Robotic partial nephrectomy vs minimally invasive radical nephrectomy for clinical T2a renal mass: a propensity score‐matched comparison from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group

Propensity Score-Matched Analysis of Radical and Partial Nephrectomy in pT3aN0M0 Renal Cell Carcinoma

BACKGROUND

We sought to evaluate oncological and functional outcomes of patients treated with partial nephrectomy (PN) and radical nephrectomy (RN) in pT3aN0M0 renal cell carcinoma (RCC).

PATIENTS AND METHODS

We conducted a retrospective analysis of surgically treated pT3aN0M0 RCC patients. Primary outcome was all-cause mortality/overall survival (ACM/OS). Secondary outcomes were cancer-specific mortality/ cancer-specific survival (CSM/CSS), recurrence/progression free survival (PFS) and new onset de novo eGFR < 45 mL/min/1.73 m2 (CKD-S3b). A propensity score matched model in a 1:1 ratio was conducted, within a caliper width of 0.01. Kaplan-Meier analysis (KMA) and Cox multivariable analysis (MVA) were fitted to delineate survival outcomes and their predictors.

RESULTS

After PSM 359 were analyzed (PN = 179 vs. RN = 180); median follow up of 38.7 (IQR 16.28-64) months. MVA for ACM revealed, high grade (HR 2.05, P = .019), and CKD-S3b at last follow up (HR 2.13, P = .018) as independent risk factors, while RN versus PN (P = .41) was not. MVA for CSM and recurrence revealed that RN versus PN was not an independent risk factor for CSM (P = .088) and recurrence (P = .277). MVA for CKD-S3b revealed RN versus PN (HR 1.67 P = .025) as associated with increased risk of CKD-S3b. KMA comparing PN versus RN revealed 5-year OS of 87.4% versus 82% (P = .26); 5-year CSS of 95.6% versus 90.3% (P = .15); 5-year PFS of 83.5% versus 77% (P = .38); 5-year CKD-S3b free survival of 80.8% versus 65.5% (P = .016).

CONCLUSION

PN exhibited oncological equipoise while reducing risk of development of eGFR < 45 mL/min/1.73 m2. PN may be considered in T3a RCC when prioritization of functional preservation is indicated.

Mini-subcostal incision technique for open radical nephrectomy: A practical alternative for complex renal masses

PURPOSE

To describe the open radical nephrectomy mini-subcostal incision technique (msRN) and evaluate renal function, perioperative, and oncological outcomes as an alternative to traditional or minimally invasive nephrectomy for complex renal masses. This study aims to document the msRN approach, highlighting its value in preserving open nephrectomy skills for selected cases.

METHODS

Patients undergoing msRN from 2013 to 2016 were retrospectively analyzed. An 8 to 12 cm incision between the costal margin and 11th rib was used, with all patients managed using a rapid recovery pathway. Clinicopathologic, perioperative, and renal function metrics were analyzed. Statistical analyses included univariable and multivariable logistic regression for predictors of length of stay (LOS) >2 days and 30-day complications. Kaplan-Meier analysis was used to evaluate overall survival, and significance was set at P < 0.05.

RESULTS

In 193 patients (median age 59.5, IQR 58.4-68.8), median tumor size was 7.2 cm (IQR 5.0-9.6), and 67.9% were ≥pT3. Notably, 56% of patients had a high R.E.N.A.L. Nephrometry score, and 41.5% had a moderate score, highlighting the complexity of the cases. Median incision was 10 cm, operating time 123 minutes (IQR 102-151), and EBL 300 mL (IQR 100-550). Twenty-three (11.9%) received blood transfusions, and median LOS was 2 days. Predictors of LOS >2 days included age (OR 1.27, P = 0.003) and operating time (OR 1.12, P = 0.015). The 30-day complication rate was 18.1%, with predictors including tumor size (OR 1.14, P = 0.032) and transfusion (OR 3.04, P = 0.031). Median eGFR decreased 34.1%, with no dialysis requirements.

CONCLUSIONS

msRN provides favorable outcomes, serving as a practical alternative to traditional and MIS approaches. Its documented utility supports the continued relevance of open surgical techniques for complex renal cases.

Perioperative and Mid-Term Oncological and Functional Outcomes After Partial Nephrectomy for Entirely Endophytic Renal Tumors: A Prospective Multicenter Observational Study (The RECORD2 Project)

BACKGROUND AND OBJECTIVES

Totally endophytic renal tumors are a unique subset that pose significant technical challenges during partial nephrectomy (PN). The aim of this study was to evaluate the perioperative, oncologic, and functional outcomes of PN in this particular setting.

MATERIALS AND METHODS

We retrospectively evaluated 4151 patients who had surgical treatment for renal tumors between January 2013 and December 2016 at 26 urological Italian Centers (RECORD 2 project). Only patients treated with PN for entirely endophytic renal tumor were considered for final analyses.

RESULTS

A total of 211 patients were included, with a median PADUA score of 10 (IQR 9-11). Open, laparoscopic, and robotic approaches were used in 94 (44.5%), 52 (24.6%), and 65 (30.8%) cases, respectively. While surgical approach did not impact complication rates, robotic PN had significantly lower median blood loss (100 vs. 185 vs. 175 cc, p = 0.04) and shorter operative time (126 vs. 140 vs. 160 min, p = 0.01) compared to open and laparoscopic PN. At a median follow-up of 36.3 months (IQR 21.9-49.2), recurrence-free survival was 93.8%. Median %eGFR drop at 24 months was 12.1 (IQR 5.1-21.9), with significant eGFR loss (≥25%) in 36 (17.1%) patients. The robotic approach was associated with a lower %eGFR drop at 1-month and 1-year evaluations, but the benefit diminished at 24 months. Multivariate analysis showed age and open surgery as independent predictors of renal function loss at 1 month and Trifecta failure.

CONCLUSIONS

The conservative management of entirely endophytic renal tumors is associated with favorable functional and oncologic outcomes. Whenever technically feasible, conservative surgery should be prioritized to optimize early renal function recovery.

French AFU Cancer Committee Guidelines - Update 2024-2026: Management of kidney cancer

OBJECTIVE

To update the French recommendations for the management of kidney cancer.

METHODS

A systematic review of the literature was conducted for the period from 2014 to 2024. The most relevant articles concerning the diagnosis, classification, surgical treatment, medical treatment, and follow-up of kidney cancer were selected and incorporated into the recommendations. The recommendations have been updated specifying the level of evidence (strong or weak).

