Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group)

Preoperative risk calculator for the probability of completing nephron sparing for kidney cancer

PURPOSE

In absence of predictive models, preoperative estimation of the probability of completing partial (PN) relative to radical nephrectomy (RN) is invariably inaccurate and subjective. We aimed to develop an evidence-based model to assess objectively the probability of PN completion based on patients' characteristics, tumor's complexity, urologist expertise and surgical approach.

DESIGN, SETTING AND PARTICIPANTS

675 patients treated with PN or RN for cT1-2 cN0 cM0 renal mass by seven surgeons at one single experienced centre from 2000 to 2019.

OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSES

The outcome of the study was PN completion. We used a multivariable logistic regression (MVA) model to investigate predictors of PN completion. We used SPARE score to assess tumor complexity. We used a bootstrap validation to compute the model's predictive accuracy. We investigated the relationship between the outcomes and specific predictors of interest such as tumor's complexity, approach and experience.

RESULTS

Of 675 patients, 360 (53%) were treated with PN vs. 315 (47%) with RN. Smaller tumors [Odds ratio (OR): 0.52, 95%CI 0.44-0.61; P < 0.001], lower SPARE score (OR: 0.67, 95%CI 0.47-0.94; P = 0.02), more experienced surgeons (OR: 1.01, 95%CI 1.00-1.02; P < 0.01), robotic (OR: 10; P < 0.001) and open (OR: 36; P < 0.001) compared to laparoscopic approach resulted associated with higher probability of PN completion. Predictive accuracy of the model was 0.94 (95% CI 0.93-0.95).

CONCLUSIONS

The probability of PN completion can be preoperatively assessed, with optimal accuracy relaying on routinely available clinical information. The proposed model might be useful in preoperative decision-making, patient consensus, or during preoperative counselling.

PATIENT SUMMARY

In patients with a renal mass the probability of completing a partial nephrectomy varies considerably and without a predictive model is invariably inaccurate and subjective. In this study we build-up a risk calculator based on easily available preoperative variables that can predict with optimal accuracy the probability of not removing the entire kidney.

Long-Term Oncologic Outcomes of Off-Clamp Robotic Partial Nephrectomy for Cystic Renal Tumors: A Propensity Score Matched-Pair Comparison of Cystic versus Pure Clear Cell Carcinoma

Few data are available on survival outcomes of partial nephrectomy performed for cystic renal tumors. We present the first long-term oncological outcomes of cystic (cystRCC) versus pure clear cell renal cell carcinoma (ccRCC) in a propensity score-matched (PSM) analysis. Our "renal cancer" prospectively maintained database was queried for "cystRCC" or "ccRCC" and "off-clamp robotic partial nephrectomy" (off-C RPN). The two groups were compared for age, gender, tumor size, pT stage, and Fuhrman grade. A 1:3 PSM analysis was applied to reduce covariate imbalance to <10% and two homogeneous populations were generated. Student t- and Chi-square tests were used for continuous and categorical variables, respectively. Ten-year oncological outcomes were compared between the two cohorts using log-rank test. Univariable Cox regression analysis was used to identify predictors of disease progression after RPN. Out of 859 off-C RPNs included, 85 cases were cystRCC and 774 were ccRCC at histologic evaluation. After applying the PSM analysis, two cohorts were selected, including 64 cystRCC and 170 ccRCC. Comparable 10-year cancer-specific survival probability (95.3% versus 100%, p = 0.146) was found between the two cohorts. Conversely, 10-year disease-free survival probability (DFS) was less favorable for pure ccRCC than cystRCC (66.69% versus 90.1%, p = 0.035). At univariable regression analysis, ccRCC histology was the only independent predictor of DFS probability (HR 2.96 95% CI 1.03-8.47, p = 0.044). At the 10-year evaluation, cystRCC showed favorable oncological outcomes after off-C RPN. Pure clear cell variant histology displayed a higher rate of disease recurrence than cystic lesions.

Preoperative Tyrosine Kinase Inhibitors Before Percutaneous Cryoablation for Clinical T1b Renal Tumors

Purpose To treat renal cell carcinoma, local ablative therapy is a viable alternative treatment option. Traditionally, cryoablation has been used for the treatment of T1a renal tumors. However, recent technological developments have expanded its application to encompass select T1b renal tumors. Here, we present a retrospective study of the utilization of preoperative tyrosine kinase inhibitors (TKIs) to induce tumor shrinkage and achieve favorable outcomes in percutaneous cryoablation (PCA). Methods We retrospectively evaluated the data from nine patients with clinical T1b renal tumors who underwent PCA. Six patients with TKI pretreatment at our institution between 2016 and 2018 were included in the study. We evaluated the safety and efficacy of preoperative TKIs prior to PCA. Results All patients received axitinib with a median treatment duration of 80.5 days (IQR: 49-85). All patients experienced tumor shrinkage (median: 13.5 mm; IQR: 7-16); five experienced downstaging to T1a following tumor shrinkage. There were no severe adverse events (common terminology criteria for adverse events (CTCAE) grade ≥ 3) in TKIs. After the discontinuation of TKIs for two weeks, all PCA procedures were performed successfully without any severe complications. During a median follow-up of 46 months, no local recurrence was observed in any of these cases. Conclusion In cases with large renal tumors, TKI pretreatment prior to PCA had potential benefits in terms of tumor shrinkage and long-term local control rate. Further well-designed studies in larger populations are needed to validate our findings.

Comparison of Perioperative, Functional, and Oncologic Outcomes of Open vs. Robot-Assisted Off-Clamp Partial Nephrectomy: A Propensity Scored Match Analysis

Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan-Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; p < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; p = 0.03), lower postoperative Clavien-Dindo ≤ 2 complications (1.3% vs. 18.3%, p < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, p = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09-4.46, p = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan-Meier analysis, no differences were observed between the two groups in terms of OS (log-rank p = 0.451), CSS (log-rank p = 0.476), DFS (log-rank p = 0.678), and MFS (log-rank p = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement.

Assessing the perioperative outcomes of abdominal drain omission after robot-assisted partial nephrectomy

The study aimed to evaluate the impact of abdominal drain placement (vs. omission) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN), focusing on complications, time to canalization, deambulation, and pain management. A prospectively-maintained institutional database was queried to get data of patients who underwent RAPN for renal masses between January 2018 and May 2023 at our Institution. Baseline, surgical, and postoperative data were collected. Retrieved patients were stratified based upon placement of abdominal drain (Y/N). Descriptive analyses comparing the two groups were conducted as appropriate.77 After adjusting for potential confounders, a logistic regression analysis was conducted to evaluate significant predictors of any grade and "major" complications. 342 patients were included: 192 patients in the "drain group" versus 150 patients in the "no-drain" group. Renal masses were larger (p < 0.001) and at higher complexity (RENAL score, p = 0.01), in the drain group. Procedures in the drain group had statistically significantly longer operative time, ischemia time, and higher blood loss (all p-values < 0.001). The urinary collecting system was more likely involved compared to the no-drain group (p = 0.01). At multivariate analysis, abdominal drainage was not a significant predictor of any grade (OR 0.79, 95%CI 0.33-1.87) and major postoperative complications (OR 3.62, 95%CI 0.53-9.68). Patients in the drain group experienced a statistically significantly higher hemoglobin drop (p < 0.01). Moreover, they exhibited statistically significant higher paracetamol consumption (p < 0.001) and need for additional opioids (p = 0.02). In summary, the study results suggest the safety of omitting drain placement and remark on the need for personalized decision-making, which considers patient and procedural factors.

Indocyanine green-marked fluorescence-guided off-clamp versus intraoperative ultrasound-guided on-clamp robotic partial nephrectomy: Outcomes on surgical procedure

Objectives

To compare surgical and functional outcomes between off-clamp robot-assisted partial nephrectomy with indocyanine-green tumour marking through preliminary superselective embolization and on-clamp robot-assisted partial nephrectomy with intraoperative ultrasound identification of the renal mass.

Material and methods

One hundred and forty patients with a single renal mass underwent indocyanine-green fluorescence-guided off-clamp robot-assisted partial nephrectomy with preoperative superselective embolization (Group A, 70 patients) versus intraoperative ultrasound-guided on-clamp robot-assisted partial nephrectomy without embolization (Group B, 70 patients). We assessed operative time, intraoperative blood loss, complications, length of stay, renal function, need for ancillary procedures and blood transfusions.

Results

Mean tumour size was 24 versus 25 mm in Group A versus Group B (p = 0.19). Mean operative time was 86.5 versus 121.8 min (p = 0.02), mean blood loss was 72.8 versus 214.2 mL (p = 0.02), and mean haemoglobin drop on postoperative day 1 was 1.1 versus 2.6 g/dL (p = 0.04) in Group A versus Group B. One-month creatinine, hospital stay and enucleated tumour volume were comparable. Ten postoperative complications occurred in Group A (13.3%) and 11 in Group B (15.3%). Following superselective embolization, no patients required blood transfusions versus two patients in Group B. Postoperative selective renal embolization was needed in one case per group.

