Comparison of perioperative outcomes following transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a propensity-matched analysis of VCQI database

Randomised controlled feasibility trial of retroperitoneal vs transperitoneal robot-assisted partial nephrectomy: the ROPARN study

OBJECTIVES

To assess the feasibility of trial recruitment and confirm that retroperitoneal robotic partial nephrectomy (RRPN) has the same oncological efficacy as transperitoneal robotic partial nephrectomy (TRPN), with time advantages and less peri-operative morbidity, in a randomised controlled trial (RCT).

PATIENTS AND METHODS

The study was designed as a single-centre, open-label, feasibility RCT. Patients with suspected localised renal cell carcinoma referred for robotic partial nephrectomy were randomised in a 1:1 ratio to receive either TRPN or RRPN. The primary outcomes were trial feasibility, postoperative mobility and pain perception. Secondary outcomes were intra-operative times, assessment of complications, and comparison of positive surgical margin (PSM) rates. The data on all randomised patients who underwent surgery were analysed descriptively.

RESULTS

Sixty-one patients underwent TRPN or RRPN (31 vs 30). Postoperative mobility within 24 h after surgery (RRPN: 77 vs TRPN: 71%; P = 0.613), median postoperative pain, assessed using a numeric rating scale (RRPN: 1.5 vs TRPN: 1.8; P = 0.509), and full bowel canalisation within 3 days (RRPN: 100% vs TRPN: 90%; P = 0.315) were more favourable in the RRPN group, but the difference was not statistically significant. In comparison to TRPN, RRPN was associated with shorter operating time (81 vs 105 min; P = 0.005), shorter time on the console (49 vs 73 min; P < 0.001) and shorter time from console to renal artery preparation (7.5 vs 18 min; P < 0.001). TRPN required a shorter time from skin incision to console (16 vs 12 min; P = 0.001). There was no statistically significant difference in tumour complexity, ischaemia time, PSM rate, blood loss or complications between the two groups.

CONCLUSION

We present the first data from an RCT comparing RRPN with TRPN. RRPN showed significant time benefits while being a safe alternative to TRPN, with a similar PSM rate. There was less postoperative morbidity in the RRPN group, although this was not statistically significant. These results underline that dorsolateral renal tumours should be preferably resected by RRPN. Further multicentre RCTs are necessary to confirm these results.

Transperitoneal vs retroperitoneal robotic partial nephrectomy: a meta-analysis and systematic review of propensity-matched studies

The main aim of this meta-analysis is to assess and compare the impact of two different surgical approaches, transperitoneal and retroperitoneal, on perioperative outcomes in robotic partial nephrectomy. A systematic search of MEDLINE, PubMed, Google Scholar, and the Cochrane Database was conducted to identify relevant studies published between January 2000 and January 2025. Included were nine non-randomized controlled trials with a total of 2420 patients with matching propensity scores. Among these patients, 1321 had robotic TPPN and 1099 had robotic RPPN, the abbreviation for robotic partial nephrectomy. Shorter operating times, shorter hospital stays, less estimated intraoperative blood loss, and fewer total postoperative problems were related to RPPN compared to TPPN. There were no notable disparities between the two groups when comparing the duration of renal ischemia, the fall in postoperative glomerular filtration rate (GFR), the occurrence of serious postoperative sequelae, or the necessity for blood transfusions. Compared to TPPN, RPPN demonstrates certain advantages in perioperative metrics such as surgical time, hospital stay, and overall complication rates. However, further high-quality studies are needed to confirm these findings.

Conversions in robot-assisted partial nephrectomy: a multicentric analysis of 2549 cases

BACKGROUND

Conversion in partial nephrectomy to radical nephrectomy occurs in 1-5%. This analysis assessed predictors for conversions in robot-assisted partial nephrectomies.

METHODS

Two thousand five hundred forty-nine patients at eight robotic centers for robot-assisted partial nephrectomy were retrospectively analyzed. Intervention was performed by 25 surgeons with varying expertise. Conversion was defined as change from robot-assisted partial nephrectomy to open partial, open radical or robot-assisted radical nephrectomy. Comparative analyses between converted and non-converted cases and within subgroups as well as multivariate regression analyses for predictors for conversion were performed.

