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

Comparison of the perioperative outcomes of robot-assisted laparoscopic transperitoneal versus retraperitoneal partial nephrectomy for posterior-lateral renal tumors: a systematic review and meta-analysis

The study aims to assess the available literature and compare the perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) for posterior-lateral renal tumors using transperitoneal (TP) and retroperitoneal (RP) approaches. Systematically searched the Embase, PubMed, and Cochrane Library databases for literature. Eligible studies were those that compared TP-RAPN and RP-RAPN for posterior-lateral renal tumors. The data from the included studies were analyzed and summarized using Review Manager 5.3, which involved comparing baseline patient and tumor characteristics, intraoperative and postoperative outcomes, and oncological outcomes. The analysis included five studies meeting the inclusion criteria, with a total of 1440 patients (814 undergoing RP-RAPN and 626 undergoing TP-RAPN). Both groups showed no significant differences in age, gender, BMI, R.E.N.A.L. score, and tumor size. Notably, compared to TP-RAPN, the RP-RAPN group demonstrated shorter operative time (OT) (MD: 17.25, P = 0.01), length of hospital stay (LOS) (MD: 0.37, P < 0.01), and lower estimated blood loss (EBL) (MD: 15.29, P < 0.01). However, no significant differences were found between the two groups in terms of warm ischemia time (WIT) (MD: -0.34, P = 0.69), overall complications (RR: 1.25, P = 0.09), major complications (the Clavien-Dindo classification ≥ 3) (RR: 0.97, P = 0.93), and positive surgical margin (PSM) (RR: 1.06, P = 0.87). The systematic review and meta-analysis suggests RP-RAPN may be more advantageous for posterior-lateral renal tumors in terms of OT, EBL, and LOS, but no significant differences were found in WIT, overall complications, major complications, and PSM. Both surgical approaches are safe, but a definitive advantage remains uncertain.

Robot-assisted single-port retroperitoneal partial nephrectomy with a novel purpose-built single-port robotic system with deformable surgical instruments

OBJECTIVE

To investigate the safety and feasibility of using a novel purpose-built single-port robotic system (the SHURUI Robotic Surgical System) with deformable surgical instruments to perform retroperitoneal single-port partial nephrectomy.

MATERIALS AND METHODS

A prospective study was conducted to recruit patients with a single renal tumor no more than 4 cm. Robot-assisted single-port partial nephrectomy was performed by using the novel purpose-built single-port robotic system with deformable surgical instruments. Patients' demographics, tumor characteristics, and perioperative parameters were recorded and analyzed.

RESULTS

Sixteen patients were recruited to the study. The median tumor size was 2.0 cm (IQR: 1.2-2.4 cm). The median R.E.N.A.L score was 6 (IQR: 4-4.5). In 3 cases, pure single-port surgery was carried out, and all the assistance was through the robotic port. Median docking time was 15.5 min (IQR: 14.25-22.25 min). Median operating time was 148.5 min (IQR: 178-238.5 min). Median console time was 107 min (IQR: 92.75-149.75 min). Median warm ischemic time was 26.5 min (IQR: 24.5-30 min). Median blood loss was 17.5 ml (IQR: 10-50 ml).

CONCLUSIONS

Retroperitoneal partial nephrectomy can be safely performed with this novel purpose-built single-port robotic system (SHURUI) with deformable surgical instruments. Further studies are needed to fully evaluate the role of this new platform.

Long term experience of robotic retroperitoneal partial nephrectomy as the default approach in the management of renal masses: should the paradigm shift?

