Robot-assisted Simple Enucleation Versus Standard Robot-assisted Partial Nephrectomy for Low- or Intermediate-complexity, Clinical T1 Renal Tumors: A Randomized Controlled Noninferiority Trial

BACKGROUND

Although partial nephrectomy has become the gold standard for T1 renal tumors whenever technically feasible, simple enucleation has shown superior results. To the best of our knowledge, no randomized controlled trials comparing these two surgical approaches have been published.

OBJECTIVE

To compare the surgical margin status for robot-assisted simple enucleation (RASE) and standard robot-assisted partial nephrectomy (sRAPN) for clinical T1 renal tumors.

DESIGN, SETTING, AND PARTICIPANTS

This is a prospective, randomized, controlled, noninferiority trial. A total of 380 patients aged 18-80 yr with newly diagnosed, sporadic, unilateral clinical T1 renal tumors (RENAL score <10) were enrolled and randomized to RASE or sRAPN. The primary endpoint was the positive surgical margin (PSM) rate, with a noninferiority margin of 7.5% set. The study was registered on ClinicalTrials.gov (NCT03624673).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We defined noninferiority for RASE versus standard RAPN as an upper 95% confidence interval (CI) bound of <7.5% for the difference in the proportion of patients with a PSM.

RESULTS AND LIMITATIONS

A cohort of 380 patients was enrolled and randomly assigned to RASE (n = 190) or sRAPN (n = 190). On intention-to-treat analysis for patients with malignant tumors, 2.3% of patients in the RASE group and 3.0% in the sRAPN group had a PSM. The RASE group showed noninferiority to the sRAPN group within a 7.5% margin (difference -0.7%, 95% CI -4.0% to 2.7%). Per-protocol analysis also demonstrated noninferiority of RASE. The RASE group had a shorter median operative time (145 vs 155 min; p = 0.018) and a lower rate of tumor bed suturing (8.9% vs 43%; p < 0.001) in comparison to the sRAPN group. Estimated blood loss was considerably lower in the sRAPN group than in the RASE group (p = 0.046). The rate of recurrence did not differ between the groups (p > 0.9).

CONCLUSIONS

RASE for the management of low- to intermediate-complexity tumors is noninferior to sRAPN in terms of the PSM rate. Long-term follow-up is needed to draw conclusions regarding oncological outcomes.

PATIENT SUMMARY

We carried out a trial to compare simple tumor enucleation versus partial nephrectomy for renal tumors. The outcome we assessed was the proportion of patients with a positive surgical margin. Our results show that simple tumor enucleation is not inferior to partial nephrectomy for this outcome. Longer follow-up is needed to assess other cancer control outcomes.

Modified laparoscopic simple enucleation with single-layer suture technique versus standard laparoscopic partial nephrectomy for treating localized renal cell carcinoma

OBJECTIVES

To compare modified laparoscopic simple enucleation (MLSE) and standard laparoscopic partial nephrectomy (SLPN) for treating localized renal cell carcinoma in our large institutional experience.

METHODS

We evaluated 385 consecutive patients who underwent MLSE or SLPN for renal tumors in our institution from January 2013 to December 2015 in terms of perioperative pathological and oncologic outcome variables. During MLSE, the single-layer suture technique was performed for renal reconstruction.

RESULTS

In total, 280 patients underwent MLSE and 105 underwent SLPN. Mean operative time was 182.1 and 192.8 min, respectively (p = 0.078). Warm ischemic time was significantly lower in the MLSE than SLPN group (23.2 vs 25.4 min; p = 0.004). The estimated blood loss was similar (p = 0.537). Tumor bed suturing was performed in 9.3 and 82.9% of MLSE and SLPN cases (p = 0.000). No hilar clamping was needed for 29 MLSE patients (10.4%) and 4 SLPN patients (3.8%) (p = 0.041). Grade III complications were reported in 5 (1.8%) MLSE patients and 7 (6.6%) SLPN patients (p = 0.034). The incidence of positive surgical margins was comparable between the MLSE and SLPN groups (1.8 and 5.7%, p = 0.086). After a median follow-up of 18 months, recurrence did not differ between the 2 groups: 9 (3.2%) MLSE patients and 4 (3.8%) SLPN patients (p = 1.000).

CONCLUSIONS

MLSE may confer shorter warm ischemic time, almost no need for tumor bed suturing and less grade III complications than SLPN, with similar oncologic outcomes. MLSE may be safe and acceptable for patients undergoing partial nephrectomy.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project)

OBJECTIVES

To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project).

MATERIALS AND METHODS

patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status.

RESULTS

SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN.

CONCLUSIONS

Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

Pancreatic schwannoma: Report of a case and review of literature. Indian J Surg. 2010;72:296-298. [PMID: 23133276 DOI: 10.1007/s12262-010-0112-6]

Connective tissue tumors of pancreas are uncommon, among them pancreatic schwannoma is very rare tumor, very few cases were reported in literature. Aggressive resections like whipple's procedure, or distal pancreatectomy are not necessary for pancreatic schwannoma as it rarely goes to malignant change and simple enuclation is sufficient.In our patient pancreatic schwannoma is associated with simple cyst in liver and absence of one kidney. Here, we are presenting a case of pancreatic schwannoma treated by simple enucleation.