title: Urine leak in minimally invasive partial nephrectomy: analysis of risk factors and role of intraoperative ureteral catheterization.
abstract: OBJECTIVE
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Homayoun
authors.initials: H
authors.lastname: Zargar
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Khalifeh
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Autorino
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Oktay
authors.initials: O
authors.lastname: Akca
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Luis Felipe
authors.initials: LF
authors.lastname: Brandão
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Humberto
authors.initials: H
authors.lastname: Laydner
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jayram
authors.initials: J
authors.lastname: Krishnan
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Dinesh
authors.initials: D
authors.lastname: Samarasekera
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: George-Pascal
authors.initials: GP
authors.lastname: Haber
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Stein
authors.affiliation: Center for Laparoscopic & Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D000368:Aged; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D015999:Multivariate Analysis; D009392:Nephrectomy / Q000009:adverse effects* / Q000379:methods; D061646:Operative Time; D051436:Renal Insufficiency, Chronic / Q000601:surgery; D015203:Reproducibility of Results; D012307:Risk Factors; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D013997:Time Factors; D016896:Treatment Outcome; D014546:Urinary Catheterization / Q000379:methods*; D014549:Urinary Incontinence / Q000209:etiology* / Q000517:prevention & control*