Robotic versus Laparoscopic Partial Nephrectomy in the New Era: Systematic Review

Nephrectomies in Saudi Arabia: A Comprehensive Analysis of Outcomes from a High-Volume Minimally Invasive Surgery Center

Literature reporting on the outcomes of the different procedures of nephrectomies (open vs laparoscopic vs robotic) in Saudi Arabia remains limited. Compare surgical and oncological outcomes between open and minimally invasive nephrectomies. A retrospective cohort study. The present study included all adult patients who underwent nephrectomies between January 1, 2015 and January 31, 2023. We collected demographic, preoperative, intraoperative, and postoperative data on 408 adult cancer patients who underwent nephrectomies at our center between January 2015 and January 2023. Statistical differences were calculated between procedure types. Overall survival was calculated using Kaplan-Meier curves with log-rank tests. P<0.05 was considered statistically significant. Measures of operative success (intraoperative blood loss, intraoperative and postoperative complications, and hospital stay) and oncological outcomes (local recurrence, metastatic progression, and chemotherapy use) between different procedure and nephrectomy types for cancer patients. A total of 408 cancer patients underwent nephrectomies. In cancer patients, open nephrectomy was associated with significantly higher intraoperative blood loss (p<0.001), incidence of blood transfusions (p<0.001), hospital stay (p<0.001), intraoperative complications (p=0.027 and p=0.001, respectively), local recurrence (p<0.001), metastatic progression (p=0.001), and chemotherapy (p=0.001) than minimally invasive surgery, but survival differences across procedure types were not statistically significant (log-rank p-value = 0.054). Regarding nephrectomy type, significant differences were observed in tumor size (p < 0.001), initial procedure type (p<0.001), operation time (p<0.001), blood transfusion (p=0.033), length of hospital stay (p=0.004), intraoperative complications (p=0.020), postoperative complications (p=0.025), Clavien classification (p=0.003), mortality (p=0.022), metastatic progression (p<0.001), and chemotherapy use (p=0.001) between simple/total nephrectomy, radical nephrectomy (RN), partial nephrectomy (PN), and nephroureterectomy. Survival differences between the four nephrectomy types were statistically significant (log-rank p value = 0.001). Minimally invasive nephrectomies reduce inpatient morbidity while conferring equivalent oncological and surgical outcomes.

Minimising warm ischaemia time during robot-assisted partial nephrectomy. A video-based assessment of tumour excision, kidney reconstruction and intermediate time

INTRODUCTION

Surgical video review is an emerging tool for assessing patient outcomes, especially in complex surgeries such as robot-assisted partial nephrectomy (RAPN). Assessing and measuring warm ischaemia time (WIT) during RAPN by dividing it into the time used for tumour excision time (ExcT), time used for kidney reconstruction time (RecT) and intermediate time (IntT) has not been performed before. This study aimed to analyse the factors that can influence all surgical times and assess their impact on positive surgical margins (PSMs) and complication rates.

METHODS

We evaluated 32 surgical video recordings from patients undergoing RAPN and measured WIT, ExcT, RecT and IntT with a stopwatch. Factors such as tumour characteristics and surgeon experience were also recorded. SPSS software was used to identify the predictors for all surgical times and to correlate ExcT with PSM and RecT with complication rate.

RESULTS

We recorded a median WIT of 1,048 s (17 min and 28 s). The median of ExcT, RecT and IntT was 398 s (37.1% of WIT), 518 s (46.7% of WIT) and 180 s (16.2% of WIT), respectively. We found a significant correlation (P < 0.001) between R.E.N.A.L. score and all surgical times. No correlation was found between ExcT and PSM (P = 0.488) and between RecT and the probability of developing complications (P = 0.544).

CONCLUSION

Tumour morphology influences all surgical times, and surgeon experience influences only ExcT. We observed a short RecT during RAPN though at the cost of increased ExcT, and we believe that improving surgical experience, especially for the excision of more complex tumours, can reduce WIT during RAPN.

Da Vinci and Hugo RAS Platforms for robot-assisted partial nephrectomy: a preliminary prospective comparative analysis of the outcomes

BACKGROUND

Robot-assisted partial nephrectomy (RAPN) has emerged as the preferred approach for T1 renal-cell-carcinoma. As new robotic platforms like Hugo RAS emerge, we seek to understand their potential in achieving similar RAPN outcomes as the established Da Vinci system.

METHODS

A prospective single-center comparative study was conducted, and 50 patients selected for RAPN were enrolled (25 Da Vinci Xi; 25 Hugo RAS). The choice of robotic system was based solely on hospital logistics criteria. Surgeries were performed by expert surgeons. Demographic data, tumor characteristics, operative details and postoperative outcomes were collected. SPSS version 22.0 was used for statistical analyses.

RESULTS

The average age of patients was 62.52±9.47 years, with no significant differences in median age, sex, and nephrometry scores between groups. Da Vinci group showed a significantly shorter docking time (12.56 vs. 20.08 min; P<0.01), while other intraoperative measures like console time and warm ischemia time were similar. The Hugo RAS group had a shorter renorraphy time (14.33 vs. 18.84 min; P=0.024). Postoperative outcomes and surgical margin positivity showed no significant differences. Each group had one patient (4%) who developed major surgical complications (Clavien IIIa). Trifecta rates were comparable between both groups (Da Vinci 88% vs. Hugo RAS 84%; P=0.93).

