Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol. 2009;182:866-872. [PMID: 19616229 DOI: 10.1016/j.juro.2009.05.037]

Outcomes of robotic-assisted radical nephrectomy during service implementation: Lessons from an audit

BACKGROUND

Robot-assisted surgery (RAS) is an extension of minimally invasive surgery rapidly gaining acceptance in many conditions. The study aims to assess and share lessons impact of RAS on the radical nephrectomy (RN) service during the implementation phase.

METHODS

Two separate analyses were carried out: to compare the outcome of all RN - before and after the implementation of RAS regardless of surgical mode, and a direct comparison between two minimal invasive approaches: Robotic-assisted radical nephrectomies (RARNs) and Laparoscopic radical nephrectomies (LRNs).

RESULTS

The study included 55 pre- and 45 robotic era RNs: 45 RARNs, 48 LRNs and 7 open radical nephrectomies (ORNs). Following RAS implementation, all RNs transitioned to RARNs. The broader comparison of all RNs in the robotic versus pre-robotic periods revealed significant reductions in estimated blood loss and the length of hospital stay, though operative times were notably longer. In the direct comparison between LRNs and RARNs, no major differences in perioperative outcomes were noted, except for a significantly longer duration of surgery in the RARN group.

CONCLUSION

The introduction of the robotic platform resulted in a paradigm shift in RN service, eliminating ORN and LRN. Despite increasing operative duration, RARNs improved certain perioperative outcomes (specifically length of stay and blood loss) and were favoured over other modalities.

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.

Meta-analysis of clinical outcomes of robot-assisted partial nephrectomy and classical open partial nephrectomy

BACKGROUND

Robotic-assisted partial nephrectomy (RAPN) has emerged as a promising alternative to classical partial nephrectomy (CPN).

AIM

This study aimed to compare the outcomes of RAPN and CPN for treating localized renal tumors through a meta-analysis of available literature.

METHODS

Chinese databases, such as CNKI, Chinese Science and Technology Periodicals Database (VIP), and Wanfang Full-text Database, were searched using Chinese search terms, and all published articles on PubMed and Web of Science were searched using English search terms. Articles on Localized Renal Tumors were included. RevMan5.3 software was used for meta-analysis. The funnel plots were drawn using Stata software to assess publication bias.

OUTCOMES

This study aimed to identify the differences between robotic-assisted partial nephrectomy and classic partial nephrectomy in patients with localized renal tumors.

RESULTS

In total, 67 articles with 17 677 patients were included. The results demonstrate the advantages of RAPN over CPN for localized renal tumors. Compared to CPN and RAPN had significant differences in intraoperative blood loss, hospital stay duration, incidence of perioperative complications, and proportion of patients requiring blood transfusion. Regarding surgical outcomes, RAPN showed more favorable results regarding the incidence of positive resection margins, postoperative decline in glomerular filtration rate (GFR), postoperative local recurrence rate, and proportion of Trifecta achieved. However, there was no significant difference between RAPN and CPN regarding 5-year tumor-specific survival rates.

CLINICAL IMPLICATIONS

The study suggests that robotic-assisted partial nephrectomy is a viable alternative to classic surgery for renal tumors.

STRENGTHS AND LIMITATIONS

The strengths of this study are the use of a comprehensive search strategy and the inclusion of studies published in both English and Chinese. The limitations of this study are the small sample size and the need for long-term follow-up data.

CONCLUSION

RAPN and CPN have similar overall survival outcomes for treating localized renal tumors. However, RAPN may offer advantages in terms of perioperative outcomes and preservation of renal function. Further studies are needed to confirm these findings and to identify the optimal surgical approach for individual patients.

Best predictive single nephrometry score component to correlate with achievement of trifecta outcome in laparoscopic and robotic surgery

BACKGROUND

To evaluate the predictive value of individual components of the R.E.N.A.L scoring system for Laparoscopic (LPN) and Robotic Partial Nephrectomy (RPN).

METHODS

Patients that had undergone a Laparoscopic (LPN) or Robotic Partial Nephrectomy (RPN) between 2018 and 2023 were reviewed. Our data collection included Race, Ethnicity, Age, BMI, R.E.N.A.L nephrometry score, and complications. Cases that achieved trifecta outcomes were designated as "Group A" and cases that did not achieve trifecta were "Group B". All the data were collected using REDCap database.

RESULTS

A total of 111 cases were included, Group A consisted of 82% of all cases, whereas Group B 18%. Radius score demonstrated significant distinction concerning trifecta attainment and was the most predictive component of the 5 scoring metrics of the nephrometry system. In a subgroup analysis, R-score of 3 or a renal mass measuring ≥ 7 cm, was a significant independent negative predictor for trifecta outcomes, as well as tumor size at presentation.

CONCLUSION

Renal nephrometry score is predictive of trifecta outcomes for patients undergoing laparoscopic or robotic partial nephrectomy. Radius of mass was the most effective predictive component of the nephrometry score for trifecta prediction.

Tracing the evolving dynamics and research hotspots in the kidney neoplasm and nephron sparing surgery field from the past to the new era

BACKGROUND

With increasing detection of small renal masses and accumulating evidence that nephron sparing surgery (NSS) could achieve oncological equivalence and functional superiority compared with radical nephrectomy (RN), NSS has become first-line therapy for some patients with localized renal masses.

OBJECTIVE

This study aims to review the publications in the kidney neoplasm and NSS field, exploring the research hotspots.

METHOD

Kidney neoplasm and NSS related publications before July 3th 2023 were obtained from the Web of Science Core Collection database. We then used bibliometric analysis to conduct performance analysis, citation analysis and co-citation network of publications, together with keyword co-occurrence analysis.

RESULTS

Seven thousand five hundred and sixty-four documents were finally retrieved, and the annual publications increased exponentially. The most productive authors were "KAOUK JH" and "GILL IS", while USA, and 12 American affiliations such as CLEVELAND CLINIC FOUNDATION and MAYO CLINIC were far leading in this field. Journal of Urology and European Urology were journals with the highest citations and h-index.

DISCUSSION

Through literature reviewing plus co-occurrence and clustering analysis, the therapeutic effects of partial nephrectomy (PN) versus RN on patients with localized renal cell carcinoma, different operative approaches of PN, and conservative NSS methods were deemed as the most focused topics.

CONCLUSION

Three aspects were the most important hotspots in this field. Firstly, how to provide the optimal management choices for different patients. Secondly, therapeutic effects of different management options and surgical techniques needed more prospective and randomized studies. Finally, more novel technologies and surgical techniques were required.

Three-dimensional computed tomography-based resection process map for robot-assisted partial nephrectomy: propensity score matching of a single-center retrospective study

BACKGROUND AND OBJECTIVES

We aimed to examine the effect of preoperative three-dimensional (3D) computed tomography (CT)-based resection process map (RPM) imaging on the outcomes of robot-assisted partial nephrectomy (RAPN).

METHODS

We retrospectively analyzed 177 patients (RPM group, n = 92; non-RPM group, n = 85) who underwent this surgery between November 2012 and April 2022. Patient-specific contrast-enhanced CT images were used to construct an RPM, a 3D representation of the kidney showing the planned tumor resection and a 5 mm safety margin. Outcome analyses were performed using propensity score matching. The primary endpoint was the trifecta achievement rate.

