Positive preoperative MSSU was significantly associated with postoperative urosepsis by logistic regression and matched-pair analysis. These higher risk patients should be counseled appropriately before surgery, and should be the focus of vigilant postoperative monitoring. The study suggests particular caution in patients with a positive preoperative MSSU without a preoperative ureteral stent.
The recent COVID-19 pandemic led to the cancellation of elective surgery across the United Kingdom. Re-establishing elective surgery in a manner that ensures patient and staff safety has been a priority. We report our experience and patient outcomes from setting up a “COVID protected” robotic unit for colorectal and renal surgery that housed both the da Vinci Si (Intuitive, Sunnyvale, CA, USA) and the Versius (CMR Surgical, Cambridge, UK) robotic systems. “COVID protected” robotic surgery was undertaken in a day-surgical unit attached to the main hospital. A standard operating procedure was developed in collaboration with the trust COVID-19 leadership team and adapted to national recommendations. 60 patients underwent elective robotic surgery in the initial 10-weeks of the study. This included 10 colorectal procedures and 50 urology procedures. Median length of stay was 4 days for rectal cancer procedures, 2 days less than prior to the COVID period, and 1 day for renal procedures. There were no instances of in-patient coronavirus transmission. Six rectal cancer patients waited more than 62 days for their surgery because of the initial COVID peak but none had an increase T-stage between pre-operative staging and post-operative histology. Robotic surgery can be undertaken in “COVID protected” units within acute hospitals in a safe way that mitigates the increased risk of undergoing major surgery in the current pandemic. Some benefits were seen such as reduced length of stay for colorectal patients that may be associated with having a dedicated unit for elective robotic surgical services.
BackgroundClinically significant CKD following surgery for kidney cancer is associated with increased morbidity and mortality, but identifying patients at increased CKD risk remains difficult. Simple methods to stratify risk of clinically significant CKD after nephrectomy are needed.MethodsTo develop a tool for stratifying patients’ risk of CKD arising after surgery for kidney cancer, we tested models in a population-based cohort of 699 patients with kidney cancer in Queensland, Australia (2012–2013). We validated these models in a population-based cohort of 423 patients from Victoria, Australia, and in patient cohorts from single centers in Queensland, Scotland, and England. Eligible patients had two functioning kidneys and a preoperative eGFR ≥60 ml/min per 1.73 m2. The main outcome was incident eGFR <45 ml/min per 1.73 m2 at 12 months postnephrectomy. We used prespecified predictors—age ≥65 years old, diabetes mellitus, preoperative eGFR, and nephrectomy type (partial/radical)—to fit logistic regression models and grouped patients according to degree of risk of clinically significant CKD (negligible, low, moderate, or high risk).ResultsAbsolute risks of stage 3b or higher CKD were <2%, 3% to 14%, 21% to 26%, and 46% to 69% across the four strata of negligible, low, moderate, and high risk, respectively. The negative predictive value of the negligible risk category was 98.9% for clinically significant CKD. The c statistic for this score ranged from 0.84 to 0.88 across derivation and validation cohorts.ConclusionsOur simple scoring system can reproducibly stratify postnephrectomy CKD risk on the basis of readily available parameters. This clinical tool’s quantitative assessment of CKD risk may be weighed against other considerations when planning management of kidney tumors and help inform shared decision making between clinicians and patients.
Objective To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot‐assisted partial nephrectomy (RAPN). Materials and Methods Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri‐operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri‐operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. Results All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559–0.668; SPARE AUC 0.612, 95% CI 0.548–0.677). Conclusion This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra‐operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.
Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Although most pelvi‐ureteric junction obstruction (PUJO) is probably congenital in aetiology, it often presents later in life. PUJO can be diagnosed during investigation of urological symptoms, or imaging for other reasons. It is thought that in the absence of infectious complications that PUJO in adults is a benign condition. Unfortunately, there is a paucity of data in this field, and in patients who have no indication for intervention; it is unclear how long they should be followed up. We also do not know how often renography should be performed during their follow‐up. The present study suggests discharging patients with minimally symptomatic and or asymptomatic PUJO at 2 years from diagnosis if they do not have symptomatic or renographic deterioration. Large multicentre prospective studies would be contributory to help elucidate further how we should be treating minimally symptomatic PUJO. OBJECTIVE To establish whether it is safe to manage minimally symptomatic and asymptomatic pelvi‐ureteric junction obstruction (PUJO) conservatively. PATIENTS AND METHODS In all, 50 patients with PUJO diagnosed with dynamic renography, and monitored with at least two renograms. RESULTS In all, 19 patients were totally asymptomatic, while 31 patients had minimal symptoms at time of diagnosis. The mean follow‐up was 53 months. During the course of follow‐up 10 of the 50 patients deteriorated. All patients who had asymptomatic renographic deterioration, deteriorated within 2 years of diagnosis. Eight of the 10 patients that deteriorated needed pyeloplasty and two nephrectomy. CONCLUSIONS Conservative management of patients with minimally symptomatic and asymptomatic PUJO is safe. Discharging patients could be considered at 2 years from diagnosis, if they remain renographically stable and asymptomatic or minimally symptomatic.
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