Impact of Trifecta definition on rates and predictors of "successful" robotic partial nephrectomy for localized renal masses: results from the Surface-Intermediate-Base Margin Score International Consortium

Open versus robotic-assisted partial nephrectomy in patients with intermediate/high-complexity kidney tumours: final results of the randomised, controlled, open-label, multicentre trial OpeRa

BACKGROUND

The prospective, randomised, open-label, multicentre OpeRa trial (NCT03849820) aimed to determine whether robotic-assisted partial nephrectomy (RAPN) is superior to open partial nephrectomy (OPN) in reducing 30-day post-operative complications during the treatment of intermediate/high-complexity renal tumours.

PATIENTS AND METHODS

Eligible patients aged ≥18 years had a renal tumour suitable for OPN or RAPN, a RENAL score ≥7, and an estimated glomerular filtration rate ≥50 ml/min/1.73 m2. Patients were randomised from 15 March 2019 to 23 November 2021 in 12 German hospitals and assigned (1 : 1) to undergo RAPN or OPN. Primary endpoint was the 30-day post-operative complication rate [Clavien-Dindo (CD) I-V] in the modified intention-to-treat population. We aimed to recruit 606 patients to detect ≥10% reduction in the primary endpoint for RAPN versus OPN.

RESULTS

A total of 240 patients were randomised to RAPN (n = 123) or OPN (n = 117). Enrolment was stopped prematurely due to slow recruitment. After patient withdrawal post-randomisation, 117 patients underwent RAPN and 90 OPN. The primary endpoint was assessable in 112 and 89 patients, respectively. The 30-day complication rate did not differ between groups: RAPN 41/112 (37%) versus OPN 41/89 (46%) (one-sided: P = 0.088). The difference of -9.5% (95% confidence interval -23.1% to 4.2%) numerically favoured RAPN. The most frequent high-grade complications (CD III-IV) to post-operative day 30 (POD30) were urine leakage [RAPN 4/112 (4%) versus OPN 2/89 (2%)] and post-operative bleeding [2/117 (2%) versus 1/89 (1%)]. Compared with OPN, RAPN patients had longer operative and warm ischaemia times, shorter hospital stay, and reported better recovery, less opioid use, less pain, and improved quality of life (QoL) up to POD30.

CONCLUSIONS

There was no statistically significant difference in the 30-day complication rate between RAPN and OPN in this underpowered trial. Few high-grade complications occurred over the whole cohort with intermediate/high-complexity tumours. Despite less intense pain management, patients undergoing RAPN reported less pain and better QoL up to POD30.

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.

Robot-assisted partial nephrectomy vs. percutaneous cryoablation for T1a renal tumors: a single-center retrospective analysis of outcomes and costs

PURPOSE

The aim of this study is to compare perioperative, functional, and oncological outcomes between robot-assisted partial nephrectomy (RAPN) and cryoablation (CRYO), based on a 3-year experience at our Institution. Additionally, a secondary aim is to conduct a comparative cost analysis between the two procedures.

METHODS

A retrospective analysis was conducted, including patients who underwent RAPN or CRYO between January 2020 and December 2023. Group 1 consisted of 59 patients who underwent RAPN, while Group 2 included 38 patients who had CRYO. The evaluation parameters included baseline characteristics, perioperative, functional, and oncological outcomes, as well as total hospitalization costs.

RESULTS

Operative time (OT), average length of hospital stay (LOS), and emetic blood loss (EBL) were significantly lower in the CRYO group. Furthermore, CRYO showed a significantly lower rate of postoperative complications of any grade (7.8% vs 16.9%); however, this was associated with a considerably higher recurrence rate (5.7% vs 1.7%). No substantial differences were found in long-term functional outcomes (ΔeGFR). In terms of costs, CRYO was more cost-effective than RAPN (€5473 vs €10,672), although the gap was partially offset by a higher reimbursement "DRG" rate for robotic partial nephrectomy (€7386 vs €4384).

CONCLUSIONS

Robot-assisted partial nephrectomy (RAPN) remains the preferred option for treating small renal masses (sRM), providing excellent oncological results and acceptable morbidity. However, percutaneous cryoablation is a valid alternative, particularly for patients unfit for surgery, as long as meticulous postoperative follow-up is carried out.

