Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH ( p = 0.545, p = 0.637).
Conclusion:The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.
Introduction: Supracostal access for percutaneous nephrolithotomy (PNL) has a known increased risk for thoracic complications (TCs). In this study, we perform a radiological review of preoperative and postoperative abdominal CT scans to assess the relationship of the upper pole of the kidney with surrounding landmarks to determine radiographic predictors of TCs. Methods: We performed a retrospective matched cohort comparison of patients who underwent supracostal PNL with and without TCs from 2012 to 2019. An experienced genitourinary (GU) radiologist reviewed pre-and postoperative CT scans to measure the craniocaudal distance between the upper renal pole and the most superior calix to the upper edge of the tip of the 12th rib, the costophrenic angle, and the posterior insertion of the diaphragm. Results: We identified 19 patients who developed TCs after undergoing PNL and compared their CT scans with 24 control patients without TCs. On a preoperative abdominal CT scan, the relationship of the upper edge of the renal parenchyma or upper pole calix with the superior edge of the tip of the 12th rib or costophrenic angle was not found to be predictive of TCs. On receiver operating characteristic analysis, diaphragmatic insertion of £2.5 cm below the upper edge of the renal parenchyma on sagittal and transverse views was predictive of TCs ( p = 0.046). On postoperative CT scan, the percutaneous nephrostomy tract traversed the posterior insertion of the diaphragm in 80% of patients who had TCs compared with 20% of patients who had no TCs. Conclusions: The decreased distance between the posterior insertion of the diaphragm (medial and lateral arcuate ligaments) and the superior edge of the renal upper pole on preoperative CT scan was associated with TCs from supracostal puncture during PNL. Critical preoperative recognition of this anatomic relationship can help preoperative planning and patient counseling and may prevent or reduce TCs.
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