Search

Objective: To describe the long-term outcomes of robot-assisted laparoscopic pyeloplasty (RALP) for the correction of ureteropelvic junction (UPJ) obstruction.Methods: A retrospective electronic medical record review of RALPs from October 2002 to July 2014 was performed, with additional follow-up for patients released from regular urological care obtained by phone. RALP success was defined as resolution of symptoms of UPJ obstruction, improved hydronephrosis radiographically, or resolution of obstruction on follow-up Tc-99m mercaptoacetyltriglycine renal scan, intravenous pyelogram, or Whitaker test. RALP failure was defined as persistence of symptoms with obstruction demonstrated on functional imaging or requirement for a subsequent UPJ procedure.Results: A total of 129 cases were identified, with an average patient age of 34.3 years. Stented RALP was performed in 80.6% of cases whereas 19.4% of patients underwent stentless RALP. A dismembered technique was performed in 90.7% of pyeloplasties, whereas 9.3% were nondismembered Fenger, Y-V, or flap pyeloplasties. Five intraoperative complications and 18 postoperative complications (Clavien I-IIIb) were described. One hundred twenty-nine patients received follow-up for a mean of 33.8 months (range 1-147 months). RALP was successful in 125/129 (96.9%), with an 8-year failure-free survival of 91.5%. When considering only stented pyeloplasties, the 8-year failure-free survival was 96.3%.Conclusion: RALP is a safe and effective minimally invasive method for correction of UPJ obstruction, resulting in lasting improvement in symptoms and resolution of obstruction for most patients. [ABSTRACT FROM AUTHOR]

Introduction: The learning curve for robotic partial nephrectomy was investigated for an experienced laparoscopic surgeon and factors associated with warm ischemia time (WIT) were assessed. Materials and Methods: Between 2007 and 2014, one surgeon completed 171 procedures. Operative time, blood loss, complications and ischemia time were examined to determine the learning curve. The learning curve was defined as the number of procedures needed to reach the targeted goal for WIT, which most recently was 20 min. Statistical analyses including multivariable regression analysis and matching were performed. Results: Comparing the first 30 to the last 30 patients, mean ischemia time (23.0-15.2 min, P < 0.01) decreased while tumor size (2.4-3.4 cm, P = 0.02) and nephrometry score (5.9-7.0, P = 0.02) increased. Body mass index (P = 0.87), age (P = 0.38), complication rate (P = 0.16), operating time (P = 0.78) and estimated blood loss (P = 0.98) did not change. Decreases in ischemia time corresponded with revised goals in 2011 and early vascular unclamping with the omission of cortical renorrhaphy in selected patients. A multivariable analysis found nephrometry score, tumor diameter, cortical renorrhaphy and year of surgery to be significant predictors of WIT. Conclusions: Adoption of robotic assistance for a surgeon experienced with laparoscopic surgery was associated with low complication rates even during the initial cases of robot‑assisted partial nephrectomy. Ischemia time decreased while no significant changes in blood loss, operating time or complications were seen. The largest decrease in ischemia time was associated with adopting evidence‑based goals and new techniques, and was not felt to be related to a learning curve. [ABSTRACT FROM AUTHOR]

