Robotic Partial Nephrectomy for Renal Tumors Larger Than 4cm

Predictive factors for pentafecta achievement in robot-assisted partial nephrectomy for intermediate highly complex RENAL tumors (RENAL score ≥ 7)

OBJECTIVES

To investigate the predictive factors for pentafecta achievement of robot-assisted partial nephrectomy (RAPN) for intermediate highly complex renal tumors (RENAL score ≥ 7).

METHODS

We retrospectively analyzed the data of 247 patients with renal tumors with a RENAL score ≥ 7 who underwent RAPN. Baseline characteristics and perioperative outcomes were compared between the pentafecta achieved group and the unachieved group. A multivariable logistic regression model was used to identify the predictive factors for pentafecta achievement for cT1 renal tumors with a RENAL score ≥ 7.

RESULTS

Of the 247 patients, 75 (30.3%) patients were in the achieved group and 172 (69.7%) patients were in the unachieved group. The median warm ischemia time and total operation time were 18 min versus 23 min (p < 0.001) and 179 min versus 201 min (p < 0.001) in the achieved and unachieved groups, respectively. In the unachieved group, six patients (3.4%) had major perioperative complications (Clavien-Dindo classification system ≥3). The median preservation rates of estimated GFR at the 1-year postoperative period were 96.5% versus 83.0% (p < 0.001) in the achieved and unachieved groups. Multivariable logistic regression models revealed that age and tumor size were independent predictive factors for pentafecta achievement for cT1 renal tumors with a RENAL score ≥ 7. There were no significant differences in cancer-free survival between the two groups (p = 0.456).

CONCLUSION

Age and tumor size were independent predictive factors for pentafecta achievement, although there was no difference in oncological outcomes between the pentafecta achieved group and the unachieved group in RAPN for cT1 renal tumors with a RENAL score ≥ 7.

Percutaneous tumor ablation versus image guided robotic-assisted partial nephrectomy for cT1b renal cell carcinoma: a comparative matched-pair analysis (UroCCR 80)

BACKGROUND

Partial nephrectomy (PN) is the gold standard treatment for cT1b renal tumors. Percutaneous guided thermal ablation (TA) has proven oncologic efficacy with low morbidity for the treatment of small renal masses (<3 cm). Recently, 3D image-guided robot-assisted PN (3D-IGRAPN) has been described, and decreased perioperative morbidity compared to standard RAPN has been reported. Our objective was to compare two minimally invasive image-guided nephron-sparing procedures (TA vs. 3D-IGRAPN) for the treatment of cT1b renal cell carcinomas (4.1-7 cm).

METHODS

Patients treated with TA and 3D-IGRAPN for cT1b renal cell carcinoma, prospectively included in the UroCCR database (NCT03293563), were pair-matched for tumor size, pathology, and RENAL score. The primary endpoint was the local recurrence rate between the two groups. Secondary endpoints included metastatic evolution, perioperative complications, decrease in renal function, and length of hospitalization.

RESULTS

A total of 198 patients were included and matched into two groups of 72 patients. The local recurrence rate was significantly higher in the TA group than that in the 3D-IGRAPN group (4.2% vs. 15.2%, P=0.04). Metastatic evolution and perioperative outcomes such as major complications, eGFR decrease, and length of hospitalization did not differ significantly between the two groups.

CONCLUSIONS

3D-IGRAPN resulted in a significantly lower local recurrence rate and comparable rates of complications and metastatic evolution compared with thermal ablation.

A multicenter comparative matched-pair analysis of percutaneous tumor ablation and robotic-assisted partial nephrectomy of T1b renal cell carcinoma (AblatT1b study-UroCCR 80)

OBJECTIVE

Renal cell carcinomas represent the sixth- and tenth-most frequently diagnosed cancer in men and women. Recently, percutaneous-guided thermal ablations have proved to be as effective as partial nephrectomy and safer for treating small renal masses (i.e.,  < 3 cm). This study compared the perioperative and recurrence outcomes of percutaneous thermal ablation (TA) and robotic-assisted partial nephrectomy (RAPN) for the treatment of T1b renal cell carcinomas (4.1-7 cm).

METHODS

Retrospective data from 11 centers on the national database, between 2010 and 2020, included 81 patients treated with thermal ablation (TA) and 308 patients treated with RAPN for T1b renal cell carcinoma, collected retrospectively and matched for tumor size, histology results, and the RENAL score. TA included cryoablation and microwave ablation. Endpoints compared the rate between the two groups: local recurrence, metastases, complications, renal function decrease, and length of hospitalization.

