Retroperitoneal Robot-assisted Partial Nephrectomy Research Articles

Comparison of the effects of transperitoneal and retroperitoneal robot-assisted partial nephrectomy

Objective: To compare the effects of transperitoneal and retroperitoneal approaches for robotic assisted partial nephrectomy (RAPN) in patients with renal cell carcinoma (RCC). Methods: We conducted a retrospective cohort study on RAPN at Affiliated Hospital of Jiangsu University. Between September 2020 and February 2024, the included patients underwent either transperitoneal approach or retroperitoneal approach. Perioperative status, stress response, quality of life, and incidence of complications were compared between the groups. Results: A total of 105 patients were included in this analysis, with 54 patients in the Retroperitoneal group, and 51 patients in the Transperitoneal group. The retroperitoneal approach was associated with significantly better perioperative indicators compared to the transperitoneal method (P<0.05). After the surgery, serum levels of interleukin-6 (IL-6), C-reactive protein (CRP), white blood cell count (WBC), and cortisol (Cor) in the Retroperitoneal group were lower than in the Transperitoneal group (P<0.05). The quality-of-life scores of patients in the Retroperitoneal group were higher (P<0.05), but no statistically significant difference in the incidence of complications between the groups (P>0.05). Conclusions: Compared with the transperitoneal approach, the retroperitoneal method of RAPN is equally safe and is associated with improved perioperative status, lower stress response, and better quality of life for RCC patients. doi: https://doi.org/10.12669/pjms.40.10.10613 How to cite this: Tao M, Cheng K, Xu W, Qian Z, Pan P. Comparison of the effects of transperitoneal and retroperitoneal robot-assisted partial nephrectomy. Pak J Med Sci. 2024;40(10):2202-2207. doi: https://doi.org/10.12669/pjms.40.10.10613 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review and meta-analysis.

Robot-assisted partial nephrectomy (RAPN) can be performed either by a transperitoneal (TP) or a retroperitoneal (RP) approach. However, the superiority of one approach over the other is not established. Hence, the primary aim of this review was to compare perioperative outcomes between these two surgical approaches. Literature was systematically searched to identify studies reporting perioperative outcomes following TP RAPN and RP RAPN. The study protocol was registered with PROSPERO (CRD42023399496). The primary outcome was comparing complication rates between the two approaches. This review included 22 studies, 5675 patients, 2524 in the RP group, and 3151 in the TP group. The overall complications were significantly lower in the RP group [Odds ratio (OR) 0.80 (0.67, 0.95), p = 0.01]. However, the rate of major complications was similar between the two groups. The operative time was significantly shorter with the RP group [Mean Difference (MD)-16.7 (- 22.3, - 11.0), p = < 0.0001]. Estimated blood loss (EBL) and need for blood transfusion (BT) were significantly lower in the RP group. There was no difference between the two groups for conversion to radical nephrectomy [OR 0.66 (0.33, 1.33), p = 0.25] or open surgery [OR 0.68 (0.24, 1.92, p = 0.47] and positive surgical margins [OR 0.93 (0.66, 1.31, p = 0.69]. Length of stay (LOS) was shorter in the RP group [MD - 0.27 (- 0.45, - 0.08), p = < 0.00001]. RP approach, compared to TP, has significantly lower complication rates, EBL, need for BT and LOS. However, due to the lack of randomized studies on the topic, further data is required.

Trans and retroperitoneal robot-assisted partial nephrectomy with HugoTM RAS system: Surgical settings and preliminary results

Trans and retroperitoneal robot-assisted partial nephrectomy with HugoTM RAS system: Surgical settings and preliminary results

A comparison of perioperative outcomes of transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review.

RAPN can be carried out via a transperitoneal or retroperitoneal approach. The choice between the two approaches is open to debate and usually based on surgeon preference. The perioperative outcomes of transperitoneal robot-assisted partial nephrectomy versus retroperitoneal robot-assisted partial nephrectomy were compared. A systematic review of the literature was performed up to May 2020, using PubMed, Cochrane, Scopus and Ovid databases. Articles were selected according to a search strategy based on PRISMA criteria. Only studies comparing TRAPN with RRAPN were eligible for inclusion.Eleven studies were included in the quantitative synthesis. Baseline demographics (age, BMI, ASA, tumour size, and RENAL nephrometry score), intraoperative data (operative time, estimated blood loss, and warm ischaemia time) and postoperative outcomes (major complications according to Clavien-Dindo, length of hospital stay (LOS) and positive surgical margin rate) were recorded. A total of 3139 patients were included (2052 TRAPN vs. 1087 RRAPN).There was no significant difference in demographic variables (age, BMI), tumour size (p = 0.06) nor the nephrometry score (p = 0.20) between the two groups.Operative time(p = 0.02), estimated blood loss (p < 0.00001) and LOS (p < 0.00001) were significantly lower in the RRAPN group. No differences were found in major postoperative complications (Clavien-Dindo > 3; p = 0.37), warm ischaemia time (p = 0.37) or positive surgical margins (p = 0.13). Future researchers must attempt to achieve adequately powered, expertise based, multi-surgeon and multi-centric studies comparing TRAPN and RRAPN. RRAPN gives similar outcomes to TRAPN. RRAPN is associated with reduced operative time and LOS. Ideally, surgeons should be familiar and competent in both RAPN approaches and adopt a risk-stratified and patient-centred individualised approach, dependent on the tumour and patient characteristics. RAPN is feasible via two approaches. The retroperitoneal approach seems to be associated with a shorter operation time and hospital stay.

