Mingmin Li

Robotic versus Open Partial Nephrectomy: A Systematic Review and Meta-Analysis

Objectives To critically review the currently available evidence of studies comparing robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN). Materials and Methods A comprehensive review of the literature from Pubmed, Web of Science and Scopus was performed in October 2013. All relevant studies comparing RPN with OPN were included for further screening. A cumulative meta-analysis of all comparative studies was performed and publication bias was assessed by a funnel plot. Results Eight studies were included for the analysis, including a total of 3418 patients (757 patients in the robotic group and 2661 patients in the open group). Although RPN procedures had a longer operative time (weighted mean difference [WMD]: 40.89; 95% confidence interval [CI], 14.39–67.40; p = 0.002), patients in this group benefited from a lower perioperative complication rate (19.3% for RPN and 29.5% for OPN; odds ratio [OR]: 0.53; 95%CI, 0.42–0.67; p<0.00001), shorter hospital stay (WMD: −2.78; 95%CI, −3.36 to −1.92; p<0.00001), less estimated blood loss(WMD: −106.83; 95%CI, −176.4 to −37.27; p = 0.003). Transfusions, conversion to radical nephrectomy, ischemia time and estimated GFR change, margin status, and overall cost were comparable between the two techniques. The main limitation of the present meta-analysis is the non-randomization of all included studies. Conclusions RPN appears to be an efficient alternative to OPN with the advantages of a lower rate of perioperative complications, shorter length of hospital stay and less blood loss. Nevertheless, high quality prospective randomized studies with longer follow-up period are needed to confirm these findings.

Laparoendoscopic single-site adrenalectomy versus conventional laparoscopic surgery: a systematic review and meta-analysis of observational studies.

PURPOSE To assess the surgical efficacy and potential advantages of laparoendoscopic single-site adrenalectomy (LESS-AD) compared with conventional laparoscopic adrenalectomy (CL-AD) based on published literature. METHODS An online systematic search in electronic databasesM including Pubmed, Embase, and the Cochrane Library, as well as manual bibliography searches were performed. All studies that compared LESS-AD with CL-AD were included. The outcome measures were the patient demographics, tumor size, blood loss, operative time, time to resumption of oral intake, hospital stay, postoperative pain, cosmesis satisfaction score, rates of complication, conversion, and transfusion. A meta-analysis of the results was conducted. RESULTS A total of 443 patients were included: 171 patients in the LESS-AD group and 272 patients in the CL-AD group (nine studies). There was no significant difference between the two groups in any of the demographic parameters expect for lesion size (age: P=0.24; sex: P=0.35; body mass index: P=0.79; laterality: P=0.76; size: P=0.002). There was no significant difference in estimated blood loss, time to oral intake resumption, and length of stay between the two groups. The LESS-AD patients had a significantly lower postoperative visual analog pain score compared with the CL-AD group, but a longer operative time was noted. Both groups had a comparable cosmetic satisfaction score. The two groups had a comparable rate of complication, conversion, and transfusion. CONCLUSIONS In early experience, LESS-AD appears to be a safe and feasible alternative to its conventional laparoscopic counterpart with decreased postoperative pain noted, albeit with a longer operative time. As a promising and emerging minimally invasive technique, however, the current evidence has not verified other potential advantages (ie, cosmesis, recovery time, convalescence, port-related complications, etc.) of LESS-AD.

Propensity-score matched analysis comparing robot-assisted with laparoscopic partial nephrectomy.

To compare the peri‐operative and early renal functional outcomes of robot‐assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for kidney tumours.

Correlations of tumor size, RENAL, centrality index, preoperative aspects and dimensions used for anatomical, and diameter-axial-polar scoring with warm ischemia time in a single surgeon's series of robotic partial nephrectomy.

