Robot-assisted Partial Nephrectomy Cases Research Articles

Impacts of Complete Endophytic Renal Tumors on Surgical, Functional, and Oncological Outcomes of Robot-Assisted Partial Nephrectomy.

Objective: Complete endophytic renal tumors (CERTs) are the most challenging for robot-assisted partial nephrectomy (RAPN). This study aimed to determine the impact of CERT on outcomes of RAPN. Methods: All RAPN cases for localized renal tumor undertaken at Yokohama City University Hospital between 2016 and 2023 were enrolled. Tumor characteristics and surgical, functional, and oncologic outcomes of RAPN were compared between CERT and non-CERT groups. Results: Consecutive 666 patients were enrolled, and 76 (11.4%) were identified as CERT (3 points of "E" score). CERT showed smaller tumor diameters (p < 0.001), more predominant hilar tumor (p = 0.029), higher "N" scores (p < 0.001) and "L" scores (p = 0.006) than non-CERT. The CERT group showed longer warm ischemia times (p < 0.001), more frequent positive surgical margins (p = 0.028), and relatively lower trifecta achievement rates (p = 0.101) than the non-CERT group. In multivariable analysis, the CERT was an independent predictor for trifecta achievement but not for pentafecta achievement. Conclusions: CERT was associated with longer warm ischemia time, positive surgical margin, and lower trifecta achievement, but not with surgical complication and pentafecta achievement in RAPN. This study suggested that CERT had limited influence on long-term renal functional preservation; however, it had strong impacts on short-term surgical outcome.

Single-Port vs Multiport Robot-Assisted Partial Nephrectomy: A Meta-Analysis.

Background: Several centers have reported their experience with single-port robot-assisted partial nephrectomy (SP-RAPN); however, it is uncertain if utilization of this platform represents an improvement in outcomes compared to multiport robot-assisted partial nephrectomy (MP-RAPN). To evaluate this, we performed a meta-analysis to compare the perioperative, oncological, and functional outcomes between SP-RAPN and MP-RAPN. Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until January 1, 2023. A meta-analysis has been reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and assessing the methodological quality of systematic reviews (AMSTAR) guidelines. The odds ratio (OR) and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI). Results: Of the 374 retrieved abstracts, 29 underwent full-text review, and 8 studies were included in the final analysis, comprising a total cohort of 1007 cases of RAPN (453 SP-RAPN cases and 554 MP-RAPN cases). Compared to MP-RAPN, the SP-RAPN group had a significantly longer ischemia time (MD = 4.6 minutes, 95% CI 2.8 to 6.3, p < 0.001), less estimated blood loss (MD = -12.4 mL, 95% CI -24.6 to -0.3, p = 0.045), higher blood transfusion rate (OR = 2.97, 95% CI 1.33 to 6.65, p = 0.008), and higher postoperative estimated glomerular filtration rate (eGFR) at 6 months (MD = 4.9 mL/min, 95% CI 0.2 to 9.7, p = 0.04). There was no significant difference in other outcomes between the two approaches, including the intraoperative complication, overall postoperative complication, minor postoperative complication (Clavien-Dindo I - II), major postoperative complication (Clavien-Dindo III-V), conversion to radical nephrectomy, pain score on day #1, pain score on discharge, morphine milligram equivalent usage, hospital stay, positive surgical margins, and postoperative eGFR. Conclusions: SP-RAPN represents an emerging technique using a novel platform. Initial studies have demonstrated that SP-RAPN is a safe and feasible approach to performing partial nephrectomy, although with inferior outcomes for ischemia time and blood transfusion rates. Further studies will be necessary to define the best usage of SP-RAPN within the surgeon's armamentarium.

Comparative analysis of perioperative outcomes between robot-assisted partial nephrectomy and open partial nephrectomy: a propensity-matched study

Aim: Partial nephrectomy is the standard treatment for small renal tumors; however, it remains unclear which surgical approach from among robot-assisted partial nephrectomy (RAPN) and open partial nephrectomy (OPN) is superior. This study aimed to compare perioperative outcomes of RAPN and OPN performed at a single institution after adjusting for preoperative patient and tumor characteristics using propensity score matching (PSM). Methods: In this retrospective cohort study, patients who underwent RAPN or OPN for a renal mass of cT1-2 N0 M0 between 2005 and 2020 at our institution were recruited. The study outcomes were perioperative outcomes, complications, and pathological and functional outcomes. PSM was used to account for baseline covariates. Results: Overall, 131 RAPN and 71 OPN cases were extracted; in addition, 58 cases of RAPN and OPN were selected via PSM. RAPN was superior to OPN in terms of estimated blood loss (10 g vs. 160 g, P &lt; 0.001), ischemia time (23 min vs. 34 min, P &lt; 0.001), and hospital duration (7 days vs. 12 days, P &lt; 0.001). There were no significant differences in the incidence of perioperative complications or in the rate of positive surgical margins (both P &gt; 0.05). With respect to functional outcomes, the rates of preservation of renal function at both 1 day and 3 months postoperatively were higher with RAPN than with OPN (85.3% vs. 69.1% and 93.3% vs. 85.6% respectively, both P &lt; 0.001). Conclusion: In selected cases, RAPN with warm ischemia appears to preserve renal function equally well or better compared to OPN with cold ischemia.

