Laparoscopic vs robot-assisted partial nephrectomy for renal tumours of >4 cm: a propensity score-based analysis

Renal and major clinical outcomes and their determinants after nephrectomy in patients with pre-existing chronic kidney disease: A retrospective cohort study

The consequences of partial nephrectomy (PN) compared to radical nephrectomy (RN) are less documented in patients with pre-existing chronic kidney disease (CKD) or with solitary kidney (SK). We assessed renal outcomes, and their determinants, after PN or RN in a retrospective cohort of patients with moderate-to-severe CKD (RN-CKD and PN-CKD) or SK (PN-SK). All surgical procedures conducted between 2013 and 2018 in our institution in patients with pre-operative estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 or with SK were included. The primary outcome was a composite criterion including CKD progression or major adverse cardio-vascular events (MACE) or death, assessed one year after surgery. Predictors of the primary outcome were determined using multivariate analyses. A total of 173 procedures were included (67 RN, and 106 PN including 27 SK patients). Patients undergoing RN were older, with larger tumors. Preoperative eGFR was not significantly different between the groups. One year after surgery, PN-CKD was associated with lower rate of the primary outcome compared to RN-CKD (43% vs 71% p = 0.007). In multivariate analysis, independent risk factors for the primary outcome were postoperative AKI (stage 1 to stage 3 ranging from OR = 8.68, 95% CI 3.23-23.33, to OR = 28.87, 95% CI 4.77-167.61), larger tumor size (OR = 1.21 per cm, 95% CI 1.02-1.45), while preoperative eGFR, age, sex, diabetes mellitus, and hypertension were not. Postoperative AKI after PN or RN was the major independent determinant of worse outcomes (CKD progression, MACE, or death) one year after surgery.

Outcomes and Techniques of Robotic-Assisted Partial Nephrectomy (RAPN) for Renal Hilar Masses: A Comprehensive Systematic Review

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly being employed in the management of renal cell carcinoma (RCC) and it is expanding in the field of complex renal tumors. The aim of this systematic review was to consolidate and assess the results of RAPN when dealing with entirely central hilar masses and to examine the various methods used to address the surgical difficulties associated with them. Methods: A thorough literature search in September 2023 across various databases focused on RAPN for renal hilar masses, adhering to PRISMA guidelines. The primary goal was to evaluate RAPN's surgical and functional outcomes, with a secondary aim of examining different surgical techniques. Out of 1250 records, 13 full-text manuscripts were reviewed. Results: Evidence is growing in favor of RAPN for renal hilar masses. Despite a predominance of retrospective studies and a lack of long-term data, RAPN shows positive surgical outcomes and preserves renal function without compromising cancer treatment effectiveness. Innovative suturing and clamping methods are emerging in surgical management. Conclusions: RAPN is a promising technique for managing renal hilar masses in RCC, offering effective surgical outcomes and renal function preservation. The study highlights the need for more long-term data and prospective studies to further validate these findings.

Robotic posterior retroperitoneal adrenalectomy versus laparoscopic posterior retroperitoneal adrenalectomy: outcomes from a pooled analysis

Background

The comparative advantages of robotic posterior retroperitoneal adrenalectomy (RPRA) over laparoscopic posterior retroperitoneal adrenalectomy (LPRA) remain a topic of ongoing debate within the medical community. This systematic literature review and meta-analysis aim to assess the safety and efficacy of RPRA compared to LPRA, with the ultimate goal of determining which procedure yields superior clinical outcomes.

Methods

A systematic search was conducted on databases including PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies, encompassing both randomized controlled trials (RCTs) and non-RCTs, that compare the outcomes of RPRA and LPRA. The primary focus of this study was to evaluate perioperative surgical outcomes and complications. Review Manager 5.4 was used for this analysis. The study was registered with PROSPERO (ID: CRD42023453816).