RESULTS

After matching, 75 patients were included in each group; mean age was 76.6 (± 9) in the TA group and 61.1 (± 12) in the RAPN group, including 69.3% and 76% men respectively. The local recurrence (LR) rate was significantly higher in the TA group than in the PN group (14.6% vs 4%; p = 0.02). The LR rate was 20% (1/5) after microwave ablation, 11.1% (1/9) after radiofrequency ablation, and 14.7% (9/61) after cryoablation. The major complication rate (Clavien-Dindo  ≥ 3) was higher following PN than after TA (5.3% vs 0%; p < 0.001). Metastases, eGFR decrease, and length of hospitalization did not differ significantly between the two groups.

CONCLUSIONS

The local recurrence rate was significantly higher after thermal ablation; however, thermal ablation resulted in significantly lower rates of complications. Thermal ablation and robotic-assisted partial nephrectomy are effective treatments for T1b renal cancer; however, the local recurrence rate was higher after thermal ablation.

KEY POINTS

• The local recurrence rate was significantly higher in the thermal ablation group than in the partial nephrectomy group. • The major complication rate (Clavien-Dindo ≥ 3) was higher following PN than after TA (5.3% vs. 0%; p < 0.001).

Comparative Analysis of Trifecta Outcomes in Robot-Assisted Partial Nephrectomy for cT1a Versus cT1b + Renal Tumours-a Single-Centre Study

Robotic assistance is being increasingly utilised for nephron-sparing surgery for complex renal masses. We evaluated the outcomes of robot-assisted partial nephrectomy (RAPN) for cT1a versus cT1b + renal masses by a comparative analysis of trifecta outcomes between these two groups of patients. We utilised our prospectively maintained database to identify patients undergoing RAPN for cT1a (group 1, n = 41) and cT1b + (group 2, n = 37) renal masses from April 2016 to March 2020. The oncological and trifecta outcomes were analysed using appropriate statistical methods. Out of 78 patients, trifecta was achieved in 30 (38.4%) patients. There was no statistically significant difference in trifecta between cT1a and cT1b + tumours (p = 0.152). We found a statistically significant difference between the two groups in terms of RENAL scores (p = 0.0005), PADUA score (p = 0.0002), and robotic console time (133.8 ± 42.8 Vs 170 ± 54.8 min for cT1a versus cT1b + , respectively) (p = 0.002). On multivariate analysis, warm ischemia time (p = 0.069), blood loss (p = 0.345), UCS repair (p = 0.691) and GFR reduction (p = 0.152) were not statistically different. There was no statistically significant difference in intraoperative and post-operative complications (p = 0.9317) or length of hospital stay (p = 0.112). Although recurrences were observed in two patients (5.4%) of the cT1b group, there was no statistical difference in the recurrence-free survival at 12 and 24 months. Our study shows that RAPN can be safely done for cT1b + renal tumours. These findings reinforce the view that RAPN should be considered a viable option for cT1b + lesions whenever technically feasible.

Perioperative outcomes following robot-assisted partial nephrectomy in elderly patients

OBJECTIVE

To compare perioperative outcomes following robot-assisted partial nephrectomy (RAPN) in patients with age ≥ 70 years to age < 70 years.

METHODS

Using Vattikuti Collective quality initiative (VCQI) database for RAPN we compared perioperative outcomes following RAPN between the two age groups. Primary outcome of the study was to compare trifecta outcomes between the two groups. Propensity matching using nearest neighbourhood method was performed with trifecta as primary outcome for sex, body mass index (BMI), solitary kidney, tumor size and Renal nephrometery score (RNS).

RESULTS

Group A (age ≥ 70 years) included 461 patients whereas group B included 1932 patients. Before matching the two groups were statistically different for RNS and solitary kidney rates. After propensity matching, the two groups were comparable for baselines characteristics such as BMI, tumor size, clinical symptoms, tumor side, face of tumor, solitary kidney and tumor complexity. Among the perioperative outcome parameters there was no difference between two groups for operative time, blood loss, intraoperative transfusion, intraoperative complications, need for radical nephrectomy, positive margins and trifecta rates. Warm ischemia time was significantly longer in the younger age group (18.1 min vs. 16.3 min, p = 0.003). Perioperative complications were significantly higher in the older age group (11.8% vs. 7.7%, p = 0.041). However, there was no difference between the two groups for major complications.

CONCLUSION

RAPN in well-selected elderly patients is associated with comparable trifecta outcomes with acceptable perioperative morbidity.

The R.E.N.A.L score’s relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience

Objective

The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.

Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality.

Results

A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05–12.7, p = 0.041).

Conclusion

Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Comparison of robot-assisted partial nephrectomy for complex (RENAL scores ≥10) and non-complex renal tumors: A single-center experience

OBJECTIVES

To compare functional and surgical outcomes of robot-assisted partial nephrectomy for complex tumors with RENAL scores ≥10 and non-complex tumors at a single academic institution.

