Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome

Trends and Costs of Minimally Invasive Surgery for Kidney Cancer in the US: A Population-based Study

OBJECTIVE

To analyze temporal trends and costs associated with the use of minimally invasive surgery (MIS) for kidney cancer in the US over the past decade. To examine the impact of social determinants of health (SDOH) on perioperative outcomes.

METHODS

The PearlDiver Mariner, a national database of insurance billing records, was queried for this retrospective observational cohort analysis. The MIS population was identified and stratified according to treatment modality, using International Classification of Diseases and current procedural terminology codes. SDOH were assessed using International Classification of Diseases codes. Negative binomial regression was used to evaluate the overall number of renal MIS and Cochran-Armitage tests to compare the utilization of different treatment modalities, over the study period. Multivariable logistic regression analysis identified predictors of perioperative complications.

RESULTS

A total of 80,821 MIS for kidney cancer were included. Minimally invasive partial nephrectomy adoption as a fraction of total MIS increased significantly (slope of regression line, reg. = 0.026, P <.001). Minimally invasive radical nephrectomy ($26.9k ± 40.9k) and renal ablation ($18.9k ± 31.6k) were the most expensive and cheapest procedures, respectively. No statistically significant difference was observed in terms of number of complications (P = .06) and presence of SDOH (P = .07) among the treatment groups. At multivariable analysis, patients with SDOH undergoing minimally invasive radical nephrectomy had higher odds of perioperative complications, while renal ablation had a significantly lower probability of perioperative complications.

CONCLUSION

This study describes the current management of kidney cancer in the US, offering a socioeconomic perspective on the impact of this disease in everyday clinical practice.

Effectiveness of Thermal Ablation for Renal Cell Carcinoma after Prior Partial Nephrectomy

Background

Repeat partial nephrectomy (PN) for tumors recurring in the ipsilateral kidney is associated with surgical complexity and a higher rate of complications.

Objective

To evaluate the local oncologic efficacy of thermal ablation (TA) for renal cell carcinoma (RCC) in the ipsilateral kidney following PN.

Design setting participation

We included patients who underwent ablation for renal tumors in the ipsilateral kidney after PN between January 2005 and December 2019. Demographics, tumor size, procedural details, complications, pathology, local oncologic outcomes, and survival outcomes are described.

Outcome measurements and statistical analysis

The procedural, pathologic, and oncologic outcomes are described. Survival rates were estimated using the Kaplan-Meier method.

Results and limitations

A total of 66 patients (46 male and 20 female) with a median age of 62 yr (interquartile range [IQR] 52-69) met our inclusion criteria. In these patients, 74 TA procedures were performed for 86 lesions (median tumor size 1.9 cm, IQR 1.6-2.5). Radiofrequency ablation and cryoablation accounted for 60 (81%) and 14 (19%) procedures, respectively. Three patients (3.7%) had Clavien-Dindo grade III complications. Of 65 lesion biopsies, 62 (95.5%) were diagnostic. The most common subtype was clear cell RCC (n = 37). The median imaging follow-up duration was 60 mo (IQR 43-88). Recurrence in the ablation zone occurred for four lesions (4.6%) at a median of 6.9 mo (IQR 6.4-10.7). The rates of overall, recurrence-free, and disease-free survival were 93.1%, 94.4%, and 65.6% at 5 yr, and 71.6%, 94.4%, and 60.1% at 10 yr, respectively. Limitations include the retrospective design and the lack of a control group.

Conclusions

TA is effective for the treatment of RCC in the ipsilateral kidney following PN.

Patient summary

Heat treatment to remove tumor tissue is an effective option for small kidney masses recurring after partial kidney removal for cancer. Long-term follow-up data revealed that this treatment resulted in low recurrence and complication rates.

Partial Nephrectomy, a Comparison between Different Modalities: A Tertiary Care Center Experience

Kidney cancer, with 4% of all malignancies, is one of the most common malignancies occurring among in adults. In Saudi Arabia, kidney cancer comprises 2.3% of all cancers, and its incidence has increased by 33%. Partial nephrectomy (PN) is considered as the gold standard for T1 renal masses. In this retrospective study, we did a chart review for all patients who underwent PNs between April 2013 and February 2019. Data comprised presentation, tumor size, type of procedure (open vs. laparoscopic vs. robotic), and intra- and post-operative complications. Chi-square, ANOVA, and cross-tabulation were done using SPSS software. P > 0.05 was considered significant. Approval was obtained from the institutional review board of King Abdullah International Medical Research Center. In all, 69 patients were identified: 26 (37.7%) males and 43 (62.3%) females, with mean age = 54.53 ± 13.21 years; mean body mass index = 32.36 ± 7.03, and mean tumor size = 3.7 ± 1.72 cm. In terms of presentation, most patients (50, 72.4%) presented incidentally as opposed to symptomatic presentation. Of these patients, 18 (26.1%) underwent open partial nephrectomy (OPN), 29 (42%) laparoscopic partial nephrectomy (LPN), and 22 (31.9%) robotic partial nephrectomy (RPN). On comparing minimally invasive surgery (MIS) PN with OPN, we found that OPN had more blood loss and a longer hospital stay but a shorter operating room (OR) time. Results of PN irrespective of the procedure type, whether it was OPN, LPN, or RPN, were similar if performed by experienced surgeons. However, open procedures involved a higher blood loss, more operative time, and longer hospital stay when compared with minimally invasive techniques.

Use of hemostatic agents for surgical bleeding in laparoscopic partial nephrectomy: Biomaterials perspective

In recent years, there was an abrupt increase in the incidence of renal tumors, which prompt up the appearance of cutting-edge technology, including minimally invasive and organ-preserving approaches, such as laparoscopic partial nephrectomy (LPN). LPN is an innovative technique used to treat small renal masses that have been gaining popularity in the last few decades due to its promissory results. However, the bleeding control remains the main challenge since the majority of currently available hemostatic agents (HAs) used in other surgical specialities are inefficient in LPN. This hurried the search for effective HAs adapted for LPN surgical peculiarities, which resulted on the emergence of different types of topical HAs. The most promising are the natural origin HAs because of their inherent biodegradability, biocompatibility, and lowest toxicity. These properties turn them top interests' candidates as HAs in LPN. In this review, we present a deep overview on the progress achieved in the design of HAs based on natural origin polymers, highlighting their distinguishable characteristics and providing a clear understanding of their hemostat's role in LPN. This way it may be possible to establish a structure-composition properties relation, so that novel HAs for LPN can be designed to explore current unmet medical needs.