Prediction of complications after laparoscopic partial nephrectomy: feasibility of E‑PASS score

PURPOSE

With significant advancements in laparoscopic procedures and tools over the last decade, the partial nephrectomy (PN) surgical approach has gradually transformed from open to laparoscopic partial nephrectomy (LPN). Although numerous studies evaluating the postoperative complications of laparoscopic partial nephrectomy can be found in the literature, a scoring system that addresses both preoperative physical condition and intraoperative risk factors has not yet been established. The Estimation of Physiological Ability and Surgical Stress (E-PASS) score is a scoring system that considers both the patient's preoperative condition and intraoperative variables to predict the risk of postoperative complications in surgically treated patients. This study aimed to assess the applicability of the E-PASS scoring system for predicting postoperative complications following LPN.

METHODS

We analyzed data of 196 patients who underwent LPN between 2017 and 2024 by a single surgeon in this single-center retrospective study. Demographic data of the patients, parameters reflecting patients' preoperative physical condition, and intraoperative risk factors were recorded. Postoperative complications were classified using the Clavien-Dindo system. The E-PASS score and its sub-scores were calculated for each patient.

RESULTS

Various degrees of complications developed in 46 patients (23.5%). Patients who developed complications had significantly higher mean age, performance scores, tumor sizes, length of hospital stay, and E-PASS values. The cutoff value of the E-PASS Comprehensive Risk Score (CRS) for predicting the development of postoperative complications was determined to be - 0.1692 (AUC = 0.676; 95% CI 0.581-0.771; p < 0.001). According to the results of the multivariate analysis, the presence of E-PASS CRS > - 0.1692 (OR 4.872; 95% CI 2.384-9.957; p < 0.001) and tumor size (OR 1.021; 95% CI 1-1.041; p = 0.047) was identified as independent risk factors predicting postoperative complications. Patients with a CRS higher than the cutoff value had a 4.87 times higher rate of postoperative complications after LPN.

CONCLUSION

The E-PASS scoring model successfully predicts postoperative complications in patients undergoing LPN by utilizing preoperative data on the patient's physical condition and surgical risk factors. The E-PASS score and its sub-scores can serve as objective criteria to determine the risk of postoperative complications both preoperatively and immediately postoperatively.

A novel preoperative evaluation technique for partial nephrectomy: three-dimensional extended renal tumor plane

OBJECTIVE

To develop a three-dimensional (3D) image based extended tumor plane technique for robotic-assisted partial nephrectomy (RAPN).

METHODS

We prospectively enrolled patients with a local renal tumor for RAPN between March 2019 and Mar 2022. 3D virtual model was reconstructed based on the computed tomography urography. The tumor plane was extended equidistantly (10 mm) to form a virtual plane. According to the relationship between the extended plane and the collection system, patients are divided into those with no collecting system involvement, renal medulla involvement, and renal calyx involvement. The primary endpoint was trifecta achievement, which was defined as warm ischemic time ≤ 25 min, negative surgical margins, and no major perioperative complications.

RESULTS

This study enrolled a total of 215 patients. The median preoperative aspects and dimensions used for an anatomical (PADUA) score was 9 (6-15). The average warm ischemic time was 21.64 ± 9.35 min. Postoperative complications occurred in 26 (12.1%) patients, of whom 14 (6.5%) classified as major complication. The number of cases with trifecta failure was 1 (5.3%) in the no involvement group, 28 (20.6%) in the renal medullary involvement group, and 24 (40.0%) in the renal calyx involvement group (p < 0.001). Logistic regression indicated that renal calyx involvement was a risk factor for trifecta failure (OR = 2.639, 95% confidence interval [1.268-5.492], p = 0.009).

CONCLUSIONS

The extended tumor plane based on three-dimensional images can is useful for the evaluation of RAPN. Determining whether the extended plane involves the collecting system, particularly the renal calyx, may impact the achievement of trifecta.

