Transperitoneal Robot-assisted Partial Nephrectomy Research Articles

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.

Impact of Visceral Fat Area on Intraoperative Complexity and Surgical Approach Decision for Robot-Assisted Partial Nephrectomy: A Comparative Analysis with BMI.

BACKGROUND Optimizing surgical approaches for robot-assisted partial nephrectomy (RAPN) is vital for better patient outcomes. This retrospective study aimed to examine how visceral fat area (VFA) and body mass index (BMI) correlate with intraoperative complexities, thereby guiding the selection of surgical techniques for RAPN. MATERIAL AND METHODS The study analyzed the medical records of 213 Chinese patients diagnosed with a range of benign and malignant renal neoplasms and treated with RAPN in 2020. Visceral fat area was quantified using computed tomography (CT) scans taken at the umbilical level. Various perioperative indicators, such as demographic details, clinicopathological parameters, operation time, estimated blood loss (EBL), warm ischemic time (WIT), and intraoperative complications, were assessed. RESULTS For the retroperitoneal approach, patients with either visceral obesity or general obesity had longer operation times (P<0.001 and P=0.004) and had a tendency for higher EBL (P=0.003 and P=0.001) compared to non-obese patients. In the transperitoneal approach, those with visceral obesity had significantly longer operation times (P=0.008) than their non-viscerally obese counterparts; however, general obesity showed no impact on operation time (P=0.251). Estimated blood loss was higher for patients with visceral obesity (P=0.004), but no significant difference was noted among those with general obesity (P=0.980). CONCLUSIONS VFA appears to offer predictive advantages over BMI in assessing intraoperative complexities for transperitoneal RAPN. When used in conjunction with BMI, it could serve as a valuable tool in selecting the most appropriate surgical approach for RAPN.

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.

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.

Impact of perinephric fat volume and the Mayo Adhesive Probability score on time to clamping in robot-assisted partial nephrectomy.

The aim of this study is to evaluate the association of perinephric fat volume (PNFV) and the Mayo Adhesive Probability (MAP) score with time to clamping (TTC) in robot-assisted partial nephrectomy (RAPN). The study subjects consisted of 73 tumors in 72 patients who underwent transperitoneal RAPN at a single cancer center between February 2020 and July 2022. Clinical characteristics including R.E.N.A.L. nephrometry score, MAP score and PNFV were evaluated in a multivariate analysis in relation to TTC, which was classified into two groups based on median TTC. PNFVand MAP score were analyzed separately. PNFVs were measured by SYNAPSE VINCENT® by a single expert urologist. Median TTC was 67 (range: 36-119) min. Spearman's rank correlation analysis indicated that a significant correlation was observed between PNFV and MAP score with a value of 0.81 (p < 0.0001). Univariate analysis revealed that R.E.N.A.L. nephrometry score ≥ 7 (p = 0.036), posterior tumor location (p = 0.033), MAP score ≥ 3 (p = 0.02) and PNFV ≥ 250ml (p = 0.02) were significant factors for prolonged TTC. In a multivariate analysis including PNFV (analysis 1), R.E.N.A.L. nephrometry score ≥ 7 (OR 3.54, p = 0.018) and PNFV ≥ 250cm3 (OR 3.94, p = 0.010) were independent factors for prolonged TTC. Similarly for MAP score (analysis 2), R.E.N.A.L. nephrometry score ≥ 7 (OR 3.54, p = 0.018) and MAP score ≥ 3 (OR 3.94, p = 0.010) were independent factors for prolonged TTC. Both MAP score and PNFV may have a significant impact on TTC.

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.

Posterior transperitoneal robot-assisted partial nephrectomy in the treatment of renal tumors: Feasibility of a hybrid approach.