Conclusions

Preoperative superselective embolization of a renal mass with indocyanine-green before off-clamp robot-assisted partial nephrectomy significantly reduces operative time and intraoperative blood loss compared to on-clamp intraoperative ultrasound-guided robot-assisted partial nephrectomy. A longer follow-up is needed to establish the effect on renal function.

3D Model Artificial Intelligence-Guided Automatic Augmented Reality Images during Robotic Partial Nephrectomy

More than ever, precision surgery is making its way into modern surgery for functional organ preservation. This is possible mainly due to the increasing number of technologies available, including 3D models, virtual reality, augmented reality, and artificial intelligence. Intraoperative surgical navigation represents an interesting application of these technologies, allowing to understand in detail the surgical anatomy, planning a patient-tailored approach. Automatic superimposition comes into this context to optimally perform surgery as accurately as possible. Through a dedicated software (the first version) called iKidney, it is possible to superimpose the images using 3D models and live endoscopic images during partial nephrectomy, targeting the renal mass only. The patient is 31 years old with a 28 mm totally endophytic right-sided renal mass, with a PADUA score of 9. Thanks to the automatic superimposition and selective clamping, an enucleoresection of the renal mass alone was performed with no major postoperative complication (i.e., Clavien-Dindo < 2). iKidney-guided partial nephrectomy is safe, feasible, and yields excellent results in terms of organ preservation and functional outcomes. Further validation studies are needed to improve the prototype software, particularly to improve the rotational axes and avoid human help. Furthermore, it is important to reduce the costs associated with these technologies to increase its use in smaller hospitals.

Assessing the Trade-off Between the Safety and Effectiveness of Off-clamp Robotic Partial Nephrectomy for Renal Masses with a High RENAL Score: A Propensity Score-matched Comparison of Perioperative and Functional Outcomes in a Multicenter Analysis

BACKGROUND

Tumors with a high nephrometry score represent a challenging surgical scenario for which robotic partial nephrectomy (RPN) is a primary option in expert hands.

OBJECTIVE

To compare perioperative and functional outcomes of off-clamp and on-clamp RPN in patients with renal masses with a high RENAL score (≥9).

DESIGN, SETTING, AND PARTICIPANTS

For this retrospective analysis, an RPN data set including 1604 patients treated at three institutions between 2003 and 2021 was queried for cases with a RENAL score ≥9.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used 1:1 propensity score matching (PSM) to select a cohort in which imbalances between the off-clamp and on-clamp groups were minimized. We used χ2 and Student t tests to compare categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare the probability of having an estimated glomerular filtration rate (eGFR) ≥45 ml/min during follow-up. Univariable and multivariable analyses were performed to identify predictors of a trifecta outcome (negative surgical margin status, no Clavien-Dindo grade ≥3 complications, eGFR decline ≤30%) and of retaining eGFR ≥45 ml/min over time.

RESULTS AND LIMITATIONS

From an overall cohort of 354 patients (142 on-clamp, 212 off-clamp), a homogeneous PSM cohort of 78 patients in each group was selected (p ≥ 0.17). In the PSM cohort, operative time was significantly shorter in the off-clamp group (p < 0.001). There were no differences between the groups in the rates of severe complications (p = 0.32) and positive surgical margins (p = 0.24). The rate of trifecta achievement was significantly higher in the off-clamp group (83.3% vs 67.9%; p = 0.03). Warm ischemia time >20 min was independently negatively associated with trifecta achievement (odds ratio 0.32, 95% confidence interval 0.14-0.74). Moreover, the off-clamp group had a significantly higher probability of retaining eGFR ≥45 ml/min over time (3 yr: 95.9% vs 81.6%; p = 0.03); every 1-min increase in warm ischemia time reduced this probability by 1.3%.

CONCLUSIONS

We found a favorable trade-off between the benefits and risks of off-clamp RPN, with similar perioperative outcomes and a net benefit in terms of trifecta achievement and long-term renal function outcomes in comparison to on-clamp RPN.

PATIENT SUMMARY

The complexity of surgery for kidney tumors can be assessed using the RENAL score, which is a measure of the location and size of a kidney tumor. In a multicenter series of patients with tumors with a high RENAL score, we compared outcomes between strategies with (on-clamp) and without (off-clamp) clamping of kidney blood vessels during robot-assisted removal of part of the affected kidney. We found that off-clamp surgery results in better postoperative kidney function.

A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors

Objective

Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors.

Methods

A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes.

Results

After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.

Conclusion

Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

Trends in the surgical management of kidney cancer by tumor stage, treatment modality, facility type, and location

Partial nephrectomy (PN) is an alternative to radical nephrectomy (RN) in the appropriate localized renal tumor. The scope of PN has expanded over time and, since the advent and proliferation of minimally invasive surgery, more surgeons have access to and have been trained in laparoscopic and robotic technology. Amid the changing surgical landscape, we sought to characterize the trends in management by cancer stage, institution type, and geographic location using the National Cancer Database (NCDB). We queried the NCDB for patients with kidney cancer from 2004 to 2019. Overall, 241,311 patients who underwent PN or RN were included in the study. The nephrectomy approach was categorized as robotic partial (RPN), robotic radical (RRN), laparoscopic partial (LPN), laparoscopic radical (LRN), open or unspecified partial (OPN), and open or unspecified radical (ORN). The categorical variables were presented as frequency and percentages. Overall, there was an increase in the utilization of robotic approaches from 2010 to 2019. For cT1 tumors, the use of RPN and RRN increased from 14.27 to 33.06% and 5.24% to 19.63%, respectively. The use of ORN for cT2 and cT3 tumors declined, with rates dropping from 54.71 to 10.76% and 64.71 to 46.64%, respectively. Conversely, the utilization of RRN rose during this period. However, ORN remained the most common approach for cT3 tumors. The use of RPN increased across different facility types, with the highest utilization observed in academic/research programs. The use of ORN for cT2 and cT3 tumors declined across facility types, although it remained most prevalent in community cancer programs. The use of robot-assisted surgery to treat localized renal cancer increased in the US between 2010 and 2019 across all stages of disease. RPN became the most used approach for cT1 disease, while LRN was preferred for cT2 disease. ORN remained the approach of choice for cT3 disease throughout the study period. Trends in facility type and geographic location largely mirrored the overall trends.

Open versus robot-assisted partial nephrectomy for highly complex renal masses: a meta-analysis of perioperitive and functional outcomes

Robot-assisted partial nephrectomy (RAPN) is increasingly being used for the complex surgical management of renal masses. The comparison of RAPN with open partial nephrectomy (OPN) has not yet led to a unified conclusion with regard to perioperative outcomes. To conduct a systematic review and meta-analysis of the literature on the perioperative outcomes of RAPN compared with OPN. We performed a systematic search in PubMed, Embase, Web of Science, and Cochrane Library database for randomized control trials (RCTs) and non-RCTs that compare OPN to RAPN. The primary outcomes included perioperative, functional and oncologic. The odds ratio (OR) and weighted mean difference (WMD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CIs). Five studies, comprising 936 patients, were included in the meta-analysis. Our findings indicated that there were no significant differences in blood loss, minor complication rate, eGFR decline from baseline, positive surgical margin, and ischemia time between OPN and RAPN. However, RAPN was associated with a shorter hospital stay (WMD 1.64 days, 95% CI - 1.17 to 2.11; p < 0.00001), lower overall complication rate (OR 1.72, 95% CI 1.21-2.45; p < 0.002), lower transfusion rate (OR 2.64, 95% CI 1.39-5.02; p = 0.003) and lower major complication rate (OR 1.76, 95% CI 1.11-2.79; p < 0.02) compared to OPN. Additionally, the operation time for OPN was shorter than that for RAPN (WMD - 10.77 min, 95% CI - 18.49 to - 3.05, p = 0.006). In comparison with OPN, RAPN exhibits better results in terms of hospital stay, overall complications, blood transfusion rate, and major complications, with no significant difference in intraoperative blood loss, minor complications, PSM, ischemia time, and short-term postoperative eGFR decline. However, the operation time of OPN is slightly shorter than that of RAPN.

Does tumor rupture during robot-assisted partial nephrectomy have an impact on mid-term tumor recurrences?

BACKGROUND

Intraoperative kidney tumor rupture (TR) can occur during robot-assisted partial nephrectomy (RAPN) in daily clinical practice, but there are no solid guidelines on the management and implications of it. The purpose of the study was to investigate the impact of TR on tumor recurrences, what a surgeon should do if this adverse event occurs, and how to avoid it.