Long term experience of robotic retroperitoneal partial nephrectomy as the default approach in the management of renal masses: should the paradigm shift?

Although retroperitoneal surgery has demonstrated a better quality of recovery compared to transperitoneal routes, Retroperitoneal Robot Assisted Partial Nephrectomy (RRAPN) remains proportionally infrequent. As the boundaries of what is achievable robotically continue to be pushed, we present our experience at a high-volume tertiary referral centre that specialises in retroperitoneal surgery, exploring its feasibility as standard of care in the management of small renal masses. A prospective database of 784 RAPNs (2009-2020) was reviewed and 721 RRAPNs (92%) were performed at our centre. In our practice, we utilise a four-port approach to RRAPN. Patient, tumour and operative characteristics were assessed and both oncological outcomes and trifecta and pentafecta achievements were determined. Pentafecta was defined as achieving trifecta (negative surgical margin, no post-operative complications and WIT of < 25min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1year. Multivariate analysis was conducted to predict peri-operative factors which may prevent achieving a trifecta/pentafecta outcome. From 784 cases, 112 RAPNs were performed for imperative reasons, whilst the remainder were elective. Mean BMI ± s.d amongst our cohort was 28.6 ± 5.7. Mean tumour size was 3.1cm (range 0.8-10.5cm) and 47% of cases were stratified as intermediate/high risk using R.E.N.A.L nephrometry scoring. Forty-six patients had lesions in a hilar location, and 31% were anterior. Median blood loss was 30mls, with an open conversion rate of 1% and transfusion rate of 1.6%. Median warm ischaemic time (WIT) was 21min, positive surgical margins were found in 4% and our post-operative Clavien 3/ > complication rate was 2.6%. We had a 1-day median length of stay with a 30day readmission rate of 2%. Of 631 patients (80%) with a definitive histological diagnosis of cancer, 23% had T1b/ > disease. Over a mean 15month follow-up period (range 1-125months), 2% of patients developed recurrences and our cohort demonstrated a 99% 5year cancer specific survival. Trifecta was achieved in 67% of cases and pentafecta in 47%. Age (p = 0.05), operative time (p = 0.008), pT1b tumours (p = 0.03), R.E.N.A.L score and blood loss (p = 0.001) were found to statistically significantly influence achievement of trifecta. Pentafecta achievement was influenced by R.E.N.A.L score (p = 0.008), operative time (p = 0.001) and blood loss (p = 0.001). We demonstrate the retroperitoneal approach in RAPN is feasible and safe irrespective of lesion location and complexity. In the hands of high-volume centres that are skilled in the retroperitoneal approach the benefits of retroperitoneal surgery can be extended even to challenging cohorts of patients without compromising their oncological or functional outcomes.

MP68-07 A COMPARISON OF TRANSPERITONEAL AND RETROPERITONEAL APPROACH IN PATIENTS UNDERGOING SINGLE-PORT ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: A REPORT FROM THE SINGLE PORT ADVANCED RESEARCH CONSORTIUM (SPARC)

