OBJECTIVE:To evaluate factors associated with the conversion of robotic-assisted partial nephrectomy (RAPN) to open partial nephrectomy (OPN) and radical nephrectomy (RN). METHODS:We retrospectively reviewed 775 consecutive RAPNs from a single surgeon. Perioperative factors were evaluated for association with RAPN conversion such as Mayo Adhesive Probability (MAP) score, length of stay (LOS), and operative time (OT). A logistic regression model was utilized to evaluate factors associated with conversion and reported as odds ratio (OR) with 95% confidence intervals. Continuous and categorical variables were analyzed through the Wilcoxon rank-sum and chi-square tests. RESULTS:Thirty-two (4.1%) patients had a conversion including 19 (2.5%) to OPN and 13 (1.7%) to RN. OPN conversions were related to bleeding (n = 7), inability to dissect perinephric fat (n = 4), liver retraction (n = 1), and failure to secure renal hilum/progress (n = 7). In contrast, conversions to RN were due to tumor involvement of the renal vein (n = 3) or ureter (n = 5) and inability to achieve negative margins (n = 5). Patients in the conversion cohort were more likely to have larger tumor size (3.7 vs 2.8 cm; p < 0.001) and higher MAP score (3.0 vs 2.0; p = 0.04). Median LOS was higher in the conversion group (3.0 vs 2.0 days; p = 0.003). Conversions were associated with postoperative complications (28.1% vs 13.7%; p = 0.023). After adjusting tumor size in our regression model, longer OT and dissection time were statistically higher in the conversion group (OR = 2.19 [1.50-3.21]; p < 0.001 and OR = 2.67 [1.82-3.94]; p < 0.001, respectively). CONCLUSIONS:Larger tumor size and higher MAP score were associated with conversions during RAPN. Conversions were associated with higher LOS, longer OT, and postoperative complications.

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (PD64)1 Sep 2021PD64-08 ANALYZING THE ASSOCIATION BETWEEN RENAL TUMOR COMPLEXITY AND FUNCTIONAL VOLUME LOSS IN ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY Essa Bajalia, Kevin Parikh, Daniela Haehn, Amanda Kahn, Laura Geldmaker, Colleen Ball, and David Thiel Essa BajaliaEssa Bajalia More articles by this author , Kevin ParikhKevin Parikh More articles by this author , Daniela HaehnDaniela Haehn More articles by this author , Amanda KahnAmanda Kahn More articles by this author , Laura GeldmakerLaura Geldmaker More articles by this author , Colleen BallColleen Ball More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002108.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Functional Volume Loss (FVL) is defined as the amount of healthy parenchyma excised during Robotic-Assisted Partial Nephrectomy (RAPN). We hypothesized that an increase in tumor complexity would lead to an increase in FVL during RAPN. METHODS: We evaluated 406 consecutive RAPN performed by a single surgeon between February 2008 through April 2019. The standard formula for calculating FVL was used: FVL standard (mL) = (specimen volume * π/6) - (tumor volume * π/6). Tumor complexity was defined as the RENAL score of patient’s tumors. RENAL score was categorized as easy (4-6), moderate (7-9), or hard (10-12). P-values less than 0.05 were considered statistically significant without adjustment for multiple testing. In addition to age and sex, we controlled for the following factors based on their known relationship with FVL: body mass index (BMI), American Society of Anesthesiologists (ASA) Score, and Mayo Adhesive Probability (MAP) Score. The adjusted expected difference in the geometric mean of FVL estimates were calculated using a multivariable linear regression model. RESULTS: Among the 406 patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22 to 84), and median FVL was 9.9 mL (IQR 3.9 to 17.7 mL). Of the 406 patient’s RENAL scores, 122 (30%) were categorized as easy, 214 (52.7%) as moderate, and 70 (17.2%) as hard. The median FVL and IQR for each RENAL category was 3.7 mL (2.0, 7.9), 12 mL (5.7, 19.4), and 16.2 mL (7.9, 24.3), respectively. All p values for median FVL were <0.001. The association of RENAL score and tumor size with FVL remained statistically significant following multivariable analysis (P<0.001). The adjusted % difference in the geometric mean of FVL (95% CI) was 199% when comparing moderate to easy RENAL scores and 261% when comparing hard to easy RENAL scores. CONCLUSIONS: Increased tumor complexity and tumor size is associated with higher FVL during RAPN resulting in greater loss of healthy renal tissue in more complex tumors. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1147-e1147 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Essa Bajalia More articles by this author Kevin Parikh More articles by this author Daniela Haehn More articles by this author Amanda Kahn More articles by this author Laura Geldmaker More articles by this author Colleen Ball More articles by this author David Thiel More articles by this author Expand All Advertisement Loading ...

