Robotic partial nephrectomy vs minimally invasive radical nephrectomy for clinical T2a renal mass: a propensity score‐matched comparison from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group

Abstract

Objective To compare outcomes of minimally invasive radical nephrectomy (MIS‐RN) and robot‐assisted partial nephrectomy (RAPN) in clinical T2a renal mass (cT2aRM). Patients and Methods Retrospective, multicentre, propensity score‐matched (PSM) comparison of RAPN and MIS‐RN for cT2aRM (T2aN0M0). Cohorts were PSM for age, sex, body mass index, American Society of Anesthesiologists (ASA) class, clinical tumour size, and R.E.N.A.L. score using a 2:1 ratio for RN:PN. The primary outcome was disease‐free survival (DFS). Secondary outcomes included overall survival (OS), complication rates, and de novo estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2. Multivariable (MVA) and Kaplan–Meier survival analyses (KMSA) were conducted. Results In all, 648 patients (216 RAPN/432 MIS‐RN) were matched. There were no significant differences in intraoperative complications (P = 0.478), Clavien–Dindo Grade ≥III complications (P = 0.063), and re‐admissions (P = 0.238). The MVA revealed high ASA class (hazard ratio [HR] 2.7, P = 0.044) and sarcomatoid (HR 5.3, P = 0.001), but not surgery type (P = 0.601) to be associated with all‐cause mortality. Increasing R.E.N.A.L. score (HR 1.31, P = 0.037), high tumour grade (HR 2.5, P = 0.043), and sarcomatoid (HR 2.8, P = 0.02) were associated with recurrence, but not surgery (P = 0.555). Increasing age (HR 1.1, P < 0.001) and RN (HR 3.9, P < 0.001) were predictors of de novo eGFR of <45 mL/min/1.73 m2. Comparing RAPN and MIS‐RN, KMSA revealed no significant differences for 5‐year OS (76.3% vs 88.0%, P = 0.221) and 5‐year DFS (78.6% vs 85.3%, P = 0.630) for pT2 RCC, and no differences for 3‐year OS (P = 0.351) and 3‐year DFS (P = 0.117) for pT3a upstaged RCC. The 5‐year freedom from de novo eGFR of <45 mL/min/1.73 m2 was 91.6% for RAPN vs 68.9% for MIS‐RN (P < 0.001). Conclusions RAPN had similar oncological outcomes and morbidity profile as MIS‐RN, while conferring functional benefit. RAPN may be considered as a first‐line option for cT2aRM.

Partial nephrectomy preserves renal function without increasing the risk of complications compared with radical nephrectomy for renal cell carcinomas of stages pT2–3a

“…Bradshaw et al . also showed no significant differences in major complications (CDC ≥3) for PN versus RN in large RCC (5.3% vs 2.3%, P = 0.063) in their recently published propensity score‐matched comparison of minimally invasive RN versus robot‐assisted PN in cT2a renal masses 26 . In the present study, we were not able to show any influence of the tumor complexity or other investigated tumor, as well as patient‐related parameters, on the occurrence of higher‐grade complications.…”

“…In the multivariable analysis for CKD, the surgical approach was an independent factor in favor of PN compared with RN (OR 51.071, 95% CI 3.570–730.5899, P = 0.004). Other authors also found that PN was associated with better postoperative renal function, with reported higher postoperative eGFR and a lower likelihood of postoperative onset of CKD 23,26,27 . As a result of better preservation of renal function, PN was observed to achieve a better health‐related and overall quality of life 28 .…”

“…Bradshaw et al . showed that RN was independently associated with renal functional decline to an eGFR <60 (OR 2.35, P < 0.001) and eGFR <45 (OR 3.85, P < 0.001) 26 . Furthermore, in their two‐center study of 202 patients with T2 renal masses undergoing RN ( n = 122) or PN ( n = 80), Kopp et al .…”

Editorial Comment from Dr Bertolo et al. to Partial nephrectomy preserves renal function without increasing the risk of complications compared with radical nephrectomy for renal cell carcinomas of stages pT2–3a

“…For instance, a similar analysis focused on cT2a masses was recently published by Bradshaw et al ., who found that robot‐assisted PN showed similar oncological outcomes and morbidity profile to minimally invasive RN, while lowering the likelihood of a de novo chronic kidney disease 2 . This was possible by means of a retrospective, multicenter, propensity score‐matched comparison within the Robotic Surgery for Large Renal Mass consortium.…”

Editorial Comment from Dr Mitsui and Dr Sadahira to Partial nephrectomy preserves renal function without increasing the risk of complications compared with radical nephrectomy for renal cell carcinomas of stages pT2–3a

“…To date, robot‐assisted partial nephrectomy (RAPN) is becoming the standard procedure for localized RCC instead of open or laparoscopic technique. Although RAPN was recommended for patients with small RCC, the adaptation of RAPN was expanded to more than cT2 RCC, because of its safety and improvement of surgeons’ techniques 2 . The authors showed PN to be superior to radical nephrectomy for both renal function preservation and complications.…”