RESULTS

Kidney cancer following prolonged occupational exposure to trichloroethylene should be considered an occupational disease. The reference examination for the diagnosis and staging of kidney cancer is the contrast-enhanced thoraco-abdominal CT scan. PET scans are not indicated in the staging of kidney cancer. Percutaneous biopsy is recommended in situations where its results will influence therapeutic decisions. It should be used to reduce the number of surgeries for benign tumors, particularly avoiding unnecessary radical nephrectomies. Kidney tumors should be classified according to the pTNM 2017 classification, the WHO 2022 classification, and the ISUP nucleolar grade. Metastatic kidney cancers should be classified according to IMDC criteria. Surveillance of tumors smaller than 2cm should be prioritized and can be offered regardless of patient age. Robot-assisted laparoscopic partial nephrectomy is the reference surgical treatment for T1 tumors. Ablative therapies and surveillance are options for elderly patients with comorbidities for tumors larger than 2cm. Stereotactic radiotherapy is an option to discuss for treating localized kidney tumors in patients not eligible for other treatments. Radical nephrectomy is the first-line treatment for locally advanced localized cancers. Pembrolizumab is recommended for patients at high risk of recurrence after surgery for localized kidney cancer. In metastatic patients, cytoreductive nephrectomy can be immediate in cases of good prognosis, delayed in cases of intermediate or poor prognosis for patients stabilized by medical treatment, or as "consolidation" in patients with complete or major partial response at metastatic sites after systemic treatment. Surgical or local treatment of metastases can be proposed for single lesions or oligometastases. Recommended first-line drugs for metastatic clear cell renal carcinoma are combinations of axitinib/pembrolizumab, nivolumab/ipilimumab, nivolumab/cabozantinib, and lenvatinib/pembrolizumab. Patients with non-clear cell metastatic kidney cancer should be presented to the CARARE Network and prioritized for inclusion in clinical trials.

CONCLUSION

These updated recommendations are a reference that will enable French and French-speaking practitioners to optimize their management of kidney cancer.

Robotic partial nephrectomy: Indications, patient selection, and setup for success

Robot-assisted partial nephrectomy (RAPN) has readily become the benchmark treatment of small renal masses (SRMs). The management of SRMs is focused on preserving renal function and limiting the morbidity of a traditional open operation, thus greatly impacting overall prognosis and long-term survival. Indications and techniques have evolved over the last 2 decades. In this article, we discuss the application of this nephron-sparing technique regarding its indications, surgical considerations, and functional outcomes.

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.

Comparison of outcomes of radical and partial nephrectomy for sarcomatoid renal cell carcinoma: analysis of the national cancer database

PURPOSE

To compare outcomes of radical (RN) and partial nephrectomy (PN) in Sarcomatoid Renal Cell Carcinoma (sRCC) utilizing a large national cohort. As RN is the reference standard for localized RCC with clinically aggressive features, PN in sRCC has been seldom studied.

METHODS

We performed a retrospective cohort analysis of the National Cancer Database from 2004 to 2019 for patients who underwent PN and RN for sRCC (T1-T3N0-N1M0). We performed multivariable analyses (MVA) to determine factors associated with PN and all-cause mortality (ACM), and Kaplan-Meier Analysis (KMA) for overall survival (OS) in Charlson 0 patients who underwent PN vs. RN according to clinical stage.

RESULTS

The cohort consisted of 5,265 patients [RN 4,582 (87.0%)/PN 683 (13.0%)]. Increased odds of receiving PN was associated with papillary RCC (OR = 1.69, p = 0.015); inversely with increasing age (OR = 0.99, p = 0.004), cT2-cT3 (OR = 0.23, p < 0.001), and cN1 (OR = 0.2, p < 0.001). Worsened ACM was associated with positive margins (HR = 1.59, p < 0.001), male (HR = 1.1, p = 0.044), Charlson [Formula: see text]2 (HR = 1.47, p < 0.001), cT2-cT3 (HR 1.17-1.39, p < 0.001-0.035), and cN1 (HR = 1.59, p < 0.001). Improved ACM was noted with PN (HR = 0.64, p < 0.001), increasing household income (HR = 0.77-0.79, p < 0.001), and private insurance (HR = 0.80, p = 0.018). KMA showed PN had improved 5-year OS compared to RN in cT1 (86.5% vs. 63.2%, p < 0.001), and cT3 (61.0% vs. 44.0% p < 0.001), but not cT2 (p = 0.67).

CONCLUSION

In select patients, PN with negative margins may not compromise outcomes and may provide benefit when indicated. Patients with private insurance and highest income experienced improved survival suggesting disparity in care.

Skill Transfer from Laparoscopic Partial Nephrectomy to the Hugo™ RAS System: A Novel Proficiency Score to Assess Surgical Quality during the Learning Curve

Background/Objectives: The absence of validated tools to assess the skill transfer from laparoscopy to robotic surgery remains an unsolved issue in the context of robot-assisted partial nephrectomy (RAPN). We aimed to describe and validate a novel proficiency score to critically evaluate the surgical quality of RAPN with the Hugo™ RAS System (Medtronic, Minneapolis, MN, USA). Methods: Between October 2022 and September 2023, 27 consecutive patients underwent off-clamp RAPN for localized renal tumors at our institution. To analyze the learning curve (LC), the cohort was chronologically divided into two phases of 6 months each. Proficiency was defined as the achievement of trifecta while maintaining a comparable intraoperative time in the interquartile range of laparoscopic partial nephrectomy performed by the same surgeon. A logistic binary regression model was built to identify predictors of proficiency achievement. Results: A proficiency score was achieved in 14 patients (74.1%). At univariable analysis, number of consecutive procedures > 12 (OR 13.7; 95%CI 2.05-21.1, p = 0.007), pathological tumor size (OR 0.92; 95%CI 0.89-0.99, p = 0.04) and essential blood hypertension (OR 0.16; 95%CI 0.03-0.82, p = 0.02) were found to be predictors of proficiency score. At multivariable analysis, after adjusting for potential confounding factors, number of consecutive procedures > 12 (OR 8.1; 95%CI 1.44-14.6, p = 0.03) was the only independent predictor of proficiency score achievement. Conclusions: Our results showed that the skills of an experienced laparoscopic surgeon are transferrable to the novel Hugo™ RAS System in the context of nephron-sparing surgery. Improved surgical quality may be expected after completing the first 12 consecutive procedures.

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.

Robot-assisted pelvic and renal surgery compared with laparoscopic or open surgery: Literature review of cost-effectiveness and clinical outcomes

BACKGROUND AND AIM

The purpose of this study was to evaluate clinical experiences and cost-effectiveness by comparing robot-assisted surgery with laparoscopic- or open surgery for pelvic and renal operations.

METHODS

A narrative review was carried out.

RESULTS

When using robotic-assisted surgery, oncological and functional results are similar to after laparoscopic or open surgery. One exception may be a shorter survival in cancer of the cervix uteri. In addition, postoperative complications after robotic-assisted surgery are similar, bleeding and transfusion needs are less, and the hospital stay is shorter but the preparation of the operating theater before and after surgery and the operation times are longer. Finally, robot-assisted surgery has, in several studies, been reported to be not cost-effective primarily due to high investment costs. However, more recent studies provide improved cost-effectiveness estimates due to more effective preparation of the operating theater before surgery, improved surgeon experience, and decreased investment costs.

CONCLUSIONS

Complications and functional and oncological outcomes after robot-assisted surgery are similar to open surgery and laparoscopic surgery. The cost-effectiveness of robot-assisted surgery is likely to equal or surpass the alternatives.

A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors

Objective

Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors.

Methods

A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes.

Results

After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.

Conclusion

Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered per se an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.

Predictors for complication in renal cancer surgery: a national register study

OBJECTIVE

Nationwide register data provide unique opportunities for real-world assessment of complications from different surgical methods. This study aimed to assess incidence of, and predictors for, post-operative complications and to evaluate 90-day mortality  following different surgical procedures and thermal ablation for renal cell carcinoma (RCC).

