Robotic partial nephrectomy for management of renal mass in patients with a solitary kidney: can we expand the indication to T2 and T3 disease?

Minimally invasive transperitoneal partial versus radical nephrectomy in obese patients: perioperative and long-term functional outcomes from a large perspective contemporary series (RECORd2 project)

BACKGROUND

The aim of this study is to evaluate the perioperative and long-term functional outcomes of laparoscopic (LPN) and robot-assisted partial nephrectomy (RAPN) in comparison to laparoscopic radical nephrectomy (LRN) in obese patients diagnosed with renal cell carcinoma.

METHODS

Clinical data of 4325 consecutive patients from The Italian REgistry of COnservative and Radical Surgery for cortical renal tumor Disease (RECORD 2 Project) were gathered. Only patients treated with transperitoneal LPN, RAPN, or LRN with Body Mass Index (BMI) ≥30 kg/m2, clinical T1 renal tumor and preoperative estimated glomerular filtration rate (eGFR) ≥60 mL/min, were included. Perioperative, and long-term functional outcomes were examined.

RESULTS

Overall, 388 patients were included, of these 123 (31.7%), 120 (30.9%) and 145 (37.4%) patients were treated with LRN, LPN, and RAPN, respectively. No significant difference was observed in preoperative characteristics. Overall, intra and postoperative complication rates were comparable among the groups. The LRN group had a significantly increased occurrence of acute kidney injury (AKI) compared to LPN and RAPN (40.6% vs. 15.3% vs. 7.6%, P=0.001). Laparoscopic RN showed a statistically significant higher renal function decline at 60-month follow-up assessment compared to LPN and RAPN. A significant renal function loss was recorded in 30.1% of patients treated with LRN compared to 16.7% and 10.3% of patients treated with LPN and RAPN (P=0.01).

CONCLUSIONS

In obese patients, both LPN and RAPN showcased comparable complication rates and higher renal function preservation than LRN. These findings highlighted the potential benefits of minimally invasive PN over radical surgery in the context of obese individuals.

Partial nephrectomy for renal tumors: recommendations of the Italian Society of Urology RCC working group

INTRODUCTION

Partial nephrectomy (PN) aims to remove renal tumors while preserving renal function without affecting oncological and perioperative surgical outcomes. Aim of this paper is to summarize the current evidence on PN and to provide evidence-based recommendations on indications, surgical technique, perioperative management and postoperative surveillance of PN for renal tumors in the Italian clinical and health care system context.

EVIDENCE ACQUISITION

This review is the result of an interactive peer-reviewing process of the recent literature on PN for renal tumors carried out by an expert panel composed of members of the Italian Society of Urology (SIU) Renal Cell Carcinoma Working Group.

EVIDENCE SYNTHESIS

PN for localized renal tumors is not inferior to radical nephrectomy in terms of survival outcomes while significantly better preserving renal function. Loss of renal function after PN is influenced by medical comorbidities/preoperative renal function and surgical variables such volume of parenchyma preserved and ischemia time. Urologists should select the clamping strategy during PN based on their experience and patient-specific factors. PN can be performed with any surgical approach based on surgeon's expertise and skills. Robotic PN has the potential to expand the minimally invasive indications without interfering with oncological outcomes. The use of 3D virtual models, real time ultrasound and fluorescence tools to assess the anatomy and vascularization of renal tumors during PN may allow a more accurate preoperative planning and intraoperative guidance. Proper postoperative surveillance protocols are essential to detect tumor recurrences and assess functional outcomes.

CONCLUSIONS

PN is the standard of care for treatment of localized T1 renal tumors. Recent data supports PN also for selected T2-T3a tumors in experienced institutions. Careful preoperative planning, adequate surgical skills and volumes and appropriate postoperative management and surveillance are paramount to optimize PN oncological and functional outcomes.

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.

Open versus robot-assisted partial nephrectomy for highly complex renal masses: a meta-analysis of perioperitive and functional outcomes

