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

Single Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience

Introduction and Objective: Since its Food and Drug Administration (FDA) approval in 2018, Intuitive Surgical DaVinci single port (SP) robotic platform has been an effectively used technology for multiple urologic procedures. The purpose of this study is to share our early intraoperative and perioperative outcomes and potential benefits for performing a lower anterior access (LAA) incision for SP robot-assisted partial nephrectomy (SP-RAPN). The LAA incision enables performing a trans- or retroperitoneal (RP) approach through the same incision and eases the transition to a RP approach. Methods: This study is a prospective review of 78 SP-RAPN cases between March 2021 and January 2023 by an experienced robotic surgeon. A single 2-3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra- and perioperative data of these patients to share the outcomes of this approach. Results: SP-RAPN was effectively completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right-sided masses, and 35 were left sided. The R.E.N.A.L Nephrometry score ranged from (4-11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 minutes, estimated blood loss was 88.3 ± 134 mL, and length of stay of 1.07 ± 0.7 days. Of the 78 cases, 40 required clamping of the renal artery with average warm ischemia time of 19.4 ± 6.7 minutes in patients who underwent clamping. No complications in all of 78 patients. Conclusions: This study demonstrates the feasibility and reproducibility of SP-RAPN using a LAA incision. This incision provides a standardized approach for surgeons to transition to the RP approach using the SP platform.

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.

Single-port vs multi-port robot-assisted partial nephrectomy: A single center propensity score-matched analysis

INTRODUCTION AND OBJECTIVES

The aim of the study is to compare key outcomes of Single-Port (SP) and Multi-Port (MP) robot-assisted partial nephrectomy (RAPN).

METHODS

A retrospective analysis was conducted on our prospectively collected database of patients who underwent SP-RAPN or MP-RAPN at our institution from January 2021 to August 2023. To adjust for potential baseline pre-operative confounders, a 1:1 propensity-score matching analysis (PSMa) was performed. The primary endpoint was to compare perioperative outcomes between the two groups. The secondary endpoint was to compare the achievement of the "Trifecta" outcome (defined as negative surgical margins, absence of high-grade complications and change in eGFR values (ΔeGFR) < 10% at 6 months follow-up) in the matched cohort.

RESULTS

After PSMa, 30 SP cases were matched 1:1 to 30 MP cases. In the matched cohort, there were no significant differences between SP and MP approaches in operative time, estimated blood loss, ischemia time, transfusions rate, intraoperative complications, postoperative complications, and positive surgical margin rates. Patients who underwent SP-RAPN had a shorter median length of stay [25 (IQR:24.0-34.5) vs 34 (IQR:30.2-48.0) hours, p < 0.003]. The Trifecta outcome was achieved in 16 (57%) of SP patients and 17 (63%) of MP patients (p = 0.8).

CONCLUSIONS

SP-RAPN can be safely implemented in a Center with an established MP-RAPN program. Despite being early in the SP-RAPN experience, key surgical outcomes are not compromised. While offering comparable perioperative and short-term functional outcomes, SP-RAPN can translate into faster recovery and shorter LOS, paving the way for outpatient robotic surgery.

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

INTRODUCTION

Robot-assisted partial nephrectomy (RAPN) can be performed either by a transperitoneal (TP) or a retroperitoneal (RP) approach. However, the superiority of one approach over the other is not established. Hence, the primary aim of this review was to compare perioperative outcomes between these two surgical approaches.

METHODS

Literature was systematically searched to identify studies reporting perioperative outcomes following TP RAPN and RP RAPN. The study protocol was registered with PROSPERO (CRD42023399496). The primary outcome was comparing complication rates between the two approaches.

RESULTS

This review included 22 studies, 5675 patients, 2524 in the RP group, and 3151 in the TP group. The overall complications were significantly lower in the RP group [Odds ratio (OR) 0.80 (0.67, 0.95), p = 0.01]. However, the rate of major complications was similar between the two groups. The operative time was significantly shorter with the RP group [Mean Difference (MD)-16.7 (- 22.3, - 11.0), p =  < 0.0001]. Estimated blood loss (EBL) and need for blood transfusion (BT) were significantly lower in the RP group. There was no difference between the two groups for conversion to radical nephrectomy [OR 0.66 (0.33, 1.33), p = 0.25] or open surgery [OR 0.68 (0.24, 1.92, p = 0.47] and positive surgical margins [OR 0.93 (0.66, 1.31, p = 0.69]. Length of stay (LOS) was shorter in the RP group [MD - 0.27 (- 0.45, - 0.08), p =  < 0.00001].

CONCLUSIONS

RP approach, compared to TP, has significantly lower complication rates, EBL, need for BT and LOS. However, due to the lack of randomized studies on the topic, further data is required.

Robotic transperitoneal versus retroperitoneal approach for anterior renal mass nephron-sparing surgery

Robotic nephron-sparing surgery is traditionally performed via a transperitoneal (TP) approach. However, the retroperitoneal (RP) approach has gained popularity, particularly for posterolateral renal masses. The RP approach is associated with shorter operative time, less blood loss, and shorter length of stay, while preserving oncologic outcomes in selected masses. Here, we aim to assess the feasibility of the RP approach in excising anterior renal masses. Patients ≥ 18 years of age who underwent robotic nephron-sparing surgery for anterior renal masses were retrospectively identified (2008-2022). Baseline demographics, tumor characteristics, and perioperative data were collected and characterized based on TP vs RP approaches. Wilcoxon rank sum test and Pearson's Chi-squared test were used to compare continuous and categorical variables, respectively. Two hundred and sixteen patients were included-178 (82.4%) underwent TP approach and 38 (17.6%) underwent RP approach. Baseline demographics, preoperative tumor size, and renal nephrometry scores were similar. The RP approach was associated with shorter operative (150 vs 203 min, p < 0.001) and warm ischemia time (12 vs 21 min, p < 0.001), and less blood loss (20 vs 100 cc, p = 0.002) (Table 1). The RP approach was associated with shorter length of stay (1 vs 2 days, p < 0.001) and less total complications (5.3% vs 19.1%, p = 0.038). Major complication (Clavien-Dindo Grade > 3) rates were similar. There was no difference in positive surgical margin rates or pathologic characteristics. Robotic RP approach for nephron-sparing surgery is feasible for eligible anterior tumors and is associated with favorable perioperative outcomes with preserved negative surgical margin rates. Table 1 Patient baseline demographics Overall Transperitoneal Retroperitoneal p value Median/N IQR/% Median/N IQR/% Median/N IQR/% N 216 178 82.4% 38 17.6% Age (years) 60.5 (52.1-67.7) 60.4 (52.8-67.7) 61.6 (49.1-69.2) 0.393 Sex Male 126 58.3% 100 56.2% 26 68.4% Female 90 41.7% 78 43.8% 12 31.6% 0.165 Race White 162 75.0% 137 77.0% 25 65.8% Asian 4 1.9% 2 1.1% 2 5.3% Black 21 9.7% 18 10.1% 3 7.9% Hispanic 26 12.0% 18 10.1% 8 21.1% Other 2 0.9% 2 1.1% 0 0.0% 0.197 Body mass index (kg/m2)  < 25 32 14.8% 25 14.0% 7 18.4% 25-30 68 31.5% 55 30.9% 13 34.2% 30-35 60 27.8% 50 28.1% 10 26.3% 35 +  56 25.9% 48 27.0% 8 21.1% 0.808 Prior abdominal surgery Yes 118 54.6% 104 58.4% 14 36.8% No 98 45.4% 74 41.6% 24 63.2% 0.015 Prior kidney surgery Yes 10 4.6% 9 5.1% 1 2.6% No 206 95.4% 169 94.9% 37 97.4% 0.518 Chronic kidney disease stage ≥ 3 Yes 45 20.8% 38 21.3% 7 18.4% No 171 79.2% 140 78.7% 31 81.6% 0.687 Charlson comorbidity index 0 138 63.9% 116 65.2% 22 57.9% 1 46 21.3% 38 21.4% 8 21.1% 2 19 8.8% 13 7.3% 6 15.8%  ≥ 3 13 6.0% 11 6.2% 2 5.3% 0.412 Tumor size (cm) 2.7 (2-3.6) 2.8 (2-3.5) 2.55 (2-3.7) 0.796 Tumor laterality Left 100 46.3% 78 43.8% 22 57.9% Right 116 53.7% 100 56.2% 16 42.1% 0.114 Clinical T stage cT1a 186 86.1% 152 85.4% 34 89.5% cT1b 30 13.9% 26 14.6% 4 10.5% 0.509 RENAL Nephrometry score Low (4 to 6) 94 43.5% 76 42.7% 18 47.4% Intermediate (7 to 9) 112 51.9% 94 52.8% 18 47.4% High (≥ 10) 19 4.6% 8 4.5% 2 5.3% 0.829 TE tumor enucleation, SPN standard margin partial nephrectomy, IQR interquartile range.

