Head to Head Impact of Margin, Ischemia, Complications, Score Versus a Novel Trifecta Score on Oncologic and Functional Outcomes After Robotic-assisted Partial Nephrectomy: Results of a Multicenter Series

An overview of renorrhaphy techniques for partial nephrectomy

Partial nephrectomy aims to provide both effective oncological management and renal function preservation. Surgical complications pertaining to the defect created during a partial nephrectomy include hemorrhage and urinary leak. Over time, approaches have advanced for managing the defect created during a partial nephrectomy. Herein, we explore techniques used for renorrhaphy in partial nephrectomy, its evolution and current state. We review the history of partial nephrectomy and the early techniques used to close the parenchymal defect, highlighting their advantages and disadvantages. The article then investigates the principles of renorrhaphy and the sliding clip technique. Modifications made to the sliding clip technique are depicted with illustrations. Single-layer versus double-layer closure and continuous versus interrupted sutures are evaluated. Non-renorrhaphy techniques, such as sealants and glues, used to seal the renal remnant are explored. By examining the evolution of renorrhaphy techniques, this article provides a comprehensive understanding of the improvements made in a key component of partial nephrectomy. We aim to provide novel insights towards better understanding the history and current state of renorrhaphy techniques in partial nephrectomy.

Trifecta outcomes of robotic partial nephrectomy in obese patients: A comparison of body mass index <25, 25 to <30, and ≥30

OBJECTIVE

We analyzed robotic partial nephrectomy (RPN) outcomes in obese patients based on body mass index (BMI) and trifecta achievement.

METHODS

We retrospectively reviewed 296 patients who underwent RPN at Kansai Medical University Hospital between 2014 and 2022. The preoperative clinical data and perioperative outcomes were evaluated. Trifecta achievement (negative surgical margin, no major complications, and no acute kidney injury on postoperative day three) and its relationship to three BMI groups (<25, 25 to <30, and ≥30) were the primary outcome. The correlation between factors in achieving trifecta and BMI was evaluated. Univariate and multivariate analyses assessed variables for achieving the trifecta with logistic regression analysis. C-statistics quantitatively evaluated the prediction accuracy.

RESULTS

Among 296 patients, 264 (89.2%) achieved trifecta (BMI categories were <25 [89.9%], 25 to <30 [89.4%], and ≥30 [82.6%]). There was no significant BMI-related difference (p = 0.566). Intraoperative blood loss increased with the BMI (p = 0.034). Multivariate analyses showed preoperative aspects and dimensions used for anatomic (PADUA) score independently predicted trifecta failure (odds ratio 1.71; 95% confidence interval 1.32-2.20; p < 0.001). The C-statistics of the PADUA score increased with increasing BMI.

CONCLUSIONS

Higher BMI patients had more intraoperative blood loss during RPN. However, RPN remains safe and has acceptable quality and functional outcomes. Since patients with high PADUA scores combined with a high BMI may be at risk of trifecta failure, this should be explained before RPN.

Impact of Mayo Adhesive Probability score and BMI on renal functional decline after robotic assisted partial nephrectomy

Purpose

The purpose of this study is to investigate the impact of Mayo Adhesive Probability (MAP) score and body mass index (BMI) on renal function decline after robotic assisted partial nephrectomy (RAPN).

Methods

We queried our prospective database for patients who underwent RAPN between January 2018 and December 2023. Outcomes were development of de novo CKD-S3 (estimated glomerular filtration rate [eGFR] < 60 ml/min/1.73 m2). Multivariable analysis (MVA) via Cox regression identified predictors for CKD-S3. Kaplan-Meier Analyses was fitted for survival assessment. Finally, multivariable linear regression was utilized to identify predictors of delta eGFR at last follow-up (preoperative eGFR-last eGFR).