RESULTS

Eighty-eight (3.5%) conversions were documented (17% open nephrectomy, 53% open partial nephrectomy, 30% robot-assisted nephrectomy). In case of conversion, patients were significantly older (P<0.001) with a higher Body Mass Index (BMI; P=0.029), larger tumor size (P<0.001), multiple tumors (P<0.001) and higher PADUA scores (P<0.001). Converting surgeons had a significantly lower experience in RAPN (median EXP 64 vs. 29, P<0.001). The main reasons to convert were unfavorable anatomic features (69%). Radical nephrectomy occurred more frequently in tumors with higher PADUA Score (P<0.001). Experienced surgeons in open renal surgery performed more often open partial nephrectomy in case of open conversion (P<0.001). Patients' age, BMI, surgeon's expertise, number of tumors, tumor size and PADUA Score were independent predictors for conversion (P<0.001). Limitations are the retrospective study design and short-term follow-up.

CONCLUSIONS

Conversions in robot-assisted partial nephrectomy are predominantly determined by patient- and tumor-related factors, but also surgical experience. Intensified surgical training might reduce the risk of conversions with an increased chance for nephron-sparing surgery in converted cases.

Perioperative and functional outcomes following robot-assisted partial nephrectomy: Descriptive analysis of Indian study group on partial nephrectomy database

Introduction

There is an unmet need for high-quality data for Robot-assisted partial nephrectomy (RAPN) in the Indian population. Indian study group on partial nephrectomy (ISGPN) is a consortium of Indian centers contributing to the partial nephrectomy (PN) database. The current study is a descriptive analysis of perioperative and functional outcomes following RAPN.

Methods

For this study, the retrospective ISGPN database was reviewed, which included patients who underwent RAPN for renal masses at 14 centers across India from September 2010 to September 2022. Demographic, clinical, radiological, perioperative, and functional data were collected and analyzed. Ethics approval was obtained from each of the participating centers.

Results

In this study, 782 patients were included, and 69.7% were male. The median age was 53 years (interquartile range [IQR 44-62]), median operative time was 180 min (IQR 133-240), median estimated blood loss was 100 mL (IQR 50-200), mean warm ischemia time was 22.7 min and positive surgical margin rates were 2.5%. The complication rate was 16.2%, and most of them were of minor grade. Trifecta and pentafecta outcomes were attained in 61.4% and 60% of patients, respectively.

Conclusions

This is the largest Indian multi-centric study using the Indian Robotic PN Collaborative database to evaluate the outcomes of robot-assisted PN, and has proven its safety and efficacy in the management of renal masses.

Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review and meta-analysis

INTRODUCTION

Robot-assisted partial nephrectomy (RAPN) can be performed either by a transperitoneal (TP) or a retroperitoneal (RP) approach. However, the superiority of one approach over the other is not established. Hence, the primary aim of this review was to compare perioperative outcomes between these two surgical approaches.

METHODS

Literature was systematically searched to identify studies reporting perioperative outcomes following TP RAPN and RP RAPN. The study protocol was registered with PROSPERO (CRD42023399496). The primary outcome was comparing complication rates between the two approaches.

RESULTS

This review included 22 studies, 5675 patients, 2524 in the RP group, and 3151 in the TP group. The overall complications were significantly lower in the RP group [Odds ratio (OR) 0.80 (0.67, 0.95), p = 0.01]. However, the rate of major complications was similar between the two groups. The operative time was significantly shorter with the RP group [Mean Difference (MD)-16.7 (- 22.3, - 11.0), p =  < 0.0001]. Estimated blood loss (EBL) and need for blood transfusion (BT) were significantly lower in the RP group. There was no difference between the two groups for conversion to radical nephrectomy [OR 0.66 (0.33, 1.33), p = 0.25] or open surgery [OR 0.68 (0.24, 1.92, p = 0.47] and positive surgical margins [OR 0.93 (0.66, 1.31, p = 0.69]. Length of stay (LOS) was shorter in the RP group [MD - 0.27 (- 0.45, - 0.08), p =  < 0.00001].

CONCLUSIONS

RP approach, compared to TP, has significantly lower complication rates, EBL, need for BT and LOS. However, due to the lack of randomized studies on the topic, further data is required.