Results

A total of seven non-RCTs were identified and included in this study, encompassing a cohort of 675 patients. The findings indicate that RPRA exhibited superior performance compared to LPRA in terms of hospital stay (weighted mean difference [WMD] -0.78 days, 95% confidence interval [CI] -1.46 to -0.10; p = 0.02). However, there were no statistically significant differences observed between the two techniques in terms of operative time, blood loss, transfusion rates, conversion rates, major complications, and overall complications.

Conclusion

RPRA is associated with a significantly shorter hospital stay compared to LPRA, while demonstrating comparable operative time, blood loss, conversion rate, and complication rate. However, it is important to note that further research of a more comprehensive and rigorous nature is necessary to validate these findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=453816, identifier CRD42023453816.

Transperitoneal Versus Retroperitoneal Single-port Robotic-assisted Partial Nephrectomy: An Analysis from the Single Port Advanced Research Consortium

BACKGROUND

In the surgical management of kidney tumors, such as in multiport technology, single-port (SP) robotic-assisted partial nephrectomy (RAPN) can be performed using the transperitoneal (TP) or retroperitoneal (RP) approach. However, there is a dearth of literature on the efficacy and safety of either approach for SP RAPN.

OBJECTIVE

To compare the peri- and postoperative outcomes of the TP and RP approaches for SP RAPN.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study using data from the Single Port Advanced Research Consortium (SPARC) database of five institutions. All patients underwent SP RAPN for a renal mass between 2019 and 2022.

INTERVENTION

TP versus RP SP RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline characteristics, and peri- and postoperative outcomes were compared between both the approaches using χ2 test, Fisher exact test, Mann-Whitney U test, and Student t test.

RESULTS AND LIMITATIONS

A total of 219 patients (121 [55.25%] TP, 98 [44.75%] RP) were included in the study. Of them, 115 (51.51%) were male, and the mean age was 60 ± 11 yr. RP had a significantly higher proportion of posterior tumors (54 [55.10%] RP vs 28 [23.14%] TP, p < 0.001), while other baseline characteristics were comparable between both the approaches. There was no statistically significant difference in ischemia time (18 ± 9 vs 18 ± 11 min, p = 0.898), operative time (147 ± 67 vs 146 ± 70 min, p = 0.925), estimated blood loss (p = 0.167), length of stay (1.06 ± 2.25 vs 1.33 ± 1.05 d, p = 0.270), overall complications (5 [5.10%] vs 7 [5.79%]), and major complication rate (2 [2.04%] vs 2 [1.65%], p = 1.000). No difference was observed in positive surgical margin rate (p = 0.472) or delta eGFR at median 6-mo follow-up (p = 0.273). Limitations include retrospective design and no long-term follow-up.

CONCLUSIONS

With proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

PATIENT SUMMARY

The use of a single port (SP) is a novel technology for performing robotic surgery. Robotic-assisted partial nephrectomy (RAPN) is a surgery to remove a portion of the kidney due to kidney cancer. Depending on patient characteristics and surgeons' preference, SP can be performed via two approaches for RAPN: through the abdomen or through the space behind the abdominal cavity. We compared outcomes between these two approaches for patients receiving SP RAPN, finding that they were comparable. We conclude that with proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

Comparing the outcomes of open, laparoscopic and robot-assisted partial nephrectomy: a network meta-analysis

OBJECTIVE

To perform a systematic review and network meta-analysis (NMA) to determine the advantages and disadvantages of open (OPN), laparoscopic (LPN), and robot-assisted partial nephrectomy (RAPN) with particular attention to intraoperative, immediate postoperative, as well as longer-term functional and oncological outcomes.

METHODS

A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-NMA guidelines. Binary data were compared using odds ratios (ORs). Mean differences (MDs) were used for continuous variables. ORs and MDs were extracted from the articles to compare the efficacy of the various surgical approaches. Statistical validity is guaranteed when the 95% credible interval does not include 1.

RESULTS

In total, there were 31 studies included in the NMA with a combined 7869 patients. Of these, 33.7% (2651/7869) underwent OPN, 20.8% (1636/7869) LPN, and 45.5% (3582/7689) RAPN. There was no difference for either LPN or RAPN as compared to OPN in ischaemia time, intraoperative complications, positive surgical margins, operative time or trifecta rate. The estimated blood loss (EBL), postoperative complications and length of stay were all significantly reduced in RAPN when compared with OPN. The outcomes of RAPN and LPN were largely similar except the significantly reduced EBL in RAPN.