MATERIAL AND METHODS

All patients undergoing surgical treatment and thermal ablation for RCC in Sweden during 2015-2019 were identified from the National Swedish Kidney Cancer Register. Frequencies and types of post-operative complications were analysed. Logistic regression models were used to identify predictors for 90-day major (Clavien-Dindo grades III-V) complications, including death.

RESULTS

The overall complication rate was 24% (1295/5505), of which 495 (8.7%) were major complications. Most complications occurred following open surgery, of which bleeding and infection were the most common. Twice as many complications were observed in patients undergoing open surgery compared to minimally invasive surgery (20% vs. 10%, P < 0.001). Statistically significant predictors for major complications irrespective of surgical category and technique were American society of anesthiologists (ASA) score, tumour diameter and serum creatinine. Separating radical and partial nephrectomy, surgical technique remained a significant risk factor for major complications. Most complications occurred within the first 20 days. The overall 90-day readmission rate was 6.2%, and 30- and 90-day mortality rates were 0.47% and 1.5%, respectively.

CONCLUSIONS

In conclusion, bleeding and infection were the most common major complications after RCC surgery. Twice as many patients undergoing open surgery suffer a major post-operative complication as compared to patients subjected to minimally invasive surgery. General predictors for major complications were ASA score, tumour size, kidney function and surgical technique.

Partial versus radical nephrectomy for complex renal mass: multicenter comparative analysis of functional outcomes (Rosula collaborative group)

BACKGROUND

Utility of partial nephrectomy (PN) for complex renal mass (CRM) is controversial. We determined the impact of surgical modality on postoperative renal functional outcomes for CRM.

METHODS

We retrospectively analyzed a multicenter registry (ROSULA). CRM was defined as RENAL Score 10-12. The cohort was divided into PN and radical nephrectomy (RN) for analyses. Primary outcome was development of de-novo estimated glomerular filtration rate (eGFR)<45 mL/min/1.73 m². Secondary outcomes were de-novo eGFR<60 and ΔeGFR between diagnosis and last follow-up. Cox proportional hazards was used to elucidate predictors for de-novo eGFR<60 and <45. Linear regression was utilized to analyze ΔeGFR. Kaplan-Meier Analysis (KMA) was performed to analyze 5-year freedom from de-novo eGFR<60 and <45.

RESULTS

We analyzed 969 patients (RN=429/PN=540; median follow-up 24.0 months). RN patients had lower BMI (P<0.001) and larger tumor size (P<0.001). Overall postoperative complication rate was higher for PN (P<0.001), but there was no difference in major complications (Clavien III-IV; P=0.702). MVA demonstrated age (HR=1.05, P<0.001), tumor-size (HR=1.05, P=0.046), RN (HR=2.57, P<0.001), and BMI (HR=1.04, P=0.001) to be associated with risk for de-novo eGFR<60 mL/min/1.73 m². Age (HR=1.03, P<0.001), BMI (HR=1.06, P<0.001), baseline eGFR (HR=0.99, P=0.002), tumor size (HR=1.07, P=0.007) and RN (HR=2.39, P<0.001) were risk factors for de-novo eGFR<45 mL/min/1.73 m². RN (B=-10.89, P<0.001) was associated with greater ΔeGFR. KMA revealed worse 5-year freedom from de-novo eGFR<60 (71% vs. 33%, P<0.001) and de-novo eGFR<45 (79% vs. 65%, P<0.001) for RN.

CONCLUSIONS

PN provides functional benefit in selected patients with CRM without significant increase in major complications compared to RN, and should be considered when technically feasible.

Robotic versus Laparoscopic Partial Nephrectomy in the New Era: Systematic Review

(1) Background: In recent years there have been advances in imaging techniques, in addition to progress in the surgery of renal tumors directed towards minimally invasive techniques. Thus, nephron-sparing surgery has become the gold standard for the treatment of T1 renal masses. The aim of this study is to investigate the benefits of robotic partial nephrectomy in comparison with laparoscopic nephrectomy. (2) Methods: We performed a systematic review according to the PRISMA criteria during September 2022. We included clinical trials, and cohort and case-control studies published between 2000 and 2022. This comprised studies performed in adult patients with T1 renal cancer and studies comparing robotic with open and laparoscopic partial nephrectomy. A risk of bias assessment was performed according to the Newcastle-Ottawa scale. (3) Results: We observed lower hot ischemia times in the robotic surgery groups, although at the cost of an increase in total operative time, without appreciating the differences in terms of serious surgical complications (Clavien III-V). (4) Conclusions: Robotic partial nephrectomy is a safe procedure, with a shorter learning curve than laparoscopic surgery and with all the benefits of minimally invasive surgery.

Partial or radical nephrectomy for complex renal mass: a comparative analysis of oncological outcomes and complications from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group

PURPOSE

To compare outcomes of robotic-assisted partial nephrectomy (RAPN) and minimally invasive radical nephrectomy (MIS-RN) for complex renal masses (CRM).

METHODS

We conducted a retrospective multicenter analysis of CRM patients who underwent MIS-RN and RAPN. CRM was defined as RENAL score 10-12. Primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), recurrence, and complications. Multivariable analysis (MVA) and Kaplan-Meier Analysis (KMA) were used to analyze functional and survival outcomes for RN vs. PN by pathological stage.

RESULTS

926 patients were analyzed (MIS-RN = 437/RAPN = 489; median follow-up 24.0 months). MVA demonstrated lack of transfusion (HR = 1.63, p = 0.005), low-grade (HR = 1.18, p = 0.018) and smaller tumor size (HR = 1.05, p < 0.001) were associated with OS. Younger age (HR = 1.01, p = 0.017), high-grade (HR = 1.18, p = 0.017), smaller tumor size (HR = 1.05, p < 0.001), and lack of transfusion (HR = 1.39, p = 0.038) were associated with CSS. Increasing tumor size (HR = 1.18, p < 0.001), high-grade (HR = 3.21, p < 0.001), and increasing age (HR = 1.02, p = 0.009) were independent risk factors for recurrence. Type of surgery was not associated with major complications (p = 0.094). For KMA of MIS-RN vs. RAPN for pT1, pT2 and pT3, 5-year OS was 85% vs. 88% (p = 0.078); 82% vs. 80% (p = 0.442) and 84% vs. 83% (p = 0.863), respectively. 5-year CSS was 98% for both procedures (p = 0.473); 94% vs. 92% (p = 0.735) and 91% vs. 90% (p = 0.581). 5-year non-CSS was 87% vs. 93% (p = 0.107); 87% for pT2 (p = 0.485) and 92% for pT3 for both procedures (p = 0.403).

CONCLUSION

RAPN in CRM is not associated with increased risk of complications or worsened oncological outcomes when compared to MIS-RN and may be preferred when clinically indicated.

