Robot-assisted partial nephrectomy vs. percutaneous cryoablation for T1a renal tumors: a single-center retrospective analysis of outcomes and costs

Renal vascular patterns assessment before robot-assisted partial nephrectomy: a video-based correlation with hilum dissection

PURPOSE

Surgical video review (SVR) is an emerging tool for assessing patient outcomes, especially in complex surgeries such as robot-assisted partial nephrectomy (RAPN). Adhesive probability and morphological scores are used to evaluate fat management and warm ischemia, respectively; however, the factors influencing renal hilum control (RHC) during RAPN have not yet been assessed. The aim of this study is to use SVR to identify the renal vascular patterns and factors that influence RHC.

METHODS

We evaluated 60 surgical video recordings of patients undergoing RAPN in 2023-2024, and measured the time to hilum control (THC) and total operation time (TOT) using a stopwatch. Patient and surgical factors were recorded and SPSS software was used to identify the correlation of these factors and vascular patterns with THC.

RESULTS

We observed a median THC of 22.7 min representing 15.1% of TOT. A significant correlation was found between previous renal surgery (p = 0.033), complex vascular anatomy on the right side (artery bifurcation behind IVC) or left side (more than one artery) (p = 0.02) and a longer THC. No significant difference was found between surgeons (p = 0.753) or surgical approach (transperitoneal vs. retroperitoneal, p = 0.87).

CONCLUSION

THC represents a relatively short part of the total RAPN time. Previous renal surgery and a complex vascular pattern with artery bifurcation behind IVC on the right side and more than one main renal artery on the left side, can lead to longer THC. A detailed understanding of renal vascular patterns can provide a patient-specific surgical planning and optimise strategies for RAPN.

Evaluation of factors predicting adherent perinephric fat in laparoscopic retroperitoenal partial nephrectomy

BACKGROUND

Adherent perinephric fat (APF) represents a clinical situation, which increases the complexity of renal surgery. We aimed to elucidate the common characteristics of patients with APF and to evaluate the extent of outcome differentiation depending on the presence of APF.

METHODS

We made a retrospective review of a prospectively maintained database of patients who underwent laparoscopic retroperitoneal partial nephrectomy for a localized renal tumor at our institution from May 2010 to January 2022. 238 patients were included in this study. Demographic, intraoperative, postoperative data and characteristics and comorbidities of all patients were evaluated. Radiographic data (tumor size, localization, side, exophytic rate, perinephric fat density [PFD]) were determined from preoperative contrast-enhanced abdominal computed tomography imaging studies. Adherent perinephric fat was classified intraoperatively by the operating surgeon. The patients were divided into two groups as the APF group and the non-APF group and predictors causing APF were investigated.

RESULTS

Intraoperative and postoperative complication rates were higher in the APF group, but the difference between intraoperative complication rates, operation duration and amount of bleeding were statistically significant. (11.6% vs. 5.9%, p = 0.033; 130 vs. 120 min, p = 0.024; 60 vs. 30 cc, p = 0.016, respectively). The most common complications were conversion to open surgery due to failure of dissection of the tumor and bleeding requiring intraoperative transfusion in the groups. On multivariable analysis using stepwise regression model, we identified male gender (OR = 3.328; 95% Cl = 1.552-7.133; p = 0.002), PFD>-100.4 Hounsfield Unit (HU) (OR = 3.24; 95% Cl = 1.549-6.777; p = 0.002) and presence of diabetes mellitus (DM) (OR = 2.513; 95% Cl = 1.192-5.299; p = 0.015), as predictor of APF.

CONCLUSION

Male gender, presence of DM and PFD>-100.4 HU are predictors of APF. This endpoint is promising for application in gaining knowledge preoperatively about the dissection difficulty level.