Background: Adherent perinephric fat (APF) contributes to surgical complexity and can be associated with adverse perioperative outcomes for partial nephrectomy (PN). The Mayo Adhesive Probability (MAP) score accurately predicts the presence of APF during robotic-assisted partial nephrectomy (RAPN). Our primary aim is to validate MAP score as a predictor of APF in open partial nephrectomy (OPNx). Methods: We reviewed 105 consecutive OPNx (100 patients) performed by a single surgeon with intraoperative determination of APE. Vtle evaluated the ability of the MAP score to discriminate between those with APF and those without APF by estimating the area under the receiver operating characteristic curve (AUROCC). The association of perioperative outcomes with APF was evaluated as well. Results: Forty-three patients [49%; 95% confidence interval (CI), 39-59%] had intraoperative identification of APE The MAP score had excellent ability to predict APF in OPNx (AUROCC, 0.82; 95% CI, 0.74-0.92). APF was observed in 6% of patients with a MAP score of 0-1, 27% with score 2, 52% with score 3, 75% with score 4, and 90% with score 5. The presence of APF was associated with longer operative times (P=0.004) and higher estimated blood loss (EBL) (P=0.003). Although not statistically significant, our study did suggest that APF may be associated with postoperative complications and prolonged length of stay (LOS) (>3 days). Conclusions: MAP score accurately predicts the presence of APF in patients undergoing OPNx. APF is associated with longer operative time and higher blood loss in OPNx.

Background: To evaluate robotic-assisted partial nephrectomy (RAPN) renal outcomes associated with ancillary pathology findings in non-neoplastic renal parenchymal tissue. Methods: Tissue samples from 378 RAPNs were analyzed for glomerular disease (GD), vascular disease (VD), and tubulointerstitial disease (TD). One hundred and fifty-two patients were excluded due to insufficient non-neoplastic tissue for analysis and 4 patients were excluded due to calyceal diverticulum. Non-neoplastic tissue was evaluated for GD (negative, moderate, or global), VD (absent, mild, moderate, or severe), and TD (present or absent). Associations of ancillary pathology factors with patient characteristics were explored using the non-parametric Kendall tau-test and propensity score adjusted longitudinal mixed effects regression models were used to evaluate associations of these pathology factors with changes in estimated glomerular filtration rate (eGFR) following RAPN. Results: One hundred and fifty-three (68.9%) patients had hypertension and 50 (22.5%) patients had diabetes. The majority of patients did not have any GD ( N = 158, 71.2%) or TD ( N = 186, 83.8%) while 129 (58.1%) had VD. VD was categorized as absent ( N = 93, 41.9%), mild ( N = 45, 20.3%), moderate ( N = 76, 34.2%), and severe ( N = 8, 6.8%). Older age ( P = 0.018), hypertension ( P < 0.001), and high grade MAP score ( P = 0.047) were associated with a higher number of ancillary pathology factors. High grade MAP score ( P = 0.03, P = 0.002) and hypertension ( P = 0.02, P < 0.001) were individually associated with GD severity and VD severity, respectively. Older age was also individually associated with VD severity ( P = 0.002) and hypertension was associated with TD ( P = 0.04). Moderate-to-severe VD was associated with a worse change in eGFR from pre-RAPN to 1-month post-RAPN compared to those with mild or no VD (difference in mean change, −3.4 ml/kg/1.73m 2 ; 95% CI, −6.6 to −0.2 ml/kg/1.73m 2 ; P = 0.036). Conclusions: Moderate-to-severe VD in non-neoplastic renal parenchyma is associated with post-operative changes in eGFR. Older age, hypertension, and high grade MAP scores are associated with the number of ancillary pathologies observed in RAPN specimens.

