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.

An Incidental Diagnosis of Extraosseous Ewing's Sarcoma in the Kidney

Ewing's sarcoma is generally observed in the skeletal and connective tissues of paediatric individuals. The occurrence of extraosseous neuroectodermal tumours is uncommon. Renal Ewing's sarcoma usually presents with flank pain, haematuria, or as an abdominal mass. Immunohistochemistry and fluorescence in situ hybridization (FISH) techniques are essential in its diagnosis and differentiation from other tumours. We present asymptomatic renal Ewing's sarcoma in a 19-year-old female patient who was diagnosed incidentally, and the CT scan confirmed a 2.8 cm left mid-pole renal mass suggestive of malignancy. She was managed with a robotic partial nephrectomy. Tumour immunohistochemistry and the FISH technique confirmed the diagnosis of Ewing's sarcoma. The patient made an uneventful recovery and was referred for chemotherapy. This case report illustrates that despite the aggressiveness of the tumour, it can be detected earlier despite an asymptomatic presentation and be successfully treated with nephron-sparing surgery and chemotherapy.

How many cases are required to achieving early proficiency in purely off-clamp robot-assisted partial nephrectomy?

Background and purpose

Off-clamp robot-assisted partial nephrectomy (Offc-RAPN) is a technically challenging procedure that can effectively avoid renal ischemia owing to the absence of hilar vessel preparation and clamping. However, data on the learning curve (LC) for this technique are limited. The purpose of this study was to assess the LC of Offc-RAPN and compare the perioperative outcomes between different learning phases.

Methods

This retrospective study included 50 consecutive patients who underwent purely Offc-RAPN between January 2022 and April 2023. Multidimensional cumulative sum (CUSUM) analysis method was used to assess LC. Spearman's correlation and LOWESS analysis were performed to analyze the continuous variables of perioperative outcomes. Baseline characteristics and perioperative outcomes were compared using χ2-test, t-test and U-test.

Results

CUSUM analysis identified two LC phases: phase I (the first 24 cases) and phase II (the subsequent 26 cases). Phase II showed significant reductions in mean operative time (133.5 vs. 115.31 min; p = 0.04), mean console time (103.21 vs. 81.27 min; p = 0.01), and mean postoperative length of stay (5.33 vs. 4.30 days; p = 0.04) compared to phase I. However, no significant differences were observed in other perioperative outcomes or baseline characteristics between the two LC phases.

Conclusions

Offc-RAPN performed by a surgeon with experience in laparoscopic and robotic surgeries achieved early proficiency in 24 cases. Moreover, Offc-RAPN alone is safe and feasible even in the initial phase of the LC for an experienced surgeon.

Can the Abdominal Aortic Atherosclerotic Plaque Index Predict Functional Outcomes after Robot-Assisted Partial Nephrectomy?

This study aims to evaluate the abdominal aortic atherosclerotic plaque index (API)'s predictive role in patients with pre-operatively or post-operatively developed chronic kidney disease (CKD) treated with robot-assisted partial nephrectomy (RAPN) for renal cell carcinoma (RCC). One hundred and eighty-three patients (134 with no pre- and post-operative CKD (no CKD) and 49 with persistent or post-operative CKD development (post-op CKD)) who underwent RAPN between January 2019 and January 2022 were deemed eligible for the analysis. The API was calculated using dedicated software by assessing the ratio between the CT scan atherosclerotic plaque volume and the abdominal aortic volume. The ROC regression model demonstrated the influence of API on CKD development, with an increasing effect according to its value (coefficient 0.13; 95% CI 0.04-0.23; p = 0.006). The Model 1 multivariable analysis of the predictors of post-op CKD found that the following are independently associated with post-op CKD: Charlson Comorbidity Index (OR 1.31; p = 0.01), last follow-up (FU) Δ%eGFR (OR 0.95; p < 0.01), and API ≥ 10 (OR 25.4; p = 0.01). Model 2 showed API ≥ 10 as the only factor associated with CKD development (OR 25.2; p = 0.04). The median follow-up was 22 months. Our results demonstrate API to be a strong predictor of post-operative CKD, allowing the surgeon to tailor the best treatment for each patient, especially in those who might be at higher risk of CKD.

Does tumor rupture during robot-assisted partial nephrectomy have an impact on mid-term tumor recurrences?

BACKGROUND

Intraoperative kidney tumor rupture (TR) can occur during robot-assisted partial nephrectomy (RAPN) in daily clinical practice, but there are no solid guidelines on the management and implications of it. The purpose of the study was to investigate the impact of TR on tumor recurrences, what a surgeon should do if this adverse event occurs, and how to avoid it.

PATIENTS AND METHODS

We retrospectively analyzed the first 100 patients who underwent RAPN at University Medical Centre Ljubljana, between 2018 and 2021. Patients were stratified into 2 groups (TR and no-TR) and were compared according to patient, tumor, pathologic, perioperative and postoperative characteristics and tumor recurrences, using the Mann-Whitney U test and chi-squared test.

RESULTS

Of the 100 patients, 14 had TR (14%); this occurred in tumors with higher RENAL nephrometry scores (P = 0.028) and mostly with papillary renal cell carcinomas (P = 0.043). Median warm ischemia time was longer for the TR group (22 vs. 15 min, P = 0.026). In terms of studied outcomes, there were no cases of local or distant recurrence after a median observation time of 39 months (interquartile range, 31-47 months) in both groups. We observed positive surgical margins on the final oncologic report in one case in the no-TR group.

CONCLUSIONS

Tumor rupture during RAPN seems to be of no mid-term oncologic importance. According to presented results, we would recommend surgeons to proceed with tumor resection if this event occurs and abstain from conversion to radical nephrectomy or open partial nephrectomy. However, more similar cases should be studied to make more solid conclusions.

Off-clamp robotic-assisted partial nephrectomy: surgical experience from a single centre

Introduction

Robot-assisted partial nephrectomy (RAPN) is a minimally invasive treatment for localized renal tumours, which can sometimes result in extended warm ischaemic time and serious complications. This study reports on surgical outcomes including feasibility, positive margins, and complications during and after surgery.

Material and methods

From January 2011 to November 2022, a single centre performed off-clamp sutureless RAPN on 287 patients. The study recorded preoperative patient characteristics, estimated glomerular filtration rate, and tumour features according to the preoperative aspects and dimensions used for an anatomical (PADUA) classification, and utilized the RENAL nephrometry scoring system. Intraoperative details and complications were documented. Postoperative complications within 30 days were classified according to the Clavien-Dindo system. Follow-up appointments were scheduled at 1, 3, and 6 months in the first year, followed by subsequent appointments every 6 months, and then annually.

Results

The study included 145 males and 142 females, with a mean age of 58.9 years and a mean body mass index of 26.7 kg/m². The mean PADUA score was 8.3, the average console time was 83 minutes, and the estimated blood loss was 280 mL. The average hospital stay was 3 days, and no intraoperative complications were observed. However, 4 patients (1.4%) experienced post-operative haemorrhage that required laparotomy (Clavien-Dindo stage IIIB), and 4 patients (1.4%) had positive surgical margins.

Conclusions

Off-clamp selective arterial clamping during minimally invasive partial nephrectomy is a safe and feasible approach for small renal tumours. Further randomized prospective studies are required to confirm if RAPN without clamping offers any renal functional benefits and reduces perioperative bleeding complications.

Analysis of trifecta outcomes in a single center with robot-assisted partial nephrectomy for T1b renal tumors

INTRODUCTION

This study was performed to investigate the preoperative factors associated with difficulty achieving trifecta in robot-assisted partial nephrectomy for clinical T1b renal cell carcinoma.

METHODS

Among 187 patients who underwent robot-assisted partial nephrectomy at our hospital from March 2012 to February 2022, we retrospectively examined 30 patients with unilateral single clinical T1b renal cell carcinoma with at least 6 months of postoperative follow-up, excluding patients with hereditary disease. The following factors were examined in detail: patient-related factors, perioperative factors, surgical techniques, tumor factors, and R.E.N.A.L. nephrometry scores. We examined the preoperative factors associated with difficulty achieving trifecta. A positive surgical margin was pathologically defined as the presence of tumor cells at the margin of the resected specimen or visually defined as intraoperative tumor incision or pseudocapsular damage.

RESULTS

Of the 30 patients in this study, 12 achieved trifecta and 18 did not. The reasons for not achieving trifecta were a warm ischemia time of >25 min (66.7%), positive surgical margin (23.3%), and Clavien-Dindo grade ≥3 complications (13.3%) (with overlapping factors). No patients had a pathologically positive surgical margin. Visually positive surgical margins were confirmed by the surgical records and surgical videos. Achieving trifecta was challenging in the multivariate analysis when the "L" component of the R.E.N.A.L. nephrometry score was ≥2 points.

CONCLUSION

A preoperative "L" component of ≥2 points in the R.E.N.A.L. nephrometry score was associated with difficulty achieving trifecta.

