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Purpose: We investigated the association between preoperative proteinuria and early postoperative renal function after robotic partial nephrectomy (RPN)., Patients and Methods: We retrospectively reviewed 1121 consecutive RPN cases at a single academic center from 2006 to 2016. Patients without pre-existing CKD (eGFR≥60 mL/min/1.73m2) who had a urinalysis within 1-month prior to RPN were included. The cohort was categorized by the presence or absence of preoperative proteinuria (trace or greater (≥1+) urine dipstick), and groups were compared in terms of clinical and functional outcomes. The incidence of acute kidney injury (AKI) was assessed using RIFLE criteria. Univariate and multivariable models were used to identify factors associated with postoperative AKI., Results: Of 947 patients, 97 (10.5%) had preoperative proteinuria. Characteristics associated with preoperative proteinuria included non-white race (p<0.01), preoperative diabetes (p<0.01) and hypertension (HTN) (p<0.01), higher ASA (p<0.01), higher BMI (p<0.01), and higher Charlson score (p<0.01). The incidence of AKI was higher in patients with preoperative proteinuria (10.3% vs. 4.6%, p=0.01). The median eGFR preservation measured within one month after surgery was lower (83.6% vs. 91%, p=0.04) in those with proteinuria; however, there were no significant differences by 3 months after surgery or last follow-up visit. Independent predictors of AKI were high BMI (p<0.01), longer ischemia time (p<0.01), and preoperative proteinuria (p=0.04)., Conclusion: Preoperative proteinuria by urine dipstick is an independent predictor of postoperative AKI after RPN. This test may be used to identify patients, especially those without overt CKD, who are at increased risk for developing AKI after RPN., Competing Interests: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Aim: To describe the pathological characteristics of the peritumoral non-neoplastic renal parenchyma (NNRP) and to investigate their impact on long-term renal function after partial nephrectomy., Materials and Methods: In our institutional robotic partial nephrectomy database, we identified 394 cases with pathological assessment of the NNRP and long-term postoperative renal functional follow-up. The NNRP was classified as normal (healthy renal parenchyma) or abnormal, based on the presence of arteriosclerosis, glomerulosclerosis, interstitial fibrosis, interstitial inflammation, and/or tubulopapillary hyperplasia. The primary outcome was a ≥ 20% decline in estimated glomerular filtration rate (eGFR) at 6 and 12 months after surgery. Multivariable analysis was used to assess the association between NNRP and eGFR decline, with adjustment for demographic, clinical, and tumor factors., Results: Overall, 250 (63.5%) pathological specimens had abnormal NNRP features. The most prevalent isolated benign pathological feature was glomerulosclerosis (18.0%), followed by arteriosclerosis (16.8%), interstitial inflammation (12.4%), interstitial fibrosis (1.2%), and tubulopapillary hyperplasia (0.4%). The abnormal NNRP group was associated with older age (p = .01), preoperative diabetes mellitus (p = .01), and preoperative hypertension (p = .01). The preoperative eGFR was significantly lower in the abnormal NNRP group (p = .01). NNRP abnormalities were not significantly associated with eGFR decline at either 6 or 12 months. The only independent predictor of eGFR decline was warm ischemia time (p = .01), and this association was only observed at 12 months., Conclusion: NNRP features are associated with preoperative comorbidities and lower baseline eGFR; however, they are not independent predictors of long-term renal functional preservation after partial nephrectomy.