Oncological and functional outcomes of open versus laparoscopic partial nephrectomy in T1b tumors: A single-center analysis

PURPOSE

This study aims to evaluate the oncological and functional results of open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) at the T1b clinical stage, which constitutes 25% of renal cell carcinomas (RCC) at diagnosis.

MATERIALS AND METHODS

The characteristics of 63 patients with stage T1b solitary tumor who underwent OPN (41) or LPN (22) were compared. The survival analysis was performed using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were performed to determine the factors affecting disease-free survival. Potential predictive factors, which might affect the postoperative glomerular filtration rate (GFR), were evaluated using multivariate linear regression analysis.

RESULTS

No differences were observed between OPN and LPN groups regarding patient and tumor characteristics. Although the warm ischemia time, intraoperative estimated blood loss, and operation duration were higher in the LPN group, no differences were noted between the two techniques regarding complication rates (p<0.001, p=0.023, p≤0.001, and p=0.190, respectively). The median hospitalization time was shorter in the LPN group than that in the OPN group (4 and 5 days, respectively), with less severe complications. No intergroup differences were observed regarding cancer-specific survival (CSS), disease-free survival (DFS), and overall survival (OS). The evaluation of the factors affecting DFS showed that age was an effective parameter (RR = 1.112, 95% CI: 1.010-8.254), but the surgical technique was not.

CONCLUSION

No differences were observed between OPN and LPN techniques between oncological and functional outcomes in patients with clinical stage T1b RCC.

Cumulative sum analysis of learning curve for video-assisted mini-laparotomy partial nephrectomy in renal cell carcinoma

Video-assisted mini-laparotomy surgery (VAMS), a hybrid of open and laparoscopic surgical techniques, is an important surgical approach in the field of partial nephrectomy. The learning curve for VAMS partial nephrectomy has not been studied to date; we therefore, evaluated this learning curve.We prospectively evaluated 20 consecutive patients who underwent VAMS partial nephrectomy performed by a single surgeon (YEY) between March 2015 and December 2016. The learning curve was evaluated using the cumulative sum method. The measure of surgical performance was composed of 3 parameters (total operation time [Op time], warm ischemic time [WIT], and estimated blood loss [EBL]).Among the 20 patients who underwent VAMS partial nephrectomy, the mean age was 54.6 years. The mean Op time and WIT were 172.5 and 28.8 minutes, respectively. The learning curve for the Op time, WIT, and EBL consisted of 3 unique phases: phase 1 (the first 7 cases), phase 2 (the next 5 to 7 cases), and phase 3 (all subsequent cases). Phase 1 represents the initial learning curve, and the phase 2 plateau represents the period of expert competency. Phase 3 represents when one is competent in VAMS partial nephrectomy.The learning curve for VAMS partial nephrectomy is relatively short and after a learning curve of approximately 7 cases, the surgeon became familiar with VAMS partial nephrectomy; after 12 to 14 cases, the surgeon became competent in this procedure.

Comparative study of off-clamp, laparoscopic partial nephrectomy (OCLPN) and conventional hilar control, laparoscopic partial nephrectomy (HCLPN) for renal tumors: One-year follow-up results of renal function change

We designed the study to compare the oncologic and renal function outcomes of off-clamp, laparoscopic partial nephrectomy (OCLPN) and conventional laparoscopic partial nephrectomy (HCLPN) for renal tumors. Methods Between March 2008 and July 2015, 114 patients who underwent laparoscopic partial nephrectomy (LPN) of a renal neoplasm were studied. We performed LPN without hilar clamp on 40 patients (OCLPN, Group 1), and conventional LPN with hilar control and renorrhaphy on another 40 patients (HCLPN, Group 2). We retrospectively reviewed the medical records of each patient's age, sex, R.E.N.A.L. nephrometry score (RNS), operation time, complications, hospitalization period, tumor size, positive resection margin, histologic classification of tumor, pathologic stage, Fuhrman grade, estimated blood loss (EBL), warm ischemic time (WIT), and estimated glomerular filtration rate (eGFR) before and one year after surgery. Results There were no significant differences in age, sex, preoperative eGFR, EBL, surgical (anesthesia) time, and tumor size between the two groups. The mean eGFR was not significantly different between the OCLPN and HCLPN groups 1 month (95 and 86.2 mL/min/1.73 m2, respectively; P = 0.106), 6 months (92.9 and 83.6 mL/min/1.73 m2, respectively; P = 0.151) and 12 months (93.8 and 84.7 mL/min/1.73 m2, respectively; P = 0.077) postoperatively. The change in eGFR after one year was 3.9% in the OCLPN group and −7.9% in the HCLPN group. Conclusions OCLPN was superior to HCLPN in preserving renal function one year after surgery, and there was no statistically significant difference in tumor treatment results.

Laparoscopic Management of Kidney Cancer: Updated Review

BACKGROUND

Laparoscopy has emerged as the preferred option for the surgical management of kidney cancer. Although many reports have been published regarding the operative outcome of renal cell carcinoma (RCC) and upper-tract transitional cell carcinoma (TCCA) treated laparoscopically, few review the oncologic outcome of these pathologies treated with laparoscopic techniques.

METHODS

We review the literature regarding the laparoscopic approaches, the complications related to laparoscopic surgery, and the long-term oncologic results of laparoscopic radical nephrectomy, partial nephrectomy, and nephroureterectomy.

RESULTS

Laparoscopic radical nephrectomy has become the new standard of care for most patients with suspected RCCs that are not amenable to nephron-sparing procedures. Laparoscopic techniques for managing RCC and TCCA are safe, follow well-established guidelines for surgical dissection, and meet or exceed perioperative convalescence and oncologic outcomes compared to traditional open procedures. The surgical techniques and the long-term outcome data for laparoscopic partial nephrectomy continue to mature.

CONCLUSIONS

Laparoscopy is a minimally invasive option available to most patients with kidney cancer. The immediate benefits of laparoscopy are well established and include less estimated blood loss, decreased pain, shorter perioperative convalescence, and improved cosmesis. Long-term oncologic outcomes of patients treated laparoscopically for kidney tumors resemble those of the open surgical approach.

Intraoperative ultrasound control of surgical margins during partial nephrectomy

Aims:

To evaluate a simple and fast technique to ensure negative surgical margins on partial nephrectomies, while correlating margin statuses with the final pathology report.