Comparative outcomes of retroperitoneal partial nephrectomy for cT1 and cT2 renal tumors: a single-center experience

BACKGROUND

Partial nephrectomy (PN) has been the main strategy for treating cT1 (≤ 7 cm) renal tumors. Previous studies have established PN's safety and effectiveness over radical nephrectomy (RN) for cT1 tumors. However, the efficacy and safety of retroperitoneal PN for larger renal tumors (> 7 cm) remained controversial. Through a size-based comparative analysis of cT1 and cT2 tumors undergoing retroperitoneal PN, we explored the impact of renal tumors larger than 7 cm on perioperative, oncological, and functional outcomes.

MATERIALS AND METHODS

From January 2017 to April 2021, we collected data from 201 patients undergoing retroperitoneal laparoscopic or robot-assisted PN. Of these, 173 (86.1%) had tumors ≤ 7 cm (Group A) and 28 (13.9%) had tumors > 7 cm (Group B). We analyzed demographics (gender, age, Body Mass Index, Charlson Comorbidity Index, preoperative hemoglobin and renal function, tumor location, operative method, RENAL score, and complexity), perioperative (operative time, warm ischemic time, estimated blood loss, hospital stay, surgical margins, complications), and functional outcomes (changes in renal function pre- and postoperatively), along with recurrence rates.

RESULTS

Mean tumor sizes in Group A and Group B were 3.67 ± 1.56 cm and 9.90 ± 2.97 cm, respectively. RENAL score analysis revealed a significant difference (7.64 vs. 9.21, P < 0.0001), attributed to the Radius and Exophytic/Endophytic property parameters. Furthermore, Group B exhibited significantly higher tumor complexity(P = 0.0009). In perioperative outcomes, Group B had a prolonged warm ischemic time (18.90 vs. 22.60 min, P = 0.0486). However, there was no significant difference in estimated blood loss and complication rates. Regarding functional outcomes, only the reduction of estimated glomerular filtration rate on postoperative day 1 was significant (-0.74 vs. -8.31, p = 0.016), with no significant differences at 3 months, 6 months, or 1 year postoperatively. For eGFR changes over time in Group B, declines at postoperative month 3 and postoperative year 1 were noted.

CONCLUSION

Despite higher preoperative RENAL scores and prolonged perioperative warm ischemic time, retroperitoneal PN for tumors > 7 cm demonstrated acceptable functional, oncological, and perioperative outcomes, with no observed gastrointestinal complications. Our findings support its feasibility as a treatment option for patients with > 7 cm or intermediate/high complexity renal tumors.

A meta-analysis of perioperative, oncological, and functional outcomes of robot-assisted partial nephrectomy for completely endophytic and hilar lesions

BACKGROUND

This study aims to compare the perioperative, functional, and oncological outcomes of robot-assisted partial nephrectomy in complex renal masses (CRM) with non-CRM tumors.

METHODS

A systematic literature review was conducted in PubMed, Embase, Web of Science, and Cochrane Library databases, following the PRISMA guidelines. The studies comparing RAPN outcomes between complex renal masses (CRM), specifically completely endophytic and hilar renal tumors, versus non-complex renal masses (non-CRM), which include non-endophytic, and non-hilar renal tumors.

RESULTS

Twelve studies involving 8126 patients were analyzed. The results revealed CRM group increased operative time (Mean Difference [MD]: 14.35 min; 95% CI: 5.14-23.55; p = 0.002), higher blood loss (MD: 20.42 mL; 95% CI: 0.83-40.02; p = 0.041), and greater decline in estimated glomerular filtration rate (eGFR) (MD: 2.19 mL/min/1.73 m2; 95% CI: 0.59-3.78; p = 0.007). Major complications were significantly more frequent in the CRM group (OR: 1.57; 95% CI: 1.15-2.13; p = 0.004). However, no significant differences were observed in length of hospital stay, positive surgical margins (PSM), or local recurrence rates.

CONCLUSIONS

RAPN for CRM is associated with longer operative times, increased blood loss, greater decline in eGFR, and higher rates of major complications. However, oncological outcomes (PSM and local recurrence rates) are comparable to those for non-CRM. These findings suggest that RAPN remains a feasible option for treating CRM in experienced centers, provided that careful patient selection and preoperative planning are followed.