Although retroperitoneal surgery has demonstrated a better quality of recovery compared to transperitoneal routes, Retroperitoneal Robot Assisted Partial Nephrectomy (RRAPN) remains proportionally infrequent. As the boundaries of what is achievable robotically continue to be pushed, we present our experience at a high-volume tertiary referral centre that specialises in retroperitoneal surgery, exploring its feasibility as standard of care in the management of small renal masses. A prospective database of 784 RAPNs (2009-2020) was reviewed and 721 RRAPNs (92%) were performed at our centre. In our practice, we utilise a four-port approach to RRAPN. Patient, tumour and operative characteristics were assessed and both oncological outcomes and trifecta and pentafecta achievements were determined. Pentafecta was defined as achieving trifecta (negative surgical margin, no post-operative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Multivariate analysis was conducted to predict peri-operative factors which may prevent achieving a trifecta/pentafecta outcome. From 784 cases, 112 RAPNs were performed for imperative reasons, whilst the remainder were elective. Mean BMI ± s.d amongst our cohort was 28.6 ± 5.7. Mean tumour size was 3.1 cm (range 0.8-10.5 cm) and 47% of cases were stratified as intermediate/high risk using R.E.N.A.L nephrometry scoring. Forty-six patients had lesions in a hilar location, and 31% were anterior. Median blood loss was 30mls, with an open conversion rate of 1% and transfusion rate of 1.6%. Median warm ischaemic time (WIT) was 21 min, positive surgical margins were found in 4% and our post-operative Clavien 3/ > complication rate was 2.6%. We had a 1-day median length of stay with a 30 day readmission rate of 2%. Of 631 patients (80%) with a definitive histological diagnosis of cancer, 23% had T1b/ > disease. Over a mean 15 month follow-up period (range 1-125 months), 2% of patients developed recurrences and our cohort demonstrated a 99% 5 year cancer specific survival. Trifecta was achieved in 67% of cases and pentafecta in 47%. Age (p = 0.05), operative time (p = 0.008), pT1b tumours (p = 0.03), R.E.N.A.L score and blood loss (p = 0.001) were found to statistically significantly influence achievement of trifecta. Pentafecta achievement was influenced by R.E.N.A.L score (p = 0.008), operative time (p = 0.001) and blood loss (p = 0.001). We demonstrate the retroperitoneal approach in RAPN is feasible and safe irrespective of lesion location and complexity. In the hands of high-volume centres that are skilled in the retroperitoneal approach the benefits of retroperitoneal surgery can be extended even to challenging cohorts of patients without compromising their oncological or functional outcomes.

Perioperative, functional, and oncological outcomes of robotic vs. laparoscopic partial nephrectomy for complex renal tumors (RENAL score ≥7): an evidence-based analysis

Objective

To evaluate the current literature comparing outcomes of robotic partial nephrectomy (RPN) versus laparoscopic partial nephrectomy (LPN) treating complex renal tumors (RENAL nephrometry score ≥7).

Methods

We systematically searched the Cochrane Library, PubMed, Google Scholar, EMBASE, and Scopus databases up to March 2023. Review Manager 5.4 performed a pooled analysis of the data for random effects. Besides, sensitivity and subgroup analyses to explore heterogeneity, Newcastle-Ottawa scale, and GRADE to evaluate study quality and level of evidence.

Results

Eight observational studies comprising 1346 patients (RPN: 695; LPN: 651) were included in this study. Compared to LPN, RPN had a shorter operative time (OT) (weight mean difference [WMD]: -14.73 min; p = 0.0003), shorter warm ischemia time (WIT) (WMD: -3.47 min; p = 0.002), lower transfusion rate (odds ratio [OR]: 0.66; p = 0.04), shorter length of stay (LOS) (WMD: -0.65 days; p < 0.00001), lower postoperative estimated glomerular filtration rate (eGFR) change (WMD = -2.33 mL/min/1.73 m2; p = 0.002) and lower intraoperative complications (OR: 0.52; p = 0.04). No significant differences were observed between the two groups in terms of estimated blood loss (EBL) (p = 0.84), conversion to radical nephrectomy (p = 0.12), postoperative complications (p = 0.11), major complications (defined Clavien-Dindo grade 3 (p = 0.43), overall complications (p = 0.15), postoperative eGFR (p = 0.28), local recurrence (p = 0.35), positive surgical margin (PSM) (p = 0.63), overall survival (OS) (p = 0.47), cancer-specific survival (CSS) (p = 0.22) and 3-year recurrence-free survival (RFS) (p = 0.53).

Conclusion

Patients with complex renal tumors (RENAL score ≥7), RPN is superior to LPN in decreasing the OT, WIT, LOS, transfusion rate, change in eGFR and the incidence of intraoperative complications while maintaining oncological control and avoiding a decline in renal function. However, our findings need further validation in a large-sample prospective randomized study.