CONCLUSION

This systematic review and NMA suggests that RAPN is the preferable operative approach for patients undergoing surgery for lower-staged RCC.

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

Perioperative, functional, and oncological outcomes of robotic vs. laparoscopic partial nephrectomy for complex renal tumors (RENAL score ≥7): an evidence-based analysis

Objective

To evaluate the current literature comparing outcomes of robotic partial nephrectomy (RPN) versus laparoscopic partial nephrectomy (LPN) treating complex renal tumors (RENAL nephrometry score ≥7).

Methods

We systematically searched the Cochrane Library, PubMed, Google Scholar, EMBASE, and Scopus databases up to March 2023. Review Manager 5.4 performed a pooled analysis of the data for random effects. Besides, sensitivity and subgroup analyses to explore heterogeneity, Newcastle-Ottawa scale, and GRADE to evaluate study quality and level of evidence.

Results

Eight observational studies comprising 1346 patients (RPN: 695; LPN: 651) were included in this study. Compared to LPN, RPN had a shorter operative time (OT) (weight mean difference [WMD]: -14.73 min; p = 0.0003), shorter warm ischemia time (WIT) (WMD: -3.47 min; p = 0.002), lower transfusion rate (odds ratio [OR]: 0.66; p = 0.04), shorter length of stay (LOS) (WMD: -0.65 days; p < 0.00001), lower postoperative estimated glomerular filtration rate (eGFR) change (WMD = -2.33 mL/min/1.73 m2; p = 0.002) and lower intraoperative complications (OR: 0.52; p = 0.04). No significant differences were observed between the two groups in terms of estimated blood loss (EBL) (p = 0.84), conversion to radical nephrectomy (p = 0.12), postoperative complications (p = 0.11), major complications (defined Clavien-Dindo grade 3 (p = 0.43), overall complications (p = 0.15), postoperative eGFR (p = 0.28), local recurrence (p = 0.35), positive surgical margin (PSM) (p = 0.63), overall survival (OS) (p = 0.47), cancer-specific survival (CSS) (p = 0.22) and 3-year recurrence-free survival (RFS) (p = 0.53).

Conclusion

Patients with complex renal tumors (RENAL score ≥7), RPN is superior to LPN in decreasing the OT, WIT, LOS, transfusion rate, change in eGFR and the incidence of intraoperative complications while maintaining oncological control and avoiding a decline in renal function. However, our findings need further validation in a large-sample prospective randomized study.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of perioperative outcomes of robotic vs. laparoscopic partial nephrectomy for renal tumors with a RENAL nephrometry score ≥7: A meta-analysis

Introduction

To compare the perioperative outcomes of robotic partial nephrectomy (RPN) vs. laparoscopic partial nephrectomy (LPN) for complex renal tumors with a RENAL nephrometry score ≥7.

Methods

We searched PubMed, EMBASE and the Cochrane Central Register for studies from 2000 to 2020 to evaluate the perioperative outcomes of RPN and LPN in patients with a RENAL nephrometry score ≥7. We used RevMan 5.2 to pool the data.

Results

Seven studies were acquired in our study. No significant differences were found in the estimated blood loss (WMD: 34.49; 95% CI: −75.16–144.14; p = 0.54), hospital stay (WMD: −0.59; 95% CI: −1.24–0.06; p = 0.07), positive surgical margin (OR: 0.85; 95% CI: 0.65–1.11; p = 0.23), major postoperative complications (OR: 0.90; 95% CI: 0.52–1.54; p = 0.69) and transfusion (OR: 0.72; 95% CI: 0.48–1.08; p = 0.11) between the groups. RPN showed better outcomes in the operating time (WMD: −22.45; 95% CI: −35.06 to −9.85; p = 0.0005), postoperative renal function (WMD: 3.32; 95% CI: 0.73–5.91; p = 0.01), warm ischemia time (WMD: −6.96; 95% CI: −7.30–−6.62; p &lt; 0.0001), conversion rate to radical nephrectomy (OR: 0.34; 95% CI: 0.17 to 0.66; p = 0.002) and intraoperative complications (OR: 0.52; 95% CI: 0.28–0.97; p = 0.04).