Impacts of completely endophytic renal masses on perioperative, oncologic, and functional outcomes in robot-assisted partial nephrectomy: a systematic review and meta-analysis

Background

The objective of this study was to perform a comprehensive pooled analysis aimed at comparing the efficacy and safety of robot-assisted partial nephrectomy (RAPN) between completely endophytic tumors (CERT) and non-completely endophytic tumors (non-CERT).

Methods

This study adhered rigorously to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct a systematic review and meta-analysis. We performed a systematic search in the PubMed, Embase, Web of Science, and Cochrane Library databases, focusing on studies published in English up to May 2024. Our analysis primarily evaluated key outcomes, specifically perioperative, functional, and oncological outcomes.

Results

A total of 2126 patients across six studies were included in the analysis. Compared to non-CERT, CERT was associated with significantly higher rates of major complications (Odds Ratio [OR]: 2.47; 95% CI: 1.14 to 5.34; p = 0.02), longer warm ischemia times (Weighted Mean Difference [WMD]: 3.27 min; 95% CI: 0.61 to 5.39; p = 0.02), a greater decline in estimated glomerular filtration rate (eGFR) (WMD: 2.93 ml/min/1.73 m2; 95% CI: 0.75 to 5.11; p = 0.008), and relatively lower trifecta achievement rates (OR: 0.63; 95% CI: 0.41 to 0.96; p = 0.03). However, no statistically significant differences were observed between the two groups in terms of operative time, length of stay, blood loss, transfusion rates, intraoperative complications, overall complications, positive surgical margins, and local recurrence.

Conclusions

Although CERT was associated with greater declines in eGFR and lower rates of trifecta achievement, it yielded perioperative, functional, and oncologic outcomes comparable to those of non-CERT in RAPN. Our findings suggest that RAPN for completely endophytic renal masses can achieve acceptable outcomes when performed in centers with substantial expertise in robotic surgery.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=555067, identifier CRD42024555067.

Comparative efficacy of cryoablation versus robot-assisted partial nephrectomy in the treatment of cT1 renal tumors: a systematic review and meta-analysis

PURPOSE

This study utilizes a meta-analytic approach to investigate the effects of cryoablation and robot-assisted partial nephrectomy on perioperative outcomes, postoperative renal function, and oncological results in patients.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Four electronic databases (PubMed, Embase, Web of Science, and the Cochrane Library database) were systematically searched to identify relevant studies published in English up to November 2023. The primary outcomes were perioperative results, complications, postoperative renal function and oncologic outcomes. Review Manager 5.4 was used for this analysis.

RESULTS

This study included a total of 10 studies comprising 2,011 patients. Compared to RAPN (Robot-Assisted Partial Nephrectomy), the CA (Cryoablation) group had a shorter hospital stay [MD -1.76 days; 95% CI -3.12 to -0.41; p = 0.01], less blood loss [MD -104.60 ml; 95% CI -152.58 to -56.62; p < 0.0001], and fewer overall complications [OR 0.62; 95% CI 0.45 to 0.86; p = 0.004], but a higher recurrence rate [OR 7.83; 95% CI 4.32 to 14.19; p < 0.00001]. There were no significant differences between the two groups in terms of operative time, minor complications (Clavien-Dindo Grade 1-2), major complications (Clavien-Dindo Grade 3-5), changes in renal function at 12 months post-operation, RFS (Recurrence-Free Survival), and OS (Overall Survival).

CONCLUSION

The evidence provided by this meta-analysis indicates that the therapeutic effects of Cryoablation (CA) are similar to those of Robot-Assisted Partial Nephrectomy (RAPN) in terms of perioperative outcomes and renal function. However, the recurrence rate of tumors treated with CA is significantly higher.

SYSTEMATIC REVIEW REGISTRATION

The study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023465846).

3D virtual model for robot-assisted partial nephrectomy in highly-complex cases (PADUA ⩾ 10)

PURPOSE

To compare two cohorts of patients submitted to robot-assisted partial nephrectomy (RAPN) for highly-complex renal masses (PADUA ⩾ 10) with versus without the use of 3DVMs.