Transperitoneal Laparoscopic and Robotic Partial Nephrectomy for Renal Cancer in Patients with Previous Abdominal Surgery: a Single Centre Experience

Patients with previous abdominal surgery are at an increased risk of peritoneal adhesions, which may complicate transperitoneal surgery. The objective of this article is to report single centre experience with transperitoneal laparoscopic and robotic partial nephrectomy for renal cancer in patients with previous abdominal surgery. We evaluated data from 128 patients who underwent laparoscopic or robotic partial nephrectomy from January 2010 to May 2020. Patients were divided into three groups according to the localization of main previous surgery: in the upper contralateral abdominal quadrant, in the upper ipsilateral abdominal quadrant or in the middle line, in lower abdominal quadrants. Each group was divided into two subgroups (laparoscopic/robotic partial nephrectomy). We separately analysed data of indocyanine green-enhanced robotic partial nephrectomy. Our study did not find significant difference in the rate of intraoperative or postoperative complications between any of the groups. The type of partial nephrectomy (robotic or laparoscopic) affected the surgery time, blood loss, and length of stay in hospital, but did not significantly influence the frequency of complications. Partial nephrectomy in group of patients with prior renal surgery led to a higher rate of intraoperative low-grade complications. We did not observe more favourable results for indocyanine green-enhanced robotic partial nephrectomy. The location of previous abdominal surgery does not influence the rate of intraoperative or postoperative complications. The type of partial nephrectomy (robotic or laparoscopic) does not affect the frequency of complications.

Surgical strategy of laparoscopic partial nephrectomy: It is more suitable to use transperitoneal approach in anterior tumor patients and retroperitoneal approach in posterior tumor patients

Background

Previous surgical strategy of transperitoneal laparoscopic partial nephrectomy (TLPN) and retroperitoneal laparoscopic partial nephrectomy (RLPN) for treatment of renal cell carcinoma (RCC) mainly depend on surgeons' preference. The aim of this study was to evaluate whether performing TLPN for anterior tumors and RLPN for posterior tumors is a more beneficial strategy.

Method

214 patients underwent TLPN or RLPN at our center were retrospectively collected and 1:1 matched for surgical approach, tumor complexity as well as operator. Baseline characteristics and perioperative outcomes were evaluated and compared, respectively.

Result

Regardless of tumor location, RLPN was associated with a faster operative time, a quicker time to first oral intake and hospital discharge compared to TLPN approach while other baseline and perioperative outcomes were comparable between groups. After taking tumor location into consideration, TLPN has an advantage in operating time (109.8 vs 115.3 mins, p = 0.03) and ischemic time (20.3 vs 24.1 mins, p = 0.001) for anterior tumor, while RLPN has an advantage in operating time (103.5 vs 116.3 mins, p<0.001), ischemic time (21.8 vs 24.8 mins, p = 7 0.001) and estimated blood loss (65.5 vs 85.4 ml, p = 0.01) for posterior tumor.

Conclusion

The selection of approach should be also dependent of the tumor location, instead of only dependent of surgeons' experience or preference.

Comparison of Transperitoneal and Retroperitoneal Robotic Partial Nephrectomy for Patients with Completely Lower Pole Renal Tumors

(1) Background: For completely lower pole renal tumors, we compared the perioperative outcomes of robotic partial nephrectomy via transperitoneal and retroperitoneal approaches. (2) Methods: Complete lower pole renal tumors were defined as tumors that received 1 point for the “L” element of the R.E.N.A.L. and located at the lower pole of kidney. After confirming consistency in baseline characteristics, oncological and functional benefits were compared. Pentafecta achievement was used to represent the perioperative optimal outcome, followed by multivariate analysis of factors associated with the lack of pentafecta achievement. (3) Results: Among 151 patients identified, 116 (77%) underwent robotic partial nephrectomy via a transperitoneal approach and 35 (23%) via a retroperitoneal approach. Patients undergoing transperitoneal robotic partial nephrectomy experienced more blood loss than those undergoing retroperitoneal robotic partial nephrectomy (50 mL vs. 40 mL, p = 0.015). No significant differences were identified for operative time (120 min vs. 120 min), ischemia time (19 min vs. 20 min), positive surgical margins (0.0% vs. 2.86%), postoperative rate of complication (12.07% vs. 5.71%). No significant differences were identified in pathologic variables, eGFR decline in postoperative 12-month (3.9% vs. 5.4%) functional follow-up. Multivariate cox analysis showed that tumor size (OR: 0.523; 95% CI: 0.371−0.736; p < 0.001) alone was independently correlated to the achievement of pentafecta. (4) Conclusions: For completely lower pole renal tumors, transperitoneal and retroperitoneal robotic partial nephrectomy provide similar outcomes. These two surgical approaches remain feasible options for these cases.

