Urine leak in minimally invasive partial nephrectomy:
					analysis of risk factors and role of intraoperative ureteral
					catheterization

Zargar, Homayoun; Khalifeh, Ali; Autorino, Riccardo; Akca, Oktay; Brandao, Luis Felipe; Laydner, Humberto; Krishnan, Jayram; Samarasekera, Dinesh; Haber, George-Pascal; Stein, Robert J.; Kaouk, Jihad H

doi:10.1590/S1677-5538.IBJU.2014.06.07

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Sumário

ORIGINAL ARTICLE • Int. braz j urol 40 (6) • Dec 2014 • https://doi.org/10.1590/S1677-5538.IBJU.2014.06.07 copy

Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization

Authorship SCIMAGO INSTITUTIONS RANKINGS

Purpose

To investigate risk factors for urine leak in patients undergoing minimally invasive partial nephrectomy (MIPN) and to determine the role of intraoperative ureteral catheterization in preventing this postoperative complication.

Materials and Methods

MIPN procedures done from September 1999 to July 2012 at our Center were reviewed from our IRB-approved database. Patient and tumor characteristics, operative techniques and outcomes were analyzed. Patients with evidence of urine leak were identified. Outcomes were compared between patients with preoperative ureteral catheterization (C-group) and those without (NC-group). Univariable and multivariable analyses were performed to identify factors predicting postoperative urine leak.

Results

A total of 1,019 cases were included (452 robotic partial nephrectomy cases and 567 laparoscopic partial nephrectomy cases). Five hundred twenty eight patients (51.8%) were in the C-group, whereas 491 of them (48.2%) in the NC-group. Urine leak occurred in 31(3%) cases, 4.6% in the C-group and 1.4% in the NC-group (p<0.001). Tumors in NC-group had significantly higher RENAL score, shorter operative and warm ischemic times. On multivariable analysis, tumor proximity to collecting system (OR=9.2; p<0.01), surgeon’s early operative experience (OR=7.8; p<0.01) and preoperative moderate to severe CKD (OR=3.1; p<0.01) significantly increased the odds of the occurrence of a postoperative urine leak.

Conclusion

Clinically significant urine leak after MIPN in a high volume institution setting is uncommon. This event is more likely to occur in cases of renal masses that are close to the collecting system, in patients with preoperative CKD and when operating surgeon is still in the learning curve for the procedure. Our findings suggest that routine intraoperative ureteral catheterization during MIPN does not reduce the probability of postoperative urine leak. In addition, it adds to the overall operative time.

complications [Subheading]; Nephrectomy; Risk Factors; Urinary Incontinence; Ureter; Urinary Catheters

Variable		Value
Age, years	Mean±SD	59.1±12.4
ASA	Median (IQR)	3 (1)
BMI, kg/m ²	Mean±SD	29.9±7
Tumor Laterality, n (%)	Right	552 (54.2)
Tumor Laterality, n (%)	Left	467 (45.8)
Tumor Size, cm	Median (IQR)	2.5 (1.7)
Technique, n (%)	Laparoscopic	567 (55.6)
Technique, n (%)	Robotic	452 (44.4)
Preoperative GFR, mL/min/1.73m ²	Median (IQR)	81.1 (29.8)
RENAL Nephrometry Score	Median (IQR)	6 (3)
Solitary Kidney, n (%)		42 (4.1)

Variable		Value
Intra operative Ureteral Catheterization, n (%)		528 (51.8)
Operative Time, min	Mean±SD	196.9±59.7
Unclamped Renal Hilum, n (%)		71 (7)
Warm Ischemia Time, min	Median (IQR)	26(15)
Zero Ischemia, n (%)		68 (6.7)
Estimated Blood Loss, mL	Median (IQR)	150 (200)
Urine Leak, n (%)		31 (3)
Urine Leak Management, n (%)	Ureteral Stenting	19 (61.3)
	CT-guided Drainage	3* (9.7)
	Observation	11 (35.5)
Length of Stay, days	Median (IQR)	3 (2)
Follow up, months	Median (IQR)	18 (34)

Variable		C-Group (n=528)	NC-Group (n=491)	p-Value
Technique, n (%)	Laparoscopic	468 (88.6)	99 (20.2)	0.001
Technique, n (%)	Robotic	60 (11.4)	392 (79.8)	0.001
RENAL Nephrometry Score, median (IQR)		6 (2)	7 (4)	0.001
Cases performed by surgeons during learning curve, n (%)		124 (23.5)	64 (13)	0.001
Tumor size > 4cm, n (%)		67 (12.7)	102 (20.8)	0.001
Tumor growth pattern >50% endophytic, n (%)		190 (39.8)	201 (46.6)	0.03
Nearness to CS or Sinus < 7mm, n (%)		206 (42.4)	219 (50.8)	0.01
Operative Time, min, mean±SD		210.6±63.5	180.5±50.1	0.001
Warm Ischemia Time, min, median (IQR)		31 (13)	20 (12)	0.001
Urine Leak, n (%)		24 (4.6)	7 (1.4)	0.001

Variable	Univariable Analysis				Multivariate Analysis

	OR	95% CI		p-value	OR	95% CI		p-value
Laparoscopic vs. Robotic	2.3	1	5.3	0.04	1.29	0.3	5.6	0.73
Age	1	0.97	1.02	0.95
Learning Curve (within vs. beyond)	1.84	0.8	4	0.13	7.8	2.5	24.3	0.001
BMI	1.03	0.99	1.07	0.13	1.06	0.99	1.13	0.07
Charlson Comorbidity Index	1.09	0.9	1.3	0.38
Preop GFR (<60 vs. ≥60mL/min/1.73m²)	2.2	1.0	4.7	0.049	3.13	1.06	9.3	0.04
RENAL score	1.19	0.95	1.5	0.13
REAL score (N removed)	1.19	0.95	1.5	0.13	0.91	0.62	1.3	0.62
Tumor Size (> 4 vs. ≤4cm)	1.2	0.5	3.0	0.67
Tumor Growth (>50% vs. ≤50% endophytic)	1.0	0.4	2.4	0.99
Nearness to CS or Sinus (<7mm vs. ≥7mm)	2.6	1.2	5.5	0.01	9.2	2.1	40.2	0.003
Ureteral Catheterization (presence vs. absence)	3.3	1.4	7.7	0.006	1.3	0.32	5.6	0.67
WIT	1	0.97	103	0.96
Zero ischemia (Yes vs. No)	1.6	0.47	5.4	0.45
EBL	1.001	1	1.002	0.001	1.002	1	1.003	0.003

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[1] Correspondence address: Jihad H. Kaouk, MD. Zegarac-Pollock Professor of Surgery. Director, Center for Laparoscopic and Robotic Surgery. Glickman Urological and Kidney Institute, Cleveland Clinic. 9500 Euclid Avenue, Q-10, Cleveland, Ohio 44195, USA. Fax: + 1 216 445-7031. E-mail: kaoukj@ccf.org