Contemporary rates and predictors of open conversion during minimally invasive partial nephrectomy for kidney cancer

Comparison of In-Hospital Outcomes at Robot-Assisted Versus Open Partial Nephrectomy

OBJECTIVE

The aim of this work is to quantify the magnitude of improvement in in-hospital outcomes between historical and contemporary robot-assisted partial nephrectomy (RPN) versus historical and contemporary open PN (OPN).

METHODS

Within the Nationwide Inpatient Sample (2010-2019), we identified patients who underwent RPN and OPN. Multivariable logistic regression models were fit.

RESULTS

Historical (2010-2014) versus contemporary (2015-2019) proportions were 39% (n = 5,897) versus 61% (n = 9168) for RPN and 59% (n = 7289) versus 41% (n = 5,120) for OPN. Relative to historical, contemporary RPN patients exhibited significantly better in-hospital outcomes in 6 of 12 categories that ranged from-76% for intraoperative complications to-24% for length of stay (LOS) ≥ 75th percentile. Relative to historical, contemporary OPN patients also exhibited significantly better in-hospital outcomes in 7 of 12 categories that ranged from-76% for intraoperative complications to-23% for LOS ≥ 75th percentile. When historical RPN was compared with historical OPN, RPN in-hospital outcomes were better in 10 of 12 comparisons that ranged from-75% for LOS ≥ 75th percentile to-28% for perioperative bleeding. Similarly, when contemporary RPN was compared with contemporary OPN, RPN outcomes were better in 8 of 12 comparisons that ranged from-75% for LOS ≥ 75th percentile to-27% for postoperative complications.

CONCLUSION

The magnitude of improvement in in-hospital outcomes was more pronounced for contemporary versus historical OPN (seven improved categories) than for contemporary versus historical RPN (six improved categories). However, contemporary RPN outperformed contemporary OPN patients in eight in-hospital outcome categories.

Trends, outcomes, and predictors of open conversion during minimally invasive radical nephroureterectomy for upper tract urothelial carcinoma: a national analysis from 2010 to 2020

We evaluated trends, predictors, and outcomes of unplanned open conversion for patients with upper tract urothelial carcinoma (UTUC) undergoing robotic radical nephroureterectomy (R-RNU) or laparoscopic RNU (L-RNU). The National Cancer Database was queried from 2010 to 2020 for patients with non-metastatic UTUC treated with RNU. Trends in surgical approach and conversion were evaluated. Demographics and outcomes including lymph node dissection, lymph node yield, positive surgical margins (PSM), prolonged length of stay (PLOS) (≥ 90th percentile), unplanned readmission (UR), and 30- and 90-day mortality were compared between converted and unconverted cases. Multivariate logistic regression evaluated predictors of conversion and whether conversion predicted adverse clinical outcomes. 25,523 cases were included (robotic = 40.4%, laparoscopic = 36.9%, open = 22.7%), where 3.2% and 9.2% of R-RNU and L-RNU cases were converted, respectively. From 2010 to 2020, robotic cases increased while open and laparoscopic approaches decreased, p < 0.001. A higher T-stage and a ureteral tumor site predicted conversion while a higher R-RNU and L-RNU facility volume, respectively, were protective against conversion, all p < 0.05. Compared to unconverted cases, conversion generally resulted in a higher rate of all adverse outcomes, and was predictive of 30-day mortality, PLOS, UR, and PSM, all p < 0.05. Conversion to open RNU is becoming less frequent but is more common with a laparoscopic approach. Oncologic complexity and facility surgical volume influence conversion rates which in turn are associated with higher rates of morbidity, mortality, and greater resource utilization when compared to unconverted cases.

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.

Preparing for the Worst: Management and Predictive Factors of Open Conversion During Minimally Invasive Renal Tumor Surgery (UroCCR-135 Study)

Background and objective

Data regarding open conversion (OC) during minimally invasive surgery (MIS) for renal tumors are reported from big databases, without precise description of the reason and management of OC. The objective of this study was to describe the rate, reasons, and perioperative outcomes of OC in a cohort of patients who underwent MIS for renal tumor initially. The secondary objective was to find the factors associated with OC.