Renal functional and cardiovascular outcomes of partial nephrectomy versus radical nephrectomy for renal tumors: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) for the treatment of renal carcinoma. A systematic literature search was performed on scientific databases including Scopus, Web of Science, MEDLINE, and EMBASE from their inception to September 2021. Studies comparing renal and cardiovascular outcomes between PN and RN in patients with renal cancer were included. The generic inverse variance method with random-effects models was used to determine the pooled hazard ratios and odds ratio for each outcome. Quality Assessment for observational studies was guided by the New-Castle Ottawa Scale. Overall, a total of 31 studies (n=51,866) reported renal outcomes, while 11 studies (n= 101,678) reported cardiovascular outcomes. When compared to PN, RN had a higher rate of new-onset postoperative EGFR <60 mL/min/1.73 m² (HR 3.39; CI 2.45 - 4.70; I²=93%; P=<0.00001) and EGFR <45 mL/min/1.73 m² (HR 4.70; CI 2.26 - 9.79; I²=98%; P=<0.0001). No difference was observed in new-onset advanced kidney disease and end-stage renal disease. A 19% reduction in cardiovascular events was observed in the PN group (HR 0.81; CI 0.70 - 0.93, P=0.002). No protective effect of PN was observed in new-onset or worsening hypertension (HR 0.85; CI 0.64 - 1.14, P=0.28) nor myocardial infarction (HR 0.86; CI 0.71 - 1.04, P=0.13). PN was associated with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with RN. However, no benefit of PN over RN was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality.

Percutaneous Ablation vs Robot-Assisted Partial Nephrectomy for Completely Endophytic Renal Masses: A Multicenter Trifecta Analysis with a Minimum 3-Year Follow-Up

Purpose: To compare outcomes of robot-assisted partial nephrectomy (RAPN) and percutaneous tumor ablation (PTA) for completely endophytic renal masses. Methods: Data of patients who underwent RAPN or PTA for treatment of completely endophytic (three points for "E" domain of R.E.N.A.L. score) were collected from seven high-volume U.S. and European centers. PTA included cryoablation, radiofrequency, or microwave ablation. Baseline characteristics, clinical, surgical, and postoperative outcomes were compared. Recurrence-free survival (RFS) was calculated with Kaplan-Meier analysis. Trifecta was used as arbitrary combined outcome parameter as proxy for treatment "quality." Multivariable logistic regression model assessed predictors of trifecta failure. Results: One hundred fifty-two patients (RAPN, n = 60; PTA, n = 92) were included in the analysis. RAPN group was younger (p < 0.001), had lower American Society of Anesthesiologists score (p = 0.002), and higher baseline estimated glomerular filtration rate (p < 0.001). There was no difference in clinical tumor size, clinical T stage, and tumor complexity scores. PTA had significantly lower rate of overall (p < 0.001) and minor (p < 0.001) complications. ΔeGFR at 1 year was statistically higher for RAPN (-15.5 mL/min vs -3.1 mL/min; p = 0.005), no difference in ΔeGFR at last follow-up (p = 0.22) was observed. No difference in recurrences (RAPN, n = 2; PTA, n = 6) and RFS was found (p = 0.154). Trifecta achievement was higher for RAPN but not statistically different (65.3% vs 58.8%; p = 0.477). R.E.N.A.L. Nephrometry Score resulted predictive of trifecta failure (odds ratio = 1.47; confidence interval = 1.13-1.90; p = 0.004). Conclusions: PTA confirms to be an effective treatment for completely endophytic renal masses, offering low complications and good mid-term functional and oncologic outcomes. These outcomes compare favorably with those of RAPN, which seem to be the preferred option for younger and less comorbid patients.

3D-Image guided robotic-assisted partial nephrectomy: a multi-institutional propensity score-matched analysis (UroCCR study 51)

PURPOSE

Robot-assisted partial nephrectomy (RAPN) is a difficult procedure with risk of significant perioperative complications. The objective was to evaluate the impact of preoperative planning and intraoperative guidance with 3D model reconstructions on perioperative outcomes of RAPN.

METHODS

We conducted a retrospective analysis of all patients who underwent RAPN for kidney tumor by three high-volume expert surgeons from academic centers. Clinical data were collected prospectively after written consent into the French kidney cancer network database UroCCR (CNIL-DR 2013-206; NCT03293563). Our cohort was divided into two groups: 3D-Image guided RAPN group (3D-IGRAPN) and control group. A propensity score according to age, pre-operative renal function and RENAL tumor complexity score was used. Both surgical techniques were compared in terms of perioperative outcomes.

RESULTS

The initial study cohort included 230 3D-IGRAPN and 415 control RAPN. Before propensity-score matching, patients in the 3D-IGRAPN group had a larger tumor (4.3 cm vs. 3.5 cm, P < 0.001) and higher RENAL complexity score (9 vs. 8, P < 0.001). Following propensity-score matching, there were 157 patients in both groups. The rate of major complications was lower for patients in the 3D-IGRAPN group (3.8% vs. 9.5%, P = 0.04). The median percentage of eGFR variation recorded at first follow-up was lower in the 3D-IGRAPN group (- 5.6% vs. - 10.5%, P = 0.002). The trifecta achievement rate was higher in the 3D-IGRAPN group (55.7% vs. 45.1%; P = 0.005).

CONCLUSION

Three-dimensional kidney reconstructions use for pre-operative planning and intraoperative surgical guidance lowers the risk of complications and improve perioperative clinical outcomes of RAPN.

Robotic-assisted laparoscopic colposuspension for female stress urinary incontinence: a prospective series

The suspension of use of sub-urethral mesh in the UK in 2018 has seen the resurgence of colposuspension in female SUI surgery. Open and laparoscopic colposuspension techniques are well recognised. We present data from 28 robotic-assisted laparoscopic colposuspension (RALCp) procedures, reporting on technique, safety and efficacy. Approval was obtained from the hospital New and Novel Procedures Committee. All patients had urodynamic assessment prior to surgery. Data was prospectively gathered and 24-h pad usage and Urinary Incontinence Short Form Questionnaire (ICIQ-UI-SF) scores were used to assess symptom severity and quality of life. PGII scores were used to assess patient satisfaction after the procedure. Paired T test analysis was conducted. Since May 2019, robotic colposuspension has been performed in 28 patients. The mean age and BMI were 49 and 27 (kg/m²), respectively, with a mean follow-up period of 12 months. 67.9% of patients had pure urodynamic SUI and 32.1% of patients had previous anti-SUI surgery. Average operating time was 127 min, blood loss 20 ml and length of stay 2 days. There was a significant 73% improvement in mean 24-h pad usage (p = 0.001) and an improvement in mean ICIQ-UI-SF scores from 18.1 to 9.4 (p = 0.0001). Day 1 mean pain score was 5/10. This is the largest series of its kind. Robotic colposuspension is safe and feasible with significant improvements seen in quality of life scores and number of pads used per day. It presents a minimally invasive treatment option in female SUI, however needs larger volume evaluation and longer follow-up for further evaluation.

Recent Advances in the Management of Localized and Locally Advanced Renal Cell Carcinoma: A Narrative Review

Purpose

To review the current status of surgical and procedural treatments for renal cell carcinoma (RCC), focusing on oncological and functional outcomes, and the use of techniques for advanced disease over the last 10 years.

Findings

Partial nephrectomy (PN) has become the reference standard for most T1 and T2 masses. In cT2 RCC, PN exhibits oncological equivalence and improved functional outcomes compared to radical nephrectomy (RN). Additionally, emerging data suggest that PN may be used to treat cT3a RCC. The robot-assisted platform is increasingly used to treat locally advanced RCC. Studies suggest safety and feasibility of robotic RN and robotic inferior vena cava tumor thrombectomy. Additionally, single-port robot-assisted laparoscopic approaches are comparable to multiport approaches in select patients. Long-term data show that cryoablation, radiofrequency ablation, and microwave ablation are equipotent in management of small renal masses. Emerging data suggest that microwave may effectively treat cT1b masses.