METHODS

We retrospectively analyzed the data of all patients who underwent robot-assisted partial nephrectomy at Kobe University Hospital (Kobe, Hyogo, Japan) from 2011 to 2020. Functional and surgical outcomes for complex tumors (RENAL score ≥10) were compared with those of patients with non-complex tumors (RENAL <10). Outcomes analyzed included blood loss, warm ischemia time, console time, perioperative complications, and preoperative and postoperative renal function.

RESULTS

A total of 348 patients were included in our present study, with a median follow-up time of 35.1 months. Of these, 299 patients (85.9%) had non-complex tumors and 49 patients (14.1%) had complex tumors. Warm ischemia time and console time were significantly longer in the complex tumors group. Major perioperative complications (Clavien-Dindo classification system ≥3) were significantly more frequent in the complex tumors group than the non-complex tumor group (16.3% vs 5.7%, P = 0.018). Postoperative preservation of estimated glomerular filtration rate and percentage of chronic kidney disease upstage by 1 year were significantly inferior in the complex tumors group. The positive surgical margin rate was 0% and 0.3% in the complex and non-complex tumor groups, respectively. There were no significant differences in recurrence-free survival between the two groups (P = 0.11).

CONCLUSIONS

Robot-assisted partial nephrectomy for complex renal tumors is safe, with no difference in oncological outcomes, although more postoperative complications and decreased renal function can be observed than non-complex tumors.

Transition from open partial nephrectomy directly to robotic surgery: experience of a single surgeon to achieve "TRIFECTA"

INTRODUCTION

Recent data suggest that robotic platform has become the most accessible minimal invasive surgery even for surgeons without previous training in laparoscopy. Laparoscopic partial nephrectomy (LPN) is a well-stablished procedure, however, with high level of complexity and long learning curve that limit its use.

OBJECTIVE

To describe safety, efficiency and learning curve of a single surgeon without previous experience in LPN to reach "TRIFECTA" at robot-assisted partial nephrectomy (RAPN).

PATIENTS AND METHODS

This is a retrospective study, with prospective data collection of 101 patients submitted to RAPN by a single surgeon. In order to analyze the learning curve, sample was chronologically divided in two phases: first phase: P1: 50 first patients, second phase: P2: 51 subsequent patients. TRIFECTA was defined as: ischemia time lower than 25 minutes, negative surgical margin and absence of severe complications (Clavien >2).

RESULTS

Mean age of patients was 54 years (SD=11.85), median tumor size was 32mm (SD=17) and surgery was performed with zero ischemia time in 33.6% of patients (29.8% at P1 and 40.9% at P2). Demographic data of patients were similar between both groups, except tumor size (P1=27.5mm vs. P2=35.3mm; p=0.02) and body mass index (BMI) (P1=26.6kg/m2 vs. P2=29kg/m2; p=0.03). Rate of bleeding, surgical time, presence of positive margin and peri-operatory surgical complications were similar in both phases. TRIFECTA was higher in P2 in relation to P1 (P1: 58% vs. P2: 87.8%; p=0.002) and median time of hot ischemia was significantly lower at P2 (P1: 17.3 vs. P2: 11.7; p=0.02). At multivariate analysis independent factors related to TRIFECTA included: chronological phase (OR 10.74; 95% IC: 1.63-70.53; p=0.013) and tumor size (OR 0.95; 95% IC: 0.91-0.99; p=0.024).

CONCLUSION

RAPN seems to be safe and efficient with good functional and oncological results (TRIFECTA) since the beginning. Experience improvement was related to treatment of larger tumors, higher proportion of patients with zero ischemia and higher rate of TRIFECTA.

Survival benefit of nephron-sparing surgery for patients with pT1b renal cell carcinoma: A population-based study

The use of partial nephrectomy (PN) to treat patients with large renal cell carcinoma (RCC) remains controversial, particularly among elderly patients. The present study compared the improvement in cancer-specific survival (CSS) in patients with pT1b RCC who underwent either PN or radical nephrectomy (RN) and investigated the effects of age and sex on CSS. A total of 20,343 patients were identified in the Surveillance, Epidemiology and End Results database. Kaplan-Meier curves and Cox regression analysis were used to compare the CSS of patients who received PN vs. those who received RN. In total, 5,375 (26.42%) and 14,968 (73.58%) patients with pT1b RCC received PN and RN, respectively. Kaplan-Meier and Cox regression analysis indicated that PN resulted in an improved CSS compared with RN (P<0.001). In addition, PN was observed to be beneficial in male (P<0.001) and female patients <75 years of age. However, it was not beneficial for female patients of ≥75 years of age (P=0.197). These preliminary results warrant further investigation in clinical trials.

Percutaneous Ablation Versus Robotic Partial Nephrectomy in the Treatment of cT1b Renal Tumors: Oncologic and Functional Outcomes of a Propensity Score-weighted Analysis

INTRODUCTION

The purpose of this study was to assess oncologic and functional outcomes of both percutaneous ablation (cryoablation and radiofrequency ablation) and robot-assisted partial nephrectomy (RAPN) in the treatment of renal tumors larger than 4 cm.