Percutaneous Ablation vs Robot-Assisted Partial Nephrectomy for Completely Endophytic Renal Masses: A Multicenter Trifecta Analysis with a Minimum 3-Year Follow-Up

Purpose: To compare outcomes of robot-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses. Methods: Data of patients who underwent RAPN or PTA for treatment of completely endophytic (three points for "E" domain of R.E.N.A.L. score) were collected from seven high-volume U.S. and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Meier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment "quality." Multivariable logistic regression model assessed predictors of trifecta failure. Results: One hundred fifty-two patients (RAPN, n = 60; PTA, n = 92) were included in the analysis. RAPN group was younger (p < 0.001), had lower American Society of Anesthesiologists score (p = 0.002), and higher baseline estimated glomerular filtration rate (p < 0.001). There was no difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (p < 0.001) and minor (p < 0.001) complications. ΔeGFR at 1 year was statistically higher for RAPN (-15.5 mL/min vs -3.1 mL/min; p = 0.005), no difference in ΔeGFR at last follow-up (p = 0.22) was observed. No difference in recurrences (RAPN, n = 2; PTA, n = 6) and RFS was found (p = 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3% vs 58.8%; p = 0.477). R.E.N.A.L. Nephrometry Score resulted predictive of trifecta failure (odds ratio = 1.47; confidence interval = 1.13-1.90; p = 0.004). Conclusions: PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications and good mid-term functional and oncologic outcomes. These outcomes compare favorably with those of RAPN, which seem to be the preferred option for younger and less comorbid patients.

Perioperative, oncologic, and functional outcomes of robot-assisted partial nephrectomy for special types of renal tumors (hilar, endophytic, or cystic): an evidence-based analysis of comparative outcomes

Purpose

This study aims to perform a pooled analysis to compare the outcomes of robot-assisted partial nephrectomy (RAPN) between complex tumors (hilar, endophytic, or cystic) and non-complex tumors (nonhilar, exophytic, or solid) and evaluate the effects of renal tumor complexity on outcomes in patients undergoing RAPN.

Methods

Four databases were systematically searched, including Science, PubMed, Web of Science, and Cochrane Library, to identify relevant studies published in English up to December 2022. Review Manager 5.4 was used for statistical analyses and calculations. The study was registered with PROSPERO (Registration number: CRD42023394792).

Results

In total, 14 comparative trials, including 3758 patients were enrolled. Compared to non-complex tumors, complex tumors were associated with a significantly longer warm ischemia time (WMD 3.67 min, 95% CI 1.78, 5.57; p = 0.0001), more blood loss (WMD 22.84 mL, 95% CI 2.31, 43.37; p = 0.03), and a higher rate of major complications (OR 2.35, 95% CI 1.50, 3.67; p = 0.0002). However, no statistically significant differences were found between the two groups in operative time, length of stay, transfusion rates, conversion to open nephrectomy and radical nephrectomy rates, estimated glomerular filtration rate (eGFR) decline, intraoperative complication, overall complication, positive surgical margins (PSM), local recurrence, and trifecta achievement.

Conclusions

RAPN can be a safe and effective procedure for complex tumors (hilar, endophytic, or cystic) and provides comparable functional and oncologic outcomes to non-complex tumors.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=394792, identifier CRD42023394792.

Identification of predictive factors for outcomes after robot-assisted partial nephrectomy based on three-dimensional reconstruction of preoperative enhanced computerized tomography

Background

Information from the RENAL score is limited. This study aimed to identify new parameters based on three-dimensional (3D) reconstruction of preoperative enhanced computerized tomography (CT) for predicting outcomes after robot-assisted partial nephrectomy (RPN).

Materials and methods

The records of kidney cancer patients who underwent RPN at Tongji Hospital from March 2015 to July 2019 were reviewed. Demographic data, laboratory examinations, postoperative hospitalization time, and enhanced CT were retrospectively collected. Some tumor parameters were obtained from 3D reconstruction of CT data. The association between these predictive factors and outcomes after RPN was analyzed.

Results

A larger tumor bed area (TBA) was associated with a longer warm ischemia time (WIT) (P-value <0.001) and tumor resection time (P-value <0.001). Moreover, TBA was significantly associated with the elevation of postoperative creatinine (P-value = 0.005). TBA (P = 0.008), distance from the tumor to the first bifurcation of the renal artery (DTA) (P <0.034), and RENAL score (P = 0.005) were significantly associated with WIT in univariate logistic regression. In multivariate logistic regression, TBA (P = 0.026) and DTA (P = 0.048) were independent risk factors for prolonged WIT (over 25 min). The predictive effect of the combination of TBA, DTA, and RENAL score was higher than the predictive effect of RENAL score alone for WIT (area under curve: 0.786 versus 0.72).

Conclusion

TBA and DTA are independently associated with the WIT of RPN, which provides additional assessment value for the complexity of kidney cancer in RPN over the RENAL score.

Comparison of Clinical Outcomes between Robot-Assisted Partial Nephrectomy and Cryoablation in Elderly Patients with Renal Cancer

Advances in imaging technologies have increased the opportunities for treating small-diameter renal cell carcinomas (RCCs) in the elderly. This retrospective study based on real-world clinical practice compared perioperative complications, preoperative and postoperative renal function, recurrence-free survival, and overall survival in elderly patients with RCC who had undergone robot-assisted partial nephrectomy (RAPN) or percutaneous cryoablation (PCA). A total of 99 patients (aged ≥70 years), including 50 and 49 patients in the RAPN and PCA groups, respectively, were analyzed. In the entire cohort, Clavien-Dindo grade ≥3 complications occurred in only one patient who had undergone RAPN. Renal function was significantly lower in the postoperative period than in the preoperative period in both the RAPN and PCA groups. The recurrence-free survival and overall survival rates were worse in the PCA group than in the RAPN group, albeit not significantly. RAPN was considered a safe and effective method for treating RCCs in elderly patients. Moreover, although the recurrence rate was slightly higher in the PCA group than in the RAPN group, PCA was deemed to be a safe alternative, especially for treating patients in whom general anesthesia poses a high risk.

Purely Off-Clamp Partial Nephrectomy: Robotic Approach Better than Open Using a Pentafecta Outcome with Propensity Score Matching

Partial nephrectomy (PN) is the gold standard treatment for localized renal masses. Robot-assisted PN (RAPN) has overcome laparoscopy’s technical limitations, greatly expanding the indications of minimally invasive PN, which is dominated by renal artery clamping in almost all published series. We compared off-clamp RAPN (OFFC-RAPN) with the open approach (OFFC-OPN) using propensity score (PS) matching. A favourable pentafecta outcome was defined as a combination of no positive surgical margins (PSM), no complications of Clavien−Dindo (CD) grade ≥ 3, post-operative eGFR loss <10%, length of hospital stay (LOS) ≤ 5 days and estimated blood loss (EBL) < 200 mL. A total of 340 consecutive patients were included. The PS-matched cohort included 142 patients: 71 matched pairs well-balanced for all covariates. The OFFC-RAPN group showed significantly shorter operative time (149.8 vs. 173.9 min, p = 0.003), lower EBL (182.1 vs. 329.3 mL, p = 0.001), and shorter LOS (5.8 vs. 6.9 days, p = 0.02), with a higher proportion of patients with LOS ≤ 5 days (57.7% vs. 23.9%, p < 0.001). No significant differences were found for PSM rate (2.8% vs. 8.4%, p = 0.27), CD > 2 complication rate (4.2% vs. 2.8%, p = 1.00) and mean ± SD eGFR change (−0.06 ± 0.3 vs. −0.8 ± 0.3, p = 0.5). Pentafecta was achieved in 56.3% and 21.1% in the OFFC-RAPN and OFFC-OPN series, respectively (p < 0.0001). On multivariable analysis, surgical approach and BMI proved to be independent predictors of achieving pentafecta. After adjusting for potential treatment selection bias, OFFC-RAPN outperformed OFFC-OPN for important peri-operative outcomes, without compromising oncological and functional safety.

Feasibility of interaortocaval clamping for renal artery during robot-assisted right partial nephrectomy: A propensity score-matching analysis

AIM

To evaluate the impact of the interaortocaval clamping technique for the right renal artery on perioperative outcomes of patients who underwent robot-assisted partial nephrectomy (RAPN).

METHODS

This study included 111 consecutive patients with right renal masses undergoing RAPN via the transperitoneal approach. In this series, standard and interaortocaval clamping techniques were defined as those for the right renal artery at the renal hilus and interaortocaval space, respectively. Based on the 3D images reconstructed from CT, interaortocaval clamping was preoperatively selected for patients in whom standard clamping of the main renal artery at the right hilum was judged to be technically difficult due to complicated vascular distribution, such as multiple branches of right renal arteries and veins and/or intertwining of these vessels.

RESULTS

Of 111 patients, 95 and 16 were classified into the standard and interaortocaval clamping groups, respectively, and interaortocaval clamping was uneventfully performed as planned in all 16. After adjusting patient variables by 1:3 propensity score-matching, 33 and 11 patients were included in the respective groups, and there were no significant differences in major clinical characteristics between them, while the incidences of multiple branches of right renal vessels as well as their intertwining beside the right renal hilus were significantly higher in the interaortocaval clamping group. However, no significant difference was noted in any of the perioperative outcomes, including operative time or intraoperative blood loss, between the two groups.