ObjectiveTo validate the Martini nomogram predicting the decline in estimated glomerular filtration rate after robotic‐assisted partial nephrectomy.MethodsEstimated glomerular filtration rate of 406 patients from a single surgeon series was calculated before robotic‐assisted partial nephrectomy and at postoperative intervals. To determine the risk group, we calculated the total score and corresponding risk of significant estimated glomerular filtration rate reduction at 15 months using the Martini nomogram. The primary outcome was a reduction in estimated glomerular filtration rate of ≥25% from preoperative levels between 1 and 12 months after surgery.ResultsThe median length of follow up for this study was 12 months (interquartile range 6–12 months). Overall, 134 (33%) patients were in the low‐, 143 (35%) in the intermediate‐, 119 (29%) in the high‐ and 10 (2%) in the very high‐risk groups. The Kaplan–Meier estimates for the probability of significant estimated glomerular filtration rate reduction by 12 months after robotic‐assisted partial nephrectomy was 12.9% in the low‐risk group, 24.0% in the intermediate‐risk group, 49.7% in the high‐risk group and 40.0% in the very high‐risk group. Harrell’s C‐index for discriminating between those with and without a significant reduction in estimated glomerular filtration rate 1–12 months after robotic‐assisted partial nephrectomy was 0.73 (95% confidence interval 0.68–0.78).ConclusionsThe risk groups proposed by the Martini nomogram are accurate in predicting those at higher risk for a >25% decline in postoperative estimated glomerular filtration rate after robotic‐assisted partial nephrectomy at 12 months.

OBJECTIVES To evaluate the learning curve of robotic-assisted partial nephrectomy as it pertains to operative time (OT) and advanced perioperative variables such as achievement of trifecta, postoperative complications, 30-day readmission rates (RR), warm ischemia time (WIT), and functional volume loss (FVL). METHODS We evaluated 418 consecutive robotic-assisted partial nephrectomy performed by a single surgeon between February 2008 and April 2019. Multivariable log-log regression models were used to evaluate the associations between case number and continuous outcomes (OT, WIT, and FVL). Multivariable logistic regression models were used to evaluate the association of case number with dichotomous outcomes (trifecta, postoperative complications, RR). RESULTS Among the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22-84), and median body mass index was 29 kg/m(2) (interquartile range 26-33). Surgeon experience was associated with shorter OT (-2.5% per 50% increase in case number; 95% confidence interval; P < .001) and plateaus around 77 cases performed. There was slight improvement with trifecta (odds ratio [per 50% increase in cases] = 1.08; 95% confidence interval) and the plateau was also at 77 cases, however, this was not statistically significant (P =.086). We did not find statistically significant associations of surgeon experience with FVL (P = .77), postoperative complications (P = .74), WIT (P = .73), or 30-day RR (P = .33). CONCLUSION There does not appear to be a relationship between surgical experience and grade 3 or higher postoperative complications, 30-day RR, WIT, or FVL. Trifecta outcomes and maximum OT performance appear to be optimized at approximately 77 cases. UROLOGY 144: 136-141, 2020. (c) 2020 Elsevier Inc.