Objectives: To compare optimum outcome achievement in open partial nephrectomy (OPN) with that in robot-assisted partial nephrectomy (RAPN)., Patients and Methods: Using our institutional partial nephrectomy (PN) database, we reviewed 605 cases performed for unifocal clinical T1 renal masses in non-solitary kidneys between 2011 and 2015. Tetrafecta, which was defined as negative surgical margins, freedom from peri-operative complications, ≥80% renal function preservation, and no chronic kidney disease upstaging, was chosen as the composite optimum outcome. Factors associated with tetrafecta achievement were assessed using multivariable logistic regression, with adjustment for age, gender, race, Charlson comorbidity score, body mass index, chronic kidney disease, tumour size, tumour complexity and approach., Results: The overall tetrafecta achievement rate was 38%. Negative margins, freedom from complications, and optimum functional preservation were achieved in 97.1%, 73.6% and 54.2% of cases, respectively. For T1a masses, the tetrafecta achievement rate was similar between approaches (P = 0.97), but for T1b masses, the robot-assisted approach achieved significantly higher tetrafecta rates (43.0% vs 21.3%; P < 0.01). On multivariable analysis, the robot-assisted approach had 2.6-fold higher odds of tetrafecta achievement than the open approach, primarily because of lower peri-operative morbidity, specifically related to wound complications. Positive surgical margin rates and renal function preservation were similar in the two approaches., Conclusions: Optimum outcomes are readily achieved regardless of PN approach. The robot-assisted approach may facilitate optimum outcome achievement for 4-7-cm masses by minimizing wound complications., (© 2017 The Authors. BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.)

Purpose: We sought to identify the preoperative factors associated with conversion from robotic partial nephrectomy to radical nephrectomy. We report the incidence of this event., Materials and Methods: Using our institutional review board approved database, we abstracted data on 1,023 robotic partial nephrectomies performed at our center between 2010 and 2015. Standard and converted cases were compared in terms of patients and tumor characteristics, and perioperative, functional and oncologic outcomes. Logistic regression analysis was done to identify predictors of radical conversion., Results: The overall conversion rate was 3.1% (32 of 1,023 cases). The most common reasons for conversion were tumor involvement of hilar structures (8 cases or 25%), failure to achieve negative margins on frozen section (7 or 21.8%), suspicion of advanced disease (5 or 15.6%) and failure to progress (5 or 15.6%). Patients requiring conversion were older and had a higher Charlson score (both p <0.01), including an increased prevalence of chronic kidney disease (p = 0.02). Increasing tumor size (5 vs 3.1 cm, p <0.01) and R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar location) score (9 vs 8, p <0.01) were also associated with an increased risk of conversion. Worse baseline renal function (OR 0.98, 95% CI 0.96-0.99, p = 0.04), large tumor size (OR 1.44, 95% CI 1.22-1.7, p <0.01) and increasing R.E.N.A.L. score (p = 0.02) were independent predictors of conversion. Compared to converted cases, at latest followup standard robotic partial nephrectomy cases had similar short-term oncologic outcomes but better renal functional preservation (p <0.01)., Conclusions: At a high volume center the rate of robotic partial nephrectomy conversion to radical nephrectomy was 3.1%, including 2.2% of preoperatively anticipated nephrectomy cases. Increasing tumor size and complexity, and poor preoperative renal function are the main predictors of conversion., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To identify predictors of poor discharge quality after robotic partial nephrectomy (RPN) at a large academic center., Methods: We queried our institutional RPN database for consecutive patients treated between 2011 and 2015. The primary outcome was poor discharge quality, defined as length of stay >3 days and/or unplanned readmission. The association between patient, disease, and provider factors and overall discharge quality was assessed using univariate and multivariable analyses., Results: Of 791 cases, 219 (27.7 %) had poor discharge quality. On univariate analysis, factors associated with poor discharge quality were older age (p < .01), black race (p = .01), social insurance (p < .01), higher ASA score (p < .01), chronic kidney disease (p < .01), increased tumor size (p < .01), and higher tumor complexity (p = .01). Surgeon case volume did not predict discharge quality (p = .63). After adjustment for covariates on multivariable analysis, race (p = .01), ASA (p = .02), CKD (p < .01), tumor size (p = .02), and tumor complexity (p = .03) still predicted poor discharge quality. In particular, the odds of poor discharge quality were highest in the setting of CKD (OR 2.62, 95 % CI 1.72-4.01), black race (OR 2.17, 95 % CI 1.32-3.57), and higher ASA (OR 1.49, 95 % CI 1.07-2.08)., Conclusions: Non-modifiable patient and disease factors predict poor discharge quality after RPN. Risk adjustment for these factors will be important for determining future reimbursement for RPN providers.

