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Fong KY, Gan VHL, Lim BJH, Chan YH, Castellani D, Chen K, Tay KJ, Ho HSS, Yuen JSP, Aslim E, Teoh J, Lim EJ. Off-clamp vs on-clamp robot-assisted partial nephrectomy: a systematic review and meta-analysis. BJU Int 2024; 133:375-386. [PMID: 38069544 DOI: 10.1111/bju.16250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2023]
Abstract
OBJECTIVE To compare intra- and postoperative outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN), using data from randomised controlled trials (RCTs) or covariate-matched studies (propensity score-matched or matched-pair analysis). METHODS A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature review was conducted on PubMed, EMBASE, Scopus and CENTRAL for relevant studies comparing off-clamp to on-clamp RAPN. Primary outcomes were estimated blood loss, postoperative percentage decrease in estimated glomerular filtration rate (eGFR), and margin positive rate. Secondary outcomes were operative time, postoperative eGFR, length of stay, all postoperative complications, major complications, and need for transfusion. Random-effects meta-analyses were performed to generate mean differences (MDs) or odds ratios (ORs). RESULTS A total of 10 studies (2307 patients) were shortlisted for analysis. There was no significant difference in estimated operative blood loss between off-clamp and on-clamp RAPN (MD 21.9 mL, 95% confidence interval [CI] -0.9 to 44.7 mL; P = 0.06, I2 = 58%). Off-clamp RAPN yielded a smaller postoperative eGFR deterioration (MD 3.10%, 95% CI 1.05-5.16%; P = 0.008, I2 = 13%) and lower odds of margin positivity (OR 0.62, 95% CI 0.40-0.94; P = 0.03, I2 = 0%). No significant differences were found for all secondary outcomes. CONCLUSIONS Off-clamp and on-clamp RAPN are similarly effective approaches for selected renal masses. Within the classic trifecta of PN outcomes, off-clamp RAPN yields similar rates of perioperative complications and may possibly offer better preservation of renal function and reduced margin-positive rates.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Valerie Huei Li Gan
- Department of Urology, Singapore General Hospital, Singapore, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore, Singapore
| | | | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Daniele Castellani
- Urology Unit, Azienda Ospedaliero-Universitaria Delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Kenneth Chen
- Department of Urology, Singapore General Hospital, Singapore, Singapore
| | - Kae Jack Tay
- Department of Urology, Singapore General Hospital, Singapore, Singapore
| | - Henry Sun Sien Ho
- Department of Urology, Singapore General Hospital, Singapore, Singapore
| | | | - Edwin Aslim
- Department of Urology, Singapore General Hospital, Singapore, Singapore
| | - Jeremy Teoh
- S.H. Ho Urology Centre, Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Ee Jean Lim
- Department of Urology, Singapore General Hospital, Singapore, Singapore
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Wei L, Wang C, Fu J, Qiangba T, Zhou X, He P, Li X, Lang L, Li C, Wang Y. Holographic 3D renal segments reconstruction protects renal function by promote choice of selective renal artery clamping during robot-assisted partial nephrectomy. World J Urol 2023; 41:2975-2983. [PMID: 37698633 DOI: 10.1007/s00345-023-04599-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023] Open
Abstract
OBJECTIVE To investigate the impact of selective artery clamping (SAC) and main artery clamping (MAC) during robot-assisted partial nephrectomy (RAPN) on renal function and the influence of holographic three-dimensional (3D) reconstruction of renal segments on the selection between SAC and MAC. METHODS This retrospective observational study included patients who underwent RAPN at First Hospital Affiliated to the Army Medical University between December 2016 and July 2022. According to the clamping methods, the patients were divided into the SAC group and the MAC group. The primary outcome was renal function. RESULTS A total of 422 patients (194 in the SAC group and 228 in the MAC group) were included. The RAPN procedures were all completed successfully. The patients in SAC group had less glomerular filtration rate (GFR) decline in the affected kidney (8.6 ± 7.0 ml/min vs. 18.7 ± 10.9 ml/min, P < 0.001) and minor estimated glomerular filtration rate (eGFR) decrease (4.3 ± 10.5 ml/min vs. 12.6 ± 12.1 ml/min, P < 0.001) than those in MAC group. Among 37 patients with baseline renal insufficiency, the GFR decline of the affected kidney in the SAC subgroup was significantly lower than in the MAC subgroup (5.5 ± 6.5 ml/min vs. 14.3 ± 9.2 ml/min, P = 0.002). The proportion of patients who underwent 3D reconstruction was significant higher in the SAC group than in the MAC group. (65.46% vs. 28.07%, P < 0.001). CONCLUSION The SAC technique during RAPN may serve as a protective measure for renal function, while the implementation of holographic 3D renal segment reconstruction technique may facilitate optimal selection of SAC.