Subjects and Methods:

This study was conducted for patients undergoing partial nephrectomy (PN) with T1–T2 renal tumors from January 2010 to the end of December 2015. Before tumor removal, intraoperative ultrasound (US) localization was performed. After tumor removal and before performing hemostasis of the kidney, the specimens were placed in a saline solution and a US was performed to evaluate if the tumor's capsule were intact, and then compared to the final pathology results.

Results:

In 177 PN(s) (147 open procedures and 30 laparoscopic procedures) were performed on 147 patients. Arterial clamping was done for 32 patients and the mean warm ischemia time was 19 ± 6 min. The mean US examination time was 41 ± 7 s. The US analysis of surgical margins was negative in 172 cases, positive in four, and in only one case it was not possible to conclude. The final pathology results revealed one false positive surgical margin and one false negative surgical margin, while all other margins were in concert with US results. The mean tumor size was 3.53 ± 1.43 cm, and the mean surgical margin was 2.8 ± 1.5 mm.

Conclusions:

The intraoperative US control of resection margins in PN is a simple, efficient, and effective method for ensuring negative surgical margins with a small increase in warm ischemia time and can be conducted by the operating urologist.

Application of renal-rotation techniques in retroperitoneoscopic partial nephrectomy

Retroperitoneoscopic partial nephrectomy (RPN) is one of the standard methods for treating T1-stage renal carcinoma, which has a narrow operational space and a difficult surgical procedure. The aim of this study was to examine the safety and feasibility of renal-rotation techniques in RPN. Between April 2012 and June 2014, the renal-rotation technique in RPN was performed in 22 male and 16 female patients, aged between 31 and 75 years (mean, 52 years), with stage T1N0M0 renal-cell carcinoma. In 29 cases the tumor was located at the ventral side of the kidney, including 22 cases at the renal hilum, and in nine cases the tumor was located at the inferior pole of the kidney. The tumor size was between 1.5 and 4.6 cm (mean, 2.8 cm). The results showed that, in all 38 cases, the procedure was successfully accomplished without conversion to open surgery. There were no intraoperative complications and only three cases of postoperative complications. The surgery duration was between 45 and 116 min (mean, 59 min); blood loss was between 10 and 120 ml (mean, 40 ml) and no patients required a blood transfusion. The average kidney ischemia time was 21 min (range, 15–38 min). No patients had local recurrence or metastasis after follow-up of between one and 26 months. In conclusion, the application of the renal-rotation technique in RPN for tumors located at the ventral side, renal hilum or at the inferior pole of the kidney is safe and feasible and worth wider clinical application.

Outcomes of partial nephrectomy in patients who meet percutaneous ablation criteria

INTRODUCTION

Treatment options for small renal masses include partial nephrectomy (PN), ablation and active surveillance. We sought to compare patients who met the criteria for percutaneous ablation but underwent robotic PN to the rest of our robotic PN cohort. This was done in order to detect any safety concerns and to define any risk factors that might contraindicate the use of robotic PN, an oncologically superior procedure, in patients who qualify for ablation.

MATERIAL AND METHODS

Our departmental renal mass registry was queried for patients who underwent robotic PN but also met criteria for percutaneous ablation. These were compared to the rest of the robotic PN cohort. Demographics, perioperative characteristics and recurrence data were compared.

RESULTS

Overall, 321 robotic PNs were identified. Of these, 26 (8.1%) met ablation criteria. Among patient characteristics, age and BMI were similar in both groups. Among operative characteristics, estimated blood loss (EBL) and operative time were similar. Warm ischemia time was significantly less for patients who met ablation criteria (14 vs. 17 minutes, p = 0.002). Mean tumor size was smaller for patients who met ablation criteria (2.3 vs. 2.7 cm, p = 0.012). Among postoperative characteristics, complications were similar overall and when present, stratified by Clavien grade.

CONCLUSIONS

Robotic PN is a safe, effective treatment option for small renal masses, even in patients who meet ablation criteria. There were no recurrences in our cohort and the majority of complications were Clavien grade 1.

Partial nephrectomy for the treatment of translocation renal cell carcinoma

BACKGROUND

The aim of this study was to evaluate the outcome of patients with translocation renal cell carcinoma (RCC) treated with partial nephrectomy.

PATIENTS AND METHODS

Our institutional review board-approved renal mass registry was queried for patients who underwent partial nephrectomy for a pathologically confirmed translocation RCC. We describe the demographic, clinical, pathological, and follow-up data for this series of patients.

RESULTS

Between 2003 and 2013, 1897 patients with RCC were treated at our institution with a radical or partial nephrectomy. In total, 10 (0.5%) patients were diagnosed with a translocation RCC. Of these patients, 4 (40%) underwent treatment with partial nephrectomy for an incidentally detected small renal mass (mean imaging diameter, 2.6 cm [range, 1.0-4.2 cm]). During a mean follow-up of 37 months (range, 8-81 months), all patients were alive without evidence of disease.

CONCLUSION

At short-term follow-up, partial nephrectomy appears to be an effective treatment option for patients with small translocation RCCs. Larger studies are required to more extensively investigate the optimal treatment of these potentially aggressive tumors.

Comparison of robotic and open partial nephrectomy: Single-surgeon matched cohort study

INTRODUCTION

We present comparative outcomes among matched patients who underwent robotic partial nephrectomy (RPN) or open partial nephrectomy (OPN) by a single surgeon at a single institution.

METHODS

We reviewed the medical records of 200 patients who underwent RPN (n = 100) or OPN (n = 100) between May 2003 and May 2013. The patients who underwent RPN were matched for age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) score, as well as tumour size, side and location. Perioperative outcomes were compared.

RESULTS

There was no significant difference between the 2 cohorts with respect to patient age, BMI, ASA score, preoperative glomerular filtration rate, tumour size and the R.E.N.A.L. nephrometry score. The mean operative time was longer in the RPN group, but there were no significant differences with respect to warm ischemic time and postoperative renal function. The length of hospitalization and use of postoperative analgesics (ketoprofen) were more favourable in the RPN cohort. There was no significant difference in the mean estimated blood loss, transfusion rate, or complications between the cohorts.

CONCLUSIONS

Considering the perioperative and postoperative parameters, RPN is a viable option as a nephron-sparing surgical procedure for small renal masses that yields outcomes comparable to those achieved with OPN. Despite matched cohort analysis among patients who underwent PN by a single surgeon, there may be inherent selection bias; therefore future prospective trials are needed.