International Expert Consensus on Metric-based Characterization of Robot-assisted Partial Nephrectomy

BackgroundRobot-assisted partial nephrectomy (RAPN) training usually takes place in vivo, and methods vary across countries/institutions. No common system exists to objectively assess trainee ability to perform RAPN at predetermined performance levels prior to in vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes. ObjectiveWe sought to identify objective performance metrics that best characterize a reference approach to RAPN, and obtain face and content validity from procedure experts through a modified Delphi meeting. Design, setting, and participantsDuring a series of online meetings, a core metrics team of three RAPN experts and a senior behavioral scientist performed a detailed task deconstruction of a transperitoneal left-sided RAPN procedure. Outcome measurements and statistical analysisBased on published guidelines, manufacturers’ instructions, and unedited videos of RAPN, the team identified performance metrics that constitute an optimal approach for training purposes. The metrics were then subjected to an in-person modified international Delphi panel meeting with 19 expert surgeons. Results and limitationsEleven procedure phases, with 64 procedure steps, 43 errors, and 39 critical errors, were identified. After the modified Delphi process, the international expert panel added 13 metrics (two steps), six were deleted, and three were modified; 100% panel consensus on the resulting metrics was obtained. Limitations are that the metrics are applicable only to left-sided RAPN cases and some might have been excluded. ConclusionsPerformance metrics that accurately characterize RAPN procedure were developed by a core group of experts. The metrics were then presented to and endorsed by an international panel of very experienced peers. Reliable and valid metrics underpin effective, quality-assured, structured surgical training for RAPN. Patient summaryWe organize a meeting among robot-assisted partial nephrectomy (RAPN) experts to identify and reach consensus on objective performance metrics for RAPN training. The metrics are a crucial starting point to improve and quality assure surgical training and patients’ clinical outcomes.

MP50-17 PROSPECTIVE COMPARATIVE STUDY TO EVALUATE THE CLINICAL UTILITY OF IRIS 3-D ANATOMICAL MODELING SOFTWARE FOR PREOPERATIVE SURGICAL PLANNING AND INTRA-OPERATIVE NAVIGATION FOR ROBOT ASSISTED PARTIAL NEPHRECTOMY (RAPN): A PRELIMINARY ANALYSIS

You have accessJournal of UrologyCME1 May 2022MP50-17 PROSPECTIVE COMPARATIVE STUDY TO EVALUATE THE CLINICAL UTILITY OF IRIS 3-D ANATOMICAL MODELING SOFTWARE FOR PREOPERATIVE SURGICAL PLANNING AND INTRA-OPERATIVE NAVIGATION FOR ROBOT ASSISTED PARTIAL NEPHRECTOMY (RAPN): A PRELIMINARY ANALYSIS Ahmed Ghazi, Tanner Corse, Thomas Osinski, Thomas Frye, William Tabayoyong, Linda Dayan, Ravi Munver, Hani Rashid, Jean Joseph, and Michael Stifelman Ahmed GhaziAhmed Ghazi More articles by this author , Tanner CorseTanner Corse More articles by this author , Thomas OsinskiThomas Osinski More articles by this author , Thomas FryeThomas Frye More articles by this author , William TabayoyongWilliam Tabayoyong More articles by this author , Linda DayanLinda Dayan More articles by this author , Ravi MunverRavi Munver More articles by this author , Hani RashidHani Rashid More articles by this author , Jean JosephJean Joseph More articles by this author , and Michael StifelmanMichael Stifelman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002625.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The objective of the study was to evaluate the clinical utility of IRIS (Intuitive Surgical Inc., Sunnyvale, CA, USA) with CT scans in comparison to CT scan alone for preoperative surgical planning and intraoperative navigation during RAPN. METHODS: This is a prospective, multi-center, post-market study (NCT04329767) with 54 currently enrolled RAPN patients. Patients were randomized into two groups with preoperative surgical planning and intraoperative navigation using either CT scans alone (N=21) or IRISTM with CT scans (N=33). Demographic and intraoperative data were collected and analyzed. A 5-point Likert-type scale evaluated the impact of each modality on anatomy interpretation, confidence completing the procedure and procedure efficiency was evaluated for every case. Overlap between the preoperative planned clamping and the actual operative clamping was evaluated. RESULTS: Results are summarized in Table 1. Tests of significance were not performed in this interim analysis of an ongoing trial. Higher incidence of surgeons in IRIS arm (97%) vs CT arm (81%) reported confidence in successfully completing the planned RAPN procedure. During intraoperative navigation, surgeons rated (>4) that all IRIS cases achieved good spatial sensation of the anatomy compared to CT cases (100% vs 76%). This was most enhanced in patients (6 vs 6) with RENAL score 10-12, where a 50-80% increase in anatomical interpretation of various critical structures was reported using IRIS. Surgeons preoperatively reviewing IRIS reported higher confidence in performing zero or selective vs global ischemia which translated to higher actual execution in IRIS (39%) vs CT arm (9.5%).Intraoperatively IRIS demonstrated improved procedure efficiency in 88% of cases vs. 29% in the CT arm, mainly attributed to ease in interpreting anatomy in the IRIS arm (91% vs 33%). CONCLUSIONS: In this pilot study comparing the utility of IRIS to standard 2D imaging during RAPN, IRIS improved self-reported surgeon confidence, efficiency, and complex anatomical interpretation particularly during complex RAPN cases with increased incidence of non-global ischemia approaches. Source of Funding: Intuitive Research Grant © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e872 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ahmed Ghazi More articles by this author Tanner Corse More articles by this author Thomas Osinski More articles by this author Thomas Frye More articles by this author William Tabayoyong More articles by this author Linda Dayan More articles by this author Ravi Munver More articles by this author Hani Rashid More articles by this author Jean Joseph More articles by this author Michael Stifelman More articles by this author Expand All Advertisement PDF DownloadLoading ...

