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Keywords:

  • robotics;
  • nephron-sparing surgery;
  • renal cell carcinoma;
  • recurrence;
  • tumour diameter;
  • laparoscopy;
  • small renal mass

What's known on the subject? and What does the study add?

  • Nephron-sparing surgery has become the standard of care for small renal masses because it allows for the same oncological control as radical nephrectomy and achieves better overall survival, while lowering the risk of subsequent chronic renal failure.
  • Mini-invasive surgical approaches have also been developed, e.g. laparoscopic partial nephrectomy (LPN) and robot-assisted laparoscopic PN (RAPN), which result in less bleeding, reduced postoperative pain, shorter length of stay (LOS) and shorter recovery time. LPN requires advanced surgical skill, has a longer learning curve and requires perseverance, which limits its large diffusion. From this prospective comparative study, we can now claim that RAPN is not inferior to pure LPN in terms of perioperative outcomes (i.e. blood loss, operative duration, warm ischaemia time, LOS).

Objective

  • To prospectively compare the surgical and pathological outcomes obtained with robot-assisted laparoscopic partial nephrectomy (RAPN) or laparoscopic PN (LPN) for renal cell carcinoma in a multicentre cohort.

Patients and Methods

  • Between 2007 and 2011, 265 nephron-sparing surgeries were performed at six French urology departments. The patients underwent either RAPN (n = 220) or LPN (n = 45) procedures.
  • The operative data included operative duration, warm ischaemia time (WIT) and estimated blood loss (EBL). The postoperative outcomes included length of stay (LOS), creatinine variation (Modification of Diet in Renal Disease group), Clavien complications and pathological results.
  • The complexity of the renal tumour was classified using the R.E.N.A.L. nephrometry scoring system. Student's t-test and chi-squared tests were used to compare variables.

Results

  • The median follow-ups for the RAPN and LPN groups were 7 and 18 months, respectively (P < 0.001).
  • Age and American Society of Anesthesiology score were significantly higher in the LPN group (P = 0.02 and P = 0.004, respectively).
  • These variables were lower in the RAPN group: WIT [mean (sd) 20.4 (9.7) vs 24.3 (15.2) min; P = 0.03], operative duration [mean (sd) 168.1 (55.5) vs 199.7 (51.2) min; P < 0.001], operating room occupation time [mean (sd) 248.3 (66.7) vs 278.2 (71.3) min; P = 0.008], EBL [mean (sd) 244.8 (365.4) vs 268.3 (244.9) mL; P = 0.01], use of haemostatic agents [used in 78% of RAPNs and 100% of LPNs; P < 0.001] and LOS [mean (sd) 5.5 (4.3) vs 6.8 (3.2) days; P = 0.05).
  • There were no significant differences between pre- and postoperative creatinine levels, pathology report or complication rates between the groups. The main limitation was due to the study's non-randomised design.

Conclusion

  • RAPN is not inferior to pure LPN for perioperative outcomes (i.e. EBL, operative duration, WIT, LOS). Only a randomised study with a longer follow-up can now provide further insight into oncological outcomes.