MATERIALS AND METHODS

We retrospectively analyzed prospectively collected data from 102 consecutive patients, who underwent minimally invasive treatment for cT1b renal tumors at our institution. Primary renal function outcome was assessed by estimated glomerular filtration rate preservation at baseline and 1 year postoperatively. Perioperative data and functional and oncologic outcome were collected. Multivariate regression models were used to compare functional outcomes between groups. Cancer-specific survival and recurrence-free survival were estimated at 2 years using the Kaplan-Meier method and compared with Cox proportional hazards regression model to calculate hazard ratios (HRs). To control for selection bias between the different treatments, we adjusted our models with an inverse probability of treatment weighting propensity score.

RESULTS

There was no significant difference in renal preservation between the groups (P = .664). Multivariate analysis did not show a statistically significant difference in terms of renal function outcomes between the RAPN and percutaneous thermal ablation groups. The adjusted HR regarding the local recurrence-free survival was significantly shorter for the cryoablation group (HR, 4.3; 95% confidence interval, 1.78-10.37; P = .001).

CONCLUSIONS

Our study demonstrated the equivalence between RAPN and percutaneous ablative techniques for the preservation of renal function in the treatment of T1b tumors. RAPN offers a better local control than percutaneous ablation, in terms of primary success rate.

Suture techniques during laparoscopic and robot-assisted partial nephrectomy: a systematic review and quantitative synthesis of peri-operative outcomes

OBJECTIVE

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri-operative outcomes after minimally invasive partial nephrectomy (MIPN).

MATERIALS AND METHODS

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot-assisted partial nephrectomy and comparative studies focused on peri-operative outcomes were included in qualitative and quantitative analyses, respectively.

RESULTS

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon's experience, robot-assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non-barbed suture. The single-layer suture technique was associated with shorter operating and ischaemia time than the double-layer technique. No comparisons were possible concerning renal functional outcomes because of non-homogeneous data reporting.

CONCLUSIONS

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double-layer suture.

Recent advancements of robotic surgery for kidney cancer

Surgical management of renal cell carcinoma has undergone a transformation in recent decades, especially with the dissemination of the robotic platform. Increasingly, larger and more complex renal lesions are now being treated in a minimally invasive fashion. The purpose of this article is to review advances in the use of the robotic approach for treatment of renal cell carcinoma, including nephron-sparing surgery, radical nephrectomy, and cytoreductive nephrectomy.

Conversion of Robot-assisted Partial Nephrectomy to Radical Nephrectomy: A Prospective Multi-institutional Study

OBJECTIVE

To assess the incidence and factors affecting conversion from robot-assisted partial nephrectomy (RAPN) to radical nephrectomy.

METHODS

Between November 2014 and February 2017, 501 patients underwent attempted RAPN by 22 surgeons at 14 centers in 9 countries within the Vattikuti Collaborative Quality Initiative database. Patients were permanently logged for RAPN prior to surgery and were analyzed on an intention-to-treat basis. Multivariable logistic regression with backward stepwise selection of variables was done to assess the factors associated with conversion to radical nephrectomy.

RESULTS

Overall conversion rate was 25 of 501 (5%). Patients converted to radical nephrectomy were older (median age [interquartile range] 66.0 [61.0-74.0] vs 59.0 [50.0-68.0], P = .012), had higher body mass index (BMI) (median 32.8 [24.9-40.9] vs 27.8 [24.6-31.5] kg/m², P = .031), higher age-adjusted Charlson comorbidity score (median 6.0 [4.0-7.0] vs 4.0 [3.0-5.0], P <.001), higher American Society of Anesthesiologists score (score ≥3; 13/25 (52.0%) vs 130/476 (27.3%), P = .021), Preoperative estimated glomerular filtration rate (P = .141), clinical tumor stage (P = .145), tumor location (P = .140), multifocality (P = .483), and RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, and anterior/posterior location relative to polar lines) nephrometry score (P = .125) were not significantly different between the groups. On multivariable analysis, independent predictors for conversion were BMI (odds ratio [95% confidence interval]; 1.070 [1.018-1.124]; P = .007) and Charlson score (odds ratio [95% confidence interval]; 1.459 [1.179-1.806]; P = .001).

CONCLUSION

RAPN was associated with a low rate of conversion. Independent predictors of conversion were BMI and Charlson score. Tumor factors such as clinical stage, location, multifocality, or RENAL score were not associated with increased risk of conversion.

