Robot-assisted Partial Nephrectomy for Complex (PADUA Score ≥10) Tumors: Techniques and Results from a Multicenter Experience at Four High-volume Centers

Predicting post-surgical complications using renal scoring systems

Current surgical approaches for renal malignancies primarily rely on qualitative factors such as patient preferences, surgeon experience, and hospital capabilities. Applying a quantitative method for consistent and reliable assessment of renal lesions would significantly enhance surgical decision-making and facilitate data comparison. Nephrometry scoring (NS) systems systematically evaluate and describe renal tumors based on their anatomical features. These scoring systems, including R.E.N.A.L., PADUA, MAP scores, C-index, CSA, and T-index, aim to predict surgical complications by evaluating anatomical and patient-specific factors. In this review paper, we explore the components and methodologies of these scoring systems, compare their effectiveness and limitations, and discuss their application in advancing patient care and optimizing surgical outcomes.

Robotic partial nephrectomy: Techniques for complex tumors

Robotic assisted partial nephrectomy is an effective and minimally invasive approach that has gained significant popularity in the past 20 years. Guidelines support prioritizing partial nephrectomy in small renal masses when technically feasible, given improvement in long term renal function and cardiovascular risk. Increasing surgeon comfort with the robotic platform has allowed for the removal of larger and more complex tumors. There are a vast number of surgical techniques described in the literature for dissection, hilum clamping, tumor resection and renorrhaphy. We aim to describe and summarize different considerations and techniques to utilize when performing robotic assisted partial nephrectomy in complex renal masses. In this review, we specifically focus on masses with higher tumor complexity (RENAL score ≥10, those that involve or about the hilum or are invasive into the renal sinus).

A Systematic Review of Surgical Outcomes: Comparing Robotic-Assisted Partial Nephrectomy and Open Partial Nephrectomy in Nephron-Sparing Surgery for Renal Tumors

A partial nephrectomy is a critical approach for nephron-sparing surgery in renal tumors, striking a balance between oncological control and the preservation of renal function. Surgeons traditionally view open partial nephrectomy (OPN) as the gold standard in kidney surgery. The emergence of robotic-assisted partial nephrectomy (RAPN) offers a minimally invasive alternative that can improve surgical precision and decrease the risk of complications during the perioperative period. This systematic review analyzes and compares OPN and RAPN based on factors such as oncological effectiveness, preservation of kidney function, perioperative outcomes, and complication rates. We followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to review and include studies, analyzing 30 studies that involved more than 26,826 patients. The research team carried out retrospective and prospective cohort studies and randomized controlled trials (RCTs). They measured the quality of these studies by using the Newcastle-Ottawa Scale (NOS) for observational studies and the Cochrane Risk of Bias tool version 2 (RoB 2; Cochrane, London, UK) for RCTs. Our findings indicate that RAPN offers significant perioperative advantages, such as reduced mean estimated blood loss (EBL) of 181 mL compared to 284 mL for OPN and shorter hospital stays averaging three days compared to six days for OPN. Follow-up durations ranged from three to 60 months. Although the surgery for RAPN takes longer, it consistently preserves renal function better, resulting in less considerable declines in the estimated glomerular filtration rate (eGFR). Oncological outcomes show that RAPN achieves a negative surgical margin (NSM) rate of 97.16%, while OPN reaches 92%. RAPN effectively handles complex renal tumors, especially those with high Preoperative Aspects and Dimensions Used for Anatomical (PADUA) or R.E.N.A.L. Nephrometry score (Radius (R), Exophytic/Endophytic properties (E), Nearness to the collecting system or sinus (N), Anterior/Posterior location (A), Location relative to polar lines (L)). In conclusion, RAPN offers significant advantages in perioperative and functional outcomes while maintaining oncological equivalence to OPN. This seals RAPN as the preferred approach in centers with robotic expertise. However, OPN remains a viable option in low-resource settings. Future research should improve access to robotic systems, standardize reporting metrics, and conduct long-term randomized trials to understand both techniques' strengths and limitations better.

Comparison of robotic-assisted and laparoscopic partial nephrectomy based on the PADUA score and the predictive value of the PADUA score and the Mayo Adhesive Probability score for postoperative complications: a single-center retrospective study

PURPOSE

This study compared perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) through the PADUA score as well as assessed the predictive value of the PADUA score and the Mayo Adhesive Probability (MAP) score for postoperative complications.

METHODS

Totally 196 patients suffering from RAPN or LPN for renal tumors were reviewed retrospectively. Patients were categorized by PADUA score (low-, moderate-, high-complexity) and MAP score (low-, intermediate-, high-grade). Evaluated outcomes included operative time (OT), warm ischemia time (WIT), estimated blood loss (EBL), drainage duration, postoperative length of stay, and absolute change in estimated glomerular filtration rate (eGFR) at three months post-surgery, along with intra- and postoperative complications.

RESULTS

RAPN outperformed LPN in the low-complexity group by lowering WIT (P = 0.022) and absolute eGFR change (P = 0.011). For moderate-complexity group, RAPN reduced WIT (P = 0.021), absolute eGFR change (P = 0.027), and postoperative length of stay (P = 0.008). In the high-complexity group, RAPN reduced OT (P = 0.015), WIT (P = 0.023), EBL (P = 0.036), absolute eGFR change (P = 0.024), and postoperative length of stay (P = 0.019). Drainage duration showed no significant differences across groups (P = 0.442, P = 0.327, P = 0.260). RAPN incurred significantly higher total costs than LPN across groups (P < 0.001). ROC analysis suggested PADUA and MAP scores as reliable predictors of postoperative complications in RAPN (AUC = 0.880,0.828) and LPN (AUC = 0.757,0.702).

CONCLUSION

RAPN provides significant advantages over LPN in managing complex renal tumors (PADUA score ≥ 10), significantly in reducing OT, WIT, EBL, and absolute eGFR change at three months post-surgery, while minimizing postoperative stay. The PADUA and MAP scores are valuable in predicting postoperative complication.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

Retrospectively registered.

Comparison of renal function between the artery and vein clamp and artery-only clamp in robot-assisted partial nephrectomy for moderate- to high-complexity renal masses: A propensity-matched study

OBJECTIVE

Artery and vein (AV) clamps can control venous bleeding in the surgical field and prevent carbon dioxide embolism, especially when large veins are expected to open. However, whether AV clamps cause more renal damage than artery-only (AO) clamps remains unclear. This study aimed to compare renal function and blood loss in surgeries using AO and AV clamps based on high RENAL nephrometry scores (RNS) in robot-assisted partial nephrectomy (RAPN).

METHODS

We retrospectively analyzed the medical records of 500 patients who underwent RAPN between March 2016 and December 2021. We performed 1:1 propensity matching for these patients.

RESULTS

A total of 340 patients with pathological malignancies who were followed up for at least 12 months were included in this analysis. A total of 291 patients with AO clamping and 49 patients with AV clamping were included. Overall, the AV clamp group had higher total RNSs and larger diameters than the AO clamp group. Propensity score-matched analysis included 37 patients in each clamp group. The median warm ischemia times of the AV and AO clamps were 25 and 22 min, respectively, with no significant difference. There were no statistically significant differences between the groups in the amount of blood loss, rate of acute kidney injury (AKI), or renal function at 1, 3, or 12 months post-RAPN.

CONCLUSION

Compared with the AO clamp, the AV clamp did not have a detrimental impact on blood loss or renal dysfunction. Consequently, AV clamps may be considered for patients presenting with moderate-to-high-complexity RNSs.

Impact of Mayo Adhesive Probability score and BMI on renal functional decline after robotic assisted partial nephrectomy

Purpose

The purpose of this study is to investigate the impact of Mayo Adhesive Probability (MAP) score and body mass index (BMI) on renal function decline after robotic assisted partial nephrectomy (RAPN).

