Role Of Robot-Assisted Partial Nephrectomy For Renal Cell Carcinomas In The Purpose Of Nephron Sparing

Robot-assisted versus conventional laparoscopic partial nephrectomy for renal hilar tumors: Parenchymal preservation and functional recovery

OBJECTIVE

To determine whether robot-assisted laparoscopic partial nephrectomy (RALPN) can benefit patients in terms of functional recovery in the treatment of renal hilar tumors compared to conventional laparoscopic partial nephrectomy (CLPN).

METHODS

Between January 2019 and July 2021, patients with hilar tumors who underwent partial nephrectomy (PN) were acquired at our center and were classified into RALPN and CLPN groups. Ipsilateral parenchymal volume (IPV) and glomerular filtration rate (GFR) were determined independently 3-5 days before and 3 months after PN using contrast-enhanced computed tomography and nuclear renal scans. Pearson correlation was used to determine the link between ipsilateral GFR preservation and IPV preserved. Concurrently, multivariable analysis was employed to determine characteristics associated with functional recovery.

RESULTS

A total of 96 patients with hilar tumors were studied, of which 41 received RALPN and 55 received CLPN. Excisional parenchymal volume was 27 and 37 cm³ (p = 0.005) in RALPN and CLPN groups, respectively, and IPV preserved was 77% and 68% (p < 0.001). Furthermore, the ipsilateral GFR preserved was 77.7% and 75.3%, respectively (p = 0.003). On Pearson correlation, ipsilateral GFR preservation was linked with IPV preserved (r = 0.36, p < 0.001). According to a multivariate study, baseline GFR, IPV preserved, and surgical procedures (RALPN vs. CLPN) were significant factors influencing functional recovery.

CONCLUSION

Our study suggests that RALPN, rather than CLPN, can achieve better functional recovery in the treatment of hilar tumors due to its ability to win more IPV preserved. RALPN should be recommended as the first-line treatment for hilar tumors, but randomized controlled trials are required to validate our findings.

Mixed Reality: A Step Further for Planning Complex Renal Tumors(RENAL nephrometry score of 7 or higher)

OBJECTIVES

Mixed reality (MR) technology has emerged in recent years and allows three-dimensional visualization, multi-angle observation, remote vision, and virtual-real interaction. This study aims to explore the influence of MR technology on the outcomes and strategy planning of robotic surgery for complex renal tumors.

PATIENTS AND METHODS

A total of 92 patients with complex renal tumors were enrolled in this study from June 2018 to June 2020. All patients were diagnosed in our department by magnetic resonance imaging（MRI）. This trial follows CONSORT guidelines and adopts a parallel single blind design and randomizes patients with a random number table. The study was approved by the institutional review board, and written informed consent was obtained from each participant. All surgeries were performed by 3 experienced and high-volume surgeons. The demographic indicators, intraoperative and postoperative complications, renal function outcomes, pathological results, and surgical strategies were recorded. Student's t-test and Wilcoxon rank-sum were used to compare continuous variables, and Pearson's chi-squared and Fisher's exact tests were used to compare categorical variables.

RESULTS

WIT is mainly composed of tumor resection time and reconstruction time, and the reconstruction time accounts for a larger proportion. For urologists treating complex renal tumors, MR technology can help them reduce warm ischemia time (21.3±4.0 vs 23.6±5.9min, P=0.031), reconstruction time (15.4±3.8 vs 17.2±4.2min, P=0.034), estimated blood loss (P=0.044), operation time (125.7±26.3 vs 144.6±27.9min, P=0.001) and intraoperative complications (P=0.030).

CONCLUSIONS

MR assisted surgery can reduce the incidence of intraoperative complications, improve perioperative outcomes, which may be a good preoperative tool for planning complex renal tumors.

Parenchymal Mass Loss During Partial Nephrectomy: Role of Devascularized Parenchymal Mass and Excised Parenchymal Mass and Impact on Functional Preservation

This study included 93 patients with renal masses who underwent standard partial nephrectomy or tumor enucleation. After surgery, parenchymal mass loss caused by devascularization resulted in more damage to renal function than excised parenchymal mass loss. Surgeons should seek better techniques to decrease devascularization during reconstruction.

INTRODUCTION

To evaluate the importance of devascularized parenchymal mass(DPM) and excised parenchymal mass(EPM) in functional preservation after standard partial nephrectomy(SPN).

PATIENTS AND METHODS

Forty-one patients who underwent pure tumor enucleation(TE) and 52 patients who underwent SPN with necessary data were included. As no EPM was lost in TE, the TE samples were used to estimate the degree of volume shrinkage that occurred when the measurements were performed in vivo with blood flow versus ex vivo without, and the shrinkage ratio was calculated as specimen volume divided by tumor volume in vivo. In SPN, the specimen volume comprised tumor volume plus EPM. The EPM was calculated as specimen volume divided by shrinkage ratio minus tumor volume in vivo. The DPM was defined as total ipsilateral parenchymal mass loss minus EPM. T tests, χ² test, and Mann-Whitney U tests were employed to compare clinical characteristics. Multivariate analysis was used to identify variables that correlated with glomerular filtration rate(GFR) preservation.

RESULTS

The mean sizes of devascularized and excised parenchymal masses were 13.6 cm³ and 5.2 cm³ (P = .01), which accounted for 7.8% and 3.4% of preoperative ipsilateral parenchymal mass (P = .03) in SPN, respectively. The shrinkage ratio was 0.71 and correlation coefficient was 0.965. After stepwise regression, DPM, and preoperative GFR were significantly associated with global GFR preservation.