PATIENTS AND METHODS

We retrospectively analyzed the first 100 patients who underwent RAPN at University Medical Centre Ljubljana, between 2018 and 2021. Patients were stratified into 2 groups (TR and no-TR) and were compared according to patient, tumor, pathologic, perioperative and postoperative characteristics and tumor recurrences, using the Mann-Whitney U test and chi-squared test.

RESULTS

Of the 100 patients, 14 had TR (14%); this occurred in tumors with higher RENAL nephrometry scores (P = 0.028) and mostly with papillary renal cell carcinomas (P = 0.043). Median warm ischemia time was longer for the TR group (22 vs. 15 min, P = 0.026). In terms of studied outcomes, there were no cases of local or distant recurrence after a median observation time of 39 months (interquartile range, 31-47 months) in both groups. We observed positive surgical margins on the final oncologic report in one case in the no-TR group.

CONCLUSIONS

Tumor rupture during RAPN seems to be of no mid-term oncologic importance. According to presented results, we would recommend surgeons to proceed with tumor resection if this event occurs and abstain from conversion to radical nephrectomy or open partial nephrectomy. However, more similar cases should be studied to make more solid conclusions.

Impact of renal sinus protrusions on achieving trifecta in robot-assisted partial nephrectomy

Objective

The objective of this work is to assess the relationship between the morphological characteristics of a central tumour and the perioperative outcomes of robot-assisted partial nephrectomy (RAPN).

Subjects and Methods

We retrospectively analysed the data from 186 patients with central tumours involving the renal sinus, who underwent RAPN in a single-centre study between February 2015 and June 2022. All cases were assigned a RENAL nephrometry score based on preoperative images. The shape of the protruding portion of the tumour was classified into four types: 'flat', 'spherical', 'single-hump', and 'complex-hump', and was independently assessed by two readers. The trifecta is defined as the warm ischemia time within 25 min, negative surgical margins, and no major postoperative complications. Univariate and multivariate analyses were performed to identify the factors associated with the failing trifecta.

Results

Trifecta was achieved in 113 cases (60.8%), and the achievement rate in flat, spherical, single-hump, and complex-hump types was 83.3%, 74.5%, 64.3%, and 21.3%, respectively. Prolonged warm ischemia time was the primary cause of the failure to achieve the trifecta. The rate of positive surgical margins and upstage to pathological T3a was greater for complex humps while the rate of major complications and postoperative GFR preservation did not differ between shapes. On multivariate analysis for failing trifecta achievement, the complex-hump protrusion was found to be an independent positive predictor (odds ratio: 15.8; p < 0.001), whereas the height and width of protrusion were not significantly related.

Conclusions

The degree of difficulty varied among central tumours, and it was not possible to precisely measure it with existing scoring systems. Complex-hump protrusions strongly correlate with failure to achieve the trifecta. Preoperative assessment of the morphology of protrusion is useful for predicting outcomes.

How far has robot-assisted partial nephrectomy reached?

Nephron-sparing surgery is the standard treatment for small renal mass (SRM). Nephron-sparing surgery has evolved from an open to a minimally invasive technique. Robot-assisted partial nephrectomy (RAPN) is the latest technique in this field and is reported to be safe and feasible, showing oncologically and functionally superior or compatible results compared with open and laparoscopic partial nephrectomy for SRM. This is not limited to only SRM but also applies to large and complex renal masses and other challenging situations. RAPN showed good oncological and functional outcomes for ≥clinical T2 renal tumors, complex renal masses (PADUA score ≥10, RENAL score ≥10), hilar renal tumors, and multiple renal tumors. In addition, the outcomes of RAPN in these challenging cases were not inferior to those in conventional cases. RAPN could also be applied to a number of challenging cases in which the open technique was considered first. RAPN showed good results in patients with a solitary kidney, horseshoe kidney, and in repeat surgeries. Furthermore, RAPN could be safely performed on obese, elderly, and pediatric patients. Finally, this review evaluates efficiency and utility of RAPN based on the results of challenging cases of renal masses and to project the future of RAPN.

Prediction of Postoperative Creatinine Levels by Artificial Intelligence after Partial Nephrectomy

Background and Objectives: Multiple factors are associated with postoperative functional outcomes, such as acute kidney injury (AKI), following partial nephrectomy (PN). The pre-, peri-, and postoperative factors are heavily intertwined and change dynamically, making it difficult to predict postoperative renal function. Therefore, we aimed to build an artificial intelligence (AI) model that utilizes perioperative factors to predict residual renal function and incidence of AKI following PN. Methods and Materials: This retrospective study included 785 patients (training set 706, test set 79) from six tertiary referral centers who underwent open or robotic PN. Forty-four perioperative features were used as inputs to train the AI prediction model. XG-Boost and genetic algorithms were used for the final model selection and to determine feature importance. The primary outcome measure was immediate postoperative serum creatinine (Cr) level. The secondary outcome was the incidence of AKI (estimated glomerular filtration rate (eGFR) < 60 mL/h). The average difference between the true and predicted serum Cr levels was considered the mean absolute error (MAE) and was used as a model evaluation parameter. Results: An AI model for predicting immediate postoperative serum Cr levels was selected from 2000 candidates by providing the lowest MAE (0.03 mg/dL). The model-predicted immediate postoperative serum Cr levels correlated closely with the measured values (R2 = 0.9669). The sensitivity and specificity of the model for predicting AKI were 85.5% and 99.7% in the training set, and 100.0% and 100.0% in the test set, respectively. The limitations of this study included its retrospective design. Conclusions: Our AI model successfully predicted accurate serum Cr levels and the likelihood of AKI. The accuracy of our model suggests that personalized guidelines to optimize multidisciplinary plans involving pre- and postoperative care need to be developed.

Comparison between minimally invasive partial nephrectomy and open partial nephrectomy for complex renal tumors: a systematic review and meta-analysis

BACKGROUND

The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy (OPN) in patients with complex renal tumors (defined as PADUA or RENAL score ≥7).

METHODS

The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, Supplemental Digital Content 1, http://links.lww.com/JS9/A394 . We conducted a systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases until October 2022. MIPN and OPN-controlled trials for complex renal tumors were included. The primary outcomes were perioperative results, complications, renal function, and oncologic outcomes.

RESULTS

A total of 2405 patients were included in 13 studies. MIPN outperformed OPN in terms of hospital stay [weighted mean difference (WMD) -1.84 days, 95% CI -2.35 to -1.33; P <0.00001], blood loss (WMD -52.42 ml, 95% CI -71.43 to -33.41; P <0.00001), transfusion rates [odds ratio (OR) 0.34, 95% CI 0.17-0.67; P =0.002], major complications (OR 0.59, 95% CI 0.40-0.86; P =0.007) and overall complications (OR 0.43, 95% CI 0.31-0.59; P <0.0001), while operative time, warm ischemia time, conversion to radical nephrectomy rates, estimated glomerular decline, positive surgical margins, local recurrence, overall survival, recurrence-free survival, and cancer-specific survival were not significantly different.

CONCLUSIONS

The present study demonstrated that MIPN was associated with a shorter length of hospital stay, less blood loss, and fewer complications in treating complex renal tumors. MIPN may be considered a better treatment for patients with complex tumors when technically feasible.

A comprehensive assessment of frailty status on surgical, functional and oncologic outcomes in patients treated with partial nephrectomy-A large, retrospective, single-center study

BACKGROUND

Partial nephrectomy (PN) is a challenging procedure, which can be associated with severe complications. In consequence, the search for accurate and independent indicators of unfavorable surgical outcomes appears warranted. We aimed at evaluating the impact of frailty status on surgical, functional and oncologic outcomes in patients undergoing PN for renal cell carcinoma (RCC).

METHODS

A retrospective, single-center study including 1,282 patients treated with PN for clinically localized cT1 RCC was performed. The modified Frailty Index (mFI) was used to assess preoperative frailty. Multivariable logistic, Poisson and linear regression analyses(MVA) tested the effect of frailty on complications, acute kidney injury(AKI), renal function decline after PN. Cumulative incidence and competing-risk analyses investigated survival outcomes.

RESULTS

Of 1,282 patients, 220 (17%) were frail. Overall, 982 (76%) vs. 123 (9.6%) vs. 171 (13%) patients underwent open vs. laparoscopic vs. robot-assisted PN. Median follow-up was 66 (IQR: 35-107) months. At MVA, frailty status predicted increased risk of complications [Odds ratio (OR): 1.46, 95%CI 1.17-1.84; P < 0.001]. Moreover, frail patients were at higher risk of postoperative AKI (OR: 1.95, 95%CI 1.13-3.35; P = 0.01). In frail patients, renal function permanently decreased over time (P = 0.01) without any renal function plateau or improvement during the follow-up, which were instead observed in the nonfrail cohort. At competing-risks analyses, frailty status predicted higher risk of other-cause mortality [Hazard ratio (HR): 1.67, 95%CI 1.05-2.66; P = 0.02], but not of cancer-specific mortality (P = 0.3).