CONCLUSIONS

The interaortocaval clamping technique during RAPN is a feasible procedure with acceptable perioperative outcomes compared with standard hilar clamping, making it possible to more accurately resect renal tumors under clear visualization without unnecessary arterial bleeding from the tumor bed in patients with complex vascular distribution at the right renal hilus; however, special attention should be paid to the considerable individual variability of the interaortocaval anatomy.

Clinical Benefits of Indocyanine Green Fluorescence in Robot-Assisted Partial Nephrectomy

Background: To compare the intraoperative and postoperative outcomes of indocyanine green (ICG) administration in robot-assisted partial nephrectomy (RAPN) and report the differences in the results between patients with benign and malignant renal tumors. Methods: From 2017 to 2020, 132 patients underwent RAPN at our institution, including 21 patients with ICG administration. Clinical data obtained from our institution’s RAPN database were retrospectively reviewed. Intraoperative, postoperative, pathological, and functional outcomes of RAPN were assessed. Results: The pathological results indicated that among the 127 patients, 38 and 89 had received diagnoses of benign and malignant tumors, respectively. A longer operative time (311 vs. 271 min; p = 0.006) but superior preservation of estimated glomerular filtration rate (eGFR) at 3-month follow-up (90% vs. 85%; p = 0.031) were observed in the ICG-RAPN group. Less estimated blood loss, shorter warm ischemia time, and superior preservation of eGFR at postoperative day 1 and 6-month follow-up were also noted, despite no significant differences. Among the patients with malignant tumors, less estimated blood loss (30 vs. 100 mL; p < 0.001) was reported in the ICG-RAPN subgroup. Conclusions: Patients with ICG-RAPN exhibited superior short-term renal function outcomes compared with the standard RAPN group. Of the patients with malignant tumors, ICG-RAPN was associated with less blood loss than standard RAPN without a more positive margin rate. Further studies with larger cohorts and prospective designs are necessary to verify the intraoperative and functional advantages of the green dye.

Comparison of perioperative outcomes among patients with exophytic, mesophytic, and endophytic renal tumors undergoing robot-assisted partial nephrectomy

OBJECTIVES

It has been well documented that partial nephrectomy for completely endophytic renal tumors is a highly challenging procedure accompanied by several technical difficulties even with the assistance of a robotic surgical system. This study aimed to compare perioperative variables among patients with exophytic, mesophytic, and endophytic renal tumors undergoing robot-assisted partial nephrectomy.

METHODS

This study retrospectively included 265 consecutive patients with localized small renal masses undergoing robot-assisted partial nephrectomy at our institution. In this study, completely endophytic tumor was defined as the mass totally covered by renal healthy parenchyma, and according to the points for the 'E' domain of RENAL nephrometry score based on preoperative computed tomography, subjects were classified into three groups as follows: exophytic, mesophytic, and endophytic tumor groups, and perioperative outcomes among these groups were compared.

RESULTS

Of 265 patients, 127, 112, and 26 were classified into the exophytic, mesophytic, and endophytic tumor groups, respectively. A significantly smaller tumor diameter was observed in the endophytic group than in the other groups (P < 0.001), whereas the RENAL nephrometry score was significantly higher (P < 0.001). In addition, the warm ischemia time in the endophytic tumor group was significantly longer than that in other groups (P = 0.009); however, no significant difference in the trifecta achievement was noted among the three groups.

CONCLUSIONS

This study suggests that robot-assisted partial nephrectomy for patients with completely endophytic tumors can be regarded as a feasible approach without marked impairment of perioperative outcomes; however, further investigation of the long-term functional and oncological outcomes in these patients is required.

Preservation of Split Renal Function After Laparoscopic and Robot-assisted Partial Nephrectomy

BACKGROUND/AIM

To analyze the effects of laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) for the treatment of renal cell carcinoma (RCC) on subsequent split renal function using renal scintigraphy.

PATIENTS AND METHODS

We retrospectively analyzed data from 174 patients who underwent LPN or RAPN by a single surgeon, and assessed their total and split renal function before and 6 months after each procedure. Split renal function was analyzed using ^99mTc-2,3 dimercaptosuccinic acid renal imaging and calculated as the total estimated glomerular filtration rate (eGFR) × uptake ratio on the surgical side/uptake ratio on the contralateral side.

RESULTS

LPN or RAPN were performed in 51 (29.3%) and 123 (70.7%) participants, respectively. Their median eGFRs before and after surgery were 32.76 and 27.74 ml/min/1.73 m², respectively, and 70 of them (40.2%) showed a preservation of split eGFR of >90%, which was used to define a successful procedure. Participants who underwent a successful procedure had significantly lower RENAL nephrometry scoring system (RNS) scores and fewer of them had external tumors. Successful procedures were associated with shorter warm ischemia time, were more likely to be RAPN, and less likely to involve parenchymal suturing. Multivariate analysis showed that a low RNS score and parenchymal suturing were significant independent predictors of split renal function following partial nephrectomy (PN).

CONCLUSION

Preoperative RNS score and the use of parenchymal suturing are significantly associated with a preservation of split renal function of >90% in patients who undergo PN for the treatment of RCC.

Novel Intraoperative Navigation Using Ultra-High-Resolution CT in Robot-Assisted Partial Nephrectomy

Simple Summary

Successful surgery in robot-assisted partial nephrectomy (RAPN), especially for highly complex tumors, relies on a detailed understanding of the anatomical relations of the tumor absolute and relative to the urinary tract and the vascular structures, including the renal pedicle. Intraoperative navigation with accurate information regarding tumor position relative to the surrounding urinary vascular structures undoubtedly assists the surgeon during RAPN. In this report, we performed RAPN with intraoperative navigation using a novel computed tomography scanner (UHR-CT) and compared its perioperative and short-term functional outcomes to those of area-detector CT (ADCT). We found that this novel navigation system using UHR-CT provided a shorter warm ischemia time and lower estimated blood loss than ADCT, and concluded this could be a useful tool for patients who undergo RAPN. This is the first report to evaluate the feasibility and usefulness of UHR-CT for intraoperative navigation during RAPN.

Abstract

To assess the perioperative and short-term functional outcomes of robot-assisted partial nephrectomy (RAPN) with intraoperative navigation using an ultra-high-resolution computed tomography (UHR-CT) scanner, we retrospectively analyzed 323 patients who underwent RAPN using an UHR-CT or area-detector CT (ADCT). Perioperative outcomes and the postoperative preservation ratio of estimated glomerular filtration rate (eGFR) were compared. After the propensity score matching, we evaluated 99 patients in each group. Although the median warm ischemia time (WIT) was less than 25 min in both groups, it was significantly shorter in the UHR-CT group than in the ADCT group (15 min vs. 17 min, p = 0.032). Moreover, the estimated blood loss (EBL) was significantly lower in the UHR-CT group than in the ADCT group (33 mL vs. 50 mL, p = 0.028). However, there were no significant intergroup differences in the postoperative preservation ratio of eGFR at 3 or 6 months of follow-up (ADCT 91.8% vs. UHR-CT 93.5%, p = 0.195; and ADCT 91.7% vs. UHR-CT 94.0%, p = 0.160, respectively). Although no differences in short-term renal function were observed in intraoperative navigation for RAPN in this propensity score–matched cohort, this study is the first to demonstrate that UHR-CT resulted in a shorter WIT and lower EBL than ADCT.

The Impact of Postoperative Renal Function Recovery after Laparoscopic and Robot-Assisted Partial Nephrectomy in Patients with Renal Cell Carcinoma

Background and objectives: This study aimed to evaluate the association between warm ischemic time (WIT) and postoperative renal function using Trifecta achievement in patients with renal cell carcinoma (RCC) who underwent robotic (RAPN) or laparoscopic partial nephrectomy (LPN). Materials and Methods: We conducted a retrospective multicenter cohort study of patients with RCC who underwent RAPN (RAPN group) or LPN (LPN group) at three institutions in Japan between March 2012 and October 2021. The primary endpoints were the rate of trifecta achievement in both surgical techniques and the association between WIT and recovery of postoperative renal function surgical outcomes. Results: The rate of trifecta achievement was significantly lower in patients with LPN than in those with RAPN (p < 0.001). WIT ≥ 25 min were 18 patients (18%) in the RAPN group and 89 (52.7%) in the LPN group. The postoperative estimated glomerular filtration rate (eGFR) was almost the same. However, 13 patients (7.7%) had a decreased in eGFR ≥ 15% at 3 months after LPN compared with the preoperative eGFR. Conclusions: The rate of trifecta achievement in the RAPN group was significantly higher than that in the LPN group. However, eGFR was identified as relatively better preserved after PN in both groups.

[Robot-assisted partial nephrectomy with selective ischemia]

INTRODUCTION

Clamping of the renal artery during partial nephrectomy leads to renal ischemia and a deterioration of its function. An alternative to total ischemia is to isolate and clamp the segmental branch of the renal artery supplying the tumor.

AIM

To evaluate the efficiency of robot-assisted partial nephrectomy (RAPN) with selective renal ischemia.