Background and Purpose: To assess the safety of omitting cortical renorrhaphy during robot-assisted partial nephrectomy and measure preliminary functional outcomes. Patients and Methods: Fifteen robot-assisted partial nephrectomies were performed with a running, base-layer suture for the collecting system and vessel hemostasis but without cortical renorrhaphy. The nonrenorrhaphy group was matched 1:2 by R.E.N.A.L. nephrometry score to a running, sliding-clip cortical renorrhaphy group retrospectively. Intraoperative blood loss, urine leaks, postoperative bleeds, and functional outcomes were evaluated. Predictors of %volume loss were evaluated using multivariable regression. Results: No differences were seen between renorrhaphy and nonrenorrhaphy in sex ( P=0.53), age ( P=0.14), body mass index ( P=0.08), Charlson score ( P=0.44), tumor diameter ( P=0.55), nephrometry score ( P=0.77), preoperative glomerular filtration rate (GFR, P=0.63), or the amount of resected healthy kidney margin ( P=0.21). Warm ischemia time was less for the nonrenorrhaphy group ( P<0.002). One pseudoaneurysm necessitating embolization (1/30=3%) was seen in the renorrhaphy group compared with none in the nonrenorrhaphy group. No urine leaks occurred in either group. The median %GFR loss was 8.8% for renorrhaphy and 4.4% for nonrenorrhaphy ( P=0.14) at a median follow-up of 4.1 months. The median %volume loss was 17 cm3 for renorrhaphy and 9 cm3 for nonrenorrhaphy ( P=0.003). In a multivariable model, both cortical renorrhaphy ( P=0.004) and tumor diameter ( P=0.004) were predictors of %volume loss. Conclusion: Omission of cortical renorrhaphy appears feasible with no urine leaks or bleeding complications observed. The percent renal volume loss was improved by omission of cortical renorrhaphy. Reconstruction technique is important to control for when studying renal function after partial nephrectomy. [ABSTRACT FROM AUTHOR]

Purpose: We sought to evaluate the relationship between hospital volume and postoperative complications following robot-assisted partial nephrectomy (RAPN) using the Nationwide Inpatient Sample. Materials and Methods: We identified patients undergoing RAPN between 2009 and 2011. Hospitals were divided into volume-based tertiles for each year (high, medium, low). Descriptive analyses were performed using Pearson's chi-squared and Student's t-test. Multivariable logistic regression assessed the association between hospital volume and postoperative complications, adjusting for age, gender, hospital region, type of hospital, primary payer, comorbidities, and kidney cancer. Results: We identified 17,583 cases from 323 hospitals, of which 112 were low volume, 112 medium volume, and 99 high volume. 13,645 (78%) cases were performed at high-volume institutions. Eleven percent of patients developed an in-hospital postoperative complication, with 15% at low-volume, 12% at medium-volume, and 10% at high-volume hospitals ( p=0.071). In addition, blood transfusion was less common at high-volume hospitals ( p=0.015). On multivariable logistic regression, high-volume hospitals had 42% decreased odds of postoperative in-hospital complications (95% confidence interval 0.37-0.90; p=0.016). Complications were associated with a $4500 increase in hospital costs. Conclusions: High-volume hospitals are associated with decreased blood transfusions and complications. With the recognition that high-volume RAPN hospitals are independently associated with improved clinical outcomes, further studies should be performed to determine the role of the hospital and surgeon volume thresholds in the performance of RAPN. [ABSTRACT FROM AUTHOR]

Purpose While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. Materials and Methods From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. Results We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). Conclusions Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy. [ABSTRACT FROM AUTHOR]

Background: Reports of robot-assisted live donor nephrectomies (LDNs) have been emerging in the literature. We sought to examine the national incidence of robot-assisted LDNs and to assess regional use and economic differences in robot-assisted versus laparoscopic LDN. Methods: Data from the Nationwide Inpatient Sample (NIS) were used to identify patients who underwent either laparoscopic or robot-assisted LDN between 2009 and 2011. Descriptive analysis was performed to examine differences between the laparoscopic and robot-assisted groups. Results: A total of 4,163 cases of LDN were performed using robot-assistance or pure laparoscopic surgery between 2009 and 2011. Of these, 142 were classified as robot-assisted nephrectomies; these cases were all from the western United States. There was no difference in the incidence of complications between the laparoscopic and robot-assisted groups ( P=0.206). Median (interquartile range [IQR]) total charges for robot-assisted LDN were $48,639 ($42,380-$53,050) vs $37,019 ($28,715-$48,816) for laparoscopic cases ( P<0.001). Conclusions: The role of robotic assistance in LDN remains to be determined; we identified no benefits to robotic assistance in our study. [ABSTRACT FROM AUTHOR]