Single-port vs multi-port robot-assisted renal surgery: analysis of perioperative outcomes for excision of high and low complexity renal masses

There is emerging but limited data assessing single-port (SP) robot-assisted surgery as an alternative to multi-port (MP) platforms. We compared perioperative outcomes between SP and MP robot-assisted approaches for excision of high and low complexity renal masses. Retrospective chart review was performed for patients undergoing robot-assisted partial or radical nephrectomy using the SP surgical system (n = 23) at our institution between November 2019 and November 2021. Renal masses were categorized as high complexity (7+) or low complexity (4-6) using the R.E.N.A.L. nephrometry scoring system. Adjusting for baseline characteristics, patients were matched using a prospectively maintained MP database in a 2:1 (MP:SP) ratio. For high complexity tumors (n = 12), SP surgery was associated with a significantly longer operative time compared to MP (248.4 vs 188.1 min, p = 0.02) but a significantly shorter length of stay (1.9 vs 2.8 days, p = 0.02). For low complexity tumors (n = 11), operative time (177.7 vs 161.4 min, p = 0.53), estimated blood loss (69.6.0 vs 142.0 mL, p = 0.62), and length of stay (1.6 vs 1.8 days, p = 0.528) were comparable between SP and MP approaches. Increasing nephrometry score was associated with a greater relative increase in operative time for SP compared to MP renal surgery (p = 0.07) using best of fit linear modeling. SP robot-assisted partial and radical nephrectomy is safe and feasible for low complexity renal masses. For high complexity renal masses, the SP system is associated with a significantly longer operative time compared to the MP technique. Careful consideration should be given when selecting patients for SP robot-assisted kidney surgery.

Retroperitoneal vs. transperitoneal robotic partial nephrectomy: a multicenter propensity-score matching analysis (PADORA Study - UroCCR n° 68)

BACKGROUND

Robot-assisted partial nephrectomy can be performed through either a transperitoneal or retroperitoneal approach. This study aimed to compare the rate of trifecta achievement between retroperitoneal (RRPN) and transperitoneal (TRPN) robot-assisted partial nephrectomy using a large multicenter prospectively-maintained database and propensity-score matching analysis.

METHODS

This study was launched by the French Kidney Cancer Research Network, under the UroCCR Project (NCT03293563). Patients who underwent TRPN or RRPN by experienced surgeons in 15 participating centers were included. Data on demographic and clinical parameters, tumor characteristics, renal function, and surgical parameters were collected. The primary outcome was the rate of trifecta achievement, which was defined as a warm ischemia time of less than 25 minutes, negative surgical margins, and no major complications. Secondary outcomes included operative time, hospital length-of-stay, blood loss, postoperative complications, postoperative renal function, and each trifecta item taken alone. Subgroup analysis was done according to tumor location.

RESULTS

A total of 2879 patients (2581 TRPN vs. 298 RRPN) were included in the study. Before matching, trifecta was achieved in 73.0% of the patients in the TRPN group compared to 77.5% in the RRPN group (P=0.094). After matching 157 patients who underwent TRPN to 157 patients who underwent RRPN, the trifecta rate was 82.8% in the TRPN group vs. 84.0% in the RRPN group (P=0.065). The RRPN group showed shorter operative time (123 vs. 171 min; P<0.001) and less blood loss (161 vs. 293 mL; P<0.001). RRPN showed a higher trifecta achievement for posterior tumors than TRPN (71% vs. 81%; P=0.017).

CONCLUSIONS

RRPN is a viable alternative to the transperitoneal approach, particularly for posterior renal tumors, and is a safe and effective option for partial nephrectomy.

Perioperative outcomes following robot-assisted partial nephrectomy in elderly patients

OBJECTIVE

To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with age ≥ 70 years to age < 70 years.

METHODS

Using Vattikuti Collective quality initiative (VCQI) database for RAPN we compared perioperative outcomes following RAPN between the two age groups. Primary outcome of the study was to compare trifecta outcomes between the two groups. Propensity matching using nearest neighbourhood method was performed with trifecta as primary outcome for sex, body mass index (BMI), solitary kidney, tumor size and Renal nephrometery score (RNS).