Methods

We queried our prospective database for patients who underwent RAPN between January 2018 and December 2023. Outcomes were development of de novo CKD-S3 (estimated glomerular filtration rate [eGFR] < 60 ml/min/1.73 m2). Multivariable analysis (MVA) via Cox regression identified predictors for CKD-S3. Kaplan-Meier Analyses was fitted for survival assessment. Finally, multivariable linear regression was utilized to identify predictors of delta eGFR at last follow-up (preoperative eGFR-last eGFR).

Results

Two-hundred fifty-eight patients were analysed (obese n = 49 [19%]; MAP score 0-2 = 135 [52.33%]; MAP score 3-5 = 123 [47.6%]) with a median follow-up of 33 (IQR 20-42) months. MVA revealed, high MAP score (HR 2.29, p = 0.019), increasing RENAL score (HR 1.26, p = 0.009), increasing age (HR 1.04, p = 0.003), obesity (HR 2.38, p = 0.006) and diabetes mellitus (HR 2.38, p = 0.005) as associated with increased risk of development of CKD-S3, while trifecta achievement was not (p = 0.63). Comparing low MAP score versus high MAP score 4-year CKD-S3 free survival was 87.8% versus 56.1% (p < 0.001). Multivariable linear regression showed that high MAP score (coefficient 6.64, p = 0.001) and BMI (coefficient 0.51, p = 0.011) were significantly associated with increased delta eGFR at last follow up.

Conclusions

MAP score and increasing BMI are predictor for long term renal functional detrimental. These insights may call consideration for closer follow-up or greater medical scrutiny prior surgery in obese patients and with elevated MAP score. Further investigations are requisite.

Management of renal sinus angiomyolipoma: modified robotic nephron-sparing surgery in a single center

BACKGROUND

Renal sinus angiomyolipoma (RSAML) is a rare and typically complex renal tumor. The objective is to present our single-center experience with a modified technique of robotic nephron-sparing surgery (NSS) for treating RSAML.

METHODS

We retrospectively evaluated 15 patients with RSAMLs who were treated with robotic NSS at the Department of Urology of Tongji hospital, ranging from November 2018 to September 2022. Renal vessels and ureter were dissected. The outer part of RSAML was resected. The rest of tumor was removed by bluntly grasp, curettage and suction. Absorbable gelatin sponges were filled in the renal sinus. The preoperative parameters, operative measures and postoperative outcomes were all collected. Follow-up was performed by ultrasonography and estimated glomerular filtration rate (eGFR).

RESULTS

Robotic NSS was successfully performed in all the patients, without any conversion to open surgery or nephrectomy. The mean operation time was 134.13 ± 40.56 min. The mean warm ischemia time was 25.73 ± 3.28 min. The median estimated blood loss was 100 [50, 270] ml and 1 patient required blood transfusion. The mean drainage duration was 5.77 ± 1.98 days. The median postoperative hospital stay was 6.90 [5.80, 8.70] days. Two patients experienced postoperative urinary tract infection (Clavien-Dindo Grade II). During the median follow-up of 25.53 ± 15.28 months, patients received 91.18% renal function preservation. No local recurrence occurred in all the patients.

CONCLUSIONS

Robotic NSS for RSAML is a complicated procedure that demands technical expertise and a well-designed strategy is critical in the operation. Treating RSAML with modified robotic NSS is safe, effective and feasible.

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.

Biophotonics-Intraoperative Guidance During Partial Nephrectomy: A Systematic Review and Meta-analysis

CONTEXT

Partial nephrectomy (PN) with intraoperative guidance by biophotonics has the potential to improve surgical outcomes due to higher precision. However, its value remains unclear since high-level evidence is lacking.

OBJECTIVE

To provide a comprehensive analysis of biophotonic techniques used for intraoperative real-time assistance during PN.

EVIDENCE ACQUISITION

We performed a comprehensive database search based on the PICO criteria, including studies published before October 2022. Two independent reviewers screened the titles and abstracts followed by full-text screening of eligible studies. For a quantitative analysis, a meta-analysis was conducted.

EVIDENCE SYNTHESIS

In total, 35 studies were identified for the qualitative analysis, including 27 studies on near-infrared fluorescence (NIRF) imaging using indocyanine green, four studies on hyperspectral imaging, two studies on folate-targeted molecular imaging, and one study each on optical coherence tomography and 5-aminolevulinic acid. The meta-analysis investigated seven studies on selective arterial clamping using NIRF. There was a significantly shorter warm ischemia time in the NIRF-PN group (mean difference [MD]: -2.9; 95% confidence interval [CI]: -5.6, -0.1; p = 0.04). No differences were noted regarding transfusions (odds ratio [OR]: 0.5; 95% CI: 0.2, 1.7; p = 0.27), positive surgical margins (OR: 0.7; 95% CI: 0.2, 2.0; p = 0.46), or major complications (OR: 0.4; 95% CI: 0.1, 1.2; p = 0.08). In the NIRF-PN group, functional results were favorable at short-term follow-up (MD of glomerular filtration rate decline: 7.6; 95% CI: 4.6, 10.5; p < 0.01), but leveled off at long-term follow-up (MD: 7.0; 95% CI: -2.8, 16.9; p = 0.16). Remarkably, these findings were not confirmed by the included randomized controlled trial.

CONCLUSIONS

Biophotonics comprises a heterogeneous group of imaging modalities that serve intraoperative decision-making and guidance. Implementation into clinical practice and cost effectiveness are the limitations that should be addressed by future research.

PATIENT SUMMARY

We reviewed the application of biophotonics during partial removal of the kidney in patients with kidney cancer. Our results suggest that these techniques support the surgeon in successfully performing the challenging steps of the procedure.

Ex Vivo Partial Nephrectomy and Autotransplantation for Complex and Multifocal Renal Cell Carcinoma at a Single Institution: A Case Series

Renal autotransplantation is a rare surgical procedure designed to preserve renal function in patients with complex urinary system diseases or highly complex renal tumors. Between 2012 and 2023, four patients underwent ex vivo partial nephrectomy (PN) and autotransplantation for complex renal tumors at our hospital. Two patients had bilateral multifocal renal tumors, including von Hippel Lindau (VHL) disease and hybrid oncocytic chromophobe tumor (HOCT). The remaining two patients had highly complex renal tumors with Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of 12, one of whom had a solitary kidney. None of the patients experienced any postoperative surgical complications. Pathologically, nine of the excised tumors had negative surgical margins, except for one of the four tumors on HOCT. Postoperative renal function decreased at one month compared to preoperative renal function (P = 0.01); however, there was no significant difference at three months (P = 0.07). None of the patients had a local recurrence or metastasis at the latest follow-up.Ex vivo PN and autotransplantation are feasible and reasonable treatment methods for highly complex and multifocal renal tumors regarding safety, local tumor control, and preservation of renal function.

Perioperative, functional, and oncologic outcomes of laparoscopic partial nephrectomy versus open partial nephrectomy for complex renal tumors: a systematic review and meta-analysis

Background

The primary aim of this present study is to undertake a comprehensive comparative analysis of the perioperative, functional, and oncologic outcomes associated with laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) as interventions for the treatment of complex renal tumors, defined as PADUA or RENAL score ≥ 7.

Methods

We systematically carried out an extensive search across four electronic databases, namely PubMed, the Cochrane Library, Embase, and Web of Science. Our objective was to identify pertinent studies published in the English language up to December 2023, and encompassed controlled trials comparing LPN and OPN as interventions for complex renal tumors.

Results

This study encompassed a total of seven comparative trials, involving 934 patients. LPN exhibited a noteworthy reduction in the length of hospital stay (weighted mean difference [WMD] -2.06 days, 95% confidence interval [CI] -2.62, -1.50; p < 0.00001), blood loss (WMD -34.05mL, 95% CI -55.61, -12.48; p = 0.002), and overall complications (OR 0.38, 95% CI 0.19, 0.79; p = 0.009). However, noteworthy distinctions did not arise between LPN and OPN concerning parameters such as warm ischemia time, renal function, and oncological outcomes.