Assessing the impact of socio-economic determinants on access to care, surgical treatment options and outcomes among patients with renal mass: Insight from the universal healthcare system

OBJECTIVE

To assess whether socio-economic disparities exist on access to care, treatment options and outcomes among patients with renal mass amenable of surgical treatment within the universal healthcare system.

METHODS

Data of consecutive patients submitted to partial nephrectomy (PN) or radical nephrectomy (RN) at our Institution between 2017 and 2020 were retrospectively evaluated. Patients were grouped according to their income level (low, intermediate, and high) based on the Indicator of Equivalent Economic Situation national criterion. Survival analysis was performed. Cox regression models were employed to analyse the impact of socio-economic variables on survival outcomes.

RESULTS

One thousand forty-two patients were included (841 PN and 201 RN). Patients at the lowest income level were found more likely symptomatic and with a higher pathological tumour stage in the RN cohort (p > 0.05). The guidelines adherence on surgical indication rate as well as the access to minimally invasive surgery did not differ according to patient's income level in both cohorts (p > 0.05). Survival curves were comparable among the groups. Cox regression analysis showed that none of the included socio-economic variables was associated with survival outcomes in our series.

CONCLUSIONS

Universal healthcare system may increase the possibility to ensure egalitarian treatment modalities for patients with renal cancer.

Randomized Clinical Trial Comparing On-clamp Versus Off-clamp Laparoscopic Partial Nephrectomy for Small Renal Masses (CLOCK II Laparoscopic Study): A Intention-to-treat Analysis of Perioperative Outcomes

Background

Recent randomized trials (RCTs) in the field of robotic partial nephrectomy (PN) showed no significant differences in perioperative outcomes between the off- and on-clamp approaches.

Objective

To compare the perioperative outcomes of on- versus off-clamp pure laparoscopic PN (LPN).

Design setting and participants

A multi-institutional analysis of the on- versus off-clamp approach during LPN in the setting of an RCT (CLOCK II trial; ClinicalTrials.gov NCT02287987) was performed.

Intervention

Off- versus on-clamp LPN.

Outcome measurements and statistical analysis

Baseline patient and tumor variables, and peri- and postoperative data were collected. Randomized allocation with a 1:1 ratio was assigned. Surgical strategy for managing the renal pedicle was dictated by the study protocol. In the off-clamp arm, the renal artery had to remain unclamped for the duration of the whole procedure. Reporting the intention-to-treat analysis is the purpose of the study.

Results and limitations

The study recruited 249 patients. Of them, 123 and 126 were randomized and allocated into the on- and off-clamp treatment groups, respectively. Treatment groups were comparable at baseline after randomization with respect to patients' demographics, comorbidities, renal function, and tumor size and complexity. A univariable analysis found no differences in the perioperative outcomes between the groups, including median (interquartile range) estimated blood loss (150 [100-200] vs 150 [100-250] ml, p = 0.2), grade ≥2 complication rate as classified according to the Clavien-Dindo system (5.7% vs 4.8%, p = 0.6), and positive surgical margin rate (8.2% vs 3.5% for the on- vs off-clamp group, p = 0.1). No differences were found in terms of the 1st (81.3 [66.7-94.3] vs 85.3 [71.0-97.7] ml/min, p = 0.2) and 5th postoperative days estimated glomerular filtration rate (83.3 [70.5-93.7] vs 83.4 [68.6-139.3] ml/min, p = 0.2). A multivariable analysis found each +1 increase in RENAL score corresponded to an increase in the protection from the occurrence of complications (odds ratio [OR] 0.72, 95% confidence interval [CI] 0.54-0.97, p = 0.034), while each +1 cm increase in tumor size corresponded to an increase in the risk of blood transfusion (OR 1.39, 95% CI 1.14-1.70, p = 0.001).

Conclusions

In the setting of an RCT, no differences were found in the perioperative and early functional outcomes between on- and off-clamp LPN.

Patient summary

In this study, we investigated, by means of a randomized trial, whether avoiding the clamping of renal artery during laparoscopic resection of renal mass is able to translate into benefits. We found no differences in terms of safety, efficacy, and renal function from the standard approach, which includes arterial clamping.

On-Clamp vs. Off-Clamp Robot-Assisted Partial Nephrectomy for cT2 Renal Tumors: Retrospective Propensity-Score-Matched Multicenter Outcome Analysis

We compared perioperative outcomes after on-clamp versus off-clamp robot-assisted partial nephrectomy (RAPN) for >7 cm renal masses. A multicenter dataset was queried for patients who had undergone RAPN for a cT2cN0cM0 kidney tumor from July 2007 to February 2022. The Trifecta achievement (negative surgical margins, no severe complications, and ≤ 30% postoperative estimated glomerular filtration rate (eGFR) reduction) was considered a surrogate of surgical quality. Overall, 316 cases were included in the analysis, and 58% achieved the Trifecta. A propensity-score-matched analysis generated two cohorts of 89 patients homogeneous for age, ASA score, preoperative eGFR, and RENAL score (all p > 0.21). Compared to the on-clamp approach, OT was significantly shorter in the off-clamp group (80 vs. 190 min; p < 0.001), the incidence of sRFD was lower (22% vs. 40%; p = 0.01), and the Trifecta rate higher (66% vs. 46%; p = 0.01). In a crude analysis, >20 min of hilar clamping was associated with a significantly higher risk of sRFD (OR: 2.30; 95%CI: 1.13−4.64; p = 0.02) and with reduced probabilities of achieving the Trifecta (OR: 0.46; 95%CI: 0.27−0.79; p = 0.004). Purely off-clamp RAPN seems to be a safe and viable option to treat cT2 renal masses and may outperform the on-clamp approach regarding perioperative surgical outcomes.

Clinical experience of using virtual 3D modelling for pre and intraoperative guidance during robotic-assisted partial nephrectomy

Objective:

Surgical planning for robotic-assisted partial nephrectomy is widely performed using two-dimensional computed tomography images. It is unclear to what extent two-dimensional images fully simulate surgical anatomy and case complexity. To overcome these limitations, software has been developed to reconstruct three-dimensional models from computed tomography data. We present the results of a feasibility study, to explore the role and practicality of virtual three-dimensional modelling (by Innersight Labs) in the context of surgical utility for preoperative and intraoperative use, as well as improving patient involvement.

Methods:

A prospective study was conducted on patients undergoing robotic-assisted partial nephrectomy at our high volume kidney cancer centre. Approval from a research ethics committee was obtained. Patient demographics and tumour characteristics were collected. Surgical outcome measures were recorded. The value of the three-dimensional model to the surgeon and patient was assessed using a survey. The prospective cohort was compared against a retrospective cohort and cases were individually matched using RENAL (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, location relative to polar lines) scores.

Results:

This study included 22 patients. Three-dimensional modelling was found to be safe for this prospective cohort and resulted in good surgical outcome measures. The mean (standard deviation) console time was 158.6 (35) min and warm ischaemia time was 17.3 (6.3) min. The median (interquartile range) estimated blood loss was 125 (50–237.5) ml. Two procedures were converted to radical nephrectomy due to the risk of positive margins during resection. The median (interquartile range) length of stay was 2 (2–3) days. No postoperative complications were noted and all patients had negative surgical margins. Patients reported improved understanding of their procedure using the three-dimensional model.