MATERIALS AND METHODS

We screened a prospective consecutive cohort of 152 patients submitted to RAPN with 3DVM and 1264 patients submitted to RAPN without 3DVM between 2019 and 2022. Only PADUA ⩾ 10 cases were considered eligible for analysis. Propensity score matching (PSM) analysis was applied. Primary endpoint was to evaluate whereas RAPNs with 3DVM were superior in terms of functional outcomes at 12-month. Secondary outcomes were to compare perioperative and oncological outcomes. Multivariable logistic regression analyses (MVA) tested the associations of clinically significant eGFR drop and 3DVMs. Subgroups analysis was performed for PAUDA-risk categories.

RESULTS

Thirty seven patients for each group were analyzed after PSM. RAPN with 3DVM presented a higher rate of selective/no clamping procedure (32.5% vs 16.2%, p = 0.03) and a higher enucleation rate (43.2% vs 29.8%, p = 0.04). Twelve-month functional preservation performed better within 3DVM group in terms of creatinine serum level (median 1.2 [IQR 1.1-1.4] vs 1.6 [IQR 1.1-1.8], p = 0.03) and eGFR (median 64.6 [IQR 56.2-74.1] vs 52.3 [IQR 49.2-74.1], p = 0.03). MVA confirmed 3DVM as a protective factor for clinically significant eGFR drop in this subgroup of patients.

CONCLUSIONS

RAPN performed with the use of 3DVM assistance for PADUA ⩾ 10 cases resulted in lower incidence of global ischemia and higher rate of enucleations. The positive impact of such technology was found at 12-month follow-up.

Achieving trifecta outcomes in robotic-assisted partial nephrectomy within a fellowship training centre

To assess the robotic-assisted partial nephrectomy (RAPN) trifecta rate within a fellowship program. Patients undergoing RAPN 01/01/2010-01/07/2023 were enrolled from a prospectively maintained database. All cases were performed jointly with surgical fellows, except when privately insured. Patients were excluded if they were converted to open or radical nephrectomy. The primary outcome was achieving the 'trifecta' of negative surgical margins, no complications < 30 days post-operatively and warm ischaemia time (WIT) < 25 min. The secondary outcomes were factors associated with trifecta success. Ethics approval was obtained. In the enrolment period, 355 patients underwent intended RAPN, of whom seven were excluded due to conversion to conversion to radical nephrectomy (6 patients) or conversion to open (one). Amongst the 348 eligible patients, median age was 60 years, 115 (33%) were female and 19 were private patients. WIT was < 25 min for 324/337 patients (96%), surgical margins were negative in 325 (93%), 294 (84%) were complication-free at 30 days and 301/320 (94%) had a < 30% decline in estimated glomerular filtration rate at 3-6 months postoperatively. Subsequently, trifecta outcomes were achieved in 253/337 (75%) patients. Comparing with patients without those with trifecta success were similar in all thirteen measured patients and tumour factors. In a teaching hospital, with a fellowship training programme, trifecta outcome is achievable for most RAPN patients, and at a rate comparable to international standards. Fellowship centres should monitor their outcomes to ensure high patient outcomes are maintained alongside training requirements.

Best predictive single nephrometry score component to correlate with achievement of trifecta outcome in laparoscopic and robotic surgery

BACKGROUND

To evaluate the predictive value of individual components of the R.E.N.A.L scoring system for Laparoscopic (LPN) and Robotic Partial Nephrectomy (RPN).

METHODS

Patients that had undergone a Laparoscopic (LPN) or Robotic Partial Nephrectomy (RPN) between 2018 and 2023 were reviewed. Our data collection included Race, Ethnicity, Age, BMI, R.E.N.A.L nephrometry score, and complications. Cases that achieved trifecta outcomes were designated as "Group A" and cases that did not achieve trifecta were "Group B". All the data were collected using REDCap database.

RESULTS

A total of 111 cases were included, Group A consisted of 82% of all cases, whereas Group B 18%. Radius score demonstrated significant distinction concerning trifecta attainment and was the most predictive component of the 5 scoring metrics of the nephrometry system. In a subgroup analysis, R-score of 3 or a renal mass measuring ≥ 7 cm, was a significant independent negative predictor for trifecta outcomes, as well as tumor size at presentation.

