RESUMO
Objectives: To analyze the preoperative variables associated to the postoperative glomerular filtration rate (GFR) outcomes after nephrectomy for benign and malignant conditions, measured by the reference isotopic technique 51Cr-ethylene diamine tetra-acetic (51Cr-EDTA) and to create a model to predict the short-term postoperative GFR. Secondary aim was to evaluate which of the common equations for GFR estimation (Cockcroft-Gault, Modification of Diet in Renal Disease [MDRD] or Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) has the best correlation with the 51Cr-EDTA. Methods: Patients undergoing unilateral nephrectomy from 2014 to 2018 were selected. Pre- and postoperative variables were prospectively collected. Univariate and multivariate analyses were done to identify independent risk factors associated with renal function outcomes and to create a model to predict the postoperative GFR. Correlation analyses were performed to evaluate the performance of various serum creatinine-based equations for GFR estimation compared with 51Cr-EDTA. Results: In total, 107 patients were evaluated. After univariate and multivariate analyses, older age (p = 0.008), higher split function of the operated kidney on dimercaptosuccinic acid (DMSA) scintigraphy (p < 0.001), and lower preoperative 51Cr-EDTA (p < 0.001) were independent risk factors for higher GFR decline. Correlation analyses showed that GFR estimated by CKD-EPI equation had the best concordance to GFR measured by 51Cr-EDTA. Conclusions: Based on our findings age, DMSA and lower preoperative 51Cr-EDTA are predictors of postoperative renal function after unilateral nephrectomy. For the assessment of estimated GFR, CKD-EPI equation appears to have the best concordance with 51Cr-EDTA.
Assuntos
Radioisótopos de Cromo/farmacocinética , Ácido Edético/farmacocinética , Nefrotomia , Insuficiência Renal Crônica/etiologia , Feminino , Taxa de Filtração Glomerular , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Insuficiência Renal Crônica/fisiopatologia , Fatores de RiscoRESUMO
ABSTRACT 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.
Assuntos
Humanos , Masculino , Feminino , Adulto , Idoso , Complicações Pós-Operatórias/etiologia , Proteinúria/complicações , Período Pré-Operatório , Injúria Renal Aguda/etiologia , Nefrectomia/efeitos adversos , Valores de Referência , Modelos Logísticos , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Estatísticas não Paramétricas , Medição de Risco , Injúria Renal Aguda/fisiopatologia , Taxa de Filtração Glomerular/fisiologia , Neoplasias Renais/cirurgia , Pessoa de Meia-Idade , Nefrectomia/métodosRESUMO
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.
Assuntos
Injúria Renal Aguda/etiologia , Nefrectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Proteinúria/complicações , Injúria Renal Aguda/fisiopatologia , Adulto , Idoso , Feminino , Taxa de Filtração Glomerular/fisiologia , Humanos , Neoplasias Renais/cirurgia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Nefrectomia/métodos , Valor Preditivo dos Testes , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Estatísticas não Paramétricas , Resultado do TratamentoAssuntos
Procedimentos Cirúrgicos Robóticos/métodos , Ureter/cirurgia , Obstrução Ureteral/cirurgia , Ureterostomia/métodos , Adulto , Constrição Patológica/cirurgia , Feminino , Humanos , Duração da Cirurgia , Posicionamento do Paciente , Reprodutibilidade dos Testes , Resultado do Tratamento , Ureterolitíase/cirurgiaAssuntos
Humanos , Feminino , Adulto , Ureter/cirurgia , Obstrução Ureteral/cirurgia , Ureterostomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Reprodutibilidade dos Testes , Resultado do Tratamento , Constrição Patológica/cirurgia , Ureterolitíase/cirurgia , Posicionamento do Paciente , Duração da CirurgiaAssuntos
Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Cálculos Coraliformes/cirurgia , Idoso , Carcinoma de Células Renais/cirurgia , Feminino , Humanos , Neoplasias Renais/cirurgia , Pelve Renal/cirurgia , Duração da Cirurgia , Reprodutibilidade dos Testes , Resultado do TratamentoRESUMO
Purpose To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. Materials and Methods MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. Results A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon’s early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. Conclusion Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall ...
Assuntos
Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Cateterismo Urinário/métodos , Incontinência Urinária/etiologia , Incontinência Urinária/prevenção & controle , Taxa de Filtração Glomerular , Cuidados Intraoperatórios , Análise Multivariada , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Nefrectomia/métodos , Duração da Cirurgia , Reprodutibilidade dos Testes , Fatores de Risco , Insuficiência Renal Crônica/cirurgia , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. AIM: In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. MATERIALS AND METHODS: Following cystoscopy and ureteral catheter insertion the patient was placed in 60° modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. RESULTS: The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. CONCLUSIONS: Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment.