MATERIAL AND METHODS

A total of 42 patients with renal tumors of stage T1a (n=34) and T1b (n=8) undergoing RAPN were included in the study. There were 25 men (59.5%) and 17 women. The mean age was 56.0 +/- 7.5 years, the tumor size ranged from 2.5 to 6.8 cm. Patients with a solitary kidney, multiple tumors, and those who underwent partial nephrectomy with clamping of the renal artery were excluded from the study. CT angiography with 3D reconstruction were used to detect the segmental branches of the renal artery, that supply the tumor. To determine the complexity of renal tumors, the RENAL nephrometric scale was used. Complications were assessed according to the Clavien-Dindo classification. In addition, mean operative time and volume of blood loss, warm ischemia time, pre- and postoperative renal function, and oncological outcomes were analyzed. The RAPN was considered successful if it was performed with selective clamping of the artery.

RESULTS

RAPN with selective ischemia was effective in 38 (90.5%) of 42 patients. In 4 (9.5%) cases with tumors of T1b stage and high RENAL scores (> 8), total ischemia was eventually used in order to control bleeding. According to CT angiography, these patients had more or equal 2 branches of renal artery, supplying the tumor. Mean operation time, volume of blood loss and warm ischemia time were 130.0+/-35 min, 185.0+/-80.0 ml and 14.0+/-3.2 min, respectively. In one case, there was an injury to the renal vein, which was sutured. Postoperative complications were observed in 5 (12.0%) patients. The glomerular filtration rate pre- and postoperatively was 76.5 and 72.0 ml/min/1.73 m2, and its decrease 1 month after RAPN was not significant (p>0.05).

CONCLUSION

Preoperative evaluation of renal arterial anatomy allows to detect the segmental branch that supplies the tumor. By its clamping, it is possible to perform efficient and safe robot-assisted partial nephrectomy without total ischemia.

Is Hypertension Associated with Worse Renal Functional Outcomes after Minimally Invasive Partial Nephrectomy? Results from a Multi-Institutional Cohort

Background: Hypertension (HTN) is a global public health issue. There are limited data regarding the effects of HTN in patients undergoing partial nephrectomy (PN) for renal tumors. To address this void, we tested the association between HTN and renal function after minimally invasive PN (MIPN). Methods: Using a multi-institutional database (2007–2017), we identified patients aged ≥ 18 years with a diagnosis of cT1 renal tumors treated with MIPN. Kaplan–Meier plots and Cox regression models addressed newly-onset CKD stage ≥ 3b or higher (sCKD). All analyses were repeated after 1:1 propensity score matching (PSM). Results: Overall, 2144 patients were identified. Of those, 35% (n = 759) were yes-HTN. Yes-HTN patients were older, more frequently male and more often presented with diabetes. Yes-HTN patients harbored higher RENAL nephrometry scores and higher cT stages than no-HTN patients. Conversely, yes-HTN patients exhibited lower preoperative eGFRs. In the overall cohort, five-year sCKD-free survival was 86% vs. 94% for yes-HTN vs. no-HTN, which translated into a multivariable HR of 1.67 (95% CI: 1.06–2.63, p = 0.026). After 1:1 PSM, virtually the same results were observed (HR 1.86, 95% CI: 1.07–3.23, p = 0.027). Conclusions: Yes-HTN patients exhibited worse renal function after MIPN when compared to their no-HTN counterparts. However, these observations need to be further tested in a prospective cohort study.

Association of statins use and mortality outcomes in prostate cancer patients who received androgen deprivation therapy: a systematic review and meta-analysis

Introduction

While several recent studies investigated the influence of statins on survival outcomes in prostate cancer (PCa) patients on androgen deprivation therapy (ADT), definitive conclusions are still missing. The present systematic review and meta-analysis aimed to develop an overarching framework for the association of statins use and survival outcomes in PCa patients who receive ADT.

Material and methods

We conducted a systematic review and meta-analysis of the literature assessing the survival outcomes for statin compared to non-statin users in PCa patients who received ADT. We searched PubMed and Web of Science for studies published before March 1, 2021. We used the random effect model in the presence of heterogeneity and the fixed-effects model in the absence of heterogeneity per the I² statistic. We did two meta-analyses; the primary meta-analysis was accomplished for articles reporting cancer-specific survival (CSS) as an outcome. A secondary meta-analysis was completed for articles reporting overall survival (OS) as an outcome.

Results

Ten studies were eligible for inclusion. Nine studies included in the first meta-analysis comprising 136,285 patients showed no statistically significant difference in CSS (HR 0.77; 95% CI 0.49–1.21) between statin users and non-users in PCa patients who received ADT. In four studies included in the second meta-analysis comprising 95,032 patients, statin users had a significantly better OS compared to non-users (HR 0.67; 95% CI 0.62–0.73).

Conclusions

Although the combination of statins and ADT in PCa patients significantly improves OS, it seems not to be through an effect on cancer-specific factors.

Comparison of Perioperative, Renal Functional, and Oncological Outcomes Between Off-Clamp and On-Clamp Robot-Assisted Partial Nephrectomy for Renal Tumors: An Updated Evidence-Based Analysis

Objectives

We aimed to report the latest and largest pooled analysis and evidence update to compare the perioperative, renal functional, and oncological outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN) for renal tumors.

Patients and methods

We performed a systematic literature search using PubMed, Embase, and Web of Science up to August 2021 for studies that compared the efficacy and/or safety between off-clamp and on-clamp RAPN for renal tumors. Outcomes measured were operating time, estimated blood loss (EBL), conversion rate, length of stay (LOS), complication rate, transfusion rate, long-term % decrease in estimated glomerular filtration rate (eGFR), positive surgical margin rate, and recurrence rate.

Results

A total of 21 eligible articles involving 4,493 patients (1,274 off-clamp versus 3,219 on-clamp) were included for the evidence synthesis. Baseline characteristics of the two groups were similar in all outcomes except that lower R.E.N.A.L. score and smaller tumor size were observed in the off-clamp group. Pooled analysis showed shorter operative time, higher EBL, and lower complication rate in the off-clamp group. No significant difference was observed in the conversion rate, LOS, and transfusion rate. The recurrence rates were similar in the two groups, while a lower positive surgical margin rate was observed in the off-clamp group. Finally, the off-clamp group had a superior postoperative renal functional outcome.

Conclusions

Given the presence of heterogeneity and potential bias, urologists should select the clamp strategy based on their experience and patient-specific factors.

Trends and safety of robot-assisted partial nephrectomy during the initial 2-year period after government approval in Japan: A nationwide database study from 2016 to 2018

OBJECTIVES

To evaluate the trends and safety of robot-assisted partial nephrectomy during the initial 2-year period after government approval for this type of procedure in April 2016.

METHODS

This nationwide retrospective study included 3722 received robot-assisted partial nephrectomy cases carried out from April 2016 to March 2018 in 124 participating institutions. The institutions were divided into lower- and higher-volume institutions according to the median of 19 robot-assisted partial nephrectomy cases during the study period. Surgical outcomes between 616 cases from lower-volume institutions and 3106 cases from higher-volume institutions were compared using propensity score matching.

RESULTS

During the study period, both the number of robot-assisted partial nephrectomy surgeries and the number of institutions in which the surgery was carried out steadily increased. Overall, the median anesthesia time was 217 min, the median postoperative length of stay was 9 days, and the proportion of blood transfusions, complications and readmissions were 0.8%, 5.1% and 1.0%, respectively. There were no significant differences in anesthesia time, incidence of blood transfusions, and complication rates between the lower-volume and higher-volume institutions. However, a slightly, but significantly, longer postoperative length of stay and a lower incidence of readmission were observed in lower-volume institutions both before and after propensity score matching.

CONCLUSIONS

Robot-assisted partial nephrectomy has become widespread during the initial 2-year period after government approval with an acceptable safety profile, regardless of the institutional caseloads. This technique has become a standard of care for stage 1 renal cancer patients in Japan.

Renal Functional and Perioperative Outcomes of Retroperitoneal Robot-Assisted Versus Laparoscopic Partial Nephrectomy with Segmental Renal Artery Clamping

Background: Retroperitoneal approach and segmental renal artery clamping in partial nephrectomy are techniques that facilitate postoperative recovery and renal function preservation. This study aimed to compare the renal function preservation and perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) with these techniques. Materials and Methods: Clinical parameters of 43 patients who had undergone retroperitoneal RAPN from March 2017 to December 2019 were retrospectively collected and compared with those of 52 patients who had undergone retroperitoneal LPN at the same period in our institution. Differences in operating time, warm ischemia time, estimated blood loss, complications, postoperative hospital stay, as well as renal function loss were compared between the two groups. Results: Background characteristics between RAPN and LPN groups such as age, gender, BMI, and tumor characteristics were comparable. All RAPNs and LPNs were successfully completed without conversion to open surgery or nephrectomy. No significant difference in operating time, estimated blood loss, complications, and postoperative hospital stay was observed between RAPN and LPN groups. The warm ischemia time in RAPN group was slightly shorter than that of LPN groups (P = .054). Compared with the LPN group, the RAPN group was significantly associated with less glomerular filtration rate reduction and renal volume loss rate (P = .042 and P = .013, respectively). Conclusions: The perioperative outcomes were comparable between the two groups. However, compared with LPN, RAPN had superiority in preserving renal function in our series.

Perioperative outcomes in patients undergoing robot-assisted partial nephrectomy: Comparative assessments between complex and non-complex renal tumors

INTRODUCTION

The aim of this study was to investigate the effects of renal tumor complexity on perioperative outcomes in patients receiving robot-assisted partial nephrectomy (RAPN).

