OBESITY AND OUTCOMES IN PARTIAL NEPHRECTOMY References
1. Eaton SH, Thirumavalaven N, Katz MH, et al. Effect of body mass index on perioperative outcomes for laparoscopic partial nephrectomy. J Endourol 2011;25:1447–1450. 2. Anast JW, Stoller ML, Meng MV, et al. Differences in complications and outcomes for obese patients undergoing laparoscopic radical, partial or simple nephrectomy. J Urol 2004;172:2287–2291. 3. Mendoza D, Newman RC, Albala D, et al. Laparoscopic complications in markedly obese urologic patients (a multiinstitutional review). Urology 1996;48:562–567. Review. 4. Gong EM, Orvieto MA, Lyon MB, et al. Analysis of impact of body mass index on outcomes of laparoscopic renal surgery. Urology 2007;69:38–43. 5. Aboumarzouk OM, Stein RJ, Haber GP, et al. Laparoscopic partial nephrectomy in obese patients: A systematic review and meta-analysis. BJU Int 2012;110:1244–1250. Review. 6. Reynolds C, Hannon M, Lehman K, et al. An obese body habitus does not preclude a minimally invasive partial nephrectomy. Can J Urol 2014;21:7145–7149. 7. Ioffe E, Hakimi AA, Oh SK, et al. Effect of visceral obesity on minimally invasive partial nephrectomy. Urology 2013; 82:612–618. 8. Isac WE, Autorino R, Hillyer SP, et al. The impact of body mass index on surgical outcomes of robotic partial nephrectomy. BJU Int 2012;110:E997–E1002. 9. Romero FR, Rais-Bahrami S, Muntener M, et al. Laparoscopic partial nephrectomy in obese and non-obese patients: Comparison with open surgery. Urology 2008;71:806–809. 10. Naeem N, Petros F, Sukumar S, et al. Robot-assisted partial nephrectomy in obese patients. J Endourol 2011;25:101–105. 11. Tan HJ, Wolf JS Jr, Ye Z, et al. Population level assessment of hospital based outcomes following laparoscopic versus open partial nephrectomy during the adoption of minimally invasive surgery. J Urol 2014;191:1231–1237. 12. American College of Surgeons. American College of Surgeons National Surgical Quality Improvement Program User Guide. Chicago, IL: American College of Surgeons; 2012. 13. Owen RM, Perez SD, Lytle N, et al. Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy. Surg Endosc 2013;27: 3555–3563.
567
14. Hardy KL, Davis KE, Constantine RS, et al. The impact of operative time on complications after plastic surgery: A multivariate regression analysis of 1753 cases. Aesthet Surg J 2014;34:614–622. 15. Liu JJ, Leppert JT, Maxwell BG, et al. Trends and perioperative outcomes for laparoscopic and robotic nephrectomy using the National Surgical Quality Improvement Program (NSQIP) database. Urol Oncol 2014; 32:473–479. 16. Kern SQ, Lustik MB, McMann LP, et al. Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program. J Endourol 2014;28:40–47. 17. Morris K, Tuorto S, Gonen M, et al. Simple measurement of intra-abdominal fat for abdominal surgery outcome prediction. Arch Surg 2010;145:1069–1073. 18. Macleod LC, Hsi RS, Gore JL, et al. Perinephric fat thickness is an independent predictor of operative complexity during robot-assisted partial nephrectomy. J Endourol 2014;28:587–591.
Address correspondence to: Robert B. Nadler, MD Department of Urology Northwestern University Feinberg School of Medicine 675 North St. Clair Street, Suite 20-150 Chicago, IL 60611 E-mail: [email protected]
Abbreviations Used ASA ¼ American Society of Anesthesiology BMI ¼ body mass index MIPN ¼ minimally invasive partial nephrectomy NSQIP ¼ National Surgical Quality Improvement Program OPN ¼ open partial nephrectomy SSI ¼ superficial surgical site infection UTI ¼ urinary tract infection
DOI: 10.1089/end.2015.0091
Editorial Comment for Sharma et al. Maxwell Meng, MD
T
he authors have used data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to examine and compare results after open and minimally invasive partial nephrectomy—
specifically, the impact of body mass index (BMI) on surgical outcomes. This robust, surgeon-driven resource has been important in not only collecting relevant data and establishing relevant outcomes-based measures, but also
Department of Urology, University of California, San Francisco, San Francisco, California.