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI (MP68)1 Apr 2020MP68-19 THE MAP SCORE CAN HELP PREDICT LONGER OPERATIVE TIME IN OPEN PARTIAL NEPHRECTOMY Katherine Cockerill*, Amanda Kahn, Daniella Haehn, Colleen Ball, and David Thiel Katherine Cockerill*Katherine Cockerill* More articles by this author , Amanda KahnAmanda Kahn More articles by this author , Daniella HaehnDaniella Haehn More articles by this author , Colleen BallColleen Ball More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000948.019AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The Mayo Adhesive Probability (MAP) score incorporates measures of perinephric fat and fat stranding in the prediction of adherent perinephric fat (APF) at the time of renal surgery. The purpose of our study is to evaluate the association between MAP score and total operative time (OT) in patients undergoing open partial nephrectomy (OPN). We also examined the association of other preoperative variables with OT. METHODS: We performed a 10 year retrospective review of 102 patients who underwent open partial nephrectomies performed for T1 tumor by a single fellowship trained surgeon at our institution. A linear regression analysis was used to examine the association of MAP score with OT in patients undergoing OPN. We also examined the association of sex, age, BMI, patient comorbidities, history of prior abdominal surgery, renal mass size, and R.E.N.A.L. score. RESULTS: A total of 102 patients underwent open partial nephrectomy at a single institution from 2008-2019 for a renal mass less than 7cm. Mean patient age was 66 years (range 57-71) and mean BMI was 30.5 kg/m2 (IQR 26.1, 33.1). Ten patients (9.8%) had partial nephrectomy performed on a solitary kidney. Median tumor size was 4.0 cm (IQR 3,6). Mean total operative time was 176 minutes (SD 62). A majority of the renal tumors were located posterior (71.7%). The location of the tumor varied between upper pole (32.4%), mid pole (14.7%), lower pole (29.4%), and hilar (27.5%) in location. Ipsilateral renal MAP score was 4-5 in 39.2% of the patients and 0-3 in 60.8%. In single variable analysis, a 1 unit increase in MAP score was associated with an 8 minute increase in OT (95% CI 2-14 minutes, p=0.01). In additional single variable analysis, only male sex (+34.8 min, p<0.001) and MAP score of 4 vs. 2 (+16 min, p=0.01) were associated with longer operative times in patients undergoing OPN. CONCLUSIONS: Higher MAP score and male sex appear to be associated with longer operative time in patients undergoing OPN for T1 renal tumors. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1042-e1043 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Katherine Cockerill* More articles by this author Amanda Kahn More articles by this author Daniella Haehn More articles by this author Colleen Ball More articles by this author David Thiel More articles by this author Expand All Advertisement PDF downloadLoading ...

Background To examine the association of preoperative Mayo Adhesive Probability (MAP) scores in the donor (MAP d ) and non-donor kidneys (MAP nd ) with post-donation renal function. Methods Three hundred thirty-one patients undergoing hand assisted laparoscopic donor nephrectomy (HALDN) were reviewed. MAP d and MAP nd were obtained. Estimated glomerular filtration rate (eGFR) was recorded preoperatively and at 1 day, 1 month, and 6 months postoperatively. Results Two hundred females and 131 males were evaluated with median BMI 26.4 kg/m 2 (range 17.1–39.6) and median age 45 years (range 19–78). MAP d score was 0 for 231 patients (69.8%) and > 0 for 100 patients (30.2%). MAP nd score was 0 for 234 patients (70.7%) and > 0 for 97 patients (29.3%). The median preoperative eGFR was 86.6 ml/min/1.73m 2 (range 48.8–138.4). After adjusting for preoperative eGFR, BMI, ASA score, and kidney sidedness, postoperative eGFR was associated with MAP score in the non-donated kidney ( p = 0.014) but not in the donated kidney ( p = 0.24). Compared to donors with MAP nd = 0, donors with a MAP nd > 0, mean eGFR was − 2.33 ml/min/1.73m 2 lower at postoperative day 1 (95% CI − 4.24 to − 0.41, p = 0.018), − 3.02 ml/min/1.73m 2 lower at 1 month (95% CI − 5.11 to − 0.93, p = 0.005), and − 2.63 ml/min/1.73m 2 lower at 6 months postoperatively (95% CI − 5.01 to − 0.26, p = 0.030). Conclusions MAP score > 0 in the non-donated kidney is associated with worse renal function in the 6 months following HALDN.

OBJECTIVES To evaluate the association between excised parenchymal mass (EPM) and postoperative renal function (eGFR) following robotic-assisted partial nephrectomy (RAPN). EPM is the amount of healthy renal parenchyma excised during partial nephrectomy in order to achieve safe surgical margins. METHODS We evaluated 406 consecutive RAPN performed by a single surgeon to eliminate variations in technique as a factor in EPM. EPM (mL) = (specimen volume * pi/6) - (tumor volume * pi/6). RENAL score was categorized as easy (4-6), moderate (7-9), or hard (10-12). EPM was grouped into four categories: <= 3.9 mL, 4.0-9.9 mL, 10.0-17.7 mL, and >17.7 mL. eGFR was evaluated preoperatively, postoperative day 1 (POD1), 1 month, and 6 months postoperatively. RESULTS Median age was 63 years (22-84 years), 252 (62.1%) were male, and median EPM was 9.9 mL (interquartile range 3.9 to 17.7 mL). The median EPM and interquartile range for each RENAL category was 3.7 mL (2.0, 7.9), 12 mL (5.7, 19.4), and 16.2 mL (7.9, 24.3), respectively. Higher EPM was associated with worse changes in eGFR at POD1 ( P = 0.005) and 1 month after RAPN ( P = 0.002) but was not statistically significant at the 6-month time period ( P = 0.35) CONCLUSION Increased tumor complexity is associated with an increase in EPM during RAPN. Increased EPM is associated with eGFR decline at POD1 and 1 month post RAPN but not at 6 months postoperatively. (C) 2020 Elsevier Inc.