Retroperitoneal laparoscopic renal tumour enucleation with local hypotension on demand

PURPOSE

Laparoscopic partial nephrectomy is the standard treatment for peripheric cT1 renal tumours and is usually performed under warm ischaemia. However, it is important to reduce ischaemia time as much as possible to avoid renal damage. The aim of our study was to investigate the feasibility and safety of our technique and to evaluate short-term functional and oncological results.

MATERIALS AND METHODS

From June 2010 to December 2012, 54 consecutive patients with T1a-T1b renal tumour were enrolled in a high-volume tertiary institution. All patients underwent laparoscopic enucleation with controlled selective hypotension on demand. Karnofsky performance status scale, R.E.N.A.L. Nephrometry Score and Clavien-Dindo Classification were used to assess patients' status, to stratify patients according to kidney disease and to evaluate complications, respectively. Renal function was evaluated with serum creatinine (sCr) and estimated glomerular filtration rate (eGFR) preoperative and 3, 5, 7 and 90 days postoperatively.

RESULTS

All the procedures were completed laparoscopically. Renal hypotension was necessary in 3/54 cases. Mean intraoperatively blood loss was 210 ± 98 ml. Renal carcinoma was found in 87 % patients. Margins revealed to be positive in 5.5 % cases. Mean hospital stay was 7.2 days. Grade IIIa and IIIb postoperative complications were 5.5 and 11 %, respectively. At 3 months, increase for sCr was 0.04 mg/dL; eGFR reduction was 1.2 ml/min. At a median follow-up of 20 months, there was one local recurrence that happened in a positive margin case.

CONCLUSIONS

Our preliminary results proved laparoscopic enucleation with controlled selective local hypotension on demand to be a feasible, safe and effective technique for T1 renal tumours.

State-of-the-art surgical management of renal cell carcinoma

There is a recognizable increase in the incidence of renal cell carcinoma and a parallel rise in the surgical management of renal cell carcinoma has occurred. However, recent literature shows that not all small, suspected renal cell carcinoma needs to be treated surgically, especially in elderly patients or those with multiple medical comorbidities. The surgical options for renal cell carcinoma have expanded from traditional open nephrectomy to partial nephrectomy and, at present, more recent outcomes data are available for the laparoscopic versions of these surgeries. Short-term results of thermal ablative technology (radiofrequency and cryoablation) show real promise as minimally invasive therapies. This review examines the most up-to-date outcomes and future directions of the surgical management of renal cell carcinoma.

Current Status of Laparoscopic Partial Nephrectomy

<p>Recently, nephron-sparing, minimally invasive surgery of small renal masses has become popular. The most typical surgery is laparoscopic partial nephrectomy (LPN). However, due to technical difficulties, the indications for LPN had been limited to small, exophytic, and peripheral tumors. This paper introduces current status of oncological outcomes and technical considerations.</p>

Laparoendoscopic single-site partial nephrectomy without hilar clamping using a microwave tissue coagulator

PURPOSE

To report our initial experience and evaluate the possibility of nonhilar clamp laparoendoscopic single-site (LESS) partial nephrectomy by using a microwave tissue coagulator.

PATIENTS AND METHODS

From December 2010 to May 2012, all patients with an exophytic, solitary, enhancing small (≤4.0 cm) renal mass were chosen to receive the study treatment. A multichannel port provided both a retroperitoneal and transperitoneal approach. A rigid, articulating apparatus was used to perform dissection, exposure of tumor, tissue coagulation, and resection without hilar clamping. Pathologic and hematologic data, subjective evaluation of pain, and scar appearance were analyzed.

RESULTS

Nonhilar clamp LESS partial nephrectomy by using a microwave tissue coagulator was performed in seven patients (mean operative time, 208 min; mean blood loss, 39 mL; mean renal mass size, 1.7 cm); one procedure with uncontrolled bleeding needed to be converted to conventional laparoscopic partial nephrectomy. No transfusion was necessary. Pathologic investigation demonstrated six renal-cell carcinomas and one oncocytoma. The hemoglobin level decreased by a mean of 1.1 g/dL. Patients did not complain about pain, and they had great satisfaction with the results. The mean duration of hospital stay was 13.8 days.

CONCLUSIONS

LESS partial nephrectomy without hilar clamping by using a microwave tissue coagulator is possible for renal masses, confers postoperative outcomes comparable to the standard counterpart, and assures patient satisfaction. By use of a microwave tissue coagulator, additional trocars were not necessary, and LESS partial nephrectomy could be accomplished through a single port, which reduced invasion and increased the cosmetic satisfaction of the patients.

Comparison of laparoscopic radiofrequency ablation and open partial nephrectomy in patients with a small renal mass

Purpose

We have performed both open partial nephrectomy (OPN) and laparoscopic radiofrequency ablation (RFA) on selected patients since January 2007 and have been following these patients through serial laboratory assessments and computed tomography (CT). The purpose of the present study was to evaluate long-term oncologic outcomes and renal function status for laparoscopic RFA versus OPN at a minimum follow-up of 3 years.

Materials and Methods

A total of 55 patients with exophytic, single small renal masses were treated with either OPN (n=14) or laparoscopic RFA (n=41) by a single surgeon. The indications for laparoscopic RFA were as follows: 1) cases with the greatest dimension of the renal mass <3 cm, and 2) cases in which the collecting system, renal calyx, and great vessels were free from the tumor margins by 1 cm.

Results

The estimated blood loss (EBL), the operation time, and the mean number of hospital days was significantly lower in the laparoscopic RFA group than in the OPN group. Oncologic data did not differ significantly between the two groups. Creatine clearance levels did not differ significantly compared with those before the operation in either group.

Conclusions

Our data suggest excellent therapeutic outcomes with laparoscopic RFA with achievement of effective operative times, hospital stays, and EBL compared with OPN. According to our indications for laparoscopic RFA, laparoscopic RFA is an effective minimally invasive therapy for the treatment of small renal masses, yielding oncologic outcomes and renal function equivalent to those of OPN.

10-year oncologic outcomes after laparoscopic and open partial nephrectomy

PURPOSE

Open partial nephrectomy has proven long-term oncologic efficacy. Laparoscopic partial nephrectomy outcomes at 5 to 7 years of followup appear comparable to those of the open approach. We present the 10-year outcomes of patients who underwent laparoscopic or open partial nephrectomy for a single clinical stage cT1 7 cm or less renal cortical tumor.