Robot-assisted partial nephrectomy (RAPN) for posterior renal tumors may be performed through anterior (transperitoneal) or posterior (retroperitoneal) approach depending on surgeon's expertise. We propose herein a surgical artifice using daVinci Xi system to combine advantages of both approaches. From November 2019 to November 2020, patients with posterior renal mass, candidate for RAPN were prospectively included after informed consent. After positioning patient in lateral position, daVinci Xi system was docked on tumor side, to initiate transperitoneal procedure. Posterolateral dissection of perinephric space along fascia retrorenalis was conducted until psoas major muscle was exposed. Three additional robotic ports were then inserted in lumbar space, and RAPN was resumed after rotating daVinci Xi boom. Demographics, tumor characteristics, perioperative outcomes, estimated glomerular filtration rate (eGFR) and follow-up data were analyzed. Ten consecutive patients underwent RAPN with the modified technique. All cases were performed robotically, without modification of port placement. Median (range) tumor diameter was 37 (21-48mm) with median RENAL score of 8 (4-10) Median operative time and warm ischemia time were respectively 128min (70-180min) and 19min (14-22). One patient had a Clavien-Dindo grade II complication. At median follow-up of 13 months (6-18), all patients had eGFR comparable to baseline. We report the feasibility and safety of a new hybrid posterior transperitoneal approach for RAPN using daVinci Xi system. Limitations include the absence of RENAL score>10 and pT2 tumors. Greater experience is needed to assess learning curve for surgeons untrained to robotic lomboscopy.

New Longitudinal Component of the RENAL Nephrometry Score for Predicting the Operative Complexity in Transperitoneal Robot-Assisted Partial Nephrectomy.

Background: In transperitoneal robot-assisted partial nephrectomy (RAPN), an L score of 3 points according to the RENAL nephrometry scoring system does not necessarily denote operative complexity. This study aimed to assess the efficacy of the newly defined longitudinal component to analyze the operative complexity of RAPN. Materials and Methods: We retrospectively analyzed transperitoneal RAPNs performed by a single experienced surgeon for renal tumors between 2017 and 2020. L component was defined as L'1 for midlocated tumors, L'2 for >50% below the polar line, and L'3 for >50% above the polar line. Multivariate regression analysis was performed to test associations between prolonged console time and preoperative factors. The perioperative outcomes were compared among the three cohorts of L' components using propensity score matching: L'1 vs L'3 and L'1 vs L'2. Results: A total of 220 cases (L'1: 107, L'2: 65, L'3: 48) were analyzed. The median console time was prolonged (>130 minutes) in 55 patients (median 108, interquartile range: 90-130 minutes). Longitudinal location (L'3 odds ratio [OR]: 2.93, p = 0.01; L'2 OR: 2.32, p = 0.04), high Mayo adhesive probability score (p = 0.001), multiple renal arteries (p = 0.03), and large size (p = 0.04) were significantly associated with prolonged console time. After matching, 26 cases of L'1 and L'3 and 43 cases of L'1 and L'2 were selected. Console time (108 minutes vs 132 minutes, p = 0.017) and warm ischemia time (17 minutes vs 22 minutes, p = 0.03) were significantly longer in L'3 than in L'1. The difference in console time between L'1 and L'2 was not statistically significant (100 minutes vs 111 minutes, p = 0.08). Conclusion: In the new longitudinal assessment, upper location predicted prolonged console time compared with a middle or lower location. The L' component may help preoperatively assess operative complexity.

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.

Comparison of the Safety and Efficacy of Valveless and Standard Insufflation During Robotic Partial Nephrectomy: A Prospective, Randomized, Multi-institutional Trial

ObjectiveTo use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation – AIS) at the conventional pressure of 15 mm Hg in robot-assisted partial nephrectomy – a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system. Materials and MethodsThree high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mm Hg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach. ResultsTwo hundred and two patients were accrued. SCE was decreased in the AIS 12 mm Hg group (p=0.003). PTX and PMS rates were not statistically significantly different across the 3 insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups – with lower SCE rates for AIS 12 mm Hg regardless of surgical approach. ConclusionAIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mm Hg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.