Objectives: To assess differences in complications after robot-assisted (RAPN) and open partial nephrectomy (OPN) among experienced surgeons., Patients and Methods: We identified patients in our institutional review board-approved, prospectively maintained database who underwent OPN or RAPN for management of unifocal, T1a renal tumours at our institution between January 2011 and August 2015. The primary outcome measure was the rate of 30-day overall postoperative complications. Baseline patient factors, tumour characteristics and peri-operative factors, including approach, were evaluated to assess the risk of complications., Results: Patients who underwent OPN were found to have a higher rate of overall complications (30.3% vs 18.2%; P = 0.038), with wound complications accounting for the majority of these events (11.8% vs 1.8%; P < 0.001). Multivariable logistic regression analysis showed the open approach to be an independent predictor of overall complications (odds ratio 1.58, 95% confidence interval 1.03-2.43; P = 0.035). Major limitations of the study include its retrospective design and potential lack of generalizability., Conclusions: The open surgical approach predicts a higher rate of overall complications after partial nephrectomy for unifocal, T1a renal tumours. For experienced surgeons, the morbidity associated with nephron-sparing surgery may be incrementally improved using the robot-assisted approach., (© 2016 The Authors BJU International © 2016 BJU International Published by John Wiley & Sons Ltd.)

Introduction: The surgical morbidity of ipsilateral synchronous multifocality (ISM) is poorly characterized. We assessed the impact of ISM on complications after robotic partial nephrectomy (RPN)., Patients and Methods: We abstracted data on RPN cases performed between 2006 and 2015 at our institution. Multifocal disease was characterized by >1 renal mass on preoperative imaging or >1 mass excision during RPN. The primary outcome was the rate of overall postoperative complications. The association between multifocality and complications was evaluated using univariate and multivariable analyses., Results: Of 1121 cases, 59 (5.3%) had >1 ipsilateral renal mass and 50 (4.5%) required >1 excision. The overall complication rate was 20.3% (230/1121). The radiographic number of ipsilateral renal masses was not significantly associated with complications (20.2% for 1 mass vs. 25.4% for >1 mass, p = 0.338). However, the actual number of ipsilateral mass excisions performed during RPN was significantly associated with complications (20.2% for ≤2 excisions vs. 42.9% for >2 excisions, p = 0.037). Major complications were higher (14.3% vs. 5.3%) for >2 versus ≤2 excision(s), but this difference was not significant (p = 0.174). The most common complications associated with multiple excisions were transfusion, urine leak, arrhythmia, venous thromboembolism, and ileus. On multivariable analysis, number of excisions independently predicted complications (OR 3.1, 95% CI 1.03-9.33, p = 0.041). Other independent predictors of complications included age, race, Charlson score, body mass index, RENAL score, and surgeon experience., Conclusions: ISM requiring ≥2 excisions is associated with increased morbidity after RPN. Pending external validation, this information may facilitate clinical decision-making and preoperative patient counseling.

