Elsevier

Urology

Volume 81, Issue 3, March 2013, Pages 573-580
Urology

Laparoscopy and Robotics
Perioperative Complications of Robot-assisted Partial Nephrectomy: Analysis of 886 Patients at 5 United States Centers

https://doi.org/10.1016/j.urology.2012.10.067Get rights and content

Objective

To review complications of robot-assisted partial nephrectomy (RAPN) at 5 centers, as classified by the Clavien system.

Materials and Methods

A multi-institutional analysis of prospectively maintained databases assessed RAPN complications. From June 2007 to November 2011, 886 patients at 5 United States centers underwent RAPN. Patient demographics, perioperative outcomes, and complications data were collected. Complication severity was classified by Clavien grade.

Results

Mean (standard deviation) data were patient age, 59.4 (11.4) years; age-adjusted Charlson Comorbidity Index, 3.0 (1.9); radiographic tumor size, 3.0 (1.6) cm; nephrometry score, 6.9 (2.0); and warm ischemia time, 18.8 (9.0) minutes. Median blood loss was 100 mL (interquartile range, 100-250 mL). Of the 886 patients, intraoperative complications occurred in 23 patients (2.6%) and 139 postoperative complications occurred in 115 patients (13.0%) for a total complication rate of 15.6%. Among the 139 postoperative complications, 43 (30.9%) were classified as Clavien 1, 64 (46.0%) were Clavien 2, 21 (15.1%) were Clavien 3, and 11 (7.9%) were Clavien 4. No complication-related deaths occurred. Intraoperative hemorrhage occurred in 9 patients (1.0%) and postoperative hemorrhage in 51 (5.8%). Forty-one patients (4.6%) required a perioperative blood transfusion, 10 (1.1%) required angioembolization, and 2 (0.2%) required surgical reexploration for postoperative hemorrhage. Urine leaks developed in 10 patients (1.1%): 3 (0.3%) required ureteral stenting, and 2 (0.2%) required percutaneous drainage. Acute postoperative renal insufficiency or renal failure developed in 7 patients (0.8%), 2 of whom required hemodialysis. The RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) nephrometry scoring system accurately predicted RAPN complication rates.

Conclusion

Complication rates in this large multicenter series of RAPN appear to be acceptable and comparable with other nephron-sparing modalities. Most complications (77.0%) are Clavien 1 and 2 and can be managed conservatively.

Section snippets

Materials and Methods

With Institutional Review Board approval, a retrospective review of deidentified, consented, prospectively maintained databases at 5 US centers was performed evaluating all patients who underwent RAPN from June 2007 to November 2011. Data for 886 patients were collected. Preoperative computed tomography or magnetic resonance imaging demonstrated contrast-enhancing renal masses in all patients. All treatment options, including surveillance, were discussed with patients. Indications for RAPN and

Results

Table 1 summarizes patient demographics, tumor characteristics, and perioperative outcomes. Of the 886 patients, intraoperative complications occurred in 23 (2.6%), and 139 postoperative complications occurred in 115 patients (13.0%), for a total complication rate of 15.6%. Postoperative complications classified by Clavien grade and organ system are listed in Table 2. Intraoperative complications occurred in 2.3%, 2.7%, and 8.2% of procedures performed for tumors with NSS scores 4 to 6, 7 to 9,

Comment

Early reports indicate that RAPN has a relatively shorter learning curve than LPN7, 8 and, hence, may facilitate the use of minimally invasive nephron-sparing surgery. Numerous studies have now described the utility of RAPN in managing large and complex renal masses, including endophytic, central, and hilar lesions.9, 11, 12, 20 Furthermore, multiple series have demonstrated equivalent preliminary oncologic and functional outcomes between RAPN and LPN.9, 12, 21

Complication rates can be used to

Conclusions

Complication rates in this large multicenter study of RAPN appear to be acceptable and comparable to other nephron-sparing modalities. Most complications (77.0%) are classified as Clavien 1 and 2 and can be managed conservatively. The NSS is a valid predictor of complication rates in the current series. The most common complication of RAPN is hemorrhage; most patients with postoperative hemorrhage can be managed conservatively. Conversion to open or laparoscopic PN or to RN is uncommon. Despite

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Financial Disclosure: Jihad H. Kaouk is a consultant for Intuitive Surgical and Ethicon. Craig G. Rogers is a speaker for Intuitive Surgical and Ethicon Biosurgery and is a consultant for Vascular Technology and Hitachi-Aloka Ultrasound. Michael D. Stifelman is a speaker for Intuitive Surgical and Baxter and is a consultant for Vascular Technology. Sam B. Bhayani is a consultant for Baxter. The other authors declare that they have no relevant financial interests.

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