(WHO/ISUP) grade (p[0.001) and regional lymph node metastasis (p[0.008), PD-L1 expression was also correlated with blood immunoglobulins (p˂0.001). Further analysis showed that patients with abnormal blood immunoglobulins had a shorter progression-free survival (PFS) (median, 9.0 vs 12.0 months, p[0.0469) and overall survival (OS) (median, 20.0 vs 25.0 months, p[0.0291) than patients with normal blood immunoglobulins. Based on the expression of PDL1 and VEGFR-2, patients with intermediate-risk disease were placed in groups, which included 21 patients who were PD-L1 (þ) VEGFR-2 (þ), 11 patients who were PD-L1 (þ) VEGFR-2 (-), 15 patients who were PD-L1 (-) VEGFR-2 (þ)and 16 patients who were PD-L1 (-) VEGFR-2 (-). The PD-L1 (-) VEGFR-2 (þ) group achieved a longer PFS (median 20 months vs 16.0 months, 9.0 months and 15.5 months, p<0.0001) and OS (33.0 months vs 24.0 months, 14.0 months and 26.5 months, p[0.0013) than the other groups. CONCLUSIONS: PD-L1-negative and VEGFR-2-positive patients with intermediate-risk disease who undergo CN may have a good prognosis. The combined detection of the PD-L1 and VEGFR-2 proteins in a primary tumor biopsy before treatment may be clinically significant for the selection of therapy in smRCC. In addition, blood immunoglobulins were potential blood markers for predicting the prognosis of TT in smRCC.

To prospectively evaluate factors that predict achievement of trifecta and pentafecta following robotic-assisted partial nephrectomy (RAPN). Clinical variables of 330 RAPNs performed for a single renal tumor were analyzed for association with post-operative trifecta and pentafecta achievement. Trifecta was defined as warm ischemia time (WIT) ≤ 25 min, negative surgical margins, and no post-operative complications ≥ Clavien grade 3. Pentafecta was defined as trifecta criteria plus > 90% preservation of estimated glomerular filtration rate (eGFR) and no stage upgrade of chronic kidney disease from pre-operative up to 12 months post-RAPN. After adjustment for multiple testing, p < 0.007 was considered statistically significant. Among 330 patients, trifecta was achieved in 280 patients (84.8%). Among the 152 patients with eGFR available at 12 months following RAPN, pentafecta was achieved in 39 (25.8%). A lower R.E.N.A.L. score was associated with increased odds of achieving trifecta (OR 3.38, p < 0.001) and pentafecta (OR 2.83 p < 0.001). No other pre-operative characteristics were associated with trifecta or pentafecta. Patients who achieved trifecta had a lower median estimated blood loss (EBL) (300 vs 400, p = 0.029) and shorter operative time (223 vs 234 min, p = 0.004) compared to patients without trifecta. There were no significant differences in EBL or operative time in patients who achieved or failed to achieve pentafecta. R.E.N.A.L score is the only pre-operative variable associated with achieving trifecta and pentafecta following RAPN. Lower EBL and operative time are associated with trifecta but not pentafecta outcomes.