MATERIALS AND METHODS

Of 1,541 patients treated with partial nephrectomy for a single cT1 tumor between 1999 and 2007 with a minimum 5-year followup, an actual followup of 10 years or greater was available in 45 and 254 after laparoscopic and open partial nephrectomy, respectively.

RESULTS

Median followup after laparoscopic and open surgery was 6.6 and 7.8 years, respectively. At 10 years the overall survival rate was 77.2%. The metastasis-free survival rate was 95.2% and 90.0% after partial nephrectomy for clinical T1a and T1b renal cell carcinoma, respectively (p <0.0001). Baseline differences between patients treated with laparoscopic and open partial nephrectomy accounted for most observed differences between the cohorts. The median glomerular filtration rate decrease was 16.9% after the laparoscopic approach and 14.1% after the open approach (p = 0.5). On multivariable analysis predictors of all cause mortality included advancing age (HR 1.52/10 years, p <0.0001), comorbidity (HR 1.33/1 U, p <0.0001), absolute indication (HR 2.25, p = 0.003) and predicted recurrence-free survival (HR 1.58/10% increased risk, p = 0.004) but not laparoscopic vs open operative approach (p = 0.13). Similarly, predictors of metastasis included absolute indication (HR 4.35, p <0.0001) and predicted recurrence-free survival (HR 2.67, p <0.0001) but not operative approach (p = 0.42).

CONCLUSIONS

The 10-year outcomes of laparoscopic nephrectomy and open partial nephrectomy are excellent in carefully selected patients with limited risk of recurrence for cT1 renal cortical tumors. Overall survival at 10 years is mediated by patient factors such as age, comorbidity and operative indication, and by cancer factors such as predicted recurrence-free survival but not by the choice of operative technique, which depends on surgeon preference and experience.

Current status of robot-assisted partial nephrectomy

What's known on the subject? and What does the study add? The use of robotic assistance for the partial nephrectomy procedure has emerged as an alternative that may help some of the technical challenges of laparoscopic partial nephrectomy. The main concerns in laparoscopic partial nephrectomy relates to a steeper 'learning curve', prolonged warm ischaemia times and the potential for postoperative haemorrhage. The article delineates the dynamics of patient preparation, the surgical team, surgical technique & post-operative care to conclude that robotic-assisted partial nephrectomy is a viable alternative to both open and laparoscopic techniques. Partial nephrectomy has shown both improved overall patient survival and more effective preservation of renal function, when compared with radical nephrectomy. Robot-assisted partial nephrectomy has several potential advantages over the laparoscopic approach. Robotic assistance allows urologists to perform this complex reconstructive procedure more quickly, with improved precision and dexterity, tremor elimination and improved visualization. The present article aims to delineate the dynamics of patient preparation and surgical team, surgical technique and postoperative care. The oncological outcomes and disease-free survival of partial nephrectomy have been found to be equivalent to open partial nephrectomy [1-4].

Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system

BACKGROUND AND OBJECTIVES

To compare postoperative complications in patients undergoing laparoscopic and open partial nephrectomy using a standardized complication-reporting system and a standardized tumor-scoring system.

METHODS

We conducted a retrospective analysis of 189 consecutive patients with nephrometry scores available who underwent elective partial nephrectomy for renal masses. Demographic, perioperative, and complication data were recorded. By using the modified Clavien scale, we graded 30- and 90-day complication rates.

RESULTS

107 patients underwent laparoscopic partial nephrectomy and 82 underwent open partial nephrectomy (N=189). Open partial nephrectomy patients had higher nephrometry scores than laparoscopic patients had (7.1±2.4 vs. 5.6±1.8, P<.001). Surgical and hospitalization times were shorter, and estimated blood loss was lower in the laparoscopic group (P<.001). At 30 days, there were more overall complications in the open group, but more major complications in the laparoscopic group (P>.05). After multivariable logistic regression analysis, only higher body mass index and higher estimated blood loss were predictors of more overall complications.

CONCLUSIONS

Laparoscopic partial nephrectomy has the advantages of decreased operative time, lower blood loss, and shorter hospital stay. The complication rate in the laparoscopic group is similar to that in the open group, despite favorable tumor characteristics in the laparoscopic group.

Prognostic significance of perirenal infiltration in renal cell carcinoma (<7 cm)

PURPOSE

Pathologic stage is the most accurate prognostic factor of renal cell carcinoma. We evaluated whether perirenal fat infiltration is a significant factor in tumors 7 cm or less in size.

MATERIALS AND METHODS

We retrospectively reviewed the record of 164 cases of tumors 7 cm or less in size. We divided the patients into two groups according to the presence of perirenal fat infiltration (group A, pT1; group B, pT3a). We evaluated relationships, recurrence-free survival and disease-specific survival according to clinicopathologic parameters. Statistical differences were calculated by log-rank test.

RESULTS

A total 131 patients were included in group A, with a mean age of 55.8 years, average tumor size was 4.2 cm, and a mean follow-up period of 43 months. Group B included 33 patients, with a mean age of 55.9 years, an average tumor size of 4.1 cm, and a mean follow-up period of 38 months. There was no significant difference in disease-specific survival; however, recurrence-free survival showed significantly different between two groups (group A: 95.5%, group B: 84.4%).

CONCLUSION

In this study, perirenal fat infiltration proved to be an independent prognostic factor for predicting disease-free survival in patients with tumors of 7 cm or less in size. Therefore, as this study showed, the presence of perirenal fat infiltration requires stricter follow-up planning, even in small renal cell carcinoma.

Comparative analysis of minimally invasive partial nephrectomy techniques in the treatment of localized renal tumors

OBJECTIVE

To report our initial experience with robot-assisted laparoscopic partial nephrectomy compared with traditional laparoscopic partial nephrectomy.

METHODS

A retrospective review of the Johns Hopkins minimally invasive urologic surgery database identified 207 consecutive patients who had undergone laparoscopic or robotic-assisted laparoscopic partial nephrectomy from 2007 to 2011 by a single surgeon. The patient demographics and pathologic, operative, and perioperative outcomes were compared between the surgical techniques. The early oncologic outcomes are reported for the entire cohort.

RESULTS

A total of 102 and 105 patients underwent laparoscopic partial nephrectomy and robotic-assisted laparoscopic partial nephrectomy, respectively. The demographic data were comparable between the 2 groups. The clinical and pathologic tumor characteristics were similar between the 2 groups, and a significant proportion (≥48%) of patients in each group had moderate to high complexity tumors. Patients undergoing robotic-assisted laparoscopic partial nephrectomy had decreased warm ischemia times, estimated blood loss, and operative times on univariate and multivariate analysis. No difference was seen in the total perioperative or significant urologic complications between the 2 groups. A review of the early oncologic outcomes revealed no local recurrences and 1 case of metastatic renal cell carcinoma.

