MANAGEMENT OF BLUNT RENAL TRAUMA · renal veins noted on HPE. Uneventful recovery. LOS 4 days Pleuritic chest pain and DVT Lt leg below knee 32 days post op. CTPA: No PE but extensive

5/13/2014 S Bandi, Mackay. AUSTRALIA. 15/13/2014 S Bandi, Mackay. AUSTRALIA. 1

NEPHRECTOMY AUDITOCTOBER 1998-SEPTEMBER 2005Dr. Sanjeev Bandi MBBS., FRCSI., FRACS(Urology)

Mater Misericordiae Hospital, Mackay, Qld 4740

This audit has been performed in conjunction with the data requirements of the Urological Society of Australasia, the Royal Australasian College of Surgeons and the Australian Council of Health Care Standards (ACHS)

Presented at the Northern Section Meeting of the Urological Society of Australasia and submitted for presentation at the AUA in 2006.


NEPHRECTOMY AUDITOCTOBER 1998-SEPTEMBER 2005

Single urologist Epidural/GA Retroperitoneal /

Transperitoneal approach Antibiotics as required Bowel preparation/IV

hydration Intermittent calf compression Sodium Heparin 5000 units bd

(in arm only) as DVT prophylaxis


NEPHRECTOMY AUDIT CRITERIAOCTOBER 1998-SEPTEMBER 2005

Patient weight and Body Habitus

Operating time Length Of Stay (LOS) % of patients requiring blood

transfusions Unplanned readmissions Histology Complications


NEPHRECTOMY AUDIT OCTOBER 1998-SEPTEMBER 2005

Patient Weight

Total weight of all patients/total number of patients

This gives an indication of patient’s body habitus and ease of surgery



Operating Time is a Measure of the Efficiency of the Surgery

Skin preparation to skin closure

Average Operating time



Length of Stay (LOS)Is a Measure of Resource Utilisation Involved With This Procedure

Day of surgery=day 0 No:of patient days for all

Nephrectomy patients/total no:of patients (excluding patients having other procedures)



Percentage of Patients Requiring Blood Transfusions

Transfusions:Pre/Intra/Post –operatively within the same admission



Unplanned Readmission

Unplanned readmission within 28 days of discharge following Nephrectomy

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NEPHRECTOMY AUDIT OCTOBER 1998-SEPTEMBER 2005Patient weight and Body Habitus

Average weight of 61 patients who underwent a Nephrectomy: 81.15kg.

Range was from 55-130kg Males 36 Females 25

Patient Weight Chart

0

20

40

60

80

100

120

140

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61

No:of Patients

Wei

gh

t in

kg

MALE

FEMALE



Operating Time is a Measure of the Efficiency of the Surgery

Average operating time in minutes for 34 Radical Nephrectomies: 205 minutes This includes 4 cases with renal vein thrombus and 6 patients with multiple tumours in same

kidney

Excluding the above the Average operating time in minutes was 181 minutesOperating Time

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34

No:of Patients

Tim

e in

min

ute

s

Male

Female

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NEPHRECTOMY AUDIT OCTOBER 1998-SEPTEMBER 2005Operating Time is a Measure of the Efficiency of the Surgery

Average operating time in minutes for 6 Partial Nephrectomies:181 minutes


Operating Time

0

50

100

150

200

250

300

350

1 2 3 4 5 6

No:of Patients

Tim

e i

n m

ins

Male

Female



Average operating time in minutes for 10 Simple/Complete Nephrectomies:162.5 minutes

Operating Time

0

50

100

150

200

250

300

1 2 3 4 5 6 7 8 9 10

No:of Patients

Tim

e in

Min

s

Female

Male



Average operating time in minutes in 11 Nephroureterectomies:278.45 minutes

Operating Time

0

100

200

300

400

500

600

1 2 3 4 5 6 7 8 9 10

No:of Patients

Tim

e i

n M

ins

Male

Female




Average LOS in 34 patients who underwent Radical Nephrectomy: 4.15 daysIf 2 patients who had LOS of 9 and 13 days were excluded the LOS dropped to 3.71 days (DRG LO3B 6.7 days and DRG LO3A 13.4 days)

Length of Stay (LOS)

0

2

4

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10 11

No:of Days

No

:of

Pat

ien

ts

Patients




Average LOS in 6 patients who had a Partial Nephrectomy: 6.16 days (DRG LO3B 6.7 days DRG LO3A 13.4 days)


0

0.5

1

1.5

2

2.5

1 2 3 4 5 6 7 8 9 10

No:of Days

No

:of

Pat

ien

ts

Patients




Average LOS in 11 patients who underwent Nephroureterectomy: 5.91 days(DRG LO3B 6.7 days DRG LO3A 13.4 days)