Methods

Between 2008 and 2022, of the 8566 patients included in the UroCCR project prospective database (NCT03293563), who underwent laparoscopic or robot-assisted minimally invasive partial (MIPN) or radical (MIRN) nephrectomy, 163 experienced OC. Each center was contacted to enlighten the context of OC: "emergency OC" implied an immediate life-threatening situation not reasonably manageable with MIS, otherwise "elective OC". To evaluate the predictive factors of OC, a 2:1 paired cohort on the UroCCR database was used.

Key findings and limitations

The incidence rate of OC was 1.9% for all cases of MIS, 2.9% for MIRN, and 1.4% for MIPN. OC procedures were mostly elective (82.2%). The main reason for OC was a failure to progress due to anatomical difficulties (42.9%). Five patients (3.1%) died within 90 d after surgery. Increased body mass index (BMI; odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.09, p = 0.009) and cT stage (OR: 2.22, 95% CI: 1.24-4.25, p = 0.008) were independent predictive factors of OC.

Conclusions and clinical implications

In MIS for renal tumors, OC was a rare event (1.9%), caused by various situations, leading to impaired perioperative outcomes. Emergency OC occurred once every 300 procedures. Increased BMI and cT stage were independent predictive factors of OC.

Patient summary

The incidence rate of open conversion (OC) in minimally invasive surgery for renal tumors is low. Only 20% of OC procedures occur in case of emergency, and others are caused by various situations. Increased body mass index and cT stage were independent predictive factors of OC.

[Treatment of localized renal cell carcinoma]

BACKGROUND

Both partial nephrectomy (pNx) and total nephrectomy (TNx) are the mainstay of the surgical treatment of renal cell carcinoma. In smaller masses, ablative treatment as well as surveillance are possible options.

OBJECTIVE

The aim of this article is to provide a closer look at the surgical methods, active surveillance and ablative options as well as the current evidence to support their use.

MATERIAL AND METHODS

This study is based on a selective literature review regarding pNx and TNx for renal cell carcinoma using the PubMed database and the review of current European and American guidelines on surgical treatment and conservative options for renal cell carcinoma.

RESULTS

The choice of surgical method depends on the intrarenal tumor configuration as well as patient comorbidities. While pNx is used for smaller localized masses TNx is usually performed in larger more complex tumors. Both methods can be performed using a minimally invasive (laparoscopic or robotically assisted) or an open approach. In patients with severe comorbidities or a limited life expectancy, local ablative treatment options as well as surveillance strategies are suitable strategies.

Unplanned Open Conversion During Radical or Partial Nephrectomy: Comparing Outcomes and Trends

OBJECTIVES

To compare perioperative outcomes between open conversion and planned open surgical approach and to investigate trends.

MATERIALS AND METHODS

The National Cancer Database (NCDB) was queried for cT1 and cT2 RCC treated by radical (RN) or partial (PN) nephrectomy between 2010 and 2016. We retrospectively analyzed patient demographics, clinical tumor characteristics, and perioperative outcomes between unplanned open conversion and planned open approaches for RN and PN.

RESULTS

In total, 152,919 patients underwent RN or PN for cT1 or cT2 RCC over the 7-year span. The rate of unplanned open conversion from MIS was 3.9% overall, remaining lowest for cT1 PN (2.7%) and highest for cT2 RN (5.9%). Cases of open conversion tended to have higher rate of upstaged disease. When comparing open conversion to a planned open case, there was no difference in the length of post-operative hospitalization. On logistic regression, unplanned open conversion from MIS was associated with higher odds of positive margin for RN but not for PN. Increased odds of 30-day's readmission were associated with unplanned open conversion from MIS in the setting of cT1 PN only.

CONCLUSION

When compared to a planned open approach, conversion to open from MIS does not affect length of hospital stay but is associated with higher odds of positive surgical margins for RN and higher odds of 30-day's readmission for cT1 PN. Advanced pathologic stage is associated with an open conversion, likely relating to increased tumor complexity. These findings should be considered preoperatively when determining the best surgical approach.