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Article of the Week: Silicone renal models and complex tumour resections prior to RALPN

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Every week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video discussing the paper.

If you only have time to read one article this week, it should be this one.

Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy

Friedrich-Carl von Rundstedt*,†, Jason M. Scovell*, Smriti Agrawal‡, Jacques Zaneveld§ and Richard E. Link*,,**

 

*Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA, †Department of Urology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany, ‡Department of Molecular and Human Genetics, Baylor College of Medicine, §Lazarus 3D LLC, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, and **Center for Reproductive Medicine, Baylor College of Medicine, Houston, TX, USA

 

Read the full article

How to Cite this Article

von Rundstedt, F.-C., Scovell, J. M., Agrawal, S., Zaneveld, J. and Link, R. E. (2017), Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy. BJU International, 119: 598–604. doi: 10.1111/bju.13712

Abstract

Objective

To describe our experience using patient-specific tissue-like kidney models created with advanced three-dimensional (3D)-printing technology for preoperative planning and surgical rehearsal prior to robot-assisted laparoscopic partial nephrectomy (RALPN).

Patients and Methods

A feasibility study of 10 patients with solid renal masses who underwent RALPN after preoperative rehearsal using 3D-print kidney models. A single surgeon performed all surgical rehearsals and procedures. Using standard preoperative imaging and 3D reconstruction, we generated pre-surgical models using a silicone-based material. All surgical rehearsals were performed using the da Vinci® robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA) before the actual procedure. To determine construct validity, we compared resection times between the model and actual tumour in a patient-specific manner. Using 3D laser scanning in the operating room, we quantified and compared the shape and tumour volume resected for each model and patient tumour.

aotw-apr-results-5

Results

We generated patient-specific models for 10 patients with complex tumour anatomy. R.E.N.A.L. nephrometry scores were between 7 and 11, with a mean maximal tumour diameter of 40.6 mm. The mean resection times between model and patient (6:58 vs 8:22 min, P = 0.162) and tumour volumes between the computer model, excised model, and excised tumour (38.88 vs 38.50 vs 41.79 mm3, P = 0.98) were not significantly different.

Conclusions

We have developed a patient-specific pre-surgical simulation protocol for RALPN. We demonstrated construct validity and provided accurate representation of enucleation time and resected tissue volume. This simulation platform can assist in surgical decision-making, provide preoperative rehearsals, and improve surgical training.

Read more articles of the week

Editorial: Touching the future – 3D printing facilitates preoperative planning, realistic simulation and enhanced precision in RALPN

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Practice taking that match-winning penalty knowing which way the keeper will dive, or take that last putt knowing the lie of the green; it would be very handy wouldn’t it?

Virtual reality (VR), augmented reality (AR), computer-generated images (CGI), and stereotactic overlay, have all been documented as adjuncts in enhancing operative patient care through planning, simulation and increased precision. But what if you could actually handle the specimen and practice operating on a model to refine operative technique before the definitive procedure? With three-dimensional (3D) printing this has now become a reality.

The work of von Rundstedt et al. [1] has the potential to transform surgical planning, operative accuracy, and training, with the development of a life-like kidney and tumour model. Their paper validates a patient-specific simulation protocol to assist in surgical decision-making through operative rehearsal. They assessed the benefits of 10 patient-specific 3D renal models for preoperative planning using tissue-like silicone, and performed model tumour excision with the robot before actual robot-assisted laparoscopic partial nephrectomy (RALPN). Nephrometry scores for tumours ranged from 7 to 11, with a relatively large mean maximal tumour diameter of 40.6 mm. In validating the model the investigators compared resection times between the model and patient (6.61 vs 7.93 min, P = 0.16) and tumour volumes between computer model, excised model, and excised tumour (38.88 vs 38.50 vs 41.79 mm3, P = 0.98), showing no significant differences.

The key principles in nephron-sparing surgery are adequate oncological excision, whilst preserving maximal renal parenchyma, with minimal ischaemia time, and avoiding complications. RALPN is challenging for complex tumours, with an extended learning curve, due partly to limitations in accurate surgical planning and surgical technique. Key anatomical considerations for planning including kidney orientation, tumour position and depth, and locality of adjacent anatomical structures (vessels, collecting system), are difficult to appreciate on conventional two-dimensional axial imaging platforms; with variance in imaging and model-planned approaches clearly noted in previous studies [2].

