Faculty Bibliography

OBJECTIVES/OBJECTIVE:To describe surgical techniques and peri-operative outcomes with secondary robotic pyeloplasty (RP), and compare them to those of primary RP. METHODS:We retrospectively reviewed our multi-institutional, Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients who underwent RP between 04/2012-09/2019. Patients were grouped according to whether they underwent a primary or secondary pyeloplasty (performed for a recurrent stricture after previously failed pyeloplasty). Perioperative outcomes and surgical techniques were compared using nonparametric independent sample median tests and chi-square tests; p<0.05 was considered significant. RESULTS:Of 158 patients, 28 (17.7%) and 130 (82.3%) underwent secondary and primary RP, respectively. Secondary RP, compared to primary RP, was associated with a higher median estimated blood loss (100.0 versus 50.0 milliliters, respectively; p<0.01) and longer operative time (188.0 versus 136.0 minutes, respectively; p=0.02). There was no difference in major (Clavien>2) complications (p=0.29). At a median follow-up of 21.1 (IQR: 11.8-34.7) months, there was no difference in success between secondary and primary RP groups (85.7% versus 92.3%, respectively; p=0.44). Buccal mucosa graft onlay ureteroplasty was performed more commonly (35.7% versus 0.0%, respectively, p<0.01) and near-infrared fluorescence imaging with indocyanine green was utilized more frequently (67.9% versus 40.8%, respectively; p<0.01) for secondary versus primary repair. CONCLUSIONS:Although performing secondary RP is technically challenging, it is a safe and effective method for recurrent ureteropelvic junction obstruction after a previously failed pyeloplasty. Buccal mucosa graft onlay ureteroplasty and utilization of near-infrared fluorescence with indocyanine green may be particularly useful in the re-operative setting.

Introduction Closed drains have traditionally been placed after partial nephrectomy due to risks of bleeding and urine leak. We sought to study the safety of a non-routine drain (NRD) protocol following transperitoneal robotic partial nephrectomy (RPN). Patients and Methods From a multi-institutional database, we have analyzed the data of 904 patients who underwent RPN. 546 (60.40%) patients underwent RPN by a surgeon who had a routine drain (RD) protocol. 358 (39.60%) patients underwent RPN by a surgeon who had a NRD protocol. Perioperative outcomes, length of stay (LOS) and readmission rates were compared between the two groups. Baseline characteristics, perioperative and postoperative outcomes were compared using Mann Whitney U test, Chi-square test and Fishers exact tests. Results Patients in the NRD protocol were more likely to have higher BMI (30.10 kg/m2 vs. 28.07 kg/m2; p <0.001), higher tumor size (3.0 cm vs. 2.5cm; p=0.001), and higher renal score (8 vs. 7; p<0.001). Rate of transfusion (0.00% NRD vs. 0.56% RD; p = 0.157) and overall complication (7.33% NRD vs. 7.82% RD; p=0.782) were comparable. Median hospital stay is 1 day for both groups. Readmission rate was also similar (0.55% NRD vs. 1.40% RD; p=0.279). In a multivariable analysis, NRD protocol was associated with shorter length of hospital stay (Incident Rate Ratio [IRR] - 0.72, p<0.001). Conclusion A NRD protocol for robotic partial nephrectomy yielded a decreased length of stay and similar perioperative outcomes. Placement of surgical drains should be based on individual circumstances, and not required on a routine basis.

OBJECTIVE:To describe a novel technique of ureteral reimplantation via robotic non-transecting side-to-side anastomosis. While the standard approach to ureteroneocystostomy has a high rate of success, it involves transection of the ureter which may impair vascularity and contribute to recurrent strictures. Our method seeks to maximally preserve distal ureteral blood flow which may reduce this risk. METHODS:We retrospectively reviewed a multi-institutional ureteral reconstruction database to identify patients who underwent this operation between 2014-2018, analyzing perioperative and postoperative outcomes. RESULTS:Our technique was utilized in 16 patients across three U.S. academic institutions. Median operative time and estimated blood loss were 178 minutes (IQR 150 - 204) and 50 mL (IQR 38 - 100) respectively. The median length of stay was 1 day (IQR 1-2). No intraoperative complications or post-operative complications with Clavien score ≥3 were reported. Post-operatively, 15/16 (93.8%) patients reported clinical improvement in flank pain, and all patients who underwent follow-up imaging had radiographic improvement with decrease in hydronephrosis at a median follow-up of 12.5 months. CONCLUSIONS:Ureteral reimplantation via a robotic non-transecting side-to-side anastomosis is a feasible and effective operation for distal ureteral stricture which may have advantages over the standard of care transecting ureteroneocystostomy.