CONCLUSION

Renal nephrometry score is predictive of trifecta outcomes for patients undergoing laparoscopic or robotic partial nephrectomy. Radius of mass was the most effective predictive component of the nephrometry score for trifecta prediction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Renorrhaphy techniques in minimally invasive partial nephrectomy: a systematic review of the literature

INTRODUCTION

In the absence of consensus on the optimal approach to renorrhaphy in partial nephrectomy, this systematic review aims to assess the various renorrhaphy techniques and their impact on surgical outcomes.

EVIDENCE ACQUISITION

A systematic review of the literature was performed in March 2022, using PubMed and Scopus, without time restrictions and research filters for studies investigating renorrhaphy techniques in partial nephrectomy. Studies providing sufficient details on renorrhaphy techniques and their outcomes during minimally invasive partial nephrectomy (PN) were included in this analysis.

EVIDENCE SYNTHESIS

Thirty-one studies with 5720 patients were included in the analysis. In most studies, tumor diameter was <4 cm. RENAL and PADUA scores as well as tumor locations were heterogeneous between the studies. The results of the use of hemostatic agents were conflicting among different studies with limited evidence regarding the benefits of its routine use in partial nephrectomy. The use of barbed and running sutures was associated with a reduced warm ischemia time. While some studies showed a decreased warm ischemia time when omitting cortical renorrhaphy, others found that it may lead to higher incidence of minor complications without any significant improvement in other outcomes.

CONCLUSIONS

There is ongoing research to determine the optimal approach to renorrhaphy. The current evidence on the routine use of hemostatic agents is limited. The use of certain techniques such as barbed sutures, sliding clips and running sutures reduced the warm ischemia time. The omission of cortical renorrhaphy is still controversial.

Retroperitoneal vs. transperitoneal robotic partial nephrectomy: a multicenter propensity-score matching analysis (PADORA Study - UroCCR n° 68)

BACKGROUND

Robot-assisted partial nephrectomy can be performed through either a transperitoneal or retroperitoneal approach. This study aimed to compare the rate of trifecta achievement between retroperitoneal (RRPN) and transperitoneal (TRPN) robot-assisted partial nephrectomy using a large multicenter prospectively-maintained database and propensity-score matching analysis.

METHODS

This study was launched by the French Kidney Cancer Research Network, under the UroCCR Project (NCT03293563). Patients who underwent TRPN or RRPN by experienced surgeons in 15 participating centers were included. Data on demographic and clinical parameters, tumor characteristics, renal function, and surgical parameters were collected. The primary outcome was the rate of trifecta achievement, which was defined as a warm ischemia time of less than 25 minutes, negative surgical margins, and no major complications. Secondary outcomes included operative time, hospital length-of-stay, blood loss, postoperative complications, postoperative renal function, and each trifecta item taken alone. Subgroup analysis was done according to tumor location.

RESULTS

A total of 2879 patients (2581 TRPN vs. 298 RRPN) were included in the study. Before matching, trifecta was achieved in 73.0% of the patients in the TRPN group compared to 77.5% in the RRPN group (P=0.094). After matching 157 patients who underwent TRPN to 157 patients who underwent RRPN, the trifecta rate was 82.8% in the TRPN group vs. 84.0% in the RRPN group (P=0.065). The RRPN group showed shorter operative time (123 vs. 171 min; P<0.001) and less blood loss (161 vs. 293 mL; P<0.001). RRPN showed a higher trifecta achievement for posterior tumors than TRPN (71% vs. 81%; P=0.017).

CONCLUSIONS

RRPN is a viable alternative to the transperitoneal approach, particularly for posterior renal tumors, and is a safe and effective option for partial nephrectomy.