The development of nephrometry scores have been designed to predict surgical complexity along with various simulation and modelling reconstructions to aid excisional techniques. Several other surgical specialties (orthopaedics, maxillofacial and craniofacial surgery, neurosurgery, plastic surgery [3]) have used 3D-printing technology for organ/lesion modelling or to produce accurate imaging-based prostheses. In the era of minimally invasive surgery and personalised medicine, 3D printing can be a powerful tool for uro-oncologists to better understand individual tumour characteristics and anatomical variations.

Currently there is limited published data on 3D renal tumour printing. This paper [1] represents the first model and validation of its kind. Previous studies of 3D-printed kidneys with renal masses have been reported but limited to depictions of anatomical visualisation of arteries, collecting system and the tumour itself [4, 5]. This is the first time that a model not only provides a 3D representation of the tumour anatomy but also allows high-fidelity simulated excision. Construct validity of these reproductions has been assessed and demonstrate a striking similarity in tumour volume, morphology, and resection time, the main limitations of previous studies [4].

Preoperative planning has never achieved this accuracy before. Operative rehearsal significantly altered the ultimate approach to tumour excision in several cases as noted by the authors. In addition, 3D printing represents a breakthrough in surgical training as it offers a great opportunity, especially in facilities were wet laboratories are not available.

With the small sample assessed and the subjective nature of the surgical technique modification between model and tumour excision, early generalisation may not be appropriate. Other limitations include the models inability to replicate viable orthotopic anatomy such as adjacent organs, dissection planes, perinephric fat thickness/adherence, and bleeding; while also excluding the renorrhaphy component of the procedure. Additionally, production costs and 3D printer access may be an initial deterrent to widespread use of this technique; however, it does address the lack of tactile feeling in AR or VR, avoids the specialised facilities required by animal or cadaveric models, can readily be accurately reproduced, and most importantly provide an accurate anatomical representation of the individual patient.

This is an important and interesting paper as it presents and validates a novel model with extirpative technique in a prospective manner. It provides a life-like model useful for patient education, procedural practice with realistic simulation, an accurate training platform, and is the easiest to access given current technology. Clinical trials are needed to confirm how 3D modelling is ultimately useful in: i) improving patient education, ii) enhancing surgical training, and iii) conferring superior clinical outcomes. Evolution of 3D printers and shrinking production costs will eventually contribute to the widespread usage of this technology.

Further development will provide functional models that replicate not only macroscopic structures but elements such as the collecting system, segmental vessels, and bleeding parenchyma. However, it may be that high-fidelity VR simulators or CGI that can generate patient-specific graphics or even provide an intraoperative stereotactic 3D overlay to guide tumour excision may eventually supersede 3D modelling. Urology has entered the 3D printing era. This study [1] shows that 3D printing is both a feasible and useful technique that may enhance current practice, while providing an improved training platform. The future is here today.

Read the full article

How to Cite this Article

von Rundstedt, F.-C., Scovell, J. M., Agrawal, S., Zaneveld, J. and Link, R. E. (2017), Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy. BJU International, 119: 598–604. doi: 10.1111/bju.13712

Nicolo de Luyk†, Benjamin Namdarian* and Benjamin Challacombe*
*Department of Urology, Guy’s and St Thomas’ Hospit als NHS Foundation Trust and Kings College, London, UK and †Department of Urology, University Hospital of Verona, Verona, Italy

 

References

 

1 von Rundstedt FC, Scovell JM, Agrawal S, Zaneveld J, Link RE. Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy. BJU Int 2017; 119: 598–604

 

2 Wake N , Rude T, Kang SK et al. 3D printed renal cancer models derived from MRI data: application in pre-surgical planning. Abdom Radiol (NY) 2017; [Epub ahead of print]. doi: 10.1007/s00261-016-1022-2

 

3 LiJ, Chen M, Fan X, Zhou H. Recent advances in bioprinting techniques: approaches, applications and future prospects. J Transl Med 2016; 14: 271. doi:10.1186/s12967-016-1028-0

 

4 Silberstein JL, Maddox MM, Dorsey P, Feibus A, Thomas R, Lee BR. Physical models of renal malignancies using standard cross-sectional imaging and 3- dimensional printers: a pilot study. Urology 2014; 84: 268–72

 

5 Bernhard JC, Isotani S, Matsugasumi T et al. Personalized 3D printed model of kidney and tumor anatomy: a useful tool for patient education. World J Urol 2016; 34: 337–45

 

Video: Silicone renal models and complex tumour resections prior to RALPN

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Utility of patient-specific silicone renal models for planning and rehearsal of complex tumour resections prior to robot-assisted laparoscopic partial nephrectomy

Read the full article

Abstract

Objective

To describe our experience using patient-specific tissue-like kidney models created with advanced three-dimensional (3D)-printing technology for preoperative planning and surgical rehearsal prior to robot-assisted laparoscopic partial nephrectomy (RALPN).