CONCLUSIONS

Frailty status predicts higher risk of adverse surgical outcomes after PN. Moreover, greater renal function decline was observed in frail patients, compared with nonfrail patients. Finally, the risk of OCM significantly overcomes the risk of dying due to RCC in frail patients.

Molecular Imaging Diagnosis of Renal Cancer Using 99mTc-Sestamibi SPECT/CT and Girentuximab PET-CT-Current Evidence and Future Development of Novel Techniques

Novel molecular imaging opportunities to preoperatively diagnose renal cell carcinoma is under development and will add more value in limiting the postoperative renal function loss and morbidity. We aimed to comprehensively review the research on single photon emission computed tomography/computed tomography (SPECT/CT) and positron emission tomography computed tomography (PET-CT) molecular imaging and to enhance the urologists' and radiologists' knowledge of the current research pattern. We identified an increase in prospective and also retrospective studies that researched to distinguish between benign and malignant lesions and between different clear cell renal cell carcinoma subtypes, with small numbers of patients studied, nonetheless with excellent results on specificity, sensitivity and accuracy, especially for ^99mTc-sestamibi SPECT/CT that delivers quick results compared to a long acquisition time for girentuximab PET-CT, which instead gives better image quality. Nuclear medicine has helped clinicians in evaluating primary and secondary lesions, and has lately returned with new and exciting insights with novel radiotracers to reinforce its diagnostic potential in renal carcinoma. To further limit the renal function loss and post-surgery morbidity, future research is mandatory to validate the results and to clinically implement the diagnostic techniques in the context of precision medicine.

3D-Image guided robotic-assisted partial nephrectomy: a multi-institutional propensity score-matched analysis (UroCCR study 51)

PURPOSE

Robot-assisted partial nephrectomy (RAPN) is a difficult procedure with risk of significant perioperative complications. The objective was to evaluate the impact of preoperative planning and intraoperative guidance with 3D model reconstructions on perioperative outcomes of RAPN.

METHODS

We conducted a retrospective analysis of all patients who underwent RAPN for kidney tumor by three high-volume expert surgeons from academic centers. Clinical data were collected prospectively after written consent into the French kidney cancer network database UroCCR (CNIL-DR 2013-206; NCT03293563). Our cohort was divided into two groups: 3D-Image guided RAPN group (3D-IGRAPN) and control group. A propensity score according to age, pre-operative renal function and RENAL tumor complexity score was used. Both surgical techniques were compared in terms of perioperative outcomes.

RESULTS

The initial study cohort included 230 3D-IGRAPN and 415 control RAPN. Before propensity-score matching, patients in the 3D-IGRAPN group had a larger tumor (4.3 cm vs. 3.5 cm, P < 0.001) and higher RENAL complexity score (9 vs. 8, P < 0.001). Following propensity-score matching, there were 157 patients in both groups. The rate of major complications was lower for patients in the 3D-IGRAPN group (3.8% vs. 9.5%, P = 0.04). The median percentage of eGFR variation recorded at first follow-up was lower in the 3D-IGRAPN group (- 5.6% vs. - 10.5%, P = 0.002). The trifecta achievement rate was higher in the 3D-IGRAPN group (55.7% vs. 45.1%; P = 0.005).

CONCLUSION

Three-dimensional kidney reconstructions use for pre-operative planning and intraoperative surgical guidance lowers the risk of complications and improve perioperative clinical outcomes of RAPN.

Identification of predictive factors for outcomes after robot-assisted partial nephrectomy based on three-dimensional reconstruction of preoperative enhanced computerized tomography

Background

Information from the RENAL score is limited. This study aimed to identify new parameters based on three-dimensional (3D) reconstruction of preoperative enhanced computerized tomography (CT) for predicting outcomes after robot-assisted partial nephrectomy (RPN).

Materials and methods

The records of kidney cancer patients who underwent RPN at Tongji Hospital from March 2015 to July 2019 were reviewed. Demographic data, laboratory examinations, postoperative hospitalization time, and enhanced CT were retrospectively collected. Some tumor parameters were obtained from 3D reconstruction of CT data. The association between these predictive factors and outcomes after RPN was analyzed.

Results

A larger tumor bed area (TBA) was associated with a longer warm ischemia time (WIT) (P-value <0.001) and tumor resection time (P-value <0.001). Moreover, TBA was significantly associated with the elevation of postoperative creatinine (P-value = 0.005). TBA (P = 0.008), distance from the tumor to the first bifurcation of the renal artery (DTA) (P <0.034), and RENAL score (P = 0.005) were significantly associated with WIT in univariate logistic regression. In multivariate logistic regression, TBA (P = 0.026) and DTA (P = 0.048) were independent risk factors for prolonged WIT (over 25 min). The predictive effect of the combination of TBA, DTA, and RENAL score was higher than the predictive effect of RENAL score alone for WIT (area under curve: 0.786 versus 0.72).

Conclusion

TBA and DTA are independently associated with the WIT of RPN, which provides additional assessment value for the complexity of kidney cancer in RPN over the RENAL score.

Recent Advances in the Management of Localized and Locally Advanced Renal Cell Carcinoma: A Narrative Review

Purpose

To review the current status of surgical and procedural treatments for renal cell carcinoma (RCC), focusing on oncological and functional outcomes, and the use of techniques for advanced disease over the last 10 years.

Findings

Partial nephrectomy (PN) has become the reference standard for most T1 and T2 masses. In cT2 RCC, PN exhibits oncological equivalence and improved functional outcomes compared to radical nephrectomy (RN). Additionally, emerging data suggest that PN may be used to treat cT3a RCC. The robot-assisted platform is increasingly used to treat locally advanced RCC. Studies suggest safety and feasibility of robotic RN and robotic inferior vena cava tumor thrombectomy. Additionally, single-port robot-assisted laparoscopic approaches are comparable to multiport approaches in select patients. Long-term data show that cryoablation, radiofrequency ablation, and microwave ablation are equipotent in management of small renal masses. Emerging data suggest that microwave may effectively treat cT1b masses.

Assessing the impact of socio-economic determinants on access to care, surgical treatment options and outcomes among patients with renal mass: Insight from the universal healthcare system

OBJECTIVE

To assess whether socio-economic disparities exist on access to care, treatment options and outcomes among patients with renal mass amenable of surgical treatment within the universal healthcare system.

METHODS

Data of consecutive patients submitted to partial nephrectomy (PN) or radical nephrectomy (RN) at our Institution between 2017 and 2020 were retrospectively evaluated. Patients were grouped according to their income level (low, intermediate, and high) based on the Indicator of Equivalent Economic Situation national criterion. Survival analysis was performed. Cox regression models were employed to analyse the impact of socio-economic variables on survival outcomes.

RESULTS

One thousand forty-two patients were included (841 PN and 201 RN). Patients at the lowest income level were found more likely symptomatic and with a higher pathological tumour stage in the RN cohort (p > 0.05). The guidelines adherence on surgical indication rate as well as the access to minimally invasive surgery did not differ according to patient's income level in both cohorts (p > 0.05). Survival curves were comparable among the groups. Cox regression analysis showed that none of the included socio-economic variables was associated with survival outcomes in our series.

CONCLUSIONS

Universal healthcare system may increase the possibility to ensure egalitarian treatment modalities for patients with renal cancer.

3D renal model for surgical planning of partial nephrectomy: A way to improve surgical outcomes

OBJECTIVE

to evaluate the impact of 3D model for a comprehensive assessment of surgical planning and quality of partial nephrectomy (PN).

MATERIALS AND METHODS

195 patients with cT1-T2 renal mass scheduled for PN were enrolled in two groups: Study Group (n= 100), including patients referred to PN with revision of both 2D computed tomography (CT) imaging and 3D model; Control group (n= 95), including patients referred to PN with revision of 2D CT imaging. Overall, 20 individuals were switched to radical nephrectomy (RN). The primary outcome was the impact of 3D models-based surgical planning on Trifecta achievement (defined as the contemporary absence of positive surgical margin, major complications and ≤30% postoperative eGFR reduction). The secondary outcome was the impact of 3D models on surgical planning of PN. Multivariate logistic regressions were used to identify predictors of selective clamping and Trifecta's achievement in patients treated with PN (n=175).