You have accessJournal of UrologyCME1 Apr 2023MP68-07 A COMPARISON OF TRANSPERITONEAL AND RETROPERITONEAL APPROACH IN PATIENTS UNDERGOING SINGLE-PORT ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: A REPORT FROM THE SINGLE PORT ADVANCED RESEARCH CONSORTIUM (SPARC) Kennedy Okhawere, Jordan Rich, Laura Zuluaga, Indu Saini, Alp Tuna Beksac, Burak Upcinar, Jennifer Nguyen, Ruben C. Sauer, Mutahar Ahmed, Reza Mehrazin, Ronney Abaza, Michael D. Stifelman, Jihad Kaouk, Simone Crivellaro, and Ketan Badani Kennedy OkhawereKennedy Okhawere More articles by this author , Jordan RichJordan Rich More articles by this author , Laura ZuluagaLaura Zuluaga More articles by this author , Indu SainiIndu Saini More articles by this author , Alp Tuna BeksacAlp Tuna Beksac More articles by this author , Burak UpcinarBurak Upcinar More articles by this author , Jennifer NguyenJennifer Nguyen More articles by this author , Ruben C. SauerRuben C. Sauer More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , Reza MehrazinReza Mehrazin More articles by this author , Ronney AbazaRonney Abaza More articles by this author , Michael D. StifelmanMichael D. Stifelman More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , and Ketan BadaniKetan Badani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003331.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Single-Port (SP) robotic-assisted partial nephrectomy (RAPN) has been established as a reasonable alternative to the (MP) multiport platform motivated by the potential to regionalize surgery and decrease morbidity. However, there is a dearth of literature on its efficiency and safety for either the transperitoneal (TP) or retroperitoneal (RP) approach. We sought to compare the perioperative and post-operative outcomes of the TP and RP approach for the SP RAPN. METHODS: Using data from the Single Port Advanced Research Consortium (SPARC) database, we conducted a retrospective analysis of 219 patients who underwent SP RPN for a renal mass between 2019 and 2022 (121 [55.25%] TP, 98 [44.75%] RP). Baseline characteristics, perioperative and postoperative data were compared between both approaches using χ2 test, Fisher exact test, Mann Whitney U test, student’s t test. RESULTS: Of the 148 patients in this study, 76 (51.35%) were male and the mean (SD) age was 60 (11) years. The RP group had a significantly higher proportion of posterior tumors [54 (55.10%), RP vs. 28 (23.14 %%), TP; p<0.001], while other baseline characteristics were comparable between the two approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (18 [SD=9] mins vs. 18 [SD=11] mins, p=0.898), operative time (147[SD=67] mins vs. 146 [SD=70] mins, p=0.925), estimated blood loss EBL (76 ml [SD=100] vs. 98 ml[SD=124], p=0.167), length of stay (1.07 [SD=2.25] day vs. 1.33 [SD=1.05] day, p=0.270), overall complication rate (5 [5.10%] vs 7 [5.79%], and major complication rate (2 [2.04%] vs. 2 [1.65%], p=1.000). No difference was observed in positive surgical margin rate (p=0.472) or delta eGFR (p=0.273). CONCLUSIONS: Trans peritoneal and retroperitoneal SP RAPN yielded similar perioperative and postoperative outcomes. The SP platform is a safe platform to perform transperitoneal and retroperitoneal RAPN. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e955 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kennedy Okhawere More articles by this author Jordan Rich More articles by this author Laura Zuluaga More articles by this author Indu Saini More articles by this author Alp Tuna Beksac More articles by this author Burak Upcinar More articles by this author Jennifer Nguyen More articles by this author Ruben C. Sauer More articles by this author Mutahar Ahmed More articles by this author Reza Mehrazin More articles by this author Ronney Abaza More articles by this author Michael D. Stifelman More articles by this author Jihad Kaouk More articles by this author Simone Crivellaro More articles by this author Ketan Badani More articles by this author Expand All Advertisement PDF downloadLoading ...

V05-11 DEVELOPMENT OF PERFUSED ROBOT-ASSISTED PARTIAL NEPHRECTOMY PROCEDURAL SIMULATION PLATFORM FOR SINGLE PORT, RETROPERITONEAL APPROACHES