METHODS

This study included 153 consecutive patients with cT1 renal masses undergoing RAPN and analyzed their perioperative outcomes, particularly tumor complexity. In this series, cT1b, completely endophytic, hilar, and cystic tumors were considered complex tumors. Patients with tumors that met at least one of the complex criterion were placed in the complex tumor group; patients with tumors that did not meet any of the complex criteria were placed in the non-complex tumor group.

RESULTS

Of the 153 patients, 54 (35.3%) had complex tumors; specifically, 18 (11.8%) had cT1b tumors, 15 (9.8%) had completely endophytic tumors, 28 (18.3%) had hilar tumors, and 8 (5.2%) had cystic tumors. The non-complex group included 99 patients (64.7%). The complex tumor group had significantly longer warm ischemia and console times than the non-complex tumor group, but there was no significant difference between them in the achievement of the trifecta. Both warm ischemia and console times were significantly correlated with the number of complex factors. Multivariate analyses of complex factors demonstrated that completely endophytic and cT1b tumors were independently associated with warm ischemia time and console time, respectively.

CONCLUSIONS

For patients with complex tumors, RAPN may be a feasible procedure with acceptable perioperative outcomes. However, special attention should be paid to long warm ischemia and console times, particularly in those with completely endophytic and/or cT1b tumors.

Therapeutic and Clinical Outcomes of Robot-assisted Partial Nephrectomy Versus Cryoablation for T1 Renal Cell Carcinoma

BACKGROUND

In cT1 renal cell carcinoma (RCC), very few studies have compared oncological outcomes and renal function preservation rates in nephron-sparing robot-assisted partial nephrectomy (RAPN) and percutaneous cryoablation (PCA).

PATIENTS AND METHODS

We retrospectively analysed 126 patients with cT1 RCC treated with RAPN (n=78) and computed tomography-guided PCA (n=48) between March 2016 and November 2019. Clinical data and outcomes were compared for the two groups.

RESULTS

There were no significant differences in the 3-year overall survival and relapse-free survival rates in the two groups (p=0.17 and p=0.093, respectively). The median percentage of estimated glomerular filtration rate preservation at 6 months after surgery was 91.8% and 91.4% in the RAPN and PCA groups, respectively (p=0.9).

CONCLUSION

In patients with cT1a RCC, oncological outcomes and renal function appear similar following RAPN and PCA.

[Comparative analysis of clinical features of robotic-assisted and laparoscopic partial nephrectomy]

INTRODUCTION

Kidney cancer (mostly renal cell carcinoma) is one of the ten most commonly diagnosed malignant tumors among men and women. Due to the widespread use of computer tomography and magnetic resonance imaging, the proportion of early-stage kidney cancers has increased. Currently, treatment options for stage 1 kidney cancer are radical nephrectomy, partial nephrectomy, and active surveillance. Among organ-preserving intervention, three main techniques can be distinguished: open surgery, minimally invasive surgery and ablation methods. To date, robotic-assisted procedures have occupied their place among minimally invasive interventions.

AIM

To carry out a comparative analysis of two methods of organ-preserving treatment of kidney tumors, namely robot-assisted and laparoscopic partial nephrectomy.

MATERIALS AND METHODS

A retrospective comparative analysis of two groups of patients with kidney tumors who underwent robotic-assisted or laparoscopic partial nephrectomy during the period from 2012 to 2019 was performed.

RESULTS

There were no differences between two groups in age, mean score on the RENAL nephrometry scale, preoperative creatinine levels, tumor size, and duration of warm ischemia. However, duration of surgery, the volume of blood loss, serum creatinine after surgery, the length of stay, the use of the technique of early unclamping of the renal artery, the use of technique "off-clamp" and the proportion of exophytic tumors with growth were significantly different between patients of two groups.

CONCLUSION

We believe that the robotic system is intuitively convenient for performing partial nephrectomy, allowing the treatment of potentially more complex cases and expanding the indications for organ-preserving procedures.

Ex Vivo Porcine Model for Robot-Assisted Partial Nephrectomy Simulation at a High-Volume Tertiary Center: Resident Perception and Validation Assessment Using the Global Evaluative Assessment of Robotic Skills Tool

Introduction: With increased demands on surgeon productivity and outcomes, residency robotics training increasingly relies on simulations. The objective of this study is to assess the validity and effectiveness of an ex vivo porcine training model as a useful tool to improve surgical skill and confidence with robot-assisted partial nephrectomy (RAPN) among urology residents. Methods: A 2.5 cm circular area of ex vivo porcine kidneys was marked as the area of the tumor. Tumor excision and renorrhaphy was performed by trainees using a da Vinci Si robot. All residents ranging from postgraduate year (PGY) 2 to 5 participated in four training sessions during the 2017 to 2018 academic year. Each session was videorecorded and scored using the global evaluative assessment of robotic skills (GEARS) by faculty members. Results: Twelve residents completed the program. Initial mean GEARS score was 16.7 and improved by +1.4 with each subsequent session (p = 0.008). Initial mean excision, renorrhaphy, and total times were 8.2, 13.9, and 22.1 minutes, which improved by 1.6, 2.0, and 3.6 minutes, respectively (all p < 0.001). Residents' confidence at performing RAPN and robotic surgery increased after completing the courses (p = 0.012 and p < 0.001, respectively). Overall, residents rated that this program has greatly contributed to their skill (4/5) and confidence (4.1/5) in robotic surgery. Conclusions: An ex vivo porcine simulation model for RAPN and robotic surgery provides measurable improvement in GEARS score and reduction in procedural time, although significant differences for all PGY levels need to be confirmed with larger study participation. Adoption of this simulation in a urology residency curriculum may improve residents' skill and confidence in robotic surgery.

Robot-Assisted Partial Nephrectomy for Patients with Multifocal Renal Tumors Arising in a Solitary Kidney: Report of Three Cases

Background: Surgical treatment of synchronous multifocal renal tumors arising in a solitary kidney remains an extremely unique and stressful challenge, since it is not easy to completely remove multiple tumors and effectively preserve the renal function without perioperative complications. In this report, we describe our experience of three patients with multifocal renal tumors detected in a solitary kidney who were treated by robot-assisted partial nephrectomy (RAPN). Case Presentation: Two men and one woman were found to have two small renal tumors in a solitary kidney, and subsequently underwent RAPN at our institution. The location of the renal tumors and surgical approach in each patient were as follows: one tumor on the abdominal side and another on the dorsal side with a transperitoneal approach, both on the abdominal side with a transperitoneal approach, and both on the dorsal side with a retroperitoneal approach. In this series, after clamping the main renal artery and resection of one tumor, an inner running suture was placed, followed by early declamping of the renal artery and then renorrhaphy, and the same procedure was repeated to manage the remaining tumor. In all patients, the trifecta outcomes were achieved, and there were no changes in the chronic kidney disease stage 1 month after RAPN, resulting in no requirement of postoperative dialysis. Conclusion: Although it is necessary to carefully select optimal candidates, RAPN with an early declamping technique could be a safe and feasible approach for the treatment of patients with synchronous multifocal renal tumors arising in a solitary kidney, facilitating the complete resection of tumor foci, minimization of warm ischemic injury, and effective preservation of the renal function.

Impact of postoperative acute kidney injury on predicting the upstaging of chronic kidney disease after robot-assisted partial nephrectomy

INTRODUCTION

The aim of our study was to assess the impact of acute kidney injury (AKI) on postoperative upstaging of chronic kidney disease (CKD) after robot-assisted partial nephrectomy (RAPN).

METHODS

This study consisted of 110 patients who had undergone RAPN and were followed up for at least 6 months after surgery. Patients were classified as AKI or non-AKI based on their serum creatinine level and estimated glomerular filtration rate within 7 days after surgery. Patient characteristics, outcome of RAPN and estimated glomerular filtration rate, and CKD upstage 6 months after surgery were compared between the AKI and non-AKI groups.

RESULTS

A total of 26 patients (23.6%) experienced AKI after surgery. RENAL (radius, exophytic/endophitic properties, nearness of the tumor to the collecting system or sinus, anterior/posterior, location relative to the polar lines) nephrometry scores were ≥7 for 22 (84.6%) in the AKI group and 39 (46.4%) in the non-AKI group (P = .0006). A significantly smaller proportion of patients in the AKI group than in the non-AKI group recovered 90% of baseline function (38.5% vs 81.0%, P < .0001). CKD upstaging occurred in a total of 27 patients 24.5%) and in a significantly larger proportion of patients in the AKI group than in the non-AKI group (42.3% vs 19.0%, P = .0160). There was no significant difference in characteristics and perioperative outcomes between the patients with and without CKD, except for in those experiencing AKI.

CONCLUSION

After RAPN, AKI can be associated with CKD upstaging.

[Nephron sparing surgery in complex kidney tumors]

AIM

To analyze the results of nephron sparing surgery (NSS) in patients with complex and large kidney tumors (R.E.N.A.L. 10-12).

MATERIALS AND METHODS

A total of 361 interventions for kidney neoplasm were performed from 2013 to 2018, including 207 (57,34%) NSS. The complex renal tumors were defined using R.E.N.A.L. nephrometry score. In 44 patients, tumors had a R.E.N.A.L. score of 10-12 (21,26%). Postoperative complications were classified using Clavien-Dindo system. Estimated glomerular filtration rate (eGFR) was assessed before operation and on the 1st-3rd postoperative day.