Transperitoneal vs. Retroperitoneal Approach in Laparoscopic Partial Nephrectomy for Posterior Renal Tumors: A Retrospective, Multi-Center, Comparative Study

Purpose: The aim of our study is to compare the perioperative, functional, and oncological outcomes of laparoscopic transperitoneal partial nephrectomy (LTPN) and laparoscopic retroperitoneal partial nephrectomy (LRPN) for posterior cT1 renal tumors. Methods: We retrospectively collected data on all patients who consecutively underwent LTPN and LRPN for posterior cT1 renal tumors in three different centers from January 2015 to January 2023. Patients with a single, unilateral, cT1 renal mass, located in the posterior renal surface were included. Patients' data regarding perioperative, functional, and oncological outcomes were collected from medical records and statistically analyzed and compared. Results: A total of 128 patients was obtained, with 53 patients in the LPTN group and 75 patients in the LRPN group. Baseline characteristics were similar. Warm ischemia time (WIT) (18.8 vs. 22.6 min, p = 0.002) and immediate postoperative eGFR drop (-6.1 vs. -13.0 mL/min/1.73 m2, p = 0.047) were significantly lower in the LPTN group. Estimated blood loss (EBL) (100 vs. 150 mL, p = 0.043) was significantly lower in the LRPN group. All other perioperative and functional outcomes and complications were similar between the groups. The positive surgical margin (PSM) rate was lower in the LRPN group, although without statistical significance (7.2% vs. 13.5%, p = 0.258). Surgical success defined by Trifecta (WIT ≤ 25 min, no PSM, and no major postoperative complication) was similar between both approaches. Conclusions: LTPN has significantly shorter WIT and a significantly smaller drop in immediate eGFR when compared to LRPN for posterior renal tumors. On the other hand, LRPN has significantly less EBL than LTPN. LRPN demonstrated fewer PSMs than LTPN, albeit without statistical significance. In terms of overall surgical success, as defined by Trifecta, both approaches achieved similar results.

A comparison of perioperative outcomes of transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review

RAPN can be carried out via a transperitoneal or retroperitoneal approach. The choice between the two approaches is open to debate and usually based on surgeon preference. The perioperative outcomes of transperitoneal robot-assisted partial nephrectomy versus retroperitoneal robot-assisted partial nephrectomy were compared. A systematic review of the literature was performed up to May 2020, using PubMed, Cochrane, Scopus and Ovid databases. Articles were selected according to a search strategy based on PRISMA criteria. Only studies comparing TRAPN with RRAPN were eligible for inclusion. Eleven studies were included in the quantitative synthesis. Baseline demographics (age, BMI, ASA, tumour size, and RENAL nephrometry score), intraoperative data (operative time, estimated blood loss, and warm ischaemia time) and postoperative outcomes (major complications according to Clavien-Dindo, length of hospital stay (LOS) and positive surgical margin rate) were recorded. A total of 3139 patients were included (2052 TRAPN vs. 1087 RRAPN). There was no significant difference in demographic variables (age, BMI), tumour size (p = 0.06) nor the nephrometry score (p = 0.20) between the two groups. Operative time (p = 0.02), estimated blood loss (p < 0.00001) and LOS (p < 0.00001) were significantly lower in the RRAPN group. No differences were found in major postoperative complications (Clavien-Dindo > 3; p = 0.37), warm ischaemia time (p = 0.37) or positive surgical margins (p = 0.13). Future researchers must attempt to achieve adequately powered, expertise based, multi-surgeon and multi-centric studies comparing TRAPN and RRAPN. RRAPN gives similar outcomes to TRAPN. RRAPN is associated with reduced operative time and LOS. Ideally, surgeons should be familiar and competent in both RAPN approaches and adopt a risk-stratified and patient-centred individualised approach, dependent on the tumour and patient characteristics. RAPN is feasible via two approaches. The retroperitoneal approach seems to be associated with a shorter operation time and hospital stay.

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.

Retroperitoneal vs. transperitoneal robotic partial nephrectomy: a multicenter propensity-score matching analysis (PADORA Study - UroCCR n° 68)

BACKGROUND

Robot-assisted partial nephrectomy can be performed through either a transperitoneal or retroperitoneal approach. This study aimed to compare the rate of trifecta achievement between retroperitoneal (RRPN) and transperitoneal (TRPN) robot-assisted partial nephrectomy using a large multicenter prospectively-maintained database and propensity-score matching analysis.

METHODS

This study was launched by the French Kidney Cancer Research Network, under the UroCCR Project (NCT03293563). Patients who underwent TRPN or RRPN by experienced surgeons in 15 participating centers were included. Data on demographic and clinical parameters, tumor characteristics, renal function, and surgical parameters were collected. The primary outcome was the rate of trifecta achievement, which was defined as a warm ischemia time of less than 25 minutes, negative surgical margins, and no major complications. Secondary outcomes included operative time, hospital length-of-stay, blood loss, postoperative complications, postoperative renal function, and each trifecta item taken alone. Subgroup analysis was done according to tumor location.