Results

Two-hundred fifty-eight patients were analysed (obese n = 49 [19%]; MAP score 0-2 = 135 [52.33%]; MAP score 3-5 = 123 [47.6%]) with a median follow-up of 33 (IQR 20-42) months. MVA revealed, high MAP score (HR 2.29, p = 0.019), increasing RENAL score (HR 1.26, p = 0.009), increasing age (HR 1.04, p = 0.003), obesity (HR 2.38, p = 0.006) and diabetes mellitus (HR 2.38, p = 0.005) as associated with increased risk of development of CKD-S3, while trifecta achievement was not (p = 0.63). Comparing low MAP score versus high MAP score 4-year CKD-S3 free survival was 87.8% versus 56.1% (p < 0.001). Multivariable linear regression showed that high MAP score (coefficient 6.64, p = 0.001) and BMI (coefficient 0.51, p = 0.011) were significantly associated with increased delta eGFR at last follow up.

Conclusions

MAP score and increasing BMI are predictor for long term renal functional detrimental. These insights may call consideration for closer follow-up or greater medical scrutiny prior surgery in obese patients and with elevated MAP score. Further investigations are requisite.

A Novel Classification System of Renal Hilar Tumors for Surgical Guidance: Technique, Outcome, and Safety

BACKGROUND

This study was designed to develop an innovative classification and guidance system for renal hilar tumors and to assess the safety and effectiveness of robot-assisted partial nephrectomy (RAPN) for managing such tumors.

METHODS

A total of 179 patients undergoing RAPN for renal hilar tumors were retrospectively reviewed. A novel classification system with surgical techniques was introduced and the perioperative features, tumor characteristics, and the efficacy and safety of RAPN were compared within subgroups.

RESULTS

We classified the tumors according to our novel system as follows: 131 Type I, 35 Type II, and 13 Type III. However, Type III had higher median R.E.N.A.L., PADUA, and ROADS scores compared with the others (all p < 0.001), indicating increased operative complexity and higher estimated blood loss [180.00 (115.00-215.00) ml]. Operative outcomes revealed significant disparities between Type III and the others, with longer operative times [165.00 (145.00-200.50) min], warm ischemia times [24.00 (21.50-30.50) min], tumor resection times [13.00 (12.00-15.50) min], and incision closure times [22.00 (20.00-23.50) min] (all p < 0.005). Postoperative outcomes also showed significant differences, with longer durations of drain removal (77.08 ± 18.16 h) and hospitalization for Type III [5.00 (5.00-6.00) d] (all p < 0.05). Additionally, Type I had a larger tumor diameter than the others (p = 0.009) and pT stage differed significantly between the subtypes (p = 0.020).

CONCLUSIONS

The novel renal hilar tumor classification system is capable of differentiating the surgical difficulty of RAPN and further offers personalized surgical steps tailored to each specific classification. It provides a meaningful tool for clinical practice.

Surgical Outcomes of Hugo™ RAS Robot-Assisted Partial Nephrectomy for Cystic Renal Masses: Technique and Initial Experience

Background: The Hugo™ Robot-Assisted Surgery (RAS) system is a new cutting-edge robotic platform designed for clinical applications. Nevertheless, its application for cystic renal tumors has not yet been thoroughly investigated. In this context, we present an initial series of Robot-Assisted Partial Nephrectomy (RAPN) procedures carried out using the Hugo™ RAS system for cystic renal masses. Methods: Between October 2022 and January 2024, twenty-seven RAPN procedures for renal tumors were performed at Fondazione Policlinico Universitario Campus Bio-Medico. Our prospective board-approved dataset was queried for "cystic features" (n = 12). Perioperative data were collected. The eGFR was calculated according to the CKD-EPI formula. Post-operative complications were reported according to the Clavien-Dindo classification. Computed tomography (CT) scans for follow-up were performed according to the EAU guidelines. Trifecta was defined as the coexistence of negative surgical margin status, no Clavien-Dindo grade ≥ 3 complications, and eGFR decline ≤ 30%. Results: All the patients successfully underwent RAPN without the need for conversion or additional port placement. The median docking and console time were 5.5 (IQR, 4-6) and 79.5 min (IQR, 58-91 min), respectively. No intraoperative complications occurred, as well as clashes between instruments or with the bedside assistant. Two minor postoperative complications were recorded (Clavien-Dindo II). At discharge, serum creatinine and eGFR were comparable to preoperative values. Only one patient (8.4%) displayed positive surgical margins. The rate of trifecta achievement was 91.7%. Conclusions: RAPN for cystic renal masses using the novel Hugo™ RAS system can be safely and effectively performed. This robotic system provided satisfactory peri-operative outcomes, preserving renal function and displaying low postoperative complications and a high trifecta rate achievement.