Conclusions

This study reveals that LPN presents several advantages over OPN. These benefits encompass a shortened hospital stay, diminished blood loss, and a reduced incidence of complications. Importantly, LPN achieves these benefits while concurrently upholding comparable renal function and oncological outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=457716, identifier CRD42023453816.

Retroperitoneoscopic Clampless, Sutureless Hybrid Therapy in the Management of Renal Hilar Tumors

OBJECTIVE

We aimed to investigate the outcomes and feasibility of a retroperitoneoscopic clampless, sutureless hybrid technique in the management of renal hilar tumors.

METHODS

A retrospective cohort of consecutive patients with renal hilar tumors who received retroperitoneoscopic clampless, sutureless hybrid therapy between January 2017 and April 2021 was included. The hybrid surgical technique involved microwave ablation (MWA), followed by clampless tumor enucleation and sutureless hemostasis. Surgical, pathological, and oncological outcomes were recorded and analyzed.

RESULTS

Sixty patients were included in this study. The median tumor size was 3.5 cm (2-5), the median RENAL score was 7 (range 6-10), the median operative time was 110 min (70-130), and the median estimated blood loss was 80 mL (30-130). The median length of postoperative hospital stay was 3 days (2-4), and no warm ischemia time was observed, except in one patient who required conversion to conventional on-clamp laparoscopic partial nephrectomy (LPN) with a 10 min warm ischemia time. Three minor complications (Clavien-Dindo grade I) and one major complication (Clavien-Dindo grade III) were recorded postoperatively. Thus far, no blood transfusions have been required. Renal dysfunction or tumor recurrence did not occur within a median follow-up of 45 months.

CONCLUSION

The retroperitoneoscopic hybrid technique involving MWA, clampless tumor enucleation, and sutureless hemostasis is a feasible and safe option for the management of selective renal hilar tumors. Complete tumor removal with maximal renal function preservation can be achieved, with a low complication rate.

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.

Predictors for complication in renal cancer surgery: a national register study

OBJECTIVE

Nationwide register data provide unique opportunities for real-world assessment of complications from different surgical methods. This study aimed to assess incidence of, and predictors for, post-operative complications and to evaluate 90-day mortality  following different surgical procedures and thermal ablation for renal cell carcinoma (RCC).

MATERIAL AND METHODS

All patients undergoing surgical treatment and thermal ablation for RCC in Sweden during 2015-2019 were identified from the National Swedish Kidney Cancer Register. Frequencies and types of post-operative complications were analysed. Logistic regression models were used to identify predictors for 90-day major (Clavien-Dindo grades III-V) complications, including death.

RESULTS

The overall complication rate was 24% (1295/5505), of which 495 (8.7%) were major complications. Most complications occurred following open surgery, of which bleeding and infection were the most common. Twice as many complications were observed in patients undergoing open surgery compared to minimally invasive surgery (20% vs. 10%, P < 0.001). Statistically significant predictors for major complications irrespective of surgical category and technique were American society of anesthiologists (ASA) score, tumour diameter and serum creatinine. Separating radical and partial nephrectomy, surgical technique remained a significant risk factor for major complications. Most complications occurred within the first 20 days. The overall 90-day readmission rate was 6.2%, and 30- and 90-day mortality rates were 0.47% and 1.5%, respectively.

CONCLUSIONS

In conclusion, bleeding and infection were the most common major complications after RCC surgery. Twice as many patients undergoing open surgery suffer a major post-operative complication as compared to patients subjected to minimally invasive surgery. General predictors for major complications were ASA score, tumour size, kidney function and surgical technique.

Objective assessment of intraoperative skills for robot-assisted partial nephrectomy (RAPN)

RAPN training usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee capacity to perform RAPN at predetermined performance levels prior to in-vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes. The authors sought to examine the reliability, construct and discriminative validity of objective intraoperative performance metrics which best characterize the optimal and suboptimal performance of a reference approach for training novice RAPN surgeons. Seven Novice and 9 Experienced RAPN surgeons video recorded one or two independently performed RAPN procedures in the human. The videos were anonymized and two experienced urology surgeons were trained to reliably score RAPN performance, using previously developed metrics. The assessors were blinded to the performing surgeon, hospital and surgeon group. They independently scored surgeon RAPN performance. Novice and Experienced group performance scores were compared for procedure steps completed and errors made. Each group was divided at the median for Total Errors score, and subgroup scores (i.e., Novice HiErrs and LoErrs, Experienced HiErrs and LoErrs) were compared. The mean inter-rater reliability (IRR) for scoring was 0.95 (range 0.84-1). Compared with Novices, Experienced RAPN surgeons made 69% fewer procedural Total Errors. This difference was accentuated when the LoErr Expert RAPN surgeon's performance was compared with the HiErrs Novice RAPN surgeon's performance with an observed 170% fewer Total Errors. GEARS showed poor reliability (Mean IRR = 0.44; range 0.0-0.8), for scoring RAPN surgical performance. The RAPN procedure metrics reliably distinguish Novice and Experienced surgeon performances. They further differentiated performance levels within a group with similar experiences. Reliable and valid metrics will underpin quality-assured novice RAPN surgical training.

RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned

Background

The surgical difficulty of partial nephrectomy (PN) varies depending on the operative approach. Existing nephrometry classifications for assessment of surgical difficulty are not specific to the robotic approach.

Objective

To develop an international robotic-specific classification of renal masses for preoperative assessment of surgical difficulty of robotic PN.

Design setting and participants

The RPN classification (Radius, Position of tumour, iNvasion of renal sinus) considers three parameters: tumour size, tumour position, and invasion of the renal sinus. In an international survey, 45 experienced robotic surgeons independently reviewed de-identified computed tomography images of 144 patients with renal tumours to assess surgical difficulty of robot-assisted PN using a 10-point Likert scale. A separate data set of 248 patients was used for external validation.

Outcome measurements and statistical analysis

Multiple linear regression was conducted and a risk score was developed after rounding the regression coefficients. The RPN classification was correlated with the surgical difficulty score derived from the international survey. External validation was performed using a retrospective cohort of 248 patients. RPN classification was also compared with the RENAL (Radius; Exophytic/endophytic; Nearness; Anterior/posterior; Location), PADUA (Preoperative Aspects and Dimensions Used for Anatomic), and SPARE (Simplified PADUA REnal) scoring systems.

Results and limitation

The median tumour size was 38 mm (interquartile range 27-49). The majority (81%) of renal tumours were peripheral, followed by hilar (12%) and central (7.6%) locations. Noninvasive and semi-invasive tumours accounted for 37% each, and 26% of the tumours were invasive. The mean surgical difficulty score was 5.2 (standard deviation 1.9). Linear regression analysis indicated that the RPN classification correlated very well with the surgical difficulty score (R2 = 0.80). The R2 values for the other scoring systems were: 0.66 for RENAL, 0.75 for PADUA, and 0.70 for SPARE. In an external validation cohort, the performance of all four classification systems in predicting perioperative outcomes was similar, with low R2 values.

Conclusions

The proposed RPN classification is the first nephrometry system to assess the surgical difficulty of renal masses for which robot-assisted PN is planned, and is a useful tool to assist in surgical planning, training and data reporting.

Patient summary

We describe a simple classification system to help urologists in preoperative assessment of the difficulty of robotic surgery for partial kidney removal for kidney tumours.

Robot-assisted partial nephrectomy for complex renal tumors: Analysis of a large multi-institutional database

INTRODUCTION

Highly complex renal masses pose a challenge to urologic surgeons' ability to perform robotic partial nephrectomy (RPN). Given the increased utilization of the robotic approach for small renal masses, we sought to characterize the outcomes and determine the safety and feasibility of RPN for complex renal masses from our large multi-institutional cohort.