RESULTS

We extracted 90 cases. The trifecta achievement rate showed no significant differences between the RPM (73.3%) and non-RPM groups (73.3%). However, the RPM group had fewer Grade 3 and higher complications (0.0% vs. 13.3%, p = 0.026). The da Vinci Xi (OR 3.38, p = 0.016) and tumor diameter (OR 0.95, p = 0.013) were independent factors affecting trifecta achievement in multivariate analysis. Using RPM imaging was associated with the absence of Grade 3 and higher perioperative complications (OR 5.33, p = 0.036) in univariate analysis.

CONCLUSIONS

Using preoperative 3D CT-based RPM images before RAPN may not affect trifecta achievement, but may reduce serious complication occurrence by providing detailed information on tumor resection.

Artificial intelligence and machine learning trends in kidney care

BACKGROUND

The integration of artificial intelligence (AI) and machine learning (ML) in kidney care has seen a significant rise in recent years. This study specifically analyzed AI and ML research publications related to kidney care to identify leading authors, institutions, and countries in this area. It aimed to examine publication trends and patterns, and to explore the impact of collaborative efforts on citation metrics.

METHODS

The study used the Science Citation Index Expanded (SCI-EXPANDED) of Clarivate Analytics Web of Science Core Collection to search for AI and machine learning publications related to nephrology from 1992 to 2021. The authors used quotation marks and Boolean operator "or" to search for keywords in the title, abstract, author keywords, and Keywords Plus. In addition, the 'front page' filter was applied. A total of 5425 documents were identified and analyzed.

RESULTS

The results showed that articles represent 75% of the analyzed documents, with an average author to publications ratio of 7.4 and an average number of citations per publication in 2021 of 18. English articles had a higher citation rate than non-English articles. The USA dominated in all publication indicators, followed by China. Notably, the research also showed that collaborative efforts tend to result in higher citation rates. A significant portion of the publications were found in urology journals, emphasizing the broader scope of kidney care beyond traditional nephrology.

CONCLUSIONS

The findings underscore the importance of AI and ML in enhancing kidney care, offering a roadmap for future research and implementation in this expanding field.

Suitability of the MP1000 system for robot-assisted partial nephrectomy: a multicenter randomized controlled noninferiority trial

PURPOSE

This study aimed to compare the safety and effectiveness of the MP1000 surgical system with the da Vinci Si robot system in robot-assisted partial nephrectomy (RAPN) through a prospective, single-blinded, randomized controlled trial.

MATERIALS AND METHODS

A total of 62 patients who were scheduled to undergo RAPN were randomly assigned to either the da Vinci Si robot or MP1000 group. A noninferiority test was conducted with a noninferior intermediate value of 10%. The study compared installation and operation times, estimated blood loss, warm ischemia time, postoperative surgical margin, rate of conversion to open surgery, eGFR level, complications, and other safety indicators between the two groups.

RESULTS

All procedures were successfully completed without the need for conversion to open or laparoscopic surgery, and no major complications were observed during the process. The test of noninferiority was achieved. There were no significant differences in median installation time, operation time, complication rate at 3 months, rate of positive surgical margin, and eGFR level at 3 months between the groups. Additionally, no evidence of recurrence was found on imaging in both groups. No difference in National Aeronautics and Space Administration task load index results for ergonomic considerations. A limitation of this study was its small sample size.

CONCLUSIONS

The MP1000 system is a suitable platform for RAPN with safety and effectiveness compared with da Vinci Si system.

Feasibility study of a novel robotic system for transperitoneal partial nephrectomy: An in vivo experimental animal study

PURPOSE

To evaluate the safety and feasibility of partial nephrectomy with the use of the novel robotic system in an in vivo animal model.

METHODS

Right partial nephrectomy was performed in female pigs by a surgical team consisting of one surgeon and one bedside assistant. Both were experienced in laparoscopic surgery and trained in the use of the novel robotic system. The partial nephrectomies were performed using four trocars (three trocars for the robotic arms and one as an assistant trocar). The completion of the operations, set-up time, operation time, warm ischemia time (WIT) and complication events were recorded. The decrease in all variables between the first and last operation was calculated.

RESULTS

In total, eight partial nephrectomies were performed in eight female pigs. All operations were successfully completed. The median set-up time was 19.5 (range, 15-30) minutes, while the estimated median operative time was 80.5 minutes (range, 59-114). The median WIT was 23.5 minutes (range, 17-32) and intra- or postoperative complications were not observed. All variables decreased in consecutive operations. More precisely, the decrease in the set-up time was calculated to 15 minutes between the first and third attempts. The operative time was reduced by 55 minutes between the first and last operation, while the WIT was decreased by 15 minutes during the consecutive attempts. No complications were noticed in any operation.

CONCLUSIONS

Using the newly introduced robotic system, all the advantages of robotic surgery are optimized and incorporated, and partial nephrectomies can be performed in a safe and effective manner.

Transperitoneal Versus Retroperitoneal Single-port Robotic-assisted Partial Nephrectomy: An Analysis from the Single Port Advanced Research Consortium

BACKGROUND

In the surgical management of kidney tumors, such as in multiport technology, single-port (SP) robotic-assisted partial nephrectomy (RAPN) can be performed using the transperitoneal (TP) or retroperitoneal (RP) approach. However, there is a dearth of literature on the efficacy and safety of either approach for SP RAPN.

OBJECTIVE

To compare the peri- and postoperative outcomes of the TP and RP approaches for SP RAPN.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study using data from the Single Port Advanced Research Consortium (SPARC) database of five institutions. All patients underwent SP RAPN for a renal mass between 2019 and 2022.

INTERVENTION

TP versus RP SP RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline characteristics, and peri- and postoperative outcomes were compared between both the approaches using χ2 test, Fisher exact test, Mann-Whitney U test, and Student t test.

RESULTS AND LIMITATIONS

A total of 219 patients (121 [55.25%] TP, 98 [44.75%] RP) were included in the study. Of them, 115 (51.51%) were male, and the mean age was 60 ± 11 yr. RP had a significantly higher proportion of posterior tumors (54 [55.10%] RP vs 28 [23.14%] TP, p < 0.001), while other baseline characteristics were comparable between both the approaches. There was no statistically significant difference in ischemia time (18 ± 9 vs 18 ± 11 min, p = 0.898), operative time (147 ± 67 vs 146 ± 70 min, p = 0.925), estimated blood loss (p = 0.167), length of stay (1.06 ± 2.25 vs 1.33 ± 1.05 d, p = 0.270), overall complications (5 [5.10%] vs 7 [5.79%]), and major complication rate (2 [2.04%] vs 2 [1.65%], p = 1.000). No difference was observed in positive surgical margin rate (p = 0.472) or delta eGFR at median 6-mo follow-up (p = 0.273). Limitations include retrospective design and no long-term follow-up.

CONCLUSIONS

With proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

PATIENT SUMMARY

The use of a single port (SP) is a novel technology for performing robotic surgery. Robotic-assisted partial nephrectomy (RAPN) is a surgery to remove a portion of the kidney due to kidney cancer. Depending on patient characteristics and surgeons' preference, SP can be performed via two approaches for RAPN: through the abdomen or through the space behind the abdominal cavity. We compared outcomes between these two approaches for patients receiving SP RAPN, finding that they were comparable. We conclude that with proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

Robotic assisted partial nephrectomy reduces warm ischemia time and improves renal function acutely compared to the traditional laparoscopic approach; A single surgeon twin centre study

Herein, we compared peri-operative and post-operative outcomes between robotic-assisted and laparoscopic partial nephrectomy. Various reviews of the current literature have detailed the lack of single-surgeon studies in this domain. Our study featured a single surgeon experienced in both approaches to reduce this bias seen in other multi-centre studies. We retrospectively analysed data from two hospitals to compare patient demographics, tumour characteristics, peri-operative and post-operative outcomes of all partial nephrectomies undertaken by a single surgeon with extensive experience in both approaches. Statistical analysis was carried out using GraphPad prism software. Warm ischaemia time was significantly reduced in the robotic arm compared to the laparoscopic group. This translated into an improvement in acute renal function. Length of stay was also significantly reduced. This study highlights some benefits of robotic-assisted in comparison to laparoscopic partial nephrectomy. Further large-scale prospective studies would be valuable in confirming these findings and justifying their usage against their financial cost.

