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Objective: To investigate whether patients requiring dialysis are a higher risk surgical population and would experience more peri-operative adverse events even when undergoing a perceived less invasive operation as a laparoscopic radical nephrectomy (LRN). LRN is generally a well-tolerated surgical procedure with minimal morbidity and mortality. Prior to transplantation, dialysis patients will often have to undergo a LRN to remove a native kidney with a suspicious mass. Materials and Methods: Patients in the American College of Surgeons National Surgical Quality Improvement Program who underwent a laparoscopic radical nephrectomy between 2011 and 2016 were included. Patients were stratified by the need for pre-operative dialysis two weeks prior to surgery, and peri-operative outcomes were compared. A multivariable logistic regression analysis was performed to test the association between the need for pre-operative dialysis and peri-operative risk. Results: There were 8,315 patients included in this analysis of which 445 (5.4%) patients required pre-operative dialysis. Patients who required pre-operative dialysis had more minor (p < .0001) and major (p=.0025) complications, a higher rate of return to the operating room (p=0.002), and a longer length of stay (LOS) (p < 0.0001) than those patients not requiring pre-operative dialysis. In a multivariate analysis, the need for pre-operative dialysis was independently associated with adverse peri-operative outcomes (OR=1.45, CI=1.08-1.95, p=.015). Conclusions: Patients requiring pre-operative dialysis were more likely to experience a peri-operative complication and have a longer LOS. For LRNs performed prior to transplantation, further risk stratification is needed, and treatment sequencing may need to be reconsidered.

Retrospective observational studies support the utility of robotic-assisted radical cystectomy (RARC). Randomized controlled trials (RCTs) have shown that RARC with extracorporeal urinary diversion may lead to decreased estimated blood loss, decreased rate of transfusion, similar oncologic outcomes, cost-effectiveness, and variable increased operative times. Although RCTs comparing RARC with open radical cystectomy are currently ongoing, it may be several years before the utility of RARC is known. The discussion on the role of cystectomy, indications, outcomes, care pathways, access to high-volume care centers, and efforts to decrease complications may prove as important as the technique itself.

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