Surgery in MotionEvolution of Robot-assisted Partial Nephrectomy: Techniques and Outcomes from the Transatlantic Robotic Nephron-sparing Surgery Study Group
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)
- et al.
Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system
Urology
(2004) - et al.
EAU guidelines on renal cell carcinoma: 2014 update
Eur Urol
(2015) - et al.
Robotic versus laparoscopic partial nephrectomy: single-surgeon matched cohort study of 150 patients
Urology
(2010) - et al.
Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes
Eur Urol
(2012) - et al.
Margin, ischemia, and complications (MIC) score in partial nephrectomy: a new system for evaluating achievement of optimal outcomes in nephron-sparing surgery
Eur Urol
(2012) - et al.
Margin, ischemia, and complications system to report perioperative outcomes of robotic partial nephrectomy: a European Multicenter Observational Study (EMOS project)
Urology
(2015) - et al.
Robot-assisted partial nephrectomy: an international experience
Eur Urol
(2010) - et al.
Technique and outcomes of robot-assisted retroperitoneoscopic partial nephrectomy: a multicenter study
Eur Urol
(2014) - et al.
“Zero ischemia” partial nephrectomy: novel laparoscopic and robotic technique
Eur Urol
(2011) - et al.
Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes
Eur Urol
(2009)
Comparison of perioperative outcomes of retroperitoneal and transperitoneal minimally invasive partial nephrectomy after adjusting for tumor complexity
Urology
Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review and meta-analysis
Int J Surg
Near-infrared fluorescence imaging: emerging applications in robotic upper urinary tract surgery
Eur Urol
Robotic partial nephrectomy with superselective versus main artery clamping: a retrospective comparison
Eur Urol
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2022, Progres en UrologieCitation 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.