Frontiers in robot-assisted retroperitoneal oncological surgery

Robot assistance has been rapidly adopted by urological surgeons and has become particularly popular for oncological procedures involving the retroperitoneal space. The wide dissemination of robot assistance probably reflects the limited amount of operating space available within the retroperitoneum and the advantages provided by robot-assisted approaches, including 3D imaging, wristed instrumentation and the shorter learning curve compared with that associated with the equivalent laparoscopic techniques. Surgical procedures that have traditionally been performed using an open or laparoscopic approach, such as partial nephrectomy, radical nephrectomy, retroperitoneal lymph node dissection, nephroureterectomy and adrenalectomy, are now often being performed using robot assistance. The frontiers of robot-assisted retroperitoneal oncological surgery are constantly expanding, with an emphasis on maintaining oncological and functional outcomes, while minimizing the level of surgical invasiveness.

Robot-Assisted Partial Nephrectomy for T1b Tumors: Strict Trifecta Outcomes

Background and Objectives:

“Trifecta” in partial nephrectomy consists of negative surgical margins, minimal renal function decrease and absence of complications. In the present article, our single-center robot-assisted partial nephrectomy (RAPN) experience in T1b renal masses is reported in terms of strict Trifecta outcomes.

Methods:

This is a retrospective analysis of patients with a tumor diameter between 4 and 7 cm (stage T1b), who underwent RAPN by a single surgeon. Preoperative, intraoperative, and postoperative data were recorded and analyzed to evaluate short-term functional and oncologic outcomes. Patients with absence of grade ≥ 2 Clavien-Dindo complications, warm ischemia time (WIT) ≤25 minutes, ≤15% postoperative estimated glomerular filtration rate (eGFR) decrease and negative surgical margins were reported to achieve strict Trifecta outcomes. P < .05 was indicated statistically significant.

Results:

A total of 150 patients underwent RAPN, and 50 patients were identified with tumor size between 4 and 7 cm. Mean WIT was 20.8 ± 6.2 minutes and mean estimated blood loss (EBL) was 269 ± 191 mL. Surgical margins were negative in all patients. Eleven patients (22%) had a >15% eGFR decrease after surgery. Nine patients (18%) had WIT longer than 25 minutes. Four patients (8%) had grade ≥2 Clavien-Dindo complications. Twenty-nine (58%) patients had strict Trifecta outcomes. Mean follow-up was 44.2 ± 27.2 months. Tumor recurrence was not observed in any patient.

Conclusions:

Robot-assisted laparoscopic partial nephrectomy for T1b renal masses can be safely performed in experienced hands. Optimal strict Trifecta outcomes and recurrence rates can be achieved.

Complications of Renal Surgery

The incidence of the small renal mass continues to increase owing to the aging population and the ubiquity imaging. Most of these tumors are stage I tumors. Management strategies include surveillance, ablation, and extirpation. There is a wide body of literature favoring nephron-sparing approaches. Although nephron-sparing surgery may yield decreased long-term morbidity, it is not without its drawbacks, including a higher rate of complications. Urologists must be attuned to the complications of surgery and develop strategies to minimize risk. This article reviews expected complications of surgery on renal masses and risk stratification schema.

Robot-assisted partial nephrectomy

Partial nephrectomy is the standard treatment for small renal masses. Currently, it is commonly performed using minimally invasive approaches, including laparoscopic and robot-assisted techniques. The aim of the present review is to report the surgical technique of robot-assisted partial nephrectomy in full detail as well as available literature results.

Robot-assisted renal surgery: current status and future directions

This paper examines the current role of robot-assisted renal surgery as complex and partial nephrectomies, including vena cava thrombus, combined nephroureterectomies, living donor nephrectomy, autotransplantation, and difficult anatomy as in patients with obesity or adhesions. Indications for robot-assisted renal surgery are comparable to those of conventional laparoscopic approaches. A reduction in the learning curve leads to a stabilization of the procedure and further increases the number of minimally invasive procedures performed. A Medline literature search for publications on the field of robotic kidney surgery has been performed using the MeSH terms: robotic surgical procedures and kidney. Future directions include progress in robotic technology and instrumentation with further miniaturization of robotic procedures as laparoendoscopic single-site interventions and progress in image-guided robotic surgery.

Robotic-assisted partial nephrectomy without using ureteral stent: a single center experience

OBJECTIVE

To share our results of robotic assisted partial nephrectomy (RAPN) we performed without using ureteral stent in a single center from Turkey.

MATERIAL AND METHODS

Medical records of consecutive 45 patients (34 men and 11 women) who underwent RAPN for kidney lesions between March 2011 and December 2014 were retrieved, and evaluated. All the procedures were performed by a transperitoneal approach without using ureteral stent prior to surgery. Renal artery clamping was used in all cases and intraoperative ultrasonography was used in 2 cases.