V04-07 3D SELECTIVE ARTERIAL CLAMPING IN ROBOT ASSISTED PARTIAL NEPHRECTOMY

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-07 3D SELECTIVE ARTERIAL CLAMPING IN ROBOT ASSISTED PARTIAL NEPHRECTOMY Pieter De Backer, Melle Belgium, Saar Vermijs, Charles Van Praet, Sarah Vandenbulcke, Maryse Lejoly, Stefanie Vanderschelden, Pieter De Visschere, Alexandre Mottrie, Charlotte Debbaut, and Karel Decaestecker Pieter De BackerPieter De Backer More articles by this author , Melle BelgiumMelle Belgium More articles by this author , Saar VermijsSaar Vermijs More articles by this author , Charles Van PraetCharles Van Praet More articles by this author , Sarah VandenbulckeSarah Vandenbulcke More articles by this author , Maryse LejolyMaryse Lejoly More articles by this author , Stefanie VanderscheldenStefanie Vanderschelden More articles by this author , Pieter De VisscherePieter De Visschere More articles by this author , Alexandre MottrieAlexandre Mottrie More articles by this author , Charlotte DebbautCharlotte Debbaut More articles by this author , and Karel DecaesteckerKarel Decaestecker More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Selective arterial clamping (SAC) in Robot-Assisted Partial Nephrectomy (RAPN) can be considered a good intermediate between an off-clamp and fully-clamped approach, minimizing the risks of bleeding, prolonged warm ischemia time (WIT) and renal function decline. Preoperative estimation of renal perfusion zones and SAC-strategy can be impractical when solely based on CT or MRI images. We describe our mathematical 3D model to preoperatively estimate and visualize the 3D SAC strategy and compare this with peri-operative outcomes of two RAPN cases. METHODS: Two patients with a single renal tumor (PADUA score 6 and 8) underwent RAPN with 3D SAC prediction. 3D arterial tree, parenchyma and tumor volume segmentations derived from preoperative four phase CT scans are inputted in our in-house developed software package. This assigns every voxel of the scanned renal volume to its nearest vessel. The result is an interactive virtual 3D render of different SAC strategies. Intra-operative visualization is performed using the TilePro™ function. After SAC, indocyanine green (ICG) is administered to check the prediction of the algorithm by assessing the renal surface information using Firefly™ fluorescence imaging. RESULTS: Both RAPN conducted according to the preoperatively defined SAC strategy were completed successfully. Dissection time was 19 and 35 minutes for the second generation renal arteries on a total surgical console time of respectively 100 and 110 minutes. Trifecta was achieved twice: negative cancer margin, no renal function decrease (GFR at day 30: resp. >60 and 89 ml/min) and no urological postoperative complications at day 1 and day 30. WIT was 15 and 18 minutes, blood loss 200 and 50 ml, respectively. Histopathology showed oncocytoma in both cases. The ICG fluorescence confirmed correct algorithmic predictions at the surface level. Respectively 16% and 57% of the renal volume was estimated to be clamped simultaneously. The model allowed for bloodless enucleation initiation away from the remaining perfused tumor zone and predicted correctly where bleeding was to be expected inside the parenchyma. CONCLUSIONS: We demonstrated the added value of 3D reconstructions and our predefined 3D SAC strategy in selected cases. A direct distance algorithm specifies the clamping positions and the corresponding perfusion zones. Visualizing this SAC strategy on the 3D reconstruction of the kidney and surrounding structures allows for a targeted approach during the RAPN procedure. Further validation of our predictions is needed and a more systematic approach to measure clinical outcome is desired. Source of Funding: VLAIO mandate HBC.2020.2252 / Orsi Academy / Ipsen Research Grant © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e293-e293 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pieter De Backer More articles by this author Melle Belgium More articles by this author Saar Vermijs More articles by this author Charles Van Praet More articles by this author Sarah Vandenbulcke More articles by this author Maryse Lejoly More articles by this author Stefanie Vanderschelden More articles by this author Pieter De Visschere More articles by this author Alexandre Mottrie More articles by this author Charlotte Debbaut More articles by this author Karel Decaestecker More articles by this author Expand All Advertisement Loading ...

MP10-09 USEFULNESS OF RESECTION PROCESS MAP IN RAPN FOR ENDOPHYTIC RENAL TUMORS AND DEVELOPMENT OF VIRTUAL REALITY SIMULATION