Comparison of Perioperative Outcomes Between Retroperitoneal Single-Port and Multiport Robot-Assisted Partial Nephrectomies

Objective: To report early institutional experience with the single-port robotic platform and compare perioperative outcomes between single-port robot-assisted partial nephrectomies (SP-RAPN) and multiport robot-assisted partial nephrectomies (MP-RAPN) when utilizing a retroperitoneal approach. Methods: A retrospective chart review of patients who underwent SP-RAPN or MP-RAPN at our institution between November 1, 2013 and May 30, 2021 was performed. Surgical platforms were compared through univariate analysis using the Kruskal-Wallis test for continuous variables and χ² test for categorical variables. Results: A total of 20 SP-RAPN and 42 MP-RAPN were performed utilizing a retroperitoneal approach. Patients who underwent SP-RAPN were more likely to have a lower radius, endophytic/exophytic, nearness, anterior/posterior, location score (4 vs 6; p = 0.0084) and their masses tended to be more exophytic, although this was not statistically significant (p = 0.0535). Patients undergoing SP-RAPN had a shorter postoperative length of hospital stay (1 vs 2 days; p < 0.0001). There were no significant differences in operative time, estimated blood loss, ischemia time, positive margin rate, malignant histology, postoperative complication rate, or Clavien-Dindo complication grade. Conclusion: Retroperitoneal SP-RAPN appear to be safe without compromising perioperative outcomes when compared with MP-RAPN for low-complexity renal masses. Further studies are recommended to assess the role of the SP for higher-complexity renal masses and to characterize variables that influence the observed difference in length of hospital stay.

Novel Gerota-edge-sling technique facilitates retroperitoneal robot-assisted partial nephrectomy: a comparative study

Background

Retroperitoneal robotic partial nephrectomy is markedly restricted by limited space and visual field. We introduced a novel Gerota-edge-sling (GES) technique with self-designed traction devices to overcome these defects by attaching Gerota fascia to abdominal wall, and comparatively evaluated its utilization with routine technique.

Methods

A retrospective analysis was performed for consecutive patients who underwent routine (control group) or GES assisted (GES group) retroperitoneal robotic partial nephrectomy for localized renal tumors in our hospital between March 2018 and June 2020. Clinical data of perioperative outcomes and complications were collected and compared. Comparison of outcomes between anterior versus posterior tumor subgroups was also conducted. Linear regression analysis was used to define the relationship between dissection time and perinephric fat status in each group.

Results

Totally 103 patients were included, 48 in control and 55 in GES group respectively. All the procedures were completed successfully without conversion or positive surgical margin. GES group had significantly decreased console time (91 ± 36 min vs. 117 ± 41 min, p < 0.01) and dissection time (67 ± 35 min vs. 93 ± 38 min, p < 0.01) than control, while ischemia time, blood loss, and nephrometry score comparable between them. No major postoperative complications occurred. Dissection time of GES group was notably shorter than that of control in both anterior/posterior subgroups. Only in control group, dissection time was positively associated with perinephric fat status.

Conclusions

The GES technique acting as an adjunct to robotic arms with space-sparing feature, notably improves surgical exposure and facilitates dissection in retroperitoneal partial nephrectomy, while having great feasibility, efficacy and safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-01079-4.

The impact of a fellow on a regional robotic-assisted partial nephrectomy service

INTRODUCTION

Training a fellow has a cost in time and effort for the surgeon and their team. Their relative inexperience may also negatively affect the patient. The aim of this study was to determine and quantify the impact of a fellow on a regional robotic-assisted partial nephrectomy service and on perioperative outcomes.

MATERIALS AND METHODS

We reviewed the prospectively collected data for 522 patients who had undergone robotic-assisted partial nephrectomy since 2015 during the tenure of six fellows. Perioperative outcomes for three groups were compared: group A (no fellow participation), group B (some participation) and group C (fellow completed entire operation). We also reviewed progression over 12 months.

RESULTS

Demographics were similar in all groups apart from the percentage of men, which was lower in group C (p < 0.05). Operative time was 27 minutes longer for group B (p < 0.001). Warm ischaemia time was significantly shorter for group A but the difference was only four minutes (p < 0.001). Length of stay was slightly shorter for group C compared with the other groups (p < 0.01). Trifecta achievement was greatest for group A (p < 0.001). There were no perioperative deaths in any group and positive margins, complications and readmissions were low and similar in all groups. Towards the end of their fellowship, fellows performed more operations independently.