OBJECTIVE To evaluate the association of tumor size, renal nephrometry systems (RNSs), including RENAL, centrality index (C-index), preoperative aspects and dimensions used for anatomical, and diameter-axial-polar scoring, and individual categories of these RNSs with warm ischemia time (WIT). METHODS A single surgeons series of robotic partial nephrectomy patients for whom RNS was available were identified from 2012 to 2013. Spearmans correlation was used to evaluate associations between the RNSs and individual categories and WIT. RESULTS Analysis was performed based on 69 patients with a median tumor size of 3.5 cm (interquartile range 2.6-4.2). Overall, each scoring system and tumor size were found to have a statistically significant association with the WIT, with the C-index system exhibiting the strongest correlation (coefficient: -0.609, P <.001), which was confirmed in the series beyond the surgeons learning curve. In the subgroup of relatively small renal masses (<3 cm), there was a statistically significant association between the C-index, preoperative aspects and dimensions used for anatomical, and diameter-axial-polar systems with WIT. However, for tumors >3 cm, none of the RNSs was found to have a statistically significant correlation with WIT, except for the tumor size (coefficient: 0.354, P = .027). For subcategories, axial scoring was found to have a consistent statistically significant correlation with WIT. CONCLUSION Overall, each RNS and tumor size strongly correlated with WIT in patients undergoing robotic partial nephrectomy. However, the RNS outperformed tumor size in small (<3 cm) renal masses with an optimal discriminating power, whereas for relatively larger (>3 cm) tumors, WIT was significantly dependent on tumor size, and every centimeter may count.

Is diameter‐axial‐polar scoring predictive of renal functional damage in patients undergoing partial nephrectomy? An evaluation using technetium Tc 99m (99Tcm) diethylene‐triamine‐penta‐acetic acid (DTPA) glomerular filtration rate

To identify the effects of diameter‐axial‐polar (DAP) scoring and other clinical variables on renal functional outcomes after partial nephrectomy (PN).

A propensity-score matched comparison of perioperative and early renal functional outcomes of robotic versus open partial nephrectomy.

Objectives To compare the perioperative and early renal functional outcomes of RPN with OPN for kidney tumors. Materials and Methods A total of 209 RPN or OPN patients with availability of preoperative cross-sectional imaging since 2009 at our center were included. To adjust for potential baseline confounders propensity-score matching was performed, which resulted in 94 OPNs matched to 51 RPNs. Perioperative and early renal functional outcomes were compared. Results In propensity-score matched analysis, RPN procedures were well tolerated and resulted in significant decreases in postoperative analgesic time (24 vs. 48 hr, p<0.001) and visual analog pain scale (3 vs. 4, p<0.001). Besides, the RPN patients had a significantly shorter LOS (9 vs. 11 days, p = 0.008) and less EBL (100 vs. 200 ml, p<0.001), but median operative time was significantly longer (229 vs. 182 min, p<0.001). Ischemia time, transfusion rates, complication rates, percentage eGFR decline and CKD upstaging were equivalent after RPN versus OPN. In multivariable logistic regression analysis, RPN patients were less likely to have a prolonged LOS (odds ratio [OR]: 0.409; p = 0.016), while more likely to experience a longer operative time (OR: 4.296; p = 0.001). However, the statistical significance for the protective effect of RPN versus OPN in EBL was not confirmed by examining the risk of EBL≥400 ml (OR: 0.488; p = 0.212). Conclusions When adjusted for potential selection biases, RPN offers comparable perioperative and early renal functional outcomes to those of OPN, with the added advantage of improved postoperative pain control and a shorter LOS.

Diameter-Axial-Polar Nephrometry is Predictive of Surgical Outcomes Following Partial Nephrectomy.

Abstract This study sought to evaluate the predictive value of the DAP (diameter-axial-polar) nephrometry system on surgical outcomes following partial nephrectomy (PN). This was a retrospective study of 237 patients who underwent open or minimally invasive PN for renal tumors at a single tertiary care center between 2009 and 2013. The primary outcomes included ischemia time >20 minutes and percentage of estimated glomerular filtration rate (eGFR) decline >10%. Statistical analysis was performed to study associations and predictions. The DAP sum score exhibited a statistically significant correlation with ischemia time, operative time (OT), estimated blood loss (EBL), length of hospital stay (LOS), and percent change in eGFR. The DAP sum score (odds ratio [OR]: 1.749; 95% confidence interval [CI] 1.379–2.220; P < 0.001) and conventional laparoscopy and laparo-endoscopic single-site (CL&LESS) surgery versus the open surgical approach (OR: 5.736; 95% CI: 2.529–13.011; P < 0.001) independently predicted an ischemia time >20 minutes. Similarly, the DAP sum score (OR: 1.297; 95% CI 1.051–1.602; P = 0.016), age-weighted Charlson comorbidity index (CCI) (OR: 4.730; 95% CI 1.463–15.291; P = 0.009), EBL (OR 2.433; 95% CI 1.095–5.407; P = 0.029), and ischemia time (OR 3.332; 95% CI 1.777–6.249; P < 0.001) were identified as independent predictors of eGFR decline >10%. Furthermore, the DAP score × ischemia time interactions were statistically significant (P < 0.001). We confirmed the predictive value of the DAP nephrometry score with respect to ischemia time and renal functional decline in an independent external cohort of patients undergoing PN. The effect of the DAP score on renal functional decline partially depends on that of ischemia time, and the individual component DAP scores may have different effects on clinical outcomes.