You have accessJournal of UrologyCME1 Apr 2023V05-11 DEVELOPMENT OF PERFUSED ROBOT-ASSISTED PARTIAL NEPHRECTOMY PROCEDURAL SIMULATION PLATFORM FOR SINGLE PORT, RETROPERITONEAL APPROACHES Nathan Schuler, Lauren Shepard, Craig Rogers, Riccardo Autorino, Sammy Elsamara, Simone Crivellaro, Jean Joseph, and Ahmed Ghazi Nathan SchulerNathan Schuler More articles by this author , Lauren ShepardLauren Shepard More articles by this author , Craig RogersCraig Rogers More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Sammy ElsamaraSammy Elsamara More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , Jean JosephJean Joseph More articles by this author , and Ahmed GhaziAhmed Ghazi More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retroperitoneal robot assisted partial nephrectomy (RAPN) has shown restricted diffusion, limited to experienced surgeons at select institutions]. However, the recent introduction of the da Vinci single port (SP) surgical platform for RAPN with its slender profile is ideal for navigating narrow spaces. We have previously developed and validated a realistic, perfused hydrogel platform for transperitoneal RAPN robotic surgery as an adequate training tool. Our objective was to develop a similar platform using the same methodology. METHODS: A contoured box was designed to replicate the intraabdominal space surrounding the kidney, emphasizing realistic responses to initial incisions, balloon dilatation, and robot docking, then subsequently 3D printed. Patient-specific renal tissue phantoms and supporting structures were created using previously validated methods. Previous work with tensile testing on PVA hydrogels validated their ability to mimic the physical properties of renal tissue. The phantom was wrapped in a simulated Gerota’s Fascia, attached to a PVA “muscle” sheet, and connected to a hydrogel AA and IVC. The completed model was fixed to the inner contour of the 3D printed body cavity section, which was then covered with a hydrogel abdominal wall with a simulated peritoneal pouch, containing simulated bowels. Experts at the University of Rochester, Cleveland clinic and Henry ford hospitals tested the model during scheduled simulation events. 6 experts with >50 case experience in Single port robotic surgery and >1000 multiport robotic cases completed a survey to evaluate the realism and educational effectiveness of this model. RESULTS: Respondents completed surveys on the novelty and effectiveness of the platform. Agreement on simulator novelty was unanimously positive (100% agree or better) (Figure 1a). Performance evaluations reached a minimum of 80% agreement for all categories, with 100% of feedback rated as neutral or better. (Figure 1b). CONCLUSIONS: This realistic simulation procedural platform for robot assisted single port retroperitoneal renal surgery provides a suitable training medium for training and experienced urologists to improve the skills required to adopt this approach. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e427 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nathan Schuler More articles by this author Lauren Shepard More articles by this author Craig Rogers More articles by this author Riccardo Autorino More articles by this author Sammy Elsamara More articles by this author Simone Crivellaro More articles by this author Jean Joseph More articles by this author Ahmed Ghazi More articles by this author Expand All Advertisement PDF downloadLoading ...

Higher risk of intraoperative bleeding in right-sided renal tumors compared to left-sided tumors in robot-assisted partial nephrectomy.

To compare intraoperative blood loss in robot-assisted partial nephrectomy (RAPN) between the right and left sides. The data of patients who underwent RAPN at a single institution between 2013 and 2021 were retrospectively analyzed. Using propensity score matching, we compared estimated blood loss (EBL) between right- and left-sided tumors. This study included 1006 patients who underwent transperitoneal RAPN (N=726) and retroperitoneal RAPN (N=280). Through matching, 303 patients were selected for each group. The mean tumor size was 3.1 ± 1.4cm. The RENAL score was 4-6 in 270 (44.5%), 7-9 in 263 (43.3%), and 10-11 in 73 (12.0%) cases. The EBL on the right side was significantly higher than on the left side (102 vs 70 mL, P=.02). The most experienced surgeon showed significant differences in EBL (116 vs 73 mL, P=.024) and blood transfusion rate (2.5 vs 0%, P=0.025) between the right and left sides. In the retroperitoneal RAPN, 104 patients were selected in each group through matching. The EBL was significantly higher on the right side than on the left side (50 vs 24 mL, P=0.02). Operative time was longer on the right side than on the left side (120 vs 109 min, P=.05). Right-sided tumors had a significantly larger EBL than left-sided tumors in RAPN. The difference was evident in the most experienced surgeon who performed RAPN for larger and complicated cases. This information may help surgeons decide whether to clamp the renal artery and vein during tumor resection in large and complicated right-sided tumors.

Multi-institutional feasibility and safety outcomes of retroperitoneal robot-assisted partial nephrectomy in morbidly obese patients.

Robotic-assisted partial nephrectomy (RAPN) is an established treatment modality for small renal masses. While retroperitoneal RAPN (rRAPN) has the benefit of avoiding the peritoneal cavity and provides more direct access to the renal hilum and posterior kidney, there is concern about the feasibility of rRAPN particularly in morbidly obese [body mass index (BMI) ≥40 kg/m2] patients. We present a large scale multi-institutional study on the outcomes of rRAPN in morbidly obese patients. A retrospective review of a cohort of morbidly obese patients who underwent rRAPN at two academic institutions was performed. Patient characteristics, operative data, and postoperative complication rates were assessed. A total of 22 morbidly obese patients were included for analysis, with a median follow-up duration of 52 months. Median patient age was 61 years and median BMI was 44.9 kg/m2. Based on nephrometry score, 55% of the masses had low complexity and 32% had intermediate complexity. Median operative time was 186.0 minutes and median warm ischemia time was 23.5 minutes. Median postoperative length of stay was 2 days, and only one patient experienced a high-grade complication within 30 days of surgery. rRAPN in select morbidly obese patients appears to have acceptable operative and postoperative outcomes. Further studies and follow-up are needed to better generalization and understand long-term impacts.

