The first assistant sparing technique robot-assisted partial nephrectomy decreases warm ischemia time while maintaining good perioperative outcomes

Operative and oncological outcomes of salvage robotic radical and partial nephrectomy: a multicenter experience

We aim to describe the perioperative and oncological outcomes for salvage robotic partial nephrectomy (sRPN) and salvage robotic radical nephrectomy (sRRN). Using a prospectively maintained multi-institutional database, we compared baseline clinical characteristics and perioperative and postoperative outcomes, including pathological stage, tumor histology, operative time, ischemia time, estimated blood loss (EBL), length of stay (LOS), postoperative complication rate, recurrence rate, and mortality. We identified a total of 58 patients who had undergone robotic salvage surgery for a recurrent renal mass, of which 22 (38%) had sRRN and 36 (62%) had sRPN. Ischemia time for sRPN was 14 min. The median EBL was 100 mL in both groups (p = 0.581). One intraoperative complication occurred during sRRN, while three occurred during sRPN cases (p = 1.000). The median LOS was 2 days for sRRN and 1 day for sRPN (p = 0.039). Postoperatively, one major complication occurred after sRRN and two after sRPN (p = 1.000). The recurrence reported after sRRN was 5% and 3% after sRPN. Among the patients who underwent sRRN, the two most prevalent stages were pT1a (27%) and pT3a (27%). Similarly, the two most prevalent stages in sRPN patients were pT1a (69%) and pT3a (6%). sRRN and sRPN have similar operative and perioperative outcomes. sRPN is a safe and feasible procedure when performed by experienced surgeons. Future studies on large cohorts are essential to better characterize the importance and benefit of salvage partial nephrectomies.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Standardization of Surgical Outcome Across the Tumor Complexity Spectrum in Robotic Partial Nephrectomy

Introduction: Standardization of surgical steps or techniques can decrease error rates, increase efficiency, and ensure reproducible outcomes. In this study, we aimed to analyze the benefit of a standardized approach to robotic partial nephrectomy (RPN) on the reproducibility of outcomes across different tumor complexities. Methods: A single-center study of patients who have undergone a transperitoneal robotic-assisted partial nephrectomy for kidney cancer using the first assistant sparing technique between May 2014 and March 2022 was performed. Overall, 496 patients were included in the analysis. We compared clinical data and perioperative and postoperative outcomes for low, moderate, and high complexity score renal tumors. Tumor complexity was stratified using the Radius, Exophytic/Endophytic, Nearness to the collecting system or sinus, Anterior/Posterior, Location relative to the polar line nephrometry score. Data were compared using Kruskal-Wallis test, Chi-square test of Independence, and Fisher's exact test. Results: Of the patients in the study, 54.64% were low tumor complexities (n = 271), 40.32% were moderate tumor complexities (n = 200), and 5.04% were high tumor complexities (n = 25). High tumor complexity patients had significantly longer operative time (149 minutes versus 137 minutes moderate complexity versus 125 minutes low complexity, P = .001), longer ischemia time (12 minutes versus 11 minutes intermediate versus 10 minutes low complexity, P = .0001), and significant reduction in estimated glomerular filtration rate (-12.58 mL/min/1.73 m² versus -5.51 mL/min/1.73 m² intermediate versus -3.08 mL/min/1.73 m² low complexity, P = .005). There was no significant difference in estimated blood loss (P = .074), blood transfusion rate (P = .454), postoperative complication rate (P = .527), surgical complication rate (P = .210), major complication rate (P = .098), length of hospital stay (P = .583), positive surgical margins (P = .872), and trifecta achievement (P = .740). Conclusion: Irrespective of tumor complexity, approaching RPN using a standardized approach will offer patients favorable perioperative outcomes. This approach has standardized our preoperative counseling, patient expectation, and postoperative surgical pathway across the tumor complexity spectrum.

Robotic partial nephrectomy: The current status

Introduction:

Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Methods:

A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review.

Results:

Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN.

Conclusions:

Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.

Selective arterial clamping does not improve outcomes in robot-assisted partial nephrectomy: a propensity-score analysis of patients without impaired renal function

OBJECTIVES

To assess the benefit of selective arterial clamping (SAC) as an alternative to main renal artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) in patients without underlying chronic kidney disease (CKD).

PATIENTS AND METHODS

Our study cohort comprised 665 patients without impaired renal function undergoing MAC (n = 589) or SAC (n = 76) during RAPN from four medical institutions in the period 2008-2015. We compared complication rates, positive surgical margin (PSM) rates, and peri-operative and intermediate-term renal functional outcome between 132 patients undergoing MAC and 66 undergoing SAC after 2-to-1 nearest-neighbour propensity-score matching for age, sex, body mass index, RENAL nephrometry score, tumour size, baseline estimated glomerular filtration rate (eGFR), American Society of Anesthesiologists (ASA) score, Charlson comorbidity index (CCI) and warm ischaemia time (WIT).

RESULTS

In propensity-score-matched patients, PSM (5.7 vs 3.0%; P = 0.407) and complication rates (13.8 vs 10.6%; P = 0.727) did not differ between the MAC and SAC groups. The incidence of acute kidney injury for MAC vs SAC (25.0 vs 32.0%; P = 0.315) within the first 30 days was similar. At a median follow-up of 7.5 months, the percentage reduction in eGFR (-9.3 vs -10.4%; P = 0.518) and progression to CKD ≥ stage 3 (7.2 vs 8.5%; P = 0.792) showed no difference.

CONCLUSIONS

Our study findings show no difference in PSM rates, complication rates or intermediate-term renal functional outcomes between patients with unimpaired renal function who underwent SAC vs those who underwent MAC. When expected WIT is low, the routine use of SAC may not be necessary. Further studies will need to determine the role of SAC in patients with a solitary kidney or with significantly impaired renal function.

Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution

PURPOSE

To review the intermediate term oncologic and functional outcomes after the surgical management of bilateral renal masses (BRM).

MATERIALS AND METHODS

After obtaining Institutional Review Board approval, the Tulane renal surgery database (n = 890 patients) was queried for patients presenting with synchronous bilateral enhancing renal masses (n = 30 renal units). We performed a retrospective chart review evaluating oncologic and functional outcomes, specifically with respect to local recurrence and metastatic disease. We also reviewed changes in glomerular filtration rates.

RESULTS

Of the 30 renal units were operated on for BRM concerning for renal cell carcinoma, 25 kidneys harbored malignancy (83.3 %). The average tumor size was 3.35 cm. Treatment of each kidney was staged; average time period to treatment of contralateral side was 3.5 months. Estimated GFR (eGFR) for these same pre-operative patients was 59 ml/min/1.73 m(2) (range 25-89). The average creatinine after treatment of one kidney was available for all patients and was 1.5 (range 0.7-2.8), with an average eGFR of 51.8 (range 29-87). The average creatinine after the second operation for these same 15 patients was 1.79 (range 0.9-3.7) with an average GFR of 41.9 (range 17-78). No patient had to undergo temporary dialysis. An average change in GFR after the second, contralateral procedure on the kidney was 17.07 mg/dl. Average oncologic follow-up was 608 days. Excluding two patients who presented with metastatic disease, the average recurrence-free survival was 92.8 %.

CONCLUSION

Our data continue to underscore the need for nephron sparing surgery (NSS), especially in the setting of BRM. The average decline in GFR of 28.9 % after treatment of both kidneys and renal cell carcinoma recurrence-free rate of 92.3 % further support the efficacy of NSS in these patients.