CONCLUSION

There is a measurable, but small, negative impact of a fellow on a robotic-assisted partial nephrectomy service, which reduces with experience. With appropriate supervision and patient selection, a fellow can be taught robotic-assisted partial nephrectomy without affecting patient safety or treatment outcome.

Computed Tomography Image under Three-Dimensional Reconstruction Algorithm Based in Diagnosis of Renal Tumors and Retroperitoneal Laparoscopic Partial Nephrectomy

This study was to explore the clinical application value of computed tomography (CT) images based on a three-dimensional (3D) reconstruction algorithm for laparoscopic partial nephrectomy (LPN) in patients with renal tumors. 30 cases of renal cell carcinoma (RCC) patients admitted to the hospital were selected as the research objects and were rolled into two groups using a random table method. The patients who received PLN under the three-dimensional reconstruction and laparoscopic technique were included in the experimental group (group A), and the patients who received LPN using CT images only were included in the control group (group B). In addition, the treatment results of the two groups of patients were compared and analyzed. Results. The effective rate of the established model was 93.3%; the total renal arteriovenous variability of group A (13.3%) was higher than that of group B (6.7%), and the operation time (131.5 ± 32.1 minutes) was much lower than that of group B (158.7 ± 36.2 minutes), showing statistical significance (P < 0.05). Conclusion. CT images based on 3D reconstruction algorithms had high clinical application value for LPN in patients with renal tumors, which could improve the efficiency and safety of LPN.

Comparison of Outcomes Between Transperitoneal and Retroperitoneal Robotic Partial Nephrectomy: A Meta-Analysis Based on Comparative Studies

Background

To compare perioperative, functional and oncological outcomes between transperitoneal robotic partial nephrectomy (TRPN) and retroperitoneal robotic partial nephrectomy (RRPN).

Methods

A literature searching of Pubmed, Embase, Cochrane Library and Web of Science was performed in August, 2020. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs) were estimated using fixed-effect or random-effect model. Publication bias was evaluated with funnel plots. Only comparative studies with matched design or similar baseline characteristics were included.

Results

Eleven studies embracing 2,984 patients were included. There was no significant difference between the two groups regarding conversion to open (P = 0.44) or radical (P = 0.31) surgery, all complications (P = 0.06), major complications (P = 0.07), warm ischemia time (P = 0.73), positive surgical margin (P = 0.87), decline in eGFR (P = 0.42), CKD upstaging (P = 0.72), and total recurrence (P = 0.66). Patients undergoing TRPN had a significant higher minor complications (P = 0.04; OR: 1.39; 95% CI, 1.01–1.91), longer operative time (P < 0.001; WMD: 21.68; 95% CI, 11.61 to 31.76), more estimated blood loss (EBL, P = 0.002; WMD: 40.94; 95% CI, 14.87 to 67.01), longer length of hospital stay (LOS, P < 0.001; WMD: 0.86; 95% CI, 0.35 to 1.37). No obvious publication bias was identified.

Conclusion

RRPN is more favorable than TRPN in terms of less minor complications, shorter operative time, less EBL, and shorter LOS. Methodological limitations of the included studies should be considered while interpreting these results.

Comparison of postoperative recovery after robot-assisted partial nephrectomy of T1 renal tumors through retroperitoneal or transperitoneal approach: A Japanese single institutional analysis

OBJECTIVE

To evaluate the quality of recovery in patients who underwent robot-assisted partial nephrectomy and to compare the outcomes of the transperitoneal or retroperitoneal approach.

METHODS

This study included 121 patients who underwent robot-assisted partial nephrectomy under general anesthesia from April 2019 to September 2019 at Tokyo Women's Medical University, Tokyo, Japan. Quality of recovery was defined according to the QoR-40 Japanese version. The participants responded to the QoR-40 Japanese version on three designated days. The patients were assigned to two groups according to the surgical approach: transperitoneal or retroperitoneal. A multivariate logistic regression analysis was carried out to identify independent factors associated with better quality of recovery.