Discussion

RPN is a safe and effective alternative to LPNs for or the treatment of complex renal tumors with a RENAL nephrometry score ≥7 with a shorter warm ischemic time and better postoperative renal function.

A comparison of outcomes between transperitoneal and retroperitoneal robotic assisted partial nephrectomy in patients with completely endophytic kidney tumors

INTRODUCTION

Retroperitoneal robotic partial nephrectomy (RPN) has been shown to have comparable outcomes to the transperitoneal approach for renal tumors. However, this may not be true for completely endophytic tumors as they pose significant challenges in RPN with increased complication rates. Hence, we sought to compare the safety and feasibility of retroperitoneal RPN to transperitoneal RPN for completely endophytic tumors.

METHODS

We performed a retrospective analysis of patients who underwent RPN for a completely endophytic renal mass using either transperitoneal or retroperitoneal approach from our multi-institutional database (n = 177). Patients who had a solitary kidney, prior ipsilateral surgery, multiple/bilateral tumors, and horseshoe kidneys were excluded from the analysis. Overall, 156 patients were evaluated (112 [71.8%] transperitoneal, 44 [28.2%] retroperitoneal). Baseline characteristics, perioperative and postoperative data were compared between the surgical transperitoneal and retroperitoneal approach using Chi-square test, Fishers exact test, t test, Mood median test and Mann Whitney U test.

RESULTS

Of the 156 patients in this study, 86 (56.9%) were male and the mean (SD) age was 58 (13) years. Baseline characteristics were comparable between the 2 approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (19.6 [SD = 7.6] minutes vs. 19.5 [SD = 10.2] minutes, P = 0.952), operative time (157.5 [SD = 44.8] minutes vs. 160.2 [SD = 47.3] minutes, P = 0.746), median estimated blood loss (50 ml [IQR: 50, 150] vs. 100 ml [IQR: 50, 200], P = 0.313), median length of stay (1 [IQR: 1, 2] day vs. 1 [IQR: 1, 2] day, P = 0.126) and major complication rate (2 [4.6%] vs. 3 [2.7%], P = 0.621). No difference was observed in positive surgical margin rate (P = 0.1.00), delta eGFR (P = 0.797) and de novo chronic kidney disease occurrence (P = 1.000).

CONCLUSION

Retroperitoneal and transperitoneal RPN yielded similar perioperative and functional outcomes in patients with completely endophytic tumors. In well-selected patients with purely endophytic tumors, either a retroperitoneal or transperitoneal approach could be considered without compromising perioperative and postoperative outcomes.

Robot-Assisted Partial Nephrectomy Mid-Term Oncologic Outcomes: A Systematic Review

Background: Robot-assisted partial nephrectomy (RAPN) is used more and more in present days as a therapy option for surgical treatment of cT1 renal masses. Current guidelines equally recommend open (OPN), laparoscopic (LPN), or robotic partial nephrectomy (PN). The aim of this review was to analyze the most representative RAPN series in terms of reported oncological outcomes. (2) Methods: A systematic search of Webofscience, PUBMED, Clinicaltrials.gov was performed on 1 August 2022. Studies were considered eligible if they: included patients with renal cell carcinoma (RCC) stage T1, were prospective, used randomized clinical trials (RCT) or retrospective studies, had patients undergo RAPN with a minimum follow-up of 48 months. (3) Results: Reported positive surgical margin rates were from 0 to 10.5%. Local recurrence occurred in up to 3.6% of patients. Distant metastases were reported in up to 6.4% of patients. 5-year cancer free survival (CFS) estimates rates ranged from 86.4% to 98.4%. 5-year cancer specific survival (CSS) estimates rates ranged from 90.1% to 100%, and 5-year overall survival (OS) estimates rated ranged from 82.6% to 97.9%. (4) Conclusions: Data coming from retrospective and prospective series shows very good oncologic outcomes after RAPN. Up to now, 10-year survival outcomes were not reported. Taken together, RAPN deliver similar oncologic performance to OPN and LPN.