Three-dimensional Augmented Reality Robot-assisted Partial Nephrectomy in Case of Complex Tumours (PADUA ≥10): A New Intraoperative Tool Overcoming the Ultrasound Guidance

BackgroundDespite technical improvements introduced with robotic surgery, management of complex tumours (PADUA score ≥10) is still a matter of debate within the field of transperitoneal robot-assisted partial nephrectomy (RAPN). ObjectiveTo evaluate the accuracy of our three-dimensional (3D) static and elastic augmented reality (AR) systems based on hyperaccuracy models (HA3D) in identifying tumours and intrarenal structures during transperitoneal RAPN (AR-RAPN), compared with standard ultrasound (US). Design, setting, and participantsA retrospective study was conducted, including 91 patients who underwent RAPN for complex renal tumours, 48 with 3D AR guidance and 43 with 2D US guidance, from July 2017 to May 2019. Surgical procedureIn patients who underwent 3D AR-RAPN, virtual image overlapping guided the surgeon during resection and suture phases. In the 2D US group, interventions were driven by US only. MeasurementsPatient characteristics were tested using the Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous ones. Intraoperative, postoperative, and surgical outcomes were collected. All results for continuous variables were expressed as medians (range), and frequencies and proportions were reported as percentages. Results and limitationsThe use of 3D AR guidance makes it possible to correctly identify the lesion and intraparenchymal structures with a more accurate 3D perception of the location and the nature of the different structures relative to the standard 2D US guidance. This translates to a lower rate of global ischaemia (45.8% in the 3D group vs 69.7% in the US group; p = 0.03), higher rate of enucleation (62.5% vs 37.5% in the 3D and US groups, respectively; p = 0.02), and lower rate of collecting system violation (10.4% vs 45.5%; p = 0.003). Postoperatively, 3D AR guidance use correlates to a low risk of surgery-related complications in 3D AR groups and a lower drop in estimated renal plasma flow at renal scan at 3 mo of follow-up (–12.38 in the 3D group vs –18.14 in the US group; p = 0.01). The main limitations of this study are short follow-up time and small sample size. ConclusionsHA3D models that overlap in vivo anatomy during AR-RAPN for complex tumours can be useful for identifying the lesion and intraparenchymal structures that are difficult to visualise with US only. This translates to a potential improvement in the quality of the resection phase and a reduction in postoperative complications, with better functional recovery. Patient summaryBased on our findings, three-dimensional augmented reality robot-assisted partial nephrectomy seems to help surgeons in the management of complex renal tumours, with potential early postoperative benefits.

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.

The Impact of Surgical Strategy in Robot-assisted Partial Nephrectomy: Is It Beneficial to Treat Anterior Tumours with Transperitoneal Access and Posterior Tumours with Retroperitoneal Access?

Available comparison of transperitoneal robot-assisted partial nephrectomy (tRAPN) and retroperitoneal robot-assisted partial nephrectomy (rRAPN) does not consider tumour's location. The aim of this study was to compare perioperative morbidity, and functional and pathological outcomes after tRAPN and rRAPN, with the specific hypothesis that tRAPN for anterior tumours and rRAPN for posterior tumours might be a beneficial strategy. A large global collaborative dataset of 1169 cT1-2N0M0 patients was used. Propensity score matching, and logistic and linear regression analyses tested the effect of tRAPN versus rRAPN on perioperative outcomes. No differences were observed between rRAPN and tRAPN with respect to complications, operative time, length of stay, ischaemia time, median 1-yr estimated glomerular filtration rate (eGFR), and positive surgical margins (all p>0.05). Median estimated blood loss and postoperative eGFR were 50 versus100ml (p<0.0001) and 82 versus 78ml/min/1.73 m2 (p=0.04) after rRAPN and tRAPN, respectively. At interaction tests, no advantage was observed after tRAPN for anterior tumours and rRAPN for posterior tumours with respect to complications, warm ischaemia time, postoperative eGFR, and positive surgical margins (all p>0.05). The techniques of rRAPN and tRAPN offer equivalent perioperative morbidity, and functional and pathological outcomes, regardless of tumour's location. Patient summaryRobot-assisted partial nephrectomy can be performed with a transperitoneal or a retroperitoneal approach regardless of the specific position of the tumour, with equivalent outcomes for the patient.