RESULTS

Group A (age ≥ 70 years) included 461 patients whereas group B included 1932 patients. Before matching the two groups were statistically different for RNS and solitary kidney rates. After propensity matching, the two groups were comparable for baselines characteristics such as BMI, tumor size, clinical symptoms, tumor side, face of tumor, solitary kidney and tumor complexity. Among the perioperative outcome parameters there was no difference between two groups for operative time, blood loss, intraoperative transfusion, intraoperative complications, need for radical nephrectomy, positive margins and trifecta rates. Warm ischemia time was significantly longer in the younger age group (18.1 min vs. 16.3 min, p = 0.003). Perioperative complications were significantly higher in the older age group (11.8% vs. 7.7%, p = 0.041). However, there was no difference between the two groups for major complications.

CONCLUSION

RAPN in well-selected elderly patients is associated with comparable trifecta outcomes with acceptable perioperative morbidity.

Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy

BACKGROUND

Ability to predict the risk of intraoperative adverse events (IOAEs) for patients undergoing partial nephrectomy (PN) can be of great clinical significance.

OBJECTIVE

To develop and internally validate a preoperative nomogram predicting IOAEs for robot-assisted PN (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

In this observational study, data for demographic, preoperative, and postoperative variables for patients who underwent RAPN were extracted from the Vattikuti Collective Quality Initiative (VCQI) database.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

IOAEs were defined as the occurrence of intraoperative surgical complications, blood transfusion, or conversion to open surgery/radical nephrectomy. Backward stepwise logistic regression analysis was used to identify predictors of IOAEs. The nomogram was validated using bootstrapping, the area under the receiver operating characteristic curve (AUC), and the goodness of fit. Decision curve analysis (DCA) was used to determine the clinical utility of the model.

RESULTS AND LIMITATIONS

Among the 2114 patients in the study cohort, IOAEs were noted in 158 (7.5%). Multivariable analysis identified five variables as independent predictors of IOAEs: RENAL nephrometry score (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.25); clinical tumor size (OR 1.01, 95% CI 1.001-1.024); PN indication as absolute versus elective (OR 3.9, 95% CI 2.6-5.7) and relative versus elective (OR 4.2, 95% CI 2.2-8); Charlson comorbidity index (OR 1.17, 95% CI 1.05-1.30); and multifocal tumors (OR 8.8, 95% CI 5.4-14.1). A nomogram was developed using these five variables. The model was internally valid on bootstrapping and goodness of fit. The AUC estimated was 0.76 (95% CI 0.72-0.80). DCA revealed that the model was clinically useful at threshold probabilities >5%. Limitations include the lack of external validation and selection bias.

CONCLUSIONS

We developed and internally validated a nomogram predicting IOAEs during RAPN.

PATIENT SUMMARY

We developed a preoperative model than can predict complications that might occur during robotic surgery for partial removal of a kidney. Tests showed that our model is fairly accurate and it could be useful in identifying patients with kidney cancer for whom this type of surgery is suitable.

Perioperative outcomes following robot-assisted partial nephrectomy for complex renal masses: A Vattikuti Collective Quality Initiative database study

Introduction

Outcomes of robot-assisted partial nephrectomy (RAPN) depend on tumor complexity, surgeon experience and patient profile among other variables. We aimed to study the perioperative outcomes of RAPN for patients with complex renal masses using the Vattikuti Collective Quality Initiative (VCQI) database that allowed evaluation of multinational data.

Methods

From the VCQI, we extracted data for all the patients who underwent RAPN with preoperative aspects and dimensions used for an anatomical (PADUA) score of ≥10. Multivariate logistic regression was conducted to ascertain predictors of trifecta (absence of complications, negative surgical margins, and warm ischemia times [WIT] <25 min or zero ischemia) outcomes.

Results

Of 3,801 patients, 514 with PADUA scores ≥10 were included. The median operative time, WIT, and blood loss were 173 (range 45-546) min, 21 (range 0-55) min, and 150 (range 50-3500) ml, respectively. Intraoperative complications and blood transfusions were reported in 2.1% and 6%, respectively. In 8.8% of the patients, postoperative complications were noted, and surgical margins were positive in 10.3% of the patients. Trifecta could be achieved in 60.7% of patients. Clinical tumor size, duration of surgery, WIT, and complication rates were significantly higher in the group with a high (12 or 13) PADUA score while the trifecta was significantly lower in this group (48.4%). On multivariate analysis, surgical approach (retroperitoneal vs. transperitoneal) and high PADUA score (12/13) were identified as predictors of the trifecta outcomes.

Conclusion

RAPN may be a reasonable surgical option for patients with complex renal masses with acceptable perioperative outcomes.