Three-dimensional virtual model for robot-assisted partial nephrectomy: a propensity-score matching analysis with a contemporary control group

PURPOSE

To compare two cohorts of patients submitted to robot-assisted partial nephrectomy (RAPN) with vs without the use of three-dimensional virtual models (3DVMs).

METHODS

We screened a prospective consecutive cohort of 152 patients submitted to RAPN with 3DVM and 1264 patients submitted to RAPN without 3DVM between 2019 and 2022. Propensity score matching analysis (PSMA) was applied. Primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes at 12-month. Secondary endopoints were to compare perioperative and oncological outcomes. Multivariable logistic regression analyses (MVA) tested the associations of clinically significant eGFR drop and 3DVMs. Subgroups analysis was performed for PAUDA-risk categories.

RESULTS

100 patients for each group were analyzed after PSMA. RAPN with 3DVM presented a higher rate of selective/no clamping procedure (32% vs 16%, p = 0.03) and a higher enucleation rate (40% vs 29%, p = 0.04). As concern to primary endopoint, 12-month functional preservation performed better within 3DVM group in terms of creatinine serum level (median 1.2 [IQR 1.1-1.4] vs 1.6 [IQR 1.1-1.8], p = 0.03) and eGFR (median 64.6 [IQR 56.2-74.1] vs 52.3 [IQR 49.2-74.1], p = 0.03). However, this result was confirmed only in the PADUA ≥ 10 renal masses. Regarding secondary endpoints, no significative difference emerged between the two cohorts. MVA confirmed 3DVM as a protective factor for clinically significant eGFR drop only in high-risk (PADUA ≥ 10) masses.

CONCLUSIONS

RAPN performed with the use of 3DVM assistance resulted in lower incidence of global ischemia and higher rate of enucleations. The positive impact of such technology was found at 12-month only in high-risk renal masses.

Robot-assisted partial nephrectomy using the novel Hugo™ RAS system: Feasibility, setting and perioperative outcomes of the first off-clamp series

INTRODUCTION

Hugo Robot-Assisted Surgery (RAS) System has been conceived with enhanced modularity but its role for nephron-sparing surgery setting still remains poorly explored. We aimed to describe our experience in robot-assisted partial nephrectomy (RAPN) with a three-arms setting for the first off-clamp series using the new Hugo RAS System.

METHODS

Patients were placed on an extended flank position at the margin of the surgical bed with a slightly flexion (45°). The first 11 mm robotic trocar (camera port) was placed along the pararectal line 14 ± 2 cm far from the umbilicus. The pneumoperitoneum was then induced through the AirSeal system (SurgiQuest, Milford, Connecticut, USA©). Two more 8 mm operative robotic ports were placed under direct vision, either 8 ± 1 cm far from optic's port. Two 12 mm laparoscopic ports for bed-assistant were placed between robotic ports. Monopolar curved shears, fenestrated grasper, and large needle driver were used in a three-instruments configuration.

RESULTS

Off-clamp RAPN was successfully performed in seven patients with cT1 renal masses using a trans-peritoneal route. Median port placement and docking time was 6 min (IQR, 4-8 min). Hemostasis was achieved through renorraphy using a single transfix stitch with sliding clips technique. There was no need for additional ports placement. No intraoperative complications occurred, no clashing of robotic instruments or between the robotic arms was observed. No technical failures of the system occurred. Median console time was 83 min (IQR, 68-115 min). Median estimated blood loss were 200 ml (IQR, 50-400 ml). All patients were discharged between post-operative day 2 and 3, without the need of hospital readmission. No complications were recorded within the first 30 post-operative days.

CONCLUSIONS

We performed the first series of off-clamp RAPN using the novel HUGO RAS System. This novel robotic platform showed an easy-friendly docking system, providing excellent perioperative outcomes with a simple three-arms configuration.