RESULTS

A total of 2879 patients (2581 TRPN vs. 298 RRPN) were included in the study. Before matching, trifecta was achieved in 73.0% of the patients in the TRPN group compared to 77.5% in the RRPN group (P=0.094). After matching 157 patients who underwent TRPN to 157 patients who underwent RRPN, the trifecta rate was 82.8% in the TRPN group vs. 84.0% in the RRPN group (P=0.065). The RRPN group showed shorter operative time (123 vs. 171 min; P<0.001) and less blood loss (161 vs. 293 mL; P<0.001). RRPN showed a higher trifecta achievement for posterior tumors than TRPN (71% vs. 81%; P=0.017).

CONCLUSIONS

RRPN is a viable alternative to the transperitoneal approach, particularly for posterior renal tumors, and is a safe and effective option for partial nephrectomy.

First Comparison of Retroperitoneal Versus Transperitoneal Robot-Assisted Nephroureterectomy with Bladder Cuff: A Single Center Study

INTRODUCTION

After recent presentation of the first complete robot-assisted retroperitoneal nephroureterectomy with bladder cuff (RRNU) for patients with upper tract urothelial cancer (UTUC), we aimed to compare this new surgical technique with robot-assisted transperitoneal nephroureterectomy (TRNU) representing the current standard of care.

METHODS

Robot-assisted nephroureterectomies (NUs) were retrospectively analyzed and compared based on two groups: transperitoneal versus retroperitoneal approach. Baseline data were collected for patient demographics, tumor characteristics, intra- (EAUiaiC) and postoperative (Clavien-Dindo) complications, and perioperative variables. Tumor characteristics included grade of malignancy, clinical stage, and surgical margin status. Short-term follow-up data including 30-day readmission rates were collected. Statistical analyses were performed assuming a significant p-value of < 0.05.

RESULTS

The analysis includes perioperative patient data after proven UTUC of 24 TRNU versus 12 RRNU (mean age: 70 versus 71 years; BMI: 25.9 versus 26.1 kg/m²; CCI score ≥ 4: 83% versus 75%; ASA score ≥ 3: 37% vs 33%). Intraoperative (16.4% vs 0%, p = 0.35) and postoperative (25% vs 12.5%, p = 0.64) complications demonstrated no significant discrepancy. Notably, RRNU demonstrated significantly shorter surgery time (p < 0.05) and length of stay (p < 0.05). There was no significant difference in histopathological tumor characteristics, whereas significantly more lymph nodes were removed through RRNU (11.0±3.3 vs. 6.4±5.1, p < 0.05). Finally, no statistical difference was shown in short-term follow-up.

CONCLUSION

We report the first head-to-head comparison between RRNU and TRNU. RRNU proves to be a safe and feasible approach which appears to be non-inferior to TRNU. RRNU expands the spectrum of minimally invasive treatment options, particularly for patients with major previous abdominal surgery.

Early Postoperative Outcomes of Retroperitoneal Partial Nephrectomy of Anterior and Posterior Renal Tumors: A Five-year Experience in A Single Center

OBJECTIVE

Partial nephrectomy (PN) is one of the surgical treatment options for renal tumors. Therefore, the aim of this study was to compare the surgical outcomes of retroperitoneal PN for anterior and posterior tumors.

MATERIALS AND METHODS

This study enrolled 177 patients who had renal tumors that were detected on abdominal computed tomography and underwent PN between January 2017 and April 2021. Tumor position was defined by the anatomic avascular Brodel's line. Surgical outcomes were compared between approaches using the chi-squared, Student's t-tests, logistic regression analysis and stratification analysis.

RESULTS

Of the 177 patients, 97 (54.8%) patients had anterior renal tumors and 80 (45.2%) had posterior renal tumors. On comparing the surgical results between the two groups, the anterior group had higher levels of hemoglobin (Hb) reduction (-1.92 g/dL vs. -1.54 g/dL, p = 0.0444), but the estimated blood loss showed no significant difference between the two groups (497.6 mL vs. 433.2 mL, p = 0.4149). In addition, the alter in estimated glomerular filtration rate (eGFR) at post-operative 1st day (p = 0.5616), 6th month (p = 0.5046) and at post-operative 1st year (p = 0.7085) were not significantly different between the two groups. Other surgical outcomes, such as blood transfusion rate, complications, and lengths of stay, also had no significant difference. Stratified analysis revealed the anterior renal tumors had a 3.76 times risk (p = 0.0186) than the posterior tumors for decreasing Hb > 10% under laparoscopic PN. No post-operative gastrointestinal-related complications were reported.

CONCLUSIONS

This study demonstrated retroperitoneal surgical access to renal tumors and revealed equivalent surgical outcomes for both anterior and posterior renal tumors. Moreover, anterior renal tumors had benefits under robotic PN for bleeding control. Retroperitoneal PN can be considered a good approach for both anterior and posterior renal tumors with few intra-abdominal complications.

Single-port versus multiport partial nephrectomy: a propensity-score-matched comparison of perioperative and short-term outcomes

The objective of this study was to compare the perioperative and short-term functional and oncological outcomes of single-port and multiport robotic-assisted laparoscopic partial nephrectomy using propensity-score analysis. We evaluated all patients who underwent robotic partial nephrectomy at our institution between January 2019 and October 2020. Patient demographics, intraoperative data, and postoperative outcomes were collected and analyzed. Propensity-score matching was performed on age, sex, body mass index, prior abdominal surgery, and nephrometry score using the optimal matching method. A post hoc sensitivity analysis was performed to examine the robustness of the results. In total, 48 and 238 patients underwent single-port and multiport robotic partial nephrectomy, respectively. Following propensity-score matching, 48 multiport cases were matched 1:1 to single-port cases. The single-port cohort had lower median opioid use at postoperative day 1 (4.6 vs 9.8 MME, p = 0.0209) and cumulative hospital stay (5.1 vs 9.3 MME, p = 0.0357). Single port also had a shorter median length of stay (1.4 vs 1.6 days, p = 0.0045), although the post hoc sensitivity analysis showed no difference between the groups [- 0.13 (95% CI; - 0.580, 0.315, p = 0.5607). There were no significant differences in operative time, estimated blood loss, ischemia time, transfusions received, or positive margin rates. In conclusion, based on our early experience, single-port robotic partial nephrectomy is a safe and acceptable alternative to multiport robotic partial nephrectomy, providing comparable perioperative and postoperative outcomes while reducing inpatient opioid use.

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.

Robot-assisted partial nephrectomy: Can retroperitoneal approach suit for renal tumors of all locations?-A large retrospective cohort study

BACKGROUND

This study aimed to explore the appropriate location of renal tumors for retroperitoneal approach.

