Perioperative outcomes between laparoscopic versus open versus robotic partial nephrectomy: Current Review

BACKGROUND

Surgical treatment of small renal tumours remain gold-standard for individuals who are suitable candidates. Over the last decade, minimally invasive surgery has provided significant advancements within the field of urological surgery. However, there is still a debate on which surgical modality is superior. This study aims to review the current literature on perioperative outcomes between laparoscopic (LPN), open (OPN) and robotic-assisted partial nephrectomy (RPN) using the standardised system, Clavien-Dindo Classification (CDC).

METHODS

A literature search was performed on Cochrane, Embase and PubMed databases. Articles between January 2016 and December 2021 were included. Perioperative outcomes investigated include estimated blood loss (EBL), operating time (OT), conversion rate (CR), warm ischaemia time (WIT), positive surgical margin (PSM) and postoperative complications using CDC. Relevant pieces of literatures were analysed and data were extracted.

RESULTS

This study included 12 studies, with a total of 3908 patients. (LPN = 1120, OPN = 1206 and RPN = 1580). LPN demonstrated a lower overall EBL (p = 0.004). There was no significant difference between OT (p = 0.291), CR (p = 0.200), WIT (p = 0.760), PSM (p = 0.549), CDC I (p = 0.556), CDC II (p = 0.779) and CDC⩾III (p = 0.663) of the three surgical approaches.

CONCLUSION

Compared with OPN and RPN, LPN demonstrated a lower EBL. All other perioperative outcomes demonstrated similar results between the three treatment modalities. Future large-scale, prospective, randomised studies is necessary to draw a definitive conclusion from this analysis.

Development of a novel score (RENSAFE) to determine probability of acute kidney injury and renal functional decline post surgery: A multicenter analysis

OBJECTIVE

To create and validate 2 models called RENSAFE (RENalSAFEty) to predict postoperative acute kidney injury (AKI) and development of chronic kidney disease (CKD) stage 3b in patients undergoing partial (PN) or radical nephrectomy (RN) for kidney cancer.

METHODS

Primary objective was to develop a predictive model for AKI (reduction >25% of preoperative eGFR) and de novo CKD≥3b (<45 ml/min/1.73m2), through stepwise logistic regression. Secondary outcomes include elucidation of the relationship between AKI and de novo CKD≥3a (<60 ml/min/1.73m2). Accuracy was tested with receiver operator characteristic area under the curve (AUC).

RESULTS

AKI occurred in 452/1,517 patients (29.8%) and CKD≥3b in 116/903 patients (12.8%). Logistic regression demonstrated male sex (OR = 1.3, P = 0.02), ASA score (OR = 1.3, P < 0.01), hypertension (OR = 1.6, P < 0.001), R.E.N.A.L. score (OR = 1.2, P < 0.001), preoperative eGFR<60 (OR = 1.8, P = 0.009), and RN (OR = 10.4, P < 0.0001) as predictors for AKI. Age (OR 1.0, P < 0.001), diabetes mellitus (OR 2.5, P < 0.001), preoperative eGFR <60 (OR 3.6, P < 0.001) and RN (OR 2.2, P < 0.01) were predictors for CKD≥3b. AUC for RENSAFE AKI was 0.80 and 0.76 for CKD≥3b. AKI was predictive for CKD≥3a (OR = 2.2, P < 0.001), but not CKD≥3b (P = 0.1). Using 21% threshold probability for AKI achieved sensitivity: 80.3%, specificity: 61.7% and negative predictive value (NPV): 88.1%. Using 8% cutoff for CKD≥3b achieved sensitivity: 75%, specificity: 65.7%, and NPV: 96%.

CONCLUSION

RENSAFE models utilizing perioperative variables that can predict AKI and CKD may help guide shared decision making. Impact of postsurgical AKI was limited to less severe CKD (eGFR<60 ml/min 71.73m2). Confirmatory studies are requisite.