Patients and Methods

A feasibility study of 10 patients with solid renal masses who underwent RALPN after preoperative rehearsal using 3D-print kidney models. A single surgeon performed all surgical rehearsals and procedures. Using standard preoperative imaging and 3D reconstruction, we generated pre-surgical models using a silicone-based material. All surgical rehearsals were performed using the da Vinci® robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA) before the actual procedure. To determine construct validity, we compared resection times between the model and actual tumour in a patient-specific manner. Using 3D laser scanning in the operating room, we quantified and compared the shape and tumour volume resected for each model and patient tumour.

Results

We generated patient-specific models for 10 patients with complex tumour anatomy. R.E.N.A.L. nephrometry scores were between 7 and 11, with a mean maximal tumour diameter of 40.6 mm. The mean resection times between model and patient (6:58 vs 8:22 min, P = 0.162) and tumour volumes between the computer model, excised model, and excised tumour (38.88 vs 38.50 vs 41.79 mm3, P = 0.98) were not significantly different.

Conclusions

We have developed a patient-specific pre-surgical simulation protocol for RALPN. We demonstrated construct validity and provided accurate representation of enucleation time and resected tissue volume. This simulation platform can assist in surgical decision-making, provide preoperative rehearsals, and improve surgical training.

View more videos

Article of the Week: Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Craig Rogers, discussing his paper.

If you only have time to read one article this week, it should be this one.

Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

 

Newaj Abdullah*, Haider Rahbar*, Ravi Barod*, Deepansh Dalela*, Jeff Larson†, Michael Johnson‡, Alon Mass§, Homayoun Zargar, Mohamad Allaf‡, Sam Bhayani†, Michael Stifelman§, Jihad Kaouk¶ and Craig Rogers*

 

*Vattikutti Urology Institute, Henry Ford Health System, Detroit, MI, †Division of Urology, Washington University in St. Louis, St. Louis, MO, ‡James Buchanan Brady Urological Institute, John Hopkins University, Baltimore, MD, §Department of Urology, New York University, New York, NY, and Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

 

Read the full article

Objective

To evaluate the outcomes of robot-assisted partial nephrectomy RAPN after major prior abdominal surgery (PAS) using a large multicentre database.

Patients and methods

We identified 1 686 RAPN from five academic centres between 2006 and 2014. In all, 216 patients had previously undergone major PAS, defined as having an open upper midline/ipsilateral incision. Perioperative outcomes were compared with those 1 470 patients who had had no major PAS. The chi-squared test and Mann–Whitney U-test were used for categorical and continuous variables, respectively.

AugAOTW4FI

Results

There was no statistically significant difference in Charlson comorbidity index, tumour size, R.E.N.A.L. nephrometry score or preoperative estimated glomerular filtration rate (eGFR) between the groups. Age and body mass index were higher in patients with PAS. The PAS group had a higher estimated blood loss (EBL) but this did not lead to a higher transfusion rate. A retroperitoneal approach was used more often in patients with major PAS (11.2 vs 5.4%), although this group did not have a higher percentage of posterior tumours (38.8 vs 43.3%, P = 0.286). Operative time, warm ischaemia time, length of stay, positive surgical margin, percentage change in eGFR, and perioperative complications were not significantly different between the groups.

Conclusions

RAPN in patients with major PAS is safe and feasible, with increased EBL but no increased rate of transfusion. Patients with major PAS had almost twice the likelihood of having a retroperitoneal approach.

Read more articles of the week

Editorial: Robot-assisted partial nephrectomy: excellent outcomes can persist despite previous abdominal surgery

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Robot-assisted surgery is increasing and patient selection is important to ensure mitigation of risk, patient safety and allow for the surgeon’s training curve. This is especially pertinent for robot-assisted partial nephrectomy (RAPN), as increasingly complex tumours and increasingly complex patients are considered potentially suitable. One factor that contributes to patient complexity is the presence of intra-abdominal adhesions, which can be predicted by previous abdominal surgery. This month’s article by Abdullah et al. [1] ‘Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery’ eloquently describes their outcomes in patients who underwent RAPN with a history of previous open abdominal surgery.