You have accessJournal of UrologySurgical Technology & Simulation: Instrumentation & Technology I (MP10)1 Sep 2021MP10-09 USEFULNESS OF RESECTION PROCESS MAP IN RAPN FOR ENDOPHYTIC RENAL TUMORS AND DEVELOPMENT OF VIRTUAL REALITY SIMULATION Atsushi Okada, Kazuya Ohashi, Kazumi Taguchi, Toshiki Etani, Shoichiro Iwatsuki, Shuzo Hamamoto, Taku Naiki, Ryosuke Ando, Noriyasu Kawai, Keiichi Tozawa, and Takahiro Yasui Atsushi OkadaAtsushi Okada More articles by this author , Kazuya OhashiKazuya Ohashi More articles by this author , Kazumi TaguchiKazumi Taguchi More articles by this author , Toshiki EtaniToshiki Etani More articles by this author , Shoichiro IwatsukiShoichiro Iwatsuki More articles by this author , Shuzo HamamotoShuzo Hamamoto More articles by this author , Taku NaikiTaku Naiki More articles by this author , Ryosuke AndoRyosuke Ando More articles by this author , Noriyasu KawaiNoriyasu Kawai More articles by this author , Keiichi TozawaKeiichi Tozawa More articles by this author , and Takahiro YasuiTakahiro Yasui More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001983.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robot-assisted partial nephrectomy (RAPN) for endophytic renal tumors is positioned as a highly difficult procedure, and it is important to perform accurate tumor resection, preserve renal function, and suppress perioperative complications. In this study, we performed a virtual excision simulation Resection Process Map (RPM) on preoperative 3DCT, verified its usefulness, and developed a VR simulation that developed the technology. METHODS: We retrospectively analyzed 100 RAPN cases conducted at our university from November 2012 to May 2020. The medical imaging workstation Ziostation® 2 was used to construct the RPM. From that image, we were able to grasp the arrangement and shape of the vessels and collecting system exposed on the resected surface by deleting the "tumor part with a 5 mm-thick renal parenchymal resection margin" on 3D-CT. The patient background, tumor properties, surgical information, and postoperative results of the endophytic RPM+ (13 patients in group A), the endophytic RPM- (23 patients in group B), and the exophytic group (64 patients in group C) were analyzed. Applying this technology, RPM data was output as an STL files, which is three-dimensional polygon data for each organ, and observation with immersive VR goggles was made possible using the medical VR application Holoeyes® XR. RESULTS: The warm ischemic times in each group were 20.4 minutes, 23.6 minutes, and 22.0 minutes, and group A was 3 minutes and 1 minute or shorter than groups B and C, respectively, but the difference was not significant. The blood loss in each group was 86.6 mL, 98.2 mL, and 111.7 mL, respectively, and which was the smallest in group A, but there was no significant difference between the groups. The surgical margin was positive in one case of the group C, and the postoperative Cre increase was the smallest at 0.03 mg/dL in group A. Grade III or higher complications were found in 4.7% of groups C only. Furthermore, the VR simulation was able to reproduce the excision area equivalent to the robotic surgical field of view for a completely endophytic renal tumor, and by performing the suture simulation, we were able to complete a safe operation. CONCLUSIONS: RPM simulations for RAPN of endophytic renal tumors and VR simulations applying the technology may be useful for achieving smooth and safe surgery. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e171-e172 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Atsushi Okada More articles by this author Kazuya Ohashi More articles by this author Kazumi Taguchi More articles by this author Toshiki Etani More articles by this author Shoichiro Iwatsuki More articles by this author Shuzo Hamamoto More articles by this author Taku Naiki More articles by this author Ryosuke Ando More articles by this author Noriyasu Kawai More articles by this author Keiichi Tozawa More articles by this author Takahiro Yasui More articles by this author Expand All Advertisement Loading ...

Test clamp procedure in robot-assisted partial nephrectomy: is it a safe procedure?

We performed test clamp procedure in robot-assisted partial nephrectomy (RAPN) to prevent massive bleeding during tumor resection and to omit dissection of non-feeding arteries around the tumor. We subsequently analyzed the safety and usefulness of the procedure. The Test clamp procedure was performed for 1 to 3min during renal artery test ischemia prior to the actual ischemia and tumor resection. We confirmed the disappearance of blood flow around the renal tumor using color Doppler ultrasonography. If arterial blood flow around the tumor remained, we surveyed the site for other arteries that needed to be clamped and repeated the test clamp procedure until renal blood flow around the tumor disappeared. We retrospectively analyzed consecutive RAPN cases performed from July 2016 to March 2020 at our institutions and reviewed medical records. The clinical data of the RAPN cases were statistically analyzed. Sixty-four RAPN cases underwent the test clamp procedure, which was categorized as the TEST group. Test clamping was performed safely without any clamping-related complications in all cases. Eleven cases (17%) underwent partial ischemia, which was a significantly higher number than that in the control group. Massive bleeding during tumor resection was more frequent in the control group. Postoperative deterioration of estimated glomerular filtration rate did not differ significantly between both groups. Although further investigation was still necessary, our findings indicate that the test clamp procedure may be a safe and secure procedure to perform in RAPN for both patients and surgeons.

A low RENAL Nephrometry Score can avoid the need for the intraoperative insertion of a ureteral catheter in robot-assisted partial nephrectomy

BackgroundIntraoperative urinary collecting system entry (CSE) in robot-assisted partial nephrectomy (RAPN) may cause postoperative urinary leakage and extend the hospitalization. Therefore, identifying and firmly closing the entry sites are important for preventing postoperative urine leakage. In RAPN cases expected to require CSE, we insert a ureteral catheter and inject dye into the renal pelvis to identify the entry sites. We retrospectively analyzed the factors associated with intraoperative CSE in RAPN and explored the indications of intraoperative ureteral catheter indwelling in RAPN.MethodsOf 104 Japanese patients who underwent RAPN at our institution from August 2016 to March 2020, 101 were analyzed. The patients were classified into CSE and non-CSE groups. The patients’ background characteristics, RENAL Nephrometry Score (RNS), and surgical outcomes were analyzed.ResultsIntraoperative CSE was observed in 41 patients (41%). The CSE group had a significantly longer operative time, console time, ischemic time, and hospital stay than the non-CSE group. In a multivariable analysis, the N-score (odds ratio [OR] = 3.9, P < 0.05) and RNS total score excluding the L-score (OR = 3.1, P < 0.05) were associated with CSE. In a logistic regression analysis, CSE showed a moderate correlation with the RNS total score excluding the L-score (AUC 0.848, cut-off 5, sensitivity 0.83, specificity 0.73).ConclusionA ureteral catheter should not be placed in patients with an RNS total score (excluding the L-score) of ≤ 4.