MATERIALS AND METHODS

We retrospectively analyzed 1040 patients with renal tumor who were treated at our institution from Janurary 2015 to June 2020 and had underwent retroperitoneal robotic assisted-laparoscopic partial nephrectomy (rRAPN). Clinical features and postoperative outcomes were evaluated.

RESULTS

Patients with incomplete data were excluded, and we included 896 patients in total. The median tumor size was 3.0 (range: 0.8-10.0) cm. The median RENAL Nephrometry Score was 7 (range: 4-11), and the median PADUA Nephrometry Score was 8 (range: 6-14). The median surgical time was 120 min, and the median warm ischemia time was 18 min. The median estimated blood loss was 50 ml. The follow-up time was 20.2 (range: 12-69) months. The mean change of eGFR 1 year after operation was 14.6% ± 19.0% compared with preoperative estimated glomerular filtration rate (eGFR). When compared the tumor at different locations, as superior or inferior pole, anterior of posterior face of kidney, there were no significant differences of intra- and post-operative outcomes such as surgical time, warm ischemia time, estimated blood loss, removal time of drainage tube and catheter, postoperative feeding time and hospital stay, and changes of eGFR one year after surgery. We also compared tumors at special locations as endophytic or exophytic, anterior of posterior hilus of kidney, there were no significant differences in surgical time, warm ischemia time, estimated blood loss and changes of eGFR. There was no significant difference in intraoperative features and postoperative outcomes when tumor larger than 4 cm was located at different positions of kidney. Though the surgical time was longer when BMI ≥ 28 (132.6 min vs. 122.5 min, p = 0.004), no significant differences were observed in warm ischemia time, estimated blood loss, changes in eGFR. Twenty-seven patients (3.0%) had tumor progression, including 8 (0.9%) recurrence, 19 (2.1%) metastasis, and 9 (1.0%) death.

CONCLUSION

Retroperitoneal approach for RAPN has confirmed acceptable intra- and postoperative outcomes and suits for renal tumors of all different locations. Large tumor size and obesity are not contraindications for rRAPN.

Single-port robot-assisted retroperitoneal surgery: A feasible approach

INTRODUCTION

The concept of surgery through a single incision has been pursued in the field of minimal invasion for the treatment of different pathologies. This, added to a retroperitoneal approach, implies less aggression for the patient at different levels. We describe the first cases of single-port robot-assisted retroperitoneal surgery (SP-RARS) in our country using the da Vinci Xi® system.

MATERIAL AND METHODS

We present two cases of patients with right adrenal masses larger than 4 cm. The first case was a 55-year-old woman with an incidental diagnosis of angiomyolipoma, and the second case was a 62-year-old man with a non-functioning adrenal adenoma. Both cases were operated through a single 4-cm subcostal incision using the da Vinci Xi® system, annulling arm 4 without reallocating laterality on the surgeon's console.

RESULTS

Both surgeries were performed with console times of 75 and 150 min, respectively, with access and docking times below 30 min. Bleeding was less than 100 cc in both surgeries without the need to make accessory incisions or leave a drainage tube. The surgical specimens were removed through the same initial incision without the need for enlargement. Postoperative intravenous analgesia was not necessary in any case (VAS 0) and hospital stay was less than 24 h in both patients without reporting any complications.

CONCLUSIONS

SP-RARS is a feasible approach using the da Vinci Xi® system.

Retroperitoneal Robot-assisted Partial Nephrectomy: A Systematic Review and Pooled Analysis of Comparative Outcomes

Context

Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity as primary minimally invasive surgical treatment for localized renal tumors, and it has preferably been performed with a transperitoneal approach. However, the retroperitoneal approach represents an alternative approach given potential advantages.

Objective

To provide an updated analysis of the comparative outcomes of retroperitoneal RAPN (R-RAPN) versus transperitoneal RAPN (T-RAPN).

Evidence acquisition

A systematic review of the literature was performed up to September 2021 using MEDLINE, EMBASE, and Web of Science databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations. A sensitivity analysis was performed considering only matched-pair studies.

Evidence synthesis

Seventeen studies, which were published between 2013 and 2021, were retrieved. None of them was a randomized clinical trial. Among the 6,266 patients included in the meta-analysis, 2261 (36.1%) and 4,005 (63.9%) underwent R-RAPN and T-RAPN, respectively. No significant difference was found in terms of baseline features. The T-RAPN group presented a higher rate of male patients (odds ratio [OR]: 0.86, p = 0.03) and larger tumor size (weighted mean difference [WMD]: 0.2 cm; p = 0.003). The R-RAPN group reported more frequent posterior renal masses (OR: 0.23; p < 0.0001). The retroperitoneal approach presented lower estimated blood loss (WMD: 30.41 ml; p = 0.001), shorter operative time (OT; WMD: 20.36 min; p = 0.0001), and shorter length of stay (LOS; WMD: 0.35 d; p = 0.002). Overall complication rates were 13.7% and 16.05% in the R-RAPN and T-RAPN groups, respectively (OR: 1.32; p = 0.008). There were no statistically significant differences between the two groups regarding major (Clavien-Dindo classification ≥3 grade) complication rate, “pentafecta” achievement, as well as positive margin rates. When considering only matched-pair studies, no difference between groups was found in terms of baseline characteristics. Posterior renal masses were more frequent in the R-RAPN group (OR: 0.6; p = 0.03). Similar to the analysis of the entire cohort, R-RAPN reported lower EBL (WMD: 35.56 ml; p < 0.0001) and a shorter OT (WMD: 18.31 min; p = 0.03). Overall and major complication rates were similar between the two groups. The LOS was significantly lower for R-RAPN (WMD: 0.46 d; p = 0.02). No statistically significant difference was found between groups in terms of overall PSM rates.

Conclusions

R-RAPN offers similar surgical outcomes to T-RAPN, and it carries potential advantages in terms of shorter OT and LOS. Available evidence remains limited by the lack of randomized clinical trials.

Patient summary

In this review of the literature, we looked at comparative outcomes of two surgical approaches to robot-assisted partial nephrectomy. We found that the retroperitoneal technique offers similar surgical outcomes to the transperitoneal one, with potential advantages in terms of shorter operative time and length of hospital stay.

Comparison of Transperitoneal and Retroperitoneal Robotic Partial Nephrectomy for Patients With Complete Upper Pole Renal Tumors

OBJECTIVES

We compared the outcomes of transperitoneal robotic partial nephrectomy (TRPN) and retroperitoneal robotic partial nephrectomy (RRPN) for complete upper pole renal masses (1 point for the "L" component of the RENAL scoring system).

MATERIAL AND METHODS

We retrospectively reviewed patients who underwent either TRPN or RRPN from 2013 to 2016. Baseline demographics and perioperative, functional, and oncological results were compared. Multivariable analysis was performed to identify factors related to pentafecta achievement (ischemia time ≤25 min, negative margin, perioperative complication free, glomerular filtration rate (eGFR) preservation >90%, and no chronic kidney disease upstaging).