RESULTS

Out of the 121 patients, 56 (46%) and 65 (54%) patients were included in the transperitoneal and retroperitoneal group, respectively. Although the QoR-40 Japanese version scores were not different between the two groups at admission, a better quality of recovery was observed in the retroperitoneal group than in the transperitoneal group at discharge based on the total score: physical comfort, emotional state, physical independence and pain. A multivariate analysis showed that the retroperitoneal approach and male sex were associated with a better QoR-40 Japanese version score at discharge.

CONCLUSIONS

A retroperitoneal approach offers better quality of recovery than a transperitoneal approach, and therefore it might represent the optimal approach in selected patients undergoing robot-assisted partial nephrectomy.

Transperitoneal vs retroperitoneal minimally invasive partial nephrectomy: comparison of perioperative outcomes and functional follow-up in a large multi-institutional cohort (The RECORD 2 Project)

BACKGROUND

Aim of this study was to evaluate and compare perioperative outcomes of transperitoneal (TP) and retroperitoneal (TR) approaches in a multi-institutional cohort of minimally invasive partial nephrectomy (MI-PN).

MATERIAL AND METHODS

All consecutive patients undergone MI-PN for clinical T1 renal tumors at 26 Italian centers (RECORd2 project) between 01/2013 and 12/2016 were evaluated, collecting the pre-, intra-, and postoperative data. The patients were then stratified according to the surgical approach, TP or RP. A 1:1 propensity score (PS) matching was performed to obtain homogeneous cohorts, considering the age, gender, baseline eGFR, surgical indication, clinical diameter, and PADUA score.

RESULTS

1669 patients treated with MI-PN were included in the study, 1256 and 413 undergoing TP and RP, respectively. After 1:1 PS matching according to the surgical access, 413 patients were selected from TP group to be compared with the 413 RP patients. Concerning intraoperative variables, no differences were found between the two groups in terms of surgical approach (lap/robot), extirpative technique (enucleation vs standard PN), hilar clamping, and ischemia time. Conversely, the TP group recorded a shorter median operative time in comparison with the RP group (115 vs 150 min), with a higher occurrence of intraoperative overall, 21 (5.0%) vs 9 (2.1%); p = 0.03, and surgical complications, 18 (4.3%) vs 7 (1.7%); p = 0.04. Concerning postoperative variables, the two groups resulted comparable in terms of complications, positive surgical margins and renal function, even if the RP group recorded a shorter median drainage duration and hospital length of stay (3 vs 2 for both variables), p < 0.0001.

CONCLUSIONS

The results of this study suggest that both TP and RP are feasible approaches when performing MI-PN, irrespectively from tumor location or surgical complexity. Notwithstanding longer operative times, RP seems to have a slighter intraoperative complication rate with earlier postoperative recovery when compared with TP.

Single-port robotic partial and radical nephrectomies for renal cortical tumors: initial clinical experience

To describe our institution's initial experience with radical (RN) and partial nephrectomy (PN) using the SP robotic system. The recent FDA approval of the da Vinci^® SP robotic platform has led to its use in minimally invasive approaches to urologic malignancies. There are little data on its feasibility and safety after implementation for radical and partial nephrectomy. All patients who underwent PN or RN using the SP system at our institution were reviewed. All PNs were performed off-clamp. Patient demographics, preoperative imaging, operative approaches, and perioperative outcomes were collected and analyzed. Sixteen patients underwent PN (n = 13) or RN (n = 3) utilizing the SP robotic system between January 2019 and June 2019. Average age was 58.6 ± 13.9 and 61.0 ± 1.7 years in each group, respectively. A retroperitoneal approach was performed in 7 (53.8%) PN patients and 1 (33.3%) RN patient. A transperitoneal approach was performed in 6 (46.1%) PNs and 2 (66.7%) RNs. Mean operative time and median estimated blood loss for PN was 176.9 ± 64.0 min and 200 (50-800) ml compared to 176.3 ± 73.8 min and 50 (50-400) ml for RN. There was one operative conversion (7.7%) to an open approach in the PN group. Length of hospital stay postoperatively averaged 1.9 ± 1.3 days and 3.3 ± 1.2 days for patients undergoing partial and radical nephrectomy, respectively. SP partial and radical nephrectomies through transperitoneal and retroperitoneal approaches appear to be feasible surgical techniques in the management of cortical renal masses. Off-clamp PN is also a feasible approach using the SP system. However, further study is needed to establish its safety and use in renal surgery across multiple institutions and larger patient cohorts.