OBJECTIVES/OBJECTIVE:To most accurately assess the risks and benefits of this technique we evaluated outcomes of selective clamping vs. full clamping in a patients with a solitary kidney undergoing robotic partial nephrectomy (RPN). SUBJECTS/PATIENTS AND METHODS/UNASSIGNED:Data from IRB approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analyzed for demographics, risk factors, intraoperative complications, and postoperative outcomes using Chi-square test, Fisher's exact test, t-test, and Mann Whitney U's test. RESULTS:Our initial cohort consisted of 4112 patients of which 72 had undergone robotic partial nephrectomy in a solitary kidney, (51 with full clamping and 21 with selective). Both groups had no significant difference in demographics, tumor size, baseline estimated glomerular filtration rate (eGFR), or warm ischemia time (WIT) (Table 1). Intraoperative outcomes, including estimated blood loss (EBL,) operative time, and intraoperative complications were similar between the two groups. Short and long term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques (Table 2). CONCLUSION/CONCLUSIONS:In a large cohort of solitary kidney patients undergoing RPN, selective clamping results in similar intraoperative and postoperative outcomes compared to full clamping and confers no additional risk of harm. However, selective clamping does not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 minutes) may have prevented identification of benefits in selective clamping; a similar study analyzing cases with longer WIT may possibly elucidate any beneficial effects of selective clamping.

OBJECTIVE:To analyze whether selective arterial clamping (SAC) and Off-Clamp (OC) techniques during robotic partial nephrectomy (RPN) are associated with a renal functional benefit in patients with stage III-V CKD. METHODS:The change in eGFR over time was compared between patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n=375, 81.2%), SAC (n=48, 10.4%) or OC (n=39, 8.4%) using a multivariable linear mixed effects model. All follow-up eGFR including baseline and follow-up between 3-24 months were included in the model for analysis. Median follow-up was 12.0 months (IQR 6.7-16.5; Range 3.0-24.0 Months). Perioperative outcomes were also compared with multivariable linear, logistic and Poisson regression models. RESULTS:In the multivariable linear mixed effects model adjusting for characteristics including tumor size and the R.E.N.A.L. Nephrometry score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β=-1.20; 95% CI=-5.45, 3.06; p=.582) and OC and MAC RPN (β=-1.57; 95% CI=-5.21, 2.08; p=.400). Only 20 (15 MAC, 2 SAC, 3 OC) patients overall experienced progression of their CKD stage at last follow-up. Mean ischemia time was 17 minutes for MAC and 15 minutes for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay or surgical margins CONCLUSION: Selective clamping and off-clamp techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.

OBJECTIVES/OBJECTIVE:To assess the incidence of post-operative arterial malformation (AM) and urine leak/urinoma (UL) after robotic partial nephrectomy (RPN) in a contemporary series. To evaluate risk factors for these complications. METHODS:All RPNs were queried from IRB-approved retrospective and prospective nephrectomy databases. Demographics, peri-operative variables, and post-operative complications were collected. Differences between cohorts were analyzed using univariate analysis. Post-operative complications were graded using the Clavien-Dindo system. UL was defined in the context of signs and symptoms of a collection with supporting evidence of urine collection via drainage or aspiration. AM was identified based on post-operative imaging indicative of arteriovenous fistula or pseudoaneurysm and/or requirement for selective embolization. Predictors of AM and UL were assessed via univariate analysis. RESULTS:395 RPNs were performed by four urologists between 1/2014-10/2018. Tumor complexity, defined by nephrometry score, was significantly greater in the prospective cohort (p=0.01). Overall incidence of post-operative complications was 5.6% with cohort-specific incidences of 5.3% and 5.8%. The retrospective cohort had a greater percentage of complications classified as >= IIIa: 8/13 (61.5%) vs. 2/8 (25%). Overall incidence of AM was 2.3% with cohort-specific incidence of 3.1% (7/225) vs. 1.1% (2/170). Overall incidence of UL was 0.25% with cohort-specific incidence of 0.55% (1/225) and 0.0% (0/170). The difference in incidence of both complications between cohorts was significant (p< 0.05). No significant predictors for AM were identified. CONCLUSIONS:The incidence of post-operative complications after RPN remains low (5.3% vs. 5.8%, overall: 5.6%). UL and AM are becoming rarer with experience, despite increasing surgical complexity (0.55% vs. 0%, 3.1% vs. 1.1%).