Trends in the surgical management of kidney cancer by tumor stage, treatment modality, facility type, and location

Partial nephrectomy (PN) is an alternative to radical nephrectomy (RN) in the appropriate localized renal tumor. The scope of PN has expanded over time and, since the advent and proliferation of minimally invasive surgery, more surgeons have access to and have been trained in laparoscopic and robotic technology. Amid the changing surgical landscape, we sought to characterize the trends in management by cancer stage, institution type, and geographic location using the National Cancer Database (NCDB). We queried the NCDB for patients with kidney cancer from 2004 to 2019. Overall, 241,311 patients who underwent PN or RN were included in the study. The nephrectomy approach was categorized as robotic partial (RPN), robotic radical (RRN), laparoscopic partial (LPN), laparoscopic radical (LRN), open or unspecified partial (OPN), and open or unspecified radical (ORN). The categorical variables were presented as frequency and percentages. Overall, there was an increase in the utilization of robotic approaches from 2010 to 2019. For cT1 tumors, the use of RPN and RRN increased from 14.27 to 33.06% and 5.24% to 19.63%, respectively. The use of ORN for cT2 and cT3 tumors declined, with rates dropping from 54.71 to 10.76% and 64.71 to 46.64%, respectively. Conversely, the utilization of RRN rose during this period. However, ORN remained the most common approach for cT3 tumors. The use of RPN increased across different facility types, with the highest utilization observed in academic/research programs. The use of ORN for cT2 and cT3 tumors declined across facility types, although it remained most prevalent in community cancer programs. The use of robot-assisted surgery to treat localized renal cancer increased in the US between 2010 and 2019 across all stages of disease. RPN became the most used approach for cT1 disease, while LRN was preferred for cT2 disease. ORN remained the approach of choice for cT3 disease throughout the study period. Trends in facility type and geographic location largely mirrored the overall trends.

Last Resort from Nursing Shortage? Comparative Cost Analysis of Open vs. Robot-Assisted Partial Nephrectomies with a Focus on the Costs of Nursing Care

Despite perioperative advantages, robot-assisted surgery is associated with high costs. However, the lower morbidity of robotic surgery could lead to a lower nursing workload and cost savings. In this comparative cost analysis of open retroperitoneal versus robot-assisted transperitoneal partial nephrectomies (PN), these possible cost savings, including other cost factors, were quantified. Therefore, patient, tumor characteristics, and surgical results of all PN within two years at a tertiary referral center were retrospectively analyzed. The nursing effort was quantified by the local nursing staff regulation and INPULS^® intensive care and performance-recording system. Out of 259 procedures, 76.4% were performed robotically. After propensity score matching, the median total nursing time (2407.8 vs. 1126.8 min, p < 0.001) and daily nursing effort (245.7 vs. 222.6 min, p = 0.025) were significantly lower after robotic surgery. This resulted in mean savings of EUR 186.48 in nursing costs per robotic case, in addition to savings of EUR 61.76 due to less frequent administrations of erythrocyte concentrates. These savings did not amortize the higher material costs for the robotic system, causing additional expenses of EUR 1311.98 per case. To conclude, the nursing effort after a robotic partial nephrectomy was significantly lower compared to open surgery; however, this previously unnoticed savings mechanism alone could not amortize the overall increased costs.

[Cancer registries in Germany: what does the future hold for urology?]

Cancer registries are defined as systematically collected information in the form of a database on tumour diseases. They can provide information about the quality of oncological care or progress in the treatment of individual cancers over time. Since 1995, all German federal states have been required by law to establish and maintain a cancer registry. The Center for Cancer Registry Data (ZfKD) at Robert Koch Institute has collected this nationwide data since 2009 and compiled it into an annually audited dataset available for research purposes. By virtue of the Cancer Early Detection and Registry Act (KFRG), which was passed in 2013, the cancer registries were given a new perspective. Since then, they have made a central contribution to the quality assurance of oncological care. The cancer registries are mainly financed by the health insurance funds. An upcoming expansion of the dataset including clinical variables and earlier provision by the ZfKD starting next year offers new opportunities for the scientific use of cancer registry data. In particular, the course of the disease will now be mapped in considerable detail. Apart from the cancer registries, there are not many useful supplemental datasets in Germany for the assessment of the nationwide healthcare situation and treatment reality on a national level. The DRG database (case-based hospital statistics) of the Federal Statistics Office records all billing data of all German hospitals with few exceptions. Another interesting supplement to the cancer registry data are the datasets of the structured quality reports, which have been mandatory for hospitals since 2003. In the future, the scientific role of cancer registries is to be further enhanced by the Act on the Pooling of Cancer Registry Data, which was passed in 2021.