CONCLUSION

Minimally invasive partial nephrectomy is associated with favorable perioperative outcomes and low morbidity. Robotic-assisted laparoscopic partial nephrectomy appears to be associated with favorable warm ischemia times compared with laparoscopic partial nephrectomy.

Laparoscopic partial nephrectomy: is it worth still performing the retroperitoneal route?

Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal laparoscopic partial nephrectomy) versus RLPN (retroperitoneal). Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups. Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 190 ± 85 min versus 154 ± 47 (P = 0.001) and 9.2 ± 6.4 days versus 6.2 ± 4.5 days (P < 0.05), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% (P = 0.67) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% (P = 0.91) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar.

Advancements in laparoscopic partial nephrectomy: expanding the feasibility of nephron-sparing

Partial nephrectomy (PN) offers equivalent oncologic outcomes to radical nephrectomy (RN) but has greater preservation of renal function and less risk of chronic kidney disease and cardiovascular disease. Laparoscopic PN remains underutilized likely because it is a technically challenging operation with higher rates of perioperative complications compared to open PN and laparoscopic RN. A review of the latest PN literature demonstrates that recent advancements in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents will likely allow greater utilization of LPN and expand its usage to increasingly more complex tumors.

Prospective multi-center study of oncologic outcomes of robot-assisted partial nephrectomy for pT1 renal cell carcinoma

BACKGROUND

Partial nephrectomy has been increasingly recommended over radical nephrectomy for the management of small renal masses based on improved renal functional outcomes without sacrifice of oncologic effectiveness. Robot-assisted partial nephrectomy (RAPN) has been introduced in an effort to offer another minimally invasive option for nephron-sparing surgery. However, reports of RAPN have been limited to short-term perioperative outcomes. The goal of this study is to report and evaluate the initial oncologic outcomes of RAPN. Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months.

METHODS

Utilizing prospectively obtained data on RAPN performed by four surgeons at four separate tertiary care centers, we selected patients with unilateral, localized, non-familial, pathologically-confirmed pT1 renal cell carcinoma and a minimum post-operative follow-up of 12 months. Survival analysis (disease-free, cancer-specific, and overall survival) was performed, and Kaplan-Meier curves were generated.

RESULTS

RAPN was performed in 124 patients with a median tumor size of 3.0 cm (IQR 2.2-4.2 cm). Median follow-up was 29 months (range 12-46 months). Positive parenchymal surgical margins occurred in two patients (1.6 %), both of whom were recurrence-free at 30 and 34 months after surgery. The three-year Kaplan-Meier estimated disease-free survival was 94.9 %, cancer-specific survival was 99.1%, and overall survival was 97.3 %.

CONCLUSIONS

In our cohort of patients with small renal carcinomas who were followed for a median of 29 months, recurrence and survival outcomes were similar to those reported for open and laparoscopic partial nephrectomy. Further long-term outcomes will be needed to definitively claim that RAPN is oncologically equivalent to other surgical approaches.

Positive surgical margins after nephron-sparing surgery

CONTEXT

Little is known on the natural history of positive surgical margins (PSMs) in partial nephrectomy (PN). Accumulating data suggest that secondary nephrectomy might not be necessary in all patients with PSMs after PN.

OBJECTIVE

Provide an overview on incidence and risk factors for PSMs after partial nephrectomy and on the rate of local and distant disease recurrence related to PSMs. We also provide recommendations on how to avoid and how to treat PSMs after PN.

EVIDENCE ACQUISITION

A nonsystematic literature research was based on Medline, Scopus, and Web of Science queries on these keywords: nephron-sparing surgery, partial nephrectomy/ies, and margin. Only human studies (original research) published in English were included.

EVIDENCE SYNTHESIS

PSMs are present in 0-7% of patients after open PN, in 0.7-4% after laparoscopic PN, and in 3.9-5.7% after robot-assisted PN. The thickness of healthy parenchyma surrounding the tumour is irrelevant as long as complete tumour removal is achieved. The coincidence of a highly malignant tumour and PSM increases the risk of local recurrence. Intermediate follow-up data indicate that the vast majority of patients with PSMs will not experience local or distant tumour recurrence. Frozen-section analysis for evaluation of resection margins during PN is of minor clinical significance, as the surgeon's gross assessment of macroscopically negative margins provides reliable results.

CONCLUSIONS

PSMs in PN are rare. As indicated by intermediate follow-up data, the majority of patients with PSMs after PN remain without disease recurrence, and a surveillance strategy seems preferable to surgical reintervention.

Current status of robotic partial nephrectomy (RPN)

OBJECTIVE

• Robotic partial nephrectomy (RPN) is a minimally invasive option for patients undergoing nephron-sparing surgery (NSS). As the technique of RPN develops and matures, intraoperative and perioperative outcomes continue to be reported. In the current review, we discuss safety, efficacy, and recent technical advances in RPN.

METHODS

• A Medline search using the keywords 'partial nephrectomy', 'robotic partial nephrectomy', 'robot partial nephrectomy', 'robot-assisted laparoscopic partial nephrectomy', and 'laparoscopic partial nephrectomy' was conducted to identify original articles, review articles, and editorials on RPN.

RESULTS

• There have been multiple recent retrospective studies comparing RPN with laparoscopic PN (LPN). These comparisons suggest a shorter learning curve for RPN and confirm the safety and feasibility of RPN, even for select complex renal masses. • Novel techniques have been developed in efforts to decrease warm ischaemia time. These include use of sliding-clip renorrhaphy, selective renal parenchymal clamping, and 'early unclamping' or 'no-clamp' techniques.

CONCLUSIONS

• RPN appears to be a viable minimally invasive option for NSS. RPN may reduce some of the technical challenges associated with LPN, and thus, extend the potential benefits of minimally invasive NSS to a larger population. • Further studies of the long-term renal functional outcomes and oncological efficacy of RPN are needed before fully advocating this technique.

Laparoscopic partial nephrectomy for completely intraparenchymal tumors

PURPOSE

Management for intraparenchymal renal tumors represents a technical challenge during laparoscopic partial nephrectomy since, unlike exophytic tumors, there are no external visual cues on the renal surface to guide tumor localization or excision. Also, hemostatic renorrhaphy and pelvicalyceal suture repair in these completely intrarenal tumors create additional challenges. We examined the safety and technical feasibility of this procedure in this cohort.