BACKGROUND:Renal tumor scoring systems, such as the contact surface area value, aim to assist in predicting outcomes following robotic-assisted partial nephrectomy. The aim of this study is to identify associations between specific postoperative outcomes and the contact surface area of renal masses.METHODS:We analyzed 332 consecutive robotic-assisted partial nephrectomies and calculated contact surface area for renal tumors with the contact surface area formula (CSA = 2πrd), where π ≈ 3.14, r = greatest tumor radius (cm), and d = greatest tumor depth (cm).RESULTS:Higher contact surface area was associated with longer warm ischemia time (P < .001), higher estimated blood loss (P < .001), and longer length of hospital stay (LOS) (P < .001). Higher contact surface area was significantly associated with decreased renal function at 1 day, 1 month, and 6 months following robotic-assisted partial nephrectomy.CONCLUSIONS:Contact surface area is associated with certain outcomes following robotic-assisted partial nephrectomy and may be a useful predictive tool.

Patients were analyzed according to surgical approach: RRN versus LRN versus ORN. Using multivariate logistic and linear regression, perioperative outcomes, including conversion to open, length of stay, readmission rates, positive surgical margins, and 30 and 90-day mortality were compared among cohorts. 1:1 Propensity matching was also performed to compare cohorts. We also analyzed utilization trends of each approach over the study period. RESULTS: A total of 9288 patients met inclusion criteria (RRN [ 842, LRN [ 2326, ORN [ 6120). On multivariate analysis, LRN had a higher rate of conversion to open compared to RRN (OR 1.48; 95% CI 1.10-1.98; p[0.0087). Compared to ORN, recipients of either RRN or LRN had similar rates of 30-day readmission, 30-day mortality, and 90-day mortality. Length of hospital stay was significantly shorter in RRN (-1.73 days 0.19; p<0.0001) and LRN (-1.40 days 0.12; p<0.0001) compared to ORN. Conversion to open from RRN or LRN added 1.3 additional days of inpatient stay. RRN and LRN were less likely to have positive surgical margin than ORN (RRN: OR 0.75; 95% CI 0.56-0.99; p[0.044, LRN: OR 0.64; 95% CI 0.52-0.78; p<0.0001). Over the study period, RRN use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, while ORN use decreased from 75% to 59.6%. CONCLUSIONS: Minimally invasive approaches are increasingly utilized in very large renal masses. After adjusting for covariates, RRN has lower rates of conversion to open but produces comparable perioperative outcomes to pure laparoscopy. Minimally invasive approaches have shorter length of inpatient stay but otherwise report similar readmission and mortality rates compared to open radical nephrectomy.

You have accessJournal of UrologyImaging/Radiology: Uroradiology I (MP36)1 Apr 2020MP36-02 A COMPARISION OF THE AORTIC-LESION-ATTENUATION-DIFFERENCE (ALAD) AND PEAK EARLY-PHASE ENHANCEMENT RATIO (PEER) TO PREOPERATIVELY DIFFERENTIATE BENIGN FROM MALIGNANT RENAL MASSES Steven Lomax*, Amanda Kahn, Colleen Ball, and David Thiel Steven Lomax*Steven Lomax* More articles by this author , Amanda KahnAmanda Kahn More articles by this author , Colleen BallColleen Ball More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000880.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To evaluate the efficacy of the Aorta-Lesion-Attenuation-Difference (ALAD) and Peak Early-phase Enhancement Ratio (PEER) on contrast-enhanced computed tomography (CECT) to differentiate between the appearances of chromophobe renal cell carcinoma (chRCC) and oncocytoma. METHODS: The cohort was comprised of 91 patients who presented with a renal mass and underwent partial or radical nephrectomy performed by a single surgeon. Patients were only included if a preoperative CECT scan was available for evaluation and the resected renal mass was pathologically confirmed for chRCC (N=29) or oncocytoma (N=62). To calculate the ALAD value, Hounsfield Units (HU) of the aorta and renal mass were measured on the same plane of CECT. ALAD is expressed by the following equation: ALAD = HUaorta – HUmass. To calculate PEER, HUs of the lesion and renal cortex adjacent to the lesion are measured on CECT and non-contrast CT. PEER is expressed as (HUcontrast tumor - HUnon-contrast tumor):(HUcontrast cortex - HUnon-contrast cortex). Values were retrospectively measured from CECT by a single reviewer. Measurements were taken from the nephrographic phase for 45 patients, excretory phase for 16 patients, and CECT scans that lacked distinct phases for 30 patients. RESULTS: ALAD median was 27.6 for oncocytic lesions and 68.5 for chRCC. A significant difference between ALAD values of oncocytoma and chRCC was observed in the nephrographic (area under the ROC curve [AUC] 0.92) and excretory phases (AUC 0.95) but was less successful using CECT scans lacking distinct phases (AUC 0.58). The PEER median was 0.74 for oncocytic lesions and 0.37 for chRCC. PEER values significantly differed while comparing oncocytomas and chRCC in the nephrographic (AUC 0.93) and excretory phases (AUC 0.96) and was also successful on CECT scans lacking distinct phases (AUC 0.90, P=0.002). When differentiating between chRCC and oncocytoma among all CT phases, PEER (AUC 0.93) significantly outperformed ALAD (AUC 0.80) (P=0.008). Our data also suggests that the ability of ALAD to differentiate between malignant and benign lesions is dependent on CT contrast phase, whereas the ability of PEER to differentiate between chRCC and oncocytoma is consistent across CT contrast phases. CONCLUSIONS: ALAD and PEER values can significantly differentiate between chRCC and oncocytoma on preoperative CECT. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e522-e522 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Steven Lomax* More articles by this author Amanda Kahn More articles by this author Colleen Ball More articles by this author David Thiel More articles by this author Expand All Advertisement PDF downloadLoading ...

