Predictors of renal function after open and robot‐assisted partial nephrectomy: A propensity score‐matched study

Long-Term Functional and Oncologic Outcomes Following Robotic Partial and Radical Nephrectomy: A Report from a Single Institution with up to 15 Years of Follow-Up

Objective: To evaluate the long-term functional and oncologic outcomes after robotic partial nephrectomy (RAPN) and radical nephrectomy (RARN). Materials and Methods: A retrospective review was performed on 1816 patients who underwent RAPN and RARN at our institution between January 2006 and January 2018. Patients with long-term follow-ups of at least 5 years were selected. Exclusion criteria included patients with a previous history of partial or radical nephrectomy, known genetic mutations, and whose procedures were performed for benign indications. Statistical analysis was performed with results as presented. Results: A total of 769 and 142 patients who underwent RAPN and RARN, respectively, met our inclusion criteria. The duration of follow-up was similar after the two procedures with a median of ∼100 months. The 5- and 10-year chronic kidney disease (CKD) upstaging-free survivals were 74.5% and 65.9% after RAPN and 53% and 46.4% after RARN, respectively. Older age was identified as a potential predictor for CKD progression after RARN, whereas older age, higher body mass index, baseline renal function, and ischemia time were shown to predict CKD progression after RAPN. Renal cell carcinoma-related mortality rates for RAPN and RARN were equally 1.1%. No statistically significant differences were identified in the local recurrence, metastatic, and disease-specific survival between the two procedures. Conclusion: Compared with RARN, RAPN conferred a better CKD progression-free survival. Several factors were identified as potential predictors for clinically significant CKD progression both in the early and late postoperative phase. Long-term oncologic outcomes between the two procedures remained similarly favorable.

Renal functional outcomes after nephrectomy in patients with localized renal cell carcinoma and diabetes mellitus: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVE

Diabetes mellitus (DM), one of the most common comorbidities in patients with renal cell carcinoma (RCC), was proven to be an important prognostic factor of overall survival for these patients. Regarding the influence on renal function after nephrectomy, evidence is still scant. This systematic review and meta-analysis was conducted to provide a more reliable analysis of the association between DM and long-term renal functional outcomes after nephrectomy.

METHODS

The PubMed, Web of Science, Embase and Cochrane Library (CENTRAL) databases were searched for eligible studies from inception to January 2023. Hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted to evaluate the association between DM and renal functional outcomes using a random effects model. Stata 17.0 software was used for statistical analysis.

RESULTS

The meta-analysis included thirteen studies consisting of 8562 RCC patients who underwent nephrectomy. Preoperative comorbidity of DM was significantly associated with poor renal functional outcomes (HR = 1.91, 95% CI 1.48-2.48, p < 0.0001), regardless of ethnicity, follow-up time, body mass index (BMI) and age. However, in the radical nephrectomy subgroup, DM was not significantly associated with renal function decline (HR = 1.91, 95% CI 0.93-3.90, p = 0.0781).

CONCLUSIONS

The aggregate evidence indicated that preexisting DM may be associated with poor renal functional outcomes in patients with RCC after nephrectomy, especially in patients receiving partial nephrectomy. Urologists should focus more on the glycemic management of these patients after nephrectomy. More high-quality studies are needed to explore the influence of DM on renal function outcomes in postoperative patients.

Predictors of renal function deterioration at one year after off-clamp non-renorrhaphy partial nephrectomy

BACKGROUND

Preservation of renal function is an important goal in renal cell carcinoma-related surgery. Although several case-dependent techniques for renal pedicle clamping and hemostasis have been used, their effects on long-term renal function are controversial.

METHODS

The clinical records of 114 patients who underwent off-clamp non-renorrhaphy open partial nephrectomy at our hospital were retrospectively reviewed. Perioperative estimated glomerular filtration rate (eGFR) preservation was calculated, and predictors of eGFR decline 12 months post-surgery and overtime deterioration of renal function were identified using a multivariate regression analysis.