RESULTS

Among tumors with R.E.N.A.L. score of 10-12, T1a, T1b and T2 stages were found in 13,64%, 70,45% and 15,91% cases, respectively. Robot-assisted partial nephrectomy was performed in 95%, while laparoscopic procedure was done in 5% of patients. Median operation time was 190 [170; 215] min, while median blood loss was 150 [100; 300] ml. There were 2 intraoperative complications (4,55%). Intraoperative complications were recorded in 2 (4.55%) patients. Postoperative complications developed in 22.73% of cases, including 3 patients with Grade I-II (6.82%) and 7 patients with Grade III complications (15.91%). Total, segmental ischemia and zero-ischemia was used in 31 (70.45%), 12 (27.27%) and 1 (2.27%) patients, respectively. The median duration of total ischemia was 20.0 [17; 25] min. A positive surgical margin was found in 1 (2.27%) patient. In 46.51% of cases, there was no decrease in eGFR in the early postoperative period. In 28% of patients, eGFR decreased by more than 20%. On average, GFR declined by 6.01%.

CONCLUSION

NSS in patients with complex renal tumors is an effective alternative to radical nephrectomy, which provides an acceptable level of postoperative complications, with moderate decrease in eGFR and low rate of positive surgical margin.

Comparison of postoperative recovery after robot-assisted partial nephrectomy of T1 renal tumors through retroperitoneal or transperitoneal approach: A Japanese single institutional analysis

OBJECTIVE

To evaluate the quality of recovery in patients who underwent robot-assisted partial nephrectomy and to compare the outcomes of the transperitoneal or retroperitoneal approach.

METHODS

This study included 121 patients who underwent robot-assisted partial nephrectomy under general anesthesia from April 2019 to September 2019 at Tokyo Women's Medical University, Tokyo, Japan. Quality of recovery was defined according to the QoR-40 Japanese version. The participants responded to the QoR-40 Japanese version on three designated days. The patients were assigned to two groups according to the surgical approach: transperitoneal or retroperitoneal. A multivariate logistic regression analysis was carried out to identify independent factors associated with better quality of recovery.

RESULTS

Out of the 121 patients, 56 (46%) and 65 (54%) patients were included in the transperitoneal and retroperitoneal group, respectively. Although the QoR-40 Japanese version scores were not different between the two groups at admission, a better quality of recovery was observed in the retroperitoneal group than in the transperitoneal group at discharge based on the total score: physical comfort, emotional state, physical independence and pain. A multivariate analysis showed that the retroperitoneal approach and male sex were associated with a better QoR-40 Japanese version score at discharge.

CONCLUSIONS

A retroperitoneal approach offers better quality of recovery than a transperitoneal approach, and therefore it might represent the optimal approach in selected patients undergoing robot-assisted partial nephrectomy.

Outcomes of minimally invasive partial nephrectomy among very elderly patients: report from the RESURGE collaborative international database

The aim of the study was to perform a comprehensive investigation of clinical outcomes of robot-assisted partial nephrectomy (RAPN) or laparoscopic partial nephrectomy (LPN) in elderly patients presenting with a renal mass. The REnal SURGery in Elderly (RESURGE) collaborative database was queried to identify patients aged 75 or older diagnosed with cT1-2 renal mass and treated with RAPN or LPN. Study outcomes were: overall complications (OC); warm ischemia time (WIT) and 6-month estimated glomerular filtration rate (eGFR); positive surgical margins (PSM), disease recurrence (REC), cancer-specific mortality (CSM) and other-cause mortality (OCM). Descriptive statistics, Kaplan-Meier, smoothed Poisson plots and logistic and linear regression models (MVA) were used. Overall, 216 patients were included in this analysis. OC rate was 34%, most of them being of low Clavien grade. Median WIT was 17 minutes and median 6-month eGFR was 54 ml/min/1.73 m2. PSM rate was 5%. After a median follow-up of 20 months, the 5-year rates of REC, CSM and OCM were 4, 4 and 5%, respectively. At MVA predicting perioperative morbidity, RAPN relative to LPN (odds ratio [OR] 0.33; p <0.0001) was associated with lower OC rate. At MVA predicting functional outcomes, RAPN relative to LPN was associated with shorter WIT (estimate [EST] -4.09; p <0.0001), and with higher 6-month eGFR (EST 6.03; p = 0.01). In appropriately selected patients with small renal masses, minimally-invasive PN is associated with acceptable perioperative outcomes. The use of a robotic approach over a standard laparoscopic approach can be advantageous with respect to clinically relevant outcomes, and it should be preferred when available.

Robot-Assisted Laparoscopic Partial Nephrectomy Vs Conventional Laparoscopic Partial Nephrectomy: Functional and Surgical Outcomes of a Prospective Single Surgeon Randomized Study

Background: Laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) are commonly used techniques for treating small renal masses. Regarding renal function (RF) preservation, no superiority of one technique over the other has yet been definitely demonstrated. Objective: To compare functional and surgical outcomes of LPN and RAPN. Patients and Methods: Between 2015 and 2019, we prospectively randomized 115 patients with cT1-T2 renal masses to LPN in total ischemia or RAPN in selective ischemia. Primary endpoint was RF preservation, assessed by renal scintigraphy (RS). RS assessments were performed preoperatively and at 6 months follow-up. Secondary endpoints included clinical, histopathologic, and surgical outcomes. Results: One hundred eight patients were included in the final analysis. Patient and tumor characteristics were comparable. No significant difference in RS values after 6 months was observed between both groups. Median (interquartile range) RF change after 6 months was -18.0% (-26.5 to -11.0) in LPN group and -20.0 (-33.2 to -12.0) in RAPN group (p = 0.3). Mean (standard deviation [SD]) warm ischemia time was 21.1 (6.1) minutes in LPN group and 19.6 (7.7) minutes in RAPN group (p = 0.2). No positive surgical margins (PSMs) occurred in the LPN group, whereas RAPN group had PSM in 4.9% (n = 3); p = 0.099. Renal volume loss after 6 months was 27.5% (22.7-45.7) in the LPN group vs 37.5 (13.7-54.2) in the RAPN group (p = 0.5). Mean operative times were lower in the LPN group (192.3 minutes [SD 44.5] vs 230.2 minutes [SD 59.6], p = 0.001). More complications occurred in the LPN group (31% vs 21%, p = 0.075). Transfusion rates were 15% for LPN and 11% for RAPN. Conclusions: In terms of preserving RF, LPN in total ischemia and RAPN in selective ischemia are comparable. In most patients, RF decrease of the affected kidney after PN seems to not exceed 25%, regardless of the surgical approach.

Robot-Assisted Partial Nephrectomy for Treatment of Juxtaglomerular Cell Tumor of the Kidney: A Case Report

Background: A juxtaglomerular cell tumor (JGCT), or a reninoma, is a rare renal tumor that can cause secondary hypertension. This is the first reported JGCT that was resected through robotic surgery. Case: We present a case of a 27-year-old female patient with 1.35-cm-sized JGCT in the lower pole of the right kidney. We effectively removed a JGCT through robot-assisted partial nephrectomy without any complications. Conclusion: The robot-assisted partial nephrectomy procedure could be a suitable choice for JGCT resection.

Predicting intra-operative and postoperative consequential events using machine-learning techniques in patients undergoing robot-assisted partial nephrectomy: a Vattikuti Collective Quality Initiative database study

OBJECTIVE

To predict intra-operative (IOEs) and postoperative events (POEs) consequential to the derailment of the ideal clinical course of patient recovery.

MATERIALS AND METHODS

The Vattikuti Collective Quality Initiative is a multi-institutional dataset of patients who underwent robot-assisted partial nephectomy for kidney tumours. Machine-learning (ML) models were constructed to predict IOEs and POEs using logistic regression, random forest and neural networks. The models to predict IOEs used patient demographics and preoperative data. In addition to these, intra-operative data were used to predict POEs. Performance on the test dataset was assessed using area under the receiver-operating characteristic curve (AUC-ROC) and area under the precision-recall curve (PR-AUC).

RESULTS

The rates of IOEs and POEs were 5.62% and 20.98%, respectively. Models for predicting IOEs were constructed using data from 1690 patients and 38 variables; the best model had an AUC-ROC of 0.858 (95% confidence interval [CI] 0.762, 0.936) and a PR-AUC of 0.590 (95% CI 0.400, 0.759). Models for predicting POEs were trained using data from 1406 patients and 59 variables; the best model had an AUC-ROC of 0.875 (95% CI 0.834, 0.913) and a PR-AUC 0.706 (95% CI, 0.610, 0.790).

CONCLUSIONS

The performance of the ML models in the present study was encouraging. Further validation in a multi-institutional clinical setting with larger datasets would be necessary to establish their clinical value. ML models can be used to predict significant events during and after surgery with good accuracy, paving the way for application in clinical practice to predict and intervene at an opportune time to avert complications and improve patient outcomes.

Feasibility and necessity of the fourth arm of the da Vinci Si surgical system for robot-assisted partial nephrectomy

BACKGROUND

To investigate the feasibility of the fourth arm of the da Vinci Si system for robot-assisted partial nephrectomy (RAPN).