Comparison of perioperative outcomes following transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a propensity-matched analysis of VCQI database.

To compare perioperative outcomes following retroperitoneal robot-assisted partial nephrectomy (RPRAPN) and transperitoneal robot-assisted partial nephrectomy (TPRAPN). With this Vattikuti Collective Quality Initiative (VCQI) database, study propensity scores were calculated according to the surgical access (TPRAPN and RPRAPN) for the following independent variables, i.e., age, sex, side of the surgery, RENAL nephrometry scores (RNS), estimated glomerular filtration rate (eGFR) and serum creatinine. The study's primary outcome was the comparison of trifecta between the two groups. In this study, 309 patients who underwent RPRAPN were matched with 309 patients who underwent TPRAPN. The two groups matched well for age, sex, tumor side, polar location of the tumor, RNS, preoperative creatinine and eGFR. Operative time and warm ischemia time were significantly shorter with RPRAPN. Intraoperative blood loss and need for blood transfusion were lower with RPRAPN. There was a significantly higher number of intraoperative complications with RPRAPN. However, there was no difference in the two groups for postoperative complications. Trifecta outcomes were better with RPRAPN (70.2% vs. 53%, p < 0.0001) compared to TPRAPN. We noted no significant change in overall results when controlled for tumor location (anteriorly or posteriorly). The surgical approach, tumor size and RNS were identified as independent predictors of trifecta on multivariate analysis. RPRAPN is associated with superior perioperative outcomes in well-selected patients compared to TPRAPN. However, the data for the retroperitoneal approach were contributed by a few centers with greater experience with this technique, thus limiting the generalizability of the results of this study.

The application of internal traction technique in retroperitoneal robot-assisted partial nephrectomy for renal ventral tumors

BackgroundFor patients with prior intra-abdominal surgery or multiple arteries, the retroperitoneal robot-assisted partial nephrectomy (rRAPN) is a better choice. The renal ventral tumor poses an additional challenge due to poor tumor exposure. This study is determined to assess the feasibility of an internal traction technique (ITT) in rRAPN for the management of renal ventral tumors.MethodsFrom November 2019 to March 2021, a total of 28 patients with renal ventral tumor underwent rRAPN. All patients had prior abdominal surgery or multiple arteries. The ITT group (20 patients), which improved the tumor exposure by traction of the kidney with suture, was compared with the traditional technique group (8 patients) in terms of warm ischemia time, estimated blood loss and postoperative hospital stay, retroperitoneal drainage, R.E.N.A.L. score, and serum creatinine. Differences were considered significant when P < 0.05.ResultsAll rRAPN surgeries were successful without conversion to radical nephrectomy or open partial nephrectomy. The warm ischemia time was lower in the ITT group (17.10 min vs. 24.63 min; P < 0.05). Estimated blood loss in the traditional technique group was 324.88 ± 79.42 mL, and in the ITT group, it was 117.45±35.25 mL (P < 0.05). No significant differences with regard to postoperative hospital stay, retroperitoneal drainage, R.E.N.A.L. score, and serum creatinine were observed between both groups. Surgical margins were negative and no intraoperative complications occurred in all the patients. After 10 months of follow-up, no recurrence or metastasis occurred in all cases.ConclusionITT is a feasible, safe, and valid procedure in rRAPN for renal ventral tumors. Application of ITT improved the exposure and reduces warm ischemic time in comparison with the conventional procedure.

Renal Functional and Perioperative Outcomes of Retroperitoneal Robot-Assisted Versus Laparoscopic Partial Nephrectomy with Segmental Renal Artery Clamping.

Background: Retroperitoneal approach and segmental renal artery clamping in partial nephrectomy are techniques that facilitate postoperative recovery and renal function preservation. This study aimed to compare the renal function preservation and perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) with these techniques. Materials and Methods: Clinical parameters of 43 patients who had undergone retroperitoneal RAPN from March 2017 to December 2019 were retrospectively collected and compared with those of 52 patients who had undergone retroperitoneal LPN at the same period in our institution. Differences in operating time, warm ischemia time, estimated blood loss, complications, postoperative hospital stay, as well as renal function loss were compared between the two groups. Results: Background characteristics between RAPN and LPN groups such as age, gender, BMI, and tumor characteristics were comparable. All RAPNs and LPNs were successfully completed without conversion to open surgery or nephrectomy. No significant difference in operating time, estimated blood loss, complications, and postoperative hospital stay was observed between RAPN and LPN groups. The warm ischemia time in RAPN group was slightly shorter than that of LPN groups (P = .054). Compared with the LPN group, the RAPN group was significantly associated with less glomerular filtration rate reduction and renal volume loss rate (P = .042 and P = .013, respectively). Conclusions: The perioperative outcomes were comparable between the two groups. However, compared with LPN, RAPN had superiority in preserving renal function in our series.