RESULTS

The median patient age was 65 years, and the median tumor size was 27 mm. The mean eGFR preservation at 1, 3, and 12 months post-surgery were 90.1%, 89.0%, and 86.9%, respectively. eGFR decline at 1 and 3 months were associated with poor eGFR preservation at 12 months with the odds ratio (95% confidence interval (CI)) of 1.97 and 3.157, respectively. Multivariate regression analyses revealed that tumor size was an independent predictor of eGFR decline at 12 months. Among 65 patients with eGFR preservation over 90% at 1 month post-surgery, eGFR value of 28 patients deteriorated below 90% at 12 months post-surgery compared with preoperative eGFR. Tumor size and eGFR preservation at 1 month were independent predictors of long-term renal function deterioration.

CONCLUSION

Tumor size predicted eGFR decline 12 months post-surgery. Only a mild decline in eGFR was observed between 3 and 12 months after open partial nephrectomy. Tumor size and eGFR preservation at 1 month predicted the deterioration of renal function over time.

A new machine-learning model to predict long-term renal function impairment after minimally invasive partial nephrectomy: the Fundació Puigvert predictive model

PURPOSE

To provide a new model to predict long-term renal function impairment after partial nephrectomy (PN).

METHODS

Data of consecutive patients who underwent minimally invasive PN from 2005 to 2022 were analyzed. A minimum of 12 months of follow-up was required. We relied on a machine-learning algorithm, namely classification and regression tree (CART), to identify the predictors and associated clusters of chronic kidney disease (CKD) stage migration during follow-up.

RESULTS

568 patients underwent minimally invasive PN at our center. A total of 381 patients met our inclusion criteria. The median follow-up was 69 (IQR 38-99) months. A total of 103 (27%) patients experienced CKD stage migration at last follow-up. Progression of CKD stage after surgery, ACCI and baseline CKD stage were selected as the most informative risk factors to predict CKD progression, leading to the creation of four clusters. The progression of CKD stage rates for cluster #1 (no progression of CKD stage after surgery, baseline CKD stage 1-2, ACCI 1-4), #2 (no progression of CKD stage after surgery, baseline CKD stage 1-2, ACCI ≥ 5), #3 (no progression of CKD stage after surgery and baseline CKD stage 3-4-5) and #4 (progression of CKD stage after surgery) were 6.9%, 28.2%, 37.1%, and 69.6%, respectively. The c-index of the model was 0.75.

CONCLUSION

We developed a new model to predict long-term renal function impairment after PN where the perioperative loss of renal function plays a pivotal role to predict lack of functional recovery. This model could help identify patients in whom functional follow-up should be intensified to minimize possible worsening factors of renal function.

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.

Effects of remote ischemic preconditioning on renal protection in patients undergoing robot-assisted laparoscopic partial nephrectomy

We aimed to evaluate the renoprotective effects of remote ischemic preconditioning (RIPC) in patients undergoing robot-assisted laparoscopic partial nephrectomy (RAPN). Data from 59 patients with solitary renal tumors who underwent RAPN with RIPC comprising three cycles of 5-min inflation to 200 mmHg of a blood pressure cuff applied to one lower limb followed by 5-min reperfusion by cuff deflation, from 2018 to 2020 were analyzed. Patients who underwent RAPN for solitary renal tumors without RIPC between 2018 and 2020 were selected as controls. The postoperative estimated glomerular filtration rate (eGFR) at the nadir during hospitalization and the percentage change from baseline were compared using propensity score matching analysis. We performed a sensitivity analysis with imputations for missing postoperative renal function data weighted by the inverse probability of the data being observed. Of the 59 patients with RIPC and 482 patients without RIPC, 53 each were matched based on propensity scores. No significant differences in the postoperative eGFR in mL/min/1.73 m2 at nadir (mean difference 3.8; 95% confidence interval [CI] - 2.8 to 10.4) and its percentage change from baseline (mean difference 4.7; 95% CI - 1.6 to 11.1) were observed between the two groups. Sensitivity analysis also indicated no significant differences. No complications were associated with the RIPC. In conclusion, we found no significant evidence of the protective effect of RIPC against renal dysfunction after RAPN. Further research is required to determine whether specific patient subgroups benefit from RIPC.Trial registration number: UMIN000030305 (December 8, 2017).

Perioperative and long-term functional outcomes of robot-assisted versus open partial nephrectomy: A single-center retrospective study of a Japanese cohort

Objective

This study aimed to compare the perioperative and long-term functional outcomes between robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) in Japanese patients.