Background: The risk of renal cell carcinoma (RCC) development in the native kidney of patients on dialysis or with a renal transplant is increased compared to the general population. This study examines perioperative outcomes of laparoscopic radical nephrectomy (LN) in dialysis patients or renal transplant patients compared to normal controls. Methods: Four hundred twelve consecutive LN were evaluated (July 2007 to October 2018). Patients were divided into three groups (control, dialysis, and transplant). Perioperative outcomes, including operating room time (OT), postoperative complications, hospital length of stay, and 90-day readmission rates, were evaluated for the three groups. Results: There were 62 patients in the dialysis group, 20 renal transplants, and 330 normal controls. Dialysis patients were younger (median: 58 years versus 67 years; P = .002) and predominantly male (73% versus 59%, P = .047). Dialysis patients compared to controls had shorter total OT (median: 133 versus 149; P = .022), more papillary RCC (27% versus 10%; P < .001), and fewer high grade tumors (73% [8/11] versus 94% [100/106]; P = .038). Renal transplant patients had a higher rate of 90-day readmission (20% versus 6%; P = .034) and more papillary RCC (30% versus 10%; P = .016) compared to controls. Conclusion: LN on dialysis patients does not alter expected perioperative outcomes compared to a large cohort of control LN. LN on renal transplant patients carries a higher 90-day readmission rate than control LN.

INTRODUCTION:To evaluate the utility of the Aorta-Lesion-Attenuation-Difference (ALAD) and Peak Early-phase Enhancement Ratio (PEER) on contrast-enhanced computed tomography (CT) to differentiate between the appearances of chromophobe renal cell carcinoma, clear cell renal cell carcinoma, and oncocytoma.MATERIAL AND METHODS:ALAD and PEER values were retrospectively measured by a reviewer from 119 patients with surgically resected renal masses (chromophobe renal cell carcinoma n = 29, clear cell renal cell carcinoma n = 28, and oncocytoma n = 62). The ALAD value is expressed as: ALAD = Hounsfield Units aorta - Hounsfield Units mass. PEER is expressed as (Hounsfield Units contrast tumor - Hounsfield Units non-contrast tumor):( Hounsfield Units contrast cortex - Hounsfield Units non-contrast cortex).RESULTS:The ALAD median was 27.6 for oncocytomas, 68.5 for chromophobe renal cell carcinoma, and 55.4 for clear cell renal cell carcinoma. A significant difference between ALAD values of oncocytoma and chromophobe renal cell carcinoma was observed in the nephrographic (area under the ROC curve 0.92) and excretory phases (area under the ROC curve 0.95). The PEER median was 0.74 for oncocytomas and 0.37 for chromophobe renal cell carcinoma. The PEER values significantly differed while comparing oncocytomas and chromophobe renal cell carcinoma in the nephrographic and excretory phases.CONCLUSIONS:Preoperative contrast-enhanced CT ALAD and PEER values both significantly differentiate between chromophobe renal cell carcinoma and oncocytoma. PEER may be more effective in contrast-enhanced CT scans lacking distinct phases.