Robot-assisted versus laparoscopic partial nephrectomy for anatomically complex T1b renal tumors with a RENAL nephrometry score ≥7: A propensity score-based analysis

Objectives

To present the perioperative, functional, and oncological outcomes of robot‐assisted partial nephrectomy (RPN) compared with laparoscopic partial nephrectomy (LPN) for anatomically complex T1b renal tumors with RENAL nephrometry scores ≥7.

Patients and methods

One hundred and seventy patients, during the study period, were retrospectively reviewed in our analysis according to inclusion criteria. Propensity score matching (PSM) (1:1) method was applied to impose restrictions on the potential baseline confounders. The comparisons of perioperative and functional outcomes between the RPN and LPN groups were conducted and analyzed after PSM, Kaplan‐Meier analyses were performed to assess the differences about oncological outcomes between the two groups before and after PSM.

Results

One hundred and nine and 61 T1b renal tumors with RENAL scores ≥7 were identified in the LPN and RPN groups, respectively. All significant differences in baseline characteristics disappeared after PSM. Except for 3 patients missing an appropriate pair, all the patients in the RPN group were successfully matched to 58 patients in the LPN group in a 1:1 ratio. Within the matched cohort, the RPN group was related to a significantly shorter mean operating time (OT) (P = .040), shorter mean warm ischemia time (WIT) (P = .023), and shorter median postoperative hospital stay (P = .023). The possibilities of surgical conversion, postoperative complication, and positive surgical margin were similar in the LPN and RPN groups. And there was also no significant difference in the pathological, renal functional, and oncological outcomes between the two series.

Conclusions

For patients with anatomically complex T1b renal tumors with a RENAL nephrometry score ≥7, RPN had an advantage over LPN in reducing OT, WIT, and postoperative hospital stay length without increasing the risk of complications and weakening the oncological control, while the two surgical methods were similar in renal functional preservation.

Simplified robot-assisted partial nephrectomy: step-by-step technique and perioperative outcomes

Controversies have been raised and still exist regarding several technical aspects of robot-assisted partial nephrectomy (RAPN). While the "perfect RAPN" has still to be determined, we aimed to report a simplified technique of RAPN in a step-by-step fashion and the perioperative outcomes of a single-center series. A simplified technique of RAPN was developed, refined and standardized over the past 7 years in an academic department of urology to make it as safe and as reproducible as possible, the main goal being to make it an "easy to learn" technique for fellows. This technique is presented in 12 key steps. The patients' characteristics and perioperative outcomes were prospectively collected and are reported herein. Since the first case performed in our department in 2010, 406 patients have undergone RAPN with a standardized and stable simplified technique after the first 30 cases, involving several key steps including systematic use of the transperitoneal approach, minimal visceral mobilization of the colon, systematic psoas exposure and ureter identification, minimal dissection of the perinephric fat, arterial clamping with early unclamping, no use of hemostatic agents or drain. The majority of RAPN were performed by surgeons with either low experience (i.e., < 20 procedures; 46.3%) or intermediate experience (i.e., 20-50 procedures; 17.2%). The mean warm ischemia time was 15.3 min. Conversions to an open approach and to radical nephrectomy were required in 14 (3.5%) and 21 (5.2%) cases, respectively. From 132 patients who experienced post-operative complications (32.5%), 47 experienced a major complication (11.6%). The positive surgical margin rate was 5.6%. The simplified technique of RAPN was feasible and reproducible with satisfactory perioperative outcomes. Most of the key steps have been assessed through single-center and multicenter clinical studies.

Retroperitoneal approach for robot-assisted partial nephrectomy: technique and early outcomes

OBJECTIVES

The aim of our study is to present early outcomes of our series of retroperitoneal-RAPN (Robot Assisted Partial Nephrectomy).

MATERIALS AND METHODS

From September 2010 until December 2015, we performed 81 RAPN procedures (44 at left kidney and 37 at right). Average size was 3cm (1-9). Average PADUA score 7.1 (5-10). Average surgical time (overall and only robot time), ischemia time, blood loss, pathological stage, complications and hospital stay have been recorded.

RESULTS

All of the cases were completed successfully without any operative complication or surgical conversion. Average surgical time was 177 minutes (75-340). Operative time was 145 minutes (80-300), overall blood loss was 142cc (60-310cc). In 30 cases the pedicle was late clamped with an average ischemia time of 4 minutes (2-7). None of the patient had positive surgical margins at definitive histology (49pT1a, 12pT1b, 3pT2a, 2pT3a). Hospital stay was 3 days (2-7).