Unlabelled: Since volume loss is the most important modifiable determinant of long-term renal function after partial nephrectomy, there is great interest in ways to reduce the loss of healthy parenchyma. We retrospectively reviewed 880 partial nephrectomies to identify predictors of excisional volume loss (EVL), based on pathologic assessment. After stepwise variable selection, we assessed age, sex, solitary kidney status, tumor size, endophytic property, estimated blood loss, surgical approach, and surgeon volume for association with EVL using multiple regression. Male sex (p<0.01), larger tumors (p<0.01), endophytic tumors (p=0.01), open approach (p<0.01), increased bleeding (p<0.01), and higher surgeon volume (p<0.01) were independently associated with greater EVL. Approach strongly influenced EVL with open surgery having 7.8 cm(3) more EVL than robotic surgery. Negative surgical margins (95.7% vs 94.1%, p=0.32) did not differ between open and robotic approaches, respectively. EVL is associated with patient, tumor, and especially provider factors, suggesting that volume preservation may be improved with surgical optimization. Lack of percent volume loss data, which precluded assessment of EVL's impact on long-term renal function, is a limitation., Patient Summary: We found that surgical approach affects the quantity of healthy kidney removed during cancer surgery, suggesting that there is room for further surgical improvement., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: The use of hemostatic agents (HA) during robotic partial nephrectomy (RPN) is largely empiric. We sought to assess the impact of HA on postoperative bleeding after RPN in a contemporary cohort., Patients and Methods: Using our institutional RPN database, we identified consecutive patients treated between 2010 and 2015. HA were routinely placed in the nephrectomy bed at the time of renorrhaphy until 2014 when their use was phased out to reduce cost. We compared postoperative bleeding outcomes (blood transfusion and hemoglobin decline) between patients who did and did not receive HA, after excluding patients with preoperative anemia (hemoglobin <11 g/dL) or high estimated blood loss (≥175 mL). The total inflation-adjusted costs (for 2015) of HA were calculated., Results: Of 544 cases, HA were used in 240 (44.1%). The mean number of agents per case was 1.4 ± 0.73, including 77 (14.2%), 52 (9.6%), and 39 (7.2%) cases in which cellulose, fibrin, or gelatin-based agents were used alone, respectively, and 72 (13.2%) cases in which multiple agents were used. The mean cost of HA per case was $488 ± 421. Nearly 90% of cases were performed by surgeons who were beyond their learning curves. Overall, 13 (2.4%) patients were transfused, and the median hemoglobin decline was 2.2 g/dL (IQR, 1.4-3.0 g/dL). On univariate analysis, HA use and type of HA were not significantly associated with blood transfusion (p = 0.20 and p = 0.29, respectively), but were associated with hemoglobin decline (p = 0.01 and p = 0.02, respectively). After adjusting for covariates, HA use was no longer significantly associated with postoperative hemoglobin decline., Conclusions: In nonanemic patients with minimal intraoperative bleeding, HA use does not alter postoperative bleeding outcomes after RPN, suggesting that their routine use in this setting merits reconsideration. Further research is needed to determine if HA may be useful in certain high-risk situations.

Purpose: To present our results of laparoscopic upper pole heminephrectomy in adult patients with duplex kidney., Materials and Methods: A total of 10 patients with an age range of 27 to 54 years old underwent laparoscopic upper pole heminephrectomy for complete duplication of the renal collecting system. The key point of the technique included the placement of a catheter in the normal ureter at the beginning of the procedure. The patient was positioned in a 45-90 degrees lateral decubitus position and a 4-port transperitoneal or 3-port retroperitoneal technique was applied followed by the mobilization of the upper pole ureter away from the renal hilum. Afterwards, the vasculature supplying the upper pole was precisely identified and ligated. Followed by transection of the ureter and its transposition cephalad to the hilum, the upper pole moiety was fully transected using the harmonic scalpel., Results: Eight patients were operated on using the transperitoneal approach and 2 using the retroperitoneal technique. One patient required preoperative percutaneous drainage due to pyonephrosis. The operation time ranged between 150 to 350 min with minimal blood loss (0-200 mL). Hemostasis was achieved with an Argon laser in one patient. The lower pole calyceal system was perforated in one patient and repaired intracorporally. No major intraoperative complications occurred. All of the patients except two had their drains removed in 72 h after the operation and were generally discharged on postoperative day 3., Conclusion: Laparoscopic upper pole heminephrectomy for an ectopic ureter is safe and reproducible and offers benefits of laparoscopic surgery even in patients with complicated urinary tract infection.