PD12-06 RETROPERITONEAL VS. TRANSPERITONEAL ROBOTIC PARTIAL NEPHRECTOMY FOR POSTERO-LATERAL RENAL MASSES: AN INTERNATIONAL MULTICENTER ANALYSIS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy I (PD12)1 Sep 2021PD12-06 RETROPERITONEAL VS. TRANSPERITONEAL ROBOTIC PARTIAL NEPHRECTOMY FOR POSTERO-LATERAL RENAL MASSES: AN INTERNATIONAL MULTICENTER ANALYSIS Umberto Carbonara, Umberto Capitanio, Daniel Eun, Ithaar Derweesh, Alessandro Larcher, Fabio Crocerossa, Lance Hampton, Francesco Montorsi, Francesco Porpiglia, and Riccardo Autorino Umberto CarbonaraUmberto Carbonara More articles by this author , Umberto CapitanioUmberto Capitanio More articles by this author , Daniel EunDaniel Eun More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Fabio CrocerossaFabio Crocerossa More articles by this author , Lance HamptonLance Hampton More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Francesco PorpigliaFrancesco Porpiglia More articles by this author , and Riccardo AutorinoRiccardo Autorino More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001987.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the last ten years, robot-assisted partial nephrectomy (RAPN) has rapidly become the preferred minimally invasive surgical treatment for localized renal tumors. Historically, RAPN has been preferably performed with a transperitoneal approach. Nevertheless, retroperitoneal RAPN (r-RAPN) represents an attractive alternative, especially for posterior or lateral renal masses as it allows immediate access to the kidney, minimizing the risk of ileus and/or potential complications related to bowel mobilization, and avoiding intraabdominal adhesions in patients with previous abdominal surgery. The aim of the present abstract was to assess the outcomes of r-RAPN in a large cohort of patients with postero-lateral renal masses comparing these results versus those of t-RAPN. METHODS: Patients with posterior (R.E.N.A.L. score grading P) or lateral (grading X) renal mass who underwent RAPN in six high-volume US and European centers were identified and stratified into two groups according to surgical approach: r-RAPN (“study group”) and t-RAPN (“control group”). Baseline characteristics, intraoperative, and postoperative data were collected and compared. When normally distributed, mean ± standard deviation (SD) was used. Instead, median and interquartile range (IQR) was adopted to report not-normal distribution data. Frequency (%) was used in categorical data. t-test or Kruskal-Wallis H test was applied to compare the differences in the distribution of continuous variables. For categorical variables, the Pearson Chi-Squared or Fishers’ exact test was used to test the differences. RESULTS: Overall, 447 patients were identified for the analysis. 231 (51.7%) and 216 (48.3%) patients underwent r-RAPN and t-RAPN, respectively. Baseline characteristics were not statistically significantly different between the groups. r-RAPN group reported lower median operative time (140 vs. 170min, p <0.001). No difference was found in ischemia time, estimated blood loss, and intraoperative complications. Overall, 47 and 54 postoperative complications were observed in r-RAPN and t-RAPN groups, respectively (20.3 vs. 25.1%, p=0.9). 1 and 2 patients reported major complications (Clavien-Dindo ≥III grade) in the retroperitoneal and transperitoneal groups (0.4 vs. 0.9%, p=0.9). There was no difference in hospital readmission rate (2.5 vs. 3, p=0.2), median length of stay (2 vs. 2days, p=0.7), and PSM rate (3 vs. 2.5%, p=0.2) between r-RAPN and t-RAPN groups. Trifecta criteria were achieved in 90.3 and 89.2% of r-RAPN and t-RAPN, respectively (p=0.7). CONCLUSIONS: r-RAPN and t-RAPN offer similar postoperative, functional, and oncological outcomes for patients with posterior-later located renal tumor. Our analysis suggests an advantage for r-RAPN in terms of shorter operative time, whereas it does not confirm a difference in terms of length of stay, as suggested by previous reports. Source of Funding: No funding © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e205-e205 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Umberto Carbonara More articles by this author Umberto Capitanio More articles by this author Daniel Eun More articles by this author Ithaar Derweesh More articles by this author Alessandro Larcher More articles by this author Fabio Crocerossa More articles by this author Lance Hampton More articles by this author Francesco Montorsi More articles by this author Francesco Porpiglia More articles by this author Riccardo Autorino More articles by this author Expand All Advertisement Loading ...

