Craig G. Rogers

Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes.

PURPOSE Robot assisted partial nephrectomy is rapidly emerging as an alternative to laparoscopic partial nephrectomy for the treatment of renal malignancy. We present the largest multi-institution comparison of the 2 approaches to date, describing outcomes from 3 experienced minimally invasive surgeons. MATERIALS AND METHODS We performed a retrospective chart review, evaluating 118 consecutive laparoscopic partial nephrectomies and 129 consecutive robot assisted partial nephrectomies performed between 2004 and 2008 by 3 experienced minimally invasive surgeons at 3 academic centers. Perioperative data were recorded along with clinical and pathological outcomes. RESULTS The robot assisted and laparoscopic partial nephrectomy groups were equivalent in terms of age, gender, body mass index, American Society of Anesthesiologists classification (2.3 vs 2.4) and radiographic tumor size (2.9 vs 2.6 cm), respectively. Comparison of operative data revealed no significant differences in terms of overall operative time (189 vs 174 minutes), collecting system entry (47% vs 54%), pathological tumor size (2.8 vs 2.5 cm) and positive margin rate (3.9% vs 1%) for robot assisted and laparoscopic partial nephrectomy, respectively. Intraoperative blood loss was less for robot assisted vs laparoscopic partial nephrectomy (155 vs 196 ml, p = 0.03) as was length of hospital stay (2.4 vs 2.7 days, p <0.0001). Warm ischemia times were significantly shorter in the robot assisted partial nephrectomy series (19.7 vs 28.4 minutes, p <0.0001). Subset analysis based on complexity revealed that tumor complexity had no effect on operative time or estimated blood loss for robot assisted partial nephrectomy, although complexity did affect these factors for laparoscopic partial nephrectomy. In addition, for simple and complex tumors robot assisted partial nephrectomy provided significantly shorter warm ischemic time than laparoscopic partial nephrectomy (15.3 vs 25.2 minutes for simple, p <0.0001; 25.9 vs 36.7 minutes for complex, p = 0.0002). There were no intraoperative complications during robot assisted partial nephrectomy vs 1 complication during laparoscopic partial nephrectomy. Postoperative complication rates were similar for robot assisted and laparoscopic partial nephrectomy (8.6% vs 10.2%). CONCLUSIONS Robot assisted partial nephrectomy is a safe and viable alternative to laparoscopic partial nephrectomy, providing equivalent early oncological outcomes and comparable morbidity to a traditional laparoscopic approach. Moreover robot assisted partial nephrectomy appears to offer the advantages of decreased hospital stay as well as significantly less intraoperative blood loss and shorter warm ischemia time, the latter of which may help to provide maximal preservation of renal reserve. In addition, operative parameters for robot assisted partial nephrectomy appear to be less affected by tumor complexity compared to laparoscopic partial nephrectomy. Interestingly while the advantages of robotic surgery have historically been believed to aid laparoscopic naïve surgeons, these data indicate that robot assisted partial nephrectomy may also benefit experienced laparoscopic surgeons.

Perioperative Outcomes of Robot-Assisted Radical Prostatectomy Compared With Open Radical Prostatectomy: Results From the Nationwide Inpatient Sample

BACKGROUND Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. OBJECTIVE Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARPs supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. DESIGN, SETTING, AND PARTICIPANTS As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389). INTERVENTION All patients underwent RARP or ORP. MEASUREMENTS We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score-matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. RESULTS AND LIMITATIONS Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score-matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28-0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31-0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77-0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26-0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. CONCLUSIONS RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes.

A Molecular Classification of Papillary Renal Cell Carcinoma

Despite the moderate incidence of papillary renal cell carcinoma (PRCC), there is a disproportionately limited understanding of its underlying genetic programs. There is no effective therapy for metastatic PRCC, and patients are often excluded from kidney cancer trials. A morphologic classification of PRCC into type 1 and 2 tumors has been recently proposed, but its biological relevance remains uncertain. We studied the gene expression profiles of 34 cases of PRCC using Affymetrix HGU133 Plus 2.0 arrays (54,675 probe sets) using both unsupervised and supervised analyses. Comparative genomic microarray analysis was used to infer cytogenetic aberrations, and pathways were ranked with a curated database. Expression of selected genes was validated by immunohistochemistry in 34 samples with 15 independent tumors. We identified two highly distinct molecular PRCC subclasses with morphologic correlation. The first class, with excellent survival, corresponded to three histologic subtypes: type 1, low-grade type 2, and mixed type 1/low-grade type 2 tumors. The second class, with poor survival, corresponded to high-grade type 2 tumors (n = 11). Dysregulation of G1-S and G2-M checkpoint genes were found in class 1 and 2 tumors, respectively, alongside characteristic chromosomal aberrations. We identified a seven-transcript predictor that classified samples on cross-validation with 97% accuracy. Immunohistochemistry confirmed high expression of cytokeratin 7 in class 1 tumors and of topoisomerase IIalpha in class 2 tumors. We report two molecular subclasses of PRCC, which are biologically and clinically distinct and may be readily distinguished in a clinical setting.