Comparison of surgical outcomes and split renal function between laparoscopic and robot-assisted partial nephrectomy: a propensity score-matched analysis

PURPOSE

The objective of this study was to compare perioperative outcomes and total and split renal function between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN). Predictive risk factors of preservation of operated renal function were also assessed.

METHODS

We retrospectively analyzed 173 patients who underwent LPN (n = 84) or RAPN (n = 89) between 2010 and 2020. After propensity score matching (1:1), perioperative outcomes and total and split renal function were assessed. Logistic regression analysis was used to evaluate predictive risk factors of preservation of operated renal function. Trifecta criteria were defined as negative surgical margins, warm ischemia time (WIT) < 25 min, and no complications more than Clavien-Dindo grade II within 4 weeks after surgery. Split renal function was evaluated by mercaptoacetyltriglycine renal scan.

RESULTS

After propensity score matching, 42 patients were allocated to each group. RAPN was associated with significantly shorter WIT (RAPN vs LPN: 12 vs 22 min; p < 0.0001) and higher trifecta achievement rate (93.3 vs 64.2%; p < 0.0001). Other perioperative outcomes and total and split renal function were not significantly different between LPN and RAPN. The R.E.N.A.L. nephrometry score (RNS) was a predictive risk factor of preservation of operated renal function in the multivariable logistic regression analysis (odds ratio 1.68, 95% confidence interval 1.29-2.20, p < 0.0001).

CONCLUSIONS

RAPN improved WIT and trifecta achievement rate, but it did not improve the preservation of operated renal function, for which RNS was found to be a strong predictive risk factor.

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of outcomes between laparoscopic and robot-assisted partial nephrectomy for complex renal tumors: RENAL score ≥7 or maximum tumor size >4 cm

INTRODUCTION

We reviewed current studies and performed a meta-analysis to compare outcomes between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) treating complex renal tumors (RENAL score ≥7 or maximum clinical tumor size >4 cm).

EVIDENCE ACQUISITION

Using the databases of PubMed, Embase, and the Cochrane Library, a comprehensive literature search was performed in April, 2020. Pooled odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect model. Publication bias was evaluated by funnel plots.

EVIDENCE SYNTHESIS

Ten observational studies including 5193 patients (LPN: 1574; RAPN: 3619) were included. There was no significant difference between the two groups regarding conversion to open (P=0.07) surgery, all complications (P=0.12), grade 1-2 complications (P=0.10), grade 3-5 complications (P=0.93), operative time (P=0.94), estimated blood loss (P=0.17). Patients undergoing LPN had a significant higher rate of conversion to radical (OR=4.33; 95% CI: 2.01-9.33; P<0.001), a longer ischemia time (IT, P<0.001; WMD=3.02 min; 95% CI: 1.67 to 4.36), a longer length of stay (LOS, P<0.001; WMD=0.67 days; 95% CI: 0.35 to 0.99), a lower rate of positive surgical margin (P=0.03; OR=0.71; 95% CI: 0.53 to 0.96), a greater eGFR decline (P<0.001; WMD=2.41 mL/min/1.73 m²; 95% CI: 1.22 to 3.60), a higher rate of CKD upstaging (P<0.001; OR=2.44; 95% CI: 1.54 to 3.87). No obvious publication bias was observed.

CONCLUSIONS

For complex renal tumors, RAPN is more favorable than LPN in terms of lower rate of conversion to radical surgery, shorter IT, shorter LOS, less eGFR decline, and lower rate of CKD upstaging. Methodological limitations of observational studies should be taken into account in interpreting these results.

