Functional Outcomes Of Robot-assisted Partial Nephrectomy Research Articles

Clinical Benefits of Indocyanine Green Fluorescence in Robot-Assisted Partial Nephrectomy.

Simple SummaryIndocyanine green (ICG) administration in robot-assisted partial nephrectomy (RAPN) can minimize warm ischemia time and preserve more parenchyma resulting in exceptional preservation of renal function and reduced incidence of postoperative complications. However, previous studies have seldom compared how ICG-RAPN use differs when used to treat benign versus malignant renal tumors because the baseline patient and tumor characteristics as well as treatment goals are completely different. The aim of our retrospective study was to compare the intraoperative and postoperative outcomes and the differences in the results of ICG administration between patients with benign and malignant tumors. We have demonstrated that ICG-RAPN yielded superior preservation of short-term renal function. Of the patients with malignant renal tumors, it had less operative blood loss without a more positive margin rate than standard RAPN.Background: To compare the intraoperative and postoperative outcomes of indocyanine green (ICG) administration in robot-assisted partial nephrectomy (RAPN) and report the differences in the results between patients with benign and malignant renal tumors. Methods: From 2017 to 2020, 132 patients underwent RAPN at our institution, including 21 patients with ICG administration. Clinical data obtained from our institution’s RAPN database were retrospectively reviewed. Intraoperative, postoperative, pathological, and functional outcomes of RAPN were assessed. Results: The pathological results indicated that among the 127 patients, 38 and 89 had received diagnoses of benign and malignant tumors, respectively. A longer operative time (311 vs. 271 min; p = 0.006) but superior preservation of estimated glomerular filtration rate (eGFR) at 3-month follow-up (90% vs. 85%; p = 0.031) were observed in the ICG-RAPN group. Less estimated blood loss, shorter warm ischemia time, and superior preservation of eGFR at postoperative day 1 and 6-month follow-up were also noted, despite no significant differences. Among the patients with malignant tumors, less estimated blood loss (30 vs. 100 mL; p < 0.001) was reported in the ICG-RAPN subgroup. Conclusions: Patients with ICG-RAPN exhibited superior short-term renal function outcomes compared with the standard RAPN group. Of the patients with malignant tumors, ICG-RAPN was associated with less blood loss than standard RAPN without a more positive margin rate. Further studies with larger cohorts and prospective designs are necessary to verify the intraoperative and functional advantages of the green dye.

“Ride the Green Light”: Indocyanine Green–marked Off-clamp Robotic Partial Nephrectomy for Totally Endophytic Renal Masses

BackgroundComplexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection. ObjectiveTo detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging. Design, setting, and participantsBetween June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN. Surgical procedurePreoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN. MeasurementsClinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed. Results and limitationsMedian tumor size was 3cm (interquartile range 2.3–3.8). The median PADUA score was 10 (9–11). Angiographic procedure was successful in all patients. Median operative time was 75min (65–85); median estimated blood loss was 250ml (200–350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2–3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3g/dl (2.1–3.3) and 11% (10–20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6–20.9%) and 12.2% (5.3–13.7%), respectively. ConclusionsWe described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins. Patient summaryRobot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.

Robot-assisted Partial Nephrectomy for Endophytic Tumors.

Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity in the management of renal masses due to its technical feasibility and shorter learning curve with superior perioperative outcomes compared to laparoscopic partial nephrectomy (LPN). Given the cumulation of surgical experience on RAPN, the indication for RAPN has been extended to more challenging, complex cases, such as hilar or endophytic tumors. Renal masses that are completely endophytic can be very challenging to surgeons. These cases are associated with poor recognition of mass extension, higher risk of inadvertent vascular, or pelvicalyceal system injury. As a result, this can lead to potential positive surgical margin, difficulty in performing renorrhaphy as well as higher perioperative complication rates. There is few evidence of oncologic and functional outcomes of RAPN on treating endophytic masses. Therefore, the objective of this review is to critically analyze the current evidence and to provide a summary on the outcomes of RAPN for endophytic renal masses.