Objective: To report long-term functional and oncological outcomes of OPN Methods: We enrolled 182 patients who underwent consecutive OPN with a diagnosis of kidney tumor in our clinic between April 2002 and February 2020 and were selected from our prospective OPN database. Preoperative demographic and clinical characteristics, intraoperative and pathological results, and patients' postoperative functional and oncological follow-up data were retrospectively analyzed. Overall survival (OS) and disease- free survival (DFS) were evaluated using Kaplan-Meier survival analysis. The time-dependent variation between preoperative and postoperative functional results was statistically analyzed and presented in a graph. Results and limitations: The mean age was 54.4 ± 10.8 yr, and the median age-adjusted Charlson comorbidity index (ACCI) was 1 (interquartile range [IQR] 0-1). The mean tumor size was 3.1 ± 1.2 cm, and the median RENAL score was 6 (IQR 5-8). The most common malign histopathological subtype was clear cell carcinoma with 76.6%, and five cases (3.4%) had positive surgical margins (PSMs). The most common surgical techniques were the retroperitoneal approach (98.9%) and cold ischemia (88.5%). Estimated glomerular filtration rate (eGFR) preservation was 92% (80.8-99.3, IQR), which translates to 32% chronic kidney disease (CKD) upstaging. Acute kidney injury (AKI) was detected in 27 (14.8%) patients according to RIFLE criteria. The intraoperative complication rate was 5.5%, and the postoperative overall complication rate (Clavien-Dindo 1-5) was 30.2%. Major complications (Clavien-Dindo 3-5) were observed in 13 (7.1%) patients. The median oncological follow-up was 42 mo (21.3- 84.6, IQR), and the 5- and 10-yr OS were 90.1% and 78.6%, 5 and 10-yr DFS were 99.4% and 92.1%, respectively. No local recurrence was observed in 5 (3.4%) patients with PSMs; only one had distant metastasis in the 8th postoperative month. The retrospective design, the small number of patients who underwent PN based on mandatory indication, and one type of surgical approach may limit the generalizability of our findings. Conclusions: This study confirms excellent long-term oncologic and functional outcomes after OPN in a cohort of patients selected from a single institution. In light of the information provided by the literature and our study, our recommendation is to push the limits of PN under every technically feasible condition in the treatment of kidney tumors to protect the kidney reserve and achieve near-perfect oncological results. [ABSTRACT FROM AUTHOR]

Objective: To identify preoperative factors that predict positive surgical margins in partial nephrectomy. Material and methods: Using our institutional partial nephrectomy database, we investigated the patients who underwent partial nephrectomy for malignant tumors between January 2011 and December 2015. Patient, tumor, surgeon characteristics were compared by surgical margin status. Multivariable logistic regression was used to identify independent predictors of positive surgical margins. Results: A total of 1025 cases were available for analysis, of which 65 and 960 had positive and negative surgical margins, respectively. On univariate analysis, positive margins were associated with older age (64.3 vs. 59.6, p<0.01), history of prior ipsilateral kidney surgery (13.8% vs. 5.6%, p<0.01), lower preoperative eGFR (74.7 mL/min/1.73 m² vs. 81.2 mL/min/1.73 m2, p=0.01), high tumor complexity (31.8% vs. 19.0%, p=0.03), hilar tumor location (23.1% vs. 12.5%, p=0.01), and lower surgeon volume (p<0.01). Robotic versus open approach was not associated with the risk of positive margins (p=0.79). On multivariable analysis, lower preoperative eGFR, p=0.01), hilar tumor location (p=0.01), and lower surgeon volume (p<0.01) were found to be independent predictors of positive margins. Conclusion: In our large institutional series of partial nephrectomy cases, patient, tumor, and surgeon factors influence the risk of positive margins. Of these, surgeon volume is the single most important predictor of surgical margin status, indicating that optimal oncological outcomes are best achieved by high-volume surgeons. [ABSTRACT FROM AUTHOR]