568
may lead to improved outcomes and reduction in complications. Although urologic procedures are contained within NSQIP and informative analyses have been performed, I anticipate that more procedure- and specialty-specific lessons (e.g., surgical risk calculators1) will emerge from ongoing efforts such as the American Urological Association Quality Registry. It appears that the minimally invasive approach to partial nephrectomy is associated with lower rates of postoperative complications compared with open surgery (7% vs 18%, respectively), although this was consistent across BMI groups. In addition, while obese patients had significantly longer operative times for both types of surgery, the absolute time differences were relatively small (20 min). It is important to note that the difference in complication rates for minimally invasive techniques was because of a lower number of Clavien I–II complications and that rates of ‡ grade III complications were comparable. Several things should be kept in mind. First, NSQIP is unable to differentiate between laparoscopic and robotassisted laparoscopic surgery, and I would be curious as to whether this is relevant. In addition, it would be interesting to evaluate the changes over time with evolution in experience and technology. Second, granularity is lacking with respect to details about tumor stage, and future studies including anatomic complexity (e.g., R.E.N.A.L. or PADUA
MENG ET AL.
nephrometry scores) will be informative; similarly, surgeon and center level data would be interesting. Third, the postoperative complications are limited to those occurring within 30 days after operation. One wonders whether extending the period to 90 days is more accurate, as for radical cystectomy,2 although I would think that this may only further support the benefits of the minimally invasive approach. References
1. Tomaszewski J, Handorf E, Kutikov A, et al. Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing radical cystectomy. J Urol 2014;191(suppl):MP2-04. 2. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90day readmissions, morbidity and mortality in a contemporary series. J Urol 2010;184:1296–1300.
Address correspondence to: Maxwell Meng, MD Department of Urology University of California, San Francisco 1600 Divisadero Street San Francisco, CA 94143 E-mail: [email protected]
Copyright of Journal of Endourology is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
1. Eaton SH, Thirumavalaven N, Katz MH, et al. Effect of body mass index on perioperative outcomes for laparoscopic partial nephrectomy. J Endourol 2011;25:1447–1450. 2. Anast JW, Stoller ML, Meng MV, et al. Differences in complications and outcomes for obese patients undergoing laparoscopic radical, partial or simple nephrectomy. J Urol 2004;172:2287–2291. 3. Mendoza D, Newman RC, Albala D, et al. Laparoscopic complications in markedly obese urologic patients (a multiinstitutional review). Urology 1996;48:562–567. Review. 4. Gong EM, Orvieto MA, Lyon MB, et al. Analysis of impact of body mass index on outcomes of laparoscopic renal surgery. Urology 2007;69:38–43. 5. Aboumarzouk OM, Stein RJ, Haber GP, et al. Laparoscopic partial nephrectomy in obese patients: A systematic review and meta-analysis. BJU Int 2012;110:1244–1250. Review. 6. Reynolds C, Hannon M, Lehman K, et al. An obese body habitus does not preclude a minimally invasive partial nephrectomy. Can J Urol 2014;21:7145–7149. 7. Ioffe E, Hakimi AA, Oh SK, et al. Effect of visceral obesity on minimally invasive partial nephrectomy. Urology 2013; 82:612–618. 8. Isac WE, Autorino R, Hillyer SP, et al. The impact of body mass index on surgical outcomes of robotic partial nephrectomy. BJU Int 2012;110:E997–E1002. 9. Romero FR, Rais-Bahrami S, Muntener M, et al. Laparoscopic partial nephrectomy in obese and non-obese patients: Comparison with open surgery. Urology 2008;71:806–809. 10. Naeem N, Petros F, Sukumar S, et al. Robot-assisted partial nephrectomy in obese patients. J Endourol 2011;25:101–105. 11. Tan HJ, Wolf JS Jr, Ye Z, et al. Population level assessment of hospital based outcomes following laparoscopic versus open partial nephrectomy during the adoption of minimally invasive surgery. J Urol 2014;191:1231–1237. 12. American College of Surgeons. American College of Surgeons National Surgical Quality Improvement Program User Guide. Chicago, IL: American College of Surgeons; 2012. 13. Owen RM, Perez SD, Lytle N, et al. Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy. Surg Endosc 2013;27: 3555–3563.