Complications after Nephron-sparing Interventions for Renal Tumors: Imaging Findings and Management

The two primary nephron-sparing interventions for treating renal masses such as renal cell carcinoma are surgical partial nephrectomy (PN) and image-guided percutaneous thermal ablation. Nephron-sparing surgery, such as PN, has been the standard of care for treating many localized renal masses. Although uncommon, complications resulting from PN can range from asymptomatic and mild to symptomatic and life-threatening. These complications include vascular injuries such as hematoma, pseudoaneurysm, arteriovenous fistula, and/or renal ischemia; injury to the collecting system causing urinary leak; infection; and tumor recurrence. The incidence of complications after any nephron-sparing surgery depends on many factors, such as the proximity of the tumor to blood vessels or the collecting system, the skill or experience of the surgeon, and patient-specific factors. More recently, image-guided percutaneous renal ablation has emerged as a safe and effective treatment option for small renal tumors, with comparable oncologic outcomes to those of PN and a low incidence of major complications. Radiologists must be familiar with the imaging findings encountered after these surgical and image-guided procedures, especially those indicative of complications. The authors review cross-sectional imaging characteristics of complications after PN and image-guided thermal ablation of kidney tumors and highlight the respective management strategies, ranging from clinical observation to interventions such as angioembolization or repeat surgery. Work of the U.S. Government published under an exclusive license with the RSNA. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Quiz questions for this article are available in the Online Learning Center. See the invited commentary by Chung and Raman in this issue.

Integration of Virtual Reality in the Control System of an Innovative Medical Robot for Single-Incision Laparoscopic Surgery

In recent years, there has been an expansion in the development of simulators that use virtual reality (VR) as a learning tool. In surgery where robots are used, VR serves as a revolutionary technology to help medical doctors train in using these robotic systems and accumulate knowledge without risk. This article presents a study in which VR is used to create a simulator designed for robotically assisted single-uniport surgery. The control of the surgical robotic system is achieved using voice commands for laparoscopic camera positioning and via a user interface developed using the Visual Studio program that connects a wristband equipped with sensors attached to the user's hand for the manipulation of the active instruments. The software consists of the user interface and the VR application via the TCP/IP communication protocol. To study the evolution of the performance of this virtual system, 15 people were involved in the experimental evaluation of the VR simulator built for the robotic surgical system, having to complete a medically relevant task. The experimental data validated the initial solution, which will be further developed.

Risk factors for hemorrhagic complications following robotic-assisted partial nephrectomy

BACKGROUND

The aim of this study was to analyze the risk factors for hemorrhagic complications in patients who underwent robotic-assisted partial nephrectomy.

METHODS

We retrospectively reviewed the records of 260 patients who underwent robotic-assisted partial nephrectomy. Hemorrhagic complications were defined as bleeding, hematoma, or arteriovenous fistula requiring hemostatic medication, blood transfusion, or therapeutic intervention. Hemorrhagic complications were graded according to the modified Clavien classification system, and the hemorrhagic complication group comprised only those complications with Clavien grade II or higher. Thereafter, we investigated the presence of any relevant association between perioperative factors and hemorrhagic complications.

RESULTS

Of 260 patients included in the study, 32 (12.3%) had hemorrhagic complications. The postoperative hemoglobin level was significantly lower in the hemorrhagic complication group than in the group without complications. The hemorrhagic complication group had significantly more essential blood loss and a significantly longer length of hospital stay. In the univariate analysis, type 2 diabetes mellitus, Radius-scores tumor size as maximal diameter exophytic/endophytic properties of the tumor nearness of the deepest portion of the tumor to the collecting system or renal sinus anterior (a)/posterior (p) descriptor location relative to the polar line., sum of the renal size plus renal sinus involvement in the PADUA score is a simple anatomical system that can be used to predict the risk of surgical and medical perioperative complications in patients undergoing open NSS, prolonged console time (>180 minutes), prolonged warm ischemic time (>25 minutes), and method of pedicle control were statistically significant risk factors. In the multivariate logistic regression analysis, warm ischemic time >25 minutes was the only significant risk factor for hemorrhagic complications (odds ratio, 3.51; 95% confidence interval, 1.28-9.59; p = 0.01).

CONCLUSION

Patients who undergo robotic-assisted partial nephrectomy with a warm ischemic time >25 minutes are significantly more likely to have hemorrhagic complications and should hence receive careful perioperative follow-up.

Preliminary experience of partial nephrectomy through a new single-port surgical robot system

PURPOSE

To explore the preliminary safety and efficacy of the Shurui single-port surgical robot in partial nephrectomy.

METHODS

This study prospectively enrolled patients with T1a renal tumours who met the inclusion criteria from February to July 2022 in The First Affiliated Hospital School of Medicine Zhejiang University. The operative outcomes and perioperative data, including clinical and histological data, were prospectively collected and analysed.

RESULTS

A total of 13 patients were included in this study, including 7 males and 6 females. The median age was 53 (33-74) years, and the average body mass index was 24.9±4.2 kg/m2. There were 6 cases of left kidney tumours and 7 cases of right kidney tumours in the 13 patients. The average tumour diameter was 1.9±0.9 cm. In all operations, the diseased tissue was removed according to the established surgical plan. The average warm ischaemia time was 26.2±9.7 minutes; the average device docking time was 3.6±1.8 minutes; and the average robotic arm operation time was 124.7±40.4 minutes. All operations were successfully completed; there was no conversion to open surgery during the operation; and no operation holes were added. The NASA-TLX score was 26.3±2.6 points, and no device-related adverse events occurred during the operation. The median time to discharge was 6 days (range, 4-11 days). Postoperative pathological examination showed that all tumour margins were negative. There were no Clavien grade ≥3 surgical complications in any of the patients during the perioperative period or at the 1-month postoperative follow-up.

CONCLUSION

The new single-port surgical robot system is safe, effective, flexible, and stable for application in partial nephrectomy.

Robotic surgery in comparison to the open and laparoscopic approaches in the field of urology: a systematic review

To establish the feasibility of robotic surgical procedures in urology in terms of the applications, merits, and demerits as well as the postoperative and oncological outcomes while comparing it with the conventional approaches. A systematic search of electronic databases was performed to identify Randomized Controlled Trials and Cohort studies on Robot-Assisted urological surgical procedures in comparison with the conventional methods. The quality assessment of included studies was performed using the Newcastle-Ottawa Scale and the revised Cochrane "Risk of Bias" tool. A qualitative narrative synthesis of the data extracted from the studies was performed and presented in tabulated form. After screening, 39 studies were included in our review (7 Randomized Controlled Trials and 32 Cohort studies). Robot-Assisted Prostatectomy appears to be associated with lower estimated blood loss and shorter length of hospital stay. For Robot-Assisted Cystectomy, the results suggest longer operative time and fewer complications. Robot-Assisted Radical Nephrectomy was found to be associated with fewer perioperative complications and longer mean operative time while Robot-Assisted Partial Nephrectomy was associated with less positive surgical margins and reduced need for postoperative analgesia. The mean operative time was longer while the length of stay was shorter for the robotic approach in inguinal lymphadenectomy and ureteral reimplantation. The feasibility of Robot-Assisted surgery varied for different outcome measures as well as for different procedures. Some common advantages were a shorter length of stay, lesser blood loss, and fewer complications while the drawbacks included longer operative time.Study protocol PROSPERO database (Registration Number: CRD42021256623).