Pure Single-Site Robot-Assisted Partial Nephrectomy Using the SP Surgical System: Initial Clinical Experience

ObjectivesTo describe the technique of pure single-site trans-peritoneal robotic partial nephrectomy using the da Vinci SP surgical system. MethodsThree consecutive patients who were diagnosed with contrast-enhanced renal masses amenable of partial nephrectomy were scheduled for robot-assisted partial nephrectomy to be performed using the SP Surgical System.Data collection received Institutional Review Board Approval (IRB 13-780). Subjects were provided with informed consent explaining the adoption of the novel surgical platform.The procedures were performed by reproducing the steps of the standard institutional multiarms robotic approach to partial nephrectomy. ResultsThe surgeries were successfully performed. There was no need for conversion to standard multiports robotic approach nor need for additional ports placement. All the procedures were completed according to a pure single-site approach. No intraoperative complications occurred. The total robotic operative time averaged 180 minutes. The warm ischemia time averaged 25 minutes. Blood loss averaged 180 mL. One patient had postoperative acute bleeding and underwent angioembolization. All patients had negative surgical margins. ConclusionThe feasibility of pure single-site transperitoneal robot-assisted partial nephrectomy using the novel SP surgical system is demonstrated. Further studies are needed to confirm the results reported herein.

Transperitoneal Robot-assisted Partial Nephrectomy with Minimum Follow-up of 5 Years: Oncological and Functional Outcomes from a Single Institution

BackgroundRobot-assisted partial nephrectomy (RAPN) is an established, minimally invasive nephron-sparing technique with excellent perioperative and intermediate oncological outcomes. However, long-term oncological outcomes have not been reported to date. ObjectiveTo report oncological and functional outcomes of RAPN among patients with minimum follow-up of 5 yr. Design, setting, and participantsData for consecutive patients undergoing RAPN since October 2006 were extracted from a prospectively-maintained institutional PN database. Patients with benign tumors, genetic mutations, prior radical or ipsilateral PN, and those with follow-up of <5 yr were excluded. InterventionTransperitoneal RAPN for renal cell carcinoma (RCC). Outcomes measurements and statistical analysisDemographic, perioperative, postoperative, functional, and oncological data were evaluated. A linear random-effects model was used to estimate the effect of follow-up duration on the estimated glomerular filtration rate (eGFR) after adjustment for potential confounders. Univariable competing-risks regression analyses were performed to evaluate the hazard ratio (HR) for cancer-related events for the variables of interest. Results and limitationsA total of 278 RAPNs for RCC were included. eGFR was significantly lower at follow-up time points than at baseline. At last follow-up (median 46 mo, interquartile range 30–58) the mean eGFR difference was −10.6ml/min (95% confidence interval −12.56 to −8.66; p < 0.0001). There were 28 deaths (10.1%) in the cohort during the follow-up period, of which five (1.8%) were related to metastatic RCC. The 5-yr and 7-yr cumulative incidence of RCC deaths was 1.80% at both 5 and 7 yr, while the cumulative incidence of local recurrence was 3.61% and 4.16%, and that of metastasis was 3.24% and 4.57% at 5 and 7 yr, respectively. Univariable competing-risks regression revealed that higher Fuhrman grade (HR 8.76; p = 0.051), larger tumor size (HR 1.67; p < 0.0001), and tumor necrosis (HR 16.73; p = 0.0019) were independent predictors of RCC death. The retrospective design and potential selection bias due to patient selection in the early RAPN experience may limit the generalizability of the findings. ConclusionsThis is the first study reporting minimum oncological follow-up of 5 yr after RAPN. The results demonstrate excellent long-term oncological outcomes after RAPN in a selected cohort of patients. Our data confirm that the renal functional deterioration after RAPN remains stable over time after the early postoperative decrease. Patient summaryRobot-assisted partial nephrectomy is being more widely used as a standard treatment for small localized renal cell carcinomas. This study reveals excellent long-term cancer control for both local recurrences and distant metastases. Renal function is stable after an initial postoperative deterioration.