Comparison of Robot-Assisted and Laparoscopic Partial Nephrectomy for Renal Hilar Tumors: Results from a Tertiary Referral Center

Objective: To compare perioperative, functional, and oncologic outcomes between robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for renal hilar tumors. Methods: We retrospectively reviewed patients who underwent minimally invasive partial nephrectomy for renal hilar tumors at our institution between January 2014 and August 2018. The entire cohort was divided into two groups according to surgical approach: RAPN and LPN group. Perioperative, functional, and oncologic outcomes of the two groups were collected and compared. Results: A total of 116 patients with renal hilar tumors were identified, including 52 patients who underwent RAPN and 64 patients who underwent LPN, respectively. Demographic baseline characteristics were similar in two groups. There were no differences between the RAPN and LPN groups for operative time, transfusion rate, conversion rate, surgical margin, perioperative complication, and hospital stay. Compared with the LPN group, the RAPN group was associated with significant less estimated blood loss (100 vs 150 mL; p < 0.001), shorter warm ischemia time (20.3 vs 24.5 minutes; p = 0.001), and higher direct cost (p < 0.001). Percentage of estimated glomerular filtration rate change at 6 months after surgery was lower in RAPN group than LPN group (10.4% vs 15.2%; p = 0.020). No significant difference was observed between the two groups in terms of oncologic outcomes. Conclusions: For hilar tumors, both RAPN and LPN were safe and feasible surgical treatments. RAPN might be associated with superior perioperative outcomes (less estimated blood loss and shorter warm ischemia time) and better postoperative renal functional preservation. RAPN might be the preferred option when condition permits for renal hilar tumors.

Comparison of Therapeutic Effects Among Different Surgical Approaches in Robot-Assisted Partial Nephrectomy: A Systematic Review and Meta-Analysis

Purpose: To systematically explore the superiority of the transperitoneal approach in robot-assisted partial nephrectomy (TP-RAPN) and retroperitoneal approach in robot-assisted partial nephrectomy (RP-RAPN). Methods: Several databases were searched including PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, CBM, Wan Fang, and VIP to identify relevant studies that reported the comparison of the TP-RAPN and RP-RAPN. Outcomes of data were pooled and analyzed with Review Manager 5.3 to compare the intraoperative and postoperative variables and postoperative complications. Based on the heterogeneity of the studies, odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (CIs) were calculated using a random-effect model or fixed-effect model. The sensitivity analysis and the subgroup analysis were used to minimize the effects of heterogeneity. And, publication bias was assessed by funnel plots. Results: In all, 16 studies met the inclusion criteria, including 2336 TP-RAPN patients and 1705 RP-RAPN patients. This meta-analysis reviewed 16 studies on RAPN, and the RP-RAPN showed shorter operative time (OT) (WMD 13.18 minutes; 95% CI 5.04-21.31; p = 0.001), shorter postoperative bowel function recovery (WMD 1.97 days; 95% CI 0.43-3.52; p = 0.01), shorter length of stay (LOS) (WMD 0.51 days; 95% CI 0.25-0.77; p = 0.0001), and lower estimated blood loss (EBL) (WMD 7.08 mL; 95% CI 1.41-12.74; p = 0.01) than the TP-RAPN. Additionally, no significant differences were found in other outcomes. Conclusions: In comparison, the RP-RAPN had significantly shorter OT, postoperative bowel function recovery time, LOS, and lower EBL. The RP-RAPN is associated with better value for posterior and laterally located tumors and is faster and equally safe and low costs for the patient.

Perioperative and Long-Term Outcomes of Robot-Assisted Partial Nephrectomy: A Systematic Review

Background

Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The objective of this review is to assess perioperative and long-term oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) compared to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).

Methods

A search in PubMed, Embase, and Cochrane (2010-2019) was conducted. Of 3877 articles screened, 7 observational studies were included.

Results

RAPN was associated with 24-50 mL less intraoperative blood loss compared to LPN and 39-84 mL less than OPN. RAPN also demonstrated trends of other postoperative benefits, such as shorter length of stay and fewer major complications. Several studies reported better long-term functional kidney outcomes, but these findings were inconsistent. Recurrence and cancer-specific survival (CSS) were similar across groups. While RAPN had a 5-year CSS of 90.1%-97.9%, LPN and OPN had survival rates of 85.9%-86.9% and 88.5-96.3% respectively.