A comparison of outcomes between transperitoneal and retroperitoneal robotic assisted partial nephrectomy in patients with completely endophytic kidney tumors

INTRODUCTION

Retroperitoneal robotic partial nephrectomy (RPN) has been shown to have comparable outcomes to the transperitoneal approach for renal tumors. However, this may not be true for completely endophytic tumors as they pose significant challenges in RPN with increased complication rates. Hence, we sought to compare the safety and feasibility of retroperitoneal RPN to transperitoneal RPN for completely endophytic tumors.

METHODS

We performed a retrospective analysis of patients who underwent RPN for a completely endophytic renal mass using either transperitoneal or retroperitoneal approach from our multi-institutional database (n = 177). Patients who had a solitary kidney, prior ipsilateral surgery, multiple/bilateral tumors, and horseshoe kidneys were excluded from the analysis. Overall, 156 patients were evaluated (112 [71.8%] transperitoneal, 44 [28.2%] retroperitoneal). Baseline characteristics, perioperative and postoperative data were compared between the surgical transperitoneal and retroperitoneal approach using Chi-square test, Fishers exact test, t test, Mood median test and Mann Whitney U test.

RESULTS

Of the 156 patients in this study, 86 (56.9%) were male and the mean (SD) age was 58 (13) years. Baseline characteristics were comparable between the 2 approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (19.6 [SD = 7.6] minutes vs. 19.5 [SD = 10.2] minutes, P = 0.952), operative time (157.5 [SD = 44.8] minutes vs. 160.2 [SD = 47.3] minutes, P = 0.746), median estimated blood loss (50 ml [IQR: 50, 150] vs. 100 ml [IQR: 50, 200], P = 0.313), median length of stay (1 [IQR: 1, 2] day vs. 1 [IQR: 1, 2] day, P = 0.126) and major complication rate (2 [4.6%] vs. 3 [2.7%], P = 0.621). No difference was observed in positive surgical margin rate (P = 0.1.00), delta eGFR (P = 0.797) and de novo chronic kidney disease occurrence (P = 1.000).

CONCLUSION

Retroperitoneal and transperitoneal RPN yielded similar perioperative and functional outcomes in patients with completely endophytic tumors. In well-selected patients with purely endophytic tumors, either a retroperitoneal or transperitoneal approach could be considered without compromising perioperative and postoperative outcomes.

Retrospective comparison of clinical outcomes of robotic-assisted laparoscopic partial nephrectomy through transabdominal or retroperitoneal approaches in patients with T1b renal tumor

BACKGROUND

We compared the intraoperative and postoperative outcomes of robotic-assisted laparoscopic partial nephrectomy (RALPN) via transabdominal or retroperitoneal approaches in patients with stage T1b renal cell carcinoma.

METHODS

The medical records for 92 patients who underwent RALPN were retrospectively collected and data on their baseline demographics, duration of operation, duration of renal artery clamping, intraoperative blood loss, recovery time of intestinal functions, surgical margin positive rate, as well as postoperative complications were analyzed.

RESULTS

Of the 92 enrolled patients, 43 and 49 patients were subjected to RALPN via the transabdominal and retroperitoneal approaches, respectively. All patients successfully completed the operation. Baseline characteristics for the transabdominal and retroperitoneal groups were comparable. Differences in operative time, renal artery clamping time, intraoperative blood loss, positive rate of surgical margin, and incidences of postoperative complications between the two approaches were insignificant. The recovery time of intestinal function after operation was significantly shorter in patients subjected to the retroperitoneal approach, relative to those subjected to transabdominal approach (p < 0.001).

CONCLUSIONS

Application of RALPN via transabdominal or retroperitoneal approaches showed comparable clinical outcomes in patients with stage T1b renal cell carcinoma. The retroperitoneal approach was superior to the transabdominal approach in terms of postoperative intestinal function recovery.

Benefits of Robotic Assisted vs. Traditional Laparoscopic Partial Nephrectomy: A Single Surgeon Comparative Study

PURPOSE

The current study aims to compare peri-operative and post-operative outcomes between robotic assisted vs. laparoscopic partial nephrectomy. Multiple reviews of the current literature have detailed the lack of single surgeon studies in this domain. To limit inter-operator bias, we utilise a single surgeon experienced in both approaches to reduce this bias seen in other multi-centre studies.

METHODS AND MATERIALS

We retrospectively compared patient demographics, tumour characteristics, peri-operative and post-operative outcomes of all partial nephrectomies undertaken by a single surgeon between 2014 and 2021 with experience in both laparoscopic and robotic surgery. The Da Vinci surgical system was utilized. Statistical analysis was carried out using GraphPad prism software version 7.03, San Diego, CA, USA.

RESULTS

Warm ischemia time was reduced by 2.6 min, length of stay reduced by 1.3 days and acute renal function deterioration was reduced by 55% with all these results being significant with robotic assisted partial nephrectomy compared to laparoscopic partial nephrectomy.

CONCLUSION

This study highlights the benefits of robotic assisted in comparison to laparoscopic partial nephrectomy. Further large-scale prospective studies and cost-benefit analysis of robotic assisted partial nephrectomy would be valuable in confirming these findings and justifying the usage against their financial cost.

Robot-assisted partial nephrectomy with a new robotic surgical system: feasibility and perioperative outcomes

PURPOSE

To evaluate the feasibility and safety of a novel robotic system (KD-SR-01) for partial nephrectomy.

METHODS

Seventeen patients with small renal mass (SRM) (≤4 cm) underwent KD-SR-01 robotic partial nephrectomy (KD-RPN) from December 2020 to March 2021 in our institution. The operative outcomes and perioperative data, including clinical and histological data, were prospectively collected and analyzed.

RESULTS

In total, 10 men and 7 women, with a median age of 51 years, underwent KD-RPN. Four transperitoneal procedures and 13 retroperitoneal procedures were successfully performed without conversion to open or conventional laparoscopic surgery. The docking time and robotic operative time were 3.3 min and 68.6 min, respectively. The warm ischemia time was 16.9 min. No major intraoperative or postoperative complications (Clavien grade ≥ III) occurred. The duration of postoperative hospital stay was 5 days. Pathologic examination revealed nine clear cell carcinomas, two papillary cell carcinomas, one oncocytoma, and five angiomyolipoma. All surgical margins were negative. The estimated globular filtration rate (eGFR) on the 1st postoperative day was significantly decreased compared to the preoperative eGFR (91.7±12.9 ml/min vs. 97.9±10.7 ml/min, P =0.036). However, no significant difference was observed between the preoperative eGFR and the value on the 4th postoperative day (95.7±13.4 ml/min vs. 97.9±10.7 ml/min, P=0.427).

CONCLUSION

KD-RPN was safe and feasible for the treatment of SRM. The early oncologic and functional outcomes were promising. Long-term follow-up and well-designed prospective comparative studies with the da Vinci platform are needed to corroborate these findings.

“Zero ischemia” laparoscopic partial nephrectomy by high-power GreenLight laser enucleation for renal carcinoma: A single-center experience

BACKGROUND

Laparoscopic partial nephrectomy has been widely used in renal cell carcinoma treatment. The efficacy of GreenLight laser on Laparoscopic partial nephrectomy is still unknown.