Comparison of Perioperative, Functional, and Oncologic Outcomes of Open vs. Robot-Assisted Off-Clamp Partial Nephrectomy: A Propensity Scored Match Analysis

Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan-Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; p < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; p = 0.03), lower postoperative Clavien-Dindo ≤ 2 complications (1.3% vs. 18.3%, p < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, p = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09-4.46, p = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan-Meier analysis, no differences were observed between the two groups in terms of OS (log-rank p = 0.451), CSS (log-rank p = 0.476), DFS (log-rank p = 0.678), and MFS (log-rank p = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement.

Trifecta Outcomes of Robot-Assisted Partial Nephrectomy Using the New Hugo™ RAS System Versus Laparoscopic Partial Nephrectomy

(1) Background: Laparoscopic partial nephrectomy (LPN) is still performed in many referred urological institutions, representing a valid alternative to robot-assisted partial nephrectomy (RAPN). We aimed to compare trifecta outcomes of LPN and RAPN with the Hugo™ RAS System. (2) Methods: Between October 2022 and September 2023, eighty-nine patients underwent minimally invasive partial nephrectomy (group A, RAPN = 27; group B, Laparoscopic PN = 62) for localized renal tumors at our Institution. Continuous variables were presented as median and IQR and compared by means of the Mann-Whitney U test, while categorical variables were presented as frequencies (%) and compared by means of the χ2 test. (3) Results: Group A showed a higher rate of male patients (81.5% vs. 59.7%, p = 0.04) and a higher trend towards larger clinical tumor size (34 vs. 29 mm, p = 0.14). All the other baseline variables were comparable between the two groups (all p > 0.05). Regarding post-operative data, group A displayed a lower operative time (92 vs. 149.5 min, p = 0.005) and a shorter hospital stay (3 vs. 5, p = 0.002). A higher rate of malignant pathology was evidenced in group A (77.8% vs. 58.1%, p = 0.07) as well as a lower trend towards positive surgical margins (3.7% vs. 4.8%, p = 0.82), even if not statistically significant. (4) Conclusions: The rate of trifecta achievement was 92.6% and 82.3% for group A and B (p = 0.10), respectively. In terms of trifecta outcomes, RAPN using the Hugo™ RAS System showed comparable results to LPN performed by the same experienced surgeon.

Development and internal validation of a nomogram predicting 3-year chronic kidney disease upstaging following robot-assisted partial nephrectomy

PURPOSE

Aim of the present study was to develop and validate a nomogram to accurately predict the risk of chronic kidney disease (CKD) upstaging at 3 years in patients undergoing robot-assisted partial nephrectomy (RAPN).

METHODS

A multi-institutional database was queried to identify patients treated with RAPN for localized renal tumor (cT1-cT2, cN0, cM0). Significant CKD upstaging (sCKD-upstaging) was defined as development of newly onset CKD stage 3a, 3b, and 4/5. Model accuracy was calculated according to Harrell C-index. Subsequently, internal validation using bootstrapping and calibration was performed. Then nomogram was depicted to graphically calculate the 3-year sCKD-upstaging risk. Finally, regression tree analysis identified potential cut-offs in nomogram-derived probability. Based on this cut-off, four risk classes were derived with Kaplan-Meier analysis tested this classification.

RESULTS

Overall, 965 patients were identified. At Kaplan-Meier analysis, 3-year sCKD-upstaging rate was 21.4%. The model included baseline (estimated glomerular filtration rate) eGFR, solitary kidney status, multiple lesions, R.E.N.A.L. nephrometry score, clamping technique, and postoperative acute kidney injury (AKI). The model accurately predicted 3-year sCKD-upstaging (C-index 84%). Based on identified nomogram cut-offs (7 vs 16 vs 26%), a statistically significant increase in sCKD-upstaging rates between low vs intermediate favorable vs intermediate unfavorable vs high-risk patients (1.3 vs 9.2 vs 22 vs 54.2%, respectively, p < 0.001) was observed.

CONCLUSION

Herein we introduce a novel nomogram that can accurately predict the risk of sCKD-upstaging at 3 years. Based on this nomogram, it is possible to identify four risk categories. If externally validated, this nomogram may represent a useful tool to improve patient counseling and management.

