Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review and meta-analysis

Transperitoneal vs retroperitoneal robotic partial nephrectomy: a meta-analysis and systematic review of propensity-matched studies

The main aim of this meta-analysis is to assess and compare the impact of two different surgical approaches, transperitoneal and retroperitoneal, on perioperative outcomes in robotic partial nephrectomy. A systematic search of MEDLINE, PubMed, Google Scholar, and the Cochrane Database was conducted to identify relevant studies published between January 2000 and January 2025. Included were nine non-randomized controlled trials with a total of 2420 patients with matching propensity scores. Among these patients, 1321 had robotic TPPN and 1099 had robotic RPPN, the abbreviation for robotic partial nephrectomy. Shorter operating times, shorter hospital stays, less estimated intraoperative blood loss, and fewer total postoperative problems were related to RPPN compared to TPPN. There were no notable disparities between the two groups when comparing the duration of renal ischemia, the fall in postoperative glomerular filtration rate (GFR), the occurrence of serious postoperative sequelae, or the necessity for blood transfusions. Compared to TPPN, RPPN demonstrates certain advantages in perioperative metrics such as surgical time, hospital stay, and overall complication rates. However, further high-quality studies are needed to confirm these findings.

Randomised controlled feasibility trial of retroperitoneal vs transperitoneal robot-assisted partial nephrectomy: the ROPARN study

OBJECTIVES

To assess the feasibility of trial recruitment and confirm that retroperitoneal robotic partial nephrectomy (RRPN) has the same oncological efficacy as transperitoneal robotic partial nephrectomy (TRPN), with time advantages and less peri-operative morbidity, in a randomised controlled trial (RCT).

PATIENTS AND METHODS

The study was designed as a single-centre, open-label, feasibility RCT. Patients with suspected localised renal cell carcinoma referred for robotic partial nephrectomy were randomised in a 1:1 ratio to receive either TRPN or RRPN. The primary outcomes were trial feasibility, postoperative mobility and pain perception. Secondary outcomes were intra-operative times, assessment of complications, and comparison of positive surgical margin (PSM) rates. The data on all randomised patients who underwent surgery were analysed descriptively.

RESULTS

Sixty-one patients underwent TRPN or RRPN (31 vs 30). Postoperative mobility within 24 h after surgery (RRPN: 77 vs TRPN: 71%; P = 0.613), median postoperative pain, assessed using a numeric rating scale (RRPN: 1.5 vs TRPN: 1.8; P = 0.509), and full bowel canalisation within 3 days (RRPN: 100% vs TRPN: 90%; P = 0.315) were more favourable in the RRPN group, but the difference was not statistically significant. In comparison to TRPN, RRPN was associated with shorter operating time (81 vs 105 min; P = 0.005), shorter time on the console (49 vs 73 min; P < 0.001) and shorter time from console to renal artery preparation (7.5 vs 18 min; P < 0.001). TRPN required a shorter time from skin incision to console (16 vs 12 min; P = 0.001). There was no statistically significant difference in tumour complexity, ischaemia time, PSM rate, blood loss or complications between the two groups.

CONCLUSION

We present the first data from an RCT comparing RRPN with TRPN. RRPN showed significant time benefits while being a safe alternative to TRPN, with a similar PSM rate. There was less postoperative morbidity in the RRPN group, although this was not statistically significant. These results underline that dorsolateral renal tumours should be preferably resected by RRPN. Further multicentre RCTs are necessary to confirm these results.

Predictors of delayed hospital discharge after robot-assisted partial nephrectomy: the impact of single-port robotic surgery

PURPOSE

To evaluate the predictors of delayed discharge for patients undergoing robot-assisted partial nephrectomy (RAPN) at our Institution since the introduction of the single port (SP) robotic system.

METHODS

We performed a retrospective review of our prospectively maintained database of patients undergoing RAPN from September 2020 to August 2024. Patients were categorized by the postoperative day of their discharge: POD1 (single overnight stay) or POD > 1 (more than one night stay). Multivariable logistic regression analysis was used to test the probability of prolonged hospital stay (defined as more than one night stay) adjusting for age at surgery, surgical approach, Charlson comorbidity index, baseline hemoglobin, antiplatelet or anticoagulant medications, clinical tumor stage, and intraoperative blood transfusion.

RESULTS

Overall, 255 patients were identified for the analysis. Patients discharged on POD1 were younger (p = 0.004), reported a lower Charlson Comorbidity Index (p = 0.002), higher preoperative hemoglobin levels (p = 0.005), and smaller tumor size (p < 0.001). Higher rates of discharge on POD1 were recorded for both multiport transperitoneal (59.5 vs. 40.5%, p = 0.02) and SP retroperitoneal (81.5 vs. 18.5%, p = 0.004). Clinical tumor stage (p = 0.02) and intraoperative blood transfusion (p = 0.05) emerged as independent risk factors for POD > 1. Baseline hemoglobin emerged as a protective factor (p = 0.05) as well as SP approach (p = 0.03).

CONCLUSION

SP-RAPN holds potential to shorten hospitalization without hampering surgical outcomes. By maximizing the adoption of a RP approach and minimizing surgical invasiveness, SP robotic surgery allows to significantly expand the pool of RAPN patients that can be discharged after a single overnight stay.