AIM

To present the first series of laparoscopic partial nephrectomy (LPN) by GreenLight laser enucleation without renal artery clamping. Due to the excellent coagulation and hemostatic properties of the laser, laser-assisted LPN (LLPN) makes it possible to perform a “zero ischemia” resection.

METHODS

Fifteen patients with T1a exogenous renal tumors who received high-power GreenLight laser non-ischemic LPN in our hospital were retrospectively analyzed. All clinical information, surgical and post-operative data, complications, pathological and functional outcomes were analyzed.

RESULTS

Surgery was successfully completed in all patients, and no open or radical nephrectomy was performed. The renal artery was not clamped, leading to no ischemic time. No blood transfusions were required, the average hemoglobin level ranged from 96.0 to 132.0 g/L and no postoperative complications occurred. The mean operation time was 104.3 ± 8.2 min. The postoperative removal of negative pressure drainage time ranged from 5.0 to 7.0 d, and the mean postoperative hospital stay was 6.5 ± 0.7 d. No serious complications occurred. Postoperative pathological results showed clear cell carcinoma in 12 patients, papillary renal cell carcinoma in 2 patients, and hamartoma in 1 patient. The mean creatinine level was 75.0 ± 0.8 μmol/L (range 61.0-90.4 μmol/L) at 1 mo after surgery, and there were no statistically significant differences compared with pre-operation (P > 0.05). The glomerular filtration rate ranged from 45.1 to 60.8 mL/min, with an average of 54.0 ± 5.0 mL/min, and these levels were not significantly different from those before surgery (P > 0.05).

CONCLUSION

GreenLight laser has extraordinary cutting and sealing advantages when used for small renal tumors (exogenous tumors of stage T1a) during LPN. However, use of this technique can lead to the generation of excessive smoke.

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

Carcinogen Biomarkers in the Urine of Electronic Cigarette Users and Implications for the Development of Bladder Cancer: A Systematic Review

CONTEXT

Use of electronic cigarettes (e-cigarettes) has rapidly increased despite unclear longitudinal health effects. Once thought to be a safer alternative to tobacco smoke, it is possible that e-cigarettes expose the user to similar carcinogenic byproducts during the vaping process. These toxicants are metabolized and excreted in the urine, and may have oncogenic implications for bladder urothelium.

OBJECTIVE

To characterize and summarize known urinary carcinogenic biomarkers in e-cigarette users as they relate to the risk of developing bladder cancer.

EVIDENCE ACQUISITION

A systematic literature search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and included PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Relevant articles published in peer-reviewed journals, through January 2019, that reported on urinary biomarkers in e-cigarettes users were included. Parent compounds and urinary biomarkers were classified according to the International Agency for Research on Cancer Monographs on the Evaluation of Carcinogenic Risks to Humans and cross referenced using the Collaborative on Health and the Environment, Toxicant and Disease Database to determine a link to bladder cancer, grouped by strength of evidence.

EVIDENCE SYNTHESIS

Our initial search identified 1385 articles, 22 of which met final inclusion criteria and were included for analysis. In summation, these studies described 40 different parent compounds and four metals found in the urine of e-cigarette users. Since each parent compound can be metabolized several different ways, 63 unique toxicant or carcinogenic metabolite biomarkers were identified. Compared with nonuser controls, e-cigarette users had higher concentrations of urinary biomarkers of several carcinogenic compounds linked to bladder cancer. The majority of studies were limited by heterogeneous reporting and a dearth of control individuals who had never smoked.

CONCLUSIONS

Biomarkers of carcinogens, several with a strong link to bladder cancer, are present in the urine of e-cigarette users. Long-term implications of urothelial exposure to these toxicants are unknown but concerning, given the similarities to tobacco smoke and its established relationship with bladder cancer. Further study on the urological safety of e-cigarettes is necessary.

PATIENT SUMMARY

Our review shows that several carcinogens that have a known link to bladder cancer are present in the urine of electronic cigarette (e-cigarette) users. Further study on the urological safety of e-cigarettes is necessary.

Holographic reconstruction technology used for intraoperative real-time navigation in robot-assisted partial nephrectomy in patients with renal tumors: a single center study

Background

To explore the efficacy and advantages of real-time navigation using holographic reconstruction (HR) technology combined with da VinciTM robotic system for partial nephrectomy (PN) in patients with renal tumor.

Methods

The clinical data of 41 patients with totally intrarenal tumors receiving robot-assisted partial nephrectomy (RAPN) from April 2018 to October 2020 in our department were collected and retrospectively analyzed. All operations were performed by the same surgeon. HR technology and three-dimensional (3D) reconstruction techniques were applied for real-time navigation to resect tumors using the da VinciTM robotic system. The relevant clinical parameters and surgical outcomes of the patients were recorded and analyzed.

Results

HR technology allowed accurate evaluation of tumors, renal hilus vessels, and surrounding organs during the operation. With real-time navigation HR, all cases were performed by RAPN. The mean operative time was 115.3±20.3 (range, 70–153) minutes, and the warm ischemia time (WIT) was 18.7±3.9 (range, 13–28) minutes. The estimated blood loss (EBL) was 98.8±18.7 (range, 60–141) mL. Negative surgical margins were reported in all cases. Patients with absence of grade ≤1 Clavien-Dindo complications. Compared with the clinical outcomes of standard RAPN, as reported in the literature, HR-assisted technology reduced the mean operative time, the WIT, and the EBL in patients undergoing RAPN. Therefore, combining HR with robotic abdominal surgery can enhance the efficiency of locating blood vessels and allow for more accurate resection of tumors.

Conclusions

As a novel and promising computer digital technology, HR can significantly improve the success of RAPN operations. This retrospective study demonstrated that HR-assisted operations resulted in shorter operation times and less perioperative complications and were thus safer and more effective in patients with renal tumors compared with RAPN not used HR.

Renal Functional and Perioperative Outcomes of Retroperitoneal Robot-Assisted Versus Laparoscopic Partial Nephrectomy with Segmental Renal Artery Clamping

Background: Retroperitoneal approach and segmental renal artery clamping in partial nephrectomy are techniques that facilitate postoperative recovery and renal function preservation. This study aimed to compare the renal function preservation and perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) with these techniques. Materials and Methods: Clinical parameters of 43 patients who had undergone retroperitoneal RAPN from March 2017 to December 2019 were retrospectively collected and compared with those of 52 patients who had undergone retroperitoneal LPN at the same period in our institution. Differences in operating time, warm ischemia time, estimated blood loss, complications, postoperative hospital stay, as well as renal function loss were compared between the two groups. Results: Background characteristics between RAPN and LPN groups such as age, gender, BMI, and tumor characteristics were comparable. All RAPNs and LPNs were successfully completed without conversion to open surgery or nephrectomy. No significant difference in operating time, estimated blood loss, complications, and postoperative hospital stay was observed between RAPN and LPN groups. The warm ischemia time in RAPN group was slightly shorter than that of LPN groups (P = .054). Compared with the LPN group, the RAPN group was significantly associated with less glomerular filtration rate reduction and renal volume loss rate (P = .042 and P = .013, respectively). Conclusions: The perioperative outcomes were comparable between the two groups. However, compared with LPN, RAPN had superiority in preserving renal function in our series.

