTM). A cystoscope was used to make the bladder lesion with electrocautery. In the first 7 pigs, our technique was to place two endoscopic loops and incise between loops leaving both bladder and specimen sealed. The specimen was removed orally. Closure was reinforced with endoscopic clips. Subsequently, technique was modified to emphasize closure by simply excising specimen and using a gastroscope suture device (OverStitch™) (n⫽2) and/or a series of clips on each edge of the defect that are approximated in pairs using endoscopic loops (n⫽1). This clip-clip-loop technique was used for gastrotomy closure. Postoperatively, animals were monitored per protocol until 2 week necropy. Preserved bladders were assessed histologically for healing. RESULTS: The intended procedure was completed in 10 chronic animals (⫽34.5kg). All survived the immediate procedure. Operative time was 135–360min (⫽233) with mean EBL⫽11.5mL. Mean margin was 2.3 cm (⫽0.45). In 7/10, all 4 margins were ⱖ2cm. Mean specimen size was 30.7 cm2 (⫽10.8). Of the first 7, 4 survived to the endpoint (57%). Three were euthanized (days 4, 10 and 11) and on necropsy had diffuse peritonitis with open bladder defects but sealed stomachs. Our veterinarian required a change in bladder closure to continue. Two alternative bladder closure techniques were devised (see methods). After the change, subsequent animals (n⫽3) appeared healthy at necropsy (100%). Histology demonstrated incomplete healing, likely reflecting inadequate survival time.
772 FACTORS PREDICTING EARLY AND LATE RENAL FUNCTION AFTER LAPAROSCOPIC PARTIAL NEPHRECTOMY Livia Lee*, Toronto, Canada; Jeff Warren, Ottawa, Canada; Yves Caumartin, Laval, Canada; Andrew A House, Patrick P. W Luke, London, Canada INTRODUCTION AND OBJECTIVES: We prospectively assessed the impact of multiple factors affecting early, intermediate and late renal function after LPN. METHODS: Between 2004 –2009, sixty-eight patients with 2 functioning renal units undergoing LPN were prospectively analysed. MDRD and Cockcroft Gault-calculated glomerular filtration rates (GFR), MAG-3 renograms with GFR and differential function were obtained at 1) preoperatively 2) immediately post-op (⬍3 days) 3) intermediate post-op (6 –12wks) and late post-op (one year). The impact of patient demographics, tumour characteristics and surgical factors on functional renal outcomes were assessed. Correlation analysis was first performed using Spearman correlation to elucidate factors correlated with GFR decline. Subsequent multivariate analysis was performed at each of the postop periods. Paired t-test was used to compare baseline GFR and renograms to these outcomes at each of the postoperative time periods. RESULTS: Spearman correlation determined that age, weight, pre-operative GFR, piece size and warm ischemia time (WIT) were correlated with early decline in GFR. However, multivariate analysis showed that in the immediate time period, only tumor weight and WIT were predictive of decreased renal function (p⬍0.01). As well, in the late post-op period, only the degree of early/intermediate reduction in renal function was predictive of persistent impaired renal function (p⬍0.00001). Paired t-test analysis showed that there was significant decline in renal function in the immediate and intermediate time points (p⬍0.001); this decline did not persist at one year, indicating capacity for late renal recovery (p⫽NS). However, paired t-test using nuclear renogram studies showed that there was persistent dysfunction of the affected kidney at one year postop (41.7% vs 49.4% preop; p⬍0.001). Taken together, this indicates that late renal recovery may occur as a result of compensation from the contralateral renal unit. CONCLUSIONS: This study confirms the negative impact of warm ishemic time upon early renal function post-LPN. Importantly, this is the first study to show that the degree of initial renal functional loss is a key determinant to renal recovery at one year. Additionally, the function of the affected kidney remains compromised at one year, and recovery of renal function is primarily by compensation from the contralateral kidney. Source of Funding: None
773 PATIENT-REPORTED COSMESIS OUTCOMES FOLLOWING UROLOGIC SURGERY: LESS VS. LAPAROSCOPIC VS. OPEN SURGERY Samuel Park*, Ephrem Olweny, Sara Best, Saad Mir, Dallas, TX; Chad Tracy, Iowa City, IA; Jeffrey Cadeddu, Dallas, TX INTRODUCTION AND OBJECTIVES: Laparoendoscopic single site surgery (LESS) continues to gain popularity in urology, with reported equivalent perioperative outcomes and superior cosmesis to conventional laparoscopy. To date, cosmesis outcomes following LESS have been touted or criticized solely based on subjective surgeon assessment. We investigated patients’ attitudes towards cosmesis following LESS urologic surgery, using a questionnaire and photographic-based survey adapted from Dunker et al. (Surg Endosc (1998) 12: 1334). METHODS: As of August 2009, consenting patients who underwent LESS (n⫽10), laparoscopic (lap) (n⫽23) or open (n⫽6) urologic surgery at our institution were asked to complete a questionnaire and photographic-based survey pertaining to: demographics; self scar assessment before and after viewing photographs of LESS, laparoscopic, and