Despite being the most frequent renal fusion anomaly, tumors arising from horseshoe kidneys (HSKs) are extremely rare and management guidance is lacking. To evaluate the perioperative, oncological, and functional outcomes of surgically treated HSK tumors. A retrospective, multicenter cohort study of 43 HSK tumors in 40 patients was conducted, and technical description of the surgical approach has been provided. Surgical resection of renal tumors arising from HSKs was performed either via open surgery or via minimally invasive surgery (MIS). We analyzed patient and tumor characteristics as well as surgical technique, and functional and oncological outcomes. Eight patients were treated by MIS and 32 by open surgery. One patient (2.5%) experienced an intraoperative complication and 13 patients (32.5%) experienced postoperative complications, of which three (7.5%) were Clavien-Dindo ≥3 complications. Surgical margins were positive in two tumors (4.7%). The most frequent histology was clear-cell renal cell carcinoma (46.5%). The median follow-up was 51 (interquartile range [IQR] 17–73) mo. The 5-yr overall, cancer-specific, and recurrence-free survival rates were 81.2%, 86.8%, and 83.1%, respectively. The percent decreases in estimated glomerular filtration rate at discharge and the last follow-up were 15% (IQR 4–26%) and 17% (IQR 1–31%), respectively. Limitations include the cohort's retrospective nature, heterogeneity, and small sample size. Surgical management of tumors in HSKs can be approached via both open surgery and MIS, with maximal preservation of functional renal parenchyma. In this cohort, rates of complications, positive surgical margins, and renal functional decrease were acceptable, considering the anatomical complexity of these kidneys and tumors. These tumors display great variation in histological subtypes. Meticulous presurgical planning, taking advantage of advanced imaging techniques, can aid in achieving good outcomes. We evaluated the surgical management of renal tumors in horseshoe kidneys, which are very rare. Although these procedures are highly complex, outcomes are acceptable. Modern imaging techniques are often required in presurgical planning. Surgical management of horseshoe kidney tumors is complex, but feasible through both open and minimally invasive surgery after meticulous presurgical planning. Rates of complications, positive surgical margins, and renal functional decrease were acceptable in this cohort, treated at high-volume centers. [ABSTRACT FROM AUTHOR]

Purpose: To present our results of laparoscopic upper pole heminephrectomy in adult patients with duplex kidney. Materials and Methods: A total of 10 patients with an age range of 27 to 54 years old underwent laparoscopic upper pole heminephrectomy for complete duplication of the renal collecting system. The key point of the technique included the placement of a catheter in the normal ureter at the beginning of the procedure. The patient was positioned in a 45-90 degrees lateral decubitus position and a 4-port transperitoneal or 3-port retroperitoneal technique was applied followed by the mobilization of the upper pole ureter away from the renal hilum. Afterwards, the vasculature supplying the upper pole was precisely identified and ligated. Followed by transection of the ureter and its transposition cephalad to the hilum, the upper pole moiety was fully transected using the harmonic scalpel. Results: Eight patients were operated on using the transperitoneal approach and 2 using the retroperitoneal technique. One patient required preoperative percutaneous drainage due to pyonephrosis. The operation time ranged between 150 to 350 min with minimal blood loss (0-200 mL). Hemostasis was achieved with an Argon laser in one patient. The lower pole calyceal system was perforated in one patient and repaired intracorporally. No major intraoperative complications occurred. All of the patients except two had their drains removed in 72 h after the operation and were generally discharged on postoperative day 3. Conclusion: Laparoscopic upper pole heminephrectomy for an ectopic ureter is safe and reproducible and offers benefits of laparoscopic surgery even in patients with complicated urinary tract infection. [ABSTRACT FROM AUTHOR]