Left Laparoscopic Radical Nephrectomy in the Presence of a Duplicated Inferior Vena Cava With Complicated Anomalous Tributaries by a Transmesocolic Approach

Laparoscopic radical nephrectomy should be executed under the most fundamental principle of early ligature of the renal artery to prevent diffusion of cancerous cells. This is extremely true in the treatment of large renal tumors touching the main renal vasculature. Obviously, the concomitance of a duplicated inferior vena cava (IVC) with associated aberrant tributaries will significantly increase the surgical difficulty and the procedural risk of vascular injury. Herein we describe a transperitoneal left laparoscopic radical nephrectomy for a large hilar left renal tumor in the presence of a duplicated IVC with complicated anomalous tributaries by a transmesocolic approach.

Synchronous Transperitoneal Laparoscopic Resection of Right Retroperitoneal Schwannoma and Left Kidney Monotypic PEComa in the Presence of a Duplicated Inferior Vena Cava (IVC)

A 21-year-old female presented with a retroperitoneal mass in the right side and a centrally located renal mass in the left kidney with an aberrant vascular anatomy of a double inferior vena cava. The 2 tumors were radically excised by a transperitoneal laparoscopic approach in one session. Histopathologic examination revealed the right retroperitoneal lesion to be a schwannoma and the renal mass to be a cluster of monotypic neoplasms with perivascular epithelioid cell differentiation (PEComas). The latter is a rare tumor.

MP59-13 DOES THE RENAL NEPHROMETRY SYSTEM HAVE ITS OWN INDICATION IN PREDICTING SURGICAL OUTCOMES?--CORRELATION OF TUMOR SIZE, R.E.N.A.L., C-INDEX, PADUA AND DAP SCORING WITH WARM ISCHEMIA TIME IN A SINGLE SURGEON'¯S SERIES OF ROBOTIC PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: Renal cell carcinoma (RCC) makes up 3-5% of all cancers. Of these, cystic RCCs constitute between 3-14%, and are often detected incidentally as complex enhancing renal cysts on imaging. Since 2004, there has been a pathological reclassification of cystic clear RCC leading to description of multilocular cystic RCC (mcRCC) as a subtype of clear cell RCC. Other types include tubulocystic RCC. We aimed to study the histologic patterns and survival outcomes of all recorded cystic RCCs using a province-wide cancer registry database for Ontario. METHODS: A retrospective review of all histologically-proven cases of cystic RCC treated by partial or radical nephrectomy (PN or RN) between 1995 and 2004 identified from the Ontario Cancer Registry was performed. Patient demographics, type of surgery, histologic features and survival outcomes were evaluated. RESULTS: A total of 107 cystic RCCs were identified in 106 patients. Mean age was 55 years, with a male preponderance of 58%. RN was performed in 55% with adrenalectomy in 25%. Mean lesion size at histology was 4.16cm(1-18cm). Vast majority (106) were cystic clearcell or multilocular cystic RCC (mcRCC) with one case of tubulocystic RCC. Ninety-five % were low grade (Fuhrman grade 1-2). There was only 1 case of vascular invasion and none of lymphatic invasion. None of the cases involved the renal pelvis or adrenal gland where removed. There were 2 small renal vein thrombi, and 3 cases of perinephric fat invasion. All cases were margin-negative. Patients had a median postoperative follow up of 5 years. Twelve deaths were reported but none were caused by RCC. CONCLUSIONS: We believe that our study is the largest series of cystic RCCs to date. It confirms a favourable histology and an excellent prognosis of mcRCC. Given that this series excludes patients who underwent surgery and had a final pathological diagnosis which was benign, the magnitude of this favourable prognosis is under-represented. This makes a strong case for nephron-sparing, adrenalsaving approach for cystic renal masses suspicious of being RCCs.