MATERIALS AND METHODS

Of 800 patients who underwent laparoscopic partial nephrectomy 55 (6.9%) had completely intraparenchymal tumors. Technical steps included intraoperative ultrasound guidance of tumor resection, en bloc hilar clamping, cold excision of tumor and sutured renal reconstruction.

RESULTS

Mean tumor size was 2.3 cm (range 1.0 to 4.5), mean blood loss was 236 cc (range 25 to 1,000) and mean warm ischemia time was 29.9 minutes (range 7 to 57). There were no positive margins. When we compared laparoscopic partial nephrectomy for intraparenchymal tumors to the same procedure in another 3 tumor groups, including completely exophytic tumors, tumors infiltrating up to sinus fat and tumors infiltrating but not up to sinus fat, there were no statistically significant differences among the groups in complications, positive margin rate, blood loss, or tumor excision or warm ischemia time.

CONCLUSIONS

Laparoscopic partial nephrectomy for completely intrarenal tumors is a technically advanced but effective, safe procedure. Facility and experience with the technique, effective use of intracorporeal laparoscopic ultrasound and adherence to sound surgical principles are the keys to success. Most recently we have performed laparoscopic and robotic partial nephrectomy for such completely intrarenal tumors using a zero ischemia technique.

Ex vivo ultrasound control of resection margins during partial nephrectomy

PURPOSE

Surgery remains the treatment of choice for localized renal neoplasms. While radical nephrectomy was long considered the gold standard, partial nephrectomy has equivalent oncological results for small tumors. The role of negative surgical margins continues to be debated. Intraoperative frozen section analysis is expensive and time-consuming. We assessed the feasibility of intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy and its correlation with margin status on definitive pathological evaluation.

MATERIALS AND METHODS

A study was done at 2 institutions from February 2008 to March 2011. Patients undergoing partial nephrectomy for T1-T2 renal tumors were included in analysis. Partial nephrectomy was done by a standardized minimal healthy tissue margin technique. After resection the specimen was kept in saline and tumor margin status was immediately determined by ex vivo ultrasound. Sequential images were obtained to evaluate the whole tumor pseudocapsule. Results were compared with margin status on definitive pathological evaluation.

RESULTS

A total of 19 men and 14 women with a mean ± SD age of 62 ± 11 years were included in analysis. Intraoperative ex vivo ultrasound revealed negative surgical margins in 30 cases and positive margins in 2 while it could not be done in 1. Final pathological results revealed negative margins in all except 1 case. Ultrasound sensitivity and specificity were 100% and 97%, respectively. Median ultrasound duration was 1 minute. Mean tumor and margin size was 3.6 ± 2.2 cm and 1.5 ± 0.7 mm, respectively.

CONCLUSIONS

Intraoperative ex vivo ultrasound of resection margins in patients undergoing partial nephrectomy is feasible and efficient. Large sample studies are needed to confirm its promising accuracy to determine margin status.

Pilot study evaluation of standard laparoscopic suturing and a novel parenchymal apposition mechanism for minimally invasive renal reconstruction

OBJECTIVES

The most technically demanding portion of a laparoscopic partial nephrectomy is the renorrhaphy. The purpose of this study was to determine whether a parenchymal apposition mechanism (PAM) device would be as effective as standard laparoscopic technique (SLT) with respect to efficiency, capability, and safety of renal defect closure.

MATERIALS AND METHODS

In this pilot study, participants were recruited to perform surgical reconstruction of a standardized renal parenchymal defect with both SLT and the PAM. The PAM prototype was engineered using two salmon egg hooks connected by absorbable suture and placed within a V-shaped foam delivery mechanism. After hook placement, tensioning of the connecting suture using a Weck clip apposed the defect edges. Each participant performed a single closure with SLT and with the PAM device of a standardized defect in ex vivo porcine kidneys. Closure time, tissue trauma/damage during closure, and the intraparenchymal pressure were recorded.

RESULTS

A total of 13 subjects, 7 medical students, 3 residents, 2 fellows, and 1 attending were enrolled. There was no statistical difference between the two methods of closure in average time for closure. In a subgroup analysis of subjects who had performed laparoscopic reconstructive procedures as the primary surgeon, SLT was significantly faster than PAM (P=.036). Mean pressures achieved in attempted closure using SLT and PAM were not significantly different (0.38 N for both groups; P=.99). The mean parenchymal trauma rating was not significantly different between the groups; however, the upper limit of the range of trauma ratings was greater in the standard closures.

CONCLUSION

This pilot study demonstrated the feasibility of PAM use in an ex vivo porcine kidney model. Additional testing and continued design modifications are necessary to explore its use in laparoscopic reconstruction of the kidney and other organs.

A Feasible Technique for Transient Vascular Occlusion by Using a Vessel Loop and Hem-o-Lok Clips in Laparoscopic Partial Nephrectomy

PURPOSE

We introduce our transient vascular occlusion technique that uses a vessel loop and Hem-o-Lok clips in laparoscopic partial nephrectomy.

MATERIALS AND METHODS

From March 2009 to March 2011, 15 consecutive patients underwent laparoscopic partial nephrectomy. All operations were performed by a single surgeon using the transperitoneal approach. The transient vascular occlusion technique was as follows. After dissection of renal vessels, the vessel loop is winded twice around the vessel. Both distal portions of the vessel loop are clipped with a Hem-o-Lok clip. When vascular occlusion is required, an additional Hem-o-Lok clip is applied to the proximal portion of the vessel loop by pulling the distal portion. When no longer needed, the vessel loop is simply cut.

RESULTS

All operations were performed successfully without open conversion. The mean tumor size was 2.5 cm (range, 1.1-3.5 cm). There were 8 cases of renal cell carcinoma and 7 cases of angiomyolipoma. All cases of renal cell carcinoma had a negative surgical margin. The mean operative time and the mean warm ischemic time were 176 minutes (range, 104-283 minutes) and 26.1 minutes (range, 18-34 minutes), respectively. There were no cases of uncontrollable intraoperative bleeding and no postoperative complications.

CONCLUSIONS

The transient vascular occlusion technique with a vessel loop and Hem-o-Lok clips is a feasible technique with simplicity, effectiveness, and safety. It is an acceptable alternative to standard vascular occlusion techniques, such as laparoscopic bulldog or Satinsky clamps.