Assuntos
Túbulos Renais Coletores/anormalidades , Túbulos Renais Coletores/cirurgia , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Ureter/cirurgia , Feminino , Humanos , Duração da Cirurgia , Reprodutibilidade dos Testes , Resultado do Tratamento , Adulto JovemRESUMO
Introduction A duplicated renal collecting system is a relatively common congenital anomaly rarely presenting in adults. Aim In this video we demonstrate our step-by-step technique of Robotic heminephrectomy in a patient with non-functioning upper pole moiety. Materials and Methods Following cystoscopy and ureteral catheter insertion the patient was placed in 600 modified flank position with the ipsilateral arm positioned at the side of the patient. A straight-line, three arm robotic port configuration was employed. The robot was docked at a 90-degree angle, perpendicular to the patient. Following mobilization the colon and identifying both ureters of the duplicated system, the ureters were followed cephalically toward, hilar vessels where the hilar anatomy was identified. The nonfunctioning pole vasculature was ligated using hem-o-lok clips. The ureter was sharply divided and the proximal ureteral stump was passed posterior the renal hilum. Ureteral stump was used as for retraction and heminephrectomy is completed along the line demarcating the upper and lower pole moieties. Renorrhaphy was performed using 0-Vicryl suture with a CT-1 needle. The nonfunctioning pole ureter was then dissected caudally toward the bladder hiatus, ligated using clips, and transected. Results The operating time was 240 minutes and blood loss was 100 cc. There was no complication post-operatively. Conclusions Wrist articulation and degree of freedom offered by robotic platform facilitates successful performance of minimally invasive heminephrectomy in the setting of an atrophic and symptomatic renal segment. .
Assuntos
Feminino , Humanos , Adulto Jovem , Túbulos Renais Coletores/anormalidades , Túbulos Renais Coletores/cirurgia , Nefrectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Ureter/cirurgia , Duração da Cirurgia , Reprodutibilidade dos Testes , Resultado do TratamentoRESUMO
PURPOSE: To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication. MATERIALS AND METHODS: MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak. RESULTS: A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon's early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak. CONCLUSION: Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall operative time.
Assuntos
Nefrectomia/efeitos adversos , Cateterismo Urinário/métodos , Incontinência Urinária/etiologia , Incontinência Urinária/prevenção & controle , Idoso , Feminino , Taxa de Filtração Glomerular , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Análise Multivariada , Nefrectomia/métodos , Duração da Cirurgia , Insuficiência Renal Crônica/cirurgia , Reprodutibilidade dos Testes , Fatores de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. OBJECTIVE: To report a large multi-institutional worldwide series of LESS in urology. DESIGN, SETTING, AND PARTICIPANTS: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. INTERVENTION: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. MEASUREMENTS: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. RESULTS AND LIMITATIONS: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160±93 min and estimated blood loss was 148±234 ml. Skin incision length at closure was 3.5±1.5 cm. Mean hospital stay was 3.6±2.7 d with a visual analog pain score at discharge of 1.5±1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. CONCLUSIONS: This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied.
Assuntos
Laparoscopia , Neoplasias Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Urologia/métodos , Adulto , Idoso , Ásia , Europa (Continente) , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , América do Sul , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Urológicos/efeitos adversosRESUMO
Robotic assisted radical prostatectomy (RARP) is gaining acceptance and popularity among urologists all over the world. Early oncologic and functional results are encouraging. In this manuscript, we describe in detail both approaches for RARP and show the results of the robotic surgery program with over 300 RARP performed at our institution.
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Humanos , Masculino , Pessoa de Meia-Idade , Laparoscopia/métodos , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Robótica/métodos , Estudos Prospectivos , Prostatectomia/instrumentação , Robótica/instrumentação , Resultado do TratamentoRESUMO
Robotic assisted radical prostatectomy (RARP) is gaining acceptance and popularity among urologists all over the world. Early oncologic and functional results are encouraging. In this manuscript, we describe in detail both approaches for RARP and show the results of the robotic surgery program with over 300 RARP performed at our institution.
Assuntos
Laparoscopia/métodos , Prostatectomia/métodos , Neoplasias da Próstata/cirurgia , Robótica/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Prostatectomia/instrumentação , Robótica/instrumentação , Resultado do TratamentoRESUMO
PURPOSE: Open retropubic simple prostatectomy is occasionally performed for symptomatic, large volume benign prostatic hyperplasia. We describe the technique of laparoscopic simple retropubic prostatectomy. MATERIALS AND METHODS: Since August 2001 at our 2 institutions laparoscopic simple retropubic prostatectomy has been performed in 17 patients with symptomatic significant prostatomegaly on transrectal ultrasonography (60 gm or greater, mean 93). Essential aspects of our 5 port technique are transverse cystotomy just proximal to the prostatovesical junction, subcapsular plane development, prostatic adenomectomy, prostatic fossa trigonization and prostatic capsule suture repair. Demographic, perioperative and outcome data were recorded. RESULTS: Mean operative time was 156 minutes (range 85 to 380), blood loss was 516 ml (range 100 to 2,500), hospital stay was 48 hours (range 15 to 110), and Foley catheter duration was 6.3 days (range 3 to 7). Mean specimen weight on pathological examination was 72 gm (range 32 to 120). Five patients (29%) required blood transfusion. Complications occurred in 3 patients (19%), that is intraoperative hemorrhage, catheter clot obstruction and duodenal ulcer bleeding in 1 each. All patients reported complete continence during a followup period of 1 month to 2 years. Considerable improvement from baseline was noted in American Urological Association score (preoperative vs postoperative 24.5 vs 9.9) and the maximum urine flow rate (preoperative vs postoperative 7 vs 22.8 cc per minute). CONCLUSIONS: Laparoscopic simple retropubic prostatectomy for large benign prostate hyperplasia is feasible. Our initial experience is presented.