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Affiliation(s)
- Ling Wei
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Cong Wang
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jian Fu
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Tudan Qiangba
- Department of Urology, Tibet CORPS Hospital of Chinese People's Armed Police Forces, Lhasa, 850000, Tibet, China
| | - Xiaozhou Zhou
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Peng He
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Xuemei Li
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Lang Lang
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Chunxia Li
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yongquan Wang
- Department of Urology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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Obrecht F, Padevit C, Froelicher G, Rauch S, Randazzo M, Shariat SF, John H, Foerster B. The Association of Ischemia Type and Duration with Acute Kidney Injury after Robot-Assisted Partial Nephrectomy. Curr Oncol 2023; 30:9634-9646. [PMID: 37999118 PMCID: PMC10670720 DOI: 10.3390/curroncol30110698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/30/2023] [Accepted: 10/30/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) after robot-assisted partial nephrectomy (RAPN) is a robust surrogate for chronic kidney disease. The objective of this study was to evaluate the association of ischemia type and duration during RAPN with postoperative AKI. MATERIALS AND METHODS We reviewed all patients who underwent RAPN at our institution since 2011. The ischemia types were warm ischemia (WI), selective artery clamping (SAC), and zero ischemia (ZI). AKI was defined according to the Risk Injury Failure Loss End-Stage (RIFLE) criteria. We calculated ischemia time thresholds for WI and SAC using the Youden and Liu indices. Logistic regression and decision curve analyses were assessed to examine the association with AKI. RESULTS Overall, 154 patients met the inclusion criteria. Among all RAPNs, 90 (58.4%), 43 (28.0%), and 21 (13.6%) were performed with WI, SAC, and ZI, respectively. Thirty-three (21.4%) patients experienced postoperative AKI. We extrapolated ischemia time thresholds of 17 min for WI and 29 min for SAC associated with the occurrence of postoperative AKI. Multivariable logistic regression analyses revealed that WIT ≤ 17 min (odds ratio [OR] 0.1, p < 0.001), SAC ≤ 29 min (OR 0.12, p = 0.002), and ZI (OR 0.1, p = 0.035) significantly reduced the risk of postoperative AKI. CONCLUSIONS Our results confirm the commonly accepted 20 min threshold for WI time, suggest less than 30 min ischemia time when using SAC, and support a ZI approach if safely performable to reduce the risk of postoperative AKI. Selecting an appropriate ischemia type for patients undergoing RAPN can improve short- and long-term functional kidney outcomes.
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Affiliation(s)
- Fabian Obrecht
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Christian Padevit
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Gabriel Froelicher
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Simon Rauch
- Department of Radiology and Nuclear Medicine, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Marco Randazzo
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Shahrokh F. Shariat
- Department of Urology, Medical University of Vienna, 1090 Vienna, Austria
- Departments of Urology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
- Karl Landsteiner Institute of Urology and Andrology, 1090 Vienna, Austria
- Division of Urology, Department of Special Surgery, Jordan University Hospital, The University of Jordan, Amman 19328, Jordan
- Department of Urology, Second Faculty of Medicine, Charles University, 15006 Prague, Czech Republic
- Institute for Urology and Reproductive Health, I.M. Sechenov First Moscow State Medical University, 119435 Moscow, Russia
| | - Hubert John
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
| | - Beat Foerster
- Department of Urology, Kantonsspital Winterthur, 8401 Winterthur, Switzerland
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Cignoli D, Basile G, Fallara G, Rosiello G, Belladelli F, Cei F, Musso G, Re C, Bertini R, Karakiewicz P, Mottrie A, Dehò F, Gallina A, Montorsi F, Salonia A, Capitanio U, Larcher A. Risks and benefits of partial nephrectomy performed with limited or with zero ischaemia time. BJU Int 2023; 132:283-290. [PMID: 36932928 DOI: 10.1111/bju.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
OBJECTIVE To test the hypothesis that longer warm ischaemia time (WIT) might have a marginal impact on renal functional outcomes and might, in fact, reduce haemorrhagic risk intra-operatively. PATIENTS AND METHODS Data from 1140 patients treated with elective partial nephrectomy (PN) for a cT1-2 cN0 cM0 renal mass were prospectively collected. WIT was defined as the duration of clamping of the main renal artery with no refrigeration and was tested as a continuous variable. The primary outcome of the study was evaluation of the effect of WIT on renal function (estimated glomerular filtration rate [eGFR]) postoperatively, at 6 months and in the long term (measured between 1 and 5 years after surgery). The secondary outcome of the study was haemorrhagic risk, defined as estimated blood loss (EBL) or peri-operative transfusions. Multivariable linear, logistic and Cox regression analyses, accounting for age, Charlson comorbidity index, clinical size, preoperative eGFR and year of surgery, were used and the potential nonlinear relationship between WIT and the study outcomes was modelled using restricted cubic splines. RESULTS A total of 863 patients (76%) underwent PN with WIT and 277 (24%) without. The baseline median eGFR was 87.3 (68.8-99.2) mL/min/1.73m2 for the on-clamp population and 80.6 (63.2-95.2) mL/min/1.73m2 for the off-clamp population. The median duration of WIT was 17 (13-21) min. At multivariable analyses predicting renal function, longer WIT was associated with decreased postoperative eGFR (estimate: -0.21, 95% confidence interval [CI] -0.31; -0.11 [P < 0.001]). Conversely, no association between WIT and eGFR was recorded at 6-month or long-term follow-up (all P > 0.8). At multivariable analyses predicting haemorrhagic risk, clampless resection with no ischaemia time and PN with short WIT was associated with an increased EBL (estimate: -21.56, 95% CI -28.33; -14.79 [P < 0.001]) and peri-operative transfusion rate (estimate: -0.009, 95% CI -0.01; -0.003 [P = 0.002]). No association between WIT and positive surgical margin status was recorded (all P = 0.1). CONCLUSION Patients and clinicians should be aware that performing PN with very limited or even with zero WIT might increase bleeding and the need for peri-operative transfusion while not improving long-term renal function outcomes.