RESULTS

Patients undergoing RAPN had a mean tumor size of 4.42 cm (2-8) and a mean renal nephrometry score of 5.82 (4-11). The mean estimated blood loss was 250 mL (150-450 ml) and the mean operative time was 195 minutes (150-300). There was no statistical difference between the preoperative and postoperative serum creatinine levels at the first follow-up visit (0.9 vs. 0.95, p=0.087). Surgical margin positivity was not detected in any patient, and the mean surgical margin distance was calculated as 0.4 mm (0.2-10). In only 1 patient disease recurrence was detected at the 21(st) month of the the follow-up period, and no distant metastases was reported in our patients at a mean follow-up of 10 months (3-36 mos). Our complication rate was 11.1% and according to the Clavien system complications were as; grade 2 (3 patients), grade 3a (1 patient) and grade 3b (1 patient).

CONCLUSION

With appropriately selected patients and adequate surgical experience, RAPN performed without using ureteral stent is a safe and feasible method for localized renal tumors.

Past, present and future of urological robotic surgery

The first urologic robotic program in the world was built at the Vattikuti Urology Institute, Henry Ford Hospital Detroit, Michigan, in 2000 under the vision of surgical innovator, Dr. Mani Menon for the radical prostatectomy. The robot-assisted radical prostatectomy continues being modified with techniques to improve perioperative and surgical outcomes. The application of robotic surgical technique has since been expanded to the bladder and upper urinary tract surgery. The evolution of surgical technique and its expansion of application will continue to improve quality, outcome parameters and experience for the patients.

Using a Harmonic Scalpel "Drilling and Clamping" Method to Implement Zero Ischemic Robotic-assisted Partial Nephrectomy: An Observation Case Report Study

Robot-assisted partial nephrectomy (RAPN) has gradually become a popular minimally invasive nephron-sparing surgical option for small renal tumors. Ischemic injury should be minimized because it impacts renal function outcomes following partial nephrectomy. Herein, the authors detail the technique and present initial perioperative outcomes of our novel harmonic scalpel "drilling and clamping" method to implement zero-ischemic RAPN. The authors prospectively collected baseline and perioperative data of patients who underwent zero ischemic RAPN performed by our harmonic scalpel "drilling and clamping" method. From April 2012 to December 2014, a total of 19 consecutive zero ischemic RAPN procedures were performed by a single surgeon. For 18 of the 19 patients, RAPN using our harmonic scalpel "Drilling and Clamping" method was successfully completed without the need for hilar clamping. The median tumor size was 3.4 cm (range: 1.8-6.2); operative time was 3.2 hours (range: 1.9-4.5); blood loss was 100 mL (range: 30-950); and postoperative hospital stay was 4 days (3-26). One patient required intraoperative blood transfusion. Two patients had intra or postoperative complications: 1 was converted to traditional laparotomy because of massive bleeding, whereas another had postoperative stress ulcer. Pathology confirmed renal cell carcinoma in 13 patients (63.2%), angiomyolipoma in 6 patients: (31.5%), and oncocytoma in 1 patient (5.3%). Mean pre- and postoperative serum creatinine (0.82 mg/dL and 0.85 mg/dL, respectively), estimated glomerular filtration rate (84.12 and 82.18, respectively), and hemoglobin (13.27 g/dL and 12.71 g/dL, respectively) were comparable. The authors present a novel zero-ischemic technique for RAPN. They believe that this technique is feasible and reproducible.

Partial Nephrectomy in Clinical T1b Renal Tumors: Multicenter Comparative Study of Open, Laparoscopic and Robot-assisted Approach (the RECORd Project)

OBJECTIVE

To evaluate perioperative results of open (OPN), laparoscopic (LPN), and robot-assisted partial nephrectomies (RAPN) and to identify predictive factors of Trifecta achievement for clinical T1b renal tumors in a multicenter prospective dataset.

METHODS

Data of 285 patients who had OPN (133), LPN (57), or RAPN (95) for cT1b renal tumors were extracted from the RECORd Project. High-volume centers were defined as ≥50 overall cases of partial nephrectomy per year. Trifecta was defined as simultaneous absence of perioperative complications, negative surgical margins, and ischemia time <25 minutes.

RESULTS

The 3 groups had comparable body mass index, preoperative hemoglobin, creatinine and estimated glomerular filtration rate, tumor clinical diameter, and growth pattern. LPN and RAPN were more frequently exclusive of high-volume centers. RAPN showed significantly lower median estimated blood loss compared with OPN and LPN. Trifecta was achieved in 62.4%, 63.2%, and 69.5% of OPN, LPN, and RAPN (P = NS) cases. Median warm ischemia time (WIT) was significantly shorter during OPN than during LPN and RAPN. RAPN had significantly shorter WIT compared with LPN. RAPN was significantly less morbid than OPN regarding intraoperative and postoperative complications. LPN (1.9%) and RAPN (2.5%) showed a lower rate of positive margins compared with OPN (6.8%) (P = NS). At multivariable analysis, exophytic tumor growth pattern, estimated blood loss, and high-volume centers were significant predictive factors for Trifecta achievement.