RESULTS

No significant differences between TRPN vs. RRPN were noted for operating time (110 vs. 114 min, p = 0.870), renal artery clamping time (19 vs. 18 min, p = 0.248), rate of positive margins (0.0% vs. 3.3%, p = 0.502), postoperative complication rates (25.0% vs. 13.3%, p = 0.140). TRPN was associated with a more estimated blood loss (50 vs. 40 ml, p = 0.004). There were no significant differences in pathologic variables, rate of eGFR decline for postoperative 12-month (9.0% vs. 7.1%, p = 0.449) functional follow-up. Multivariate analysis identified that only RENAL score (odd ratio: 0.641; 95% confidence interval: 0.455-0.904; p = 0.011) was independently associated with the pentafecta achievement.

CONCLUSIONS

For completely upper pole renal masses, both TRPN and RRPN have good and comparable results. Both surgical approaches remain viable options in the treatment of these cases.

First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique

Introduction

While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach.

Methods

Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.

Results

The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m²; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9–6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100–250). No patient experienced postoperative complications exceeding Clavien–Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission.

Conclusion

We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03920-1.

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.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique

INTRODUCTION AND OBJECTIVE

The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain.

MATERIAL AND METHODS

We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4 cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment.

RESULTS

From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6 ± 16.3 min, with <150 mL bleeding, mean length of stay of 35.8 ± 13.3 h and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8 ± 18 mm. No complications were reported according to the Clavien-Dindo scale.

CONCLUSIONS

Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

Single-port retroperitoneoscopic adrenalectomy: Initial experience and standardization of the technique

INTRODUCTION AND OBJECTIVE

The minimally invasive surgical approach to adrenal gland pathology is the most widely used nowadays, and retroperitoneoscopy occupies a relevant place. However, the evolution of these techniques towards even less invasive surgery through single-port access is anecdotal. The aim of this work is to describe our initial experience in single-port retroperitoneoscopic surgery (SPORS) of the adrenal gland focusing on perioperative data and postoperative pain.

MATERIAL AND METHODS

We collected and analyzed the demographic and operative data of a series of patients undergoing adrenalectomy through SPORS. All procedures were performed through a single 3-4cm subcostal incision with a multichannel port. Surgical data such as operative time, bleeding, length of stay and presence of complications were collected. We used the visual analog scale (VAS) for postoperative pain assessment.

RESULTS

From December 2018 to August 2020, 6 patients with different types of adrenal pathology underwent consecutive surgeries in our Department by the same surgeon using SPORS. All surgeries were performed without requiring accessory trocar placement or reconversion to open surgery. The mean operative time was 91.6±16.3minutes, with <150mL bleeding, mean length of stay of 35.8±13.3hours and postoperative pain of VAS ≤3 (median 0.5). The mean size of specimens was 57.8±18mm. No complications were reported according to the Clavien-Dindo scale.

CONCLUSIONS

Even in initially adverse cases, SPORS adrenalectomy is a feasible and safe technique with good cosmetic and perioperative results.

Retroperitoneal versus transepritoneal robot-assisted partial nephrectomy for postero-lateral renal masses: an international multicenter analysis

PURPOSE

To assess the outcomes of retroperitoneal robot-assisted partial nephrectomy (r-RAPN) in a large cohort of patients with postero-lateral renal masses comparing to those of transperitoneal RAPN (t-RAPN).

METHODS

Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN ("study group") and t-RAPN ("control group"). Baseline characteristics, intraoperative, and postoperative data were collected and compared.

RESULTS

Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170 min, p < 0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p = 0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥ III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p = 0.9). There was no difference in hospital re-admission rate, median length of stay, and PSM rate. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p = 0.7).

CONCLUSION

r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with postero-lateral renal tumors. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports.

Retroperitoneal or transperitoneal approach in robot-assisted partial nephrectomy, which one is better?

Purpose

To systematically assess the perioperative outcomes of retroperitoneal (RP) and transperitoneal (TP) approaches in robot‐assisted partial nephrectomy (RAPN), we conducted an updated meta‐analysis.

Methods

A literature retrieval of multi‐database including PubMed, Web of Science, Embase, Cochrane Library, and CNKI was performed to identify eligible comparative studies from the inception dates to January 2021. Perioperative outcomes included operative time (OT), estimated blood loss (EBL), warm ischemia time (WIT), postoperative length of stay (PLOS), positive surgical margin (PSM), and complications (major complications and overall complications). Outcomes of data were pooled and analyzed with Review Manager 5.4.1.

Results

Twenty‐one studies involving a total of 2482 RP and 3423 TP approach RAPN patients met the inclusion criteria. Operating time (OT) (weighted mean difference [WMD] −16.60; 95% confidence interval [CI] −23.08, −10.12; p < 0.01) and PLOS (WMD −0.46 days; 95% CI −0.69, −0.23; p < 0.01) were shorter in RP‐RAPN. Besides, lower EBL (WMD −21.67; 95% CI −29.74, −13.60; p < 0.05) was also found in RP‐RAPN. Meanwhile, no significant differences were found in other outcomes.

Conclusions

RP‐RARN was superior to TP‐RAPN in patients undergoing RAPN in terms of OT, PLOS, and estimated blood loss. Besides these two approaches have no significant differences in PSMs or perioperative complications.

The future of "Retro" robotic partial nephrectomy

Partial nephrectomy (PN) is the gold standard treatment for appropriately selected renal masses. Recent surgical advancements and adoption of the robotic technique has led to greater adoption of nephron-sparing surgery. Robotic PN was initially described via the transperitoneal (TP) approach, however, retroperitoneal (RP) access is possible and in some cases more desirable. In the RP approach, the kidney is accessed from its posterior surface and the intraperitoneal space is avoided. The RP approach to PN has the benefit of avoiding intraperitoneal viscera and colonic mobilization in patients with extensive prior abdominal surgery. The technique also eliminates the need for renal unit rotation in patients with posterior tumors and affords access to masses directly posterior to the renal hilum. The RP and TP approach to PN have shown similar oncologic and perioperative outcomes. Several recent studies have reported shorter operative times and lengths of stay (LOS) with comparable warm ischemia times for the RP approach when compared to transperitoneal PN (tPN). Given the indispensable deliverables of this approach in select patients, robotic retroperitoneal PN (rPN) should be in the armamentarium of a versatile urologic kidney surgeon. This review describes the current state of rPN and compares the indications and outcomes of the TP and RP approaches.

Retroperitoneal robot-assisted laparoscopic partial nephrectomy for posterior located renal tumours: Technique and early term outcomes

BACKGROUND

Traditionally, the trans-peritoneal approach is preferred for robot-assisted partial nephrectomy (RPN). However, retroperitoneal RPN (RP-RPN) has recently become widespread because of the advantages of easier access to the hilum, ease dissection of posterior tumours, and lower probability of intra-peritoneal organ injury. We aimed to present our initial experience of the RP-RPN series in posteriorly located renal tumours.