CONCLUSION

The DPM comprises most of parenchymal mass loss after SPN and plays a more important role than EPM on functional outcomes. Surgeons should pay more attention to reducing devascularization during partial nephrectomy.

The efficacy evaluation of partial nephrectomy with selective renal artery branch occlusion by laparoscopy

BACKGROUND

To investigate the clinical application and effect of laparoscopic partial nephrectomy with renal artery branch occlusion in the treatment of early renal tumors.

METHODS

A retrospective analysis was conducted on the clinical data of 15 cases of renal tumor patients who underwent partial nephrectomy by laparoscopic selective renal artery branch occlusion in our department from January 2017 to January 2018. Nine male patients and 6 female patients were aged 46 to 65 years, with an average age of 54.3 ± 7.2 years. The diameters of tumors were 2.2 to 4.0 cm, with an average of 3.3 ± 0.7 cm. There are 10 tumors locating on the left side and 5 on the right side. Preoperative renal glomerular filtration rate (GFR) were 77.3 to 61.9 mL/min with an average of 47.6 ± 7.5 mL/min. All patients' diseased kidneys underwent renal computer tomography angiography examination before surgery. And the diseased kidney underwent reexamination of renal GFR. The operation time, renal artery branch occlusion time, intraoperative blood loss, postoperative hospital stay, changes of renal function, and complications were evaluated.

RESULTS

All surgery were completed successfully, the surgery time was 136.7 ± 15.2 min, intraoperative renal artery branch occlusion time was 21.3 ± 4.5 min, the intraoperative blood loss was 223.3 ± 69.5 mL, the postoperative hospital stay was 6.5 ± 1.7 days, and the postoperative 1-month GFR was 49.5 ± 6.6 mL/min. There was no significant difference between the renal GFR before and after surgery (P > .05). There was no blood transfusion and transfer open surgery cases. The patients were followed up for 3 to 15 months without complications.

CONCLUSIONS

Partial nephrectomy with selective renal artery branch occlusion by laparoscopy is a safe, feasible, and effective method for the treatment of early renal cancer. It makes good use of the technical advantages of clear operation field and fine operation of laparoscopic surgery, avoids the heat ischemia process of the whole kidney, and can better protect the renal function.

Elective partial and radical nephrectomy in patients with renal cell carcinoma in CT1B stadium

Background/Aim. In renal cell carcinoma (RCC) the choice of surgical technique, radical (RN) or partial nephrectomy (PN) is still centre dependant because there still are no absolute recommendations for this approach. This study aims to analyze the oncological aspects, time until recurrent disease appears and cancer-specific survival in patients with RCC in T1bN0?0 depending on the type of surgical procedure partial or radical nephrectomy. Methods. A clinical observational study of a series of cases was conducted that analyzed data of 154 patients operated in our institution with a mean follow up a period not less than five years. The inclusion criteria included: renal tumours 4-7 cm, histopathological confirmation of RCC, absence of metastasis and normal serum creatinine. Exclusion criteria included: the presence of other malignancies, solitary functional kidney or comorbidities that can compromise renal function, bilateral tumours or unilateral multiple tumours. Results. The study analyzed data of 154 patients, 97 radical nephrectomies and 57 patients that underwent partial nephrectomy. Analyzing cancer-specific survival in four patients with RN there was a disease advancement that led to a lethal outcome, one PN patient died as a result of local relapse and distant metastasis. Conclusion. Based on our results PN is a good and safe treatment option for patients with RCC in T1b stadium. Partial nephrectomy offers a similar tumour control and better cancer-specific survival.

The clinical application value of mixed-reality-assisted surgical navigation for laparoscopic nephrectomy

Purpose

Laparoscopic nephrectomy (LN) has become the preferred method for renal cell carcinoma (RCC). Adequate preoperative assessment or intraoperative navigation is key to the successful implementation of LN. The aim of this study was to evaluate the clinical application value of mixed‐reality–assisted surgical navigation (MRASN) in LN.

Patients and Methods

A total of 100 patients with stage T1N0M0 renal tumors who underwent laparoscopic partial nephrectomy (LPN) or laparoscopic radical nephrectomy (LRN) were prospectively enrolled and divided into a mixed‐reality‐assisted laparoscopic nephrectomy (MRALN) group (n = 50) and a non–mixed‐reality‐assisted laparoscopic nephrectomy (non‐MRALN) group (n = 50). All patients underwent renal contrast‐enhanced CT scans. The CT DICOM data of all patients in the MRALN group were imported into the mixed‐reality (MR) postprocessing workstation and underwent holographic three‐dimensional visualization (V3D) modeling and MR displayed, respectively. We adopted the Likert scale to evaluate the clinical application value of MRASN. The consistency of evaluators was assessed using the Cohen kappa coefficient (k).

Results

No significant differences in patient demographic indicators between the MRALN group and the non‐MRALN group (P > .05). The subjective score of MRASN clinical application value in operative plan formulation, intraoperative navigation, remote consultation, teaching guidance, and doctor‐patient communication were higher in the MRASN group than in the non‐MRASN group (all P < .001). There were significantly more patients for whom LPN was successfully implemented in the MRALN group than in the non‐MRALN group (82% vs 46%, P < .001). The MRALN group had a shorter operative time (OT) and warm ischemia time (WIT) and less estimated blood loss (EBL) than the non‐MRALN group (all P < .001).

Conclusion

MRASN is helpful for operative plan formulation, intraoperative navigation, remote consultation, teaching guidance, and doctor‐patient communication. MRALN may effectively improve the successful implementation rate of LPN and reduce the OT, WIT, and EBL.