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Affiliation(s)
- Daniele Cignoli
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Basile
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Fallara
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Rosiello
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Federico Belladelli
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Cei
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giacomo Musso
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Chiara Re
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Bertini
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Pierre Karakiewicz
- Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montreal Health Center, Montreal, QC, Canada
| | - Alexandre Mottrie
- Department of Urology, OLV Ziekenhuis Aalst, Aalst, Belgium
- ORSI Academy, Melle, Belgium
| | - Federico Dehò
- Department of Urology, Ospedale di Circolo e Fondazione Macchi-ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Andrea Gallina
- Department of Urology, Ospedale Regionale di Lugano, Civico USI-Università della Svizzera Italiana, Lugano, Switzerland
| | - Francesco Montorsi
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrea Salonia
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Umberto Capitanio
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Larcher
- Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Functional Outcomes after Selective Clamping in Robot-Assisted Partial Nephrectomy. J Clin Med 2022; 11:jcm11195648. [PMID: 36233518 PMCID: PMC9572118 DOI: 10.3390/jcm11195648] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/22/2022] [Accepted: 09/24/2022] [Indexed: 11/17/2022] Open
Abstract
This study aimed to assess the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN). We retrospectively analyzed 372 patients who had undergone RAPN at our hospital between July 2010 and March 2021. After propensity score matching between the full and selective clamping groups, perioperative outcomes and postoperative preservation ratio of the estimated glomerular filtration rate (eGFR) were compared at 6 and 12 months of follow-up. After propensity score matching, we evaluated 47 patients from each group. While no significant differences were observed in surgical time, warm ischemia time, or incidence rates of all grades of complications between the two cohorts, the estimated blood loss (EBL) was significantly lower in the full clamping group than in the selective clamping group (30 vs. 60, p = 0.046). However, no significant intergroup differences were observed in the postoperative preservation ratio of eGFR at 6 or 12 months of follow-up (full clamping 94.0% vs. selective clamping 92.7%, p = 0.509, and full clamping 92.0% vs. selective clamping 91.6%, p = 0.476, respectively). Selective clamping resulted in higher EBL rates than did full clamping in RAPN. However, selective clamping provided no renal functional advantage over full clamping in our propensity-score-matched cohort.
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Hu J, Jin D, Fan R, Xie X, Zhou Z, Chen Y, Zhang Y, Zhang J, Gao L, Jiang J, Zhang Y, Liang P. The relationships of acute kidney injury duration and severity with long-term functional deterioration following partial nephrectomy. Int Urol Nephrol 2021; 54:1623-1628. [PMID: 34718932 DOI: 10.1007/s11255-021-03033-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the effect of acute kidney injury (AKI) duration and severity on long-term renal functional outcomes in patients undergoing partial nephrectomy (PN). METHODS Altogether 292 consecutive patients undergoing laparoscopic PN from 2010 to 2018 were identified in two medical centers. In addition, the AKI duration {transient AK [≤ 3d] or persistent AKI [> 3d]} was combined with AKI severity (stages) to elucidate their relationships with long-term functional results. Kaplan-Meier (KM) analysis was also used to compare among patients with no AKI, transient AKI, and persistent AKI. Moreover, the Cox-proportional hazards regression model was utilized to assess the risk factors for renal function deterioration. RESULTS Altogether 67 patients (22.9%) experienced postoperative AKI. 75% eGFR preserve rate during the follow-up was compared among patients with no AKI, transient AKI and persistent AKI using KM analysis and log-rank test, which revealed significant difference. After adjusting for age and warm ischemia time by multivariate model proportional hazards analysis, AKI duration and severity were identified as the risk factors (Stage 1-transient AKI vs. non-AKI: adjusted hazard ratio (HR) 4.361, 95% confidential interval (CI) [2.062-9.233], p < 0.001; stage 1-persistent AKI vs. non-AKI: adjusted HR 6.706, 95% CI [2.405-18.699], p < 0.001; stage 2/3-transient AKI vs. non-AKI: adjusted HR 8.949, 95% CI [1.571-50.963], p = 0.014; stage 2/3-persistent AKI vs. non-AKI: adjusted HR 13.453, 95% CI [11.353-133.798], p = 0.027). CONCLUSIONS The AKI duration after PN is an important risk factor for long-term renal functional deterioration. Besides, AKI duration combined with AKI severity can be more comprehensive to understand the role of AKI on ultimately renal function. TRIAL REGISTRATION Chinese ClinicalTrials: ChiCTR2000034080.
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Affiliation(s)
- Jian Hu
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Dachun Jin
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China
| | - Runze Fan
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Xiaodu Xie
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Zhihao Zhou
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Yanlin Chen
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Yao Zhang
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China
| | - Jun Zhang
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China
| | - Liang Gao
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China
| | - Jun Jiang
- Department of Urology, Daping Hospital/Army Medical Center of PLA, Army Medical University, Chongqing, 400042, China.
| | - Yuanfeng Zhang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China.
| | - Peihe Liang
- Department of Urology, The Second Affiliated Hospital of Chongqing Medical University, No. 76, Linjiang Rd, Yuzhong District, Chongqing, 400010, China.