Hospital rating websites play a minor role for uro-oncologic patients when choosing a hospital for major surgery: results of the German multicenter NAVIGATOR-study

PURPOSE

Hospital rating websites (HRW) offer decision support in hospital choice for patients. To investigate the impact of HRWs of uro-oncological patients undergoing elective surgery in Germany.

METHODS

From 01/2020 to 04/2021, patients admitted for radical prostatectomy, radical cystectomy, or renal tumor surgery received a questionnaire on decision-making in hospital choice and the use of HRWs at 10 German urologic clinics.

RESULTS

Our study includes n = 812 completed questionnaires (response rate 81.2%). The mean age was 65.2 ± 10.2 years; 16.5% were women. Patients were scheduled for prostatectomy in 49.1%, renal tumor surgery in 20.3%, and cystectomy in 13.5% (other 17.1%). Following sources of information influenced the decision process of hospital choice: urologists' recommendation (52.6%), previous experience in the hospital (20.3%), recommendations from social environment (17.6%), the hospital's website (10.8%) and 8.2% used other sources. Only 4.3% (n = 35) used a HRW for decision making. However, 29% changed their hospital choice due to the information provided HRW. The most frequently used platforms were Weisse-Liste.de (32%), the AOK-Krankenhausnavigator (13%) and Qualitaetskliniken.de (8%). On average, patients rated positively concerning satisfaction with the respective HRW on the Acceptability E-Scale (mean values of the individual items: 1.8-2.1).

CONCLUSION

In Germany, HRWs play a minor role for uro-oncologic patients undergoing elective surgery. Instead, personal consultation of the treating urologist seems to be far more important. Although patients predominantly rated the provided information of the HRW as positive, only a quarter of users changed the initial choice of hospital.

Robotic-assisted tumor enucleation versus standard margin partial nephrectomy: Perioperative, renal functional, and oncologic outcomes for low and intermediate complexity renal masses

PURPOSE

Standard margin partial nephrectomy (SPN) with sharp incision across normal renal parenchyma carries perioperative morbidity and renal functional implications. Tumor enucleation (TE) is an alternative approach using a natural plane of dissection around the tumor pseudocapsule to maximize parenchymal preservation. We compared perioperative, functional, and oncologic outcomes for robotic-assisted TE to SPN.

MATERIALS AND METHODS

Patients ≥18 years of age undergoing robotic-assisted TE or SPN were included (2008-2020). Baseline demographics and tumor characteristics were compared. Perioperative, renal functional, and oncologic outcomes were assessed for comparative effectiveness.

RESULTS

A total of 467 patients were included with 176 (37.7%) TE and 291 (62.3%) SPN. Baseline characteristics and final histology were comparable; 18% of patients had baseline stage 3 chronic kidney disease. TE had lower median blood loss, operative time, length of stay, and fewer complications compared to SPN. Positive margin rates were higher for TE vs. SPN (8.5% vs. 3.4%, P = 0.04) with similar recurrence rates (2.3% vs. 3.4%, P = 0.48) and no difference in cancer-specific or overall survival with median 4.0 years follow-up. Baseline estimated glomerular filtration rate was comparable (76.1 vs. 78.2, P = 0.63) while renal function in the first year was better preserved with TE (74.6 vs. 68.1, P < 0.001) showing an 8-point estimated glomerular filtration rate (P = 0.001) advantage after adjustment. The rate of stage ≥3 chronic kidney disease by 12 months was lower for TE compared to SPN (21.5% vs. 34.1%, P = 0.006).

CONCLUSIONS

TE is an alternative approach to SPN associated with favorable perioperative and renal functional outcomes. While positive margin rates are higher, longer-term recurrence rates are no different suggesting pseudocapsule disruption during TE has limited impact on oncologic outcomes.

Alternative- and focal therapy trends for prostate cancer: a total population analysis of in-patient treatments in Germany from 2006 to 2019

Purpose

Focal therapy (FT) offers an alternative approach for prostate cancer (PCa) treatment in selected patients. However, little is known on its actual establishment in health care reality.

Patients and methods

We defined FT as high-intensity focused ultrasound (HIFU), hyperthermia ablation, cryotherapy, transurethral ultrasound ablation (TULSA) or vascular-targeted photodynamic therapy (VTP) TOOKAD^®. We analyzed the nationwide German hospital billing database for a PCa diagnosis in combination with FT. For analyses on the hospital level, we used the reimbursement.INFO tool based on hospitals’ quality reports. The study period was 2006 to 2019.