Methods

We retrospectively analyzed 242 patients who underwent either RAPN or OPN between 2007 and 2017 at our hospital. Propensity score matching was carried out between the two groups at a ratio of 1:1. Perioperative outcomes and postoperative estimated glomerular filtration rates (eGFR) were compared at one and three years of follow-up.

Results

After propensity score matching, we evaluated 39 patients from each group. The ischemia duration of the RAPN group was significantly shorter than that of the OPN group (18 vs. 24, p < 0.001). Moreover, the estimated blood loss (EBL) was significantly lower in the RAPN group than in the OPN group (50 vs. 174, p < 0.001). However, there were no significant differences in the postoperative eGFR between the two groups at one or three years of follow-up (OPN 54.8 vs. RAPN 61.2, p = 0.109, and OPN 54.8 vs. RAPN 55.5, p = 0.262, respectively).

Conclusion

RAPN resulted in shorter ischemia durations and lower rates of EBL than did OPN; however, no differences in long-term renal function were observed between RAPN and OPN in our propensity-score matched Japanese cohort.

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This study aimed to compare the perioperative and long-term functional outcomes of RAPN and OPN in Japanese patients.

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RAPN resulted in shorter ischemia durations and lower rates of estimated blood loss than OPN.

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No differences in long-term renal function were observed between RAPN and OPN.

Short-Term and Long-Term Renal Outcomes in Patients With Obesity After Minimally Invasive Versus Open Partial Nephrectomy for the Treatment of Renal Cancer: Retrospective Study

Background

Obesity is significantly associated with renal cell carcinoma. Surgery is the preferred treatment for demarcated lesions of renal cell carcinoma; however, obesity increases the complexity of surgical outcomes. Minimally invasive surgical techniques are preferred over open partial nephrectomy (OPN), but controversy remains regarding the most efficacious technique in patients with obesity.

Objective

This study aims to determine whether minimally invasive partial nephrectomy (MIPN) or OPN better preserves renal function and investigate short- and long-term renal outcomes in patients with obesity undergoing a partial nephrectomy.

Methods

We conducted a retrospective chart review of 242 adult patients aged ≥18 years who underwent MIPN or OPN between January 1, 2005, and December 31, 2016, at the University of Arkansas for Medical Sciences. Using creatinine as a measure of kidney function, patients’ preoperative levels were compared with their postoperative levels in 2-time frames: short (3-6 months postsurgery) or long (>6 months). The primary outcome was the change in creatinine values from preoperative to >6 months postoperatively in patients with obesity. Secondary outcomes included the change in creatinine values from preoperative to 3 to 6 months postoperatively in patients with obesity who underwent MIPN versus OPN. We also analyzed the creatinine values of nonobese patients (BMI <30) who underwent partial nephrectomy using the same time frames. Unconditional logistic regression was used to estimate crude and multivariable-adjusted odds ratios (ORs) and 95% CI to observe associations between surgery type and changes in creatinine values from while stratifying for obesity.

Results

A total of 140 patients were included in the study, of whom 75 were obese and 65 were nonobese. At >6 months after MIPN (n=20), the odds of patients with obesity having a decrease or no change in creatinine values was 1.24 times higher than those who had OPN (n=13; OR 1.24, 95% CI 0.299-6.729; P=.80). At 3 to 6 months after MIPN (n=27), the odds were 0.62 times lower than those after OPN (n=17; OR 0.62, 95% CI 0.140-2.753; P=.56). In the nonobese group, at 3 to 6 months after undergoing minimally invasive surgery (n=18), the odds of having a decrease or no change in creatinine values was 4.86 times higher than those who had open surgery (n=21; OR 4.86, 95% CI 1.085-21.809; P=.04). At more than 6 months after MIPN (n=14), the odds were 4.13 times higher than those after OPN (n=11; OR 4.13, 95% CI 0.579-29.485; P=.16).

Conclusions

We observed a nonstatistically significant preservation of renal function in patients with obesity who underwent OPN at 3 to 6 months postoperatively. Conversely, after 6 months, the same was true for MIPN, indicating the long-term benefit of MIPN. In the nonobese group, MIPN was favored over OPN. 