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Abstract
Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.
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Affiliation(s)
- Ellen O'Connor
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Brennan Timm
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia.,North Eastern Urology, Heidelberg, Australia
| | - Nathan Lawrentschuk
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,Department of Urology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Joseph Ischia
- Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Australia
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Sri D, Thakkar R, Patel HRH, Lazarus J, Berger F, McArthur R, Lavigueur-Blouin H, Afshar M, Fraser-Taylor C, Le Roux P, Liban J, Anderson CJ. Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the "Trifecta and Pentafecta". J Robot Surg 2020; 15:571-577. [PMID: 32885379 PMCID: PMC8295154 DOI: 10.1007/s11701-020-01141-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/17/2020] [Indexed: 12/29/2022]
Abstract
Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if “Trifecta” and “Pentafecta” outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008–2019) was analysed. “Pentafecta” was defined as achievement of “Trifecta” (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres’ outcomes.
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Affiliation(s)
- D Sri
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK.
| | - R Thakkar
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - H R H Patel
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - J Lazarus
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - F Berger
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - R McArthur
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | | | - M Afshar
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - C Fraser-Taylor
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - P Le Roux
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - J Liban
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
| | - C J Anderson
- St George's Hospital NHS Trust, Tooting, London, SW17 0QT, UK
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9
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Xu J, Xu S, Yao B, Xu R, Xu Y, Sun F, Qiu Q, Shi H. Segmental artery clamping versus main renal artery clamping in nephron-sparing surgery: updated meta-analysis. World J Surg Oncol 2020; 18:210. [PMID: 32799867 PMCID: PMC7429898 DOI: 10.1186/s12957-020-01990-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 08/05/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Ischemia-reperfusion injury is harmful in partial nephrectomy (PN) in renal cell carcinoma. Choosing an appropriate surgical method is important to reduce ischemia-reperfusion injury. This study aimed to compare the effect of segmental artery clamping (SAC) and main renal artery clamping (MAC) on patients who underwent PN. METHODS Studies from January 2008 to November 2019 were identified by an electronic search of English and Chinese databases, including PubMed, Excerpt Medica Database, Cochrane Library, Wanfang, VIP, and Chinese National Knowledge Internet, without language restriction. Two reviewers were involved in the trial. The effects on operation time (OT), warm ischemia time (WIT), length of hospital stay (LOS), blood transfusion rate, postoperative complication rate, Clavien classification (≥ 3), and positive surgery margin (PSM) were evaluated using Stata software. Standardized mean difference (SMD, for continuous data) and pooled odds ratios (for count data) with 95% confidence interval (CI) were used as effect indicators. RESULTS Thirty-two studies were included. SAC decreased the 1-week (SMD = - 0.973; 95% CI = - 1.414, - 0.532; P = 0.000), 1-month (SMD = - 0.411; 95% CI = - 0.769, - 0.053; P = 0.025), and 3-month (affected kidney: SMD = - 0.914; 95% CI = - 1.662, - 0.617; P = 0.000) percentages of postoperative changes in renal function (estimated glomerular filtration rate) between the SAC and MAC groups. Sub-group analysis showed that the SAC group had longer OT (SMD = 0.562; 95% CI = 0.252, 0.871; P = 0.000) than the MAC group. However, no differences were observed in the OT, WIT, LOS, blood transfusion rate, postoperative complication rate, Clavien classification (≥ 3), and PSM between the two groups. CONCLUSIONS SAC is superior to MAC in terms of short-term postoperative renal function recovery. The use of SAC or MAC depends on tumor size, location, surgical modality, and surgeon's judgments.
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Affiliation(s)
- Jinhong Xu
- Tongren City People's Hospital Affiliated to Guizhou Medical University, Tongren, 554319, Guizhou, China
| | - Shuxiong Xu
- Department of Urology, Guizhou Provincial People's Hospital Affiliated to Guizhou Medical University, Guiyang, 550002, Guizhou, China
| | - Biao Yao
- Department of Oncology, Tongren City People's Hospital Affiliated to Guizhou Medical University, Tongren, 554319, Guizhou, China
| | - Run Xu
- Department of Oncology, Tongren City People's Hospital Affiliated to Guizhou Medical University, Tongren, 554319, Guizhou, China
| | - Yuangao Xu
- Department of Urology, Guizhou Provincial People's Hospital Affiliated to Guizhou Medical University, Guiyang, 550002, Guizhou, China
| | - Fa Sun
- Department of Urology, Guizhou Provincial People's Hospital Affiliated to Guizhou Medical University, Guiyang, 550002, Guizhou, China
| | - Qian Qiu
- Institute of Tuberculosis Research, Chongqing Public Health Medical Center, Chongqing, 100036, China
| | - Hua Shi
- Tongren City People's Hospital Affiliated to Guizhou Medical University, Tongren, 554319, Guizhou, China.
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Badani KK, Kothari PD, Okhawere KE, Eun D, Hemal A, Abaza R, Porter J, Lovallo G, Ahmed M, Munver R, Stifelman MD. Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help? BJU Int 2020; 125:893-897. [PMID: 32125072 DOI: 10.1111/bju.15043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. PATIENTS AND METHODS Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. RESULTS Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. CONCLUSION In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.