Retroperitoneal Robot-Assisted Partial Nephrectomy (rRAPN): Surgical Technique and Review.

We aim to offer a description of the surgical technique and to review the current state retroperitoneal robot-assisted partial nephrectomy (rRAPN). Partial nephrectomy is the standard treatment for localized kidney tumours. rRAPN is especially useful for kidney tumours of posterior location. It offers advantages such as direct access to the renal artery and no need for bowel mobilization. The disadvantages are the small working space and the less familiar anatomical landmarks. It is a reproducible technique that achieves similar oncological and functional results to the more traditional transperitoneal route (tRAPN). High-quality randomized studies are needed to ascertain the role of new technologies as modern high-flow insufflation systems, intracavitary ultrasound, 3D planning, and augmented reality (AR), in the performance of this operation. rRAPN is especially useful for kidney tumours of posterior location. Robotic surgeons ideally should become familiar with both approaches, transperitoneal or retroperitoneal.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy.

To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN). Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677). This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

How to improve outcome in nephron-sparing surgery: the impact of new techniques.

Nephron-sparing partial nephrectomy is the state of the art for localized small renal mass and it is gaining attention also for more advanced cases. In the present narrative review, we discuss the new developments that have occurred in the advancement of this approach over the past few years. Off-clamp, selective/superselective clamp and early-unclamping techniques are safe and feasible approaches, with potentially superior functional outcomes, and noninferior complications rate and oncological outcomes, when compared with main artery clamping. Renorrhaphy must preserve the physiological vascularization of residual parenchyma. Running sutures, particularly using barbed wires, shorten the operating and ischemia times. A further advantage could derive from avoiding a double-layer suture. Transperitoneal robot-assisted partial nephrectomy (RAPN) and retroperitoneal RAPN can be considered equivalent in terms of perioperative morbidity, functional and oncologic outcomes, regardless of tumor's location, thus the choice of the approach should be driven by the surgeon's expertise. Future improvements should be introduced by the single-port robotic surgery, which seems to be safe and feasibly also in an off-clamp manner. Significant advances have recently been achieved in nephron-sparing surgery technique. However, future studies with standardized reporting of these new techniques are needed to assess the real impact of them on early and long-term functional outcomes.

Retroperitoneal robot-assisted laparoscopic partial nephrectomy for posterior located renal tumours: Technique and early term outcomes.

Traditionally, the trans-peritoneal approach is preferred for robot-assisted partial nephrectomy (RPN). However, retroperitoneal RPN (RP-RPN) has recently become widespread because of the advantages of easier access to the hilum, ease dissection of posterior tumours, and lower probability of intra-peritoneal organ injury. We aimed to present our initial experience of the RP-RPN series in posteriorly located renal tumours. Twenty-one patients were included in the study, who underwent RP-RPN by a single surgeon between July 2019 and January 2020. RP-RPN was carried out only in posteriorly located renal tumours with ischemic (on-clamp) or zero ischemic (off-clamp) techniques. Patients with solitary kidney and a history of previous retroperitoneal surgery in the lumbodorsal region were excluded from the study. All cases completed without any operative complication and conversion to open or radical nephrectomy. Seven cases were completed as zero ischemic and 14 cases as ischemic technique. The mean operation time was 157.86±64.24minutes and estimated blood loss was 173.81±136.84mL. The mean warm ischemia time was 15.81±12.42minutes. Positive surgical margin observed in 4.8% of the patients. The mean length of stay was 3.33±0.79days. The mean estimated glomerular filtration rate (eGFR) change in the 3rd postoperative month was -3.71±8.57ml/min/1.73m2 (4.6%). Mean follow-up period was 10.29±4.86months. New-onset stage 3-4 chronic kidney disease (eGFR<60m/min/1.73m2 ) was not observed during the follow-up period. RP-RPN is a safe and feasible approach with acceptable oncological and functional results. We think that RP-RPN can be applied as an alternative to the trans-peritoneal approach for selected cases, especially in renal tumours with the posterior location.