Nomograms provide improved accuracy for predicting survival after radical cystectomy

Aims: To develop multivariate nomograms that determine the probabilities of all-cause and bladder cancer–specific survival after radical cystectomy and to compare their predictive accuracy to that of American Joint Committee on Cancer (AJCC) staging. Methods: We used Cox proportional hazards regression analyses to model variables of 731 consecutive patients treated with radical cystectomy and bilateral pelvic lymphadenectomy for bladder transitional cell carcinoma. Variables included age of patient, gender, pathologic stage (pT), pathologic grade, carcinoma in situ, lymphovascular invasion (LVI), lymph node status (pN), neoadjuvant chemotherapy (NACH), adjuvant chemotherapy (ACH), and adjuvant external beam radiotherapy (AXRT). Two hundred bootstrap resamples were used to reduce overfit bias and for internal validation. Results: During a mean follow-up of 36.4 months, 290 of 731 (39.7%) patients died; 196 of 290 patients (67.6%) died of bladder cancer. Actuarial all-cause survival estimates were 56.3% [95% confidence interval (95% CI), 51.8-60.6%] and 42.9% (95% CI, 37.3-48.4%) at 5 and 8 years after cystectomy, respectively. Actuarial cancer-specific survival estimates were 67.3% (62.9-71.3%) and 58.7% (52.7-64.2%) at 5 and 8 years, respectively. The accuracy of a nomogram for prediction of all-cause survival (0.732) that included patient age, pT, pN, LVI, NACH, ACH, and AXRT was significantly superior (P = 0.001) to that of AJCC staging–based risk grouping (0.615). Similarly, the accuracy of a nomogram for prediction of cancer-specific survival that included pT, pN, LVI, NACH, and AXRT (0.791) was significantly superior (P = 0.001) to that of AJCC staging–based risk grouping (0.663). Conclusions: Multivariate nomograms provide a more accurate and relevant individualized prediction of survival after cystectomy compared with conventional prediction models, thereby allowing for improved patient counseling and treatment selection.

The Expanding Role of Partial Nephrectomy: A Critical Analysis of Indications, Results, and Complications

CONTEXT The gained expertise in the surgical technique of partial nephrectomy (PN) with excellent oncologic outcome and reduced morbidity has contributed to more frequent use of PN in many centres of reference, and the recent evidence favouring PN over radical nephrectomy (RN) in the prevention of chronic kidney disease and possibly linking it to a better overall survival (OS) will constitute a strong argument for wider use of PN. OBJECTIVE To objectively analyse the advantages of PN over RN and to evaluate the risk-benefit ratio of expanding the indications of PN T1b renal cortical tumours. EVIDENCE ACQUISITION Literature searches on English-language publications were performed using the National Library of Medicine database. The queries included the keywords partial nephrectomy and nephron sparing surgery. Eight hundred four references were scrutinised, and 175 publications were identified and reviewed. Sixty-nine articles were selected for this review. These references formed the basis for this analysis and were selected based on their relevance and the importance of their content. EVIDENCE SYNTHESIS The use of PN has been steadily increasing, particularly in tertiary care centres. This trend is now strengthened by evidence supporting the role of PN in reducing the risk of chronic kidney disease in patients with renal masses < or =4 cm. A wider use of PN for larger tumours, granted technical feasibility, is supported by the preliminary evidence, suggesting an OS advantage favouring PN over RN. However, the potential for selection bias and residual confounding factors may contribute to the observed difference. In the carefully selected patients with tumours >4 cm, PN obtained equivalent oncologic outcome to that achieved after RN. Although higher morbidity rates were seen after PN, the complication type and severity were not prohibitive. CONCLUSIONS The available evidence supports elective PN as the standard surgical treatment for renal cortical tumours < or =4 cm. For larger tumours, PN has demonstrated feasibility and oncologic safety in the carefully selected patient population studied.

