Robot-assisted partial nephrectomy for large renal masses: a multi-institutional series

Nephrometry scores to predict oncological outcomes following partial nephrectomy (UroCCR Study 70)

PURPOSE

Partial nephrectomy (PN) for large or complex renal tumors can be difficult and associated with a higher risk of recurrence than radical nephrectomy. We aim to evaluate the clinical useful of nephrometry scores for predicting oncological outcomes in a large cohort of patients who underwent PN for renal cell carcinomas.

METHODS

Our analysis included patients who underwent PN for renal cell carcinoma in 21 French academic centers (2010-2020). RENAL, PADUA, and SPARE scores were calculated based on preoperative imaging. Uni- and multivariate cox models were performed to identify predictors of recurrence-free survival and overall survival. The area under the curve (AUC) was used to identify models with the highest discrimination. Decision curve analyses (DCAs) determined the net benefit associated with their use.

RESULTS

A total of 1927 patients were analyzed with a median follow-up of 32 months (14-45). RENAL score (p = 0.01), age (p = 0.002), histological type (p = 0.001), high nuclear grade (p = 0.001), necrotic component (p < 0.001), and positive margins (p = 0.005) were significantly related to recurrence in multivariate analyses. The discriminative performance of the 3 radiological scores was modest (65, 63, and 63%, respectively). All 3 scores showed good calibration, which, however, deteriorated with time. Decision curve analysis of the three models for the prediction of overall and recurrence-free survival was similar for all three scores and of limited clinical relevance.

CONCLUSION

The association between nephrometry scores and oncological outcomes after NP is very weak. The use of these scores for predicting oncological outcomes in routine practice is therefore of limited clinical value.

How far has robot-assisted partial nephrectomy reached?

Nephron-sparing surgery is the standard treatment for small renal mass (SRM). Nephron-sparing surgery has evolved from an open to a minimally invasive technique. Robot-assisted partial nephrectomy (RAPN) is the latest technique in this field and is reported to be safe and feasible, showing oncologically and functionally superior or compatible results compared with open and laparoscopic partial nephrectomy for SRM. This is not limited to only SRM but also applies to large and complex renal masses and other challenging situations. RAPN showed good oncological and functional outcomes for ≥clinical T2 renal tumors, complex renal masses (PADUA score ≥10, RENAL score ≥10), hilar renal tumors, and multiple renal tumors. In addition, the outcomes of RAPN in these challenging cases were not inferior to those in conventional cases. RAPN could also be applied to a number of challenging cases in which the open technique was considered first. RAPN showed good results in patients with a solitary kidney, horseshoe kidney, and in repeat surgeries. Furthermore, RAPN could be safely performed on obese, elderly, and pediatric patients. Finally, this review evaluates efficiency and utility of RAPN based on the results of challenging cases of renal masses and to project the future of RAPN.

Robotic-assisted partial nephrectomy: single-layer cortical renorrhaphy is associated with reduced rate of renal artery pseudoaneurysm compared to double-layer renorrhaphy

The study compares the outcome of patients who underwent single-layer outer cortical renorraphy (SLOCR) and double-layer cortical renorraphy (DLR) in our institution. The retrospective analysis of 181 patients who underwent RAPN was performed. Propensity score matching was accomplished on 67 patients using age, BMI, size, distance from collecting system, hilar location and pathological stage. Intraoperative factors assessed included warm ischemia time, renorraphy time, blood loss and operative duration (Levey et al. in Clin Chem 53:766-772, 2007) Post-operative hospital stay, complications like renal artery pseudoaneurysm (RAP), hemorrhage, urine leak and reduction in eGFR were measured. The 67 patients in SLOCR group were compared with similar number in the DLR group using propensity score matching. Warm ischemia time (P < .001), renorraphy time (P < .001) and symptomatic pseudoaneurysm (RAP) rate (P < .001) were significantly less in SLOCR group. SLOCR is associated with reduced rate of symptomatic post-operative RAP.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Robotic partial nephrectomy for management of renal mass in patients with a solitary kidney: can we expand the indication to T2 and T3 disease?

BACKGROUND

Management of complex renal masses is challenging in a solitary kidney setting. We retrospectively compared oncological and renal functional outcomes between robotic and open partial nephrectomy (PN) in patients with a pT2-pT3 renal mass and a solitary kidney.