Randomized Controlled Feasibility Trial of Robot-assisted Versus Conventional Open Partial Nephrectomy: The ROBOCOP II Study

BACKGROUND

There is no evidence from randomized controlled trials (RCTs) comparing robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN).

OBJECTIVE

To assess the feasibility of trial recruitment and to compare surgical outcomes between RAPN and OPN.

DESIGN, SETTING, AND PARTICIPANTS

ROBOCOP II was designed as single-center, open-label, feasibility RCT. Patients with suspected localized renal cell carcinoma referred for PN were randomized at a 1:1 ratio to either RAPN or OPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was the feasibility of recruitment, assessed as the accrual rate. Secondary outcomes included perioperative and postoperative data. Data were analyzed descriptively in a modified intention-to-treat population consisting of randomized patients who underwent surgery.

RESULTS AND LIMITATIONS

A total of 50 patients underwent RAPN or OPN (accrual rate 65%). In comparison to OPN, RAPN had lower blood loss (OPN 361 ml, standard deviation [SD] 238; RAPN 149 ml, SD 122; difference 212 ml, 95% confidence interval [CI] 105-320; p < 0.001), less need for opioids (OPN 46%; RAPN 16%; difference 30%, 95% CI 5-54; p = 0.024), and fewer complications according to the mean Comprehensive Complication Index (OPN 14, SD 16; RAPN 5, SD 15; difference 9, 95% CI 0-18; p = 0.008). OPN has a shorter operative time (OPN 112 min, SD 29; RAPN 130 min, SD 32; difference -18 min, 95% CI -35 to -1; p = 0.046) and warm ischemia time (OPN 8.7 min, SD 7.1; RAPN 15.4 min, SD 7.0; difference 6.7 min, 95% CI -10.7 to -2.7; p = 0.001). There were no differences between RAPN and OPN regarding postoperative kidney function.

CONCLUSIONS

This first RCT comparing OPN and RAPN met the primary outcome of the feasibility of recruitment; however, the window for future RCTs is closing. Each approach has advantages over the other, and both remain safe and effective options.

PATIENT SUMMARY

For patients with a kidney tumor, open surgery and robot-assisted keyhole surgery are both feasible and safe approaches for partial removal of the affected kidney. Each approach has known advantages. Long-term follow-up will explore differences in quality of life and cancer control outcomes.

Robot-Assisted Renal Surgery with the New Hugo Ras System: Trocar Placement and Docking Settings

The current literature relating to the novel HugoTM RAS System lacks consistent data concerning the bedside features of robot-assisted partial nephrectomy (RAPN). To describe the trocar placement and docking settings for RAPN with a three-arm configuration to streamline the procedure with HugoTM RAS, between October 2022 and April 2023, twenty-five consecutive off-clamp RAPNs for renal tumors with the HugoTM RAS System were performed. We conceived a trouble-free three-arm setting to ease and standardize RAPN trocar placement and docking settings with HugoTM RAS. Perioperative data were collected. Post-operative complications were reported according to the Clavien-Dindo classification. The eGFR was calculated according to the CKD-EPI formula. Continuous variables were presented as the median and IQR, while frequencies were reported as categorical variables. Off-clamp RAPNs were successfully performed in all cases without the need for conversion or additional port placement. The median age and BMI were 69 years (IQR, 60-73) and 27.3 kg/m2 (IQR, 25.7-28.1), respectively. The median tumor size and R.E.N.A.L. score were 32.5 mm (IQR, 26-43.7) and 6 (IQR, 5-7), respectively. Two patients were affected by cT2 renal tumors. The median docking and console time were 5 (IQR, 5-6) and 90 min (IQR, 68-135.75 min), respectively, with slightly progressive improvements in the docking time achieved. No intraoperative complications occurred alongside clashes between instruments or with the bed assistant. In experienced hands, this simplified three-instrument configuration of the HugoTM RAS System for off-clamp RAPN resulted in feasible and safe practice, providing patient-tailored trocar placement and docking with non-inferior peri-perioperative outcomes to other robotic platforms.