Robotic-assisted versus traditional laparoscopic partial nephrectomy: comparison of outcomes and evaluation of learning curve

OBJECTIVES

To examine the transition to robot-assisted laparoscopic partial nephrectomy (RALPN) from pure laparoscopic partial nephrectomy (LPN) and investigate the learning curve (LC). RALPN has emerged as a minimally invasive alternative to nephron-sparing surgery.

METHODS

A total of 150 consecutive patients were identified who underwent LPN or RALPN in the initial experience of a single surgeon since 2006. The perioperative data were evaluated using appropriate comparative tests. The LC was investigated by examining the operative times, warm ischemia times (WITs), and estimated blood loss (EBL) in groups of 25 consecutive patients. To account for laparoscopic LC, the outcomes of patients who underwent surgery in 2009 or later were also compared.

RESULTS

Of the 150 patients, 102 and 48 underwent LPN and RALPN, respectively. The patient and tumor characteristics were similar. The mean operative time (193 vs 152 minutes, P < .001), WIT (18.0 vs 14.0, P < .001), and EBL (245 vs 122 mL, P = .001) favored RALPN. Improvements in the operative time (P = .01), WIT (P = .006), and EBL (P = .01) were noted as experience increased in the LPN cohort and was most pronounced after the first 25 LPN patients. Since 2009, 55 and 44 patients underwent LPN and RALPN, respectively. Although the absolute differences were less, the operative time (182 vs 150, P < .001), WIT (15.3 vs 13.3, P < .001), and EBL (206 vs 118, P = .005) favored RALPN.

CONCLUSIONS

RALPN appears to have shorter operative and ischemia times and less blood loss compared with LPN. After a LC of approximately 25 cases, the transition from LPN to RALPN can be undertaken without an additional LC and can be associated with immediate benefits.

Robotic-assisted partial nephrectomy: Has it come of age?

Surgical resection is the gold standard for the treatment of renal cell carcinoma, and partial nephrectomy (PN) is the treatment of choice for tumors smaller than 4 cm in size. A laparoscopic PN is a viable alternative to a traditional open PN, demonstrating good oncologic and functional outcomes. A laparoscopic PN is a challenging procedure, particularly performing intracorporeal suturing under the time constraints of warm ischemia. The introduction of the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA) with wristed instruments and magnified, 3-dimensional vision may facilitate the technical challenges of a minimally invasive PN. The technique of robotic partial nephrectomy (RPN) is still evolving and a number of institutions have recently reported their results. In this article, we present a review of the literature and our technique for robotic PN using a transperitoneal approach.

Multicenter experience with nonischemic multiport laparoscopic and laparoendoscopic single-site partial nephrectomy utilizing bipolar radiofrequency ablation coagulator

Objective. To investigate feasibility of multiport and laparoendoscopic single-site (LESS) nonischemic laparoscopic partial nephrectomy (NI-LPN) utilizing bipolar radiofrequency coagulator. Methods. Multicenter retrospective review of 60 patients (46 multiport/14 LESS) undergoing NI-LPN between 4/2006 and 9/2009. Multiport and LESS NI-LPN utilized Habib 4X bipolar radiofrequency coagulator to form a hemostatic zone followed by nonischemic tumor excision and renorrhaphy. Demographics, tumor/perioperative characteristics, and outcomes were analyzed. Results. 59/60 (98.3%) successfully underwent NI-LPN. Mean tumor size was 2.35 cm. Mean operative time was 160.0 minutes. Mean estimated blood loss was 131.4 mL. Preoperative/postoperative creatinine (mg/dL) was 1.02/1.07 (P = .471). All had negative margins. 12 (20%) patients developed complications. 3 (5%) developed urine leaks. No differences between multiport and LESS-PN were noted as regards demographics, tumor size, outcomes, and complications. Conclusion. Initial experience demonstrates that nonischemic multiport and LESS-PN is safe and efficacious, with excellent short-term preservation of renal function. Long-term data are needed to confirm oncological efficacy.

Robotic partial nephrectomy: the real benefit

PURPOSE OF REVIEW

Robot-assisted partial nephrectomy (RPN) is an option for patients desiring minimally invasive nephron-sparing surgery. RPN outcomes, including safety, functional results, and oncological control, continue to be reported as the technique emerges. In the current review, we chronicle the development, recent advances, and current status of RPN.

RECENT FINDINGS

RPN appears to have a shorter learning curve when compared to alternative minimally invasive techniques. Outcomes from recent series have confirmed the safety and feasibility of RPN in the management of small renal masses, many of them in complex locations. Recent comparative studies have demonstrated favorable-to-equivalent outcomes for RPN when compared to laparoscopic partial nephrectomy (LPN), particularly in regards to decreased warm ischemia time. Novel technical developments include use of TilePro, the fourth robotic arm, sliding-clip renorrhaphy, and selective clamping techniques.

SUMMARY

RPN appears to have favorable early-to-intermediate stage outcomes. RPN helps with the technical challenges of LPN, potentially extending the benefits of minimally invasive nephron-sparing surgery to a wider audience of patients and surgeons.

[Partial nephrectomy for cancer and percutaneous biopsy: Oncologic results]

OBJECTIVES

To evaluate the results of partial nephrectomy (NP) for cancer in 60 patients selected by the biopsy of the tumor by analyzing the information, oncologic follow-up.

PATIENTS

It was a cohort study unicenter retrospective from 1994 to 2006. The biopsy was systematically done for patients who were candidates for elective NP. The criteria for elective indications NP tumors were less than 4cm, low grade Fuhrman (I and II). The tubulopapillary tumors (TBP) on biopsy were excluded from the elective indications. The parameters studied were the biopsy data, overall survival, disease-free survival.

RESULTS

The median age was 59 years (32-79 years) and 69% of tumor were fortuitous discovery. Indications of need accounted for 30% of cases (single kidney, bilateral tumors and chronic renal failure [CRF]). Biopsy allowed a diagnosis in 89% of cases. There was one death in specific postoperative immediately. A final histology was 75% of clear cell carcinoma, 13.3% of chromophobe and 11.7% of TBP, 96.6% of T1a including 86.6% of low grade and no surgical margin. The median follow-up was 49 months with 98.5% of specific survival at 5 years, one local recurrence and no general recurrence.

CONCLUSION

The study has shown that the selection of patients by biopsy gives satisfactory carcinologic results with 98.5% specific survival at the end of follow-up; it is between 89 and 100% in the literature.