Use of Bariatric Ports in 4-Arm Robotic Partial Nephrectomy: A Comparative Study With the Standard 3-Arm Technique

Objectives

We aim to compare the outcomes of a 3-arm versus a 4-arm robotic assisted partial nephrectomy (RAPN) using the da Vinci Si model; as well as, illustrate the deployment of long ports to decrease arm collision during the 4-arm approach.

Patients and Methods

Results of RAPN in a Middle Eastern tertiary referral center from August 2013 to December 2017 are reported. Comparison between 3 versus 4-arm robotic approaches was done in regards to patient and tumor characteristics, operative parameters, and postoperative outcomes. Statistical analysis was performed with the Student’s t-test and chi-squared test.

Results

Forty consecutive 3-arm RAPNs and 40 consecutive 4-arm RAPNs were retrospectively evaluated. Differences in tumor complexity between the two groups were statistically insignificant. Similarly, surgical margin positivity, mean ischemia time, estimated blood loss, length of hospital stay, and mean change in serum creatinine were statistically insignificant between the two groups. Mean operative time was significantly shorter by 42 minutes in the 4-arm vs 3-arm group (p=0.01).

Conclusions

The addition of a 4^th arm in RAPN can be of benefit in centers that still rely on the da Vinci Si model. The ease of hilar dissection, retraction, and surgeon independence instigated a statistically significant decrease in operative time with 4-arm use.

Comparative Outcomes and Predictive Assessment of Trifecta in Open, Laparoscopic, and Robotic-Assisted Partial Nephrectomy Cases with Renal Cell Carcinoma: A 10-Year Experience at Ramathibodi Hospital

Purpose

To compare perioperative and trifecta outcomes of open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robotic-assisted laparoscopic partial nephrectomy (RPN) in patients with small renal mass at Ramathibodi Hospital, and to determine predictive factors in connection with trifecta.

Methods

We retrospectively reviewed 141 patients who underwent partial nephrectomy by eight experienced surgeons from January 2009 to December 2018. Baseline preoperative characteristics, postoperative and trifecta outcomes of the three treatment modalities were compared and analyzed. Univariate analysis was performed to determine predictive factors for trifecta achievement.

Results

A total of 70 patients had complete data available. Eighteen OPN, 11 LPN and 41 RPN cases were identified and reviewed. All preoperative and perioperative parameters were similar, except for operative time, which was significantly shorter in the OPN group compared with those undergoing LPN and RPN (135 vs 189 and 225 min, respectively; p-value = 0.001). Of these 70 patients, 59 were deemed eligible for and included in trifecta analysis, which revealed similar trifecta outcomes (64.29%, 45.45%, and 64.71% in the OPN, LPN, and RPN groups, respectively; p-value = 0.388). Univariate analysis showed that length of hospital stay was a negative associated factor for trifecta achievement (p-value = 0.007, 95% CI = 0.619 (0.44–0.88)).

Conclusion

Although OPN displayed the shortest operative time, the trifecta achievement rate was not significantly different among the three groups. The sole parameter, which was negatively associated with trifecta outcome achievement, was the length of hospital stay.

Development of a mechanical decoupling surgical scissors for robot-assisted minimally invasive surgery

In minimally invasive surgery, surgical instruments with a wrist joint have better flexibility. However, the bending motion of the wrist joint causes a coupling motion between the end-effector and wrist joint, affecting the accuracy of the movement of the surgical instrument. Aiming at this problem, a new gear train decoupling method is proposed in the paper, which can automatically compensate for the coupled motion in real-time. Based on the performance tests of the instrument prototype, a series of decoupling effects tests are carried out. The test results show that the surgical instrument has excellent decoupling ability and stable performance.

Open Partial Nephrectomy vs. Robot-assisted Partial Nephrectomy for a Renal Tumor Larger than 4 cm: a Propensity Score Matching Analysis

BACKGROUND

To compare open partial nephrectomy (OPN) and robot-assisted partial nephrectomy (RAPN) in the management of renal tumors larger than 4 cm.

METHODS

Clinical records of 220 patients who underwent OPN or RAPN for a single renal tumor ≥ 4.0 cm with a normal contralateral kidney were reviewed. After determining the propensity score, surgical parameters, functional outcomes, and oncological outcomes were compared between OPN (n = 67) and RAPN (n = 67) groups of patients.

RESULTS

The RAPN group had longer operation time (149.0 min vs. 173.3 min, P = 0.030) and longer ischemic time (20.3 min vs. 29.4 min, P = 0.001), but shorter hospital stay (8.2 days vs 6.0 days, P = 0.001) than the OPN group. Estimated blood loss (P = 0.053), pain visual analog score at 1 day postoperatively (P = 0.194), and complications of grade III or higher (P = 0.403) were similar between OPN and RAPN groups. There was no radical conversion or positive surgical margin in either group. Mean change in 6-month estimated glomerular filtration rate was significantly better in the RAPN group (-8.2 vs. -3.1, P = 0.027). There was no statistical difference in recurrence-free survival (P = 0.970) or cancer-specific survival (P = 0.345) between the two groups.

CONCLUSION

RAPN is a safe and feasible surgical modality comparable to OPN for managing renal tumors larger than 4 cm in terms of surgical, functional, and oncological outcomes.

Responsible Artificial Intelligence as a Secret Ingredient for Digital Health: Bibliometric Analysis, Insights, and Research Directions

With the unparallel advance of leading-edge technologies like artificial intelligence (AI), the healthcare systems are transforming and shifting for more digital health. In recent years, scientific productions have reached unprecedented levels. However, a holistic view of how AI is being used for digital health remains scarce. Besides, there is a considerable lack of studies on responsible AI and ethical issues that identify and suggest practitioners' essential insights towards the digital health domain. Therefore, we aim to rely on a bibliometric approach to explore the dynamics of the interplay between AI and digital health approaches, considering the responsible AI and ethical aspects of scientific production over the years. We found four distinct periods in the publication dynamics and the most popular approaches of AI in the healthcare field. Also, we highlighted the main trends and insightful directions for scholars and practitioners. In terms of contributions, this work provides a framework integrating AI technologies approaches and applications while discussing several barriers and benefits of AI-based health. In addition, five insightful propositions emerged as a result of the main findings. Thus, this study's originality is regarding the new framework and the propositions considering responsible AI and ethical issues on digital health.

Robotic-assisted laparoscopic tumor enucleation is a feasible technique for renal hilar tumors: A retrospective study

BACKGROUND AND OBJECTIVE: This study aimed to evaluate the safety and efficacy of robot-assisted laparoscopic tumor enucleation (RAE) for the treatment of renal hilar tumors and to describe our experience with renorrhaphy-related surgical techniques.

METHODS

Retrospective data were collected from 173 consecutive patients who underwent RAE for localized renal tumors (cT1-cT2N0M0) at our hospital between September 2014 and November 2019.

RESULTS

Seventy-five patients had renal hilar tumors and 98 patients had nonhilar tumors. There were no statistical differences between the hilar and nonhilar groups in operation time (190 [115-390] vs. 190 [110-390] min, p = 0.889), warm ischemia time (26 [12-60] vs. 27 [17-41] min, p = 0.257), hospital stay duration (8 [3-16] vs. 7.5 [4-18] days, p = 0.386), renal function (estimated glomerular filtration rate, 102.5 [29.4-144] vs. 101.3 [64.2-134.7] ml/min/1.73 m² , p = 0.631); creatinine level, (76 [43-169] vs. 78.5 [50-281.3] µmol/L, p = 0.673), perioperative complications rate, or surgical margin status. However, patients with hilar tumors lost significantly more blood than did those with nonhilar tumors (250 [50-1500] vs. 200 [20-1200] ml, p = 0.007). During the follow-up period (median, 30 months), three patients in each group experienced recurrence. The 5-year recurrence-free rates were 93.0% and 95.4% in the hilar and nonhilar tumor groups, respectively (p = 0.640).

