Robot-assisted Partial Nephrectomy In Patients Research Articles

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.

Comparison of surgical, functional, and oncological outcomes of open and robot-assisted partial nephrectomy.

BACKGROUND:We aimed to compare the surgical, oncological, and functional outcomes of robot-assisted partial nephrectomy (RAPN) with open partial nephrectomy (OPN) in the management of small renal masses.MATERIALS AND METHODS:Between 2009 and 2013, a total of 46 RAPN patients and 20 OPN patients was included in this study. Patients’ demographics, mean operative time, estimated blood loss (EBL), warm ischemia time (WIT), length of hospital stay, pre- and post-operative renal functions, complications and oncological outcomes were recorded, prospectively.RESULTS:Mean tumor size was 4.04 cm in OPN group and 3.56 cm in RAPN group (P = 0.27). Mean R.E.N.A.L nephrometry score was 6.35 in OPN group and 5.35 in RAPN group (P = 0.02). The mean operative time was 152 min in OPN group and 225 min in RAPN group (P = 0.006). The mean EBL in OPN and RAPN groups were 417 ml and 268 ml, respectively (P = 0.001). WIT in OPN group was significantly shorter than RAPN group (18.02 min vs. 23.33 min, P = 0.003). The mean drain removal time and the length of hospital stay were longer in OPN group. There were no significant differences in terms of renal functional outcomes and postoperative complications between groups.CONCLUSION:Minimally invasive surgical management of renal masses with RAPN offers better outcomes in terms of EBL and length of stay. However, the mean operative time and WIT were significantly shorter in OPN group. RAPN is a safe and effective minimally invasive alternative to OPN in terms of oncological and functional outcomes.

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We appreciate this thoughtful commentary and agree that estimated glomerular filtration rate (eGFR) does not represent a perfect metric to evaluate any clinical benefits attributable to integration of fluorescence-enhanced selective clamping into robotic partial nephrectomy. However, certain points should be considered before using this as a basis to conclude that the results presented here are without meaning. First, although our patient population does indeed display a wide range of postoperative eGFR and includes some with paradoxical eGFR increases (in both control and selective clamp cohorts), such a distribution is consistent with literature values from a number of prior large and multi-institutional studies. 1 Scoll B.J. Uzzo R.G. Chen D.Y. et al. Robot-assisted partial nephrectomy: a large single-institutional experience. Urology. 2010; 75: 1328-1334 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar , 2 Patel M.N. Krane L.S. Bhandari A. et al. Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol. 2010; 57: 310-316 Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar , 3 Kumar R.K. Sammon J.D. Kaczmarek B.F. et al. Robot-assisted partial nephrectomy in patients with baseline chronic kidney disease: a multi-institutional propensity score-matched analysis. Eur Urol. 2014; 65: 1205-1210 Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Second, although eGFR is certainly sensitive to the multitude of factors identified by the commentators, these would need to have preferentially affected eGFR in 1 of the 2 groups for a detection bias to be introduced. In the absence of any such evidence, one would assume that eGFR variability affected both the control and selective clamp cohorts in a similar manner. Lastly, we agree that future analyses of this technique in the present and other populations would benefit by integrating degree of parenchyma sparing, as well as additional patient or tumor characteristics, outcome metrics, and longer follow-up. Such work could further delineate the contribution of minimized ischemia vs parenchymal volume sparing in ultimate renal function, while perhaps providing additional guidance on indications for this and other approaches to partial nephrectomy. In the interim, however, we believe that the results presented here serve as promising evidence of successful intraoperative minimization of ischemic kidney injury. Editorial CommentUrologyVol. 84Issue 2PreviewThe authors have published excellent results with the use of near-infrared imaging (NIRF) and selective clamp robotic partial nephrectomy. We use NIRF, as the authors do, to facilitate selective clamping and believe the technology to be highly predictable for renal perfusion. However, one may speculate that there may be an unrecognized error in the quantified renal functional benefits. Full-Text PDF

MP54-07 ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS WITH BASELINE CHRONIC KIDNEY DISEASE: A MULTICENTER PROPENSITY SCORE MATCHED ANALYSIS