Results

We identified 23,677 cases of FT from 2006 to 2019. Considering all PCa cases with surgery, radiotherapy or FT, the share of FT was stable at 4%. The annual caseload of FT increased to a maximum of 2653 cases in 2008 (p < 0.001) and then decreased to 1182 cases in 2014 (p < 0.001). Since 2015, the cases of FT remained on a plateau around 1400 cases per year. The share of HIFU was stable at 92–96% from 2006 to 2017 and decreased thereafter to 75% in 2019 (p = 0.015). In 2019, VTP-TOOKAD^® increased to 11.5% and TULSA to 6%. In 2006, 21% (62/299) of urological departments performed FT and 20 departments reached > 20 FT procedures. In 2019, 16% (58/368) of urological departments performed FT and 7 departments reached > 20 FT. In 2019, 25 urological departments offered FT other than HIFU: 5 centers hyperthermia ablation, 11 centers VTP TOOKAD^®, 3 centers cryotherapy, 6 centers TULSA.

Conclusion

The FT development in Germany followed the Gartner hype cycle. While HIFU treatment is the most commonly performed FT, the share of newer FT modalities such as VTP-TOOKAD^® and TULSA is remarkably increasing.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-04024-0.

Treatment trends for muscle-invasive bladder cancer in Germany from 2006 to 2019

Purpose

To examine national treatment trends of muscle-invasive bladder cancer (MIBC) in Germany with a special focus on radical cystectomy (RC).

Patients and methods

Population-based data were derived from the nationwide hospital billing database of the German Federal Statistical Office and institution-related information from the reimbursement.INFO tool based on hospitals’ quality reports from 2006 to 2019. Additionally, we used the German National Center for Cancer Registry data to analyze all cases of bladder cancer with stage ≥ T2 who received RC, chemotherapy, radiation therapy or a combination from 2006 to 2017.

Results

The annual number of RC cases in Germany increased by 28% from 5627 cases in 2006 to 7292 cases in 2019 (p = 0.001). The proportion of patients undergoing RC remained constant at about 75% in all age groups between 2006 and 2017 (p = 0.3). Relative to all performed RC, the proportion of patients > 75 years increased from 25% in 2006 to 38% in 2019 (p = 0.03). The proportion of patients receiving a combination of RC and chemotherapy increased from 9% in 2006 to 13% in 2017 (p = 0.005). In 2006, 8 of 299 urology departments (2.7%) performed more than 50 RCs per year, which increased to 17 of 360 (4.7%) in 2019. In 2019, 107 departments (29%) performed 25–49 RCs and 236 (66%) departments performed < 25 RCs.

Conclusion

In Germany, three out of four patients with MIBC receive RC and the proportion of patients > 75 years is increasing. The combination of surgery and chemotherapy is increasingly used. With overall increasing case numbers, there is a slight tendency towards centralization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-022-04017-z.

[Trends in uro-oncological surgery in Germany-comparative analyses from population-based data]

Obwohl urologische maligne Erkrankungen mit etwa 100.000 Neuerkrankungen pro Jahr eine relevante gesundheitsökonomische Aufgabe darstellen, existieren kaum Erkenntnisse über die Struktur und Entwicklung der entsprechenden tumorchirurgischen Eingriffe an den mehr als 400 urologisch-chirurgisch tätigen Kliniken in Deutschland. Somit erfassten wir mittels Datenbankabfrage der DRG-Datenbank („diagnosis related groups“) des statistischen Bundesamtes sämtliche Fälle von 5 großen tumorchirurgischen Eingriffen in Deutschland (Prostatektomie, Zystektomie, Nierentumoroperation, retroperitoneale Lymphadenektomie, penischirurgische Eingriffe) von 2006 bis 2013 (bzw. 2016) und untersuchten die Einflüsse von technischen Neuerungen sowie Leitlinienänderungen auf die Entwicklungen der Fallzahlen. Zudem analysierten wir die Zusammenhänge zwischen jährlicher Fallzahl und perioperativem Ergebnis. Die Ergebnisse zeigten eine deutliche Korrelation zwischen Fallzahlvolumen (und damit Expertise) einer Klinik und einem verbesserten perioperativen Ergebnis. Dennoch existiert kaum Tendenz zur Zentralisierung bei diesen uroonkologischen Eingriffen. Die Fallzahlentwicklungen scheinen vielmehr vom Werbeeffekt durch technische Innovationen oder auch vom regionalen Bezug der Patienten zu einer bestimmten Klinik abhängig zu sein. Zentral gesteuerte Versuche mittels Einführung von Mindestfallzahlen oder der freiwilligen Zertifizierung von Zentren hatten in der Vergangenheit nur geringen Einfluss auf die Fallzahlverteilungen.