0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1 2 3 4 5 6 7 8 9 10

No:of Days

No

:of

Pat

ien

ts

Patients




Average LOS in 10 patients who underwent Simple Complete Nephrectomy:3.33 days(DRG LO3B 6.7days and DRG LO3A 13.4 days)1 exclusion who had excision of tail of pancreas and drainage of perinephric abscess in a diabetic with NF kidney and XGP secondary to staghorn calculus who presented with urosepsis

Length of Stay(LOS)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

No:of Days

No

:of

Pat

ien

ts

Patients


NEPHRECTOMY AUDIT OCTOBER 1998-SEPTEMBER 2005Size of Renal Carcinomas removed

Average size of renal tumour removed in 32 patients : 4.91 centimetres

2 Radical Nephrectomies for Renal Calyceal and Pelvic TCC

Range 1.8 -12 centimetres


NEPHRECTOMY AUDIT OCTOBER 1998-SEPTEMBER 2005Percentage of Patients Requiring Blood Transfusions

9/61 patients: 14.75% 4 RCC with renal vein

involvement had autologous blood, 2 patients after partial nephrectomy, 1 pre op anaemic patient with DM,XGP and perinephric abscess, 2 with anaemia and multifocal TCC of bladder and kidney.

Total no:of units transfused 28(1,2,2,2,3,4,4,5,5)


NEPHRECTOMY AUDIT OCTOBER 1998-SEPTEMBER 2005UNPLANNED READMISSIONS/REOPERATIONS

1 re operation to drain retroperitoneal

collection at 34 days

Left Nephrectomy, Adrenaleectomy &

Excision of Tail of Pancreas for kidney with

XGP.

Diabetic with Urosepsis and NF kidney with

staghorn calculus and perinephric abscess

Weight 98kg Height 162 cms(5ft 1in) Age 62

LOS 53 days



PATHOLOGY

Renal Cell Carcinomas : 32Clear cell 20Multifocal/Papillary 7Sarcomatoid 3Chromophobe 2

Transitional Cell Carcinomas of Renal Pelvis/calyces and Ureter 11

Angiomyolipomas 1 Oncocytomas 3 Chronic Pyelonephritis 10 Xanthogranulomatous Pyelonephritis

(XGP) 3 Hamartoma of renal vasculature 1



Complications

No deaths No pulmonary emboli No Hospital acquired bacteraemia 1 Profuse diarrhoea from Ural

sachets(Pre existing IBS) – LOS 10 days 1 subcutaneous emphysema secondary to

rib #’s caused by Finochetti retractor in 78yr old male ( LOS 13days) –Nursing home resident

1 patient had an AMI post op requiring extended stay in hospital( LOS 10days)



Complications 2

2 loin hernias, 1 required surgery. 1 recurrent retroperitoneal tumour

recurrence 11 months post op in spite of clear margins and 5 lymph nodes clear of disease 1 Sevoflurane inducedhepatitis causing nausea and malaise(LOS 4 days)

1 CVA 72 hours after a Lt Radical Nephrectomy for multifocal(3) Papillary/Chromophil Renal carcinomas secondary to a bleed in the mid brain (LOS 9 DAYS)



Complications 3

1 patient aged 66 Lt Radical

Nephrectomy for 9.5cm Clear cell

carcinoma pT3b. Tumour thrombi in

renal veins noted on HPE.

Uneventful recovery. LOS 4 days Pleuritic chest pain and DVT Lt leg

below knee 32 days post op.

CTPA: No PE but extensive

lymphadenopathy and 2.8cm Rt

lower lobe mass. Pre Op CXR was normal.

Action Point: CT CHEST IN LARGE TUMOURS > 5CMS



Complications 4

1 patient developed Guillain-Barre syndrome type paresis with weakness in lower limbs 5 weeks after surgery for Renal Carcinoma with renal vein involvement. Known diabetic with chronic renal impairment andhypertension and morbid obesity(130kg)



ACKNOWLEDGEMENTS

Ms Gail Van Moolenbrookand Ms Margaret Chetcuti at

the Medical Records

Department at the Mater Hospital in Mackay.

Vignesh Bandi for teaching

me to use Microsoft Excel.

A follow up study with 10 year survival data is planned.

Documents

MANAGEMENT OF BLUNT RENAL TRAUMA · renal veins noted on HPE. Uneventful recovery. LOS 4 days Pleuritic chest pain and DVT Lt leg below knee 32 days post op. CTPA: No PE but extensive