METHODS

We performed a retrospective analysis of patients with R.E.N.A.L. Nephrometry Scores ≥10 who underwent RPN in our multi-institutional cohort (N = 372). Baseline demographic, clinical and tumor related characteristics were evaluated with the primary endpoint of trifecta achievement (defined as negative surgical margin, no major complications, and warm ischemia time ≤25 min). Relationships between variables were assessed using the chi-square test of independence, Fisher exact test, Mann-Whitney U test, and Kruskal Wallis test. Logistic regression was used to evaluate the relationship between baseline characteristics and trifecta achievement.

RESULTS

Of 372 patients in the study, mean age was 58 years, and median BMI was 30.49 kg/m². The median tumor size was 4.3 cm (3.0-5.9 cm). Most of the patients had R.E.N.A.L. scores of 10 (n = 253; 67.01%). Overall, trifecta was achieved in 72.04% of patients. Stratifying intraoperative and postoperative outcomes by R.E.N.A.L. scores, there was no significant difference in trifecta achievement, operative time, warm ischemia time (WIT), open conversion, major complication, or positive margin rates. Length of hospital stay was significantly longer for higher R.E.N.A.L. scores (median days 2 vs. 1, P = 0.012). Multivariate analyses for factors associated with trifecta achievement concluded that age and baseline eGFR were independently associated with trifecta achievement.

CONCLUSION

RPN is a safe and reproducible procedure for complex tumors with R.E.N.A.L. Nephrometry scores ≥10. Our results suggest excellent rates of trifecta achievement and short-term functional outcomes when performed by experienced surgeons. Long-term oncological and functional evaluation are needed to further support this conclusion.

Three-dimensional virtual models assistance predicts higher rates of "successful" minimally invasive partial nephrectomy: an Institutional analysis across the available trifecta definitions

PURPOSE

3D virtual models (3DVMs) are nowadays under scrutiny to improve partial nephrectomy (PN) outcomes. Five different Trifecta definitions have been proposed to optimize the framing of "success" in the PN field. Our aim is to analyze if the use of 3DVMs could impact the success rate of minimally invasive PN (mi-PN), according to the currently available definitions of Trifecta.

MATERIALS AND METHODS

At our Institution 250 cT1-2N0M0 renal masses patients treated with mi-PN were prospectively enrolled. Inclusion criteria were the availability of contrast-enhanced CT, baseline and postoperative serum creatinine, and eGFR. These patients were then compared with a control group of 710 patients who underwent mi-PN with the same renal function assessments, but without 3DVMs. Multivariable logistic regression (MLR) models were used to predict the trifecta achievement according to the different trifecta definitions.

RESULTS

Among the definitions, Trifecta rates ranged between 70.8% to 97.4% in the 3DVM group vs. 56.8% to 92.8% in the control group (all p values < 0.05). 3DVMs showed better postoperative outcomes in terms of ΔeGFR, ( - 16.6% vs.  - 2.7%, p = 0.03), postoperative complications (15%, vs 22.9%, p = 0.002) and major complications (Clavien Dindo > 3, 2.8% vs 5.6%, p = 0.03). At MLR 3DVMs assistance independently predicted higher rates of successful PN across all the available definitions of Trifecta (OR: 2.7 p < 0.001, OR:2.0 p = 0.0008, OR:2.8 p = 0.02, OR 2.0 p = 0.003).

CONCLUSIONS

The 3DVMs availability was found to be the constant predictive factor of successful PN, with a twofold higher probability of achieving Trifecta regardless of the different definitions available in Literature.

Comparison of perioperative outcomes of robotic vs. laparoscopic partial nephrectomy for renal tumors with a RENAL nephrometry score ≥7: A meta-analysis

Introduction

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) vs. laparoscopic partial nephrectomy (LPN) for complex renal tumors with a RENAL nephrometry score ≥7.

Methods

We searched PubMed, EMBASE and the Cochrane Central Register for studies from 2000 to 2020 to evaluate the perioperative outcomes of RPN and LPN in patients with a RENAL nephrometry score ≥7. We used RevMan 5.2 to pool the data.

Results

Seven studies were acquired in our study. No significant differences were found in the estimated blood loss (WMD: 34.49; 95% CI: −75.16–144.14; p = 0.54), hospital stay (WMD: −0.59; 95% CI: −1.24–0.06; p = 0.07), positive surgical margin (OR: 0.85; 95% CI: 0.65–1.11; p = 0.23), major postoperative complications (OR: 0.90; 95% CI: 0.52–1.54; p = 0.69) and transfusion (OR: 0.72; 95% CI: 0.48–1.08; p = 0.11) between the groups. RPN showed better outcomes in the operating time (WMD: −22.45; 95% CI: −35.06 to −9.85; p = 0.0005), postoperative renal function (WMD: 3.32; 95% CI: 0.73–5.91; p = 0.01), warm ischemia time (WMD: −6.96; 95% CI: −7.30–−6.62; p &lt; 0.0001), conversion rate to radical nephrectomy (OR: 0.34; 95% CI: 0.17 to 0.66; p = 0.002) and intraoperative complications (OR: 0.52; 95% CI: 0.28–0.97; p = 0.04).

Discussion

RPN is a safe and effective alternative to LPNs for or the treatment of complex renal tumors with a RENAL nephrometry score ≥7 with a shorter warm ischemic time and better postoperative renal function.

The State of Robotic Partial Nephrectomy: Operative, Functional, and Oncological Outcomes From A Robust Multi-Institution Collaborative

OBJECTIVE

To describe the most recent surgical, functional, and oncological outcomes of RPN utilizing one of the largest, prospectively maintained, multi-institution consortium of patients undergoing robotic renal surgery.

MATERIALS AND METHODS

Data was obtained from a prospectively maintained multi-institutional database of patients who underwent RPN for clinically localized kidney cancer between 2018 and 2022 by 9 high-volume surgeons. Demographic and tumor characteristics as well as operative, functional, and oncological outcomes were queried.

RESULTS

A total of 2836 patients underwent RPN. Intraoperative, postoperative, and 30-day major complication rates were 2.68%, 11.39%, and 3.24%, respectively. Median tumor size was 3.0 cm. Tumors with low complexity had a shorter median operative time, lower median EBL, shorter median ischemia time, lower postoperative complication rate, and lower decline in renal function There was no significant difference between tumor complexities with respect to the rate of conversion to radical nephrectomy, conversion to open, major complications, and positive margins. Lower BMI, smaller clinical tumor size, lower tumor complexity, and higher baseline eGFR were significantly associated with trifecta achievement.

CONCLUSION

Patient BMI, baseline eGFR, and tumor characteristics such as size and complexity are the most important predictors of trifecta achievement. Patients with complex tumors should be counseled that they are at increased risk of complications and worsening renal function after robotic partial nephrectomy.

Partial nephrectomy in solitary kidneys: comparison between open surgery and robotic-assisted laparoscopy on perioperative and functional outcomes (UroCCR-54 study)

PURPOSE

The management of solitary kidney tumors is a surgical challenge, requiring irreproachable results on both oncological and functional outcomes. The goal of our study was to compare the perioperative results of robotic-assisted partial nephrectomy (RAPN) to open surgery in this indication.

METHODS

We led a multicentric study based on the prospectively maintained French national database UroCCR. Patients who underwent partial nephrectomy on a solitary kidney between 1988 and 2020 were included. Clinical and pathological data were retrospectively analyzed. The main outcome of the study was the analysis of the variation of the estimated glomerular filtration rate (eGFR) calculated according to MDRD at 3, 6, 12, and 24 months depending on the chosen surgical approach. The secondary outcomes were the comparison of Trifecta success, perioperative complications, and length of hospital stay.