METHODS

From a multi-institutional series, we identified 20 robotic partial nephrectomies (RPN) and 15 open partial nephrectomies (OPN) patients confirmed to have a pT2 or pT3 renal cancer. Surgeries were performed between January 2012 and July 2019. Patients with familial renal cell carcinoma, prior ipsilateral PN, or multiple ipsilateral synchronous tumors were excluded from the analysis. Baseline characteristics, perioperative and postoperative outcomes were compared using χ² test, Fisher's Exact Test, Mann-Whitney U Test, and Student's t-test.

RESULTS

Baseline characteristics were comparable. Cold ischemia was utilized more in the open group (92.9% vs. 15.8%, P<0.001). OPN group had a longer ischemia time (48.9 min vs. 27.3 min, P<0.001), a higher major complication rate (38.5% vs. 11.1%, P=0.009), and a higher length of stay was (5 vs. 3.5 days, P=0.023). Positive surgical margin rate was comparable (20% OPN vs. 15% RPN; P=1.000). At a mean follow up of 21 months local recurrence rates (1 OPN vs. 2 RPN, P=1.000) were comparable, chronic kidney disease upstaging rate (46.7% OPN vs. 45.0% RPN, P=0.922) and estimated glomerular filtration rate preservation at one year (75.2%% in OPN vs. 79.1% RPN, P=0.707) were comparable.

CONCLUSIONS

In select cases and experienced hands, the robotic approach offers a reasonable alternative to open surgery in patients with pT2 and pT3 tumors and a solitary kidney.

Trifecta achievement in patients undergoing partial nephrectomy: a systematic review and meta-analysis of predictive factors

PURPOSE

The predictors of trifecta achievement in partial nephrectomy (PN) were poorly inquired and remained a controversial area of discovery. To evaluate predictive factors of trifecta achievement in patients undergoing PN.

MATERIALS AND METHODS

A systematic literature search was performed to identify relevant articles. Only studies focusing on postoperative trifecta achievement and exploring its predictor with multivariable analyses were included. The trifecta achievement was defined as negative surgical margins, warm ischemia time <25 minutes, and no complications. Merged odds ratio (OR) and 95% confidence interval (CI) were used to evaluate the predictive effect.

RESULTS

Thirteen studies with 7066 patients meeting the inclusion criteria were included. The rate of trifecta achievement ranged from 43.3% to 78.6%. Merged results showed that preoperative eGFR (OR: 1.01, 95% CI: 1.00, 1.02, P=0.02), operative time (OR: 0.99, 95% CI: 0.99, 1.00, P=0.02), estimated blood loss (OR: 1.00, 95% CI: 1.00, 1.00, P <0.001), tumor size (OR: 0.70, 95% CI: 0.58, 0.84, P <0.001), medium (OR: 0.39, 95% CI: 0.18, 0.84, P=0.02) and high PADUA score (OR: 0.23, 95% CI: 0.08, 0.64, P=0.005) were independently associated with trifecta achievement. A publication bias was identified for tumor size. Sensitivity analysis confirmed the stability of result for tumor size.

CONCLUSIONS

Larger tumor size, medium and high PADUA score are associated with decreased probability of trifecta achievement. After verifying by further high-quality studies, these variables can be incorporated into tools to predict probability of trifecta achievement during clinical practice.

Pilot experience of simultaneous robotic-assisted partial nephrectomy for bilateral renal tumors-single center analysis

INTRODUCTION

Bilateral renal tumors accounts for approximately 3% of renal tumors. However, surgical treatment methods for bilateral renal tumors have not yet been established. It is imperative to balance the need for curative surgery with the goal of maximal functional preservation in patients with bilateral synchronous renal tumors. Therefore, partial nephrectomy may be the optimal surgical treatment for bilateral synchronous renal tumors.

METHODS

We conducted a retrospective, observational study to analyze the clinical outcome of simultaneous robotic-assisted partial nephrectomy (RAPN) for bilateral renal tumors at our institution between 2016 and 2019. A total of eight patients were enrolled and the number of renal masses in the 16 kidneys was 18.

