Abstract
Introduction and Objective: Robot-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN), but there are concerns over costs and objective benefit. In the setting of very large renal masses (>10 cm), comparison between techniques is limited and it is unclear whether a robotic approach confers any perioperative benefit over LRN or open radical nephrectomy (ORN). In this study, perioperative outcomes of RRN, LRN, and ORN for very large renal masses are compared. Methods: Using the National Cancer Database, patients were identified who underwent radical nephrectomy for kidney tumors >10 cm diagnosed from 2010 to 2015. Patients were analyzed according to surgical approach. Perioperative outcomes, including conversion to open, length of stay, readmission rates, positive surgical margins, and 30- and 90-day mortality were compared among cohorts. Results: A total of 9288 patients met inclusion criteria (RRN = 842, LRN = 2326, ORN = 6120). Compared with ORN, recipients of RRN or LRN had similar rates of 30-day readmission and 30- and 90-day mortality. Length of hospital stay was significantly shorter in RRN (-1.73 days ±0.19; p < 0.0001) and LRN (-1.40 days ±0.12; p < 0.0001) compared with ORN. LRN had a higher rate of conversion to open compared with RRN (odds ratio 1.48; 95% confidence interval 1.10-1.98; p = 0.0087). Conversion to open from RRN or LRN added 1.3 additional days of inpatient stay. Over the study period, RRN use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, whereas ORN use decreased from 75% to 59.6%. Conclusions: Minimally invasive approaches are increasingly utilized in very large renal masses. RRN has lower rates of conversion to open but produces comparable perioperative outcomes to LRN. Minimally invasive approaches have a shorter length of inpatient stay but otherwise report similar surgical margin status, readmission rates, and mortality rates compared with ORN.
Highlights
Introduction and ObjectiveRobot-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN), but there are concerns over costs and objective benefit
Over the 6-year study period, robotassisted radical nephrectomy (RRN) use increased from 4.1% to 14.8%, LRN from 20.9% to 25.6%, whereas open radical nephrectomy (ORN) use decreased from 75% to 59.6%
ORN use increased from 59.9% to 78% with increasing tumor size (10–12.5, 12.5–15, ‡15 cm), whereas RRN decreased from 10.9% to 6.2% and LRN decreased from 29.2% to 15.7% (Fig. 2)
Summary
Introduction and ObjectiveRobot-assisted radical nephrectomy (RRN) is increasingly utilized as an alternative to laparoscopic radical nephrectomy (LRN), but there are concerns over costs and objective benefit. Since being introduced nearly 30 years ago, minimally invasive radical nephrectomy is more commonly performed than open radical nephrectomy (ORN).[1,2] Over this period, it has been demonstrated that laparoscopic radical nephrectomy (LRN) has similar oncological outcomes when compared with ORN, while providing improved perioperative morbidity, blood loss, analgesia requirements, and hospital length of stay.[3,4] Since the introduction of robotassisted radical nephrectomy (RRN), multiple studies have attempted to define its role in the management of renal masses while recognizing its high hospital costs.[5,6] Despite its increased costs without proven benefit in perioperative or oncologic outcomes, RRN continues to become increasingly utilized in the United States.[5].
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