RESULTS

In total, 150 patients were included; 68 (45%) in the RAPN group and 82 (55%) in the open surgery group. The two groups were comparable for all data. The variation of eGFR at 3, 6, 12, or 24 months was comparable without any significant difference between the 2 groups (p = 0.45). Trifecta was achieved in 40% of the patients in the RAPN group and 33% in the open group (p = 0.42). A significant difference was observed for the length of stay, 5 days for the robot group versus 9 days for the open surgery group (p < 0.0001).

CONCLUSION

In our study, the surgical approach did not modify functional results and we noted a significant decrease in hospital stay and complications in the RAPN group. RAPN is a safe and efficient method for management of kidney tumors in solitary kidneys.

A survey of augmented reality methods to guide minimally invasive partial nephrectomy

INTRODUCTION

Minimally invasive partial nephrectomy (MIPN) has become the standard of care for localized kidney tumors over the past decade. The characteristics of each tumor, in particular its size and relationship with the excretory tract and vessels, allow one to judge its complexity and to attempt predicting the risk of complications. The recent development of virtual 3D model reconstruction and computer vision has opened the way to image-guided surgery and augmented reality (AR).

OBJECTIVE

Our objective was to perform a systematic review to list and describe the different AR techniques proposed to support PN.

MATERIALS AND METHODS

The systematic review of the literature was performed on 12/04/22, using the keywords "nephrectomy" and "augmented reality" on Embase and Medline. Articles were considered if they reported surgical outcomes when using AR with virtual image overlay on real vision, during ex vivo or in vivo MIPN. We classified them according to the registration technique they use.

RESULTS

We found 16 articles describing an AR technique during MIPN procedures that met the eligibility criteria. A moderate to high risk of bias was recorded for all the studies. We classified registration methods into three main families, of which the most promising one seems to be surface-based registration.

CONCLUSION

Despite promising results, there do not exist studies showing an improvement in clinical outcomes using AR. The ideal AR technique is probably yet to be established, as several designs are still being actively explored. More clinical data will be required to establish the potential contribution of this technology to MIPN.

Nephrometric scoring system: Recent advances and outlooks

A nephrometry scoring system is a key standard to evaluate the feasibility of partial nephrectomy (PN). Whether based on two-dimensional or three-dimensional images, simplicity, effectiveness, and practicality are the keys to the nephrometric scoring system. Since the emergence of RENAL score in 2009, numerous scoring systems based on different anatomical parameters are established to seek accurately and few parameters to assess the risk of PN and complications. This study aimed to achieve a three-game winning streak in PN more easily and efficiently (negative resection margin, maximum preservation of normal nephron function, and avoiding short-term and long-term complications). Using PubMed, we counted 28 kinds of nephrometric scoring systems. We considered only English literatures published and excluded editorials, commentaries, and meeting abstracts. To the best of our knowledge, this is to date and most comprehensive summary as well as an outlook of the nephrometric scoring system.

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.

Partial Versus Radical Nephrectomy: Complexity of Decision-Making and Utility of AUA Guidelines

INTRODUCTION

The American-Urological-Association(AUA) Guidelines for renal cancer(2017) recommend consideration for radical-nephrectomy(RN) over partial(PN) whenever there is increased oncologic-risk; and RN should be prioritized if three other criteria are all also met: 1) increased tumor-complexity; 2) no preexisting chronic-kidney-disease/ proteinuria, and 3) normal contralateral kidney that will likely provide estimated glomerular-filtration-rate (eGFR) >45ml/min/1.73m² even if RN is performed. Our objective was to assess the complexity of decision-making about RN/PN and utility of AUA Guidelines statements regarding this issue.

PATIENTS AND METHODS

Retrospective review of 267 consecutive RN/PN from 2019(100-RN/167-PN). High tumor-complexity was defined as R.E.N.A.L.≥9. Increased oncologic-risk was defined as tumor >7cm, locally-advanced or infiltrative-features on imaging, or high-risk pathology on biopsy, if obtained. New-baseline GFR after RN was estimated using global-GFR, split-renal-function_{contralateral}, and presuming 25% renal-functional-compensation.

RESULTS

163 patients(61%) fit scenarios that are well-defined in the Guidelines. Of these, 34 had strong indications for RN, and all had RN. Twelve of 129 patients(9.3%) underwent RN despite Guidelines generally favoring PN. The remaining 104 patients(39%) did not fit within situations where the Guidelines provide specific recommendations. In these patients, RN was often performed despite functional-considerations favoring PN due to overriding concerns about oncologic-risk and/or tumor-complexity.

CONCLUSION

Our data demonstrate complexity of decision-making about PN/RN as almost 40% of patients did not fit well-described AUA Guidelines descriptors. Compliance was generally strong although occasional overutilization of RN remains a concern in our series, and will be addressed with additional education. Further studies will be required to assess the generalizability of our findings in other institutions/settings.

Robot-Assisted Partial Nephrectomy Mid-Term Oncologic Outcomes: A Systematic Review

Background: Robot-assisted partial nephrectomy (RAPN) is used more and more in present days as a therapy option for surgical treatment of cT1 renal masses. Current guidelines equally recommend open (OPN), laparoscopic (LPN), or robotic partial nephrectomy (PN). The aim of this review was to analyze the most representative RAPN series in terms of reported oncological outcomes. (2) Methods: A systematic search of Webofscience, PUBMED, Clinicaltrials.gov was performed on 1 August 2022. Studies were considered eligible if they: included patients with renal cell carcinoma (RCC) stage T1, were prospective, used randomized clinical trials (RCT) or retrospective studies, had patients undergo RAPN with a minimum follow-up of 48 months. (3) Results: Reported positive surgical margin rates were from 0 to 10.5%. Local recurrence occurred in up to 3.6% of patients. Distant metastases were reported in up to 6.4% of patients. 5-year cancer free survival (CFS) estimates rates ranged from 86.4% to 98.4%. 5-year cancer specific survival (CSS) estimates rates ranged from 90.1% to 100%, and 5-year overall survival (OS) estimates rated ranged from 82.6% to 97.9%. (4) Conclusions: Data coming from retrospective and prospective series shows very good oncologic outcomes after RAPN. Up to now, 10-year survival outcomes were not reported. Taken together, RAPN deliver similar oncologic performance to OPN and LPN.

Assessing Trifecta Achievement after Percutaneous Cryoablation of Small Renal Masses: Results from a Multi-Institutional Collaboration

Background and Objectives: To assess efficacy and safety of Percutaneous Cryoablation (PCA) of small renal masses (SRMs) using Trifecta outcomes in a large cohort of patients who were not eligible for surgery. Materials and methods: All PCAs performed in four different centers between September 2009 and September 2019 were retrospectively evaluated. Patients were divided in two different groups depending on masses dimensional criteria: Group-A: diameter ≤ 25 mm and Group-B: diameter > 25 mm. Complications rates were reported and classified according to the Clavien−Dindo system. The estimate glomerular filtration rate (eGFR) was calculated before PCA and during follow-up schedule. Every patient received a Contrast Enhanced Ultrasound (CEUS) evaluation on the first postoperative day. Radiological follow-up was taken at 3, 6, and 12 months for the first year, then yearly. Radiological recurrence was defined as a contrast enhancement persistence and was reported in the study. Finally, Trifecta outcome, which included complications, RFS, and preservation of eGFR class, was calculated for every procedure at a median follow-up of 32 months. Results: The median age of the patients was 74 years. Group-A included 200 procedures while Group-B included 140. Seventy-eight patients were eligible for Trifecta evaluation. Trifecta was achieved in 69.6% of procedures in Group-A, 40.6% in Group-B (p = 0.02). We observed an increased rate of complication in Group-B (13.0% vs. 28.6; p < 0.001). However, 97.5% were <II Clavien−Dindo grade. No differences were found between the two groups regarding eGFR before and after treatment. Further, 24-months RFS rates were respectively 98.0% for Group-A and 92.1% in Group-B, while at 36 months were respectively 94.5% and 87.5% (p = 0.08). Conclusions: PCA seems to be a safe and effective treatment for SRM but in the need of more strict dimensional criteria to achieve a higher possible success rate.