CONCLUSIONS

For experienced robot laparoscopists, RAE is a safe, effective, and feasible procedure for renal hilar tumors, without increased risk of positive surgical margins or worse midterm oncologic outcomes compared with nonhilar tumors.

Evaluating the impact of surgical supply cost variation during partial nephrectomy on patient outcomes

Background

Reducing surgical supply costs can help to lower hospital expenditures. We aimed to evaluate whether variation in supply costs between urologic surgeons performing both robotic or open partial nephrectomies is associated with differential patient outcomes.

Methods

In this retrospective cohort study, we reviewed 399 consecutive robotic (n=220) and open (n=179) partial nephrectomies performed at an academic center. Surgical supply costs were determined at the institution-negotiated rate. Through retrospective review, we identified factors related to case complexity, patient comorbidity, and perioperative outcomes. Two radiologists assigned nephrometry scores to grade tumor complexity. We created univariate and multivariable models for predictors of supply costs, length of stay, and change in serum creatinine.

Results

Median supply cost was $3,201 [interquartile range (IQR): $2,201–3,808] for robotic partial nephrectomy and $968 (IQR: $819–1,772) for open partial nephrectomy. Mean nephrometry score was 7.0 (SD =1.7) for robotic procedures and 8.2 (SD =1.6) for open procedures. In multivariable models, the surgeon was the primary significant predictor of variation in surgical supply costs for both procedure types. In multivariable mixed-effects analysis with surgeon as a random effect, supply cost was not a significant predictor of change in serum creatinine for robotic or open procedures. Supply cost was not a statistically significant predictor of length of stay for the open procedure. Supply cost was a significant predictor of longer length of stay for the robotic procedure, however it was not a clinically meaningful change in length of stay (0.02 days per $100 in supply costs).

Conclusions

Higher supply spending did not predict significantly improved patient outcomes. Variability in surgeon supply preference is the likely source of variability in supply cost. These data suggest that efforts to promote cost-effective utilization and standardization of supplies in partial nephrectomy could help reduce costs without harming patients.

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.

Role of minimally invasive partial nephrectomy in the management of renal mass

Partial nephrectomy is recommended for surgical management of small renal masses (SRM), or lesions ≤7 cm. The decision for surgical intervention involves a balanced patient assessment. Minimally invasive approach, which includes laparoscopic and robotic techniques, has shown to have improved blood loss, length of hospitalization, and post-operative pain while maintaining oncologic efficacy when compared to an open approach. Transperitoneal approach is preferred at most centers; however, retroperitoneoscopic minimally invasive surgery (MIS) partial nephrectomy expertise is essential for comprehensive kidney cancer care. With advances in surgical technology and deep penetration of robotics into surgical training and practice, robotic partial nephrectomy has become the modality of choice in modern clinical practice. This review discusses the indications and outcomes for various minimally invasive approaches of partial nephrectomy.

Comparison of Therapeutic Effects Among Different Surgical Approaches in Robot-Assisted Partial Nephrectomy: A Systematic Review and Meta-Analysis

Purpose: To systematically explore the superiority of the transperitoneal approach in robot-assisted partial nephrectomy (TP-RAPN) and retroperitoneal approach in robot-assisted partial nephrectomy (RP-RAPN). Methods: Several databases were searched including PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, CBM, Wan Fang, and VIP to identify relevant studies that reported the comparison of the TP-RAPN and RP-RAPN. Outcomes of data were pooled and analyzed with Review Manager 5.3 to compare the intraoperative and postoperative variables and postoperative complications. Based on the heterogeneity of the studies, odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using a random-effect model or fixed-effect model. The sensitivity analysis and the subgroup analysis were used to minimize the effects of heterogeneity. And, publication bias was assessed by funnel plots. Results: In all, 16 studies met the inclusion criteria, including 2336 TP-RAPN patients and 1705 RP-RAPN patients. This meta-analysis reviewed 16 studies on RAPN, and the RP-RAPN showed shorter operative time (OT) (WMD 13.18 minutes; 95% CI 5.04-21.31; p = 0.001), shorter postoperative bowel function recovery (WMD 1.97 days; 95% CI 0.43-3.52; p = 0.01), shorter length of stay (LOS) (WMD 0.51 days; 95% CI 0.25-0.77; p = 0.0001), and lower estimated blood loss (EBL) (WMD 7.08 mL; 95% CI 1.41-12.74; p = 0.01) than the TP-RAPN. Additionally, no significant differences were found in other outcomes. Conclusions: In comparison, the RP-RAPN had significantly shorter OT, postoperative bowel function recovery time, LOS, and lower EBL. The RP-RAPN is associated with better value for posterior and laterally located tumors and is faster and equally safe and low costs for the patient.

Robotic partial nephrectomy in a child with kidney tumor

Robotic surgery is gaining wider utility in adults; however, few reports have addressed the applicability of robotic surgery for renal tumors in children. The aim of this report is to share our experience in an 8-year-old child with metanephric stromal tumor. To our knowledge, besides being a rare tumor, this is the youngest case reported in the literature whose kidney tumor has been successfully removed with robotic partial nephrectomy. There is a worldwide tendency to perform minimal invasive surgery for kidney tumors. In the presence of an experienced team and proper conditions, we believe that robotic partial nephrectomy will be the preferred option in future.

Factors affecting renal function preservation among patients not achieving trifecta after laparoscopic partial nephrectomy for clinical T1a renal masses

INTRODUCTION

The goal of partial nephrectomy for renal tumors is complete tumor removal with the preservation of renal function and no complications. Trifecta (total ischemia time < 25 minutes, negative surgical margins, and no surgical complications) is widely used to evaluate success after partial nephrectomy. We investigated factors affecting renal function preservation among patients not achieving trifecta after laparoscopic partial nephrectomy.

METHODS

Sixty-six patients who underwent laparoscopic partial nephrectomy for clinical T1a renal masses between December 2006 and March 2016 were examined. We defined preserved renal function as the preservation of an estimated glomerular filtration rate ≥ 90% 1 year after surgery. We examined factors affecting renal function preservation among patients not achieving trifecta after laparoscopic partial nephrectomy.

RESULTS

Thirty out of 66 patients (45%) did not achieve trifecta. In an evaluation of 66 patients, a multivariate analysis identified tumor size (P = .04) as an independent predictor affecting the achievement of trifecta. Tumor size was significantly smaller in the trifecta achievement group (1.9 ± 0.1 cm) than in the non-achievement group (2.2 ± 0.6 cm) (P = .04). We found that renal function was preserved 1 year after surgery in 14 out of the 30 patients not achieving trifecta. In univariate analysis, age (P = .01) was significantly associated with affecting the preservation of renal function among these patients. Patients with preserved renal function were significantly younger (47.8 ± 2.5 years) than those without (58.5 ± 2.9 years) (P = .01).

CONCLUSION

Renal function may be preserved in younger patients even if they do not achieve trifecta after partial nephrectomy for small renal masses.

Novel virtual reality based training system for fine motor skills: Towards developing a robotic surgery training system

BACKGROUND

Training surgeons to use surgical robots are becoming part of surgical training curricula. We propose a novel method of training fine-motor skills such as Microscopic Selection Task (MST) for robot-assisted surgery using virtual reality (VR) with objective quantification of performance. We also introduce vibrotactile feedback (VTFB) to study its impact on training performance.