Robotic-assisted Partial Nephrectomy for “Very Small” (

BackgroundPatient with “very small” (<2 cm) renal mass can be offered active surveillance, thermal ablation, or partial nephrectomy. The management strategy will consider patient preferences and prioritize potential harms associated with each of these options. To date, outcomes of robot-assisted partial nephrectomy (RAPN) in patients with “very small” renal masses have not been reported. ObjectiveTo assess the outcomes of RAPN among patients with “very small” renal masses. Design, setting, and participantsThis was a retrospective analysis of a multi-institutional database including RAPN cases performed at eight high-volume US and European centers between 2009 and 2019. Patients were stratified into two groups according to clinical tumor size: <2 cm (“very small” renal mass, study group) and 2–4 cm (control group). InterventionRAPN for renal masses. Outcome measurements and statistical analysisBaseline characteristics and intraoperative, pathological, and postoperative data were compared between the study and the control group. A “trifecta” was used as surrogate of “surgical quality.” Results and limitationsOverall, a total of 1019 patients were included in the analysis. Of these, 352 had a renal mass of <2 cm (34.5%) and 667 (65.5%) had a renal mass of 2–4 cm. At baseline, the study group presented a lower rate of chronic kidney disease ≥stage III (p < 0.001), a lower RENAL score (p = 0.001), and lower rates of hilar (p = 0.04) and endophytic (p = 0.02) masses. Warm ischemia time was shorter for the study group (median 14 vs 18 min, p < 0.001), which also showed a lower rate of overall postoperative complications (9.6% vs 14.7%, p < 0.001) and no major complications. In terms of oncological outcomes, three and ten patients developed a local recurrence in the study and the control group, respectively (p = 0.1). In the study group, higher estimated glomerular filtration rates were found at discharge (p = 0.001) and at the last follow-up (p = 0.007), which showed a “trifecta” achievement of 90.6%. The retrospective design may limit the generalizability of the findings. ConclusionsWhenever an active treatment is indicated or warranted, RAPN represents a minimally invasive management option for “very small” renal masses, as it carries minimal risk of complications and has minimal impact on renal function. While both active surveillance and kidney ablation remain valid management options in these cases, RAPN can be offered and discussed with patients as it provides excellent outcomes with low morbidity. Patient summaryIn this report, we observed that robot-assisted partial nephrectomy represents a true minimally invasive active treatment for “very small” renal masses (<2 cm), as it carries minimal risk of complications and has minimal impact on renal function.

Laparoscopic Partial Nephrectomy in Allograft Kidney

The incidence of renal tumor on the allograft kidney is relatively rare. There is no standard treatment available for the management of such cases. However, if technically feasible nephron-sparing surgical approaches, whether open or minimally invasive, should be preferred for the management of these challenging cases. To our knowledge, there is no pure laparoscopic technique reported in the literature but only 3 cases of robot-assisted partial nephrectomy. In this article, we aimed to present the application of pure transperitoneal laparoscopic partial nephrectomy for the management of a renal mass on the allograft kidney.

PD11-04 COMPARING ENDOSCOPIC ROBOT-ASSISTED SIMPLE ENUCLEATION AND STANDARD ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR T1 RENAL CELL CARCINOMA: INITIAL RESULTS OF A NON-INFERIORITY RANDOMIZED CONTROLLED TRIAL

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (PD11)1 Apr 2020PD11-04 COMPARING ENDOSCOPIC ROBOT-ASSISTED SIMPLE ENUCLEATION AND STANDARD ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR T1 RENAL CELL CARCINOMA: INITIAL RESULTS OF A NON-INFERIORITY RANDOMIZED CONTROLLED TRIAL Qun Lu*, Xiaozhi Zhao, Changwei Ji, Guangxiang Liu, Linfeng Xu, and Hongqian Guo Qun Lu*Qun Lu* More articles by this author , Xiaozhi ZhaoXiaozhi Zhao More articles by this author , Changwei JiChangwei Ji More articles by this author , Guangxiang LiuGuangxiang Liu More articles by this author , Linfeng XuLinfeng Xu More articles by this author , and Hongqian GuoHongqian Guo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000845.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephron-sparing surgery is the gold standard treatment for localized renal masses. Although published studies have showed excellent long-term oncologic results of simple enucleation (SE), many urologists still consider SE an unsafe technique with a high risk of incomplete tumor excision. This is a non-inferiority, randomized controlled trial to compare the peri-operative, renal functional and oncologic outcomes of endoscopic robot-assisted simple enucleation (ERASE) and standard robot-assisted partial nephrectomy (RAPN) in the treatment of T1 renal cell carcinoma (RCC). METHODS: Patients with newly diagnosed sporadic, unilateral, T1 presumed RCC were recruited for this clinical trial from October 2018. This trial was registered in ClinicalTrials.gov (NCT03624673). The protocol had been approved by the ethics committee of Nanjing Drum Tower Hospital. The inclusion criteria were clinical T1 RCC, age 18 to 80 years, normal contralateral renal function, RENAL score <=9 and willingness to participate in this study. The exclusion criteria were intolerance of robotic surgery, metastastic renal cell carcinoma, entry into collection system or hematuria and a history of other renal diseases. The primary outcome measure was rate of positive surgical margin (PSM). The Surface–Intermediate–Base margin score was reported for each tumor specimen. On the basis of the assumption of no difference in PSM rate between two techniques, we calculated that 190 participants per group were needed. RESULTS: The trial had presently enrolled 180 patients, of whom 90 were randomized to the ERASE group and 90 to the RAPN group. Demographic characteristics were similar. Mean operative time was 162.0 and 169.9 min, respectively (p=0.297). Warm ischemic time was comparable in the ERASE and RAPN group (18.7 vs 21.3 min; p=0.056). The estimated blood loss was similar (p=0.129). Tumor bed suturing was performed in 8.9% and 83.3% of ERASE and RAPN cases (P=0.000). No hilar clamping was performed in 8 (8.9%) ERASE patients and 5 (5.6%) RAPN patients (p=0.388). The rates of intraoperative and postoperative complications were similar. The incidence of PSMs was comparable between the ERASE and RAPN groups (2.2% and 3.3%, p= 1.000). No recurrence was found in the two groups during follow-up. CONCLUSIONS: The initial results of this trial reveal that ERASE is an oncologically safe and effective alternative to RAPN for T1 renal cell carcinoma. ERASE confers comparable peri-operative and oncologic results with RAPN, with similar incidence of PSM. The final results of this trial are required to validate our findings. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e254-e254 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Qun Lu* More articles by this author Xiaozhi Zhao More articles by this author Changwei Ji More articles by this author Guangxiang Liu More articles by this author Linfeng Xu More articles by this author Hongqian Guo More articles by this author Expand All Advertisement PDF downloadLoading ...