Surgical and functional outcomes of robot-assisted versus laparoscopic partial nephrectomy with cortical renorrhaphy omission

To evaluate the surgical and functional outcomes between robot-assisted (CRO-RAPN) vs. laparoscopic (CRO-LPN) methods of cortical-renorrhaphy-omitting partial nephrectomy. Between July 2012 and June 2020, patients with localized clinical T1-2 renal masses who underwent CRO-RAPN or CRO-LPN were reviewed. The outcomes of the two groups were compared using propensity-score matching. Trifecta was defined as negative surgical margin, warm ischemic time < 25 min, and absence of complications of Clavien-Dindo grade III or more until three months postoperatively. The preservation rate of the estimated glomerular filtration rate (eGFR) was evaluated at six months postoperatively. Among 291 patients (CRO-RAPN, n = 210; CRO-LPN, n = 81) included in the study, 150 matched pairs of patients were analyzed. Compared to the CRO-LPN group, the CRO-RAPN group was associated with shorter warm ischemic time (13 min vs. 20 min, P < 0.001), shorter total operation time (162 min vs. 212 min, P < 0.001), less estimated blood loss (40 mL vs. 119 mL, P = 0.002), lower incidence of overall complications (3% vs. 16%, P = 0.001), higher preservation rate of eGFR at six months postoperatively (93% vs. 89%, P = 0.003), and higher trifecta achievement rate (84% vs. 64%, P = 0.004). CRO-RAPN contributed to shorter warm ischemic time, less blood loss, fewer complications, and higher preservation of renal function, all of which allowed this technique to achieve a higher rate of trifecta compared to CRO-LPN.

Three-dimensional imaging reconstruction of the kidney's anatomy for a tailored minimal invasive partial nephrectomy: A pilot study

Objective

Methods

Results

Conclusion

Patient REnal and Tumor Attribute Score (PRETA Score): a comprehensive renal nephrometry score for use in patients with renal masses planned for minimally invasive nephron sparing surgery

Few comprehensive nephrometry scoring systems correlate renal morphology and patient factors like presence of chronic kidney disease (CKD) with the trifecta outcomes after partial nephrectomy (PN). We have proposed a new nephrometry score that correlates these factors to perioperative outcomes in minimally invasive PN. Records of all patients who underwent robot assisted laparoscopic PN at our institute were retrospectively reviewed. Baseline patient characteristics and imaging features were noted. Centrality Index or C-Index score and Mayo Adhesive Probability (MAP) score were calculated. Intraoperative and post-operative outcomes along with trifecta outcomes of PN were also noted. A total of 63 patients underwent PN, of which 50 had positive and 13 had negative trifecta outcomes. A total of 22 patients developed post-operative complications, with the majority being Clavien-Dindo Grade 1 and Grade 2 complications. Size of the tumor, presence of CKD, Centrality Index, Mayo Adhesive Probability score, nearness to hilum, and presence of congenital anomaly of the kidney or solitary kidney were significant predictors of negative trifecta outcomes on multivariate analysis. Based on these parameters we developed the Patient REnal Tumor Attribute (PRETA) score. The score ranges from 6 to 14. Patients with a score of 6 were at low risk of negative trifecta outcomes, those with a score of 7-10 were at moderate risk, and those with a score > 10 were at high risk. Prospective validation of this score was then done on the next 15 consecutive PN patients. In developing this score, we have done away with redundant parameters and have incorporated patient factors which have an important effect on patient outcomes after minimally invasive PN.

Perioperative outcomes following robot-assisted partial nephrectomy for complex renal masses: A Vattikuti Collective Quality Initiative database study

Introduction

Outcomes of robot-assisted partial nephrectomy (RAPN) depend on tumor complexity, surgeon experience and patient profile among other variables. We aimed to study the perioperative outcomes of RAPN for patients with complex renal masses using the Vattikuti Collective Quality Initiative (VCQI) database that allowed evaluation of multinational data.

Methods

From the VCQI, we extracted data for all the patients who underwent RAPN with preoperative aspects and dimensions used for an anatomical (PADUA) score of ≥10. Multivariate logistic regression was conducted to ascertain predictors of trifecta (absence of complications, negative surgical margins, and warm ischemia times [WIT] <25 min or zero ischemia) outcomes.

Results

Of 3,801 patients, 514 with PADUA scores ≥10 were included. The median operative time, WIT, and blood loss were 173 (range 45-546) min, 21 (range 0-55) min, and 150 (range 50-3500) ml, respectively. Intraoperative complications and blood transfusions were reported in 2.1% and 6%, respectively. In 8.8% of the patients, postoperative complications were noted, and surgical margins were positive in 10.3% of the patients. Trifecta could be achieved in 60.7% of patients. Clinical tumor size, duration of surgery, WIT, and complication rates were significantly higher in the group with a high (12 or 13) PADUA score while the trifecta was significantly lower in this group (48.4%). On multivariate analysis, surgical approach (retroperitoneal vs. transperitoneal) and high PADUA score (12/13) were identified as predictors of the trifecta outcomes.

Conclusion

RAPN may be a reasonable surgical option for patients with complex renal masses with acceptable perioperative outcomes.

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.

Simplified PADUA renal (SPARE) nephrometry score validation and long-term outcomes after robot-assisted partial nephrectomy

BACKGROUND

International guidelines suggest the use of anatomic scores to predict surgical outcomes after partial nephrectomy (PN). We aimed at validating the use of Simplified PADUA Renal (SPARE) nephrometry score in robot-assisted PN (RAPN).

MATERIALS AND METHODS

Three hundred and sixty-eight consecutive RAPN patients were included. Primary endpoints were overall complications, postoperative acute kidney injury (AKI) and TRIFECTA achievement. Secondary endpoint was estimated glomerular filtration rate (eGFR) decrease at last follow-up. Multivariable logistic and linear regression models were used.

RESULTS

Of 368 patients, 229 (62%) vs. 116 (31%) vs. 23 (6.2%) harboured low- vs. intermediate- vs. high-risk renal mass, according to SPARE classification. SPARE score predicted higher risk of overall complications (Odds ratio [OR]: 1.23, 95%CI 1.09-1.39; P < 0.001), and postoperative AKI (OR: 1.20, 95%CI 1.08-1.35; P < 0.01). Moreover, SPARE score was associated with lower TRIFECTA achievement (OR: 0.89, 95%CI 0.81-0.98; P = 0.02). Predicted accuracy was 0.643, 0.614 and 0.613, respectively. After a median follow-up of 40 (IQR: 21-66) months, eGFR decrease ranged from -7% in low-risk to -17% in high-risk SPARE.

CONCLUSIONS

SPARE scoring system predicts surgical success in RAPN patients. Moreover, SPARE score is associated with eGFR decrease at long-term follow-up. Thus, the adoption of SPARE score to objectively assess tumor complexity prior to RAPN may be preferable.

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.

Sex and Gender Differences in Kidney Cancer: Clinical and Experimental Evidence

Simple Summary

Kidney cancer is a frequent malignant tumor that accounts for approximately 5% of all cancer incidences. It affects both males and females, but males are twice as likely to develop kidney cancer than females. Evidence shows that this discrepancy takes root in individual differences, such as genetics or pathologies that affect the patient. It is then reflected in the clinical characteristics of the tumors, as males have larger and more aggressive tumors. Understanding the sex- and gender-based differences in kidney cancer is essential to be able to offer patients individualized medicine that would better cover their needs in terms of prevention, diagnosis and treatment.

Abstract

Sex and gender disparities have been reported for different types of non-reproductive cancers. Males are two times more likely to develop kidney cancer than females and have a higher death rate. These differences can be explained by looking at genetics and genomics, as well as other risk factors such as hypertension and obesity, lifestyle, and female sex hormones. Examination of the hormonal signaling pathways bring further insights into sex-related differences. Sex and gender-based disparities can be observed at the diagnostic, histological and treatment levels, leading to significant outcome difference. This review summarizes the current knowledge about sex and gender-related differences in the clinical presentation of patients with kidney cancer and the possible biological mechanisms that could explain these observations. Underlying sex-based differences may contribute to the development of sex-specific prognostic and diagnostic tools and the improvement of personalized therapies.

