Urologic Oncology: Seminars and Original Investigations
Original articleRobotic versus open partial nephrectomy for highly complex renal masses: Comparison of perioperative, functional, and oncological outcomes
Introduction
Considerable evidence suggests that partial nephrectomy (PN) for localized renal cell carcinoma has equivalent oncological outcomes when compared to radical nephrectomy [1], [2]. Another unique feature of PN over radical nephrectomy relates to better renal functional preservation, which may confer a lower risk of cardiovascular disease, translating into better overall survival [3]. Various surgical approaches for PN have been described, including open (OPN) and minimally invasive techniques, namely laparoscopic (LPN) and the robot-assisted (RAPN). The adoption of minimally invasive approaches has achieved broad acceptance with favorable outcomes. An initial comparison of 1,800 LPN and OPN for single renal tumors showed functional (3 months renal functional outcomes were 97.9% and 99.6% of renal units retaining function, respectively) and early oncological (3 years cancer-specific survival was 99.3% and 99.2%, respectively) outcomes equivalent to those of OPN [4]. With technological evolution and the adoption of robotic surgical platforms, multiple comparative series showed that RAPN has perioperative outcomes similar to those of LPN [5], [6]. The high-definition, three-dimensional optical system, and the wristed instruments of RAPN have been described to allow the surgeon to perform more precise tumor excision and renorrhaphy, providing advantages over LPN [7]. Moreover, as the RAPN experience has evolved, a preference toward such an approach when performing larger and more complex renal tumors has been observed at tertiary care centers [8]. Indeed, tumor size and anatomical characteristics should be considered in order to determine the complexity of the tumor before PN. In order to have a consistent nomenclature, Kutikov et al. introduced the R.E.N.A.L. nephrometry score to quantify the anatomical characteristics of renal masses on imaging studies based on tumor size, location, and depth [9]. This scoring system implements a standardized anatomical classification to facilitate surgical decision-making, and categorize the complexity of the renal masses (RENAL score range of 4 to 6, 7 to 9, and 10 to 12 are deemed too low, moderate, and high complexity lesions, respectively). Notably, a recent multi-institutional study showed a significant association of RENAL score in predicting prolonged warm ischemia time and high-grade postoperative complications after RAPN [10], [11]. A paucity of comparative studies between RAPN and OPN is available for highly complex renal tumors [11]. Trying to contribute in filling the gap in the literature, we performed the present study. The primary aim was to compare the perioperative outcomes of OPN and RAPN for renal tumors with RENAL score > 9. Factors potentially associated with occurrence of complications were investigated. The secondary aim was to compare the functional and the oncological outcomes.
Section snippets
2.1. Study population
The institutional review board-approved PN database was reviewed to obtain data from consecutive patients who underwent PN for renal tumors from January 2006 to December 2016 (IRB 5065 and 15-1593). Patients who had solitary kidneys, multifocal tumors, and radiographic evidence of metastatic disease were excluded.
Moreover, specifically for the purpose of the study, only patients with RENAL score > 9 were extracted and considered for the analysis.
All patients had undergone preoperative
Results
A total of 279 patients who underwent PN for highly complex renal mass (RENAL score > 9) were extracted.
Two hundred three patients underwent RAPN; 76 underwent OPN. Patients in RAPN and OPN groups were comparable at baseline in demographics, renal functional data, and tumor characteristics (Table 1).
The intraoperative, postoperative data, and complication rates are reported in Table 2. Compared to RAPN, patients who underwent OPN were found to have higher blood losses (300 vs. 200 ml; P <
Discussion
Partial nephrectomy has demonstrated a reduction in renal function impairment with no difference in oncological outcomes including better long-term survival when compared with radical nephrectomy [2], [3]. For decades, the open approach has been the standard for performing PN. With advancements in minimally invasive surgery, LPN rapidly gained interest for localized renal cell carcinoma due to its reduced invasiveness. Nevertheless, with LPN being a challenging procedure, robot-assisted surgery
Conclusion
In our large institutional series of patients with highly complex solid renal tumors as classified by RENAL score > 9, RAPN appeared to be a safe and effective alternative to OPN with the advantages of reduced blood loss, shorter ischemia time and length of stay.
Financial disclosures
Jihad H. Kaouk certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (e.g., employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Endocare, Inc, Intuitive. - J.H. Kaouk (consultant).
Juan Garisto, Riccardo Bertolo, Daniel Sagalovich,
Acknowledgments
None.
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