CONCLUSIONS

The retroperitoneal robotic partial nephrectomy approach is safe and allows treatment of even quite complex tumors. It also combines the already well known advantages guaranteed by the da Vinci® robotic surgical system, with the advantages of the retroperitoneoscopic approach.

Retroperitoneal Robotic Partial Nephrectomy: Systematic Review and Cumulative Analysis of Comparative Outcomes

OBJECTIVES

To compare the outcomes of retroperitoneal vs transperitoneal approach for robot-assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

A systematic review of the literature was performed through January 2018 using PubMed, Scopus, and Ovid databases. Article selection proceeded according to the search strategy based on PRISMA criteria. Only studies comparing retroperitoneal to transperitoneal approach for RAPN were deemed eligible for inclusion.

RESULTS

Seven retrospective case-control studies were identified and included in the analysis, with a total number of 1379 patients (866 for transperitoneal group; 513 for retroperitoneal group). In the retroperitoneal group, tumors were slightly larger [weighted mean difference (WMD): 0.29 cm; 95% confidence interval (CI): 0.04-0.54; p = 0.02], and more frequently located posterior/lateral (odds ratio: 0.61; 95% CI: 0.41-0.90; p = 0.01). In two of the studies only posterior tumors had been included. Both operating time (WMD 20.17 min; 95% CI 6.46-33.88; p = 0.004) and estimated blood loss (WMD 54.57 mL; 95% CI 6.73-102.4; p = 0.03) were significantly lower in the retroperitoneal group. In addition, length of stay was significantly shorter in the retroperitoneal group (WMD 0.46 days; CI 95% 0.15-0.76; p = 0.003). No differences were found regarding overall (p = 0.67) and major (p = 0.82) postoperative complications, warm ischemia time (p = 0.96), and positive surgical margins (p = 0.95).

CONCLUSIONS

Retroperitoneal RAPN can offer in select patients similar outcomes to those of the most common transperitoneal RAPN. Furthermore, it may be particularly advantageous for posterior upper pole and perihilar tumors and associated with reduction in operative time and hospital stay. Robotic surgeons should be ideally familiar with both approaches to adapt their surgical strategy to confront renal neoplasms from a position of technical advantage and ultimately optimize outcomes.

Robotic Partial Nephrectomy for Posterior Tumors Through a Retroperitoneal Approach Offers Decreased Length of Stay Compared with the Transperitoneal Approach: A Propensity-Matched Analysis

INTRODUCTION

We sought to compare surgical outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy (RPN) for posterior tumors.

PATIENTS AND METHODS

Using our multi-institutional RPN database, we reviewed 610 consecutive cases for posterior renal masses treated between 2007 and 2015. Primary outcomes were complications, operative time, length of stay (LOS), surgical margin status, and estimated glomerular filtration rate (eGFR) preservation. Secondary outcomes were estimated blood loss, warm ischemia time (WIT), disease recurrence, and disease-specific mortality. Due to significant differences in treatment year and tumor size between approaches, retroperitoneal cases were matched 1:4 to transperitoneal cases based on propensity scores using the greedy algorithm. Outcomes were compared between approaches using the chi-square and Mann-Whitney U tests.

RESULTS

After matching, 296 transperitoneal and 74 retroperitoneal cases were available for analysis, and matched groups were well balanced in terms of treatment year, age, gender, race, American Society of Anesthesiologists physical status classification (ASA) score, body mass index, tumor laterality, tumor size, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus, anterior/posterior, location relative to polar lines) score, and hilar location. Compared with transperitoneal, the retroperitoneal approach was associated with significantly shorter mean LOS (2.2 vs 2.6 days, p = 0.01), but longer mean WIT (21 vs 19 minutes, p = 0.01). Intraoperative (p = 0.35) and postoperative complications (p = 0.65), operative time (p = 0.93), positive margins (p = 1.0), and latest eGFR preservation (p = 0.25) were not significantly different between approaches. No differences were detected in the other outcomes.

CONCLUSIONS

Among high-volume surgeons, transperitoneal and retroperitoneal RPN achieved similar outcomes for posterior renal masses, although with slight differences in LOS and WIT. Retroperitoneal RPN may be an effective option for the treatment of certain small posterior renal masses.