METHODS

Twenty-one patients were included in the study, who underwent RP-RPN by a single surgeon between July 2019 and January 2020. RP-RPN was carried out only in posteriorly located renal tumours with ischemic (on-clamp) or zero ischemic (off-clamp) techniques. Patients with solitary kidney and a history of previous retroperitoneal surgery in the lumbodorsal region were excluded from the study.

RESULTS

All cases completed without any operative complication and conversion to open or radical nephrectomy. Seven cases were completed as zero ischemic and 14 cases as ischemic technique. The mean operation time was 157.86 ± 64.24 minutes and estimated blood loss was 173.81 ± 136.84 mL. The mean warm ischemia time was 15.81 ± 12.42 minutes. Positive surgical margin observed in 4.8% of the patients. The mean length of stay was 3.33 ± 0.79 days. The mean estimated glomerular filtration rate (eGFR) change in the 3rd postoperative month was -3.71 ± 8.57 ml/min/1.73 m² (4.6%). Mean follow-up period was 10.29 ± 4.86 months. New-onset stage 3-4 chronic kidney disease (eGFR < 60 m /min/1.73m² ) was not observed during the follow-up period.

CONCLUSION

RP-RPN is a safe and feasible approach with acceptable oncological and functional results. We think that RP-RPN can be applied as an alternative to the trans-peritoneal approach for selected cases, especially in renal tumours with the posterior location.

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.

Single overnight stay after robot-assisted partial nephrectomy: a bi-center experience

BACKGROUND

Despite hospital length of stay (LOS) being shorter for robot-assisted partial nephrectomy (RAPN) compared to its open counterpart, several series in the literature report on average a LOS of 2-3 days or more. We aimed to assess factors predicting a prolonged length of stay (beyond a single overnight stay) in patients undergoing RAPN.

METHODS

Patients who underwent RAPN between 2010 and 2019 at two USA Centers were included and divided into two groups according to LOS: the study group included all patients who were discharged on POD1, whereas the control group included patients with LOS ≥2 days. Demographics, surgical and perioperative outcomes were compared between the groups. Multivariable logistic regression analyses were used to identify independent predictors of LOS ≥2.

RESULTS

Overall, 173 (60.5%) patients discharged on POD1, and 113 (39.5%) discharged on POD≥2. Patients in the study group presented a lower mean BMI (29 vs. 32, P=0.02). Retroperitoneal approach was performed in 13.3% patients with shorter LOS (P<0.001). There was a statistically significant difference in median OT (144 vs. 168 min, P=0.005) and WIT (19 vs. 23 min, P=0.001). We observed six postoperative complications (3.6%) in patients discharged on POD1 and 35 (30.5%) in control group (P<0.001). Major complications (Clavien-Dindo grade ≥III) were observed in three of POD1 patients (1.8 vs. 6.1%, P<0.001). There was no difference in hospital readmission rate. On logistic regression analysis, independent predictors of prolonged LOS were OT (OR=1.01, 95% CI: 1.0-1.2, P=0.001), and occurrence of a postoperative complication (OR=2.2, 95% CI: 2.0-2.5, P<0.001).

CONCLUSIONS

Our findings confirm that a single overnight stay after RAPN is feasible and safe. In our experience, and within the limitations of the present analysis, prolonged operative time and occurrence of immediate postoperative complications translate into higher risk of prolonged hospital stay. Besides adopting a minimally invasive approach, surgeons should also implement perioperative care pathways facilitating early discharge without increasing the risk of readmission.

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.

Retroperitoneal Versus Transperitoneal Robotic Partial Nephrectomy: A Multicenter Matched-pair Analysis

BACKGROUND

With increasing acceptance of robotic partial nephrectomy over the last decade, there is an ongoing discussion about the transperitoneal versus retroperitoneal access.

OBJECTIVE

To report outcomes after transperitoneal (TRPN) versus retroperitoneal (RRPN) robotic partial nephrectomy.

DESIGN, SETTING, AND PARTICIPANTS

A total of 754 patients were identified from the databases of three high-volume centers who underwent either TRPN (n = 551) or RRPN (n = 203).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Perioperative data were evaluated retrospectively. A propensity score matched-pair analysis was performed with the following variables: grade of renal insufficiency, age, body mass index, tumor diameter, and preoperative aspects and dimensions used for an anatomical (PADUA) score with a subsequent subgroup analysis for tumor location. For quality outcomes, the margin, ischemia, and complications (MIC) criteria were used (negative margins, ischemia time <20 min, and no major complications). Statistical analyses included chi-square and Mann-Whitney U tests.

RESULTS AND LIMITATIONS

In all, 176 patients could be matched in each group. The median tumor diameter was 28 mm with a PADUA score of 9. In 11% of RRPN versus 44% of TRPN cases, an anterior tumor location was found, and in 55% versus 30%, a posterior lesion was found (p < 0.001). Operative time (119 vs 139 min, p < 0.001) and warm ischemia time (9 vs 10 min, p = 0.003) were significantly shorter for RRPN. No significant differences were observed between intra- and postoperative complication rates, with 8% major complications in TRPN versus 3% in RRPN (p = 0.06). The MIC criteria were achieved in 90% in the RRPN versus 88% in the TRPN group, without differences for tumor location.

CONCLUSIONS

Significant differences between TRPN and RRPN could be found for intraoperative time, while complication rates and quality outcomes were comparable. RRPN can also be a considerable alternative for anterior tumors.

PATIENT SUMMARY

In this study, we demonstrate that robotic partial nephrectomy is feasible with either a transperitoneal or a retroperitoneal surgical access. The posterior approach can also be used for anterior renal tumors and may result in shorter operative time.

Propensity Score Matched Analysis Comparing Robotic-Assisted with Laparoscopic Posterior Retroperitoneal Adrenalectomy

Objectives: To compare the perioperative outcomes between robotic posterior retroperitoneal adrenalectomy (RPRA) with laparoscopic posterior retroperitoneal adrenalectomy (LPRA) for adrenal tumors and to identify which group of patients may benefit from RPRA.Methods: A total of 401 patients who fulfilled the inclusion criteria were collected and analyzed; among them, 86 and 315 patients underwent RPRA and LPRA, respectively. To adjust for potential baseline confounders, propensity score matching (PSM) was conducted at a 1:1 ratio. Patient demographics and perioperative outcomes were compared between the two groups.Results: After matching, no differences were found between the two groups in patient demographics or tumor characteristics. The median length of postoperative stay (3 vs. 4 days, p = 0.001) was significantly shorter in the RPRA group, but this group also showed a higher median total hospitalization cost (8121.89 vs. 4107.92 $, p < 0.001). There was no difference in the median operative duration (100 vs. 110 min, p = 0.554), median estimated blood loss (50 vs. 50 ml, p = 0.730), transfusion rate (p = 0.497) or incidence of postoperative complications (p = 0.428).Conclusions: According to our research, RPRA leads to a shorter postoperative hospitalization stay but a higher total hospitalization cost than LPRA after propensity score matching.