Robot-Assisted Partial Nephrectomy: An International Experience

BACKGROUND Robot-assisted partial nephrectomy (RAPN) is emerging as a viable approach for nephron-sparing surgery (NSS), though many reports to date have been limited by evaluation of a relatively small number of patients. OBJECTIVE We present the largest multicenter RAPN experience to date, culling data from four high-volume centers, with focus upon functional and oncologic outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective chart review was performed for 183 patients who underwent RAPN at four centers between 2006 and 2008. SURGICAL PROCEDURE RAPN was performed using methods outlined in the supplemental video material. Though operative technique was similar across all institutions, there were minor variations in trocar placement and hilar control. MEASUREMENTS Perioperative parameters, including operative time, warm ischemic time, blood loss, and perioperative complications were recorded. In addition, we reviewed functional and oncologic outcomes. RESULTS AND LIMITATIONS Mean age at treatment was 59.3 yr. Mean tumor size was 2.87 cm. Mean total operative time was 210 min while mean ischemic time was 23.9 min. Calyceal repair was required in 52.1% of procedures. Mean estimated blood loss was 131.5 ml. Sixty-nine percent of excised tumors were malignant, of which 2.7% exhibited positive surgical margins. The incidence of major complications was 8.2%. At up to 26 mo follow-up, there have been no documented recurrences and no significant change in serum creatinine (1.03 vs 1.04 mg/dl, p=0.84) or estimated glomerular filtration rate (eGFR) from baseline (82.2 vs 79.4 mg/ml per square meter, p=0.74). The study is limited by its retrospective nature, and the outcomes are likely influenced by the robust prior laparoscopic renal experience of each of the surgeons included in this study. CONCLUSIONS RAPN is a safe and efficacious approach for NSS, offering short ischemic times, as well as perioperative morbidity equivalent to other standard approaches. Moreover, RAPN is capable of providing patients with excellent functional and oncologic outcomes.

Robotic Partial Nephrectomy for Renal Hilar Tumors: A Multi-Institutional Analysis

PURPOSE Laparoscopic partial nephrectomy is an advanced surgical procedure requiring technical skill in minimally invasive techniques. Tumors located adjacent to the renal hilum pose an additional challenge. We report a multi-institutional study of robotic partial nephrectomy for renal hilar tumors and describe our results. MATERIALS AND METHODS We evaluated patients from 2 institutions who underwent robotic partial nephrectomy for renal hilar tumors. Renal hilar tumors were defined as tumors abutting the renal artery and/or renal vein on preoperative imaging. After clamping the renal hilar vessels tumors were excised with fine dissection from the renal vessels followed by sutured renal reconstruction. RESULTS Robotic partial nephrectomy was successfully performed on 11 patients (mean age 56.4 years, range 30 to 76). Mean tumor size was 3.8 cm (range 2.3 to 6.4). Mean warm ischemia time was 28.9 minutes (range 20 to 39) and mean operating time was 202 minutes (range 154 to 253). Mean blood loss was 220 ml (range 50 to 750). Mean hospital stay was 2.6 days (range 1 to 4). Histopathological evaluation confirmed 8 cases of clear cell renal cell carcinoma, 1 of papillary renal cell carcinoma and 2 of chromophobe renal cell carcinoma. Surgical margins were negative for malignancy in all cases. CONCLUSIONS Robotic partial nephrectomy is a safe and feasible approach for select patients with renal hilar tumors. Robotic assistance may facilitate tumor resection and renal reconstruction for challenging renal hilar tumors, offering a minimally invasive and nephron sparing surgical option for select patients who might otherwise require open surgery or total nephrectomy.

Robotic Partial Nephrectomy for Renal Tumors Larger Than 4 cm

BACKGROUND Minimally invasive partial nephrectomy (PN) is most commonly performed for renal tumors < or =4 cm in size. Robotic PN (RPN) for tumors >4 cm has not been assessed. OBJECTIVE To evaluate the safety and feasibility of RPN for tumors >4 cm in the context of patients undergoing RPN for tumors < or =4 cm. DESIGN, SETTING, AND PARTICIPANTS We reviewed data for 71 consecutive patients who underwent transperitoneal RPN at a tertiary care center between August 2007 and September 2009 by a single surgeon. Patients were stratified into two groups: 15 with tumors >4 cm on preoperative imaging (group 1) and 56 patients with tumors < or =4 cm (group 2). INTERVENTION All patients underwent transperitoneal RPN by a single surgeon. MEASUREMENTS Preoperative, perioperative, pathologic, and functional outcomes data were analyzed and compared between groups. We used chi(2) and student t tests for categorical and continuous variables, respectively. A p value <0.05 was considered statistically significant. RESULTS AND LIMITATIONS Mean radiographic tumor size was 5.0 cm (4.1-7.9) for group 1 and 2.1cm (0.7-3.8) for group 2. No significant differences were found between groups for estimated blood loss, total operative time, hospital stay, complication rates, and change in estimated glomerular filtration rate. Patients with larger tumors had longer median warm ischemia times (25 vs 20 min; p=0.011). Limitations of our study include the retrospective nature the analysis, small sample size, and single-surgeon experience. CONCLUSIONS In our initial experience, RPN for tumors >4 cm is safe and feasible, showing comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times. Future studies with extended follow-up are necessary to determine the viability of RPN for large tumors as an effective form of treatment.