Conclusion:

This study shows the potential benefit of three-dimensional modelling technology with positive uptake from surgeons and patients. Benefits are improved perception of vascular anatomy and resection approach, and procedure understanding by patients. A randomised controlled trial is needed to evaluate the technology further.

Level of evidence:

2b

Single- versus multi-port robotic partial nephrectomy: a comparative analysis of perioperative outcomes and analgesic requirements

Evidence supporting the safe use of the single-port (SP) robot for partial nephrectomy is scarce. The purpose of this study was to compare perioperative outcomes for patients undergoing robotic assisted SP vs multi-port (MP) partial nephrectomy (PN) in a time-matched cohort. All patients with clinically localized renal masses who underwent robotic PN from January 2019 to March 2020 were evaluated. Patients were stratified according to SP vs MP approach. Postoperative analgesia was administered in accordance with department-wide opioid stewardship protocol and outpatient opioid use was tracked. Total of 78 patients underwent robotic PN with 26 patients in the SP cohort. The majority of renal masses had low-complexity (53, 67.9%) R.E.N.A.L. nephrometry scores, without a significant difference between the two cohorts (p = 0.19). A retroperitoneal approach was performed in 16 (20.5%) patients overall, though more commonly via the SP robotic approach (13 vs 3, p < 0.001). Mean operative time for SP cases was 183.9 ± 63.5 min vs 208.6 ± 65.0 min in the MP cohort (p = 0.12). Rate of conversion to radical nephrectomy was 3.8% vs 9.6% for SP vs MP cases, respectively, (p = 0.37). The majority of patients were discharged on postoperative day one (67.9%) irrespective of operative approach (p = 0.60). There were no differences in inpatient milligram morphine equivalents administered (MME, p = 0.08) or outpatient postoperative MME prescribed (p = 0.21) between the two cohorts. In this retrospective single-institution study, SP robotic approach offers similar short-term perioperative outcomes to MP platforms for minimally invasive, nephron-sparing surgery. Using the SP system was not associated with a reduction in postoperative opioid analgesic requirements.

Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer

BACKGROUND

Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis.

METHODS

The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis.

RESULTS

The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254).

CONCLUSIONS

Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients.

Potential benefit of lymph node dissection during radical nephrectomy for kidney cancer: A review and critical analysis of current literature

Objective

The role of lymph node dissection (LND) is still controversial in patients with renal cell carcinoma undergoing surgery. We aimed to provide a comprehensive review of the literature about the effect of LND on survival, prognosis, surgical outcomes, as well as patient selection and available LND templates.

Methods

Recent literature (from January 2011 to December 2021) was assessed through PubMed and MEDLINE databases. A narrative review of most relevant articles was provided.

Results

The frequencies in which LNDs are being carried out are decreasing due to an increase in minimally invasive and nephron sparing surgery. Moreover, randomized clinical trials and meta-analyses failed to show any survival advantage of LND versus no LND. However, retrospective studies suggest a survival benefit of LND in high-risk patients (bulky tumors, T3-4 stage, and cN1 patients). Moreover, extended LND might provide important staging information, which could be of interest for adjuvant treatment planning.

Conclusion

No level 1 evidence of any survival advantage deriving from LND is currently available in literature. Thus, the role of LND is limited to staging purposes. However, low grade evidence suggests a possible role of LND in high-risk patients. Randomized clinical trials are warranted to corroborate these findings.

Diagnostic Workup for Patients with Solid Renal Masses: A Cost-Effectiveness Analysis

Background: For patients with solid renal masses, a precise differentiation between malignant and benign tumors is crucial for forward treatment management. Even though MRI and CT are often deemed as the gold standard in the diagnosis of solid renal masses, CEUS may also offer very high sensitivity in detection. The aim of this study therefore was to evaluate the effectiveness of CEUS from an economical point of view. Methods: A decision-making model based on a Markov model assessed expenses and utilities (in QALYs) associated with CEUS, MRI and CT. The utilized parameters were acquired from published research. Further, a Monte Carlo simulation-based deterministic sensitivity analysis of utilized variables with 30,000 repetitions was executed. The willingness-to-pay (WTP) is at USD 100,000/QALY. Results: In the baseline, CT caused overall expenses of USD 10,285.58 and an efficacy of 11.95 QALYs, whereas MRI caused overall expenses of USD 7407.70 and an efficacy of 12.25. Further, CEUS caused overall expenses of USD 5539.78, with an efficacy of 12.44. Consequently, CT and MRI were dominated by CEUS, and CEUS remained cost-effective in the sensitivity analyses. Conclusions: CEUS should be considered as a cost-effective imaging strategy for the initial diagnostic workup and assessment of solid renal masses compared to CT and MRI.

Estimated Glomerular Filtration Rate Decline at 1 Year After Minimally Invasive Partial Nephrectomy: A Multimodel Comparison of Predictors

Background

Long-term renal function after partial nephrectomy (PN) is difficult to predict as it is influenced by several modifiable and nonmodifiable variables, often intertwined in complex relations.

Objective

To identify variables influencing long-term renal function after PN and to assess their relative weight.

Design, setting, and participants

A total of 457 patients who underwent either robotic (n = 412) or laparoscopic PN (n = 45) were identified from a multicenter international database.

Outcome measurements and statistical analysis

The 1-yr estimated glomerular filtration rate (eGFR) percentage loss (1YPL), defined as the eGFR percentage change from baseline at 1 yr after surgery, was the outcome endpoint. Predictors evaluated included demographic data, tumor features, and operative and postoperative variables. Bayesian multimodel analysis of covariance was used to build all possible models and compare the fit of each model to the data via model Bayes factors. Bayesian model averaging was used to quantify the support for each predictor via the inclusion Bayes factor (BF_incl). High-dimensional undirected graph estimation was used for network analysis of conditional independence between predictors.

Results and limitations

Several models were found to be plausible for estimation of 1YPL. The best model, comprising postoperative eGFR percentage loss (PPL), sex, ischemia technique, and preoperative eGFR, was 207 times more likely than all the other models regarding relative predictive performance. Its components were part of the top 44 models and were the predictors with the highest BF_incl. The role of cold ischemia, solitary kidney status, surgeon experience, and type of renorraphy was not assessed.

Conclusions

Preoperative eGFR, sex, ischemia technique, and PPL are the best predictors of eGFR percentage loss at 1 yr after minimally invasive PN. Other predictors seem to be irrelevant, as their influence is insignificant or already nested in the effect of these four parameters.

Patient summary

Kidney function at 1 year after partial removal of a kidney depends on sex, the technique used to halt blood flow to the kidney during surgery, and kidney function at baseline and in the early postoperative period.

Partial versus radical nephrectomy in clinical T2 renal masses

OBJECTIVE

To report perioperative, renal functional and oncologic outcomes for patients undergoing partial or radical nephrectomy for cT2 renal masses.

METHODS

Retrospective review of patients who underwent partial (n = 72) or radical nephrectomy (n = 379) for cT2 renal masses from 2000 to 2016. After propensity adjustment using inverse probability weighting, the following were compared by surgery (partial or radical nephrectomy): complications, renal function measured by estimated glomerular filtration rate as continuous and as <60 mL/min/1.73 m2 at 1 and 3 years postoperatively and overall, metastases-free survival and cancer-specific survival in patients with renal cell carcinoma.