The study retrospectively analysed 1 686 patients who had undergone RAPN from a prospective database from five large American academic institutions. A sub-group of 216 patients (13%) had undergone major prior abdominal surgery (PAS); this was defined as those marked by upper midline or ipsilateral incisions. The authors chose such incisions due to the increased potential for adhesions within the expected surgical field for RAPN, which could interfere with performance [2]. The list of prior surgeries is wide ranging such as laparotomy, open cholecystectomy, open appendicectomy and open ipsilateral PN; 12% (25 patients) had had multiple previous procedures.

The study found that there was no statistical difference between the two groups in the areas of Charlson comorbidities index, tumour size, R.E.N.A.L. nephrometry score [consists of (R)adius (tumour size as maximal diameter), (E)xophytic/endophytic properties of the tumour, (N)earness of tumour deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line], and preoperative estimated GFR. They also found no difference between intraoperative and postoperative complications (<4% Clavien ≥3 in PAS group), positive surgical margins and change in renal function.

Their initial concern that previous surgery increases robotic operative time was ill founded, as there was no statistical difference in median (interquartile range) operative times: PAS 172 (132–224) vs169 (139–208) min. However, they did find statistical difference in estimated blood loss, which was higher in the PAS group (150 vs 100 mL; P = 0.039); but this did not translate to a difference in transfusion rates.

They also found the PAS patients were older (median 63 vs 60 years) and had a higher median body mass index (30.3 vs 29 kg/m2). This is an important finding in the context of offering robotic minimally invasive surgery in an increasingly obese and ageing surgical population.

Achieving safe access is a crucial step in all laparoscopic or robot-assisted surgery and is potentially complicated by the presence of adhesions. It was of particular interest to read of the access techniques used: Hasson vs Veress needle vs retroperitoneal approach. The latter was used more in the PAS group (11.2% vs 5.4%), despite a lower percentage of posterior tumours (38.8% vs 43.3%). This suggests surgical preference for choosing a retroperitoneal approach was related to avoidance of potential adhesions rather than tumour location.

Conceptually the Hassan technique, with access achieved by direct vision, could offer safety benefits in the presence of potential adhesions; however, access via Veress needle insufflation occurred in most of their cases. The authors describe the use of the Hassan technique in instances of failure of Veress access but the incidence that this occurred is not provided. They estimated that 24 cases were converted to open due to access-related issues.

Further interrogation of the 180 open PNs performed during the study period could provide a valuable comparative group and understand why they were not deemed suitable for a robot-assisted approach.

The study can be commended for its large patient database, multicentre design, and breadth of outcomes assessed. It supports the findings of Zargar et al. [3] showing comparable perioperative complications and open conversions of RAPN in patients with and without a history of PAS in their similar sized, but single-centre study. This is also in agreement with assessments of other robotic procedures supporting the relative safety of robotic surgery in patients with a history of PAS.

One of the limitations of this study is the lack of discussion on the decision-making process for choice of access technique. Individual surgeons and/or the recommendations of multi-disciplinary teams will favour the technique with the perceived best outcome and may select out more favourable cases to each arm. Abdullah et al. [1] results may be an indication of appropriate technique selection rather than safety of the robot or individual access techniques.

This study provides robotic surgeons with increasing confidence to offer RAPN and its potential advantages of reduced blood loss, pain and recovery time to patients despite the presence of potential adhesions from PAS. Individual case selection remains imperative to maintain optimal surgical outcomes. Complex cases may be safely tackled in high-volume established RAPN programmes; but they may not be suitable for surgeons earlier in their experience. Robotic surgeons should be well trained and confident in managing the potential complications of bowel injury in these challenging cases.