Comparisons of surgical outcomes between transperitoneal and retroperitoneal approaches in robot-assisted laparoscopic partial nephrectomy for lateral renal tumors: a propensity score-matched comparative analysis

OBJECTIVE

To compare the surgical outcomes between the transperitoneal (TP) and retroperitoneal (RP) approaches in robot-assisted laparoscopic partial nephrectomy (RAPN) for lateral tumors.

METHODS

This study included patients who underwent RAPN for lateral renal tumors between 2013 and 2019. Lateral tumors were defined as X of A factors in the RENAL nephrometry score. In total, 290 and 48 patients with TP and RP, respectively, were included in the analysis. To minimize the effects of selection bias, the following variables were adjusted using 1:1 propensity score matching: age, sex, body mass index, American Society of Anesthesiologists score, preoperative estimated glomerular filtration rate, tumor size, and RENAL nephrometry score.

RESULTS

After matching, 48 patients were allocated to each group. The mean age was 55 years, and the mean preoperative estimated glomerular filtration rate (eGFR) was 68-69 mL/min/1.73 m². The mean tumor size was 30-31 mm. The RP group had a shorter operative time (124 vs. 151 min, p = 0.0002), shorter console time (74 vs. 110 min, p < 0.0001), shorter warm ischemic time (14 vs. 17 min, p = 0.0343), lower estimated blood loss (EBL) (33 vs. 52 ml, p = 0.0002), and shorter postoperative length of hospital stay (PLOS) (3.3 vs. 4.0 days, p < 0.0001) than the TP group. The change in eGFR, incidence rate of perioperative complication, and positive surgical margin rate did not significantly differ between the two groups.

CONCLUSION

RP had better surgical outcomes, including shorter operative time, lower EBL, and shorter PLOS for lateral renal tumors, which may suggest that RP is the optimal approach for selected lateral renal tumors.

A Single Overnight Stay After Robotic Partial Nephrectomy Does Not Increase Complications

Objectives: To evaluate the feasibility of postoperative day 1 (POD1) discharge after robotic partial nephrectomy (RPN) and to determine whether a protocol targeting a shorter length of stay (LOS) is associated with any difference in the rate of postoperative complications. Materials and Methods: We reviewed a prospectively maintained, multi-institutional database of patients who underwent RPN from September 2013 to September 2016. Three of the six participating surgeons used a protocol that targeted discharge on POD1, whereas three surgeons did not. Patient characteristics and postoperative complication rates between the two groups were compared. Results: A total of 665 patients were included, 455 of whom were treated by surgeons utilizing a POD1 discharge protocol, whereas 210 were not. The mean LOS for those in the POD1 protocol group was 1.13 days vs 2.02 days in the non-protocol group. Between groups, there were no differences in age (p = 0.098), body mass index (p = 0.164), tumor size (p = 0.502), or R.E.N.A.L. Nephrometry score (p = 0.974), but POD1 discharge protocol patients had higher age-adjusted Charlson comorbidity score (4 vs 2, p = 0.033), were less likely to have a hilar tumor (15.9% vs 23.1%, p = 0.03), and had a larger percent decrease in discharge estimated glomerular filtration rate (-15.9% vs -7.1%, p < 0.001). There were no differences in the rates of overall (p = 0.715), major (p = 0.164), medical (p = 0.089), or surgical complications (p = 0.301) or in complications by the Clavien-Dindo category (p = 0.13). Conclusion: Discharge on POD1 after RPN is feasible, reproducible by different surgeons, and not associated with an increased risk of postoperative complications.

Lessons learned from clinical outcome and tumor features of patients underwent selective artery embolization due to postoperative bleeding following 2076 partial nephrectomies: propensity scoring matched study

PURPOSE

To evaluate the clinical and tumor characteristics in patients undergoing selective artery embolization (SAE) for bleeding after partial nephrectomy (PN).

METHODS

We retrospectively evaluated patients who underwent SAE from 2076 patients who underwent PN. The clinical and tumor characteristics of these patients were analyzed using entire data and propensity score matching (PSM). 76 patients who underwent PN (control, n = 38 patients; SAE, n = 38) were enrolled in PSM.

RESULTS

SAE was performed in 41 patients who underwent open (19/1171), laparoscopic (4/60), and robot-assisted PN (18/845). The median period from PN to SAE was 12 days (interquartile range 8-24 day). The most common symptom of 31 (75.61%) patients was gross hematuria, followed by flank pain (3/41). Follow-up imaging revealed large pseudoaneurysm in 7 asymptomatic patients. The main reason for SAE on angiography was pseudoaneurysm (32/41), followed by arteriovenous fistula (5/41). Technical and clinical success was achieved in all patients. There was no statistical difference in the estimated glomerular filtration rate after 1 year, surgical methods, or baseline characteristics between the two groups. Conversely, there was statistically significant difference in ischemic time in the entire data and PSM. In the embolization group, renal masses showed statistically significant endophytic (p = 0.006) and posterior (p = 0.028) characteristics.

CONCLUSIONS

SAE is an effective method for controlling postoperative bleeding while preserving renal function after PN. And, we suggest more attentive postoperative surveillance about vascular complications in patients with longer ischemia time or renal masses with endophytic and posterior locations.

Novel technique: direct access partial nephrectomy approach through a transperitoneal working space (Roskilde technique)

Objectives: To describe a direct access partial nephrectomy technique through a transperitoneal working space (Roskilde technique).Materials and methods: Prospective single-center descriptive study between April 2015 and January 2017. The surgical outcomes are evaluated according to the Trifecta criteria (negative margins, warm ischemia time < 20 min and a Clavien-Dindo complication score < 3).Surgical procedure: The same access to the transperitoneal cavity as in a Standard transperitoneal Partial Nephrectomy was used. A direct access was established by incision of the peritoneum directly onto the renal fascia. The renal vessels and tumor were identified and the tumor removed with standard technique. The perinephric fat and peritoneum were then closed with a running suture.Results: In total, 122 patients underwent the Roskilde technique. The mean age was 62.2 years, the median Padua score was 12 (IQR = 9-12) and the median tumor size was 32 mm (IQR = 12-90). The median operative time was 101 min (IQR = 90-125). The trifecta achievement criteria goal was achieved in 116/122 (95%), with a median warm ischemia time of 8 min (IQR = 0-12).Conclusions: The Roskilde technique is safe and feasible. It can be performed on complex renal masses, and it seems to result in short operative times and high Trifecta achievement.Trial registration: None.

The Impact of Surgical Strategy in Robot-assisted Partial Nephrectomy: Is It Beneficial to Treat Anterior Tumours with Transperitoneal Access and Posterior Tumours with Retroperitoneal Access?