Parallel comparison of R.E.N.A.L., PADUA, and C-index scoring systems in predicting outcomes after partial nephrectomy: A systematic review and meta-analysis

Objective

To parallelly compare the applicability of the radius, exophytic/endophytic, nearness, anterior/posterior, location nephrometry score (R.E.N.A.L.), the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA), and the centrality index (C‐index) scoring systems in predicting clinical outcomes after partial nephrectomy (PN).

Methods

We searched EMBASE, PubMed, Ovid, and Web of Science to perform a meta‐analysis examining the correlation coefficients between three nephrometry scores (NSs) and warm ischemia time (WIT), estimated blood loss (EBL), operation time (OT), length of stay (LOS), and absolute change in eGFR (ACE) up to 25 January 2021.

Results

In total, 13 studies including 1496 patients met the criteria for further analysis. Overall, all scoring systems had statistically significant correlations with the WIT, EBL, OT, ACE and LOS and ACE, except for the correlation between PADUA and LOS (r = 0.16 [−0.00, 0.31], p > 0.05). The C‐index had the strongest correlation with WIT (r = −0.35 [−0.43, −0.26], p < 0.05) and ACE (r = −0.29 [−0.48, −0.10], p < 0.05). Weak correlations were observed between OT as well as EBL and each scoring system. Publication bias was observed in PADUA score predicting ACE (p = 0.04) and high heterogeneity was found in some of our results.

Conclusion

Until now, this is the first meta‐analysis that parallelly compares these three scoring systems in predicting outcomes after PN. We found that all NSs showed a statistically significant correlation with WIT, EBL, OT, and ACE. Moreover, the C‐index scoring system is the best predictor of WIT and ACE. Due to the existence of publication bias and high heterogeneity, more well‐designed and large‐scale studies are warranted for validation.

To our knowledge, this is the first meta‐analysis that parallelly compares these three scoring systems in predicting outcomes after PN. Overall, three scoring systems were significantly correlated with WIT, EBL, OT and ACE. Moreover, the C‐index scoring system outperformed R.E.N.A.L. and PADUA scoring systems in WIT and ACE.

Preoperative Assessment of Renal Sinus Invasion by Renal Cell Carcinoma according to Tumor Complexity and Imaging Features in Patients Undergoing Radical Nephrectomy

Objective

To identify the association between renal tumor complexity and pathologic renal sinus invasion (RSI) and evaluate the usefulness of computed tomography tumor features for predicting RSI in patients with renal cell carcinoma (RCC).

Materials and Methods

This retrospective study included 276 consecutive patients who underwent radical nephrectomy for RCC with a size of ≤ 7 cm between January 2014 and October 2017. Tumor complexity and anatomical renal sinus involvement were evaluated using two standardized scoring systems: the radius (R), exophytic or endophytic (E), nearness to collecting system or sinus (N), anterior or posterior (A), and location relative to polar lines (RENAL) nephrometry and preoperative aspects and dimensions used for anatomical classification (PADUA) system. CT-based tumor features, including shape, enhancement pattern, margin at the interface of the renal sinus (smooth vs. non-smooth), and finger-like projection of the mass, were also assessed by two independent radiologists. Univariable and multivariable logistic regression analyses were performed to identify significant predictors of RSI. The positive predictive value, negative predictive value (NPV), accuracy of anatomical renal sinus involvement, and tumor features were evaluated.

Results

Eighty-one of 276 patients (29.3%) demonstrated RSI. Among highly complex tumors (RENAL or PADUA score ≥ 10), the frequencies of RSI were 42.4% (39/92) and 38.0% (71/187) using RENAL and PADUA scores, respectively. Multivariable analysis showed that a non-smooth margin and the presence of a finger-like projection were significant predictors of RSI. Anatomical renal sinus involvement showed high NPVs (91.7% and 95.2%) but low accuracy (40.2% and 43.1%) for RSI, whereas the presence of a non-smooth margin or finger-like projection demonstrated comparably high NPVs (90.0% and 91.3% for both readers) and improved accuracy (67.0% and 73.9%, respectively).

Conclusion

A non-smooth margin or the presence of a finger-like projection can be used as a preoperative CT-based tumor feature for predicting RSI in patients with RCC.

Three-dimensional Virtual Models' Assistance During Minimally Invasive Partial Nephrectomy Minimizes the Impairment of Kidney Function

Three-dimensional virtual models (3DVMs) are nowadays under scrutiny to improve partial nephrectomy (PN) outcomes. This report aims to analyze their impact on renal function preservation after minimally invasive PN. A total of 100 patients treated with minimally invasive PN with contrast-enhanced computed tomography from which a 3DVM was obtained, and having undergone baseline and 3rd month postoperative renal scans were prospectively enrolled and compared with a control group of 251 patients without 3DVMs. Weighted differential of pre- and postoperative renal scan-based effective renal plasmatic flow (b-WD ERPF) was calculated, according to the availability of 3DVMs and PADUA risk category. Multivariable logistic regression (MLR) models predicting a significant loss of renal function (LORF; ERPF drop >20%) were performed, overall and according to PADUA risk categories. The b-WD ERPF of the 3DVM group showed significantly lower LORF (-10%) than that of the control group (-19.6%, p =  0.02). In MLR, the availability of a 3DVM was found to be the only protective factor against a significant LORF (odds ratio [OR] = 0.3, p =  0.002). Moreover, after stratification as per tumor surgical complexity, this protective role was observed in both PADUA 8-9 and ≥10 category risk patients (OR = 0.3, p =  0.03 and OR = 0.1, p =  0.01). PATIENT SUMMARY: The drop in operated kidney function was significantly lower in surgeries assisted by three-dimensional virtual models (3VDMs), indicating that the availability of a 3VDM is the only protective factor against a significant functional damage.

Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis

BACKGROUND

Despite efforts aimed at preserving renal function, the functional decline after robot-assisted partial nephrectomy (RAPN) is not negligible. To address the risk of intraparenchymal vessel injuries during renorrhaphy, with consequent loss of functional renal parenchyma, we introduced a new surgical technique for RAPN.

OBJECTIVE

To compare perioperative patient outcomes between selective-suturing or sutureless RAPN (suRAPN) and standard RAPN (stRAPN).

DESIGN, SETTING, AND PARTICIPANTS

Ninety-two consecutive patients undergoing RAPN for a renal mass performed by a high-volume surgeon at a European tertiary center were included. Propensity-score matching was used to account for baseline differences between suRAPN and stRAPN patients.

INTERVENTION

RAPN using a selective-suturing or sutureless technique versus standard RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Perioperative outcomes included operative time, blood loss, length of stay, and intraoperative and 30-d postoperative complications. We also evaluated trifecta achievement (warm ischemia time ≤25 min, negative surgical margins, and no perioperative complications) and the incidence of postoperative acute kidney injury (AKI). We applied χ² tests, t tests, and Kruskal-Wallis tests to assess differences in perioperative outcomes between suRAPN and stRAPN.

RESULTS AND LIMITATIONS

Overall, 29 patients (31%) were treated with suRAPN. Only one suRAPN patient experienced intraoperative complications (p = 0.9). Two suRAPN patients (6.9%) and four stRAPN patients (13.8%) experienced 30-d postoperative complications (p = 0.3). Operative time (110 vs 150 min; p < 0.01) and length of stay (2 vs 3 d; p = 0.02) were shorter for suRAPN than for stRAPN. The trifecta outcome was achieved in 25 suRAPN patients (86%) and 20 stRAPN patients (70%; p = 0.1). Only one suRAPN patient (3.4%) versus five stRAPN patients (17%) experienced postoperative AKI (p = 0.2). Finally, the decrease in the estimated glomerular filtration rate at 6-mo follow-up was lower in the suRAPN (-5.2%) than in the stRAPN group (-9.1%; p < 0.01). Lack of randomization represents the main study limitation.