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 2014MP54-07 ROBOTIC PARTIAL NEPHRECTOMY IN PATIENTS WITH BASELINE CHRONIC KIDNEY DISEASE: A MULTICENTER PROPENSITY SCORE MATCHED ANALYSIS Ramesh Kumar, Jesse Sammon, Jihad Kaouk, Sam Bhayani, Michael Stifelman, Mohamad Allaf, Bartosz Kaczmarek, Ali Khalifeh, Michael Gorin, Ganesh Sivarajan, Youssef Tanagho, and Craig Rogers Ramesh KumarRamesh Kumar More articles by this author , Jesse SammonJesse Sammon More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Sam BhayaniSam Bhayani More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , Mohamad AllafMohamad Allaf More articles by this author , Bartosz KaczmarekBartosz Kaczmarek More articles by this author , Ali KhalifehAli Khalifeh More articles by this author , Michael GorinMichael Gorin More articles by this author , Ganesh SivarajanGanesh Sivarajan More articles by this author , Youssef TanaghoYoussef Tanagho More articles by this author , and Craig RogersCraig Rogers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1596AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for preservation of renal function. We evaluate functional outcomes of RPN in patients with baseline CKD relative to patients undergoing RPN without baseline CKD. Methods A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007-2012 were identified. A total of 172 patients who underwent RPN with pre-existing CKD (estimated glomerular filtration rate [eGFR] 15-60 ml/min) were identified. Perioperative results of 121 patients were compared against propensity score matched controls without CKD (eGFR ≥ 60 ml/min). The propensity score matching considered the following variables: age, gender, race, BMI, ASA, CCI, ischemia time, multiple tumors, solitary kidney, tumor size and R.E.N.A.L. nephrometry score. Results After propensity score matching, patients with baseline CKD had a lower percent eGFR decrease at first follow-up (-5.1 vs. -10.9) that remained significant at a mean follow-up of 12.6 months (-2.8 vs. -9.1, p<0.05) and had less CKD upstaging (11.8% vs. 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs. 56.2%, p=0.006) and had a higher overall rate of surgical complications (21.5 vs. 10.7%, p=0.007). Conclusions RPN in patients with baseline CKD is associated with a smaller decrease in renal function and less CKD upstaging compared to patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e574 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Ramesh Kumar More articles by this author Jesse Sammon More articles by this author Jihad Kaouk More articles by this author Sam Bhayani More articles by this author Michael Stifelman More articles by this author Mohamad Allaf More articles by this author Bartosz Kaczmarek More articles by this author Ali Khalifeh More articles by this author Michael Gorin More articles by this author Ganesh Sivarajan More articles by this author Youssef Tanagho More articles by this author Craig Rogers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot-assisted Partial Nephrectomy in Patients with Baseline Chronic Kidney Disease: A Multi-institutional Propensity Score–Matched Analysis

BackgroundRobot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function. ObjectiveTo evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD. Design, setting, and participantsA total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15–60ml/min per 1.73 m2) were identified. Perioperative results of 121 patients were compared against propensity score–matched controls without CKD (eGFR ≥60ml/min per 1.73 m2). InterventionRPN in patients with or without baseline CKD. Outcome measurements and statistical analysisDescriptive statistics and propensity score–matched operative and functional outcomes. Results and limitationsAfter propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (−5.1 vs −10.9), which remained significant at a mean follow-up of 12.6 mo (−2.8 vs −9.1, p<0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p=0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p=0.007). The retrospective analysis was the main limitation of this study. ConclusionsRPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay.

A Comparison of Surgical and Functional Outcomes of Robot-Assisted Versus Pure Laparoscopic Partial Nephrectomy

Robot-assisted partial nephrectomy (RAPN) is emerging as an alternative to laparoscopic partial nephrectomy (LPN) for the treatment of small renal tumors. We compare the results of LPN and RAPN performed by a single surgeon. Data from 100 consecutive patients who underwent LPN (n=52) or RAPN (n=48) performed by a single experienced laparoscopic surgeon between October 2007 and June 2010 were analyzed retrospectively. Perioperative data, including clinical, pathological, and functional outcomes, were compared between the LPN and RAPN groups. No significant differences were found between groups with regard to mean estimated blood loss, main operation time, warm ischemic time, intraoperative complications, postoperative complications, hospital stay, or percent reduction of hemoglobin. The mean duration of follow-up was 16.2 months for LPN patients versus 8.9 months for RAPN patients (P<.001). With respect to the clamping method, more artery-only clamping occurred during RAPN than LPN (38.5 vs 75%, respectively, P=.001). The mean pathological tumor volume for LPN was 4.0 cm(3) vs 8.2 cm(3) for RAPN (P=.006). The mean resected healthy tissue volume was 25.1 cm(3) for LPN versus 16.1 cm(3) for RAPN (P=.044). There were no significant differences in positive margins or changes in renal function between the 2 cohorts. RAPN is a comparable and alternative option to LPN, providing equivalent oncological and functional outcomes, as well as comparable morbidity to LPN. Although RAPN could offer the advantages of saving more healthy marginal tissue, longer-term and larger studies are necessary to evaluate the functional advantages.

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.

