Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: Feasibility, renal functional, and oncological outcomes with minimum 1 year follow-up

Abstract

Objectives Minimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncological outcomes with minimum 1 year follow up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm. Methods and Materials The urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate and nuclear renal scans assessed at baseline, 3 and 12 months post-operatively. All tumors were assigned R.E.N.A.L. nephrometry scores (www.nephrometry.com). Results The median nephrometry score for the largest tumor from each kidney was 9 (range 6–11) while the median size was 5 cm (range 4.1–15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, p=0.006) was observed at three months and at twelve months postoperatively (49% vs. 45.5%, p=0.014). No patients had evidence of recurrence or metastatic disease at a median follow up of 22 months (range 12–36). Conclusions RALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncological outcomes are promising at a median follow up of 22 months, but longer follow up is required.

Simple enucleation for the treatment of highly complex renal tumors: Perioperative, functional and oncological results

“…26 Few studies on highly complex RCC are available, and most with short follow-up, therefore whether the correlation between adverse pathological findings/poor survival outcome and higher nephrometry score is stronger than that with higher TNM stage is still debated. In a study on 80 patients treated 27 In another study of 19 RPN in RCC with moderate-high nephrometry score, 28 no increased progression rate was found, but with a median follow-up of 22 months only. In the current study, 5 year RFS and CSS were 90.8% and 96.1% respectively.…”

Multi-Institutional Analysis of Robot-Assisted Partial Nephrectomy for Renal Tumors >4 cm Versus ≤4 cm in 445 Consecutive Patients

“…RPN has been demonstrated to be safe and feasible for challenging renal tumors, such as large and hilar renal masses. 6,7,19 The aim of our study was to demonstrate the feasibility of RPN for tumors > 4 cm and to emphasize that robotic assistance may offer advantages even for surgeons who are experienced in minimally invasive techniques.…”

“…Patients with tumors > 4 cm had a longer median WIT (25 vs 20 min, P = 0.011). Gupta and coworkers 7 reported on 17 patients with tumors > 4 cm (median tumor size, 5 cm), with a median EBL of 500 mL, median operative time of 390 minutes, and median WIT of 36 minutes. They attributed these outcomes to a higher median nephrometry score of 9 (6-11), a multifocality rate of 42%, and the fact that 89.5% of tumors were > 50% endophytic.…”

“…Reports of robot-assisted partial nephrectomy (RPN) for tumors > 4 cm are limited to a few small single institution series. 6,7 We report outcomes of RPN for tumors > 4 cm compared with tumors £ 4 cm in a large multicenter study.…”

Laparoscopic partial nephrectomy: state of the art review

“…49 Gupta et al similarly reported no local or metastatic recurrences following RPN at a median follow-up of 22 months. 78 Despite these early promising data for RPN, some studies have also shown a higher, albeit statistically insignificant, occurrence of positive surgical margins 79 Early studies had demonstrated an insignificant oncologic effect of PSM with respect to local or metastatic recurrence, 80,81 but emerging data conflict with these earlier findings. 82 Pending further studies on the oncologic significance of PSM during PN, meticulous and complete surgical resection with close follow-up of patients with known PSM is recommended.…”