THE JOURNAL OF UROLOGY姞
e311
open surgical scars; body image; and willingness to undergo future LESS procedures at varying levels of surgical risk. Surveys were administered ⫽/⬎ 3 months after surgery. Scars were rated on a Likert scale ranging from 1 (revolting) to 10 (beautiful). Survey responses were grouped into “upper” (7–10), “mid” (5– 6) or “lower” (1– 4) tiers for comparison. RESULTS: For LESS vs. Lap vs. Open, “upper” tier responses for overall scar satisfaction were recorded by 67%, 43%, and 40% of patients respectively. For the overall cohort, “upper” tier ratings for cosmetic appeal of photographs of LESS vs. lap vs. open scars were recorded by 69%, 46%, and 23% respectively. When asked to re-evaluate their own scars after viewing the photographs, “upper” tier scar satisfaction ratings increased to 80% vs. 57% vs. 50% for the LESS vs. lap vs. open groups respectively. Lastly, when the overall cohort was queried on desire to undergo LESS in the future, assuming equivalent operative risk, 5% greater risk, or 10% greater risk, preference for LESS decreased from 33%, to 31%, to 15%, while preference for laparoscopy increased from 41%, to 49%, to 54% respectively. CONCLUSIONS: Preliminary data suggest that patients value the cosmetic advantage provided by LESS surgery. Patient-reported cosmesis outcomes following LESS are superior to those for conventional laparoscopy or open surgery. Desire to undergo future LESS declined in proportion to theoretical increases in surgical risk, suggesting that LESS may be offered as a surgical alternative to willing patients provided that perioperative risks are not increased. Ongoing assessment pending further patient accrual is underway. Source of Funding: None
774 TRANSGASTRIC NOTESTM PARTIAL CYSTECTOMY: A PROSPECTIVE CHRONIC PORCINE STUDY Mark D. Sawyer*, Irma Lengu, Matthew Steinway, Jeffrey Marks, Wenbin Xiao, Gregory MacLennan, Steve Schomisch, Joseph Trunzo, Lee E. Ponsky, Cleveland, OH INTRODUCTION AND OBJECTIVES: Natural Orifice Translumenal Endoscopic Surgery (NOTESTM) uses a natural orifice to access the peritoneum. Clinical transgastric NOTES procedures have been described, but not in Urology. After demonstrating feasibility of transgastric NOTES partial cystectomy in an acute model, our group initiated a prospective chronic porcine study to evaluate outcomes and pathologic healing of the bladder closure. METHODS: This IACUC approved study was intended to include ten animals for a two week survival period. All procedures were performed under anesthesia with antibiotics administered prior in a dedicated OR suite. After making a gastrotomy, the peritoneum was accessed using a specialized gastroscope (R-ScopeTM). A cystoscope was used to make the bladder lesion with electrocautery. In the first 7 pigs, our technique was to place two endoscopic loops and incise between loops leaving both bladder and specimen sealed. The specimen was removed orally. Closure was reinforced with endoscopic clips. Subsequently, technique was modified to emphasize closure by simply excising specimen and using a gastroscope suture device (OverStitch™) (n⫽2) and/or a series of clips on each edge of the defect that are approximated in pairs using endoscopic loops (n⫽1). This clip-clip-loop technique was used for gastrotomy closure. Postoperatively, animals were monitored per protocol until 2 week necropy. Preserved bladders were assessed histologically for healing. RESULTS: The intended procedure was completed in 10 chronic animals (⫽34.5kg). All survived the immediate procedure. Operative time was 135–360min (⫽233) with mean EBL⫽11.5mL. Mean margin was 2.3 cm (⫽0.45). In 7/10, all 4 margins were ⱖ2cm. Mean specimen size was 30.7 cm2 (⫽10.8). Of the first 7, 4 survived to the endpoint (57%). Three were euthanized (days 4, 10 and 11) and on necropsy had diffuse peritonitis with open bladder defects but sealed stomachs. Our veterinarian required a change in bladder closure to continue. Two alternative bladder closure techniques were devised (see methods). After the change, subsequent animals (n⫽3) appeared healthy at necropsy (100%). Histology demonstrated incomplete healing, likely reflecting inadequate survival time.