'Trifecta' outcomes of robot-assisted partial nephrectomy: a large Japanese multicenter study.

The objective of this study was to evaluate the early surgical outcomes of robot-assisted partial nephrectomy (RAPN) for small renal masses in a large Japanese multicenter series. A total of 804 consecutive cases of RAPN were examined at 42 institutes between 2011 and 2016. Medical records for clinical, pathological characteristics and perioperative outcomes were retrospectively reviewed. Univariable and multivariable analyses were performed to determine factors predicting Trifecta achievement. The median tumor size was 2.6cm. The median RENAL score was 7. The median warm ischemia time was 21min. The median estimated blood loss was 30mL. Eight patients (1.0%) were converted to radical nephrectomy. The overall and Clavien-Dindo grade ≥ 3 complication rates were 13.0% and 5.8%, respectively. Pathologically, 91.4% of tumors were malignant and the positive surgical margin (PSM) rate was 1.1%. During the median 27.1-month observation period, the recurrence rate was 1.6%. Postoperative preservation rates of eGFR at 1, 6, 12 and 24months were 90.3, 89.8, 89.4 and 89.2%, respectively. Trifecta was achieved in 62.1%. Multivariable analysis demonstrated that tumor diameter, estimated blood loss and hilar location of the tumor were significant negative factors predicting Trifecta achievement. The rate of Trifecta achievement for T1b tumors and hilar tumors was significantly lower (48.4% and 50.0%, respectively). RAPN was safely performed with acceptable oncological and functional outcomes, but the rate of Trifecta accomplishment for T1b or hilar tumors was significantly lower than that for T1a or non-hilar tumors, respectively.

Robot-Assisted Partial Nephrectomy for Renal Tumor ≤7 cm in Diameter

The aim of this study was to compare the perioperative results of robot-assisted partial nephrectomy (RAPN) with those of laparoscopic partial nephrectomy (LPN) for cT1 renal tumors. From August 2015 to March 2018, 63 consecutive cases undergoing LPN and RAPN (30 cases of LPN and 33 cases of RAPN) for renal tumors ≤7cm in diameter (cTla: 42 cases and cT1b: 21 cases) were evaluated. The trifecta was defined on the basis of the following three criteria: ischemic time less than 25 minutes, no positive surgical margin, and no perioperative complications within four weeks postoperative. The background factors were compared between the two groups. There were no cases requiring changes in the operation methods. There was no significant difference in age, body mass index, gender, or tumor side between the two groups. While the mean tumor diameter and mean RENAL nephrometry score (RNS) were 32.6 mm and 7.3, respectively, there were no differences between the two groups. The warm ischemic time of RAPN was significantly shorter than that of LPN (12.7 min vs 19.9 min, P = 0.0007), and the estimated blood loss of RAPN was less than that of LPN (58.6 ml vs 160.3 ml, P = 0.0005). While there was no apparent tumor damage, tumor exposure on the resection surface was observed in two cases. Perioperative complications were observed in four cases. The trifecta achievement rate of RAPN and that of LPN was 93.9% (31 cases) and 66.7% (20 cases), respectively. The initial perioperative results of RAPN were comparable with those of LPN for cT1 renal tumors.