RESULTS

Overall, 73 (80.2%) patients in Study group and 53 (63.1%) patients in Control group achieved the Trifecta (p=0.01). The preoperative plan of arterial clamping was recorded as clampless, main artery and selective in 22 (24.2%), 22 (24.2%) and 47 (51.6%) cases in Study group vs. 31 (36.9%), 46 (54.8%) and 7 (8.3%) cases in Control group, respectively (p<0.001). At multivariate logistic regressions, the use of 3D model was found to be independent predictor of both selective or super-selective clamping and Trifecta's achievement.

CONCLUSION

3D-guided approach to PN increase the adoption of selective clamping and better predict the achievement of Trifecta.

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

The application of internal traction technique in retroperitoneal robot-assisted partial nephrectomy for renal ventral tumors

Background

For patients with prior intra-abdominal surgery or multiple arteries, the retroperitoneal robot-assisted partial nephrectomy (rRAPN) is a better choice. The renal ventral tumor poses an additional challenge due to poor tumor exposure. This study is determined to assess the feasibility of an internal traction technique (ITT) in rRAPN for the management of renal ventral tumors.

Methods

From November 2019 to March 2021, a total of 28 patients with renal ventral tumor underwent rRAPN. All patients had prior abdominal surgery or multiple arteries. The ITT group (20 patients), which improved the tumor exposure by traction of the kidney with suture, was compared with the traditional technique group (8 patients) in terms of warm ischemia time, estimated blood loss and postoperative hospital stay, retroperitoneal drainage, R.E.N.A.L. score, and serum creatinine. Differences were considered significant when P < 0.05.

Results

All rRAPN surgeries were successful without conversion to radical nephrectomy or open partial nephrectomy. The warm ischemia time was lower in the ITT group (17.10 min vs. 24.63 min; P < 0.05). Estimated blood loss in the traditional technique group was 324.88 ± 79.42 mL, and in the ITT group, it was 117.45±35.25 mL (P < 0.05). No significant differences with regard to postoperative hospital stay, retroperitoneal drainage, R.E.N.A.L. score, and serum creatinine were observed between both groups. Surgical margins were negative and no intraoperative complications occurred in all the patients. After 10 months of follow-up, no recurrence or metastasis occurred in all cases.

Conclusion

ITT is a feasible, safe, and valid procedure in rRAPN for renal ventral tumors. Application of ITT improved the exposure and reduces warm ischemic time in comparison with the conventional procedure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02684-1.

Potential benefit of lymph node dissection during radical nephrectomy for kidney cancer: A review and critical analysis of current literature

Objective

The role of lymph node dissection (LND) is still controversial in patients with renal cell carcinoma undergoing surgery. We aimed to provide a comprehensive review of the literature about the effect of LND on survival, prognosis, surgical outcomes, as well as patient selection and available LND templates.

Methods

Recent literature (from January 2011 to December 2021) was assessed through PubMed and MEDLINE databases. A narrative review of most relevant articles was provided.

Results

The frequencies in which LNDs are being carried out are decreasing due to an increase in minimally invasive and nephron sparing surgery. Moreover, randomized clinical trials and meta-analyses failed to show any survival advantage of LND versus no LND. However, retrospective studies suggest a survival benefit of LND in high-risk patients (bulky tumors, T3-4 stage, and cN1 patients). Moreover, extended LND might provide important staging information, which could be of interest for adjuvant treatment planning.

Conclusion

No level 1 evidence of any survival advantage deriving from LND is currently available in literature. Thus, the role of LND is limited to staging purposes. However, low grade evidence suggests a possible role of LND in high-risk patients. Randomized clinical trials are warranted to corroborate these findings.

Cone-beam CT-guided tagging of endophytic renal tumors with indocyanine green via trans-arterial selective delivery in patients undergoing robot-assisted partial nephrectomy with near infrared fluorescence imaging

PURPOSE

To evaluate the safety, efficacy, and clinical impact of pre-operative cone-beam CT (CBCT)-guided selective embolization of endophytic renal tumors with the fluorescent dye indocyanine green (ICG) and lipiodol in patients undergoing robot-assisted partial nephrectomy (RAPN) using near infrared fluorescent imaging (NIFI).

MATERIALS AND METHODS

Patients with renal endophytic tumors eligible for RAPN and trans-arterial embolization with ICG and lipiodol were prospectively included. Technical success was defined as the completion of the embolization procedure. Radiographic success, defined as the lipiodol accumulation into the nodule, was classified as poor, moderate, good, and optimal based on post-embolization CBCT. Surgical visibility of the tumors during RAPN with the use of NIFI was classified as: not visible, visible with poorly defined margins, and visible with well-defined margins.

RESULTS

Forty-one patients underwent pre-operative selective embolization. Technical success was 100%. Lipiodol accumulation at CBCT was poor in 2/41 (4.9%), moderate in 6/41 (14.6%), good in 25/41 (61.0%), and optimal in 8/41 patients (19.5%). During RAPN with NIFI, tumors were visible with well-defined margins in 26/41 (63.4%), visible with blurred margins in 14/41 (34.1%) and not visible in 1/41 (2.4%) of cases. There were no adverse events following endovascular embolization.

CONCLUSION

Pre-operative trans-arterial super-selective embolization of endophytic renal tumors with ICG and lipiodol in patients undergoing RAPN is safe and effective, allowing accurate intraoperative visualization and resection of endophytic tumors.

Impact of Trifecta definition on rates and predictors of "successful" robotic partial nephrectomy for localized renal masses: results from the Surface-Intermediate-Base Margin Score International Consortium

BACKGROUND

Over the years, five different Trifecta score definitions have been proposed to optimize the framing of "success" in partial nephrectomy (PN) field. However, such classifications rely on different metrics. The aim of the present study was to explore how the success rate of robotic PN, as well as its drivers, vary according to the currently available definitions of Trifecta.

METHODS

Data from consecutive patients with cT1-2N0M0 renal masses treated with robotic PN at 16 referral centers from September 2014 to March 2015 were prospectively collected. Trifecta rate was defined for each of the currently available definitions. Multivariable logistic regression analysis was used to evaluate possible predictors of "Trifecta failure" according to the different adopted formulation.

RESULTS

Overall, 289 patients met the inclusion criteria. Among the definitions, Trifecta rates ranged between 66.4% and 85.9%. Multivariable analysis showed that predictors for "Trifecta failure" were mainly tumor-related (i.e. tumor's nephrometry) for those Trifecta scores relying on WIT as a surrogate metric for postoperative renal function deterioration (definitions 1,2), while mainly surgery-related (i.e. ischemia time and excision strategy) for those including the percentage change in postoperative eGFR as the functional cornerstone of Trifecta (definitions 3-5).

CONCLUSIONS

There was large variability in rates and predictors of "unsuccessful PN" when using different Trifecta scores. Further research is needed to improve the value of the Trifecta metrics, integrating them into routine patient counseling and standardized assessment of surgical quality across institutions.

Robotic partial nephrectomy for management of renal mass in patients with a solitary kidney: can we expand the indication to T2 and T3 disease?

BACKGROUND

Management of complex renal masses is challenging in a solitary kidney setting. We retrospectively compared oncological and renal functional outcomes between robotic and open partial nephrectomy (PN) in patients with a pT2-pT3 renal mass and a solitary kidney.

METHODS

From a multi-institutional series, we identified 20 robotic partial nephrectomies (RPN) and 15 open partial nephrectomies (OPN) patients confirmed to have a pT2 or pT3 renal cancer. Surgeries were performed between January 2012 and July 2019. Patients with familial renal cell carcinoma, prior ipsilateral PN, or multiple ipsilateral synchronous tumors were excluded from the analysis. Baseline characteristics, perioperative and postoperative outcomes were compared using χ² test, Fisher's Exact Test, Mann-Whitney U Test, and Student's t-test.

RESULTS

Baseline characteristics were comparable. Cold ischemia was utilized more in the open group (92.9% vs. 15.8%, P<0.001). OPN group had a longer ischemia time (48.9 min vs. 27.3 min, P<0.001), a higher major complication rate (38.5% vs. 11.1%, P=0.009), and a higher length of stay was (5 vs. 3.5 days, P=0.023). Positive surgical margin rate was comparable (20% OPN vs. 15% RPN; P=1.000). At a mean follow up of 21 months local recurrence rates (1 OPN vs. 2 RPN, P=1.000) were comparable, chronic kidney disease upstaging rate (46.7% OPN vs. 45.0% RPN, P=0.922) and estimated glomerular filtration rate preservation at one year (75.2%% in OPN vs. 79.1% RPN, P=0.707) were comparable.

CONCLUSIONS

In select cases and experienced hands, the robotic approach offers a reasonable alternative to open surgery in patients with pT2 and pT3 tumors and a solitary kidney.