567
14. Hardy KL, Davis KE, Constantine RS, et al. The impact of operative time on complications after plastic surgery: A multivariate regression analysis of 1753 cases. Aesthet Surg J 2014;34:614–622. 15. Liu JJ, Leppert JT, Maxwell BG, et al. Trends and perioperative outcomes for laparoscopic and robotic nephrectomy using the National Surgical Quality Improvement Program (NSQIP) database. Urol Oncol 2014; 32:473–479. 16. Kern SQ, Lustik MB, McMann LP, et al. Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program. J Endourol 2014;28:40–47. 17. Morris K, Tuorto S, Gonen M, et al. Simple measurement of intra-abdominal fat for abdominal surgery outcome prediction. Arch Surg 2010;145:1069–1073. 18. Macleod LC, Hsi RS, Gore JL, et al. Perinephric fat thickness is an independent predictor of operative complexity during robot-assisted partial nephrectomy. J Endourol 2014;28:587–591.
Address correspondence to: Robert B. Nadler, MD Department of Urology Northwestern University Feinberg School of Medicine 675 North St. Clair Street, Suite 20-150 Chicago, IL 60611 E-mail: [email protected]
Abbreviations Used ASA ¼ American Society of Anesthesiology BMI ¼ body mass index MIPN ¼ minimally invasive partial nephrectomy NSQIP ¼ National Surgical Quality Improvement Program OPN ¼ open partial nephrectomy SSI ¼ superficial surgical site infection UTI ¼ urinary tract infection
DOI: 10.1089/end.2015.0091
Editorial Comment for Sharma et al. Maxwell Meng, MD
T
he authors have used data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to examine and compare results after open and minimally invasive partial nephrectomy—
specifically, the impact of body mass index (BMI) on surgical outcomes. This robust, surgeon-driven resource has been important in not only collecting relevant data and establishing relevant outcomes-based measures, but also
Department of Urology, University of California, San Francisco, San Francisco, California.
568
may lead to improved outcomes and reduction in complications. Although urologic procedures are contained within NSQIP and informative analyses have been performed, I anticipate that more procedure- and specialty-specific lessons (e.g., surgical risk calculators1) will emerge from ongoing efforts such as the American Urological Association Quality Registry. It appears that the minimally invasive approach to partial nephrectomy is associated with lower rates of postoperative complications compared with open surgery (7% vs 18%, respectively), although this was consistent across BMI groups. In addition, while obese patients had significantly longer operative times for both types of surgery, the absolute time differences were relatively small (20 min). It is important to note that the difference in complication rates for minimally invasive techniques was because of a lower number of Clavien I–II complications and that rates of ‡ grade III complications were comparable. Several things should be kept in mind. First, NSQIP is unable to differentiate between laparoscopic and robotassisted laparoscopic surgery, and I would be curious as to whether this is relevant. In addition, it would be interesting to evaluate the changes over time with evolution in experience and technology. Second, granularity is lacking with respect to details about tumor stage, and future studies including anatomic complexity (e.g., R.E.N.A.L. or PADUA
MENG ET AL.
nephrometry scores) will be informative; similarly, surgeon and center level data would be interesting. Third, the postoperative complications are limited to those occurring within 30 days after operation. One wonders whether extending the period to 90 days is more accurate, as for radical cystectomy,2 although I would think that this may only further support the benefits of the minimally invasive approach. References
1. Tomaszewski J, Handorf E, Kutikov A, et al. Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing radical cystectomy. J Urol 2014;191(suppl):MP2-04. 2. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90day readmissions, morbidity and mortality in a contemporary series. J Urol 2010;184:1296–1300.
Address correspondence to: Maxwell Meng, MD Department of Urology University of California, San Francisco 1600 Divisadero Street San Francisco, CA 94143 E-mail: [email protected]
Copyright of Journal of Endourology is the property of Mary Ann Liebert, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
