Hand-Assisted Laparoscopic Versus Robot-Assisted Laparoscopic Partial Nephrectomy: Comparison of Short-Term Outcomes and Cost

Prediction of pentafecta achievement following laparoscopic partial nephrectomy: Implications for robot-assisted surgery candidates

BACKGROUND

In clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making.

METHODS

Patients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN.

RESULTS

RAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P < 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased.

CONCLUSION

When pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.

Use of Digital Rectal Examination as an Adjunct to Prostate Specific Antigen in the Detection of Clinically Significant Prostate Cancer

PURPOSE

Guidelines from the NCCN^® (National Comprehensive Cancer Network®) advocate digital rectal examination screening only in men with elevated prostate specific antigen. We investigated the effect of prostate specific antigen on the association of digital rectal examination and clinically significant prostate cancer in a large American cohort.

MATERIALS AND METHODS

We evaluated the records of the 35,350 men who underwent digital rectal examination in the screening arm of the Prostate, Lung, Colorectal and Ovarian Cancer Screening trial for the development of clinically significant prostate cancer (Gleason 7 or greater). Followup was 343,273 person-years. The primary outcome was the rate of clinically significant prostate cancer among men with vs without suspicious digital rectal examination. We performed competing risks regression to evaluate the interaction between time varying suspicious digital rectal examination and prostate specific antigen.

RESULTS

A total of 1,713 clinically significant prostate cancers were detected with a 10-year cumulative incidence of 5.9% (95% CI 5.6-6.2). Higher risk was seen for suspicious vs nonsuspicious digital rectal examination. Increases in absolute risk were small and clinically irrelevant for normal (less than 2 ng/ml) prostate specific antigen (1.5% vs 0.7% risk of clinically significant prostate cancer at 10 years), clinically relevant for elevated (3 ng/ml or greater) prostate specific antigen (23.0% vs 13.7%) and modestly clinically relevant for equivocal (2 to 3 ng/ml) prostate specific antigen (6.5% vs 3.5%).

CONCLUSIONS

Digital rectal examination demonstrated prognostic usefulness when prostate specific antigen was greater than 3 ng/ml, limited usefulness for less than 2 ng/ml and marginal usefulness for 2 to 3 ng/ml. These findings support the restriction of digital rectal examination to men with higher prostate specific antigen as a reflex test to improve specificity. It should not be used as a primary screening modality to improve sensitivity.

Comparison of Hand-Assisted Laparoscopic vs Robot-Assisted Laparoscopic vs Open Partial Nephrectomy in Patients with T1 Renal Masses

PURPOSE

To evaluate the validity of hand-assisted laparoscopic partial nephrectomy (HALPN) for small renal masses, patients who underwent HALPN, robot-assisted laparoscopic partial nephrectomy (RALPN), or open partial nephrectomy (OPN) at a single medical institution were compared in terms of perioperative outcomes.

PATIENTS AND METHODS

In this retrospective cohort study, all 590 consecutive patients who underwent HALPN (n=89), RALPN (n=147), or OPN (n=354) between July 2011 and April 2014 in a single institute were compared in terms of perioperative outcomes, including the mean operative time, warm ischemia time (WIT), length of the hospital stay, change in the estimated glomerulofiltration rate (eGFR), duration of analgesic use, surgical margins, and adverse events. The patient groups were compared by a multivariate regression model, in which adjustments were made for differences in baseline demographic and tumor characteristics.

RESULTS

OPN associated with a significantly longer mean operative time (187 minutes) than RALPN (162 minutes; p<0.001) or HALPN (172 minutes; p=0.013), a longer hospital stay (7.3, 5.3, and 5.9 days, respectively; p<0.001 and <0.001, respectively), and a longer duration of analgesic use (6.6, 4.6, and 5.4 days, respectively; p<0.001 and <0.001, respectively). HALPN and RALPN were equivalent in terms of operative time. RALPN had a significantly longer WIT than HALPN and OPN (p<0.001 and <0.001, respectively). HALPN had a significantly longer hospital stay than RALPN (p=0.026). The three methods differed in terms of eGFR change (p=0.028), but multivariate analysis found that the surgical method was not a significant factor for eGFR. The three methods did not differ in terms of complication rates.

CONCLUSIONS

HALPN associated with shorter operative and convalescence times compared with OPN. HALPN was generally not inferior to RALPN in terms of perioperative outcomes, although it associated with a longer convalescence.

Technique and outcomes of robot-assisted retroperitoneoscopic partial nephrectomy: a multicenter study

BACKGROUND

Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN.

OBJECTIVE

To demonstrate RARPN technique and outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013.

SURGICAL PROCEDURE

RARPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS).

RESULTS AND LIMITATIONS

The median age was 60 yr (interquartile range [IQR]: 52-66), and the median body mass index (BMI) was 28.2 kg/m(2) (IQR: 25.6-32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7-3.1). Median OT and WIT were 165 min (IQR: 134-200) and 19 min (IQR: 16-24), respectively; median EBL was 75 ml (IQR: 50-150), and median LOS was 2 d (IQR: 1-3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31-10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: -0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075).

CONCLUSIONS

RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT.

PATIENT SUMMARY

Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.

Evaluation of robotic and laparoscopic partial nephrectomy for small renal tumours (T1a)

OBJECTIVE

To compare laparoscopic partial nephrectomy (LPN) with robotic PN (RPN) using meta-analytical techniques, since there has been a rise in the incidence of small renal masses (SRM; <4 cm) minimally invasive approaches are becoming more popular in dealing with such pathologies.

MATERIALS AND METHODS

A systematic review of the literature was performed to identify studies comparing LPN and RPN. Comparative studies evaluating RPN and LPN that fulfilled the inclusion criteria were selected. Data on preoperative, operative (operative time, estimated blood loss [EBL], and warm ischaemia time [WIT]), postoperative (length of stay [LOS]) variables and complications were collected. A meta-analysis using random effect model was performed. A further Bland-Altman analysis of some of the operative variables was done to compare their reproducibility and mean difference in techniques.

RESULTS

Six studies matched the selection criteria. In all, 256 patients were analysed (40% RPN and 60% LPN). There was no significant different in EBL (P = 0.12, 95% confidence interval [CI] -12.01 to 104.26). Similarly, there was no significant different in WIT between the groups (P = 0.23, 95% CI -15.22 to 3.70). Also, LOS (P = 0.22, 95% CI -0.38 to 0.09) and overall postoperative complication rates were not significantly different between the groups (P = 0.84, 95% CI -0.05 to 0.06).

CONCLUSIONS

Despite multiple studies reporting better perioperative variables for RPN, the present study found no significant differences between RPN and LPN. This has implications for both the surgeon and the patient. Lack of randomised controlled trials in addition to a lack of long-term oncological data for RPN are current limitations.