Platinum Priority ā Review ā Kidney CancerEditorial by Aaron M. Potretzke and Sam B. Bhayani on pp. 902ā903 of this issueComparison of Perioperative Outcomes Between Robotic and Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-analysis
Introduction
Partial nephrectomy (PN) is the gold standard for the treatment of small renal masses (<4Ā cm) [1], [2]. Evolution has progressed from open radical nephrectomy through open PN to minimally invasive PN including laparoscopic PN (LPN) and robotic PN (RPN) [3]. However, the technical and ergonomic challenge of laparoscopic suturing has limited the dissemination of LPN [3]. Surgical robots were developed to facilitate minimally invasive surgery and to assist surgeons performing surgical procedures [4]. It has been reported that RPN can be performed successfully after a 25-case learning curve [3].
Evaluation of RPN is needed because it does not directly improve patient outcomes. Although some authors [5], [6] reported that RPN provided equivalent perioperative outcomes with the added advantage of significantly shorter warm ischemia time (WIT) compared with LPN, the true benefit of RPN over LPN among previous comparison studies [3], [5], [6], [7], [8], [9], [10], [11] is still controversial. In addition, the renal functional and oncologic advantages of RPN for patients with renal cancer are not well studied because of the lack of studies with which to perform meta-analyses. The numbers of papers on this subject have increased recently, so it appears to be the right time to perform meta-analyses of outcomes such as kidney function, estimated glomerular filtration rate (eGFR), and serum creatinine (sCr) for RPN versus LPN using statistical power even though there are no randomized studies. Although randomized controlled trials are powerful tools, they are limited by ethical issues, patient preferences, and the time and cost for intervention therapy, especially in robotic surgery. Consequently, our aim was to evaluate the perioperative outcomes of WIT, length of stay (LOS), estimated blood loss (EBL), changes of eGFR and sCr, conversion rate to radical surgery and open surgery, and positive surgical margin (PSM) rates of RPN versus LPN for patients with renal cancer, using recent research.
Section snippets
Search strategy
We searched Ovid-Medline (1946ā2013), Embase (inceptionā2013), and the Cochrane Central Register of Controlled Trials (in the Cochrane Library) on July 5, 2013. Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi) were also searched. Search terms combined patient-related terms (kidney or renal neoplasm, kidney or renal cancer, kidney or renal carcinoma) and intervention terms (robotics, computer-assisted surgery, telerobot, remote operation, remote surgery, da Vinci).
Inclusion criteria and study eligibility
We evaluated the
Evidence synthesis
Table 1 shows the characteristics of the included studies. Three were prospective cohort studies, and 20 were retrospective cohort studies with no randomization. Included studies were of varying methodological quality. Among the 2240 patients, the mean ages of the RPN group (1152 patients) ranged from 51 to 64 yr; the mean ages of the LPN group (1088 patients) ranged from 49 to 69 yr (Table 1). The MINORS sum scores ranged from 6 to 14, and the mean score of all the included studies was 10.4.
Conclusions
This meta-analysis showed that RPN is associated with more favorable results than LPN in terms of lower conversion rate to open surgery and radical nephrectomy, favorable eGFR, shorter WIT, and shorter LOS. The result should be applied carefully in clinical practice because of the low quality of evidence. To establish robust safety and effectiveness outcomes of robotic surgery, well-designed randomized clinical studies with long-term follow-up periods are needed.
References (37)
- et al.
Systematic review of oncological outcomes following surgical management of localised renal cancer
Eur Urol
(2012) - et al.
EAU guidelines on renal cell carcinoma: the 2010 update
Eur Urol
(2010) - et al.
Robotic-assisted versus traditional laparoscopic partial nephrectomy: comparison of outcomes and evaluation of learning curve
Urology
(2011) - et al.
Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes
Eur Urol
(2012) - et al.
Every minute counts when the renal hilum is clamped during partial nephrectomy
Eur Urol
(2010) - et al.
Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis
Eur Urol
(2012) - et al.
Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system
Urology
(2004) - et al.
Robot-assisted partial nephrectomy versus laparoscopic partial nephrectomy: a single institution experience [in French]
Prog Urol
(2013) - et al.
A matched comparison of perioperative outcomes of a single laparoscopic surgeon versus a multisurgeon robot-assisted cohort for partial nephrectomy
J Urol
(2012) - et al.
Renal damage caused by warm ischaemia during laparoscopic and robot-assisted partial nephrectomy: an assessment using Tc 99m-DTPA glomerular filtration rate
Eur Urol
(2010)