MP42-04 MODIFIED ROBOT-ASSISTED SIMPLE ENUCLEATION WITH SINGLE LAYER RENORRHAPHY TECHNIQUE VERSUS STANDARD ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR TREATING LOCALIZED RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV1 Apr 2018MP42-04 MODIFIED ROBOT-ASSISTED SIMPLE ENUCLEATION WITH SINGLE LAYER RENORRHAPHY TECHNIQUE VERSUS STANDARD ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR TREATING LOCALIZED RENAL CELL CARCINOMA Xiaozhi Zhao, Qun Lu, Rong Yang, Guangxiang Liu, Feng Qu, Xiaogong Li, Weidong Gan, and Hongqian Guo Xiaozhi ZhaoXiaozhi Zhao More articles by this author , Qun LuQun Lu More articles by this author , Rong YangRong Yang More articles by this author , Guangxiang LiuGuangxiang Liu More articles by this author , Feng QuFeng Qu More articles by this author , Xiaogong LiXiaogong Li More articles by this author , Weidong GanWeidong Gan More articles by this author , and Hongqian GuoHongqian Guo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1311AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Nephron-sparing surgery is the gold standard treatment for localized renal masses. Simple enucleation has proven to be oncologically safe. In this study, we used our large institutional experience to compare perioperative results and early oncological outcomes with modified robot-assisted simple enucleation (MRASE) and robot-assisted partial nephrectomy (RAPN) for treating localized renal tumors. METHODS We evaluated 445 consecutive patients who underwent MRASE or RAPN for renal tumors in our institution from September 2014 to July 2017 in terms of perioperative pathologic and oncologic outcome variables. In simple enucleation, the surgeon used the pseudocapsule as the anatomical landmark to enucleate the tumor by blunt dissection, with no visible rim of normal parenchyma. The single layer suture technique was performed for renal reconstruction. RESULTS In total, 310 patients underwent MRASE and 135 underwent RAPN. Mean operative time was 181.3 and 192.3 min, respectively (p=0.038). Warm ischemic time was significantly lower in the MRASE than RAPN group (20.9 vs 24.3 min; p=0.000). The estimated blood loss was similar (p=0.381). Tumor bed suturing was performed in 8.7% and 79.3% of MRASE and RAPN cases (P=0.000). No hilar clamping was performed in 42 MRASE patients (13.5%) and 8 RAPN patients (5.9%) (p=0.019). Grade III and IV complications were reported in 6 (1.9%) MRASE patients and 9 (6.7%) RAPN patients (p=0.024). The incidence of positive surgical margins was comparable between the MRASE and RAPN groups (1.9% and 5.2%, p= 0.118). After a median follow-up of 18 months, recurrence did not differ between the 2 groups: 9 (2.9%) MRASE patients and 5 (3.7%) RAPN patients (p=0.881). CONCLUSIONS MRASE may confer shorter warm ischemic time, almost no need for tumor bed suturing and less Grade III and IV complications than RAPN, with similar oncologic outcomes. MRASE may be safe and acceptable for patients undergoing partial nephrectomy. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e537 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Xiaozhi Zhao More articles by this author Qun Lu More articles by this author Rong Yang More articles by this author Guangxiang Liu More articles by this author Feng Qu More articles by this author Xiaogong Li More articles by this author Weidong Gan More articles by this author Hongqian Guo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Hospital volume and outcomes of robot-assisted partial nephrectomy.

To evaluate the impact of hospital volume on outcomes of robot-assisted partial nephrectomy (RAPN). Patients with renal cell carcinoma who underwent RAPN between 2010 and 2013 were identified in the National Cancer Database. Hospital yearly RAPN volume was categorized into groups by sorting patients as closely as possible into five groups of equal size (quintiles): very low; low; medium; high; and very high volume. Outcomes included 30-day mortality, 90-day mortality, open conversion, prolonged length of hospital stay (PLOS; defined as >3 days), 30-day readmission rate, and positive surgical margin (PSM) rate. Unadjusted analyses and multivariable logistic regressions were used to compare outcomes. Sensitivity analyses with hospital volume considered as a continuous variable were also performed. A total of 18 724 RAPN cases were included. Hospital volume quintiles were: very low volume, 1-7 cases (n = 3 693); low volume, 8-14 cases (n = 3 719); medium volume, 15-23 cases (n = 3 833); high volume, 24-43 cases (n = 3 649); and very high volume, ≥44 cases (n = 3 830). There was no significant difference in 30-day or 90-day mortality among the five groups. Multivariable logistic regression analysis (reference: very low volume) showed that higher hospital volume was associated with lower odds of conversion (low [odds ratio {OR}: 0.88; P = 0.377]; medium [OR: 0.60; P = 0.001]; high [OR: 0.57; P < 0.001]; very high [OR: 0.47; P < 0.001]), lower odds of PLOS (low [OR: 0.93; P = 0.197], medium [OR: 0.75; P < 0.001]; high [OR: 0.62; P < 0.001]; very high [OR: 0.45; P < 0.001]), and lower odds of PSMs (low [OR: 0.76; P < 0.001]; medium [OR: 0.76, P < 0.001]; high [OR: 0.59; P < 0.001]; very high [OR: 0.34; P < 0.001]). Sensitivity analyses confirmed increasing hospital volume (per 1-case increase) was associated with lower odds of conversion (OR: 0.986; P < 0.001), PLOS (OR: 0.989; P < 0.001) and PSMs (OR: 0.984; P < 0.001). A difference in 30-day readmission rate was found in unadjusted analysis but not in adjusted analyses. Undergoing RAPN at higher-volume hospitals may have better peri-operative outcomes (conversion to open and LOS) and lower PSM rates. Future studies are needed to explore the detailed components that lead to the superior outcomes in higher-volume hospitals.

Hyperaccuracy Three-dimensional Reconstruction Is Able to Maximize the Efficacy of Selective Clamping During Robot-assisted Partial Nephrectomy for Complex Renal Masses

BackgroundAvailable technologies could avoid global ischemia for the removal of a renal tumor. ObjectiveTo present hyperaccuracy three-dimensional (HA3D) reconstruction during robot-assisted partial nephrectomy (RAPN) and compare its efficacy in sponsoring successful selective clamping of renal arterial branches during RAPN. Design, setting, and participantsPatients undergoing RAPN (January 2016–July 2017) for renal mass PADUA score ≥10 who underwent abdominal computed tomography scan with angiography. Since February 2017 HA3D reconstruction was performed. Surgical procedureHA3D reconstruction-aided RAPN and standard RAPN with selective clamping. MeasurementsIntraoperative variables focusing on the renal arterial pedicle management and success rate of its planned management. Results and limitationsThirty-one patients in group no HA3D and 21 in group HA3D. The median (standard deviation) tumor size was 50.9 and 50.8mm (p=0.97), and median PADUA scores 10.5 and 11 (p=0.85) for groups no HA3D and HA3D, respectively. In group no HA3D, a significantly higher number of patients underwent global ischemia (80% vs 24%, p<0.01). Of note, in 90% of the group HA3D cases, intraoperative management of the renal pedicle was performed as preoperatively planned; in 39% of the group no HA3D cases, management of the renal arterial pedicle was varied intraoperatively (p=0.04). We disclose the limited sample size and the experimental technique. ConclusionsPreoperative simulation of selective ischemia was feasible and effective with HA3D reconstruction. In all the RAPN cases performed, selective clamping was successful, avoiding ischemia of the healthy renal remnant. A strict collaboration between urologists and bioengineers is mandatory to improve the technology. Patient summaryIn this report, we found that an accurate three-dimensional reconstruction of the kidney before conservative surgery for renal cancer seems to help in avoiding the global ischemia of the kidney. Further studies are needed to conclude if avoiding a percentage of ischemia to the kidney is clinically relevant.