The Impact of Postoperative Renal Function Recovery after Laparoscopic and Robot-Assisted Partial Nephrectomy in Patients with Renal Cell Carcinoma

Background and objectives: This study aimed to evaluate the association between warm ischemic time (WIT) and postoperative renal function using Trifecta achievement in patients with renal cell carcinoma (RCC) who underwent robotic (RAPN) or laparoscopic partial nephrectomy (LPN). Materials and Methods: We conducted a retrospective multicenter cohort study of patients with RCC who underwent RAPN (RAPN group) or LPN (LPN group) at three institutions in Japan between March 2012 and October 2021. The primary endpoints were the rate of trifecta achievement in both surgical techniques and the association between WIT and recovery of postoperative renal function surgical outcomes. Results: The rate of trifecta achievement was significantly lower in patients with LPN than in those with RAPN (p < 0.001). WIT ≥ 25 min were 18 patients (18%) in the RAPN group and 89 (52.7%) in the LPN group. The postoperative estimated glomerular filtration rate (eGFR) was almost the same. However, 13 patients (7.7%) had a decreased in eGFR ≥ 15% at 3 months after LPN compared with the preoperative eGFR. Conclusions: The rate of trifecta achievement in the RAPN group was significantly higher than that in the LPN group. However, eGFR was identified as relatively better preserved after PN in both groups.

Expanding the limits of nephron-sparing surgery: Surgical technique and mid-term outcomes of purely off-clamp robotic partial nephrectomy for totally endophytic renal tumors

OBJECTIVES

To report surgical technique, perioperative, oncological, and mid-term functional outcomes in a single-center purely off-clamp robotic partial nephrectomy series for totally endophytic masses.

METHODS

A retrospective analysis of a prospectively collected, institutional review board-approved renal cancer database was carried out to include patients with a totally endophytic renal tumor treated with off-clamp robotic partial nephrectomy between January 2013 and December 2020 at our center. Our database was queried to identify cases that had been assigned 3 points for the "E" domain of the R.E.N.A.L. nephrometry score and 3 points for the "exophytic rate" domain of the PADUA (Preoperative Aspects and Dimensions Used for an Anatomical) nephrometry score. Preoperative indocyanine green renal mass marking was performed in 33 patients, in whom the tumor was vascularized by a specific feeding artery. Surgical steps, perioperative, oncological and functional data were reported.

RESULTS

Fifty-six consecutive patients with totally endophytic renal masses were treated. The median tumor diameter was 3 cm, and median PADUA and R.E.N.A.L. scores were both 10. The median operative time was 82 min. Low-grade Clavien complications occurred in two patients (3.6%) and high-grade Clavien complications were observed in four patients (7.1%). Positive surgical margins were detected in one patient; 2-year recurrence-free, cancer-specific, and overall survival rates were 100%, 100%, and 98.2%, respectively. At a median follow-up of 24 months, new onset of chronic kidney disease stage 3b occurred in one patient. At last follow-up, the median estimated glomerular filtration rate was 77 mL/min, with a median estimated glomerular filtration rate percent decrease of 5.5%. Trifecta was achieved in 91% of patients.

CONCLUSIONS

Purely off-clamp robotic partial nephrectomy is a feasible and safe surgical approach, even in totally endophytic renal tumors, providing a favorable perioperative complications rate, excellent oncological outcomes, and negligible impact on renal function at mid-term follow-up. Indocyanine green preoperative marking of endophytic renal tumors represents a useful tool for rapid intraoperative identification of the mass, real-time control of resection margins, and a more precise dissection.

Impact of surgical approach and resection technique on the risk of Trifecta Failure after partial nephrectomy for highly complex renal masses

INTRODUCTION

We aimed to compare the outcomes of open vs robotic partial nephrectomy (PN), focusing on predictors of Trifecta failure in patients with highly complex renal masses.

PATIENTS AND METHODS

We queried the prospectively collected database from the SIB International Consortium, including 507 consecutive patients with cT1-2N0M0 renal masses treated at 16 high-volume referral centres, to select those with highly complex (PADUA score ≥10) tumors undergoing PN. RT was classified as enucleation, enucleoresection or resection according to the SIB score. Trifecta was defined as achievement of negative surgical margins, no acute kidney injury and no Clavien-Dindo grade ≥2 postoperative surgical complications. Multivariable logistic regression analysis was used to assess independent predictors of Trifecta failure.

RESULTS

113 patients were included. Patients undergoing open PN (n = 47, 41.6%) and robotic PN (n = 66, 58.4%) were comparable in baseline characteristics. RT was classified as enucleation, enucleoresection and resection in 46.9%, 34.0% and 19.1% of open PN, and in 50.0%, 40.9% and 9.1% of robotic PN (p = 0.28). Trifecta was achieved in significantly more patients after robotic PN (69.7% vs. 42.6%, p = 0.004). On multivariable analysis, surgical approach (open vs robotic, OR: 2.62; 95%CI: 1.11-6.15, p = 0.027) and tumor complexity (OR for each additional unit of the PADUA score: 2.27; 95%CI: 1.27-4.06, p = 0.006) were significant predictors of Trifecta failure, while RT was not. The study is limited by lack of randomization; as such, selection bias and confounding cannot be entirely ruled out.

CONCLUSIONS

Tumor complexity and surgical approach were independent predictors of Trifecta failure after PN for highly complex renal masses.

Robotic-Assisted Partial Nephrectomy: Techniques to Improve Clinical Outcomes

PURPOSE OF REVIEW

To summarize current options available for robot-assisted partial nephrectomy RECENT FINDINGS: Partial nephrectomy (PN) is a standard treatment option for management of cT1 renal masses. It may be carried out by multiple approaches. Robot-assisted (RA) PN is one such option. The goal of treatment is both correct oncological (negative surgical margins) and functional (preservation of sufficient amount of renal parenchyma of the operated kidney) outcome. Appropriate outcomes depend on multiple factors. There are many, but among others tumor characteristics (size, location, i.e., tumor complexity), patient baseline renal function, patient comorbidities, and performance status etc. Based on all these, the surgeon adapts the intervention for each mass/patient by preoperative planning, absence/use/duration of warm or cold ischemia, perioperative imaging, resection technique adapted to tumor location and depth of invasion, use of hemostatics, type and degree of renal parenchymal closure and others details. Nephroprotective agents have not shown efficacy so far. It should not be forgotten that surgeon's experience plays a key role in the achievement of good results. Although multiple factors have a role in the RA partial nephrectomy, surgeon experience and adaptation of technique of intervention have the crucial role in the achievement of both functional and oncological results.

A Nomogram for the Prediction of Intermediate Significant Renal Function Loss After Robot-assisted Partial Nephrectomy for Localized Renal Tumors: A Prospective Multicenter Observational Study (RECORd2 Project)

BACKGROUND

Robot-assisted partial nephrectomy (RAPN) is increasingly adopted for the treatment of localized renal tumors; however, rates and predictors of significant renal function (RF) loss after RAPN are still poorly investigated, especially at a long-term evaluation.

OBJECTIVE

To analyze the predictive factors and develop a clinical nomogram for predicting the likelihood of ultimate RF loss after RAPN.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively evaluated all patients treated with RAPN in a multicenter series (RECORd2 project).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Significant RF loss was defined as >25% reduction in estimated glomerular filtration rate (eGFR) from preoperative assessment at 48th month follow-up after surgery. Uni- and multivariable logistic regression analyses for RF loss were performed. The area under the receiving operator characteristic curve (AUC) was used to quantify predictive discrimination. A nomogram was created from the multivariable model.

RESULTS AND LIMITATIONS

A total of 981 patients were included. The median age at surgery was 64.2 (interquartile range [IQR] 54.3-71.4) yr, and 62.4% of patients were male. The median Charlson Comorbidity Index (CCI) was 1 (IQR 0-2), 12.9% of patients suffered from diabetes mellitus, and 18.6% of patients showed peripheral vascular disease (PVD). The median Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 7 (IQR 7-9). Imperative indications to partial nephrectomy were present in 3.6% of patients. Significant RF loss at 48th month postoperative evaluation was registered in 108 (11%) patients. At multivariable analysis, age (p = 0.04), female gender (p < 0.0001), CCI (p < 0.0001), CCI (p < 0.0001), diabetes (p < 0.0001), PVD (p < 0.0001), eGFR (p = 0.02), imperative (p = 0.001) surgical indication, and PADUA score (p < 0.0001) were found to be predictors of RF loss. The developed nomogram including these variables showed an AUC of 0.816.

CONCLUSIONS

We developed a clinical nomogram for the prediction of late RF loss after RAPN using preoperative and surgical variables from a large multicenter dataset.

PATIENT SUMMARY

We developed a nomogram that could represent a clinical tool for early detection of patients at the highest risk of significant renal function impairment after robotic conservative surgery for renal tumors.