Retroperitoneal Robotic Partial Nephrectomy: Systematic Review and Cumulative Analysis of Comparative Outcomes.

To compare the outcomes of retroperitoneal vs transperitoneal approach for robot-assisted partial nephrectomy (RAPN). A systematic review of the literature was performed through January 2018 using PubMed, Scopus, and Ovid databases. Article selection proceeded according to the search strategy based on PRISMA criteria. Only studies comparing retroperitoneal to transperitoneal approach for RAPN were deemed eligible for inclusion. Seven retrospective case-control studies were identified and included in the analysis, with a total number of 1379 patients (866 for transperitoneal group; 513 for retroperitoneal group). In the retroperitoneal group, tumors were slightly larger [weighted mean difference (WMD): 0.29 cm; 95% confidence interval (CI): 0.04-0.54; p = 0.02], and more frequently located posterior/lateral (odds ratio: 0.61; 95% CI: 0.41-0.90; p = 0.01). In two of the studies only posterior tumors had been included. Both operating time (WMD 20.17 min; 95% CI 6.46-33.88; p = 0.004) and estimated blood loss (WMD 54.57 mL; 95% CI 6.73-102.4; p = 0.03) were significantly lower in the retroperitoneal group. In addition, length of stay was significantly shorter in the retroperitoneal group (WMD 0.46 days; CI 95% 0.15-0.76; p = 0.003). No differences were found regarding overall (p = 0.67) and major (p = 0.82) postoperative complications, warm ischemia time (p = 0.96), and positive surgical margins (p = 0.95). Retroperitoneal RAPN can offer in select patients similar outcomes to those of the most common transperitoneal RAPN. Furthermore, it may be particularly advantageous for posterior upper pole and perihilar tumors and associated with reduction in operative time and hospital stay. Robotic surgeons should be ideally familiar with both approaches to adapt their surgical strategy to confront renal neoplasms from a position of technical advantage and ultimately optimize outcomes.

MP59-06 ANALYSIS OF PREDICTIVE FACTORS ASSOCIATED WITH PROLONGED OPERATIVE TIME DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV1 Apr 2017MP59-06 ANALYSIS OF PREDICTIVE FACTORS ASSOCIATED WITH PROLONGED OPERATIVE TIME DURING ROBOT-ASSISTED PARTIAL NEPHRECTOMY Hidekazu Tachibana, Toshio Takagi, Tsunenori Kondo, and Kazunari Tanabe Hidekazu TachibanaHidekazu Tachibana More articles by this author , Toshio TakagiToshio Takagi More articles by this author , Tsunenori KondoTsunenori Kondo More articles by this author , and Kazunari TanabeKazunari Tanabe More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1822AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES During robot-assisted partial nephrectomy (RAPN), surgeons often face difficulty exposing the renal hilum and tumor before tumor resection and renorrhaphy. Consequently, operative time may be prolonged. In the present study, we aimed to identify the predictive factors associated with prolonged operative time for RAPN. METHODS Patients who underwent transperitoneal RAPN for renal tumor at our institution between 2012 and 2015 were retrospectively analyzed. Early cases managed after the adoption of the da Vinci surgical system were excluded. Multivariate regression analysis was used to test associations between prolonged operative time (>150 min) and perioperative factors. RESULTS In total, 297 patients were included in this study; however, 95 early cases were excluded. RAPN was performed by 3 experienced surgeons using an early unclamping technique. The median operative time was 132 min (interquartile range, 109-155 min) and operative time was prolonged in 62 cases. The cohort of patients with prolonged operative time (prolonged group) was significantly older (P=0.0018), had a higher male-female ratio (P=0.02), and had higher BMI (P=0.0093) than the group with shorter operative times (standard group). In addition, the tumor was also more likely to be larger (P=0.025), on the left side (P=0.005), and posteriorly positioned (P=0.03). Furthermore, the RENAL nephrometry score was likely to be higher for the prolonged group compared with the standard group. Moreover, warm ischemia time was longer (21 vs. 16 min; P<0.0001) and postoperative decrease in renal function (3 months) was greater (-9.0 vs. -4.7%; P=0.038) for the prolonged group than for the standard group. Multivariate analysis indicated that age (odds ratio [OR], 1.04; P=0.0015), BMI (OR, 1.12; P=0.013), left-sidedness (OR, 3.21; P=0.0007), posterior position (OR, 2.47; P=0.016), and high RENAL score (OR, 3.39; P=0.012) were significantly associated with prolonged operative time. CONCLUSIONS In addition to tumor complexity, age, BMI, and left-sidedness are predictive of prolonged operative times for RAPN. These factors may contribute to the difficulty exposing the renal hilum and renal tumor. Further investigation of the time spent during each part of the procedure is indicated. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e782-e783 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Hidekazu Tachibana More articles by this author Toshio Takagi More articles by this author Tsunenori Kondo More articles by this author Kazunari Tanabe More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transperitoneal Robot-Assisted Partial Nephrectomy: A Comparison of Posterior and Anterior Renal Masses