RESULTS

There was no positive surgical margin after RAPN in our case series and no local recurrence or metastasis during the follow-up period. The only complication of simultaneous RAPN in the present case series was that one patient experienced acute kidney injury after operation without need for dialysis therapy.

CONCLUSION

Our study suggests that simultaneous RAPN for bilateral renal tumors might be feasible both for the preservation of renal function and for oncological outcome such as negative surgical margin.

Comparison of 3-dimensional laparoscopy and conventional laparoscopy in the treatment of complex renal tumor with partial nephrectomy: A propensity score-matching analysis

To compare the efficacies of 3-dimensional laparoscopic partial nephrectomy and conventional laparoscopic partial nephrectomy for complex renal tumors. The complex renal tumors was defined as Preoperative Aspects and Dimensions Used for an anatomical (PADAU) ≥10, including some cT1b tumors.This was a retrospective analysis of patients with local complex renal tumors who presented to our hospital from January 2014 to January 2018. All patients were managed with laparoscopic partial nephrectomy (LPN) or 3-dimensional partial nephrectomy (3DLPN).There were 48 patients in the LPN group and 60 in the 3DLPN group. In the matched groups, demographic and tumor characteristics including Charlson Comorbidity Index, PADUA, based on the preoperative images, were similar. By contrast, 3DLPN achieved better results in terms of warm ischemia time (19 vs 27 minutes), operation time (105 vs 128 minutes), postoperative complications (14.9% vs 23.4%), and marginal width (0.6 cm vs 0.4 cm). We found statistically significant differences in terms of length of stay, estimated blood loss (EBL), positive surgical margin (PSM), and conversion to open or radical nephrectomy (RN). Median follow-up time was 17 and 18.5 months for the LPN and 3DLPN groups, respectively. The recovery of renal function (% change eGFR, 0 vs -8.7) was significantly different between the 3DLPN and LPN groups, whereas 12-month recurrence-free survival did not differ.Both 3-dimensional laparoscopic nephron-sparing nephrectomy and conventional laparoscopic partial nephrectomy are safe, effective, and acceptable approaches to treating complex renal tumors, while the former may facilitate tumor resection and renorrhaphy for challenging cases, offering a minimally invasive surgical option for patients who may otherwise require open surgery.

Circular RNA SMARCA5 is overexpressed and promotes cell proliferation, migration as well as invasion while inhibits cell apoptosis in bladder cancer

Background

This study aimed to investigate the function of circular RNA SMARCA5 (circ-SMARCA5) on cell proliferation, apoptosis, migration and invasion in bladder cancer.

Methods

Ten pairs of human bladder cancer tissue and adjacent tissue, five human bladder cancer cell lines (including TCCSUP, 5637, J82, UM-UC-3 and T-24) and normal human urothelial cell line SV-HUC-1, were obtained for the detection of circ-SMARCA5. Control overexpression and ShRNA, circ-SMARCA5 overexpression and ShRNA were constructed and transfected into UM-UC-3 cells as Control(+), Control(−), Circ-SMARCA5(+) and Circ-SMARCA5(−) groups. The role of circ-SMARCA5 was investigated in terms of cellular proliferation, apoptosis, migration, and invasion.

Results

Circ-SMARCA5 was overexpressed in tumor tissue compared to paired adjacent tissue and it was also overexpressed in TCCSUP, 5637, J82 and UM-UC-3 cells compared to normal human urothelial cell line SV-HUC-1. In UM-UC-3 cells, cell proliferation ability, migration rate and invasion cell count were increased in Circ-SMARCA5(+) group compared to Control(+) group, while reduced in Circ-SMARCA5(−) group compared to Control(−) group. Regarding the cell apoptosis, apoptosis rate and apoptotic protein C-Caspase 3 expression were decreased in Circ-SMARCA5(+) group than those in Control(+) group but raised in Circ-SMARCA5(−) group compared to Control(−) group, meanwhile, the anti-apoptotic protein Bcl-2 expression was elevated in Circ-SMARCA5(+) group than that in Control(+) group but reduced in Circ-SMARCA5(−) group compared to Control(−) group.

Conclusions

Circ-SMARCA5 is overexpressed, and promotes cell proliferation, migration and invasion, but represses apoptosis in bladder cancer.