Impact of renal sinus protrusions on achieving trifecta in robot-assisted partial nephrectomy

Objective

The objective of this work is to assess the relationship between the morphological characteristics of a central tumour and the perioperative outcomes of robot-assisted partial nephrectomy (RAPN).

Subjects and Methods

We retrospectively analysed the data from 186 patients with central tumours involving the renal sinus, who underwent RAPN in a single-centre study between February 2015 and June 2022. All cases were assigned a RENAL nephrometry score based on preoperative images. The shape of the protruding portion of the tumour was classified into four types: 'flat', 'spherical', 'single-hump', and 'complex-hump', and was independently assessed by two readers. The trifecta is defined as the warm ischemia time within 25 min, negative surgical margins, and no major postoperative complications. Univariate and multivariate analyses were performed to identify the factors associated with the failing trifecta.

Results

Trifecta was achieved in 113 cases (60.8%), and the achievement rate in flat, spherical, single-hump, and complex-hump types was 83.3%, 74.5%, 64.3%, and 21.3%, respectively. Prolonged warm ischemia time was the primary cause of the failure to achieve the trifecta. The rate of positive surgical margins and upstage to pathological T3a was greater for complex humps while the rate of major complications and postoperative GFR preservation did not differ between shapes. On multivariate analysis for failing trifecta achievement, the complex-hump protrusion was found to be an independent positive predictor (odds ratio: 15.8; p < 0.001), whereas the height and width of protrusion were not significantly related.

Conclusions

The degree of difficulty varied among central tumours, and it was not possible to precisely measure it with existing scoring systems. Complex-hump protrusions strongly correlate with failure to achieve the trifecta. Preoperative assessment of the morphology of protrusion is useful for predicting outcomes.

3D renal model for surgical planning of partial nephrectomy: A way to improve surgical outcomes

OBJECTIVE

to evaluate the impact of 3D model for a comprehensive assessment of surgical planning and quality of partial nephrectomy (PN).

MATERIALS AND METHODS

195 patients with cT1-T2 renal mass scheduled for PN were enrolled in two groups: Study Group (n= 100), including patients referred to PN with revision of both 2D computed tomography (CT) imaging and 3D model; Control group (n= 95), including patients referred to PN with revision of 2D CT imaging. Overall, 20 individuals were switched to radical nephrectomy (RN). The primary outcome was the impact of 3D models-based surgical planning on Trifecta achievement (defined as the contemporary absence of positive surgical margin, major complications and ≤30% postoperative eGFR reduction). The secondary outcome was the impact of 3D models on surgical planning of PN. Multivariate logistic regressions were used to identify predictors of selective clamping and Trifecta's achievement in patients treated with PN (n=175).

RESULTS

Overall, 73 (80.2%) patients in Study group and 53 (63.1%) patients in Control group achieved the Trifecta (p=0.01). The preoperative plan of arterial clamping was recorded as clampless, main artery and selective in 22 (24.2%), 22 (24.2%) and 47 (51.6%) cases in Study group vs. 31 (36.9%), 46 (54.8%) and 7 (8.3%) cases in Control group, respectively (p<0.001). At multivariate logistic regressions, the use of 3D model was found to be independent predictor of both selective or super-selective clamping and Trifecta's achievement.

CONCLUSION

3D-guided approach to PN increase the adoption of selective clamping and better predict the achievement of Trifecta.

Surgical and functional outcomes of robot-assisted versus laparoscopic partial nephrectomy with cortical renorrhaphy omission