Robotic-assisted laparoscopic partial nephrectomy. Retrospective descriptive study over a 10-year period. Anesthetic experience

Introduction: Robot-assisted laparoscopic surgery is currently the surgical treatment of choice for small renal masses. Objective: Reviewing the anesthetic management and perioperative morbidity of patients undergoing robotic-assisted laparoscopic partial nephrectomy (RALPN) from 2009 to 2019 at Hospital Universitario Donostia. Material and methods: Retrospective, descriptive, observational study involving 343 patients. Results: 95 % of the patients were ASA II-III. Transient renal artery clamping was performed in 91 %, with a mean ischemia time of 17.79 minutes. The mean duration of the procedure under balanced general anesthesia was 184 min. Standard monitoring was performed along with invasive arterial pressure monitoring (IAP), central venous catheter (CVC) and EV1000 platform (Edwards®) for complex patients. Complications were recorded in 40 patients (11.67 %). Patients under anti-aggregation therapy experienced more bleeding than non-anti-aggregation patients (p 0.04) but did not require more transfusions. Patients with a higher anesthetic risk did not experience more complications. No statistically significant association was found between worsening renal function and the occurrence of intraoperative complications. 21 patients (6 %) were readmitted due to complications; the most frequent complication was renal artery pseudoaneurysm that required endovascular embolization. Conclusions: It should be highlighted that after ten years of experience with this technique, the patients with a higher anesthetic risk have not experienced serious perioperative complications. RALPN is a safe technique that demands a careful anesthetic support. A robot-assisted approach alone is not a guarantee for success without strong teamwork.

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.

Predictive Value of Nephrometry Scores in Nephron-sparing Surgery: A Systematic Review and Meta-analysis

CONTEXT

Over the last decade, several nephrometry scores (NSs) have been introduced with the aim of facilitating preoperative decision making, planning, and counseling in the field of nephron-sparing surgery. However, their predictive role remains controversial.

OBJECTIVE

To describe currently available nephrometry scores and to determine their predictive role for different outcomes by performing a systematic review and meta-analysis of the literature.

EVIDENCE ACQUISITION

PubMed, Embase®, and Web of Science were screened to identify eligible studies. Identification and selection of the reports were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). A pooled analysis of NS predictive role of intraoperative, postoperative, oncological, and functional outcomes was performed. Odds ratio was considered the effect size. All the analyses were performed using Stata 15.0, and statistical significance was set at p≤ 0.05.

EVIDENCE SYNTHESIS

Overall, 51 studies meeting our inclusion criteria were identified and considered for the analysis. Except for one prospective randomized trial, all the studies were retrospective. All the studies were found to be of intermediate quality, except for one of high quality. Most studies assessed the predictive role of the Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) scores, mostly regarding complications after nephron-sparing surgery. RENAL was an independent predictor of an on-clamp procedure (p< 0.001). Mayo Adhesive Probability score was related to adhesive perinephric fat (p= 0.005). Continuous and high-complexity RENAL scores were predictors of warm ischemia time (WIT; p= 0.006 and p< 0.001, respectively). Continuous (p< 0.001) and high-complexity (p< 0.001) PADUA scores were related to WIT. Continuous and high-complexity RENAL scores were predictors of overall complications (p= 0.002 and p< 0.001, respectively). PADUA score was related to complications both as continuous (p< 0.001) and as a categorical value (p< 0.002). The RENAL scores R=3 (p= 0.008), E=2 (p= 0.039), and hilar location (p= 0.006) were predictors of histological malignancy. Continuous and categorical RENAL scores were independent predictors of an estimated glomerular filtration rate (eGFR) increase (p= 0.006 and p< 0.001, respectively). The Diameter-Axial-Polar score (p= 0.018) and Peritumoral Artery Scoring System (PASS; p= 0.02) were also independent predictors.

CONCLUSIONS

The literature regarding nephrometry scoring systems is sparse, and mostly focused on RENAL and PADUA, which are easy to calculate and have a good correlation with most outcomes. Renal Pelvic Score is the best predictor of pelvicalyceal entry/repair and urine leak, whereas Surgical Approach Renal Ranking and PASS strongly predict surgical approach and renal function variation, respectively. Other nephrometry scores based on mathematical models are limited by their complexity, and they lack evidence supporting their predictive value.

PATIENT SUMMARY

We reviewed the medical literature regarding the use and value of so-called "nephrometry scores," which are scoring systems based on radiological imaging and made to grade the complexity of a renal tumor. We analyzed whether these scoring systems can predict some of the outcomes of patients undergoing surgical removal of renal tumors.

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

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