New Generation of 3D Virtual Models with Perfusional Zones: Perioperative Assistance for the Best Pedicle Management during Robotic Partial Nephrectomy

Selective clamping during robot-assisted partial nephrectomy (RAPN) may reduce ischemia-related functional impairment. The intraoperative use of 3D-virtual models (3DVMs) can improve surgical planning, resulting in a greater success rate for selective clamping. Our goal is to introduce a new generation of 3DVMs, which consider the perfusion volumes of the kidney. Patients listed for RAPN from 2021 to 2022 were recruited. A selective clamping strategy was designed and intraoperatively performed based on the specifically generated 3DVMs. The effectiveness of selective clamping was evaluated using near-infrared-fluorescence imaging (NIRF) and 3DVM. Perfusion areas extensions were compared, and relevant preoperative characteristics were analyzed. In 61 of 80 (76.25%) cases, selective clamping was performed. The concordance between the 3DVM areas and the NIRF-enhanced areas was verified (k = 0.91). According to the distribution of perfused areas crossing the tumor, there were one, two, three, four, and five crossing areas, with relative perfusion rates of 13.75%, 35%, 32.5%, 13.75%, and 5%, respectively. Lesion diameter and mesorenal location were the only factors related to a higher number (>3) of perfusion volumes crossing the lesion. The implementation of mathematical algorithms to 3DVMs allows for precise estimation of the perfusion zone of each arterial branch feeding the organ, leading to the performance of safe and effective pedicle management planning.

Search for the optimized and key nephrometry elements combination in retroperitoneal laparoscopic partial nephrectomy: A retrospective study

Background

The nephrometry scoring system plays a key role in the preoperative evaluation of partial nephrectomy, and scoring systems based on anatomical characteristics have high similarity in scoring elements. Currently, there is little research on scoring systems related to retroperitoneal laparoscopic partial nephrectomy, and there is a lack of research on the combination of scoring elements, which requires further investigation.

Methods

We retrospectively analyzed the clinical records of 107 patients who underwent retroperitoneal laparoscopic partial nephrectomy conducted by a single operator at a single center. The score and scoring elements were generated based on imaging. The scoring elements of each scoring system and all combinations of two to five elements were extracted. The predictive ability of different score combinations was evaluated by AUC value, and the key parameters of the score were found by taking the intersection. A nomogram was constructed and evaluated.

Results

We observed that with an increase in scoring elements, the strongest combination of elements did not significantly increase the predictive ability of warm ischemia time (P>0.05), postoperative complications (P>0.05), and trifecta achievement (P>0.05). The combination of the maximum tumor diameter and the distance between tumor and collecting system or renal sinus had a good comprehensive predictive ability, and there is no significant difference with the traditional score (P>0.05). The nomogram generated according to this combination has an excellent prediction ability for predicting whether obtain trifecta of partial nephrectomy.

Conclusions

Within the range of two to five elements, the critical degree of elements is more important than the number of elements. The maximum tumor diameter and the distance between the tumor and the collecting system or renal sinus was the key element of the prediction ability.

Robotic Partial Nephrectomy with En Bloc Removal of a Renal Vein Thrombus for Multiple cT3a Renal Cell Carcinoma Lesions

Partial nephrectomy (PN) may be recommended for selected patients with advanced-stage (>cT2) renal cell carcinoma (RCC) with the aim of avoiding dialysis and chronic kidney disease–related comorbidities. The spread of robotic surgery has led to expansion of PN indications to more challenging scenarios and even frontier surgeries, including advanced-stage RCC. Here we describe the management of a patient with a solitary kidney diagnosed with multiple cT3a (renal vein thrombus) RCC who was treated using a conservative robotic approach. The most crucial surgical considerations for this procedure were: (1) tailored planning of the surgical approach using three-dimensional reconstruction software; (2) accurate boundary delineation for the tumors and thrombus; (3) avoiding unnecessary warm ischemia time; (4) performing an anatomical excision to follow eventual tumor bulging; and (5) en bloc removal of the main lesion and its thrombus. No perioperative complications were recorded. Histopathology revealed clear cell RCC for all four lesions with nucleolar grade 3 and negative surgical margins. At 12-mo follow-up the patient was disease-free. When performed by an experienced surgeon, PN plus venous thrombus excision for imperative cases with cT3 RCC may represent a valid treatment option with valuable oncological and functional outcomes.

Patient summary

We describe the case of patient who had a single kidney with multiple kidney tumors and tumor extension into a blood vessel. The patient was treated with robot-assisted removal of the tumors, sparing as much kidney tissue as possible. This technique was found to be safe and effective, with no complications and good intermediate-term results.