INTRODUCTION AND OBJECTIVE: The complexities of RAPN can lead to a steep learning curve. We assessed the surgical learning curve and plateau point for achieving trifecta and minimizing OT in RAPN. METHODS: We evaluated 418 consecutive RAPN from a fellowship trained robotic surgeon between February 2008 and April 2019. The cases were separated into increments of 50. Cases were excluded from analysis if the patient had a prior RAPN performed at our institution (7 cases), if the patient was treated for calyceal diverticulum (4 cases), or if it was classified as a combo case (1 case). Trifecta was defined as warm ischemia time<25 minutes, negative surgical margins, and no grade 3 or higher postoperative complications. For the primary analysis we explored the correlation between surgical case number and patient outcomes using the Kendall correlation test. Age, sex, body mass index, tumor size, Mayo Adhesive Probability score, and R.E.N.A.L. score were all adjusted for as potential confounding variables in the spline regression methods. All statistical tests were twosided. P values < 0.05 were considered statistically significant. RESULTS: Among the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22 to 84), and median body mass index was 29 kg/m (IQR 26, 33). 272 patients achieved trifecta and average OT was 200 minutes. We found that RAPN experience (higher case number) was associated with shorter OT (P<0.001). OT (minutes) for the case increments were as follows: 1-50 (222.3 43.6), 51-100 (204.1 47.2), 101-150 (202.1 30.2), 151-200 (201.7 35.3), 201-250 (196.5 46.0), 251-300 (188.2 37.6), 301-350 (194.0 40.7), and 401-418 (186.1 40.4). Trifecta achievement for the increments were as follows: 1-50 (63%), 51-100 (82%), 101-150 (66%), 151-200 (67%), 201-250 (54%), 251-300 (71%), 301-350 (84%), 351-400 (74%), and 401-418 (72%). Although we did not find statistically significant overall increasing or decreasing trends in trifecta with surgeon experience, the restricted cubic spline logistic regression suggests peak performance with slightly under 100 cases (Figure 1). CONCLUSIONS: Maximizing OT performance and achievement of trifecta in RAPN appears to occur at a learning curve of about 100 cases. Source of Funding: None

Multinucleate Giant Cell (GC) reaction is a biological response that occurs secondary to infection, an implanted foreign body, tissue injury, or inflammation. In rare instances GC reactions have been reported following tissue ablation. Multinucleate GC reactions and tumefactive fat necrosis both have the ability to mimic cancer recurrence or metastasis and can appear as enhancing masses. We discuss a case of a surgically resected retroperitoneal perinephric mass thought to be recurrent renal cell carcinoma (RCC) that was pathologically confirmed as tumefactive fat necrosis with multinucleate GC reaction 2 years following percutaneous cryoablation of a small renal mass.

Objective: Diagnostic work-up of suspicious renal masses has traditionally been conducted with contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI). However, patients who are not candidates for intravenous contrast due to allergy, renal insufficiency, or those on dialysis are discouraged from utilizing traditional contrast imaging due to risks of anaphylaxis, nephrotoxicity, or further kidney damage. We evaluated contrast-enhanced ultrasound (CEUS) in patients on dialysis who would benefit from alternative imaging options to CECT or MRI.Methods: Following IRB approval, nine renal masses from eight patients (aged 54-74 years) with chronic renal insufficiency were evaluated with CEUS and shown to be enhancing after the intravenous administration of ultrasound contrast agent. The ultrasound contrast agent Lumason (Sulfur hexafluoride lipid type-A microspheres, Bracco Diagnostics, Monroe Township, NJ, USA) was utilized. Enhancement was considered present when microbubble contrast agent was visualized within the lesion of interest.Results: Nine CEUS enhancing masses were pathologically examined following laparoscopic radical nephrectomy. Eight of the nine lesions were renal cell carcinoma (two clear cell, four papillary, two cystic). One resected mass was an unspecified benign renal lesion.Conclusions: In this sample of surgically resected tumors, CEUS was effective in characterizing renal lesions as solid neoplasms or complex cystic lesions suspicious for neoplasm-findings which merit further investigation.