Kidney ventrally rotation technique in retroperitoneal robot-assisted partial nephrectomy for posterior hilar tumor: technical feasibility and preliminary results

PurposeThe retroperitoneal robotic assisted partial nephrectomy (RAPN) is suitable for tumors locating on the posterior side of the kidney. However, the posterior hilar tumor poses an additional surgical challenge due to the special location and poor tumor exposure. We developed a novel kidney ventrally rotation technique to overcome this difficulty during retroperitoneal RAPN and evaluated its efficacy in a retrospective case-control comparative study.MethodsFrom March 2016 to April 2019, a total of 39 patients with posterior renal hilar tumor underwent retroperitoneal RAPN. The kidney ventrally rotation technique, which improved the tumor exposure by opening the peritoneum and rotating the kidney ventrally, was applied in 24 cases, and the conventional RAPN was performed in the other 15 cases (control group). Perioperative data was analyzed to evaluate the efficacy of the kidney ventrally rotation technique.ResultsIn kidney rotation group, the 24 patients underwent RAPN successfully without converting to open surgery or radical nephrectomy. The warm ischemia time was 17.4 ± 6.6 min, which was significantly shorter than 24.5 ± 8.3 min in control group. The mean operation time (80 ± 24 min) and estimated blood loss (104 ± 65 ml) were not different from the control group. No sever complications occurred, and no positive surgical margin was found in all the malignant cases. After 14 months follow-up, no recurrence or metastasis occurred in all cases.ConclusionKidney ventrally rotation technique is safe and feasible for improving the exposure of posterior renal hilar tumor during retroperitoneal RAPN. It could be regarded as an efficient option for the management of posterior hilar tumor.

Retroperitoneal Robot-Assisted Partial Nephrectomy in Obese Patients.

Objectives: To report our experience with retroperitoneal robotic-assisted partial nephrectomy (RAPN) in obese patients. Patients and Methods: From April 2012 to December 2018, 127 patients with body mass index (BMI) ≥30 kg/m2 underwent RAPN, of whom 110 patients had retroperitoneal RAPN. We reviewed the patients' demographic, operative data, perioperative and postoperative complications, and postoperative histology. Results: The median BMI was 33.1 kg/m2 (interquartile range [IQR] 31.5-36.6). The median age of the patients was 59 years. The mean histological size of tumor was 32.2 mm (IQR 23.8-40). The median total surgical time was 130 minutes (IQR 110-176) with a median warm ischemia time of 22.0 minutes. The tumor was located anteriorly in 25% of the cases. The median R.E.N.A.L.* nephrometry score was 6. The median estimated blood loss was 30 mL (IQR 10-80). Three cases were converted to open partial nephrectomy because of bleeding (2.7%). Four patients and one patient returned within 30 days with postoperative complications Clavien-Dindo classification grade 2 and 3a, respectively. Two patients needed perioperative blood transfusion because of bleeding. The median length of stay was 1 day (IQR 1-2). Conclusion: Retroperitoneal RAPN is feasible in patients with high BMI and provides good surgical access to treat nonanterior renal masses. Retroperitoneal RAPN is associated with less blood loss, shorter surgical time, and warm ischemia time when compared with transperitoneal RAPN studies.

Trans-peritoneal vs. retroperitoneal robotic assisted partial nephrectomy in posterior renal tumours: need for a risk-stratified patient individualised approach. A systematic review and meta-analysis.

To systematically review world literature and compare peri-operative outcome including operating time (OT), estimated blood loss (EBL), warm ischemia time (WIT), length of stay (LOS) and complications between retroperitoneal robotic assisted partial nephrectomy (RP-RAPN) and trans-peritoneal robotic assisted partial nephrectomy (TP-RAPN) for posteriorly located renal masses. All randomised trials and observational studies comparing RP-RAPN and TP-RAPN for posteriorly located renal masses were considered. The GRADE approach (Grading of Recommendations Assessment, Development and Evaluation, GRADE) was used to rate the quality of evidence. 82 potential publications were identified. 3 were included in the review. All three studies were observational comparative studies. 347 and 550 patients underwent RP-RAPN and TP-RAPN, respectively, for posteriorly located tumours. There was statistically significant difference in LOS between the 2 techniques, favouring the RP-RAPN cohort: risk ratio (M-H, random, 95% CI), - 0.42 [- 0.67, - 0.18], p < 0.0006. There was no statistically significant difference in overall complication rates between the two techniques: risk ratio (M-H, fixed, 95% CI), 0.80 [0.49, 1.30], p = 0.37. There was no statistically significant difference in ≥ Clavien 3a complication rates between the two t echniques: risk ratio (M-H, fixed, 95% CI), 1.17 [0.62, 2.19], p = 0.63. OT, EBL, WIT and positive margin rates were similar for both approaches. The quality of evidence for complications, LOS and remaining outcomes were 'moderate', 'low' and 'very low', respectively, on GRADE approach. The current review suggests that the LOS with RP-RAPN are significantly lesser than TP-RAPN for posterior tumours. The RP-RAPN does not appear to offer any advantage over TP-RAPN for other peri-operative outcomes such as WIT, OT and EBL. The surgical margin rates and morbidity between the two approaches appear to be similar.