Stephen Ryan

Outcomes of Robot-assisted Partial Nephrectomy for Clinical T2 Renal Tumors: A Multicenter Analysis (ROSULA Collaborative Group)

BACKGROUNDnWhile partial nephrectomy (PN) represents the standard surgical management for cT1 renal masses, its role for cT2 tumors is controversial. Robot-assisted PN (RAPN) is being increasingly implemented worldwide.nnnOBJECTIVEnTo analyze perioperative, functional, and oncological outcomes of RAPN for cT2 tumors.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective analysis of a large multicenter, multinational dataset of patients with nonmetastatic cT2 masses treated with robotic surgery (ROSULA: RObotic SUrgery for LArge renal mass).nnnINTERVENTIONnRobotic-assisted PN.nnnOUTCOME MEASUREMENTS AND STATISTICAL ANALYSISnPatients demographics, lesion characteristics, perioperative variables, renal functional data, pathology, and oncological data were analyzed. Univariable and multivariable regression analyses assessed the relationships with the risk of intra-/postoperative complications, recurrence, and survival.nnnRESULTS AND LIMITATIONSnA total of 298 patients were analyzed. Median tumor size was 7.6 (7-8.5) cm. Median RENAL score was 9 (8-10). Median ischemia time was 25 (20-32) min. Median estimated blood loss was 150 (100-300) ml. Sixteen patients had intraoperative complications (5.4%), whereas 66 (22%) had postoperative complications (5% were Clavien grade ≥3). Multivariable analysis revealed that a lower RENAL score (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.21-0.65, p=0.02) and pathological pT2 stage (OR 0.51, 95% CI 0.12-0.86, p=0.001) were protective against postoperative complications. A total of 243 lesions (82%) were malignant. Twenty patients (8%) had positive surgical margins. Ten deaths and 25 recurrences/metastases occurred at a median follow-up of 12 (5-35) mo. At univariable analysis, higher pT stage was predictive of a likelihood of recurrences/metastases (p=0.048). While there was a significant deterioration of renal function at discharge, this remained stable over time at 1-yr follow-up. The main limitation of this study is its retrospective design.nnnCONCLUSIONSnRAPN in the setting of select cT2 renal masses can safely be performed with acceptable outcomes. Further studies are warranted to corroborate our findings and to better define the role of robotic nephron sparing for this challenging indication.nnnPATIENT SUMMARYnThis report shows that robotic surgery can be used for safe removal of a large renal tumor in a minimally invasive fashion, maximizing preservation of renal function, and without compromising cancer control.

Comparison of functional outcomes of robotic and open partial nephrectomy in patients with pre-existing chronic kidney disease: a multicenter study

BackgroundWe compared renal functional outcomes of robotic (RPN) and open partial nephrectomy (OPN) in patients with chronic kidney disease (CKD), a definite indication for nephron-sparing surgery.MethodsA multicenter retrospective analysis of OPN and RPN in patients with baseline ≥u2009CKD Stage III [estimated glomerular filtration rate (eGFR) <u200960xa0mL/min/1.73xa0m2] was performed. Primary outcome was change in eGFR (ΔeGFR, mL/min/1.73xa0m2) between preoperative and last follow-up with respect to RENAL nephrometry score group [simple (4–6), intermediate (7–9), complex (10–12)]. Secondary outcomes included eGFR decline >u200950%.Results728 patients (426 OPN, 302 RPN, mean follow-up 33.3xa0months) were analyzed. Similar RENAL score distribution (pu2009=u20090.148) was noted between groups. RPN had lower median estimated blood loss (pu2009<u20090.001), and hospital stay (3 vs. 5xa0days, pu2009<u20090.001). Median ischemia time (OPN 23.7 vs. RPN 21.5xa0min, pu2009=u20090.089), positive margin (pu2009=u20090.256), transfusion (pu2009=u20090.166), and 30-day complications (pu2009=u20090.208) were similar. For OPN vs. RPN, mean ΔeGFR demonstrated no significant difference for simple (0.5 vs. 0.3, pu2009=u20090.328), intermediate (2.1 vs. 2.1, pu2009=u20090.384), and complex (4.9 vs. 6.1, pu2009=u20090.108). Cox regression analysis demonstrated that decreasing preoperative eGFR (OR 1.10, pu2009=u20090.001) and complex RENAL score (OR 5.61, pu2009=u20090.03) were independent predictors for eGFR decline >u200950%. Kaplan–Meier analysis demonstrated 5-year freedom from eGFR decline >u200950% of 88.6% for OPN and 88.3% for RPN (pu2009=u20090.724).ConclusionsRPN and OPN demonstrated similar renal functional outcomes when stratified by tumor complexity group. Increasing tumor age and tumor complexity were primary drivers associated with functional decline. RPN provides similar renal functional outcomes to OPN in appropriately selected patients.