METHODS

We use a VR-based environment to perform MST with varying degrees of difficulties. Using a well-known human-computer interaction paradigm and incorporating VTFB, we quantify the performance: speed, precision and accuracy.

RESULTS

MST with VTFB showed statistically significant improvement in performance metrics leading to faster completion of MST with higher precision and accuracy compared to that without VTFB.

DISCUSSION

The addition of VTFB to VR-based training for robot-assisted surgeries may improve performance outcomes in real robotic surgery. VTFB, along with proposed performance metrics, can be used in training curricula for robot-assisted surgeries.

Predictors for trifecta achievement of robot-assisted partial nephrectomy in high-complexity tumors (Preoperative Aspects and Dimensions Used for an Anatomical score ≥10)

INTRODUCTION

Robot-assisted partial nephrectomy (RAPN) is emerging as an effective treatment oncologically and functionally for clinically localized renal tumors. However, RAPN in high-complexity tumors with a Preoperative Aspects and Dimensions Used for an Anatomical score ≥10 remains challenging. In this study, the feasibility of RAPN for high-complexity tumors was assessed.

METHODS

The study cohort consisted of 177 cases with clinically localized renal cell carcinoma who had undergone RAPN at our hospital from July 2010 to February 2018. They were assessed for perioperative parameters and trifecta achievement (ie, negative surgical margins, warm ischemia time <25 minutes, and no complications).

RESULTS

Among the 177 cases who had undergone RAPN, 60 had high-complexity tumors, and 117 had non-high-complexity (ie, intermediate- or low-complexity) tumors. There were no significant differences in the operative and console times between the cohorts, but estimated intraoperative blood loss was much lower in the non-high-complexity group. Although the average warm ischemia time was less than 25 minutes in both groups, it was significantly shorter in the non-high-complexity group. Trifecta achievement rates significantly differed between the high- and non-high-complexity groups (68.3% vs 86.3%). Comparisons of four operative parameters (ie, BMI, tumor size, endophytic properties, and hilar tumor) using univariate analysis in the 60 high-complexity tumor cases showed that BMI and tumor size were independent factors (P = 0.05 and 0.018, respectively). In multivariate analysis, tumor size was the only factor directly associated with trifecta achievement (P = 0.029).

CONCLUSION

The trifecta achievement rate was significantly lower in the high-complexity group. Only tumor size affected trifecta achievement during RAPN in cases with high-complexity tumors (Preoperative Aspects and Dimensions Used for an Anatomical score ≥10).

Near-infrared fluorescence imaging for intraoperative margin assessment during robot-assisted partial nephrectomy

OBJECTIVES

To demonstrate how using a standardised dosing strategy of indocyanine green (ICG) dye with near-infrared fluorescence (NIRF) imaging can be used to differentiate renal tumours from normal renal parenchyma during robot-assisted partial nephrectomy (RAPN).

PATIENTS AND METHODS

We reviewed a prospectively collected database of 361 consecutive RAPNs using NIRF between June 2011 and March 2018, and determined the rate at which differential fluorescence was achieved. Tumour and kidney fluorescence or afluorescence were recorded intraoperatively and compared to histological results on final pathology.

RESULTS

Of 330 tumours, after 31 exclusions for nonvisible tumours due to adherent fat, completely intrarenal location or for incomplete data, 288 (87.3%) successfully exhibited differential fluorescence. Among the predominant histologies, 249 of 277 (89.9%) renal cell carcinomas did not fluoresce, as well as 23 of 32 (71.9%) oncocytomas. Real-time gross assessment of resection margin for fluorescence yielded a positive margin rate on final pathology of 0.30%.

CONCLUSION

When administered with a standardised ICG-dosing strategy, NIRF successfully achieved differential fluorescence in a large majority of tumours during RAPN with an exceedingly low positive margin rate.

Omitting Cortical Renorrhaphy in Robot-Assisted Partial Nephrectomy: Is it Safe? A Single Center Large Case Series

Introduction: Preserving renal function after robot-assisted partial nephrectomy (RAPN) is important and influenced by the technique of renal reconstruction among other parameters, including ischemia time and amount of healthy renal tissue resected. It is believed that reconstruction with a second layer of cortical renorrhaphy is necessary to prevent urinary leaks and postoperative bleeding, but this is associated with the potential loss of healthy renal parenchyma and may result in worse outcomes postoperatively. Purpose: To assess the safety of omitting cortical renorrhaphy during RAPN. Patients and Methods: A retrospective analysis of 146 consecutive patients undergoing a RAPN with single or double layer renorrhaphy at the Wirral University Teaching Hospital from 2014 to 2019. Data obtained included: Patient demographics, tumor RENAL nephrometry, Perioperative parameters; blood loss, duration, and warm ischemia time (WIT), Postop complications, change in estimated glomerular filtration rate (eGFR) (pre and 3 months postop), length of stay, and oncologic outcomes. Results: In total 146 patients were identified. One hundred-six had double renorrhaphy and 40 inner layer only renorrhaphy. No significant differences were seen between these two cohorts in terms of patient demographics, RENAL nephrometry score, tumor size, or location. Perioperative parameters showed a reduced duration of surgery in the single renorrhaphy group with a mean of 125 minutes compared to143 minutes in the double renorrhaphy (p = 0.006) and a tendency toward a shorter WIT of 12.9 minutes vs 14.0 minutes reaching borderline statistical significance (p = 0.05) but no difference in blood loss volume (p = 0.25). Postoperatively there was no statistical difference in the length of hospital stay (p = 0.85), loss in eGFR at 3 months (0.06), or complication (p = 0.56). After a median follow-up of 35 months no recurrences or deaths were observed in either group. Conclusions: Omission of cortical renorrhaphy appears feasible and safe with no urine leaks or excess complications observed.

Comparisons of the safety and effectiveness of robot-assisted versus laparoscopic partial nephrectomy for large angiomyolipomas: a propensity score-matched analysis

OBJECTIVE

To compare the safety and effectiveness of robot-assisted partial nephrectomy (RAPN) versus laparoscopic partial nephrectomy (LPN) for large angiomyolipomas (AMLs).

MATERIALS AND METHODS

We retrospectively evaluated 150 patients who were treated with either RAPN or LPN for large angiomyolipomas from 2014 to 2018. Propensity score matching was performed on age, gender, BMI, Charlson Comorbidity Index, tumour side and size, preoperative eGFR and RENAL score.

RESULTS

In total, 63 and 87 patients underwent RAPNs and LPNs, respectively. There were more large and complex AMLs in the RAPN cohort, with the median tumour maximal diameters and RENAL scores differing between the two groups (8 versus 7 cm and 9 versus 8, P = 0.01). After matching, the median warm ischemic time was significantly shorter in the RAPNs versus the LPNs (17 versus 22 min, P = 0.001). The rate of intraoperative complications in the RAPNs appeared lower than the LPNs (3.2% versus 8.1%). The median postoperative length of stay was significantly shorter in the RAPN cohort than the LPNs (P = 0.001). Twelve months after surgery, RAPNs received a 94.6% renal function prevention; while this was 90.8% in LPNs (P = 0.001). Subgroup analysis indicated that prior selective arterial embolization (SAE) was related to better renal function preservation in the RAPN cohort (P = 0.01). No recurrence occurred in either of the two cohorts.

CONCLUSIONS

RAPN is a safe and effective alternative to LPNs for large AMLs with a shorter warm ischemic time and higher renal preservation rate. Recurrence was equivalent in both RAPNs and LPNs.