Category: Laparoscopic/ Robotic: Other
Introduction & Objective :
Decreasedfunctional outcome after partial nephrectomy is associated with overall mortality. We aimed to create a model that predicts significant eGFR reduction (≥25% from baseline) in patients undergoing robot-assisted partial nephrectomy (RAPN) and to investigate the role of acute kidney injury (AKI) in this patient population.
999 patients were identified from a multi-institutional database. Renal function was defined according to the KDIGO guidelines for chronic kidney disease (CKD). AKI was defined as >25% reduction in eGFR from pre-RAPN to discharge. A nomogram to predict significant eGFR reduction within 12 months of RAPN was built based on the coefficients of Cox survival function that ultimately included age, sex, Charlson comorbidity index, baseline GFR category, R.E.N.A.L. Nephrometry score, AKI in patients with normal baseline renal function and AKI on CKD. The proportional hazard (PH) assumption was evaluated through the Schönfeld test.Internal validation was performed using the leave-one-out cross-validation. Calibration was graphically investigated. The decision curve analysis (DCA) was used to evaluate the net clinical benefit, while the classification and regression tree (CART) for time-dependent outcomes was utilized to identify prognostic groups<./p>
Median (IQR) age at surgery was 61 years (51,68). Overall, 135 patients experienced significant eGFR reduction, median follow-up for survivors was 12.3 months. The 12-month probability of significant eGFR reductionwas 18%. All variables fitted into the model, including AKI in patients with normal renal function (HR:4.30; CI:3.45,7.22; p<0.001) and AKI on CKD (HR:4.99; CI:1.92,9.67; p<0.001), emerged as predictors of significant eGFR reduction, (all p≤0.049; Table 1) and were considered to build a nomogram. The internally-validated cindex resulted 72.98%. The model demonstrated excellent calibration and a net benefit at the DCA with probabilities ≥4%. The CART identified four prognostic groups. In the intermediate, high and very high-risk groups the significant eGFR reductionprobabilities were: 18.6%, 46% and 81%, respectively. This model requires external validation.
Conclusions : We developed a nomogram that accurately predicts significant eGFR reduction within 12 months of RAPN. This model may serve as a tool for early identification of patients at high-risk for significant renal function decline after surgery.
Alberto Martini– Fellow, Icahn School of Medicine at Mount Sinai, New York, New York
Shivaram Cumarasamy– Icahn School of Medicine at Mount Sinai, New York, New York
Alp Tuna Beksac– Fellow, Icahn School of Medicine at Mount Sinai, New York, New York
Ronney Abaza– Director - Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio
Daniel Eun– Professor, Temple University, Philadelphia, Pennsylvania
Akshay Bhandari– Professor, Columbia University Division of Urology at Mount Sinai Medical Center, Miami Beach, Florida
Ashok Hemal– Professor , Wake Forest Baptist Medical Center, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
James Porter– Medical Director for Robotic Surgery, Swedish Medical Center, Seattle, Washington
Ketan Badani– Professor of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
Icahn School of Medicine at Mount Sinai
New York, New York
Endourological Society Fellow in Minimally Invasive and Robotic Surgery at Icahn School of Medicine at Mount Sinai.
Director - Robotic Surgery
OhioHealth Dublin Methodist Hospital
Columbia University Division of Urology at Mount Sinai Medical Center
Miami Beach, Florida
Wake Forest Baptist Medical Center
Wake Forest Baptist Medical Center
Winston-Salem, North Carolina
Dr. Hemal is working as a professor in the department of Urology, Comprehensive Cancer Center & Prof., Institute for Regenerative Medicine at Wake Forest Baptist Medical Center. He is well known for his pioneering work in minimally invasive surgery. He has been active in the field of endourology since 1989, laparoscopy since 1992 and robot-assisted surgery since 2001. His contributions to laparoscopic & robot-assisted urologic surgery include the development of new techniques in uro-oncology & commitment to sharing and disseminating knowledge. He has conducted live demonstrations of endourological, laparoscopic & robot-assisted urologic procedures at more than 350 conferences around the world. He has been a visiting professor to more than 350 institutions around the globe to deliver guest lectures and keynote speeches. His trainees have been involved in the establishment of more than 50 minimally invasive programs. He has edited six books & 450 scientific papers and chapters in the book. He is on editorial board of several journals and President of society of robotic urologic surgery.He serves as a member of scientific committee in American Urology Association, World Congress of Endourology & SIU. Dr. Hemal has been the recipient of many academic distinctions and awards. He has been awarded three times by President of India including the most prestigious honor a physician can receive, the “Dr. B.C. Roy Award,” in 2004 for his contributions in the field of cost-effective minimally invasive surgery and highest civilian honor “Padma-Shree” in 2007 for development of robotic urologic surgery. Other prestigious awards to his credit are Urologist of the Decade award, Guest Scholar of the American College of Surgeons, SIU scholar and Fulbright scholar. Dr. Hemal is consistently included in Best Doctors of America, Top Doctors of America, Top Prostate Cancer Specialists and Who’s Who in the World for past several years.
Medical Director for Robotic Surgery
Swedish Medical Center