CONCLUSION

Clinically, T1b renal tumors suitable for NSS can be safely treated by LPN or RAPN in high-volume centers. RAPN allows for significantly lower WIT and estimated blood loss with higher rate of Trifecta achievement compared with LPN.

Early unclamping might reduce the risk of renal artery pseudoaneurysm after robot-assisted laparoscopic partial nephrectomy

OBJECTIVES

To determine the influence of the early unclamping technique on the risk of renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy.

METHODS

From January 2013 to October 2014, 96 patients underwent robot-assisted laparoscopic partial nephrectomy for renal masses at Tokyo Women's Medical University Hospital, Tokyo, Japan. Computed tomography angiography was carried out 3-4 days after surgery. Early in the series, renal hilum was left unclamped and renorrhaphy was subsequently carried out (conventional unclamping technique). An early unclamping technique has been used since November 2013.

RESULTS

A total of 61 patients underwent robot-assisted laparoscopic partial nephrectomy with early unclamping, and 35 patients underwent robot-assisted laparoscopic partial nephrectomy with conventional unclamping. Ischemia time was significantly shorter in the early unclamping group (16.5 vs. 23.1 min; P < 0.01). The early unclamping group showed a significantly lower incidence of asymptomatic renal artery pseudoaneurysm relative to the conventional unclamping group (11.4% vs. 28.6%; P = 0.03). Multivariate analysis showed that the early unclamping technique was a significant independent factor in reducing the risk of renal artery pseudoaneurysm (hazard ratio 0.27; P = 0.01).

CONCLUSIONS

The present findings suggest that an early unclamping technique might reduce ischemic time and risk of renal artery pseudoaneurysm. The absence of arterial bleeding before renorrhaphy is likely to be a key step in preventing renal artery pseudoaneurysm during robot-assisted laparoscopic partial nephrectomy.

Review of robot-assisted partial nephrectomy in modern practice

Partial nephrectomy (PN) is currently the standard treatment for T1 renal tumors. Minimally invasive PN offers decreased blood loss, shorter length of stay, rapid convalescence, and improved cosmesis. Due to the challenges inherent in laparoscopic partial nephrectomy, its dissemination has been stifled. Robot-assisted partial nephrectomy (RAPN) offers an intuitive platform to perform minimally invasive PN. It is one of the fastest growing robotic procedures among all surgical subspecialties. RAPN continues to improve upon the oncological and functional outcomes of renal tumor extirpative therapy. Herein, we describe the surgical technique, outcomes, and complications of RAPN.

[Robot-assisted laparoscopic partial nephrectomy: functional and oncological outcomes]

BACKGROUND

In recent years, small renal masses (SRM) have been increasingly detected as an incidental finding of radiological or ultrasound studies for other indications. Organ-sparing renal tumor resection as open partial nephrectomy (OPN) is the international standard for renal tumors <7 cm.

RESULTS

Due to technical developments, minimally invasive procedures have emerged as an alternative to OPN. In experienced hands, conventional laparoscopic partial nephrectomy (LPN) has achieved good functional and oncological results comparable to OPN. Robot-assisted laparoscopic partial nephrectomy (RAPN) has been performed since 2004. Compared to LPN, RAPN provides a faster learning curve, better visualization and more versatile instrumentation due to the degrees of freedom of the articulated instruments. After about 30 procedures, a level of experience is reached, which is characterized by good functional results, less blood loss, and shorter warm ischemia time of the kidney as compared to LPN. This can relate to a shorter hospital stay and faster recovery. Complications according to the Clavien classification are mostly grade I and II and are mainly treated conservatively.

CONCLUSION

Oncological long-term results are not available yet; so that RAPN cannot be considered as an equivalent treatment to LPN and OPN. Until long-term evidence is available, decisions regarding the surgical technique for organ-sparing renal tumor resection will be determined by patient's wishes and surgeon's preference.

Comparison of surgical, functional, and oncological outcomes of open and robot-assisted partial nephrectomy

BACKGROUND:

We aimed to compare the surgical, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) with open partial nephrectomy (OPN) in the management of small renal masses.

MATERIALS AND METHODS:

Between 2009 and 2013, a total of 46 RAPN patients and 20 OPN patients was included in this study. Patients’ demographics, mean operative time, estimated blood loss (EBL), warm ischemia time (WIT), length of hospital stay, pre- and post-operative renal functions, complications and oncological outcomes were recorded, prospectively.

RESULTS:

Mean tumor size was 4.04 cm in OPN group and 3.56 cm in RAPN group (P = 0.27). Mean R.E.N.A.L nephrometry score was 6.35 in OPN group and 5.35 in RAPN group (P = 0.02). The mean operative time was 152 min in OPN group and 225 min in RAPN group (P = 0.006). The mean EBL in OPN and RAPN groups were 417 ml and 268 ml, respectively (P = 0.001). WIT in OPN group was significantly shorter than RAPN group (18.02 min vs. 23.33 min, P = 0.003). The mean drain removal time and the length of hospital stay were longer in OPN group. There were no significant differences in terms of renal functional outcomes and postoperative complications between groups.