INTRODUCTION/BACKGROUND:Iatrogenic ureteral injuries represent a common surgical problem encountered by practicing urologists. With the rapidly expanding applications of robotic-assisted laparoscopic surgery, ureteral reconstruction has been an important field of recent advancement. This collaborative review sought to provide an evidence-based analysis of the latest surgical techniques and outcomes for robotic-assisted repair of ureteral injury. EVIDENCE ACQUISITION/METHODS:A systematic review of the literature up to December 2017 using PubMed/Medline was performed to identify relevant articles. Those studies included in the systematic review were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Additionally, expert opinions were included from study authors in order to critique outcomes and elaborate on surgical techniques. A cumulative outcome analysis was conducted analyzing comparative studies on robotic versus open ureteral repair. EVIDENCE SYNTHESIS/RESULTS:Thirteen case series have demonstrated the feasibility, safety, and success of robotic ureteral reconstruction. The surgical planning, timing of intervention, and various robotic reconstructive techniques need to be tailored to the specific case, depending on the location and length of the injury. Fluorescence imaging can represent a useful tool in this setting. Recently, three studies have shown the feasibility and technical success of robotic buccal mucosa grafting for ureteral repair. Soon, additional novel and experimental robotic reconstructive approaches might become available. The cumulative analysis of the three available comparative studies on robotic versus open ureteral repair showed no difference in operative time or complication rate, with a decreased blood loss and hospital length of stay favoring the robotic approach. CONCLUSIONS:Current evidence suggests that the robotic surgical platform facilitates complex ureteral reconstruction in a minimally invasive fashion. High success rates of ureteral repair using the robotic approach mirror those of open surgery, with the additional advantage of faster recovery. Novel techniques in development and surgical adjuncts show promise as the role of robotic surgery evolves.

BACKGROUND:Minimally invasive treatment of long, multifocal ureteral strictures or failed pyeloplasty is challenging. Robot-assisted buccal mucosa graft ureteroplasty (RBU) is a technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. OBJECTIVE:To evaluate outcomes for RBU in a multi-institutional cohort of patients treated for revision ureteropelvic junction obstruction and long or multifocal ureteral stricture at three tertiary referral centers. DESIGN, SETTING, AND PARTICIPANTS/METHODS:This retrospective study involved data for 19 patients treated with RBU at three high-volume centers between October 2013 and July 2016. SURGICAL PROCEDURE/METHODS:RBU was performed using either an onlay graft after incising the stricture or an augmented anastomotic repair in which the ureter was transected and re-anastomosed primarily on one side, and a graft was placed on the other side. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS/UNASSIGNED:Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS/CONCLUSIONS:The onlay technique was used for 79%, while repair was carried out using the augmented anastomotic technique for the remaining cases. The reconstruction was reinforced with omentum in 95% of cases. The ureteral stricture location was proximal in 74% and mid in 26% of cases. A prior failed ureteral reconstruction was present in 53% of patients. The median stricture length was 4.0cm (range 2.0-8.0), operative time was 200min (range 136-397), estimated blood loss was 95ml (range 25-420), and length of stay was 2 d (range 1-15). There were no intraoperative complications. At median follow-up of 26 mo, the overall success rate was 90%. CONCLUSIONS:RBU is a feasible and effective technique for managing complex proximal and mid ureteral strictures. PATIENT SUMMARY/UNASSIGNED:We studied robotic surgery for long ureteral strictures using grafts at three referral centers. Our results demonstrate that robotic buccal mucosa graft ureteroplasty is a feasible and effective technique for ureteral reconstruction.

OBJECTIVE: To determine whether patient-specific 3D printed renal tumor models change pre-operative planning decisions made by urological surgeons in preparation for complex renal mass surgical procedures. MATERIALS AND METHODS: From our ongoing IRB approved study on renal neoplasms, ten renal mass cases were retrospectively selected based on Nephrometry Score greater than 5 (range 6-10). A 3D post-contrast fat-suppressed gradient-echo T1-weighted sequence was used to generate 3D printed models. The cases were evaluated by three experienced urologic oncology surgeons in a randomized fashion using (1) imaging data on PACS alone and (2) 3D printed model in addition to the imaging data. A questionnaire regarding surgical approach and planning was administered. The presumed pre-operative approaches with and without the model were compared. Any change between the presumed approaches and the actual surgical intervention was recorded. RESULTS: There was a change in planned approach with the 3D printed model for all ten cases with the largest impact seen regarding decisions on transperitoneal or retroperitoneal approach and clamping, with changes seen in 30%-50% of cases. Mean parenchymal volume loss for the operated kidney was 21.4%. Volume losses >20% were associated with increased ischemia times and surgeons tended to report a different approach with the use of the 3D model compared to that with imaging alone in these cases. The 3D printed models helped increase confidence regarding the chosen operative procedure in all cases. CONCLUSIONS: Pre-operative physical 3D models created from MRI data may influence surgical planning for complex kidney cancer.