CONCLUSIONS

Initial findings suggest similar perioperative outcomes for RAPN when using Hugo RAS compared to the Da Vinci system. Further research with long-term follow-up is necessary to evaluate oncological and functional outcomes.

Renal anatomical classification systems cannot predict the occurrence of vascular complications after partial nephrectomy

OBJECTIVES

To determine the relationship between renal tumor complexity and vascular complications after partial nephrectomy using PADUA, RENAL, and ZS scores.

METHODS

Between January 2007 and December 2018, a total of 1917 patients with available cross-sectional imaging were enrolled in the study. Logistic regressions were used to identify independent predictors of vascular complications.

RESULTS

Of 1917 patients, 31 (1.6%) developed vascular complications, including 10 females and 21 males. The high-complexity category was significantly associated with a decreased risk of vascular complication in PADUA (OR = 0.256; 95%CI = 0.086-0.762; P = 0.014) and ZS score (OR = 0.279; 95%CI = 0.083-0.946; P = 0.040). Laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy were independent risk factors for vascular complications. Meanwhile, the incidence was significantly reduced in the recent 4 years in the high score tumor group alone in PADUA (0.2% [1/474] vs. 2.2% [3/139], P = 0.038) and ZS score (0.2% [1/469] vs. 2.7% [3/112], P = 0.024). In the first 8 years, laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy were the only two independent risk factors for vascular complications. In the recent 4 years, only the high-complexity category was significantly associated with a decreased risk of vascular complication in the PADUA score (OR = 0.110; 95%CI = 0.013-0.938; P = 0.044).

CONCLUSION

The renal anatomic classification system cannot predict the occurrence of vascular complications after partial nephrectomy.

Surgical Phase Duration in Robot-Assisted Partial Nephrectomy: A Surgical Data Science Exploration for Clinical Relevance

(1) Background: Surgical phases form the basic building blocks for surgical skill assessment, feedback, and teaching. The phase duration itself and its correlation with clinical parameters at diagnosis have not yet been investigated. Novel commercial platforms provide phase indications but have not been assessed for accuracy yet. (2) Methods: We assessed 100 robot-assisted partial nephrectomy videos for phase durations based on previously defined proficiency metrics. We developed an annotation framework and subsequently compared our annotations to an existing commercial solution (Touch Surgery, Medtronic™). We subsequently explored clinical correlations between phase durations and parameters derived from diagnosis and treatment. (3) Results: An objective and uniform phase assessment requires precise definitions derived from an iterative revision process. A comparison to a commercial solution shows large differences in definitions across phases. BMI and the duration of renal tumor identification are positively correlated, as are tumor complexity and both tumor excision and renorrhaphy duration. (4) Conclusions: The surgical phase duration can be correlated with certain clinical outcomes. Further research should investigate whether the retrieved correlations are also clinically meaningful. This requires an increase in dataset sizes and facilitation through intelligent computer vision algorithms. Commercial platforms can facilitate this dataset expansion and help unlock the full potential, provided that the phase annotation details are disclosed.

A Literature Review of Perioperative Outcomes of Robotic Radical Nephrectomy (RRN) Versus Laparoscopic Radical Nephrectomy (LRN) for Renal Cell Carcinoma (RCC)

Renal cell carcinoma (RCC) is an adenocarcinoma of the renal cortex. Radical nephrectomy remains the standard of care for managing massive renal tumours. Robotic-assisted radical nephrectomy is an increasing alternative technique to laparoscopic radical nephrectomy (LRN). The da Vinci Surgical System allows for improved dexterity, increased visualisation, tremor filtration and an ergonomic setting to enhance surgeon comfort. The aim was to compare the perioperative outcomes pertaining to operative time, intraoperative complications, blood loss and length of hospital stay between the robotic and LRN for RCC. Studies that compared the perioperative findings between robotic radical nephrectomy (RNN) and LRN for RCC were included. The literature review was carried out according to the Cochrane collaboration standards where applicable. Highly sensitive search strategies like MeSH terms and controlled vocabularies were used to identify relevant studies that compare the RNN outcomes to the LRN. Following the literature search, a total of 73 articles were collected, 60 articles were excluded at the stage of reviewing the titles, eight articles were excluded after reading the abstracts, and five articles were included in this paper. Five studies were included in this analysis, with a total sample size of 1770 patients, 735 were in the robotic arm, and 1035 were in the laparoscopic arm. Generally, there were no differences between both arms in terms of demographic data and age of patients. Closer analysis of the perioperative outcomes did not reveal significant differences between the two groups related to the estimated blood loss, length of hospital stay or post-operative complications. The laparoscopic techniques have less operative time than the robotic ones. RRN is an expanding approach for patients with RCC with some potential technical benefits over laparoscopic ones. RRN is similar to LRN in the perioperative outcomes, with few potential drawbacks of RRN, including higher costs. However, a prospective comparison of RRN with LRN in many cases at multiple centres with long-term oncological results best illustrates the status of RRN versus LRN.