Sophie Rintoul-Hoad, Rick Catterwell and Ben Challacombe
Urology Centre, Guy’s and St Thomas’ Hospitals NHS Trust, Great Maze Pond, London, UK

 

Read the full article

 

References

 

1 Abdullah N, Rahbar H, Barod R et al. Multicentre outcomes of robot- assisted partial nephrectomy after major open abdominal surgery. BJU Int 2016; 118: 298–301

 

2 Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management. Dig Surg 2001; 18: 260–73

 

3 Zargar H, Isac W, Autorino R et al. Robot-assisted laparoscopic partial nephrectomy in patients with previous abdominal surgery: single center experience. Int J Med Robot 2015; 11: 389–94

 

Video: Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

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Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

Newaj Abdullah*, Haider Rahbar*, Ravi Barod*, Deepansh Dalela*, Jeff Larson†, Michael Johnson‡, Alon Mass§, Homayoun Zargar, Mohamad Allaf‡, Sam Bhayani†, Michael Stifelman§, Jihad Kaouk¶ and Craig Rogers*

 

*Vattikutti Urology Institute, Henry Ford Health System, Detroit, MI, †Division of Urology, Washington University in St. Louis, St. Louis, MO, ‡James Buchanan Brady Urological Institute, John Hopkins University, Baltimore, MD, §Department of Urology, New York University, New York, NY, and Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

 

Read the full article

Objective

To evaluate the outcomes of robot-assisted partial nephrectomy RAPN after major prior abdominal surgery (PAS) using a large multicentre database.

Patients and methods

We identified 1 686 RAPN from five academic centres between 2006 and 2014. In all, 216 patients had previously undergone major PAS, defined as having an open upper midline/ipsilateral incision. Perioperative outcomes were compared with those 1 470 patients who had had no major PAS. The chi-squared test and Mann–Whitney U-test were used for categorical and continuous variables, respectively.

AugAOTW4FI

Results

There was no statistically significant difference in Charlson comorbidity index, tumour size, R.E.N.A.L. nephrometry score or preoperative estimated glomerular filtration rate (eGFR) between the groups. Age and body mass index were higher in patients with PAS. The PAS group had a higher estimated blood loss (EBL) but this did not lead to a higher transfusion rate. A retroperitoneal approach was used more often in patients with major PAS (11.2 vs 5.4%), although this group did not have a higher percentage of posterior tumours (38.8 vs 43.3%, P = 0.286). Operative time, warm ischaemia time, length of stay, positive surgical margin, percentage change in eGFR, and perioperative complications were not significantly different between the groups.

Conclusions

RAPN in patients with major PAS is safe and feasible, with increased EBL but no increased rate of transfusion. Patients with major PAS had almost twice the likelihood of having a retroperitoneal approach.

Read more articles of the week

Highlights from BAUS 2016

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1.1

In the week following Britain’s exit from Europe after the BREXIT referendum, BAUS 2016 got underway in Liverpool’s BT convention Centre. This was the 72nd meeting of the British Association of Urological Surgeons and it was well attended with 1120 delegates (50% Consultant Member Urologists, 30% Trainees, 10% Non member Urologists/Other, 10% Nurses, HCP’S, Scientists).

1.2

Monday saw a cautionary session on medicolegal aspects in Andrology, focusing on lawsuits over the last year. Mr Mark Speakman presented on the management issue of testicular torsion. This sparked further discussion on emergency cover for paediatrics with particular uncertainty noted at 4 and 5 year olds and great variation in approach dependent on local trust policy. Mr Julian Shah noted the most litigious areas of andrology, with focus on cosmesis following circumcisions. Therefore serving a reminder on the importance of good consent to manage patients’ expectations.

1.3

In the Dragons’ Den, like the TV show, junior urologists pitched their ideas for collaborative research projects, to an expert panel. This year’s panel was made up of – Mark Emberton, Ian Pearce, and Graeme MacLennan. The session was chaired by Veeru Kasivisvanathan, Chair of the BURST Research Collaborative.

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Eventual winner Ben Lamb, a trainee from London, presented “Just add water”. The pitch was for an RCT to investigate the efficacy of water irrigation following TURBT against MMC in reducing tumour recurrence. Ben proposed that water, with its experimental tumouricidal properties, might provide a low risk, low cost alternative as an adjuvant agent following TURBT. Judges liked the scientific basis for this study and the initial planning for an RCT. The panel discussed the merits of non-inferiority vs. superiority methodology, and whether the team might compare MMC to MMC with the addition of water, or water instead of MMC. They Dragons’ suggested that an initial focus group to investigate patients’ views on chemotherapy might help to focus the investigation and give credence to the final research question, important when making the next pitch- to a funding body, or ethics committee.