METHODS

Fifty-eight consecutive patients underwent RAPN with the same port placements. After reviewing the surgical videos and records, 38 patients showing usefulness of the fourth arm were categorized into Group A and those not showing usefulness into Group B. The background data, tumor characteristics, and perioperative outcomes were compared between the groups.

RESULTS

Group B had a larger proportion of tumors located on the inner side of the kidney, and the console time was significantly longer. Multivariable logistic regression analysis showed that tumors located on the inner side of the kidney were associated with the non-use of the fourth arm of the da Vinci Si system during RAPN.

CONCLUSIONS

Our findings suggested that use of fourth arm in RAPN by da Vinci Si should be considered for each tumor location.

Initial learning curve for robot-assisted partial nephrectomy performed by a single experienced robotic surgeon

INTRODUCTION

The objective of this study was to evaluate the initial learning curve for robot-assisted partial nephrectomy (RAPN) using the da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, California).

METHODS

This study included the initial 65 consecutive patients with small renal tumors who had undergone RAPN at our institution. A single trained surgeon with extensive experience in robot-assisted radical prostatectomy, but not in laparoscopic partial nephrectomy, performed RAPN for all patients using the da Vinci Xi. The learning curve was analyzed by examining the perioperative outcomes among five groups each consisting of 13 consecutive patients.

RESULTS

In this series, the median tumor size and R.E.N.A.L. nephrometry score were 23 mm and 7, respectively, and the median console time and warm ischemia time (WIT) were 116 and 15 minutes, respectively. Fifty-eight patients (89.2%) achieved trifecta outcomes, meaning that the ischemic time was ≤25 minutes, there was a negative surgical margin, and no major postoperative complications occurred. Although there were no significant changes in R.E.N.A.L. nephrometry scores over time, increased surgeon experience was significantly associated with a shorter console time and WIT. Drawing logarithmic approximation curves enabled the achievement of a console time ≤150 minutes and WIT ≤20 minutes at the sixth and fourth procedures, respectively. Furthermore, multivariate analysis identified an independent correlation between surgeon experience with WIT, but not with console time.

CONCLUSION

These findings suggest that regardless of a surgeon's prior experience in laparoscopic partial nephrectomy, an experienced robotic surgeon can perform RAPN using the da Vinci Xi with acceptable perioperative outcomes after a small number of procedures.

On-clamp versus off-clamp robotic partial nephrectomy: A systematic review and meta-analysis

BACKGROUND

The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this meta-analysis is to summarize the available evidence on the comparative studies assessing the outcomes of these two approaches.

MATERIAL AND METHODS

A systematic review of the literature on PubMed, ScienceDirect^®, and Embase^® was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Only comparative and case-control studies were submitted to full-text assessment and meta-analysis. RevMan 5.3 software was used.

RESULTS

From the initial retrieval of 1937 studies, 15 fulfilling inclusion criteria were selected and provided 2075 patients for analysis (702 off-clamp, 1373 on-clamp). Baseline tumor's features showed a significant difference in size (weighted mean difference: -0.58 cm; 95% confidence interval: [-1.06, -0.10]; p = 0.02) and R.E.N.A.L. score (weighted mean difference: -0.53; 95% confidence interval: [-0.81, -0.25]; p = 0.0002), but not in the exophytic property, the location, and the PADUA score. Pooled analysis revealed shorter operative time (p = 0.02) and higher estimated blood loss (p = 0.0002) for the off-clamp group. Overall complication and transfusion rates were similar, while higher major complication rate was observed in the on-clamp approach (5.6% vs 1.9%, p = 0.03). No differences in oncological outcomes were found. Finally, functional outcomes (assessed by estimated glomerular filtration rate at early postoperative, 3 month, 6 month, and last available follow-up) were not statistically different.

CONCLUSION

This meta-analysis shows that off-clamp robot-assisted partial nephrectomy is reserved to smaller renal masses. Under such conditions, no differences with the on-clamp approach emerged.

Nomogram for predicting the likelihood of postoperative surgical complications in patients treated with partial nephrectomy: a prospective multicentre observational study (the RECORd 2 project)

OBJECTIVE

To identify meaningful predictors and to develop a nomogram of postoperative surgical complications in patients treated with partial nephrectomy (PN).

PATIENTS AND METHODS

We prospectively evaluated 4308 consecutive patients who had surgical treatment for renal tumours, between 2013 and 2016, at 26 Italian urological centres (RECORd 2 project). A multivariable logistic regression for surgical complications was performed. A nomogram was created from the multivariable model. Internal validation processes were performed using bootstrapping with 1000 repetitions.

RESULTS

Overall, 2584 patients who underwent PN were evaluated for the final analyses. The median (interquartile [IQR]) American Society of Anesthesiologists (ASA) score was 2 (2-3). In all, 72.4% of patients had clinical T1a (cT1a) stage tumours. The median (IQR) Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score was 7 (6-8). Overall, 34.3%, 27.7%, 38% of patients underwent open PN (OPN), laparoscopic PN (LPN), and robot-assisted PN (RAPN). Overall and major postoperative surgical complications were recorded in 10.2% and 2.5% of patients, respectively. At multivariable analysis, age, ASA score, cT2 vs cT1a stage, PADUA score, preoperative anaemia, OPN and LPN vs RAPN, were significant predictive factors of postoperative surgical complications. We used these variables to construct a nomogram for predicting the risk of postoperative surgical complications. At decision curve analysis, the nomogram led to superior outcomes for any decision associated with a threshold probability of >5%.

CONCLUSION

Several clinical predictors have been associated with postoperative surgical complications after PN. We used this information to develop and internally validate a nomogram to predict such risk.

Comparison of postoperative pain between laparoscopic and robot-assisted partial nephrectomies for renal tumors: A propensity score matching analysis

Robot-assisted partial nephrectomy (RAPN) has emerged as an alternative to laparoscopic partial nephrectomy (LPN) for removal of renal tumors. Several advantages of robotic surgery have been reported, but there is no comparative study on postoperative pain between the 2 techniques. Therefore, we compared the postoperative numerical rating scale (NRS) of pain intensity between patients who underwent LPN and those who underwent RAPN.We included 705 patients who underwent either LPN (n = 200) or RAPN (n = 505) for renal tumors between January 2000 and September 2016. After 1:1 propensity score matching, the final analysis included 142 patients each in the LPN and RAPN groups. The primary endpoint was postoperative NRS of pain intensity. The secondary endpoints were opioid requirement, opioid-related complications, and duration of hospital stay.Preoperative and intraoperative values of propensity score matched patients (n = 284) were not significantly different between the LPN and RAPN groups. There was no significant difference in NRS of pain intensity between the 2 groups. Opioid requirement was different between the 2 groups on postoperative day (POD) 0 (12.4 vs 11.3 mg of morphine-equivalent dose), but not from POD 1 to POD 4. The incidence of opioid-related complications and duration of hospital stay were not significantly different between the 2 groups.Postoperative pain was not significantly different between patients who underwent RAPN and those who underwent LPN. This result provides a potentially useful knowledge of postoperative pain characteristics in RAPN and LPN.

The significance of predictable traumatic area by renorrhaphy in the prediction of postoperative ipsilateral renal function

Introduction

To determine the relationship between the actual renal function loss and volume loss in robot-assisted partial nephrectomy (RAPN) using a novel three-dimensional volume analyzer.

Material and methods

We respectively evaluated the medical records of 23 consecutive patients who underwent RAPN between January 2012 and March 2016 and the data on their kidney function and parenchymal mass specific to the operated kidney. Parenchymal volume was measured by computerized tomography and reconstructed with a Synapse Vincent volumetric analyzer. Using this system, we predicted the renal vascular territory and other trauma areas involved in renorrhaphy. All measurements were taken within 3 and 6 months pre- and postoperatively, respectively.

RESULTS

The actual postoperative renal parenchymal volume was significantly correlated with the virtual predicted residual renal volume excluding the tumor and resected margin (r = 0.435, p <0.05). The ratio of split estimated glomerular filtration rate (eGFR) postoperative/preoperative) was significantly correlated with the virtual predicted residual renal volume excluding the resected margin and the traumatic area by renorrhaphy (r = 0.401, p <0.05).

Conclusions

When predicting the reduction of renal function of the diseased side following partial nephrectomy, adding the extent of the area traumatized by renorrhaphy might be useful for predicting the postoperative split renal function of the affected kidney.

Renal Functional and Perioperative Outcomes of Selective Versus Complete Renal Arterial Clamping During Robot-Assisted Partial Nephrectomy: Early Single-Center Experience With 39 Cases

OBJECTIVE

The objective of this study was to investigate clinical outcomes in patients undergoing selective versus conventional complete renal arterial clamping during robot-assisted partial nephrectomy (RAPN).

METHODS

This study included 19 patients with renal tumors who received RAPN incorporating selective arterial clamping (group 1). The renal functional as well as perioperative outcomes in group 1 were compared with those in 20 patients with renal tumors undergoing RAPN with total clamping of the renal artery (group 2) during the same period.