Conclusions

RAPN may be associated with a lower estimated blood loss and comparable long-term outcomes when compared to other surgical approaches. However, additional randomized or propensity matched studies are warranted to fully assess long-term functional kidney and oncologic outcomes.

Perioperative and Mid-term Oncological and Functional Outcomes After Partial Nephrectomy for Complex (PADUA Score ≥10) Renal Tumors: A Prospective Multicenter Observational Study (the RECORD2 Project)

BACKGROUND

Partial nephrectomy (PN) for complex renal masses has a non-negligible risk of perioperative complications. Furthermore, late functional and oncological outcomes of patients submitted to these challenging surgeries still remain to be determined.

OBJECTIVES

To report the perioperative and mid-term oncological and functional outcomes of PN for complex masses (Preoperative Aspects and Dimensions Used for an Anatomical [PADUA] score≥10) in a large multicenter prospective observational study.

DESIGN, SETTING, AND PARTICIPANTS

We prospectively evaluated patients treated with PN for complex renal tumors at 26 urological centers (Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease [RECORD2] project).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariate logistic regression analyses explored the predictors of surgical complications. Multivariable Cox regression analyses estimated the hazard of renal function loss and disease recurrence. Kaplan-Meier estimates assessed the probability of survival.

RESULTS AND LIMITATIONS

In total, 410 patients who underwent PN for complex masses were evaluated. Clinical T1b and T2 tumors accounted for 43.2% and 9.8% of the cases. Overall, 45.9%, 18.8%, and 35.4% of patients underwent open, laparoscopic, and robotic PN, respectively. Intraoperative complications occurred in 15 (3.6%) patients, while postoperative surgical complications were recorded in 76 (18.5%) patients. At multivariable analysis, preoperative hemoglobin (odds ratio [OR]: 0.67; p<0.001) and open (OR: 3.91; p<0.001) versus robotic surgical approach were found to be the only predictors of surgical complications. An estimated glomerular filtration rate drop of >25% from baseline was observed in 30.2% and 17.6% of patients at 1st month and 2 yr after surgery, respectively. Two-year recurrence-free survival was 97.1%; positive surgical margins (hazard ratio [HR]: 3.35; p=0.009), nucleolar grading (HR: 5.61; p<0.001), and tumor stage (HR: 2.62; p=0.05) were associated with recurrence.

CONCLUSIONS

In a large series, PN for complex renal masses was a safe technique with an acceptable rate of perioperative complications and excellent mid-term oncological and functional results.

PATIENT SUMMARY

In this study, we evaluated peri- and postoperative outcomes of patients treated with partial nephrectomy for complex renal masses. Open surgery was associated with higher complications than the robotic approach. Some histological features were found to be associated with disease recurrence.

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

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

Prediction of pentafecta achievement following laparoscopic partial nephrectomy: Implications for robot-assisted surgery candidates

BACKGROUND

In clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making.

METHODS

Patients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN.

RESULTS

RAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P < 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased.

CONCLUSION

When pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.

The Mayo Adhesive Probability Score Predicts Longer Dissection Time During Laparoscopic Partial Nephrectomy

Background: To examine the impact of the Mayo adhesive probability (MAP) score on the surgical complexity of exposing the tumor during laparoscopic partial nephrectomy (LPN). Patients and Methods: Our study included 318 patients who underwent LPN from January 2017 to December 2018 at our institution. Patients were divided into a lower MAP score group (≤2, n = 172) and a higher MAP score group (≥3, n = 146). Perioperative outcomes were compared between the groups. The operative time was predominantly occupied by the dissection time and the warm ischemia time (WIT). Results: A higher MAP score was associated with a longer operative time (131 vs 110 minutes, p < 0.001) and longer dissection time (71 vs 54 minutes, p < 0.001), respectively. The estimated blood loss (EBL) increased in patients with a higher MAP score (50 vs 20 mL, p < 0.001). No significant difference was found with respect to the WIT (21 vs 20 minutes, p = 0.370). In the multivariate linear regression model, male gender (β = 11.199, p = 0.001), body mass index (β = 1.197, p = 0.008), and MAP score (β = 9.958, p = 0.002) were significantly associated with the prolongation of dissection time. Conclusions: The MAP score was significantly associated with the prolongation of dissection time during LPN. In addition, the EBL increased in patients with a higher MAP score. Therefore, the MAP score can predict surgical complexity of exposing the tumor in patients undergoing LPN.