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Affiliation(s)
- Ketan K Badani
- Department of Urology, Mount Sinai Medical School, New York, NY, USA
| | - Pankti D Kothari
- Department of Urology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Daniel Eun
- Department of Urology, Lewis Katz School of Medicine Temple University, Philadelphia, PA, USA
| | - Ashok Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ronney Abaza
- Department of Urology, OhioHealth Dublin Methodist Hospital, Dublin, OH, USA
| | - James Porter
- Department of Urology, Swedish Urology, Seattle, WA, USA
| | - Gregory Lovallo
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mutahar Ahmed
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Ravi Munver
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Michael D Stifelman
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
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Gul ZG, Tam A, Badani KK. Robotic partial nephrectomy: The current status. INDIAN JOURNAL OF UROLOGY : IJU : JOURNAL OF THE UROLOGICAL SOCIETY OF INDIA 2020; 36:16-20. [PMID: 31983821 PMCID: PMC6961424 DOI: 10.4103/iju.iju_174_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). Methods: A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review. Results: Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN. Conclusions: Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.
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Affiliation(s)
- Zeynep G Gul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Andrew Tam
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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12
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Beksac AT, Okhawere KE, Rosen DC, Elbakry A, Dayal BD, Daza J, Sfakianos JP, Ronney A, Eun DD, Bhandari A, Hemal AK, Porter J, Stifelman MD, Badani KK. Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy? BJU Int 2019; 125:442-448. [PMID: 31758657 DOI: 10.1111/bju.14956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD). PATIENTS AND METHODS The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n = 375, 81.2%), SAC (n = 48, 10.4%) or OC (n = 39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24 months, were included in the model for analysis. The median follow-up was 12.0 months (interquartile range 6.7-16.5; range 3.0-24.0 months). RESULTS In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β = -1.20, 95% confidence interval [CI] -5.45, 3.06; P = 0.582) and OC and MAC RPN (β = -1.57, 95% CI -5.21, 2.08; P = 0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17 min for MAC and 15 min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. CONCLUSION SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.
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Affiliation(s)
- Alp Tuna Beksac
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kennedy E Okhawere
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Daniel C Rosen
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amr Elbakry
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bheesham D Dayal
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jorge Daza
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Abaza Ronney
- Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Columbus, OH, USA
| | - Daniel D Eun
- Department of Urology, Temple University School of Medicine, Philadelphia, PA, USA
| | - Akshay Bhandari
- Division of Urology, Columbia University at Mount Sinai, Miami Beach, FL, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | | | - Ketan K Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Kim WH, Yoon HK, Lee HJ. Acute kidney injury and long-term renal function after partial nephrectomy-is there a true association? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S241. [PMID: 31656820 DOI: 10.21037/atm.2019.08.89] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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14
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Yoon HK, Lee HJ, Yoo S, Park SK, Kwon Y, Jun K, Jeong CW, Kim WH. Acute Kidney Injury Adjusted for Parenchymal Mass Reduction and Long-Term Renal Function after Partial Nephrectomy. J Clin Med 2019; 8:jcm8091482. [PMID: 31540394 PMCID: PMC6780324 DOI: 10.3390/jcm8091482] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 01/20/2023] Open
Abstract
We sought to evaluate the association of postoperative acute kidney injury (AKI) adjusted for parenchymal mass reduction with long-term renal function in patients undergoing partial nephrectomy. A total of 629 patients undergoing partial nephrectomy were reviewed. Postoperative AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria, by using either the unadjusted or adjusted baseline serum creatinine level, accounting for renal parenchymal mass reduction. Estimated glomerular filtration rates (eGFRs) were followed up to 61 months (median 28 months) after surgery. The primary outcome was the functional change ratio (FCR) of eGFR calculated by the ratio of the most recent follow-up value, at least 24 months after surgery, to eGFR at 3-12 months after surgery. Multivariable linear regression analysis was performed to evaluate whether unadjusted or adjusted AKI was an independent predictor of FCR. As a sensitivity analysis, functional recovery at 3-12 months after surgery compared to the preoperative baseline was analyzed. Median parenchymal mass reduction was 11%. Unadjusted AKI occurred in 16.5% (104/625) and adjusted AKI occurred in 8.6% (54/629). AKI using adjusted baseline creatinine was significantly associated with a long-term FCR (β = -0.129 ± 0.026, p < 0.001), while unadjusted AKI was not. Adjusted AKI was also a significant predictor of functional recovery (β = -0.243 ± 0.106, p = 0.023), while unadjusted AKI was not. AKI adjusted for the parenchymal mass reduction was significantly associated with a long-term functional decline after partial nephrectomy. A creatinine increase due to remaining parenchymal ischemic injury may be important in order to predict long-term renal functional outcomes after partial nephrectomy.
