Perioperative complications of robot-assisted partial nephrectomy

Timing, incidence and management of delayed bleeding after partial nephrectomy in patients at risk for recurrent, bilateral, multifocal renal tumors

INTRODUCTION

Delayed bleeding is a potentially serious complication after partial nephrectomy (PN), with reported rates of 1%-2%. Patients with multiple renal tumors, including those with hereditary forms of kidney cancer, are often managed with resection of multiple tumors in a single kidney which may increase the risk of delayed bleeding, though outcomes have not previously been reported specifically in this population. The objective of this study was to evaluate the incidence and timing of delayed bleeding as well as the impact of intervention on renal functional outcomes in a cohort primarily made up of patients at risk for bilateral, multifocal renal tumors.

METHODS

A retrospective review of a prospectively maintained database of patients with known or suspected predisposition to bilateral, multifocal renal tumors who underwent PN from 2003 to 2023 was conducted. Patients who presented with delayed bleeding were identified. Patients with delayed bleeding were compared to those without. Comparative statistics and univariate logistic regression were used to determine potential risk factors for delayed bleeding.

RESULTS

A total of 1256 PN were performed during the study period. Angiographic evidence of pseudoaneurysm, AV fistula and/or extravasation occurred in 24 cases (1.9%). Of these, 21 were symptomatic presenting with gross hematuria in 13 (54.2%), decreasing hemoglobin in 4(16.7%), flank pain in 2(8.3%), and mental status change in 2 (8.3%), while 3 patients were asymptomatic. Median number of resected tumors was 5 (IQR 2-8). All patients underwent angiogram with super-selective embolization. Median time to bleed event was 13.5 days (IQR 7-22). Factors associated with delayed bleeding included open approach (OR 2.2, IQR(1.06-5.46), P = 0.04 and left-sided surgery (OR 4.93, IQR(1.67-14.5), P = 0.004. Selective embolization had little impact on ultimate renal functional outcomes, with a median change of 11% from the baseline eGFR after partial nephrectomy and embolization. One patient required total nephrectomy for refractory bleeding after embolization.

CONCLUSIONS

Delayed bleeding after PN in a cohort of patients with multifocal tumors is an infrequent event, with similar rates to single tumor series. Patients should be counseled regarding timing and symptoms of delayed bleeding and multidisciplinary management with interventional radiology is critical for timely diagnosis and treatment.

Intermediate to Long-Term Clinical Outcomes of Percutaneous Cryoablation for Renal Masses

PURPOSE

The purpose of this study was to evaluate the effectiveness and adverse outcomes of percutaneous cryoablation (CA) for treatment of renal masses in a large cohort of patients.

MATERIALS AND METHODS

This retrospective analysis included 299 CA procedures (297 masses in 277 patients) performed between July 2007 and May 2018 at a single institution. The mean patient age was 66.1 years (range, 30-93 years) with 65.8% being male. A total of 234 (78.8%) masses were biopsy-proven renal cell carcinoma (RCC). The mean maximal tumor diameter was 2.5 cm (range, 0.7-6.6 cm). Efficacy was assessed only for ablations of biopsy-proven RCC, whereas the evaluation of adverse events and renal function included all masses. Complications were graded according to the Society of International Radiology classification.

RESULTS

Major complications occurred in 3.0% of procedures (n = 9), none of which resulted in death or permanent disability. The mean imaging follow-up period was 27.4 months (range, 1-115) for the 199 RCC patients (204 ablated tumors) with follow-up imaging available. Complete response on initial follow-up imaging at mean 4.2 months (range, 0.3-75.6) was achieved in 195 of 204 tumors (95.6%) after a single session and in 200 of 204 tumors (98.0%) after 1 or 2 sessions. Of the RCC patients achieving complete response initially, local recurrence during the follow-up period occurred in 3 of 200 tumors (1.5%). Metastatic progression occurred in 10 of 193 (5.2%) RCC patients without prior metastatic disease during follow-up.

