Elsevier

European Urology

Volume 76, Issue 2, August 2019, Pages 222-227
European Urology

Surgery in Motion
Evolution of Robot-assisted Partial Nephrectomy: Techniques and Outcomes from the Transatlantic Robotic Nephron-sparing Surgery Study Group

https://doi.org/10.1016/j.eururo.2018.11.038Get rights and content

Abstract

Background

Robot-assisted partial nephrectomy (RAPN) is considered a feasible minimally invasive alternative to open partial nephrectomy (OPN) for the surgical treatment of renal tumors.

Objective

To provide further evidence supporting the effectiveness of RAPN in a contemporary patient population treated at one of three tertiary care centers for robotic surgery and to describe the evolution of RAPN-based technical improvements.

Design, setting, and participants

The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group prospectively collected data from 635 patients subjected to RAPN for clinically localized kidney cancer between 2010 and 2016 at three high-volume tertiary care centers.

Surgical procedure

RAPN was performed using methods outlined in the supplementary video using either the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA).

Measurements

Clinical data were collected within a prospectively maintained multi-institutional database. Intra- and postoperative data as well as surgical outcomes were assessed. Descriptive statistical analysis was performed and multivariable logistic regression models were fitted to determine the predictors of surgical outcomes.

Results and limitations

Mean patient age was 60.7 yr and mean preoperative tumor size was 33 mm. According to the PADUA score, 202 (31.8%) patients had a low-, 235 (37.0%) had an intermediate-, and 198 (31.2%) had a high-complexity tumor. In the majority of patients, a transperitoneal approach was used (n = 447; 70.4%). Mean operative time was 156.3 min and mean estimated blood loss was 171 ml. Overall, 25 (3.9%) patients experienced a significant (Clavien-Dindo >2) complication after surgery. No statistically significant differences between pre- and postoperative creatinine values were observed (p  0.823). Finally, optimal surgical outcomes defined according to the margin, ischemia, and complication score were achieved in 459 (72.3%) individuals. At a mean follow-up of 26 mo, only two local and two distant recurrences of the disease were observed. Finally, in multivariable logistic regression models, tumor complexity was associated with the risk of not achieving optimal surgical outcomes.

Conclusions

RAPN represents an effective minimally invasive alternative to OPN in the treatment of clinically localized renal tumors.

Patient summary

We reported contemporary experience with RAPN for the treatment of kidney cancer. RAPN appears to be a safe and effective procedure, resulting in optimal outcomes in the majority of individuals despite tumor complexity.

Introduction

Robotic-assisted partial nephrectomy (RAPN) was first described in 2004 by Gettman and colleagues [1] and, since its introduction in clinical practice, has progressively gained increasing popularity. To date, RAPN is considered a feasible minimally invasive alternative to open partial nephrectomy (OPN) for the surgical treatment of renal tumors [2]. The main advantages of robotic surgery as compared with the traditional laparoscopic approach have been demonstrated by several studies, and include a three-dimensional magnified view of the surgical field, enhanced dexterity, and greater precision in both dissection and reconstruction. In clinical practice, these advantages translate into a shorter learning curve and broader indications of RAPN as compared with the standard laparoscopic partial nephrectomy (LPN) [3], [4], [5], [6], [7]. Consequently, in expert hands, RAPN has become a feasible option for the treatment of complex renal masses [3], [4], [5], [6], [7].

Several studies have shown that RAPN may result in comparable, if not better, outcomes relative to OPN [8], [9]. These results are attributed to increasing surgical experience as well as the development and application of novel surgical techniques aimed at reducing the morbidity of this procedure. The current study was conceived to provide further evidence supporting the effectiveness of RAPN in a contemporary patient population treated at one of three tertiary care centers for robotic surgery. In addition, we demonstrate the evolution of RAPN-based technical improvements as well as the application of novel technologies that allows the use of RAPN even in patients with highly complex renal tumors.

Section snippets

Patient population

The Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group prospectively collected data from patients subjected to RAPN for clinically localized kidney cancer between 2010 and 2016 at three high-volume tertiary care centers (Humanitas Clinical and Research Center, Milan, Italy; Onze-Lieve-Vrouw Hospital, Aalst, Belgium; and Swedish Medical Center, Seattle, WA, USA). All patients underwent either preoperative computed tomography (CT) scan or magnetic resonance imaging to precisely

Results

Descriptive characteristics of the study cohort are shown in Table 1. Among 737 patients subjected to RAPN within the study period, 635 had complete demographic, perioperative, and pathological information, and were therefore included in the analysis. Of these patients, 399 (62.8%) were males. Mean patient age was 60.7 yr, mean body mass index was 29.4 kg/m2, mean preoperative tumor size was 33 mm, and mean estimated glomerular filtration rate (eGFR) was 70.4. Right tumors were observed in 324

Discussion

The current multi-institutional collaborative study provides further evidence supporting the use of RAPN for the treatment of renal masses. More specifically, in expert hands, RAPN provides optimal surgical and oncological outcomes in the great majority of patients. In addition, we validate the role of both the PADUA and RENAL nephrometry scores in predicting the outcomes of RAPN, therefore supporting their routine use in clinical practice.

According to current guidelines, RAPN is considered an

Conclusions

The current study provides further evidence supporting the role of RAPN as a viable and effective minimally invasive alternative to OPN in the treatment of clinically localized renal tumors. Despite surgical experience and technological improvements, tumor complexity still represents an independent predictor of optimal surgical outcomes.

Author contributions: James Porter had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the

References (29)

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    Citation Excerpt :

    After complete incision of the fascia retrorenalis, the posterior approach led to direct access to the renal artery, which was controlled using a silicone rubber loop (Fig. 6). Further surgical steps were similar to those described by others: removal of perinephric fat to expose the renal tumor, introduction of sutures and intracorporeal bag, tumor excision favoring enucleation when feasible with extreme consideration of surgical margins, elective closure of large vessels and excretory system, and sliding-clip renorrhaphy [10]. A video description of the surgical technique is available online (https://www.youtu.be/_5r2YtL4ad4).

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These authors contributed equally.

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