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Affiliation(s)
- Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Yongsuk Kwon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Kwanghoon Jun
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Chang Wook Jeong
- Department of Urology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
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15
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Cacciamani GE, Medina LG, Gill TS, Mendelsohn A, Husain F, Bhardwaj L, Artibani W, Sotelo R, Gill IS. Impact of Renal Hilar Control on Outcomes of Robotic Partial Nephrectomy: Systematic Review and Cumulative Meta-analysis. Eur Urol Focus 2019; 5:619-635. [DOI: 10.1016/j.euf.2018.01.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/25/2017] [Accepted: 01/22/2018] [Indexed: 11/17/2022]
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16
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Kobayashi S, Cho B, Huaulmé A, Tatsugami K, Honda H, Jannin P, Hashizumea M, Eto M. Assessment of surgical skills by using surgical navigation in robot-assisted partial nephrectomy. Int J Comput Assist Radiol Surg 2019; 14:1449-1459. [PMID: 31119486 DOI: 10.1007/s11548-019-01980-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/16/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To assess surgical skills in robot-assisted partial nephrectomy (RAPN) with and without surgical navigation (SN). METHODS We employed an SN system that synchronizes the real-time endoscopic image with a virtual reality three-dimensional (3D) model for RAPN and evaluated the skills of two expert surgeons with regard to the identification and dissection of the renal artery (non-SN group, n = 21 [first surgeon n = 9, second surgeon n = 12]; SN group, n = 32 [first surgeon n = 11, second surgeon n = 21]). We converted all movements of the robotic forceps during RAPN into a dedicated vocabulary. Using RAPN videos, we classified all movements of the robotic forceps into direct action (defined as movements of the robotic forceps that directly affect tissues) and connected motion (defined as movements that link actions). In addition, we analyzed the frequency, duration, and occupancy rate of the connected motion. RESULTS In the SN group, the R.E.N.A.L nephrometry score was lower (7 vs. 6, P = 0.019) and the time to identify and dissect the renal artery (16 vs. 9 min, P = 0.008) was significantly shorter. The connected motions of inefficient "insert," "pull," and "rotate" motions were significantly improved by SN. SN significantly improved the frequency, duration, and occupancy rate of connected motions of the right hand of the first surgeon and of both hands of the second surgeon. The improvements in connected motions were positively associated with SN for both surgeons. CONCLUSION This is the first study to investigate SN for nephron-sparing surgery. SN with 3D models might help improve the connected motions of expert surgeons to ensure efficient RAPN.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Advanced Medical Initiatives Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Urology, Kyushu University, Fukuoka, Japan
| | - Byunghyun Cho
- Department of Advanced Medical Initiatives Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Arnaud Huaulmé
- Faculty of Medicine, National Institute of Health and Scientific Research, University of Rennes 1, Rennes, France
| | | | - Hiroshi Honda
- Department of Radiology, Kyushu University, Fukuoka, Japan
| | - Pierre Jannin
- Faculty of Medicine, National Institute of Health and Scientific Research, University of Rennes 1, Rennes, France
| | - Makoto Hashizumea
- Department of Advanced Medical Initiatives Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatoshi Eto
- Department of Advanced Medical Initiatives Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Urology, Kyushu University, Fukuoka, Japan
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Beksac AT, Shah QN, Paulucci DJ, Lewis S, Taouli B, Badani KK. A Comparison of Excisional Volume Loss Calculation Methods to Predict Functional Outcome After Partial Nephrectomy. J Endourol 2019; 33:35-41. [DOI: 10.1089/end.2018.0639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Alp Tuna Beksac
- Department of Urology and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Qainat N. Shah
- Department of Urology and Icahn School of Medicine at Mount Sinai, New York, New York
| | - David J. Paulucci
- Department of Urology and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sara Lewis
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bachir Taouli
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ketan K. Badani
- Department of Urology and Icahn School of Medicine at Mount Sinai, New York, New York
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18
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Reevaluating Warm Ischemia Time as a Predictor of Renal Function Outcomes After Robotic Partial Nephrectomy. Urology 2018; 120:156-161. [DOI: 10.1016/j.urology.2018.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/10/2018] [Accepted: 06/12/2018] [Indexed: 11/21/2022]
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19
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Ficarra V, Crestani A, Inferrera A, Novara G, Rossanese M, Subba E, Giannarini G. Positive Surgical Margins After Partial Nephrectomy: A Systematic Review and Meta-Analysis of Comparative Studies. KIDNEY CANCER 2018. [DOI: 10.3233/kca-180037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Vincenzo Ficarra
- Department of Human and Paediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Messina, Italy
| | - Alessandro Crestani
- Urology Unit, Academic Medical Centre “Santa Maria della Misericordia”, Udine, Italy
| | - Antonino Inferrera
- Department of Human and Paediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Messina, Italy
| | - Giacomo Novara
- Department of Surgical, Oncologic, and Gastrointestinal Disease, Urologic Unit, University of Padua, Padua, Italy
| | - Marta Rossanese
- Department of Human and Paediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Messina, Italy
| | - Enrica Subba
- Department of Human and Paediatric Pathology “Gaetano Barresi”, Urologic Section, University of Messina, Messina, Italy
| | - Gianluca Giannarini
- Urology Unit, Academic Medical Centre “Santa Maria della Misericordia”, Udine, Italy
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Zhang L, Wu B, Zha Z, Zhao H, Yuan J, Jiang Y. Comparison of selective and main renal artery clamping in partial nephrectomy of renal cell cancer: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11856. [PMID: 30142777 PMCID: PMC6112923 DOI: 10.1097/md.0000000000011856] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The aim of the present study was to perform a systematic review and meta-analysis of the studies comparing the efficiency and safety of selective renal artery clamping (SAC) and main renal artery clamping (MAC) in partial nephrectomy (PN) for renal cell cancer (RCC). METHODS According to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, a literature search on PubMed, EMBASE, Web of Science, and Chinese National Knowledge Infrastructure were conducted to identify relevant studies published through December 2017. Outcomes of interest included baseline characteristics and perioperative surgical variables. RESULTS In all, 14 studies involving 2824 RCC patients comparing SAC and MAC were included in this meta-analysis. No differences were detected in mean patient body mass index (P = .08), tumor size (P = .22), baseline estimated glomerular filtration rate (eGFR) (P = .60), American Society of Anesthesiologists score (P = .97), or RENAL score (P = .70). The mean age was significantly younger in the SAC group compared with the MAC group (P = .002). There was no difference between SAC and MAC groups in terms of warm ischemia time (P = .31), transfusion rate (P = .18), length of hospital stay (P = .47), or postoperative complication rate (P = .23). Although SAC had longer operating time (OT) (P = .04) and more estimated blood loss (EBL) (P = .0002), a lower percentage decrease in eGFR in the SAC group was found compared to the MAC group (P = .002). CONCLUSIONS Patients undergoing PN with SAC had longer OT and higher EBL. SAC was more frequently used in younger patient. SAC offered better renal function preservation when compared with MAC for RCC. Given the inherent limitations of the included studies, further well-designed randomized controlled trials are required to verify these findings.