Robotic surgery for cT2 kidney cancer: analysis of the National Cancer Database

Robotic surgery for renal cell carcinoma (RCC) is increasingly adopted for cT1 disease, but its utilization for cT2 disease remains unexplored. We aimed to characterize the trend in robotic approach for cT2 RCC. The National Cancer Database was queried for patients who were diagnosed with cT2N0M0 RCC from 2010 to 2016 and underwent subsequent radical (RN) or partial (PN) nephrectomy. Analysis of treatment trends was performed and logistic regression (LR) undertaken for predictors of surgical approach. 21,258 patients met inclusion criteria for analysis; 1698 (8%) underwent a PN and 19,560 (92%) underwent RN. Use of robotics in PN increased 346% (12.3-42.6%) and 351% (6.2-21.8%) for RN during the studied time period. Robotic PN or RN was associated with shorter hospital stay compared to non-robotic approaches (p < 0.001). Academic institutions were more likely to perform a robotic procedure and the uninsured were less likely to receive robotic approach. There was no association between age, sex, race, or income and surgical approach. On LR, robotic approach was independently associated with academic institutions and a more recent year of diagnosis. There was no significant difference in the rate of positive margins, 30-day readmission, or 30/90-day mortality between approaches. Robotic PN and RN is becoming an increasingly popular approach in the treatment of cT2 RCC. Utilization of robotics is associated with academic institutions and results in a shorter hospital stay without significant differences rate of positive margins, readmission rates, or 30/90-day mortality.

Partial versus radical nephrectomy in clinical T2 renal masses

OBJECTIVE

To report perioperative, renal functional and oncologic outcomes for patients undergoing partial or radical nephrectomy for cT2 renal masses.

METHODS

Retrospective review of patients who underwent partial (n = 72) or radical nephrectomy (n = 379) for cT2 renal masses from 2000 to 2016. After propensity adjustment using inverse probability weighting, the following were compared by surgery (partial or radical nephrectomy): complications, renal function measured by estimated glomerular filtration rate as continuous and as <60 mL/min/1.73 m² at 1 and 3 years postoperatively and overall, metastases-free survival and cancer-specific survival in patients with renal cell carcinoma.

RESULTS

After propensity adjustment, clinical and radiographic features were well-balanced between groups. Overall and severe complications were more common for partial compared with radical nephrectomy, although not statistically significant (19 vs 13%, P = 0.14 and 4 vs 2%, P = 0.3, respectively). Estimated glomerular filtration rate change at 1 and 3 years was more pronounced in radical compared with partial nephrectomy (median -16 vs -5 and -14 vs -2, respectively, P < 0.001). A greater proportion of radical nephrectomy patients had an estimated glomerular filtration rate <60 at 1 and 3 years (55 vs 17% and 48 vs 17%, respectively, P < 0.01). In renal cell carcinoma patients, overall, metastases-free and cancer-specific survival were not significantly different between groups (median survivor follow up 7.1 years, interquartile range 3.6-11.4).

CONCLUSIONS

Partial nephrectomy appears to be a relatively safe and a potentially effective treatment for cT2 renal masses, conferring better renal functional preservation compared with radical nephrectomy. These data support continued use of partial nephrectomy for renal masses >7 cm in appropriately selected patients.

Standardized Incidence Rate, Risk and Survival Outcomes of Second Primary Malignancy Among Renal Cell Carcinoma Survivors: A Nested Case-Control Study

Purpose

Second primary malignancy (SPM) is challenging for treatment and long-term survival. We sought to investigate the standardized incidence rate (SIR), risk factors, and survival outcomes for SPM after renal cell carcinoma (RCC) treatment.

Method

A nested case-control study was designed, we identified all T1-4N0-1M0 RCC patients diagnosed between 2004 and 2015 in the Surveillance, Epidemiology, and End Results database and followed them for SPM diagnosis for up to 13 years. Patients with SPM diagnosis ≥6 months after treatment of primary T1-4N0-1M0 RCC were identified as the case cohort and SPM-free patients were the control cohort. SIRs and the excess risk were calculated. A competing risks and Cox model were used to evaluate the risk factors of SPM and overall survival (OS).

Results

A cohort of 6,204 RCC patients with SPM were matched with a control group of 31,020 RCC patients without SPM. The median time-to-SPM interval was 54.5 months in RCC patients with SPM diagnosis. Besides, an SPM of T3/4 or/and M1 stage diagnosis was positively associated with a longer time-to-SPM interval. SIR of SPM increased by follow-up time and decreased with age at diagnosis (P_{for all <}0.001). SPM in the kidney had the highest SIR (54.6, P <0.001) among all SPMs. Prostate cancer (29.8%) in males and breast cancer (23.5%) in females were the most common SPM. Older age, black ethnicity, male sex, higher family income, papillary RCC, and lower TNM stage were significant risk factors for SPM diagnosis. The proportion of deaths from SPM exceeds that of deaths from RCC 3 years after the first RCC treatment. Patients with SPM and early time-to-SPM interval shortens the OS compared with SPM-free patients. The 5-year OS was 85.9% and 58.9% from the first RCC and the SPM diagnosis, respectively. Besides, patients with low-grade/early-stage SPM could benefit from aggressive surgical treatment for solid tumors.

Conclusions

Collectively, our study described the epidemiological characteristics of SPM among RCC survivors and identified the independent predictors of the SPM diagnosis and its survival outcomes. This study highlights the importance of patient education and follow-up after the surgery for RCC.

The efficacy evaluation of partial nephrectomy with selective renal artery branch occlusion by laparoscopy

BACKGROUND

To investigate the clinical application and effect of laparoscopic partial nephrectomy with renal artery branch occlusion in the treatment of early renal tumors.

METHODS

A retrospective analysis was conducted on the clinical data of 15 cases of renal tumor patients who underwent partial nephrectomy by laparoscopic selective renal artery branch occlusion in our department from January 2017 to January 2018. Nine male patients and 6 female patients were aged 46 to 65 years, with an average age of 54.3 ± 7.2 years. The diameters of tumors were 2.2 to 4.0 cm, with an average of 3.3 ± 0.7 cm. There are 10 tumors locating on the left side and 5 on the right side. Preoperative renal glomerular filtration rate (GFR) were 77.3 to 61.9 mL/min with an average of 47.6 ± 7.5 mL/min. All patients' diseased kidneys underwent renal computer tomography angiography examination before surgery. And the diseased kidney underwent reexamination of renal GFR. The operation time, renal artery branch occlusion time, intraoperative blood loss, postoperative hospital stay, changes of renal function, and complications were evaluated.

RESULTS

All surgery were completed successfully, the surgery time was 136.7 ± 15.2 min, intraoperative renal artery branch occlusion time was 21.3 ± 4.5 min, the intraoperative blood loss was 223.3 ± 69.5 mL, the postoperative hospital stay was 6.5 ± 1.7 days, and the postoperative 1-month GFR was 49.5 ± 6.6 mL/min. There was no significant difference between the renal GFR before and after surgery (P > .05). There was no blood transfusion and transfer open surgery cases. The patients were followed up for 3 to 15 months without complications.

CONCLUSIONS

Partial nephrectomy with selective renal artery branch occlusion by laparoscopy is a safe, feasible, and effective method for the treatment of early renal cancer. It makes good use of the technical advantages of clear operation field and fine operation of laparoscopic surgery, avoids the heat ischemia process of the whole kidney, and can better protect the renal function.

Risk factors for progression of chronic kidney disease after robotic partial nephrectomy in elderly patients: results from a multi-institutional collaborative series

BACKGROUND

Robotic partial nephrectomy (RPN) in patients ≥75 years is certainly underused with concerns regarding surgical quality and a negligible impact on renal function. The aim of this study was to identify predictors of progression of chronic kidney disease for purely off-clamp (ocRPN) and on-clamp RPN (onRPN) in elderly patients on a multi-institutional series.

METHODS

A collaborative minimally-invasive renal surgery dataset was queried for "RPN" performed between July 2007 and March 2021 and "age≥75 years". A total of 205 patients matched the inclusion criteria. Descriptive analyses were used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQR) were reported for continuous variables. Baseline, perioperative and functional data were compared between groups. New-onset of stages 3b,4,5 CKD in onRPN and ocRPN cohorts was computed by Kaplan-Meier analysis. Univariable and multivariable Cox regression analyses were performed to identify predictors of progression to severe CKD (sCKD [stages ≥3b]). For all statistical analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Mean age of the cohort considered was 78 years (IQR 76-80). At a median follow-up of 29 months (IQR 14.5-44.5), new onset CKD-3b and CKD-4,5 stages was observed in 16.6% and 2.4% of patients, respectively. At Kaplan-Meier analysis, onRPN was associated with a significantly higher risk of developing sCKD (p=0.002). On multivariable analysis, hypertension (HR 2.64; 95% CI 1.14-6.11; p=0.023), on-clamp approach (HR 3.41; 95% CI 1.50-7.74; p=0.003) non-achievement of trifecta (HR 0.36; 95% CI 0.17-0.78; p=0.01) were independent predictors of sCKD.

