Robot-assisted Partial Nephrectomy: A Large Single-institutional Experience

Abstract

Objectives-Nephron-sparing surgery is an established treatment for patients with small renal masses. The laparoscopic approach has emerged as an alternative to open nephron-sparing surgery, but it is recognized to be technically challenging. The robotic surgical system may enable faster and greater technical proficiency, facilitating a minimally invasive approach to more difficult lesions while reducing ischemia time. We report experience with 100 robot assisted partial nephrectomy (RAPN) operations performed at our institution.Methods-100 RAPN operations were performed for suspicious solid renal lesions over 21 months. Clinicopathologic variables, nephrometry scores, operative parameters, and renal functional outcomes were prospectively recorded and analyzed.Results-Median tumor size was 2.8 cm (range 1.0 to 8). Nephrometry scores of resected lesions were low in 47.9% of patients, medium in 45.7%, and high in 6.4% patients. 46.8% of patients had tumors > 50% intraparenchymal, and 61.7% had tumors <7mm from the renal sinus or collecting system. 17.0% were touching a first order vessel in the renal hilum. Mean warm ischemia time was 25.5 minutes (range 0 to 53). Mean change in postoperative GFR improved 6.32 ml/min/1.73m 2 (range −41.9 to 68.9). Histology was renal cell carcinoma in 81% (87/107) of tumors. There were 5 microscopically positive margins on final pathology (5.7%). Major and minor complication rates were 6% and 5%, respectively. There were 2 conversions to open surgery.Conclusions-RAPN appears to be a safe and technically feasible minimally invasive approach to nephron-sparing surgery even in more complex cases, with acceptable pathologic and renal function outcomes.

Nonmodifiable Factors and Complications Contribute to Length of Stay in Robot-Assisted Partial Nephrectomy

“…While the mean hospital length of stay (LOS) for roboticassisted partial nephrectomy (RPN) is shorter compared with open surgery, a subset of patients still requires longer hospitalizations. 7,8 With increased scrutiny on healthcare utilization and a pressure to reduce costs, analysis of hospital LOS is essential for identifying predictors that can be used in preoperative planning and perioperative quality control and process improvement. 9 This may become more important with the implementation of the ''two-midnight rule'' of Centers for Medicare & Medicaid Services, and the possibility of a specific LOS impacting reimbursement.…”

Robotic-assisted partial nephrectomy without using ureteral stent: a single center experience

“…In the same study the authors also reported a lower rate of transition to open surgery and radical nephrectomy, shorter warm ischemia time, shorter hospital stays, and lesser changes in glomerular filtration rates in the RAPN group. [13] In RAPN series by Scoll et al [14] performed on 100 patients, the average size of the excised tumors (2.8 cm), ischemia time (25.5 min), surgical margin positivity rate (5.7%), transition rate to open surgery (2%), major (6%) and minor (5%) complica tion rates were reported as indicated. A retrospective study by Long et al [15] which compared cases with 199 RAPN and 182 LPN did not detect a significant difference across the perioperative parameters but reported a lower rate of transition (1% vs. 11.5% for LPN) to open surgery, and a smaller decrease (12.6% vs. 16%) in the glomerular filtration rate in the RAPN group Abourmarzouk et al [16] conducted a comparative study with 717 patients (313 RAPN vs. 404 LPN) and discovered a shorter warm ischemia time in the RAPN group but did not detect a significant difference with respect to other parameters.…”

“…[20] In our study warm ischemia time which was the most significant predictive factor in PN was around 20 minutes in accordance with the medical literature (≤25 mins). [3,5,10,14,19] Lack of any significant difference between the pre-and postoperative serum creatinine levels of our patients can be evaluated as an indicator of the appropriateness of the procedure we performed in terms of warm ischemia times. Again, the mean surgical margin distance of 0.4 mm (0.2-1 cm) detected among our patients who had RCC can be considered a safe distance oncologically.…”

Partielle Nephrektomie – pro robotisch assistierte laparoskopische Operation

“…In anderen Kollektiven handelte es sich nur um Komplikationen der Kategorien I und II [13]. Urinome traten in 1,6-2,0% der Fälle auf, alle konnten durch Einlage eines Ureterkatheters oder einer Drainage behoben werden, es waren keine weiteren operativen Eingriffe notwendig [11,14,15]. Im Vergleich dazu berichten Gill et al [13] an einer 1800 Patienten umfassenden nierenerhaltend offen und laparoskopisch operierten Kohorte, die hiläre, mesophytisch und endophytisch gelegene Tumoren sowie imperative und elektive Indikationsstellung mit einschloss, über das Auftreten von Urinomen bei der offenen Nierentumorresektion in 7,4% der Fälle, bei der laparoskopischen in 3,1% der Fälle.…”