[Robot-assisted surgery for renal cell carcinoma - today a standard?]

Twenty years have passed since the first reports on robot-assisted kidney tumor surgery in 2001. However, robotic surgery has not spread to all German urologic departments yet. Hence, one has to question whether robot-assisted kidney tumor surgery can be considered a standard today. Until now, no prospective randomized controlled trials have compared robot-assisted radical nephrectomy with the open or laparoscopic approach. Regardless, laparoscopy and robotics both have proven better perioperative and comparable oncological outcomes than with open nephrectomy. In direct comparison, robot-assisted nephrectomy has no additional benefits over the laparoscopic approach and is less cost-effective. However, reports on robot-assisted level III or IV vena cava tumor thrombectomies illustrate that robotic surgery can be superior to the laparoscopic approach in highly complex interventions. Likewise, no prospective randomized controlled trials have analyzed robot-assisted partial nephrectomy yet. When conducted by experienced surgeons, robotic and laparoscopic partial nephrectomies can also have lower morbidity compared to the open approach. No consensus has been reached when directly comparing robotic and laparoscopic partial nephrectomy. However, evidence is increasing that robot-assisted partial nephrectomy can offer additional benefits, especially for the treatment of highly complex endophytic renal tumors. Thereof, head-to-head comparisons are often impacted by patient- and tumor-related factors, as well as the learning curve of the surgeon, bed-side assistant and the annual caseload of the department. Hence, one has to conclude that robot-assisted kidney tumor surgery has evolved into a standard procedure with good results. The perioperative outcomes of robot-assisted surgery are superior to the open technique at a comparable oncological follow-up. Even if robot-assisted interventions are often more expensive than laparoscopic surgery due to higher costs of acquisition, robotics have the potential to gain superior results especially in very complex tumor surgery. Due to expiring patent protections, new manufacturers and the development of new technologies, the market of robotic surgery will most likely undergo significant changes and its costs will probably decrease within the next years.

The comprehensive complication index (CCI): proposal of a new reporting standard for complications in major urological surgery

PURPOSE

The comprehensive complication index (CCI) is a new tool for reporting the cumulative burden of postoperative complications on a continuous scale. This study validates the CCI for urological surgery and its benefits over the Clavien-Dindo-Classification (Clavien).

MATERIAL AND METHODS

Data from a prospectively maintained data base of all consecutive patients at a university care-center was analyzed. Complications after radical cystectomy (RC), radical prostatectomy (RP), and partial nephrectomy (PN) were classified using the CCI and Clavien system. Differences in complications between the CCI and the Clavien were assessed and correlation analyses performed. Sample size calculations for hypothetical clinical trials were compared between CCI and Clavien to evaluate whether the CCI would reduce the number of required patients in a clinical trial.

RESULTS

682 patients (172 RC, 297 RP, 213 PN) were analyzed. Overall, 9.4-46.6% of patients had > 1 complication cumulatively assessed with the CCI resulting in an upgrading in the Clavien classification for 2.4-32.4% of patients. Therefore, scores between the systems differed for RC: CCI (mean ± standard deviation) 26.3 ± 20.8 vs. Clavien 20.4 ± 16.7, p < 0.001; PN: CCI 8.4 ± 14.7 vs. Clavien 7.0 ± 11.8, p < 0.001 and RP: CCI 5.8 ± 11.7 vs. Clavien 5.3 ± 10.6, p = 0.102. The CCI was more accurate in predicting LOS after RC than Clavien (p < 0.001). Sample size calculations based in the CCI (for future hypothetical trials) resulted in a reduction of required patients for all procedures (- 25% RC, - 74% PN, - 80% RP).

CONCLUSION

The CCI is more accurate to assess surgical complications and reduces required sample sizes that will facilitate the conduction of clinical trials.