Clinical Outcomes Following Radical Cystectomy for Primary Nontransitional Cell Carcinoma of the Bladder Compared to Transitional Cell Carcinoma of the Bladder

PURPOSE The effect of bladder cancer histological subtypes other than transitional cell carcinoma (nonTCC) on clinical outcomes remains uncertain. We conducted a multi-institutional retrospective study of patients with bladder cancer treated with radical cystectomy to assess the impact of nonTCC histology on bladder cancer specific outcomes. MATERIALS AND METHODS A total of 955 consecutive patients underwent radical cystectomy with bilateral pelvic lymphadenectomy for bladder cancer at 3 academic institutions. TCC was present in the radical cystectomy specimen in 888 patients (93%). NonTCC histology was present in 67 patients (7%), including squamous cell carcinoma in 26, adenocarcinoma in 13, small cell carcinoma in 10 and other nonTCC subtypes (ie spindle cell carcinoma, carcinosarcoma and undifferentiated carcinoma) in 18. For patients alive at last followup median followup was 39 and 23 months for patients with TCC and nonTCC histologies, respectively. Bladder cancer specific progression and survival were assessed using Kaplan-Meier and multivariate Cox proportional hazards analyses. RESULTS Bladder cancer specific progression and mortality did not differ significantly between patients with SCC and TCC histologies. Patients with nonTCC and nonSCC bladder cancer were at significantly increased risk for progression and death compared to patients with TCC or SCC (p <0.001). This association remained statistically significant in patients with organ confined disease (stage pT2 or lower) and patients with nonorgan confined disease (stage pT3 or higher) (p <0.001). In a multivariate analysis nonTCC and nonSCC histology was associated with an increased risk of bladder cancer progression and death (OR 2.272 and 2.585, respectively, p <0.001), even after adjusting for final pathological stage, lymph node status, lymphovascular invasion and neoadjuvant or adjuvant treatments. CONCLUSIONS NonTCC and nonSCC histological subtype is an independent predictor of bladder cancer progression and mortality in patients undergoing radical cystectomy for bladder cancer. Patients with bladder TCC and SCC share similar stage specific clinical outcomes.

Practice Patterns and Outcomes of Open and Minimally Invasive Partial Nephrectomy Since the Introduction of Robotic Partial Nephrectomy: Results from the Nationwide Inpatient Sample

PURPOSE We determined practice patterns and perioperative outcomes of open and minimally invasive partial nephrectomy in the United States since the introduction of a robot-assisted modifier in the Nationwide Inpatient Sample. MATERIALS AND METHODS We identified all patients with nonmetastatic disease treated with open, laparoscopic or robotic partial nephrectomy in the Nationwide Inpatient Sample between October 2008 and December 2010. Utilization rates were assessed by year, patient and hospital characteristics. We evaluated the perioperative outcomes of open vs robotic and open vs laparoscopic partial nephrectomy using binary logistic regression models adjusted for patient and hospital covariates. RESULTS In a weighted sample of 38,064 partial nephrectomies 66.9%, 23.9% and 9.2% of the procedures were open, robotic and laparoscopic operations, respectively. In 2010 the relative annual increase in open, robotic and laparoscopic partial nephrectomy was 7.9%, 45.4% and 6.1%, respectively. Compared to open partial nephrectomy patients treated with minimally invasive partial nephrectomy were less likely to receive blood transfusion (robotic vs laparoscopic OR 0.56, p <0.001 vs OR 0.68, p = 0.016), postoperative complication (OR 0.63, p <0.001 vs OR 0.78, p <0.009) or prolonged length of stay (OR 0.27 vs OR 0.41, each p <0.001). Only patients who underwent the robotic procedure were less likely to experience an intraoperative complication (robotic vs laparoscopic OR 0.69, p = 0.014 vs OR 0.67, p = 0.069). Excess hospital charges were higher after robotic surgery (OR 1.35, p <0.001). CONCLUSIONS The dissemination of robotic surgery for partial nephrectomy in the United States has been rapid and safe. Compared to open partial nephrectomy the robotic procedure had lower odds than laparoscopic partial nephrectomy for most study outcomes except hospital charges. Robotic partial nephrectomy has now supplanted laparoscopic partial nephrectomy as the most common minimally invasive approach for partial nephrectomy.