To evaluate the surgical and functional outcomes between robot-assisted (CRO-RAPN) vs. laparoscopic (CRO-LPN) methods of cortical-renorrhaphy-omitting partial nephrectomy. Between July 2012 and June 2020, patients with localized clinical T1-2 renal masses who underwent CRO-RAPN or CRO-LPN were reviewed. The outcomes of the two groups were compared using propensity-score matching. Trifecta was defined as negative surgical margin, warm ischemic time < 25 min, and absence of complications of Clavien-Dindo grade III or more until three months postoperatively. The preservation rate of the estimated glomerular filtration rate (eGFR) was evaluated at six months postoperatively. Among 291 patients (CRO-RAPN, n = 210; CRO-LPN, n = 81) included in the study, 150 matched pairs of patients were analyzed. Compared to the CRO-LPN group, the CRO-RAPN group was associated with shorter warm ischemic time (13 min vs. 20 min, P < 0.001), shorter total operation time (162 min vs. 212 min, P < 0.001), less estimated blood loss (40 mL vs. 119 mL, P = 0.002), lower incidence of overall complications (3% vs. 16%, P = 0.001), higher preservation rate of eGFR at six months postoperatively (93% vs. 89%, P = 0.003), and higher trifecta achievement rate (84% vs. 64%, P = 0.004). CRO-RAPN contributed to shorter warm ischemic time, less blood loss, fewer complications, and higher preservation of renal function, all of which allowed this technique to achieve a higher rate of trifecta compared to CRO-LPN.

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.

Surgical Quality, Antihypertensive Therapy, and Electrolyte Balance: A Novel Trifecta to Assess Long-Term Outcomes of Adrenal Surgery for Unilateral Primary Aldosteronism

BACKGROUND

To propose a trifecta that summarizes endpoints and predicts their maintenance after adrenalectomy (n = 90) for unilateral primary aldosteronism (UPA).

METHODS

Trifecta was defined as coexistence of: ≥50% antihypertensive therapeutic intensity score reduction (∆TIS), no hypokalemia at 3 months, and no Clavien grade 2-5. Logistic regression was used to identify predictors of trifecta. Probability of clinical, biochemical, and simultaneous success according to trifecta were assessed by Kaplan-Meier. Cox regression was used to identify predictors of long-term clinical, biochemical, and simultaneous success. For all analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Simultaneous success rate was 50%. On multivariable analysis, TIS was an independent predictor of trifecta achievement (HR 3.28; 95% CI 1.07-10.9; p = 0.03). At Kaplan-Meier, trifecta predicted higher success for all endpoints (each p < 0.03). On multivariable Cox analysis, adenoma size (AS) ≥6 cm and trifecta were independent predictors of biochemical (AS: HR 2.87; 95% CI 1.53-5.36; trifecta: HR 2.1; 95% CI 1.13-3.90; each p < 0.02) and simultaneous success (AS: HR 3.81; 95% CI 1.68-8.65; trifecta: HR 4.29; 95% CI 2.08-8.86; each p < 0.01), while trifecta was an independent predictor of complete clinical success (HR 2.84; 95% CI 1.45-5.58; p < 0.01).

CONCLUSIONS

Trifecta and AS are independent predictors of either long-term complete clinical, biochemical, or combined success after adrenalectomy for UPA.

External Validation of a Novel Comprehensive Trifecta System in Predicting Oncologic and Functional Outcomes of Partial Nephrectomy: Results of a Multicentric Series

BACKGROUND

To validate a novel trifecta for evaluating outcomes of partial nephrectomy (PN) on a multicentric dataset.

METHODS

Between 2007 and 2020, three renal cancer databases were queried for patients with solitary renal masses who underwent PN (n = 649). Trifecta was estimated for overall cohort and contributing centers. Overall survival (OS), cancer-specific survival (CSS) and end-stage renal disease (ESRD) probabilities were assessed by Kaplan-Meier. Cox regression was used to identify predictors of OS, CSS, ESRD. For all analyses, a p < 0.05 was considered significant.

RESULTS

At a median follow-up of 22.7 months (IQR 12.5-76.5) overall trifecta was 76.7% [Centre A; (n = 230; 68.6%), B (n = 68; 77.3%), C (n = 200; 88.4%); p = 0.001). On Kaplan-Meier, patients achieving trifecta exhibited higher OS (p = 0.024), higher CSS (p = 0.015) and lower ESRD rates (p = 0.024). On multivariable analysis, age (HR 1.04; 95% CI 1.01-1.08) and trifecta (HR 0.34; 95% CI 0.15-0.76) were independent predictors of OS while pT stage (HR 1.95; 95% CI 0.45-8.43) and trifecta (HR 0.33; 95% CI 0.16-0.67) were predictors of CSS (each p < 0.01). Preoperative CKD stage ≥ 3a (HR 13.1; 95% CI 4.07-42.6) and trifecta (HR 0.41; 95% CI 0.19-0.87) were independent predictors of ESRD (each p < 0.05).