Robot-assisted partial nephrectomy (RAPN) for posterior renal masses necessitates access to the posterior surface of the kidney either via a transperitoneal (TP) or retroperitoneal (RP) approach. While advocates of an RP approach claim reduced morbidity for posterior tumors, it is a less familiar approach to many urologists. In our institution, a TP approach is used for all patients undergoing RAPN. We compared demographics and perioperative outcomes of TP RAPN for posterior and anterior/lateral renal masses. Our institutional renal mass database was queried for patients with available preoperative imaging who underwent TP RAPN from 2007 to 2013. Posterior masses were accessed by opening the Gerota fascia and rotating the kidney anteromedially. Demographic and perioperative outcomes were compared for patients with posterior masses and anterior/lateral masses. Overall, 260 TP RAPN were identified. Of these, 92 were for posterior tumors and 168 were for anterior and lateral tumors. Renal-cell carcinoma (RCC) was found in 77.3% of cases. Patient demographic and tumor characteristics were similar between groups. Among operative characteristics, warm ischemia time (17 vs 16.5, min P=0.70), operative time (160 vs 159 min, P=0.82), estimated blood loss (100 vs 100 mL, P=0.44), RCC positive surgical margins (1.4% vs 1.5%), and postoperative complications (19.6% vs 16.1%, P=1.0) were similar for posterior and anterior/lateral tumors, respectively. TP RAPN is a safe, effective treatment option for patients with posterior renal masses with no additional morbidity compared with anterior/lateral renal masses. RP PN remains an alternative treatment option.

Robot-Assisted Partial Nephrectomy

Robot-assisted partial nephrectomy (RAPN) is a viable option for patients and surgeons who desire a minimally invasive alternative for the performance of nephron-sparing surgery (NSS). NSS has become the norm for the management of small renal masses. Numerous series have shown favorable outcomes for RAPN. RAPN has a shortened learning curve and eases the transition to minimally invasive NSS. We describe the indications, preparation, instrumentation, setup, technique, and complications for transperitoneal RAPN using a two- or three-arm approach. We also suggest strategies and tips so that surgeons early in the learning curve can effectively anticipate, avoid, and, if inevitable, manage complications.

Transperitoneal Robot-Assisted Partial Nephrectomy for Tumors in Posterior Locations

Abstract Introduction: Robot-assisted partial nephrectomy is one of the fastest growing robotic procedures. It was quickly adopted by urologists with many different training levels as a minimally invasive alternative to open nephrectomy. 1 Larger tumors in more difficult locations are increasingly done.2 The technique of placing the robotic camera lateral to the robotic arms is useful for tumors in posterior locations. This port placement also optimizes motion of the robotic arms and decreases collisions.3 Most current published series come from large academic institutions,4 and little has been published from the community setting. We illustrated the technique in this 7-min video with three cases performed by a community urologist with no fellowship training. Methods: The technique of placing the robotic camera lateral to the robotic arms is usually performed at our institution when approaching tumors in posterior locations. The robotic camera is placed 3 fingerbreadths from the costal margin, in between ...