V405 ENUCLEATION TECHNIQUES FOR CHALLENGING ROBOT-ASSISTED PARTIAL NEPHRECTOMY CASES

You have accessJournal of UrologyRenal & Ureter Oncology1 Apr 2012V405 ENUCLEATION TECHNIQUES FOR CHALLENGING ROBOT-ASSISTED PARTIAL NEPHRECTOMY CASES Quoc-Dien Trinh, Wooju Jeong, Khurshid R. Ghani, Jay Jhaveri, Jesse D. Sammon, Shyam Sukumar, Michael Ehlert, Fred Muhletaler, Mani Menon, and Craig G. Rogers Quoc-Dien TrinhQuoc-Dien Trinh Detroit, MI More articles by this author , Wooju JeongWooju Jeong Detroit, MI More articles by this author , Khurshid R. GhaniKhurshid R. Ghani Detroit, MI More articles by this author , Jay JhaveriJay Jhaveri Detroit, MI More articles by this author , Jesse D. SammonJesse D. Sammon Detroit, MI More articles by this author , Shyam SukumarShyam Sukumar Detroit, MI More articles by this author , Michael EhlertMichael Ehlert Detroit, MI More articles by this author , Fred MuhletalerFred Muhletaler Detroit, MI More articles by this author , Mani MenonMani Menon Detroit, MI More articles by this author , and Craig G. RogersCraig G. Rogers Detroit, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.470AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy remains a standard management option for T1 tumors, according to the 2009 AUA guidelines. Robot-assisted partial nephrectomy (RAPN) has been described for complex cases, namely hilar, T1b and endophytic tumors, as well as solitary kidneys. Enucleation has been described for select cases of partial nephrectomy to preserve renal function with good oncological control. In this video, we describe tips to minimize warm ischemia time and parenchymal loss during robot-assisted partial nephrectomy in patients with renal insufficiency and complex tumors, including enucleation and selective ligation. METHODS Between August 2007 and September 2010, 22 patients with stage III chronic kidney disease (eGFR<60) underwent RAPN. Perioperative outcomes were evaluated. Enucleation and selective ligation techniques were utilized when indicated to allow for off-clamp resection or early unclamping. RESULTS Mean preoperative eGFR was 51 and mean age was 65.4 years. Moreover, mean BMI was 32 Kg/m2 and mean tumor size was 3.0 cm. Perioperative outcomes were as follows: mean warm ischemia time 14.4 min; mean OR time 237 min; mean estimated blood loss 172 ml and mean length of stay 2.4 days. A total of 26 tumors were removed, with either hilar clamping (16) or no clamping (10). Two patients had a solitary kidney and two patients underwent enucleation. Early unclamping was done in one patient after running the inner layer with a barbed suture. Mean percent decrease in postoperative eGFR was 9% at 1 month and 5% at last follow-up. Patients were followed up to 19.3 months (mean 5.7). There was one positive margin from tumor enucleation in a solitary kidney. There was no recurrence at up to 19.3 months follow-up. CONCLUSIONS As demonstrated by the two cases presented in this video, enucleation and selective ligation techniques during RAPN are feasible and may be used to minimize ischemic damage in patients at risk for renal insufficiency. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e165-e166 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Quoc-Dien Trinh Detroit, MI More articles by this author Wooju Jeong Detroit, MI More articles by this author Khurshid R. Ghani Detroit, MI More articles by this author Jay Jhaveri Detroit, MI More articles by this author Jesse D. Sammon Detroit, MI More articles by this author Shyam Sukumar Detroit, MI More articles by this author Michael Ehlert Detroit, MI More articles by this author Fred Muhletaler Detroit, MI More articles by this author Mani Menon Detroit, MI More articles by this author Craig G. Rogers Detroit, MI More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Cost comparison of laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy.

402 Background: Although nephron-sparing surgery is the standard of care for the treatment of small renal masses, partial nephrectomy (PN) remains under-utilized. A potential reason for the discrepancy is the desire for minimally invasive surgical approaches but limitation of the advanced laparoscopic techniques needed to perform PN. Robot-assisted surgery has eased the transition to minimally invasive prostate surgery and may also do so for PN, although some believe costs may be prohibitive. The purpose of this investigation was to quantify the cost of robot-assisted PN (RAPN) compared to laparoscopic PN (LPN). Methods: An institutional renal tumor database was used to identify consecutive patients with normal renal function who underwent RAPN for a localized renal mass by a single surgeon who had performed &lt; 25 previously. The 35 RAPN patients were compared to the last 35 similar patients who underwent LPN by a surgeon who had performed &gt; 150 previous LPNs. Surgical outcomes were compared. Because room time, length of stay and Cxs were similar, cost was compared based only on the total operating room charges (ORC). Total ORC included surgeon and anesthesia fees, as well as labor and supply costs. The depreciation of the robot was included in the ORC as a higher per unit time charge than for LPN. Data on charges were available for the first 29 RAPN patients which were then compared to the last 29 LPN patients. Results: Dates of operation ranged from October 2008 to July 2009 for LPN and January 2010 to August 2010 for RAPN. Patient and tumor characteristics were similar between groups, except tumor size, which was larger in the RAPN group (3.6 ± 1.8 cm vs. 2.7 ± 0.9 cm, p = 0.007). Cxs, surgical and oncologic outcomes were similar. Mean ORC (IQR) for the LPN group was $28,606 (4,796) and for the RAPN group was $30,874 (20,389) representing a difference of $2,269. If you subtract an additional $858 for the average yearly inflation rate (3%), the difference is $1,411. Conclusions: RAPN is a safe option with perioperative outcomes similar to those of LPN performed by an experienced surgeon. A cost difference of $2,269 per procedure as estimated using ORC may decrease as the experience of the operating room staff and surgeon increase. No significant financial relationships to disclose.