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Ellis RJ, Cho Y, Del Vecchio SJ, McStea M, Morais C, Coombes JS, Wood ST, Gobe GC, Francis RS. Outcome Measures Used to Report Kidney Function in Studies Investigating Surgical Management of Kidney Tumours: A Systematic Review. Eur Urol Focus 2018; 5:1074-1084. [PMID: 29728307 DOI: 10.1016/j.euf.2018.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 03/26/2018] [Accepted: 04/16/2018] [Indexed: 01/20/2023]
Abstract
CONTEXT Most practice decisions relevant to preserving kidney function in patients managed surgically for kidney tumours are driven by observational studies. A wide range of outcome measures are used in these studies, which reduces comparability and increases the risk of reporting bias. OBJECTIVE To comprehensively and succinctly describe the outcomes used to evaluate kidney function in studies evaluating surgical management of kidney tumours. EVIDENCE ACQUISITION Electronic search of the PubMed database was conducted to identify studies with at least one measure of kidney function in patients managed surgically for kidney tumours, published between January 2000 and September 2017. Abstracts were initially screened for eligibility. Full texts of articles were then evaluated in more detail for inclusion. A narrative synthesis of the evidence was conducted. EVIDENCE SYNTHESIS A total of 312 studies, involving 127905 participants, were included in this review. Most were retrospective (n=274) studies and conducted in a single centre (n=264). Overall, 78 unique outcome measures were identified, which were grouped into six outcome categories. Absolute postoperative kidney function (n=187), relative kidney function (n=181), and postoperative chronic kidney disease (n=131) were most frequently reported. Kidney function was predominantly quantified using estimated glomerular filtration rate or creatinine clearance (n=255), most using the modification of diet in renal disease equation (n=182). Only 70 studies provided rationale for specific outcome measures used. CONCLUSIONS There is significant variability in the reporting and quantification of kidney function in studies evaluating patients managed surgically for kidney tumours. A standardised approach to measuring and reporting kidney function will increase the effectiveness of outcomes reported and improve relevance of research findings within a clinical context. PATIENT SUMMARY Although we know that the removal of a kidney can reduce kidney function, clinical significance of various approaches is a matter of debate. This article demonstrates significant variability in the way kidney function was reported across all studies of patients with kidney cancer undergoing surgery, indicating a need for standardisation.
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Affiliation(s)
- Robert J Ellis
- Centre for Kidney Disease Research, University of Queensland Faculty of Medicine, Translational Research Institute, Brisbane, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia.