Other proposals were from Ryad Chebbout, working with Marcus Cumberbatch, an academic trainee from Sheffield. Proposing to address the current controversy over the optimal surgical technique for orchidopexy following testicular torsion. His idea involved conducting a systematic review, a national survey of current practice followed by a Delphi consensus meeting to produce evidence based statement of best practice. The final presentation was from Sophia Cashman, East of England Trainee for an RCT to assess the optimal timing for a TWOC after urinary retention. The panel liked the idea of finally nailing down an answer to this age-old question.

1.5

Waking up on Tuesday with England out of the European football cup as well as Europe the conference got underway with an update from the PROMIS trial (use of MRI to detect prostate cancer). Early data shows that multi-parametric MRI may be accurate enough to help avoid some prostate biopsies.

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The SURG meeting provided useful information for trainees, with advice on progressing through training and Consultant interviews. A debate was held over run through training, which may well be returning in the future. The Silver cystoscope was awarded to Professor Rob Pickard voted for by the trainees in his deanery, for his devotion to their training.
Wednesday continued the debate on medical expulsion therapy (MET) for ureteric stones following the SUSPEND trial. Most UK Urologists seem to follow the results of the trial and have stopped prescribing alpha blockers to try and aid stone passage and symptoms. However the AUA are yet to adopt this stance and feel that a sub analysis shows some benefit for stones >5mm, although this is not significant and pragmatic outcomes. Assistant Professor John Hollingsworth (USA) argued for MET, with Professor Sam McClinton (UK) against. A live poll at the end of the session showed 62.9% of the audience persuaded to follow the SUSPEND trial evidence and stop prescribing MET.

1.7

In the debate of digital versus fibreoptic scopes for flexible ureteroscopy digital triumphed, but with a narrow margin.

1.8

In other updates and breaking news it appears that BCG is back! However during the shortage EMDA has shown itself to be a promising alternative in the treatment of high grade superficial bladder cancer.
The latest BAUS nephrectomy data shows that 90% are performed by consultant, with 16 on average per consultant per year. This raises some issues for registrar training, however with BAUS guidelines likely to suggest 20 as indicative numbers this is looking to be an achievable target for most consultants. Robotic advocates will be encouraged, as robotic partial nephrectomy numbers have overtaken open this year. The data shows 36% of kidney tumours in the under 40 years old are benign. Will we have to consider biopsying more often? However data suggests we should be offering more cytoreductive nephrectomies, with only roughly 1/10 in the UK performed compared to 3/10 in the USA.

1.91.10

The andrology section called for more recruitment to The MASTER trial (Male slings vs artificial urinary sphincters), whereas the OPEN trial has recruited(open urethroplasty vs optical urethotomy). In the treatment of Peyronie’s disease collagenase has been approved by NICE but not yet within the NHS.

Endoluminal endourology presentation showed big increases in operative numbers with ureteroscopy up by 50% and flexible ureteroscopy up by 100%. Stents on strings were advocated to avoid troubling stent symptoms experienced by most patients. New evidence may help provide a consensus on defining “stone free” post operation. Any residual stones post-operatively less than 2mm were shown to pass spontaneously and therefore perhaps may be classed as “stone free”.

Big changes seem likely in the treatment of benign prostatic hyperplasia, with a race to replace the old favorite TURP. Trials have of TURP (mono and bipolar) vs greenlight laser are already showing similar 2 year outcomes with the added benefit of shorter hospital stays and less blood loss. UROLIFT is an ever more popular alternative with data showing superiority to TURP in lifestyle measures, likely because it preserves sexual function, and we are told it can be performed as a 15 minute day case operation. The latest new therapy is apparently “Aquabeam Aquablation”, using high pressured water to remove the prostate. Non surgical treatments are also advancing with ever more accurate super selective embolisation of the prostatic blood supply.

1.11

This year all accepted abstracts were presented in moderated EPoster sessions. The format was extremely successful removing the need for paper at future conferences? A total of 538 abstracts were submitted and 168 EPosters displayed. The winner of best EPoster was P5-5 Altaf Mangera: Bladder Cancer in the Neuropathic Bladder.

1.12

The best Academic Paper winner was Mark Salji of the CRUK Beatson institute, titled “A Urinary Peptide Biomarker Panel to Identify Significant Prostate Cancer”. Using capillary electrophoresis coupled to mass spectrometry (CE-MS) they analysed 313 urine samples from significant prostate cancer patients (Gleason 8-10 or T3/4 disease) and low grade control disease. They identified 94 peptide urine biomarkers which may provide a useful adjunct in identifying significant prostate cancer from insignificant disease.