RESULTS

After propensity adjustment, clinical and radiographic features were well-balanced between groups. Overall and severe complications were more common for partial compared with radical nephrectomy, although not statistically significant (19 vs 13%, P = 0.14 and 4 vs 2%, P = 0.3, respectively). Estimated glomerular filtration rate change at 1 and 3 years was more pronounced in radical compared with partial nephrectomy (median -16 vs -5 and -14 vs -2, respectively, P < 0.001). A greater proportion of radical nephrectomy patients had an estimated glomerular filtration rate <60 at 1 and 3 years (55 vs 17% and 48 vs 17%, respectively, P < 0.01). In renal cell carcinoma patients, overall, metastases-free and cancer-specific survival were not significantly different between groups (median survivor follow up 7.1 years, interquartile range 3.6-11.4).

CONCLUSIONS

Partial nephrectomy appears to be a relatively safe and a potentially effective treatment for cT2 renal masses, conferring better renal functional preservation compared with radical nephrectomy. These data support continued use of partial nephrectomy for renal masses >7 cm in appropriately selected patients.

How to Deal with Renal Cell Carcinoma >7 cm: Radical Surgery

For renal cell carcinoma >7 cm (T2), radical nephrectomy should be the preferred surgical approach because of higher oncologic safety and fewer any-grade and severe complications. The better renal function preservation with partial nephrectomy does not translate into an improvement in overall survival.

Outcomes in robot-assisted partial nephrectomy for imperative vs elective indications

OBJECTIVES

To assess and compare peri-operative outcomes of patients undergoing robot-assisted partial nephrectomy (RAPN) for imperative vs elective indications.

PATIENT AND METHODS

We retrospectively reviewed a multinational database of 3802 adults who underwent RAPN for elective and imperative indications. Laparoscopic or open partial nephrectomy (PN) were excluded. Baseline data for age, gender, body mass index, American Society of Anaesthesiologists score and PADUA score were examined. Patients undergoing RAPN for an imperative indication were matched to those having surgery for an elective indication using propensity scores in a 1:3 ratio. Primary outcomes included organ ischaemic time, operating time, estimated blood loss (EBL), rate of blood transfusions, Clavien-Dindo complications, conversion to radical nephrectomy (RN) and positive surgical margin (PSM) status.

RESULTS

After propensity-score matching for baseline variables, a total of 304 patients (76 imperative vs 228 elective indications) were included in the final analysis. No significant differences were found between groups for ischaemia time (19.9 vs 19.8 min; P = 0.94), operating time (186 vs 180 min; P = 0.55), EBL (217 vs 190 mL; P = 0.43), rate of blood transfusions (2.7% vs 3.7%; P = 0.51), or Clavien-Dindo complications (P = 0.31). A 38.6% (SD 47.9) decrease in Day-1 postoperative estimated glomerular filtration rate was observed in the imperative indication group and an 11.3% (SD 45.1) decrease was observed in the elective indication group (P < 0.005). There were no recorded cases of permanent or temporary dialysis. There were no conversions to RN in the imperative group, and seven conversions (5.6%) in the elective group (P = 0.69). PSMs were seen in 1.4% (1/76) of the imperative group and in 3.3% of the elective group (7/228; P = 0.69).

CONCLUSION

We conclude that RAPN is feasible and safe for imperative indications and demonstrates similar outcomes to those achieved for elective indications.

Predicting the risk of postoperative acute kidney injury: development and assessment of a novel predictive nomogram

OBJECTIVE

This study aimed to establish and internally verify the risk nomogram of postoperative acute kidney injury (AKI) in patients with renal cell carcinoma.

METHODS

We retrospectively collected data from 559 patients with renal cell carcinoma from June 2016 to May 2019 and established a prediction model. Twenty-six clinical variables were examined by least absolute shrinkage and selection operator regression analysis, and variables related to postoperative AKI were determined. The prediction model was established by multiple logistic regression analysis. Decision curve analysis was conducted to evaluate the nomogram.

RESULTS

Independent predictors of postoperative AKI were smoking, hypertension, surgical time, blood glucose, blood uric acid, alanine aminotransferase, estimated glomerular filtration rate, and radical nephrectomy. The C index of the nomogram was 0.825 (0.790-0.860) and 0.814 was still obtained in the internal validation. The nomogram had better clinical benefit when the intervention was decided at the threshold probabilities of >4% and <79% for patients and doctors, respectively.

CONCLUSIONS

This novel postoperative AKI nomogram incorporating smoking, hypertension, the surgical time, blood glucose, blood uric acid, alanine aminotransferase, the estimated glomerular filtration rate, and radical nephrectomy is convenient for facilitating the individual postoperative risk prediction of AKI in patients with renal cell carcinoma.

Comparison between minimally-invasive partial and radical nephrectomy for the treatment of clinical T2 renal masses: results of a 10-year study in a tertiary care center

BACKGROUND

Even if partial nephrectomy (PN) is nowadays considered the standard for managing cT1 renal masses, its role in the management of cT2 kidney tumors is controversial. We aimed to compare oncologic and functional outcomes of minimally invasive radical nephrectomy (RN) and PN in cT2 renal masses.

METHODS

Patients with cT2 renal masses underwent minimally-invasive PN or RN performed by a highly experienced single surgeon from 2009 to 2019 were considered. Demographic, perioperative and functional variables were compared. Cumulative incidence plot and competing risks regression (CRR) models were used to test differences in 5-year cancer-specific mortality (CSM) and 5-year other-cause mortality (OCM) rates. Kaplan-Meier and Cox regression model was used to test differences in 5-year progression free survival (PFS) rates.

RESULTS

Overall, 52 PN vs. 64 RN patients were identified. Relative to RN, PN patients recorded higher rates of complications (25% vs. 7.8%, P=0.02) but lower upstaging rate (≥pT3a 64.1% vs. 19.2%, P<0.0001). Functional outcomes were in favor of PN (all P<0.001). No differences were recorded between 5-year CSM and OCM according to nephrectomy type. At CRR models, older age and upstaging were independent predictors of 5-year OCM and CSM, respectively (all P<0.01). Finally, only upstaging, high grade tumors and presence of positive surgical margins were identified as independent predictors of 5-year PFS (all P<0.01).

CONCLUSIONS

In experienced hands the treatment of cT2 renal neoplasms with minimally-invasive PN is feasible, providing perioperative and oncological safety profiles comparable to RN, with advantages in terms of functional outcomes.

Single-Port robot assisted partial nephrectomy: initial experience and technique with the da Vinci Single-Port platform (IDEAL Phase 1)

BACKGROUND

To evaluate the safety and feasibility of robotic-assisted laparoscopic partial nephrectomy (RAPN) performed using the da Vinci Single-Port (SP) platform.

METHODS

A retrospective review was conducted from December 2018 to December 2019 of 14 consecutive patients with localized renal cancer who underwent SP robot-assisted partial nephrectomy at a single institution. The procedures were performed by 2 experienced robotic surgeons, reproducing the steps of the standard multiport robotic approach to partial nephrectomy. A transperitoneal approach was utilized with a 2.5 cm para-rectus incision with one assistant 12 mm laparoscopic port.

