Robot‐assisted partial nephrectomy (RAPN) for completely endophytic renal masses: a single institution experience

Abstract

Objective• To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) for completely endophytic renal tumours. Patients and Methods• Medical records of patients who had undergone RAPN for a completely endophytic (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) enhancing renal mass at our Centre from 2006 to 2012 were retrieved from our prospectively maintained RAPN database and used for this analysis.• Demographics, surgical and early postoperative outcomes were compared with those of patients with exophytic masses (i.e. 1 point for the 'E' domain) and those of patients with mesophytic masses (i.e. 2 points for the 'E' domain). Results• In all, 65 patients (mean age 56 years; mean body mass index 29.4 kg/m 2 ; mean Charlson comorbidity index 3.2) were included in the study group, accounting for 16.7% of RAPN cases over the study period. The main surgical outcomes were: mean operative time 175 min, mean estimated blood loss 225 mL, and mean warm ischaemia time 21.7 min.• Pathology showed a malignant histology in 48 cases (74%), mostly clear cell renal cell carcinoma. Two positive margins (3%) were found.• Patients with a completely endophytic mass had smaller tumours on preoperative imaging (mean 2.6 vs 3.3 for mesophytic vs 3.7 cm for exophytic; P < 0.001), and higher overall R.E.N.A.L. score (mean 8.7 vs 7.6 vs 6.4; P < 0.001).• There was a lower rate of unclamped cases in the endophytic group (3.1% vs 4.8% vs 18%; P < 0.001).• There were no differences in intraoperative complications, length of hospital stay, positive margin rate, postoperative change in estimated glomerular filtration rate, given a similar length of follow-up (mean 12.6 vs 15.7 vs 14.5 months; P = 0.3). Conclusion• RAPN for completely intraparenchymal renal tumours can be safely and effectively performed in centres with significant robotic expertise, with surgical outcomes resembling those obtained in the general RAPN population.

Open partial nephrectomy for entirely intraparenchymal tumors: a matched case-control study of oncologic outcome and complication rate

“…Contemporaneous with the development of minimally invasive PN, several reports have now confirmed similar outcomes for open (24, 25) versus robotic PN of complex tumors (18, 25-27). Authors have emphasized the low rate of major complications (19, 25, 26), oncological safety (19, 25, 26), short time of warm ischemia (19, 26), and superior preservation of renal function (24); all of which are in line with our data. The introduction of particular management measures and tools, such as intraoperative US (28), which is now strongly advised for complex tumors, may also result in improved outcomes.…”

“…This could be explained by selection bias or by the fact that in the majority of previous studies, endophytic lesions were defined as all those extending intrarenally by >50% of their diameter. Indeed the lack of any significant differences in relation to polar line and entirely endophytic versus exophytic masses has already been described (19). …”

“…The introduction of particular management measures and tools, such as intraoperative US (28), which is now strongly advised for complex tumors, may also result in improved outcomes. In terms of contemporary series on endophytic renal tumors and robot assisted partial nephrectomy (19), the surgical management of such lesions is technically extremely challenging. Therefore, open surgery remains the best option for countries and regions where surgical robots are unavailable.…”

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

“…In a previous study on 65 robotic PN for completely endophytic RCC, mean WIT, EBL, complications rate and trifecta achievement resulted 21.7 min, 226cc, 9.2%, and 60%, Table 2 Oncological and functional data at latest follow-up. respectively, 21 with a morbidity apparently much lower. However, in this study only the 35.4% had high-risk nephrometry, and the mean tumor diameter was 2.5 cm.…”

Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses

“…The positive surgical margin incidence has been reported to range between 0% and 11% for OPN, 6,8,9,11,12 between 0.8% and 4%for LPN, 6,8,[13][14][15][16][17] and between 2.2% to 5.7%for RPN. 9,13,[18][19][20] …”