Comparison of Robot-Assisted and Laparoscopic Partial Nephrectomy for Completely Endophytic Renal Tumors: A High-Volume Center Experience

Objectives: To compare the perioperative, functional, and oncologic outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for completely endophytic renal tumors (three points for the "E" element of the R.E.N.A.L. scoring system). Materials and Methods: We retrospectively reviewed patients who underwent either RAPN or LPN between 2013 and 2016. Baseline characteristics, perioperative, functional, and oncologic outcomes were compared. Univariable and multivariable logistic analyses were performed to determine factors associated with pentafecta achievement (ischemia time ≤25 minutes, negative margin, no perioperative complication, return of estimated glomerular filtration rate [eGFR] to >90% from baseline, and no chronic kidney disease upstaging). Results: No significant differences between RAPN vs LPN were noted for operating time (105 minutes vs 108 minutes, p = 0.916), estimated blood loss (50 mL vs 50 mL, p = 0.130), renal artery clamping time (20 minutes vs 20 minutes, p = 0.695), rate of positive margins (3.3% vs 2.0%, p = 1.000), and postoperative complication rates (18.0% vs 21.6%, p = 0.639). RAPN was associated with a higher direct cost ($11240 vs $5053, p < 0.001). There were no significant differences in pathology variables, rate of eGFR decline for postoperative 12-month (9.8% vs 10.6%, p = 0.901) functional follow-up. Multivariate analysis identified that only RENAL score was independently associated with the pentafecta achievement. Conclusions: For completely endophytic renal tumors, both RAPN and LPN have excellent and similar results. Both operation techniques remain viable options in the management of these cases.

Robot-assisted versus laparoscopic partial nephrectomy for anatomically complex T1b renal tumors with a RENAL nephrometry score ≥7: A propensity score-based analysis

Objectives

To present the perioperative, functional, and oncological outcomes of robot‐assisted partial nephrectomy (RPN) compared with laparoscopic partial nephrectomy (LPN) for anatomically complex T1b renal tumors with RENAL nephrometry scores ≥7.

Patients and methods

One hundred and seventy patients, during the study period, were retrospectively reviewed in our analysis according to inclusion criteria. Propensity score matching (PSM) (1:1) method was applied to impose restrictions on the potential baseline confounders. The comparisons of perioperative and functional outcomes between the RPN and LPN groups were conducted and analyzed after PSM, Kaplan‐Meier analyses were performed to assess the differences about oncological outcomes between the two groups before and after PSM.

Results

One hundred and nine and 61 T1b renal tumors with RENAL scores ≥7 were identified in the LPN and RPN groups, respectively. All significant differences in baseline characteristics disappeared after PSM. Except for 3 patients missing an appropriate pair, all the patients in the RPN group were successfully matched to 58 patients in the LPN group in a 1:1 ratio. Within the matched cohort, the RPN group was related to a significantly shorter mean operating time (OT) (P = .040), shorter mean warm ischemia time (WIT) (P = .023), and shorter median postoperative hospital stay (P = .023). The possibilities of surgical conversion, postoperative complication, and positive surgical margin were similar in the LPN and RPN groups. And there was also no significant difference in the pathological, renal functional, and oncological outcomes between the two series.

Conclusions

For patients with anatomically complex T1b renal tumors with a RENAL nephrometry score ≥7, RPN had an advantage over LPN in reducing OT, WIT, and postoperative hospital stay length without increasing the risk of complications and weakening the oncological control, while the two surgical methods were similar in renal functional preservation.