Partial nephrectomy (PN) is a technically challenging procedure, making selection of appropriate patients paramount to a successful operation. To identify patients at increased risk of an adverse outcome after PN, there are a number of scoring systems available. The nephrometry score was initially described in a series of laparoscopic and open partial and radical nephrectomies. We compare the association of the nephrometry score with perioperative outcomes in a population of robot-assisted partial nephrectomies. A total of 119 patients were retrospectively reviewed. Correlation and regressional analysis was performed. We identified the separate variables R, E, N, and L to have limited correlation and no predictive value to patient outcomes. Nephrometry score and grade were found to have stronger correlation and predictive value than the individual components of the R.E.N.A.L. nephrometry score. Size of tumor measured on a continuous scale was found to have the strongest correlation and predictive value to outcomes. Outcomes predicted included operative time, length of stay, warm ischemia time, and entry into the collecting system. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the incidence of pediatric robotic-assisted laparoscopic pyeloplasties (RALPs) and to determine if there were regional or age-related trends associated with the performance of RALP. Methods: Using 2005-2010 data from the Nationwide Inpatient Sample (NIS), the incidence of and trends in pyeloplasty in patients less than 18 years of age were assessed. This was broken down by open, laparoscopic, and robotic techniques when possible. Multiple logistic regression determined which characteristics were associated with increased performance of RALP. Population weighting was used to estimate national rates. Results: A total of 15,498 pediatric pyeloplasties were performed between 2005 and 2010. Coding for robotics began at the end of 2008, and, since then, 750 of the 5557 pediatric pyeloplasties were robotic. The rate of RALP remained unchanged from 2008-2010 (odds ratio [OR] 0.93, P = .051); however, there was an overall increase in minimally invasively procedures (RALP or laparoscopic) since 2005 (OR 1.4, P <.001). Factors associated with increased performance of RALP were aged above 11 years (OR 50.3, P <.001) and living in the northeast (OR 3.0, P = .001), midwest (OR 2.9, P = .001), or west (OR 4.31, P <.001) compared with the south. Conclusion: An estimated 750 robotic pyeloplasties were performed in the United States between the end of 2008 and 2010. There was an increase in the total number of pyeloplasties performed using minimally invasive techniques since 2005. Older children are more likely and patients living in the south are less likely to be treated with robotic assistance. [ABSTRACT FROM AUTHOR]

Purpose: We evaluated trends and associated characteristics in the use of robotics for pyeloplasty as treatment for ureteropelvic junction obstruction. Materials and Methods: Data from the Nationwide Inpatient Sample were used to evaluate pyeloplasty trends from 2005 to 2010. Patients treated with pyeloplasty and procedure method (robotic, laparoscopic or open) were identified by ICD-9-CM codes. Coding for robotics was initiated in the fourth quarter of 2008. Multivariable analysis was performed to examine characteristics affecting the odds of undergoing robotic pyeloplasty vs other approaches to pyeloplasty. Results: We identified 3,947 pyeloplasties performed between 2005 and 2010, including 1,642 since the fourth quarter of 2008. There was a statistically significant increase in the number of robotic pyeloplasties (p <0.001). Mean total charges for robotic vs nonrobotic procedures were $40,200 vs $37,817 (p = 0.106). Characteristics related to undergoing a robotic procedure included surgery at a teaching hospital (OR 1.29, 95% CI 1.04–1.59, p = 0.021) and in the Northeast (OR 1.54, 95% CI 1.17–2.04, p = 0.002) or Midwest (OR 1.62, 95% CI 1.23–2.12, p <0.001) compared with the South. When the primary payer was Medicaid vs private insurance, patients were 46% less likely to undergo the procedure robotically (p <0.001). There was no significant difference in charges between robotic and open pyeloplasty. Conclusions: The number of robotic pyeloplasties performed quarterly in the United States is increasing, although there are disparities in the adoption of the robotic approach among geographic regions and hospital types. [ABSTRACT FROM AUTHOR]

The article discusses the report "Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts," by K. Ahmed and colleagues. Topics include the application of a standardised training curriculum for robotic surgery training, the use of virtual reality simulation, and the critical role of non-technical skills such as leadership, trouble-shooting, communication, and teamwork in avoiding adverse events.