CONCLUSIONS

RPN in patients≥75 years is a safe surgical option. On-clamp approach, hypertension and non-achievement of trifecta were independent predictors of sCKD in the elderly after RPN.

Salvage Robot-assisted Renal Surgery for Local Recurrence After Surgical Resection or Renal Mass Ablation: Classification, Techniques, and Clinical Outcomes

BACKGROUND

Salvage treatment for local recurrence after prior partial nephrectomy (PN) or local tumor ablation (LTA) for kidney cancer is, as of yet, poorly investigated.

OBJECTIVE

To classify the treatments and standardize the nomenclature of salvage robot-assisted renal surgery, to describe the surgical technique for each scenario, and to investigate complications, renal function, and oncologic outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Sixty-seven patients underwent salvage robot-assisted renal surgery from October 2010 to December 2020 at nine tertiary referral centers.

SURGICAL PROCEDURE

Salvage robot-assisted renal surgery classified according to treatment type as salvage robot-assisted partial or radical nephrectomy (sRAPN or sRARN) and according to previous primary treatment (PN or LTA).

MEASUREMENTS

Postoperative complications, renal function, and oncologic outcomes were assessed.

RESULTS AND LIMITATIONS

A total of 32 and 35 patients underwent salvage robotic surgery following PN and LTA, respectively. After prior PN, two patients underwent sRAPN, while ten underwent sRARN for a metachronous recurrence in the same kidney. No intra- or perioperative complication occurred. For local recurrence in the resection bed, six patients underwent sRAPN, while 14 underwent sRARN. For sRAPN, the intraoperative complication rate was 33%; there was no postoperative complication. For sRARN, there was no intraoperative complication and the postoperative complication rate was 7%. At 3 yr, the local recurrence-free rates were 64% and 82% for sRAPN and sRARN, respectively, while the 3-yr metastasis-free rates were 80% and 79%, respectively. At 33 mo, the median estimated glomerular filtration rates (eGFRs) were 57 and 45 ml/min/1.73 m² for sRAPN and sRARN, respectively. After prior LTA, 35 patients underwent sRAPN and no patient underwent sRARN. There was no intraoperative complication; the overall postoperative complications rate was 20%. No local recurrence occurred. The 3-yr metastasis-free rate was 90%. At 43 mo, the median eGFR was 38 ml/min/1.73 m². The main limitations are the relatively small population and the noncomparative design of the study.

CONCLUSIONS

Salvage robot-assisted surgery has a safe complication profile in the hands of experienced surgeons at high-volume institutions, but the risk of local recurrence in this setting is non-negligible.

PATIENT SUMMARY

Patients with local recurrence after partial nephrectomy or local tumor ablation should be aware that further treatment with robot-assisted surgery is not associated with a worrisome complication profile, but also that they are at risk of further recurrence.

Comparison between minimally-invasive partial and radical nephrectomy for the treatment of clinical T2 renal masses: results of a 10-year study in a tertiary care center

BACKGROUND

Even if partial nephrectomy (PN) is nowadays considered the standard for managing cT1 renal masses, its role in the management of cT2 kidney tumors is controversial. We aimed to compare oncologic and functional outcomes of minimally invasive radical nephrectomy (RN) and PN in cT2 renal masses.

METHODS

Patients with cT2 renal masses underwent minimally-invasive PN or RN performed by a highly experienced single surgeon from 2009 to 2019 were considered. Demographic, perioperative and functional variables were compared. Cumulative incidence plot and competing risks regression (CRR) models were used to test differences in 5-year cancer-specific mortality (CSM) and 5-year other-cause mortality (OCM) rates. Kaplan-Meier and Cox regression model was used to test differences in 5-year progression free survival (PFS) rates.

RESULTS

Overall, 52 PN vs. 64 RN patients were identified. Relative to RN, PN patients recorded higher rates of complications (25% vs. 7.8%, P=0.02) but lower upstaging rate (≥pT3a 64.1% vs. 19.2%, P<0.0001). Functional outcomes were in favor of PN (all P<0.001). No differences were recorded between 5-year CSM and OCM according to nephrectomy type. At CRR models, older age and upstaging were independent predictors of 5-year OCM and CSM, respectively (all P<0.01). Finally, only upstaging, high grade tumors and presence of positive surgical margins were identified as independent predictors of 5-year PFS (all P<0.01).

CONCLUSIONS

In experienced hands the treatment of cT2 renal neoplasms with minimally-invasive PN is feasible, providing perioperative and oncological safety profiles comparable to RN, with advantages in terms of functional outcomes.

Comparison of Sutureless and Conventional Laparoscopic Partial Nephrectomy: A Propensity Score-Matching Analysis

Objective: To compare the functional outcome, safety and efficacy of sutureless and conventional laparoscopic partial nephrectomy.

Methods: After the inclusion and exclusion criteria were applied, our study reviewed 379 patients with T1 stage renal tumors. We applied propensity score matching (PSM) to limit potential baseline confusion. Perioperative and functional outcomes between sutureless laparoscopic partial nephrectomy (sLPN) and conventional laparoscopic partial nephrectomy (cLPN) groups were compared and analyzed before and after PSM.

Results: Of our 379 patients with T1 stage renal tumors, 199 and 180 were identified in the cLPN and sLPN groups, respectively. After applying PSM with preoperative features, 116 patients in the cLNP group were paired to 116 patients in the sLNP group. We found that all differences in preoperative baseline characteristics disappeared. All the preoperative characteristics (age, gender, tumor diameter, RENAL nephrometry score, side, preoperative eGFR, hypertension, diabetes mellitus, ASA score) were not statistically different between the two groups. The operative time (OT) (p < 0.001) and warm ischemia time (WIT) (p < 0.001) of the sLPN group were of shorter duration than that of the cLPN group. The eGFR baseline was almost equal, but there was a statistically smaller decrease in eGFR in the sLPN than in the cLPN group 1 week after surgery (14.3 vs. 7.4, p < 0.001) and after 6 months (11.9 vs. 5.0, p < 0.001). After both preoperative features and WIT were included in PSM, fifty-one pairs of patients were identified between the groups, the WIT difference between them disappeared, while the decrease in eGFR between the groups remained as it was previously at 1 week (15.4 vs. 8.6, p < 0.001) and at 6 months (13.0 vs. 6.2, p < 0.001).

Conclusion: Sutureless laparoscopic partial nephrectomy is as safe and effective as conventional laparoscopic partial nephrectomy, and compared to cLPN, sLPN can effectively reduce the WIT, retain more renal parenchyma and protect renal function.

Trends in the surgical management of renal cell carcinoma in a contemporary tertiary care setting

Background

In the last three eras, the incidence of renal cell carcinoma (RCC) has increased, due to increased radiological studies. The expected 5-year survival rate has become better, associated with the identification of small size renal masses. However, this survival improvement may be secondary to improved surgical techniques and medical therapies for these malignancies.

Objectives

The objective was to report the trends of clinical presentation, peri-operative, oncological outcomes, and surgical management trends for RCCs over the period.

Methods

After Institutional Review Board approval, a retrospective study for adult patients was conducted, who presented with renal mass and were managed between 2008 and 2019. Variables, including demographics, perioperative and pathological outcomes analyzed using descriptive statistics for continuous variables reported as mean ± standard deviation and categorical variables values compared by Chi-square test. Survival Analysis calculated using the Kaplan-Meier method. The level of significance is set at P-value < 0.05.

Results

A total of 588 patients underwent surgical treatment for kidney cancer from January 2008 to January 2019. 237 (40.30%) were females and 351 (59.69%) males. The clinical presentation was higher as an incidental diagnosis of 58.67%. 71.25% of patients were from outside Riyadh city. Pathology was mostly clear cell RCC 61.22% and grade 2 (57.48%). Tumor size, surgery time, and length of hospital stay showed a significant difference between the three periods (both P > 0.05). Robotic surgery performed more than open (P < 0.0001). There was no significant difference in the survival time, when compared to patients by the regions and when compared by the primary tumors (Log-Rank P = 0.4821). Patients from the Riyadh region (median = 54.0) had a significantly higher recurrence time (Log-Rank P < 0.0001).

Conclusion

There was a rising trend in the incidence of RCC associated with comorbidities and incidental diagnosis. In our study period we found increase in the trend of minimal invasive approach. The size of the tumor, blood loss and operative time decreases over the period of time. The Robotic assisted nephrectomy approach has become increased over the period of time duration in present study.