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia; Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Sharon J Del Vecchio
- Centre for Kidney Disease Research, University of Queensland Faculty of Medicine, Translational Research Institute, Brisbane, Australia; Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
| | - Megan McStea
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Christudas Morais
- Centre for Kidney Disease Research, University of Queensland Faculty of Medicine, Translational Research Institute, Brisbane, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Science, University of Queensland, Brisbane, Australia; NHMRC Chronic Kidney Disease Centre for Research Excellence, University of Queensland, Brisbane, Australia
| | - Simon T Wood
- Centre for Kidney Disease Research, University of Queensland Faculty of Medicine, Translational Research Institute, Brisbane, Australia; Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
| | - Glenda C Gobe
- Centre for Kidney Disease Research, University of Queensland Faculty of Medicine, Translational Research Institute, Brisbane, Australia; NHMRC Chronic Kidney Disease Centre for Research Excellence, University of Queensland, Brisbane, Australia
| | - Ross S Francis
- Centre for Kidney Disease Research, University of Queensland Faculty of Medicine, Translational Research Institute, Brisbane, Australia; Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
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Taweemonkongsap T, Suk-Ouichai C, Chotikawanich E, Jitpraphai S, Woranisarakul V, Ramart P, Phinthusophon K, Amornvesukit T, Leewansangtong S, Srinualnad S, Nualyong C. The Impact of Arterial Clamping Technique in Robot-Assisted Partial Nephrectomy on Renal Function and Surgical Outcomes: Six-Year Experience at Siriraj Hospital, Thailand. Urol Int 2018; 100:301-308. [DOI: 10.1159/000486319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/12/2017] [Indexed: 01/20/2023]
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Robot-assisted partial nephrectomy: systematic review of functional results. Curr Opin Urol 2017; 28:123-131. [PMID: 29278584 DOI: 10.1097/mou.0000000000000482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Various ischemia type during partial nephrectomy for renal cell cancer (RCC) resulted in different postoperative functional outcomes. Our objective was to systematically review the contemporary literature on robot-assisted partial nephrectomy (RPN) and investigate the association of ischemia type and tumor complexity with postoperative functional outcomes of the operated kidney and overall. RECENT FINDINGS Forty-five of the 99 reports identified were selected for qualitative analysis. All included studies were observational and nonrandomized. Overall, we found that patients undergoing RPN with zero ischemia and selective artery clamping had a lower decrease in glomerular filtration rates of the operated kidney in comparison to both warm and cold ischemia. This association seems also to play a role in patients with bilateral kidneys harboring complex tumors. SUMMARY Zero ischemia and selective artery clamping provide the best functional outcomes following robotic partial nephrectomy. This seems to be of particular relevance in patients with single kidney or tumors of high complexity. Whether these changes are statistically or clinically significant cannot be determined within this systematic review.
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Rosen DC, Paulucci DJ, Abaza R, Eun DD, Bhandari A, Hemal AK, Badani KK. Is Off Clamp Always Beneficial During Robotic Partial Nephrectomy? A Propensity Score-Matched Comparison of Clamp Technique in Patients with Two Kidneys. J Endourol 2017; 31:1176-1182. [DOI: 10.1089/end.2017.0450] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Daniel C. Rosen
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David J. Paulucci
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ronney Abaza
- Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio
| | - Daniel D. Eun
- Department of Urology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Akshay Bhandari
- Division of Urology, Columbia University at Mount Sinai, Miami Beach, Florida
| | - Ashok K. Hemal
- Department of Urology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ketan K. Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
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Abstract
Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.
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Dong W, Wu J, Suk-Ouichai C, Caraballo Antonio E, Remer EM, Li J, Zabell J, Isharwal S, Campbell SC. Ischemia and Functional Recovery from Partial Nephrectomy: Refined Perspectives. Eur Urol Focus 2017; 4:572-578. [PMID: 28753855 DOI: 10.1016/j.euf.2017.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/17/2017] [Accepted: 02/02/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Nephron mass preservation is a key determinant of functional outcomes after partial nephrectomy (PN), while ischemia plays a secondary role. Analyses focused specifically on recovery of the operated kidney appear to be most informative, yet have only included limited numbers of patients. OBJECTIVE To evaluate the relative impact of parenchymal preservation and ischemia on functional recovery after PN using a more robust cohort allowing for more refined perspectives about ischemia. DESIGN, SETTING, AND PARTICIPANTS A total of 401 patients managed with PN with necessary studies were analyzed for function and nephron mass preserved specifically within the kidney exposed to ischemia. INTERVENTION PN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The nephron mass preserved was measured from computed tomography scans <2 mo before and 3-12 mo after PN. Patients with two kidneys were required to have nuclear renal scans within the same timeframes. Recovery from ischemia was defined as the percent function preserved normalized by the percent nephron mass preserved. Pearson correlation was used to evaluate relationships between functional recovery and nephron mass preservation or ischemia time. Multivariable linear regression assessed predictors for recovery from ischemia. RESULTS AND LIMITATIONS The median tumor size was 3.5cm and the median RENAL score was 8. Cold and warm ischemia were utilized in 151 and 250 patients, and the median ischemia time was 27 and 21min, respectively. The function preserved was strongly correlated with nephron mass preserved(r=0.63; p<0.001). Median recovery from ischemia was significantly higher for hypothermia (99% vs 92%; p<0.001) and remained consistently strong even with longer duration. Multivariable analysis demonstrated that recovery from ischemia, which normalizes for nephron mass preservation, was significantly associated with ischemia type and duration (both p<0.05). However, each additional 10min of warm ischemia was associated with only a 2.5% decline in recovery from ischemia. Limitations include the retrospective design. CONCLUSIONS Our data suggest that functional recovery from clamped PN is most reliable with hypothermia. Longer intervals of warm ischemia are associates with reduced recovery; however, incremental changes are modest and may not be clinically significant in patients with a normal contralateral kidney. PATIENT SUMMARY Functional recovery after clamped partial nephrectomy is primarily dependent on preservation of nephron mass. Recovery is most reliable when hypothermia is applied. Longer intervals of warm ischemia are associated with reduced recovery; however, the incremental changes are modest.
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Affiliation(s)
- Wen Dong
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Urology, Sun Yat- sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jitao Wu
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Urology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Chalairat Suk-Ouichai
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Division of Urology, Department of Surgery, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Erick M Remer
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jianbo Li
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Zabell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sudhir Isharwal
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Steven C Campbell
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
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