The Office of Education offered 20 courses. Popular off-site courses were ultrasound for the Urologist, at Broadgreen Hospital, a slightly painful 30 min drive from the conference centre. However well worth the trip, delivered by Radiology consultants this included the chance to scan patients volunteers under guidance, with separate stations for kidneys, bladder and testicles and learning the “knobology” of the machines.

Organised by Tamsin Greenwell with other consultant experts in female, andrology and retroperitoneal cancer, a human cadaveric anatomy course was held at Liverpool university. The anatomy teaching was delivered by both Urology consultants and anatomists allowing for an excellent combination of theory and functional anatomy.

BAUS social events are renowned and with multiple events planned most evenings were pretty lively. The official drinks reception was held at the beautiful Royal Liver Building. The venue was stunning with great views over the waterfront and the sun finally shining. Several awards were presented including the Gold cystoscope to Mr John McGrath for significant contribution to Urology within 10 years appointment as consultant. The Keith Yeates medal was awarded to Mr Raj Pal, the most outstanding candidate in the first sitting of the intercollegiate specilaity examination, with a score of over 80%.

1.13

During the conference other BAUS awards presented include the St Peter’s medal was awarded to Margeret Knowles, Head of section of molecular oncology, Leeds Institute of Cancer and Pathology, St James University hospital Leeds. The St Paul’s medal awarded to Professor Joseph A. Smith, Vanderbilt University, Nashville, USA. The Gold medal went to Mr. Tim Terry, Leicester General Hospital.

An excellent industry exhibition was on display, with 75 Exhibiting Companies present. My personal fun highlight was a flexible cystoscope with integrated stent remover, which sparked Top Gear style competiveness when the manufacturer set up a time-trial leaderboard. Obviously this best demonstrated the speed of stent removal with some interesting results…

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Social media review shows good contribution daily.

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Thanks BAUS a great conference, very well organised and delivered with a great educational and social content, looking forward to Glasgow 2017! #BAUS2017 #Glasgow #BAUSurology

Nishant Bedi

Specialist Training Registrar North West London 

Twitter: @nishbedi

 

Article of the Week: Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of SRMs

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Month heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Jihad Kaouk discussing his paper. 

If you only have time to read one article this week, it should be this one.

Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of Small Renal Masses: A Multi-Institutional Study

 

Homayoun Zargar*, Mohamad E. Allaf†, Sam Bhayani‡, Michael Stifelman§, Craig Rogers, Mark W. Ball†, Jeffrey Larson‡
, Susan Marshall§, Ramesh Kumar¶ and Jihad H. Kaouk*

 

*Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, †The Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, MD, ‡Dept. of Urology, Washington University School of Medicine, St. Louis, MO, §Dept. of Urology, New York University School of Medicine, New York, NY, and Henry Ford Health System, Vattikuti Urology Institute, Detroit, MI, USA

 

Read the full article
OBJECTIVE

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed ‘optimal outcome’ for the RPN group.

PATIENTS AND METHODS

Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The ‘optimal outcome’ was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and ‘optimal outcome’ achievement.

RESULTS

In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of ‘optimal outcome’ for the RPN group was 38.5%.

CONCLUSIONS

In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for ‘optimal outcome’ might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

 

Read more articles of the week

Editorial: Robotic Partial Nephrectomy: The Treatment of Choice for Minimally Invasive Nephron Sparing Surgery

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Early in the adoption of robotic partial nephrectomy (RPN) as an alternative to laparoscopic PN (LPN) for the treatment of small renal masses, several of the current authors presented a similar comparison of LPN and RPN. They found RPN to result in shorter hospital stay, less blood loss, and shorter warm ischaemia time (WIT) compared with LPN [1]. They discovered that RPN outcomes were not dependent on the complexity of the tumour, which clearly impacted LPN results. They concluded that RPN is a safe and viable alternative to LPN and offered benefits even for experienced laparoscopic surgeons.