CONCLUSIONS

On external validation, trifecta was an independent predictor of all PN endpoints, regardless of hilar control and ischemia duration.

Robot-Assisted versus Laparoscopic Partial Nephrectomy for Giant Sporadic Renal Angiomyolipomas of ≥7 cm: A Propensity Score-Matched Analysis

Background

To compare the perioperative and functional outcomes between robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for giant sporadic renal angiomyolipomas (AMLs) of ≥7 cm.

Materials and Methods

Patients with sporadic renal AMLs of ≥7 cm who underwent RAPN or LPN in the First Affiliated Hospital of Nanchang University between 2015 and 2020 were retrospectively analyzed. Propensity score matching (1 : 1) was performed to adjust for potential baseline confounders. Perioperative and functional outcomes of the RAPN and LPN groups were collected and compared.

Result

After propensity score matching, no statistically significant differences in baseline characteristics were found between the groups (41 vs. 41). Within the matched cohort, the warm ischemia time (WIT) in the RAPN group was significantly shorter than that in the LPN group (21 vs. 27 min, p < 0.001). In addition, the RAPN group was associated with improved postoperative renal function (72.8 vs. 69.8 mL/min/1.73 m², p=0.045). WIT and preoperative renal function are independent predictors of renal function at 6 months postoperatively, and renal score and operation method are independent predictors of WIT.

Conclusion

RAPN and LPN are safe and feasible minimally invasive treatments for sporadic giant renal AMLs, but RAPN is associated with shorter WIT and better postoperative renal functional preservation. WIT and preoperative renal function are independent predictors of renal function at 6 months postoperatively, while the RENAL score and surgical method are independent risk factors to WIT. For giant and complex renal AMLs, RAPN is the first choice when condition permits.

Risk factors for progression of chronic kidney disease after robotic partial nephrectomy in elderly patients: results from a multi-institutional collaborative series

BACKGROUND

Robotic partial nephrectomy (RPN) in patients ≥75 years is certainly underused with concerns regarding surgical quality and a negligible impact on renal function. The aim of this study was to identify predictors of progression of chronic kidney disease for purely off-clamp (ocRPN) and on-clamp RPN (onRPN) in elderly patients on a multi-institutional series.

METHODS

A collaborative minimally-invasive renal surgery dataset was queried for "RPN" performed between July 2007 and March 2021 and "age≥75 years". A total of 205 patients matched the inclusion criteria. Descriptive analyses were used. Frequencies and proportions were reported for categorical variables while medians and interquartile ranges (IQR) were reported for continuous variables. Baseline, perioperative and functional data were compared between groups. New-onset of stages 3b,4,5 CKD in onRPN and ocRPN cohorts was computed by Kaplan-Meier analysis. Univariable and multivariable Cox regression analyses were performed to identify predictors of progression to severe CKD (sCKD [stages ≥3b]). For all statistical analyses, a two-sided p < 0.05 was considered significant.

RESULTS

Mean age of the cohort considered was 78 years (IQR 76-80). At a median follow-up of 29 months (IQR 14.5-44.5), new onset CKD-3b and CKD-4,5 stages was observed in 16.6% and 2.4% of patients, respectively. At Kaplan-Meier analysis, onRPN was associated with a significantly higher risk of developing sCKD (p=0.002). On multivariable analysis, hypertension (HR 2.64; 95% CI 1.14-6.11; p=0.023), on-clamp approach (HR 3.41; 95% CI 1.50-7.74; p=0.003) non-achievement of trifecta (HR 0.36; 95% CI 0.17-0.78; p=0.01) were independent predictors of sCKD.

CONCLUSIONS

RPN in patients≥75 years is a safe surgical option. On-clamp approach, hypertension and non-achievement of trifecta were independent predictors of sCKD in the elderly after RPN.