RESULTS

No conversions to open or laparoscopic surgery occurred and no additional laparoscopic assistant ports were required. The median total operative time was 202 (162-231) minutes and the median total room time was 258 (215-295) minutes. The warm ischemia time averaged 20 minutes ± 8 minutes. 2 patients required angioembolization due to postoperative acute bleeding (Clavien-Dindo Grade 3a complication). Trifecta outcome (<25 min warm ischemia, no perioperative complications and negative margins) was achieved in 79% of patients. In one case, a positive margin was present. The median length of stay was of 1 day (Interquartile Range 1-2) with a median pain score on postoperative day 1 of 3.5 (Interquartile Range 2.4-5). 1/14 (7%) patient needed narcotic use at one week from discharge. At a median follow up of 5.0 (4.0-8.0) months, no patients have had evidence of disease recurrence.

CONCLUSIONS

In this initial cohort, considering the introduction of a new technology, we observed satisfactory outcomes for several key perioperative variables including operative time, warm ischemia time, surgical margins, hospital stay, pain requirements in patients undergoing RAPN with the SP platform. For experienced robotic surgeons, RAPN with the SP platform is a safe and feasible approach for single site partial nephrectomy.

Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass

CONTEXT

With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced.

OBJECTIVE

To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making.

CONCLUSIONS

Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care.

PATIENT SUMMARY

With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Recurrence after radical and partial nephrectomy in high complex renal tumor using propensity score matched analysis

We evaluated the recurrence after radical and partial nephrectomy in patients with RENAL nephrometry score [RENAL] ≥ 10. A total of 474 patients (radical nephrectomy [RN, n = 236] & partial nephrectomy [PN, n = 238]) in a single tertiary referral institution from December 2003 to December 2019 were assessed. Functional outcomes, defined as estimated glomerular filtration rate changes, relapse pattern, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were evaluated using propensity score-matched analysis. The predictors of recurrence and survival were assessed by Cox-regression analysis. 44 patients in the RN group and 88 in the PN group were included without significant differences in preoperative clinical factors after matching. The PN patients achieved significantly higher renal function preservation rates (p < 0.001). There were five recurrences in RN and six in PN. The PN patients revealed 5-year RFS rate (86.8%), 5-year CSS rate (98.5%), and 5-year OS rate (98.5%) comparable to the RN patients (RFS: 88.7% [p = 0.780], CSS: 96.7% [p = 0.375], and OS: 94.3% [p = 0.248]). Patients with a body mass index (BMI) ≥ 23 had lower 5-year RFS rates (85.5%) and OS rates (95.6%) than those with BMI < 23 (RFS: 90.0% [p = 0.195], OS: 100% [p = 0.117]) without significance. The significant predictor of recurrence was the pathologic T stage (hazard ratio [HR] 3.99, 95% confidence [CI] 1.10–14.50, p = 0.036). The significant predictor of death was the R domain of the RENAL (HR 3.80, 95% CI 1.03–14.11, p = 0.046). PN, if technically feasible, could be considered to preserve renal function in patients with RENAL ≥ 10. Nonetheless, PN needs to be implemented with caution in some patients due to the higher potentiality for recurrence and poor survival.

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T3a Renal Masses: A Multicenter Analysis

BACKGROUND

Use of partial nephrectomy (PN) in T3 renal cell carcinoma (RCC) is controversial.

OBJECTIVE

To evaluate quality outcomes of robot-assisted PN (RAPN) for clinical T3a renal masses (cT3aRM).

DESIGN, SETTING, AND PARTICIPANTS

This was a retrospective multicenter analysis of patients with cT3aN0M0 RCC who underwent RAPN.

INTERVENTION

RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was a trifecta composite outcome of negative surgical margins, warm ischemia time (WIT) ≤25 min, and no perioperative complications. The optimal outcome was defined as achieving this trifecta and ≥90% preservation of the estimated glomerular filtration rate (eGFR) and no stage upgrading of chronic kidney disease. Multivariable analysis (MVA) identified risk factors associated with lack of the optimal outcome. Kaplan-Meier analysis was conducted for survival outcomes.

RESULTS AND LIMITATIONS

Analysis was conducted for 157 patients (median follow-up 26 mo). The median tumor size was 7.0 cm (interquartile range [IQR] 5.0-7.8) and the median RENAL score was 9 (IQR 8-10). Median estimated blood loss (EBL) was 242 ml (IQR 121-354) and the median WIT was 19 min (IQR 15-25). A total of 150 patients (95.5%) had negative margins. Complications were noted in 25 patients (15.9%), with 4.5% having Clavien grade 3-5 complications. The median change in eGFR was 7 ml/min/1.72 m², with ≥90% eGFR preservation in 55.4%. The trifecta outcome was achieved for 64.3% and the optimal outcome for 37.6% of the patients. MVA revealed that greater age (odds ratio [OR] 1.06; p = 0.002), increasing RENAL score (OR 1.30; p = 0.035), and EBL >300 ml (OR 5.96, p = 0.006) were predictive of failure to achieve optimal outcome. The 5-yr recurrence-free survival, cancer-specific survival, and overall survival, were 82.1%, 93.3%, and 91.3%, respectively. Limitations include the retrospective design.

CONCLUSIONS

RAPN for select cT3a renal masses is feasible and safe, with acceptable quality outcomes. Further investigation is requisite to delineate the role of RAPN in cT3a RCC.

PATIENT SUMMARY

Robot-assisted partial nephrectomy in patients with stage 3a kidney cancer provided acceptable survival, functional, and morbidity outcomes in the hands of experienced surgeons, and may be considered as an option when clinically indicated.

Partial nephrectomy preserves renal function without increasing the risk of complications compared with radical nephrectomy for renal cell carcinomas of stages pT2-3a

OBJECTIVES

To compare the operative and functional result of partial and radical nephrectomy in renal cell carcinomas of stages pT2-3a.

METHODS

Consecutive patients with renal cell carcinoma of stages pT2-3a, cN0 and cM0, who underwent partial or radical nephrectomy between January 2005 and October 2019 at a tertiary care center were included. Data were collected retrospectively. End-points included severe postoperative complications (Clavien-Dindo classification ≥3), acute and chronic renal function impairment, and overall survival. Uni- and multivariable outcome analyses were based on logistic regression.

RESULTS

A total of 158 patients were included (110 radical nephrectomy and 48 partial nephrectomy). Over time, partial nephrectomy was increasingly used. A RENAL score ≥10 was the only independent predictor influencing the surgical approach (radical nephrectomy vs partial nephrectomy, odds ratio 8.62, 95% confidence interval 3.32-22.37, P < 0.001). No significant differences in complications for radical nephrectomy versus partial nephrectomy were found (12.7% vs 8.3%, P = 0.424). Renal function was better preserved in the partial nephrectomy group (the latest chronic kidney disease stage ≥3: radical nephrectomy 73% vs partial nephrectomy 41%, P = 0.005). The surgical approach was a significant factor for chronic kidney disease (odds ratio 51.07, 95% confidence interval 3.57-730.59, P = 0.004). Overall survival did not significantly differ between radical nephrectomy and partial nephrectomy (mean overall survival 85.86 months, 95% confidence interval 3.83-78.36 vs 81.28 months, 95% confidence interval 4.59-72.29, P = 0.702).

CONCLUSIONS

In selected patients, partial nephrectomy can be used in large or locally advanced renal cell carcinoma. Compared with radical nephrectomy, it allows better preservation of renal function without harboring an increased risk of severe postoperative complications.