Transition from open partial nephrectomy directly to robotic surgery: experience of a single surgeon to achieve “TRIFECTA”

Abstract

Introduction: Recent data suggest that robotic platform has become the most accessible minimal invasive surgery even for surgeons without previous training in laparoscopy. Laparoscopic partial nephrectomy (LPN) is a well-stablished procedure, however, with high level of complexity and long learning curve that limit its use. Objective: To describe safety, efficiency and learning curve of a single surgeon without previous experience in LPN to reach “TRIFECTA” at robot-assisted partial nephrectomy (RAPN). Patients and Methods: This is a retrospective study, with prospective data collection of 101 patients submitted to RAPN by a single surgeon. In order to analyze the learning curve, sample was chronologically divided in two phases: first phase: P1: 50 first patients, second phase: P2: 51 subsequent patients. TRIFECTA was defined as: ischemia time lower than 25 minutes, negative surgical margin and absence of severe complications (Clavien >2). Results: Mean age of patients was 54 years (SD=11.85), median tumor size was 32mm (SD=17) and surgery was performed with zero ischemia time in 33.6% of patients (29.8% at P1 and 40.9% at P2). Demographic data of patients were similar between both groups, except tumor size (P1=27.5mm vs. P2=35.3mm; p=0.02) and body mass index (BMI) (P1=26.6kg/m 2 vs. P2=29kg/m 2 ; p=0.03). Rate of bleeding, surgical time, presence of positive margin and peri-operatory surgical complications were similar in both phases. TRIFECTA was higher in P2 in relation to P1 (P1: 58% vs. P2: 87.8%; p=0.002) and median time of hot ischemia was significantly lower at P2 (P1: 17.3 vs. P2: 11.7; p=0.02). At multivariate analysis independent factors related to TRIFECTA included: chronological phase (OR 10.74; 95% IC: 1.63-70.53; p=0.013) and tumor size (OR 0.95; 95% IC: 0.91-0.99; p=0.024). Conclusion: RAPN seems to be safe and efficient with good functional and oncological results (TRIFECTA) since the beginning. Experience improvement was related to treatment of larger tumors, higher proportion of patients with zero ischemia and higher rate of TRIFECTA.

Predicting Strict Trifecta Outcomes after Robot-Assisted Partial Nephrectomy: Comparison of RENAL, PADUA, and C-Index Scores

“…In a similar study including 63 patients undergoing laparoscopic PN in T1a renal masses, Osaka et al reported that the tumor size and surgeon's learning curve were predictors of Trifecta outcomes (26). Similar to this findings, the experience of the surgeon and the size of the tumor independently predicted Trifecta outcomes (19). Another study reported that the significant predictors of Trifecta success were the tumor size, EBL, OT, robotic surgery, and high risk RENAL scores in the multivariate analysis (22).…”

“…The Trifecta achievement rate in previous studies has ranged between 31.6% and 87.8% ( 17 – 19 ). Several reasons such as surgical experience, different definitions of Trifecta, and surgical approach could have been implicated as adversely influencing the outcomes of Trifecta.…”

“…In contrast, Zargar et al reported that robotic PNs were more likely than laparoscopic approach to achieve the Trifecta ( 22 ). In a study evaluating the surgical experience found that increased experience leads to higher proportion of Trifecta ( 19 ). In our study, the strict Trifecta rate was 59.3%.…”

Practical evaluation of the R.E.N.A.L. score system in 150 laparoscopic nephron sparing surgeries

“…Some reports show that robotic assisted NSS is safe and feasible with good short term oncological outcome, and possibility to be performed in complex cases with better results. Further experience is needed to validate RS in this scenario (32,33). Laparoscopy is still performed in a lot of countries where the access to robotic surgery is limited, even in complex cases (34).…”

Trifecta achievement in patients undergoing partial nephrectomy: a systematic review and meta-analysis of predictive factors

“…It provides a definition of an ideal surgical outcome that includes the following three criteria: negative surgical margins, maximum renal function retention and patient recovery without complications. The use of trifecta rate as a key indicator of partial nephrectomy success has been widely reported (8)(9)(10)(11). Recently, some researchers have proposed several anatomic classification scoring systems to classify and stratify patients into different anatomic complexity groups, and allow doctors to evaluate perioperative outcomes (12)(13)(14)(15).…”