The current report in this edition of BJUI furthers the comparison of RPN and LPN and expands the assessment to include five high-volume centres of excellence in robotic surgery [2]. This retrospective, multi-institutional review of 1 185 RPN and 646 LPN represents the largest comparison to date of these two approaches for minimally invasive PN. Despite higher patient comorbidities and R.E.N.A.L. nephrometry scores in the RPN patients compared with the LPN group, there were fewer overall complications (16.2% vs 25.9%), a lower positive surgical margin rate (3.2% vs 9.7%) and a lower WIT (18 vs 26 min). They also found a much higher percentage of RPN patients (70% vs 33%) meeting the Trifecta criteria, defined as negative surgical margins, no perioperative complications, and a WIT of ≤25 min. Finally, the authors introduce a more stringent composite measure of ‘optimal outcomes’, which is the Trifecta with the addition of 90% estimated GFR preservation and no chronic kidney disease upgrading. They report 38.5% of RPN patients meeting optimal outcomes compared with 24.1% for LPN.

This study clearly demonstrates the superiority of RPN over LPN and is supported by other single-surgeon reports [3]. These results also exceed those reported for open PN with the added benefit of reduced hospital stay [4]. However, it is important to recognise that these results represent a mature experience with RPN by the leaders in the field of robotic renal surgery. Many of these authors pioneered the techniques currently used for RPN, and therefore these results may not apply to centres without the same experience or case volumes. One limitation of this report is the non-concurrent experience of LPN and RPN. The results of RPN came after an initial experience with LPN and therefore the outcomes of RPN may have benefitted from the lessons learned with LPN prior to RPN.

Reporting surgical outcomes as composite results, such as the Trifecta, allows for comparison between reports and sets an outcomes bar for future studies. Most composite measures include assessment of surgical margin status and complications, but there is no current agreement as to the optimal measure of renal functional outcomes. The current Trifecta used a WIT of ≤25 min as a measure of renal function impact, while the margin, ischaemia, and complications (MIC) score uses a WIT of <20 min [5], and others have used 90% renal parenchyma preservation as part of the Trifecta [6]. The impact of WIT on renal function has been questioned given the recently recognised importance of preserved renal parenchyma as an important predictor of renal function after PN [7]. Until there is consensus as to the best measure of renal function after nephron-sparing surgery, composite outcomes such as the Trifecta and the optimal outcomes as described by the authors will have limited utility.

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James Porter
Robotic Surgery, Swedish Medical Center, Seattle , WA, USA
References

 

1 Benway BM, Bhayani SB, Rogers CG et al. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol 2009; 182:866–72

 

2 Zargar H, Allaf M, Bhayani S et al. Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study. BJU Int 2015; 407–14

 

3 Mullins JK, Feng T, Pierorazio PM, Patel HD, Hyams ES, Allaf ME. Comparative analysis of minimally invasive partial nephrectomy techniques in the treatment of localized renal tumors. Urology 2012; 80: 316–21

 

4 Gill IS, Kavoussi LR, Lane BR et al. Comparison of 1800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 2007; 178: 41–6

 

5 Buffi N, Lista G, Larcher A et al. Margin, ischemia, and complications (MIC) score in partial nephrectomy: a new system for evaluating achievement of optimal outcomes in nephron-sparing surgery. Eur Urol 2012; 62: 617–8

 

6 Hung AJ, Cai J, Simmons MN, Gill IS. “Trifecta” in partial nephrectomy. J Urol 2013; 189: 36–42

 

7 Mir MC, Campbell RA, Sharma N et al. Parenchymal volume preservation and ischemia during partial nephrectomy: functional and volumetric analysis. Urology 2013; 82: 263–8

 

Video: Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of SRMs

/by

Trifecta and Optimal Peri-operative outcomes of Robotic and Laparoscopic Partial Nephrectomy In Surgical Treatment Of Small Renal Masses: A Multi-Institutional Study

 

Homayoun Zargar*, Mohamad E. Allaf†, Sam Bhayani‡, Michael Stifelman§, Craig Rogers, Mark W. Ball†, Jeffrey Larson‡, Susan Marshall§, Ramesh Kumar¶ and Jihad H. Kaouk*

 

*Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, †The Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, MD, ‡Dept. of Urology, Washington University School of Medicine, St. Louis, MO, §Dept. of Urology, New York University School of Medicine, New York, NY, and Henry Ford Health System, Vattikuti Urology Institute, Detroit, MI, USA

 

Read the full article
OBJECTIVE

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed ‘optimal outcome’ for the RPN group.

PATIENTS AND METHODS

Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The ‘optimal outcome’ was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and ‘optimal outcome’ achievement.

RESULTS

In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of ‘optimal outcome’ for the RPN group was 38.5%.

CONCLUSIONS

In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for ‘optimal outcome’ might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.

 

Read more articles of the week
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