RESULTS

In group 1, tumor resection under selective arterial clamping could be completed in all patients without intraoperative conversion to conventional RAPN with total clamping. There were no significant differences in the tumor size, RENAL nephrometry score, or preoperative estimated glomerular filtration rate (eGFR) between groups 1 and 2. Furthermore, no significant differences were noted in the estimated blood loss, operative time, or warm ischemia time between the 2 groups. Although there was no significant difference in the rate of decrease in eGFR 4 weeks after RAPN between the 2 groups, the rate of decrease in eGFR 1 week after RAPN in group 1 was significantly lower than that in group 2. The choice of selective or total clamping was also identified as an independent predictor of a postoperative decrease in eGFR by > 10% at 1 week, but not 4 weeks, after RAPN.

CONCLUSIONS

A precise segmental clamping technique is feasible and safe for performing RAPN, resulting in an improved postoperative renal function, particularly early after surgery.

Urinary fistula after robot-assisted partial nephrectomy: a multicentre analysis of 1 791 patients

OBJECTIVE

To evaluate the incidence of and risk factors for a urine leak in a large multicentre, prospective database of robot-assisted partial nephrectomy (RPN).

PATIENTS AND METHODS

A database of 1 791 RPN from five USA centres was reviewed for urine leak as a complication of RPN. Patient and tumour characteristics were compared between patients with and those without postoperative urine leaks. Fisher's exact test was used for qualitative variables and Wilcoxon sum-rank tests were used for quantitative variables. A review of the literature on PN and urine leak was conducted.

RESULTS

Urine leak was noted in 14/1 791 (0.78%) patients who underwent RPN. The mean (sd) nephrometry score of the entire cohort was 7.2 (1.9), and 8.0 (1.9) in patients who developed urine leak. The median (range) postoperative day of presentation was 13 (3-32) days. Patients with urine leak presented in delayed fashion with fever (two of the 14 patients, 14%), gastrointestinal complaints (four patients, 29%), and pain (five patients, 36%). Eight of the 14 patients (57%) required admission, while eight (57%) and nine (64%) had a drain or stent placed, respectively. Drains and stents were removed after a median (range) of 8 (4-13) days and 21 (8-83) days, respectively. Variables associated with urine leak included tumour size (P = 0.021), hilar location (P = 0.025), operative time (P = 0.006), warm ischaemia time (P = 0.005), and pelvicalyceal repair (P = 0.018). Upon literature review, the historical incidence of urine leak ranged from 1.0% to 17.4% for open PN and 1.6-16.5% for laparoscopic PN.

CONCLUSION

The incidence of urine leak after RPN is very low and may be predicted by some preoperative factors, affording better patient counselling of risks. The low urinary leak rate may be attributed to the enhanced visualisation and suturing technique that accompanies the robotic approach.

Feasibility and accuracy of computational robot-assisted partial nephrectomy planning by virtual partial nephrectomy analysis

OBJECTIVES

To evaluate the feasibility and accuracy of virtual partial nephrectomy analysis, including a color-coded three-dimensional virtual surgical planning and a quantitative functional analysis, in predicting the surgical outcomes of robot-assisted partial nephrectomy.

METHODS

Between 2012 and 2014, 20 patients underwent virtual partial nephrectomy analysis before undergoing robot-assisted partial nephrectomy. Virtual partial nephrectomy analysis was carried out with the following steps: (i) evaluation of the arterial branch for selective clamping by showing the vascular-supplied area; (ii) simulation of the optimal surgical margin in precise segmented three-dimensional model for prediction of collecting system opening; and (iii) detailed volumetric analyses and estimates of postoperative renal function based on volumetric change. At operation, the surgeon identified the targeted artery and determined the surgical margin according to the virtual partial nephrectomy analysis. The surgical outcomes between the virtual partial nephrectomy analysis and the actual robot-assisted partial nephrectomy were compared.

RESULTS

All 20 patients had negative cancer surgical margins and no urological complications. The tumor-specific renal arterial supply areas were shown in color-coded three-dimensional model visualization in all cases. The prediction value of collecting system opening was 85.7% for sensitivity and 100% for specificity. The predicted renal resection volume was significantly correlated with actual resected specimen volume (r(2) = 0.745, P < 0.001). The predicted estimated glomerular filtration rate was significantly correlated with actual postoperative estimated glomerular filtration rate (r(2) = 0.736, P < 0.001).

CONCLUSIONS

Virtual partial nephrectomy analysis is able to provide the identification of tumor-specific renal arterial supply, prediction of collecting system opening and prediction of postoperative renal function. This technique might allow urologists to compare various arterial clamping methods and resection margins with surgical outcomes in a non-invasive manner.

Robot-assisted versus laparoscopic partial nephrectomy for localized renal tumors: a meta-analysis

BACKGROUND

Robot-assisted partial nephrectomy (RAPN) is being performed more frequently for the minimally invasive management of localized renal tumors. However, it's unclear whether RAPN is more efficacious than the standard laparoscopic partial nephrectomy (LPN). The objective of this meta-analysis is to compare RAPN and LPN in terms of perioperative and oncologic outcomes for the treatment of localized renal tumors.

METHODS

A systematic search of electronic databases including MEDLINE, EMBASE and OVID was conducted. Comparative studies comparing RAPN and LPN for the treatment of localized renal tumors were regarded eligible. The mean difference (MD), odds ratio (OR) and their corresponding 95% confidence intervals (CI) were calculated for each outcome. The methodologic quality of the included studies was evaluated using the strict criteria of the Newcastle-Ottawa scale.

RESULTS

14 comparative studies (n = 1539 participants) were included in the present meta-analysis. Operative time was similar for RAPN and LPN (MD = 6.33, 95% CI [-23.93, 36.59]), however, warm ischemia time favored RAPN (MD = -3.29, 95% CI [-6.47, -0.10]). There was no significant difference in estimated blood loss (EBL) (MD = -42.24, 95% CI [-87.10, 2.61]) and length of stay (LOS) (MD = -0.29, 95% CI [-0.89, 0.32]). The incidence of intraoperative complications was similar for RAPN and LPN (OR = 0.68, 95% CI [0.29, 1.58]), as well as incidence of postoperative minor complications (OR = 1.10, 95% CI [0.80, 1.51]) and postoperative major complications distributions by Clavien classification (OR = 0.99, 95% CI [0.61, 1.61]). In addition, no significant difference was found in terms of positive surgical margin rate (OR = 1.12, 95% CI [0.56, 2.25]).

CONCLUSIONS

RAPN had similar operative time, LOS, EBL, and perioperative complications compared with LPN, as well as positive margin rates. RAPN appears to offer the advantage of decreased WIT compared with LPN. Studies with long-term follow up are needed to compare RAPN and LPN in terms of long-term complications and oncologic outcomes.

Predictive factors of complications after robot-assisted laparoscopic partial nephrectomy: a retrospective multicentre study

OBJECTIVE

To analyse the predictive factors of complications after robot-assisted laparoscopic partial nephrectomy (RALPN).

MATERIALS AND METHODS

Data from six French institutions on 240 patients who underwent RALPN between 2009 and 2011 were retrospectively reviewed. Clinical (age, body mass index, American Society of Anesthesiologists and Charlson comorbidity index scores, anticoagulant treatment), tumoral (size, R.E.N.A.L nephrometry score) and operative (surgeon experience, blood loss, opening of the collecting system, operating time) variables were considered. Univariate and multivariate regression models were used to assess the impact of these variables on the occurrence of global and major postoperative complications, classified according to the Clavien system.

RESULTS

The median (range) patient age was 61 (26-83) years. Tumours were of low complexity in 62% of cases. Median (range) operating time, blood loss and warm ischaemia time were 161 (45-425) min, 100 (0-2500) mL and 20 (0-59) min, respectively. Postoperative complications occurred in 79 (33%) patients. Complications were ≥ grade III in 25 (10%) patients and were mostly haemorrhagic. In multivariate analysis, surgeon's experience (hazard ratio [HR]: 2.14 [1.07-4.27], P = 0.03) and blood loss (HR: 1.002 [1.001-1.003], P < 0.001) were independent predictors of overall complications. When considering major complications, opening of the collecting system was the only factor that was significant (OR: 2.99 [1.2-7.26], P = 0.02). Nephrometry R.E.N.A.L. score was not associated with postoperative complications.

CONCLUSION

In our experience, RALPN is associated with a 30% risk of postoperative complications; surgeon's experience, blood loss and opening of the collecting system were the three predictors of postoperative complications.

Robot-assisted partial nephrectomy in contemporary practice

Laparoscopic renal surgery is associated with reduced blood loss, shorter hospital stay, enhanced cosmesis, and more rapid convalescence relative to open renal surgery. Laparoscopic partial nephrectomy (LPN) is a minimally invasive, nephron-sparing alternative to laparoscopic radical nephrectomy (RN) for the management of small renal masses. While offering similar oncological outcomes to laparoscopic RN, the technical challenges and prolonged learning curve associated with LPN limit its wider dissemination. Robot-assisted partial nephrectomy (RAPN), although still an evolving procedure with no long-term data, has emerged as a viable alternative to LPN, with favorable preliminary outcomes. This article provides an overview of the role of RAPN in the management of renal cell carcinoma. The clinical indications and principles of surgical technique for this procedure are discussed. The oncological, renal functional, and perioperative outcomes of RAPN are also evaluated, as are complication rates.