Perioperative and long-term renal functional outcomes of robotic versus laparoscopic partial nephrectomy: a multicenter matched-pair comparison.

We compared perioperative and long-term renal functional outcomes of robot-assisted partial nephrectomy (RAPN) with laparoscopic partial nephrectomy (LPN) for small renal masses. A total of 1,032 patients were included for evaluation; propensity score matching was performed to adjust for potential baseline confounders, which resulted in 195 LPNs matched to 195 RAPNs. Patient characteristics including preoperative estimated glomerular filtration rate (eGFR) were investigated, and postoperative results were evaluated. No significant differences were found between the groups with regard to age, body mass index, sex distribution, preoperative eGFR, or tumor size. The mean follow-up period was 32.4 ± 21.1 months for LPN patients versus 31.1 ± 24.5 months for RAPN patients (p = 0.589). Operative time (p < 0.001) and warm ischemic time (p < 0.001) were significantly shorter in the RAPN group. No significant differences were observed in the overall change in eGFR (p = 0.768) or positive surgical margin rate (p = 0.653). A multivariate analysis showed that preoperative eGFR and hypertension significantly influenced the risk of stage 3 and 4 chronic kidney disease. A significant deterioration in renal function occurred 3 months after surgery. However, renal function increased gradually after the nadir eGFR was reached. The amount of renal functional recovery was higher in the RAPN group. Operative parameters for RAPN appear to be less affected by tumor complexity. Functional outcomes of RAPN were superior to those of LPN. Renal function recovered continuously during the 60-month follow-up period after partial nephrectomy.

Off-clamp Robot-assisted Partial Nephrectomy Preserves Renal Function: A Multi-institutional Propensity Score Analysis

BackgroundOngoing efforts are focused on minimizing or eliminating renal ischemia during robot-assisted partial nephrectomy (RPN). Although various techniques allowing the elimination of renal hilar clamping have been described, large multi-institutional studies assessing perioperative and functional outcomes of this approach are lacking. ObjectiveTo evaluate perioperative and functional outcomes of RPN without hilar clamping and to assess comparative effectiveness relative to clamped RPN. Design, setting, and participantsA multi-institutional data analysis of prospectively collected records of 886 RPNs performed by high-volume surgeons across five academic institutions between 2007 and 2011 was carried out. A total of 66 patients who underwent RPN without hilar clamping were identified. After the exclusion of 17 patients, perioperative results of 49 patients were compared against propensity score matched clamped controls. InterventionRPN without hilar clamping. Outcome measurements and statistical analysisDescriptive statistics and propensity score matching. Results and limitationsPatients undergoing off-clamp RPN had a mean tumor size of 2.5cm (standard deviation [SD]: ±2.1) and a mean RENAL nephrometry score of 5.3 (SD: ±1.5). The mean preoperative estimated glomerular filtration rate (eGFR) was 81 (SD: ±29). The mean estimated blood loss (EBL) was 210ml (SD: ±212), and the mean operative time was 155min (SD: ±46). No Clavien 3–5 complications were recorded. The mean postoperative change in eGFR was 3% at first follow-up (1–3 mo), and no patient required postoperative dialysis. The positive surgical margin rate was 3% (n=2), with no disease recurrence reported at a mean follow-up of 21 mo. In propensity score matched analyses, the off-clamp RPN patients had a significantly shorter mean operative time (156min compared with 185min, p<0.001), a higher EBL (228ml compared with 157ml, p=0.009), and a smaller decrease in eGFR (2% compared with −6%, p=0.008). The retrospective analysis was the main limitation of this study. ConclusionsWith appropriately selected patients and adequate surgeon experience, off-clamp RPN is safe and feasible. Off-clamp RPN was associated with higher EBL, shorter operative times, and smaller decrease in renal function.