Robot-assisted partial nephrectomy (RAPN) is increasingly being used for the complex surgical management of renal masses. The comparison of RAPN with open partial nephrectomy (OPN) has not yet led to a unified conclusion with regard to perioperative outcomes. To conduct a systematic review and meta-analysis of the literature on the perioperative outcomes of RAPN compared with OPN. We performed a systematic search in PubMed, Embase, Web of Science, and Cochrane Library database for randomized control trials (RCTs) and non-RCTs that compare OPN to RAPN. The primary outcomes included perioperative, functional and oncologic. The odds ratio (OR) and weighted mean difference (WMD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CIs). Five studies, comprising 936 patients, were included in the meta-analysis. Our findings indicated that there were no significant differences in blood loss, minor complication rate, eGFR decline from baseline, positive surgical margin, and ischemia time between OPN and RAPN. However, RAPN was associated with a shorter hospital stay (WMD 1.64 days, 95% CI - 1.17 to 2.11; p < 0.00001), lower overall complication rate (OR 1.72, 95% CI 1.21-2.45; p < 0.002), lower transfusion rate (OR 2.64, 95% CI 1.39-5.02; p = 0.003) and lower major complication rate (OR 1.76, 95% CI 1.11-2.79; p < 0.02) compared to OPN. Additionally, the operation time for OPN was shorter than that for RAPN (WMD - 10.77 min, 95% CI - 18.49 to - 3.05, p = 0.006). In comparison with OPN, RAPN exhibits better results in terms of hospital stay, overall complications, blood transfusion rate, and major complications, with no significant difference in intraoperative blood loss, minor complications, PSM, ischemia time, and short-term postoperative eGFR decline. However, the operation time of OPN is slightly shorter than that of RAPN.

Robotic Partial vs Radical Nephrectomy for Clinical T3a Tumors: A Narrative Review

Introduction: T3a renal masses include a diverse group of tumors that invade the perirenal and/or sinus fat, pelvicaliceal system, or renal vein. The majority of cT3a renal masses represent renal cell carcinoma (RCC) and have historically been treated with radical nephrectomy (RN) given their aggressive nature. With the adoption of minimally invasive approaches to renal surgery, the combination of improved observation, pneumoperitoneum, and robotic articulation has allowed urologists to consider partial nephrectomy (PN) for more complex tumors. Herein, we review the existing literature regarding robot-assisted PN (RAPN) and robot-assisted RN (RARN) in the management of T3a renal masses. Methods: A literature search was performed using PubMed for articles evaluating the role of RARN and RAPN for T3a renal masses. Search parameters were limited to English language studies. Applicable studies were abstracted and included in this narrative review. Results: T3a RCC caused by renal sinus fat or venous involvement is associated with ∼50% lower cancer-specific survival than those with perinephric fat invasion alone. CT and MRI can both be used to stage cT3a tumors, however, MRI is more accurate when assessing venous involvement. Upstaging to pT3a RCC during RAPN does not confer a worse prognosis than pT3a tumors treated with RARN; however, patients who undergo RAPN for T3a RCC with venous involvement have relatively higher rates of recurrence and metastasis. Intraoperative tools including drop-in ultrasound, near-infrared fluorescence, and 3D virtual models improve the ability to perform RAPN for T3a tumors. In well-selected cases, warm ischemia times remain reasonable. Conclusions: cT3a renal masses represent a diverse group of tumors. Depending on substratification of cT3a, RARN or RAPN can be employed for treatment of such masses.

Cryoablation following neoadjuvant tyrosine kinase inhibitor as treatment of a T1a renal clear cell carcinoma in a patient with a solitary kidney

The case is presented of a woman in her 60s with renal cell carcinoma in a solitary kidney with normal renal function. Because of the solitary kidney status, the management strategy described in acknowledged guidelines was not possible. The patient was treated with standard first-line tyrosine kinase inhibitor followed by percutaneous CT-guided cryoablation. Before and after the procedure the patient had normal kidney function. The treatment resulted in local cancer control, but a bone metastasis developed in the thoracic part of the spine.

Application and clinical efficacy of modified early unclamping technique in robot-assisted laparoscopic partial nephrectomy

OBJECTIVE

To investigate the clinical safety and efficacy of a modified early unclamping technique in robot-assisted laparoscopic partial nephrectomy (RAPN).

METHODS

The clinical data of 38 patients with renal tumors who underwent the modified early unclamping technique in RAPN surgery admitted to the Department of Urology, the Third People's Hospital of Hangzhou and the First Affiliated Hospital of Nanchang University from January 2018 to April 2021 were retrospectively analyzed. The control group consisted of 78 patients with renal tumors who underwent standard clamping during the RAPN surgery completed by the same surgeon during the same period. The perioperative-related indicators and postoperative renal function recovery were analyzed and compared between the two groups.

RESULTS

All patients (n = 116) finished the RAPN successfully, and none were transferred to radical or open surgery in either group. The warm ischemia time in the modified early unclamping group was significantly lower than that in the standard clamping group (P < 0.001). After surgery, the renal function index at each time point in the modified early unclamping group was higher than that in the standard clamping group; renal function gradually returned to near preoperative levels after 3 months in both groups. Postoperative follow-up showed no tumor recurrence or metastasis.

CONCLUSION

The application of a modified early unclamping technique in RAPN surgery is safe and feasible. Compared with standard clamping, modified early unclamping can significantly shorten the warm ischemia time of kidneys without increasing the volume of intraoperative blood loss and complications, which helps to protect the postoperative renal function of patients.