CONCLUSIONS

A selective-suturing or sutureless technique in RAPN is feasible and safe. Moreover, suRAPN is a lower-impact surgical procedure. We obtained promising results for trifecta and functional outcomes, but prospective randomized trials are needed to validate the impact of selective suturing or a sutureless technique on long-term functional outcomes.

PATIENT SUMMARY

We assessed a new technique in robotic surgery to remove part of the kidney because of kidney cancer. Our new technique involves selective suturing or no suturing of the area from where the tumor is removed. We found that the rate of complications did not increase and the operating time and length of hospital stay were shorter using this new technique.

Robot-assisted partial nephrectomy for high-complexity tumors (PADUA score ≥10): Perioperative, long-term functional and oncologic outcomes

OBJECTIVES

To evaluate the safety and efficacy, and long-term functional and oncologic outcomes of robot-assisted partial nephrectomy in high-complexity tumors.

METHODS

Data of 155 patients with a high-complexity tumor (PADUA score ≥10) were reviewed. Trifecta achievement, intra-, perioperative, functional, and oncologic outcomes were analyzed and compared between patients with increasing complexity.

RESULTS

Of the 155 patients, 65 (41.9%) patients had a PADUA score of 10, 55 (35.5%) had a PADUA score of 11, and 35 (22.6%) had a PADUA score of 12-13, respectively. The median (interquartile range) operative time, warm ischemia time and estimated blood loss were 150 min (112-186 min), 26 min (23-32 min) and 250 mL (100-500 mL), respectively. Postoperatively, complications occurred in 25 (16.1%) patients, and positive surgical margins in 15 (10.5%) patients. Trifecta was achieved in 67 (43.2%) patients. At a median follow-up period of 58 months, the median estimated glomerular filtration rate preservation was 87% (78-110), and 12 (7.7%) patients developed new-onset chronic kidney disease. Recurrence-free survival and overall survival rates were 93.6% and 96.7%, respectively. Positive surgical margins were statistically different between the groups of PADUA score 10, 11 and 12-13 (P = 0.017), whereas functional and oncologic outcomes were similar. In multivariate logistic regression analysis, increasing tumor size (odds ratio 1.48, 95% confidence interval 1.21-1.87; P < 0.001) and the American Society of Anesthesiologists score 2/3 (odds ratio 0.48, 95% confidence interval 0.24-0.96; P = 0.041) were independent predictors of trifecta failure.

CONCLUSIONS

Robot-assisted partial nephrectomy is a safe and effective treatment for high-complexity tumors providing excellent long-term functional and oncologic outcomes.

The clinical value of indocyanine green fluorescence navigation system for laparoscopic partial nephrectomy in the case of complex renal clear cell carcinoma (R.E.N.A.L score ≥7)

Objective: We demonstrated the potential clinical utility of the indocyanine green (ICG) fluorescence navigation system for laparoscopic partial nephrectomy in the case of complex renal clear cell carcinoma (R.E.N.A.L score ≥7).

Methods: Compared with the general laparoscopic partial nephrectomy and ICG fluorescence laparoscopic partial nephrectomy, a series of indicators were analyzed: the basic information like age, sex, and the tumor location; the operative information like the time of renal ischemia, the blood loss, and the complications; and other important indexes like the renal function, the volume of the tumor, and the weight of the specimens.

Results: 60 patients were included in this study. 21 patients in the group of fluorescence laparoscopy, and 39 patients in the group of general laparoscopy. There was no statistical difference for most indexes except the renal function. Preoperative serum creatinine was close (82.4±11.7 vs. 77.5±12.7, mmol/l, p=0.15). However, the patients in the group of fluorescence laparoscopy got a smaller serum creatinine growth degree (12.9±5.3 vs. 17.9±7.3, mmol/l, p=0.008), and a less decreasing level of GFR (16.5±6.4 vs. 24.4±9.8, mL/(min*1.73m²), p=0.001) after the operation. In addition, the average volume of the tumor (28.8±9.8 vs. 26.9±8.2, cm³, p=0.43) and the weight of the specimens (32.3±10.4 vs. 33.9±8.9, g, p=0.52) were no statistical difference. But the group of fluorescence laparoscopy had a smaller ratio of the weight/ the volume (1.13±0.06 vs. 1.28±0.10, g/cm³, p<0.001). And the two groups had a similar test-positivity rate of surgical margins (p=0.19).

Conclusion: Without increasing the rate of positive surgical margins, ICG fluorescence navigation system for laparoscopic partial nephrectomy for complex renal clear cell carcinoma could conserve more normal renal tissue.

Comparison of Robot-Assisted and Laparoscopic Partial Nephrectomy for Renal Hilar Tumors: Results from a Tertiary Referral Center

Objective: To compare perioperative, functional, and oncologic outcomes between robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for renal hilar tumors. Methods: We retrospectively reviewed patients who underwent minimally invasive partial nephrectomy for renal hilar tumors at our institution between January 2014 and August 2018. The entire cohort was divided into two groups according to surgical approach: RAPN and LPN group. Perioperative, functional, and oncologic outcomes of the two groups were collected and compared. Results: A total of 116 patients with renal hilar tumors were identified, including 52 patients who underwent RAPN and 64 patients who underwent LPN, respectively. Demographic baseline characteristics were similar in two groups. There were no differences between the RAPN and LPN groups for operative time, transfusion rate, conversion rate, surgical margin, perioperative complication, and hospital stay. Compared with the LPN group, the RAPN group was associated with significant less estimated blood loss (100 vs 150 mL; p < 0.001), shorter warm ischemia time (20.3 vs 24.5 minutes; p = 0.001), and higher direct cost (p < 0.001). Percentage of estimated glomerular filtration rate change at 6 months after surgery was lower in RAPN group than LPN group (10.4% vs 15.2%; p = 0.020). No significant difference was observed between the two groups in terms of oncologic outcomes. Conclusions: For hilar tumors, both RAPN and LPN were safe and feasible surgical treatments. RAPN might be associated with superior perioperative outcomes (less estimated blood loss and shorter warm ischemia time) and better postoperative renal functional preservation. RAPN might be the preferred option when condition permits for renal hilar tumors.

Robot-assisted partial nephrectomy versus standard laparoscopic partial nephrectomy for renal hilar tumor: A prospective multi-institutional study

OBJECTIVE

To investigate whether robot-assisted partial nephrectomy compared with laparoscopic partial nephrectomy is effective for renal hilar tumor removal.

METHODS

This was a prospective, multicenter, single-arm, open-label trial with a 2-year enrollment period. A total of 22 academic hospitals in Japan participated in the present study. Comparison with historical control values from reported studies of laparoscopic partial nephrectomy was carried out. The warm ischemia time and positive surgical margin rate were set as primary perioperative and oncological outcomes. In the historical control group, these were 27.7 min and 13%, respectively.

RESULTS

The analysis population included 105 participants. The mean warm ischemia time was 20.2 (95% confidence interval 16.7-21.8; P < 0.0001 vs 27.7). Two of 103 participants (1.9%) had a positive surgical margin (95% confidence interval 0.5-6.8%). Both results satisfy the prespecified decision criteria for the superiority of robot-assisted partial nephrectomy over the historical control of laparoscopic partial nephrectomy. Resected weight and preoperative estimated glomerular filtration rate were predictive factors of functional loss of the partially nephrectomized kidney after robot-assisted partial nephrectomy.

CONCLUSION

Robot-assisted partial nephrectomy for clinical T1 renal hilar tumors results in shorter warm ischemia time than and comparable positive surgical margin rate to those reported for laparoscopic partial nephrectomy.