CONCLUSIONS

CA for renal masses is safe and remains efficacious through intermediate- and long-term follow-up.

Complications of Minimally Invasive Surgery and Their Management

Minimally invasive surgery, including both traditional laparoscopic and robot-assisted laparoscopic approaches, has increasingly become the standard of care for urologic abdominal and pelvic surgery. This is a comprehensive review of the contemporary literature regarding complications of laparoscopic and robotic urologic surgery. The review highlights pertinent studies with the goal of providing the minimally invasive urologic surgeon with an up-to-date overview of general and procedure-specific complications and their management.

Robot-assisted renal surgery: current status and future directions

This paper examines the current role of robot-assisted renal surgery as complex and partial nephrectomies, including vena cava thrombus, combined nephroureterectomies, living donor nephrectomy, autotransplantation, and difficult anatomy as in patients with obesity or adhesions. Indications for robot-assisted renal surgery are comparable to those of conventional laparoscopic approaches. A reduction in the learning curve leads to a stabilization of the procedure and further increases the number of minimally invasive procedures performed. A Medline literature search for publications on the field of robotic kidney surgery has been performed using the MeSH terms: robotic surgical procedures and kidney. Future directions include progress in robotic technology and instrumentation with further miniaturization of robotic procedures as laparoendoscopic single-site interventions and progress in image-guided robotic surgery.

Impact of fellowship training on robotic-assisted laparoscopic partial nephrectomy: benchmarking perioperative safety and outcomes

To provide perioperative benchmark data for surgeons entering practice from formal robotic training and performing robotic-assisted laparoscopic partial nephrectomy (RAPN). Perioperative outcomes of the first 100 RAPN from a surgeon entering into practice directly from robotic fellowship training were analyzed. Postoperative complications were categorized by Clavien-Dindo grade. Surgical "trifecta scores" and Margin, Ischemia, and Complication (MIC) scoring were utilized to assess surgical outcomes. Statistical analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, North Carolina). Median age of the cohort was 63 years (22-81 years), and 34 (34.3%) patients were over age 65. Forty-one (41.4%) patients had a BMI > 30. Thirteen (13.1%) had RENAL 10-12 tumors, 22 of which (22.2%) were >4 cm in size. Median warm ischemia time was 17 min, and 13 patients had resection without warm ischemia. Five patients were converted to open partial nephrectomy, and 1 patient was converted to laparoscopic nephrectomy. Twenty-one patients (21.2%) experienced a complication, 6 of whom had a major (Clavien grade 3 or higher) complication with one grade 5 complication. Operating room time decreased with experience, but surgical complications and hospital stay did not change with experience. MIC score of renal cell carcinoma (RCC) patients was 74.7%, while the surgical trifecta was reached in 71.3 % of RCC patients. Surgeons may enter practice directly from formal robotic training and perform RAPN with perioperative outcomes, surgical complications, surgical trifecta scores, and MIC scoring in line with those the most experienced robotic partial nephrectomists.

[Robot-assisted laparoscopic partial nephrectomy: functional and oncological outcomes]

BACKGROUND

In recent years, small renal masses (SRM) have been increasingly detected as an incidental finding of radiological or ultrasound studies for other indications. Organ-sparing renal tumor resection as open partial nephrectomy (OPN) is the international standard for renal tumors <7 cm.

RESULTS

Due to technical developments, minimally invasive procedures have emerged as an alternative to OPN. In experienced hands, conventional laparoscopic partial nephrectomy (LPN) has achieved good functional and oncological results comparable to OPN. Robot-assisted laparoscopic partial nephrectomy (RAPN) has been performed since 2004. Compared to LPN, RAPN provides a faster learning curve, better visualization and more versatile instrumentation due to the degrees of freedom of the articulated instruments. After about 30 procedures, a level of experience is reached, which is characterized by good functional results, less blood loss, and shorter warm ischemia time of the kidney as compared to LPN. This can relate to a shorter hospital stay and faster recovery. Complications according to the Clavien classification are mostly grade I and II and are mainly treated conservatively.