Available comparison of transperitoneal robot-assisted partial nephrectomy (tRAPN) and retroperitoneal robot-assisted partial nephrectomy (rRAPN) does not consider tumour's location. The aim of this study was to compare perioperative morbidity, and functional and pathological outcomes after tRAPN and rRAPN, with the specific hypothesis that tRAPN for anterior tumours and rRAPN for posterior tumours might be a beneficial strategy. A large global collaborative dataset of 1169 cT1-2N0M0 patients was used. Propensity score matching, and logistic and linear regression analyses tested the effect of tRAPN versus rRAPN on perioperative outcomes. No differences were observed between rRAPN and tRAPN with respect to complications, operative time, length of stay, ischaemia time, median 1-yr estimated glomerular filtration rate (eGFR), and positive surgical margins (all p>0.05). Median estimated blood loss and postoperative eGFR were 50 versus100ml (p<0.0001) and 82 versus 78ml/min/1.73 m² (p=0.04) after rRAPN and tRAPN, respectively. At interaction tests, no advantage was observed after tRAPN for anterior tumours and rRAPN for posterior tumours with respect to complications, warm ischaemia time, postoperative eGFR, and positive surgical margins (all p>0.05). The techniques of rRAPN and tRAPN offer equivalent perioperative morbidity, and functional and pathological outcomes, regardless of tumour's location. PATIENT SUMMARY: Robot-assisted partial nephrectomy can be performed with a transperitoneal or a retroperitoneal approach regardless of the specific position of the tumour, with equivalent outcomes for the patient.

Retroperitoneoscopy in urology: a systematic review

INTRODUCTION

In the past years, several authors have focused on the role of retroperitoneoscopic laparoscopy in the treatment of urological diseases. Aim of our study is to systematically review the available literature on retro-peritoneoscopic laparoscopy in urology.

EVIDENCE ACQUISITION

A systematic review of the literature using the Medline, Scopus, and Web of Science databases for relevant articles published until June 2018 was performed using both the Medical Subjects Heading and free test protocols. The MeSH search was conducted by combining the following terms: "retroperitoneoscopy," "posterior laparoscopy," "retroperitoneoscopic." Only randomized clinical trials were included in the analysis. Risk of bias assessment and forest plots were used to summarize data.

EVIDENCE SYNTHESIS

Nine RCTs on simple, partial and radical nephrectomy, pyeloplasty, ureterolithotomy and nephrolithotomy comparing RP to other techniques were included in the analysis. Retroperitoneoscopic approach in simple or radical nephrectomy is to be considered a valid alternative to transperitoneal laparoscopic approach. Outcomes and safety profiles (6-8% conversion rate) are similar and the approach depends on surgeon's preferences. Randomized studies analyzing retroperitoneoscopic pyeloplasty showed better results in terms of perioperative morbidity (tramadol use: 147 vs. 179 mg, P=0.002) and return to normal activities when compared to either anterior laparoscopic either to minimally invasive open approach. Two randomized studies have confirmed the efficacy (stone-free rate: 94%) and safety (no Clavien-Dindo >II complications) of ureterolithotomy and nephrolithotomy (stone-free rate: 95%) in the management of large renal and ureteral stones.

CONCLUSIONS

Retroperitoneoscopic approach in urological diseases is a valid alternative to the anterior approach. Evidence suggest lower morbidity for the retroperitoneoscopic approach however technical complexity may limit its widespread.

A Multi-Institutional Propensity Score Matched Comparison of Transperitoneal and Retroperitoneal Partial Nephrectomy for cT1 Posterior Tumors

OBJECTIVE

To compare the perioperative and renal functional outcome between transperitoneal and retroperitoneal robotic partial nephrectomy (TP-RPN and RP-RPN) in the largest cohort to date of RP-RPN for posterior tumors.

METHODS

We identified 519 patients who met eligibility criteria and underwent TP-RPN (n = 357, 68.8%) or RP-RPN (n = 162, 31.2%) for a posteriorly located cT1 tumor. Patients were propensity score (PS) matched on preoperative and tumor-specific characteristics. Perioperative outcome and renal function outcome at median follow-up 22 months were compared.

RESULTS

Between the PS matched TP-RPN (n = 157, 50%) and RP-RPN (n = 157, 50%) patients, operative time (OT) (185.0 versus 157.0, P < .001) was longer in TP-RPN versus RP-RPN patients. No significant differences in ischemia time (P = .618), blood loss (P = .178), positive surgical margins (P = .501), overall postoperative complications (P = .861), or progression of chronic kidney disease stage at median 22 months (P = .599) were identified. Length of stay (LOS) was reduced in RP-RPN patients (P = .017), but was not different once an institution used a postoperative day (POD)-1 discharge protocol (P = .579). Operative times were similar between groups in patients with obesity (P = .293) or a cT1b renal mass (P = 908).

CONCLUSION

RP-RPN for posterior tumors resulted in reduced OT and a shorter LOS compared to TP-RPN. When surgeons aimed to routinely discharge patients on POD-1, the surgical approach did not influence LOS. Operative time was similar between RP and TP-RPN among patients with obesity or a cT1b renal mass. All other measures, including ischemia time, blood loss, margin rates, complications, and renal function, did not differ between the two approaches.

Retroperitoneal vs Transperitoneal Robot-assisted Partial Nephrectomy: Comparison in a Multi-institutional Setting

OBJECTIVES

To evaluate retroperitoneal robot-assisted partial nephrectomy (RAPN) against transperitoneal approach in a multi-institutional prospective database, after accounting for potential selection bias that may affect this comparison.

PATIENTS AND METHODS

Post-hoc analysis of the prospective arm of the Vattikuti Collective Quality Initiative database from 2014 to 2018. Six hundred and ninety consecutive patients underwent RAPN by 22 surgeons at 14 centers in 9 countries. Patients who had surgery at centers not performing retroperitoneal approach (n = 197) were excluded. Inverse probability of treatment weighting was done to account for potential selection bias by adjusting for age, gender, body mass index, comorbidities, side of surgery, location/size/complexity of tumor, renal function, American Society of Anesthesiologists score, and year of surgery. Operative and perioperative outcomes were compared between weighted transperitoneal and retroperitoneal cohorts.

RESULTS

Ninety-nine patients underwent retroperitoneal RAPN; 394 underwent transperitoneal RAPN. Hospital stay in days-median 3.0 (Interquartile range [IQR] 2.0-4.0) transperitoneal vs 1.0 (1.0-3.0) retroperitoneal; P < .001, and blood loss in mL-125 (50-250) transperitoneal vs 100 (50-150) retroperitoneal; P = .007-were lower in the retroperitoneal group. There were no differences in operative time (P = .6), warm ischemia time (P = .6), intraoperative complications (P = .99), conversion to radical nephrectomy (P = .6), postoperative major complications (P = .6), positive surgical margins (P = .95), or drop in estimated glomerular filtration rate (P = .7).

CONCLUSION

In a multi-institutional setting, both retroperitoneal and transperitoneal approach to RAPN have comparable operative and perioperative outcomes, except for shorter hospital stay with the retroperitoneal approach.

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.