Does the Level of Assistant Experience Impact Operative Outcomes for Robot-Assisted Partial Nephrectomy?

A skilled assistant surgeon is presumed necessary during robot-assisted partial nephrectomy (RAPN) to minimize warm ischemia time (WIT) and to facilitate complex renorrhaphy. Studies observing impact of resident participation have focused on robotic prostatectomies, showing no impact on core surgical outcomes. Herein, we evaluated the level of experience of the bedside assistant and its impact on perioperative outcomes in RAPN. All RAPN cases in our healthcare system from January 2011 to December 2013 were retrospectively reviewed. The cases were divided into teaching and nonteaching hospitals. There were 18 fellowship-trained attending surgeons. At teaching hospitals, surgeries were performed by an attending physician and postgraduate year (PGY)-2 or PGY-3 resident at bedside; at nonteaching hospitals, surgeries were performed by two attending surgeons. We compared age, gender, body mass index, Charlson comorbidity index, operative difficulty by R.E.N.A.L. nephrometry score, and operative outcomes (WIT, estimated blood loss, operative time (OT), positive margin rate, length of stay (LOS), postoperative glomerular filtration rate, and readmission rate). Of the 170 patients captured, 162 had R.E.N.A.L. nephrometry score and WIT: 112 from teaching hospitals and 50 from nonteaching hospitals. Patient characteristics were equivalent between both cohorts with the exception of the R.E.N.A.L. score, which was higher (6.3 vs 5.7, p = 0.046) in the teaching hospitals cohort. Regarding operative outcomes, we noted an overall increase in LOS by 1 day (p = 0.001) and OT by 16 minutes (p = 0.011) in the teaching hospitals. We observed that increased LOS was the only clinically relevant measure negatively impacted by resident physician involvement during RAPN.

Instrument Life for Robot-assisted Laparoscopic Radical Prostatectomy and Partial Nephrectomy: Are Ten Lives for Most Instruments Justified?

To investigate the rate of premature instrument exchange during robot-assisted laparoscopic radical prostatectomy (RALRP) and robot-assisted partial nephrectomy (RAPN). The majority of robotic instruments have a predetermined lifespan of 10 uses; however, it is unknown if instruments are routinely exchanged before 10 uses in clinical practice. We retrospectively reviewed instrument use in consecutive RALRP and RAPN cases performed by high-volume robotic surgeons at 1 tertiary care center between January 2011 and October 2014. The number of instruments used per case was evaluated and instances of additional instrument utilization were noted. Exchange number was compared between the first and second half of cases performed. Operative times were compared between cases with and without exchange. Student's t-test and Pearson's χ(2)-test were used to determine statistical significance. Three surgeons performed 1579 RALRP procedures and 2 surgeons performed 313 RAPN procedures. During RALRP, monopolar curved scissors required exchange in 12.4% cases. Other instruments were exchanged in less than 2% of cases. Exchange rates were similar to those for RAPN. Only exchange of Prograsp forceps decreased with increasing surgeon experience (P = .02) and instrument exchange did not lengthen operative times (P >.05 for all instruments). During RALRP and RAPN, monopolar curved scissors required exchange in approximately 10% of cases whereas other instruments were rarely exchanged. Robotic instrument lifetime may not uniformly be 10 uses. The preset lifetime of robotic instruments and/or pricing should be reevaluated.

The learning curve and factors affecting warm ischemia time during robot-assisted partial nephrectomy.

Introduction:The learning curve for robotic partial nephrectomy was investigated for an experienced laparoscopic surgeon and factors associated with warm ischemia time (WIT) were assessed.Materials and Methods:Between 2007 and 2014, one surgeon completed 171 procedures. Operative time, blood loss, complications and ischemia time were examined to determine the learning curve. The learning curve was defined as the number of procedures needed to reach the targeted goal for WIT, which most recently was 20 min. Statistical analyses including multivariable regression analysis and matching were performed.Results:Comparing the first 30 to the last 30 patients, mean ischemia time (23.0–15.2 min, P < 0.01) decreased while tumor size (2.4–3.4 cm, P = 0.02) and nephrometry score (5.9–7.0, P = 0.02) increased. Body mass index (P = 0.87), age (P = 0.38), complication rate (P = 0.16), operating time (P = 0.78) and estimated blood loss (P = 0.98) did not change. Decreases in ischemia time corresponded with revised goals in 2011 and early vascular unclamping with the omission of cortical renorrhaphy in selected patients. A multivariable analysis found nephrometry score, tumor diameter, cortical renorrhaphy and year of surgery to be significant predictors of WIT.Conclusions:Adoption of robotic assistance for a surgeon experienced with laparoscopic surgery was associated with low complication rates even during the initial cases of robot-assisted partial nephrectomy. Ischemia time decreased while no significant changes in blood loss, operating time or complications were seen. The largest decrease in ischemia time was associated with adopting evidence-based goals and new techniques, and was not felt to be related to a learning curve.