CONCLUSION

Oncological long-term results are not available yet; so that RAPN cannot be considered as an equivalent treatment to LPN and OPN. Until long-term evidence is available, decisions regarding the surgical technique for organ-sparing renal tumor resection will be determined by patient's wishes and surgeon's preference.

Laparoscopic surgery in patients with liver cirrhosis with gallbladder stones: Effect on immunity and complications

AIM: To study the effect of laparoscopic surgery on immunity and complications in patients with liver cirrhosis and gallbladder stones.

METHODS: Eighty patients with liver cirrhosis and gallbladder stones were randomly divided into either an observation group or a control group. Patients in the observation group underwent laparoscopic surgery, and patients in the control group underwent open surgery. Arterial blood samples were taken to determine plasma concentrations of adrenaline, norepinephrlne and dopamine. Intraoperative blood loss, operative time, flow rate, and length of hospital stay were recorded. C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and T lymphocyte subsets (CD4, CD8) were determined.

RESULTS: Intraoperative blood loss, operative time, postoperative flow and drainage time, anal exhaust time and hospital stay in the observation group were significantly lower than those in the control group (165.84 mL ± 50.23mL vs 240.33 mL ± 150.56 mL, 91.78 min ± 21.74 min vs 137.94 min ± 30.55 min, 274.37 mL ± 121.15 mL vs 418.53 mL ± 132.24 mL, 2.34 d ± 1.46 d vs 5.72 d ± 1.84 d, 1.33 d ± 0.73 d vs 2.73 d ± 1.33 d, 8.43 d ± 1.24 d vs 11.54 d ± 3.22 d, P < 0.05 for all). The levels of CRP, IL-6 and TNF-α in the observation group were significantly lower than those in the control group (6.13 mg/L ± 1.64 mg/L vs 14.24 mg/L ± 2.52 mg/L, 9.44 pg/mL ± 1.65 pg/mL vs 12.82 pg/mL ± 1.54 pg/mL, 10.42 pg/mL ± 1.64 pg/mL vs 19.83 pg/mL ± 1.53 pg/mL, P < 0.05 for all). Preoperatively, there were no significant differences in the percentages of CD4⁺ and CD8⁺ lymphocytes or CD4/CD8 ratio between the observation group and control group (42.53% ± 4.63% vs 42.42% ± 4.64%, 29.32% ± 2.44% vs 29.13% ± 2.64%, 1.65 ± 0.26 vs 1.66 ± 0.24, P > 0.05 for all). On postoperative days 1 and 3, the percentages of CD4⁺ and CD8⁺ lymphocytes and CD4/CD8 ratio were significantly higher in the observation group than in the control group (day 1: 33.22% ± 2.52% vs 28.24% ± 2.74%, 19.83% ± 2.53% vs 14.24% ± 2.52%, 1.11 ± 0.23 vs 0.73 ± 0.33, P < 0.05 for all; day 3: 39.42% ± 2.64% vs 34.12% ± 2.34%, 24.44% ± 2.65 vs 19.82% ± 2.54%, 1.43 ± 0.24 vs 1.04 ± 0.22, P < 0.05 for all). The percentages of CD4⁺ and CD8⁺ lymphocytes and CD4/CD8 ratio were significantly higher on postoperative days 1 and 3 in both groups compared with preoperative values (P < 0.05 for all). The percentages of patients developing infection and hypoalbuminemia were significantly lower in the observation group than in the control group (7.5% vs 25.0%, 10.0% vs 30.0%, P < 0.05). The incidence of blood coagulation dysfunction did not differ significantly between the two groups (20.0% vs 25.0%, P > 0.05).

CONCLUSION: Compared with open surgery, laparoscopic surgery is associated with less trauma, more rapid recovery, lower effect on immune function and response, and lower incidence of adverse reactions in patients with liver cirrhosis and gallbladder stones.