CONCLUSION:

Minimally invasive surgical management of renal masses with RAPN offers better outcomes in terms of EBL and length of stay. However, the mean operative time and WIT were significantly shorter in OPN group. RAPN is a safe and effective minimally invasive alternative to OPN in terms of oncological and functional outcomes.

The growth of computer-assisted (robotic) surgery in urology 2000-2014: The role of Asian surgeons

Objective

A major role in the establishment of computer-assisted robotic surgery (CARS) can be traced to the work of Mani Menon at Vattikuti Urology Institute (VUI), and of many surgeons of Asian origin. The success of robotic surgery in urology has spurred its acceptance in other surgical disciplines, improving patient comfort and disease outcomes and helping the industrial growth. The present paper gives an overview of the progress and development of robotic surgery, especially in the field of Urology; and to underscore some of the seminal work done by the VUI and Asian surgeons in the development of robotic surgery in urology in the US and around the world.

Methods

PubMed/Medline and Scopus databases were searched for publications from 2000 through June 2014, using algorithms based on keywords “robotic surgery”, ”prostate”, “kidney”, “adrenal”, “bladder”, “reconstruction”, and “kidney transplant”. Inclusion criteria used were published full articles, book chapters, clinical trials, prospective and retrospective series, and systematic reviews/meta-analyses written in English language. Studies from Asian institutions or with the first/senior author of Asian origin were included for discussion, and focused on techniques of robotic surgery, relevant patient outcomes and associated demographic trends.

Results

A total of 58 articles selected for final review highlight the important strides made by robots in urology, from robotic radical prostatectomy in 2000 to robotic kidney transplant in 2014. In the hands of an experienced robotic surgeon, it has been demonstrated to improve functional patient outcomes and minimize perioperative complications compared to open surgery, especially in urologic oncology and reconstructive urology. With increasing surgeon proficiency, the benefits of robotic surgery were consistently seen across different surgical disciplines, patient populations, and strata.

Conclusion

The addition of robot to the surgical armamentarium has allowed better patient care and improved disease outcomes. VUI and surgeons of Asian origin have played a pioneering role in dissemination of computer-assisted surgery.

Significant impact of R.E.N.A.L. nephrometry score on changes in postoperative renal function early after robot-assisted partial nephrectomy

BACKGROUND

Our objective was to evaluate the significance of the R.E.N.A.L. nephrometry score (RNS)--developed to quantitatively evaluate the complexity of renal tumors in a reproducible manner--in perioperative and renal functional outcomes following robot-assisted partial nephrectomy (RAPN).

METHODS

This study assessed 48 consecutive patients with renal tumors who underwent RAPN. Preoperative RNS for each patient was calculated, and its impact on several parameters associated with perioperative outcomes, including postoperative renal function, was investigated with Spearman's rank correlation test.

RESULTS

Mean RNS in the 48 patients was 6.8; of these 48 patients, 21 (43.7%), 24 (50.0%), and three (6.3%) were classified into low-, moderate-, and high-complexity groups, respectively. The RNS was significantly correlated with resected tumor weight and postoperative changes in estimated glomerular filtration rate (eGFR) at both 1 and 4 weeks--but not age, body mass index (BMI), preoperative eGFR, operative time, warm ischemia time, estimated blood loss, postoperative complications, or eGFR-- after RAPN. No component of the RNS (R: radius; E: exophytic/endophytic properties; N: nearness of tumor to the collecting system or sinus; A: anterior/posterior; L: location relative to polar lines) alone had a significant impact on postoperative changes in eGFR at 1 and 4 weeks, whereas resected tumor weight was significantly associated with the R and E subcategories.

CONCLUSIONS

Measurement of total RNS is useful for predicting renal functional outcomes early after RAPN.

Perioperative complications of robot-assisted partial nephrectomy

The incidence of renal cell carcinoma continues to increase with utilization of diagnostic abdominal imaging with migration towards a proportionally greater detection of small renal masses (SRM). Robot-assisted partial nephrectomy (RAPN) has become an attractive minimally invasive treatment modality for SRM's due to the technical advantages and shortened learning curve compared to laparoscopic partial nephrectomy (LPN) while preserving comparable perioperative outcomes. With advances in ablative approaches for stage I renal cell carcinoma (RCC) and controversy surrounding the role of extirpative surgery for SRM's, systematic understanding of the complications associated with RAPN has become even more imperative. This review aims to summarize and evaluate the contemporary literature, compile reported intraoperative complications, describe conventional and nephron-sparing surgery (NSS) specific postoperative complications, and assess factors associated with an increased likelihood for perioperative complications following RAPN.