Carlo Andrea Bravi1, Alessandro Larcher1, Umberto Capitanio1, Andrea Mari2, Alessandro Antonelli3, Walter Artibani4, Maurizio Barale5, Roberto Bertini1, Pierluigi Bove6, Eugenio Brunocilla7, Luigi Da Pozzo8, Fabrizio Di Maida2, Cristian Fiori9, Paolo Gontero5, Vincenzo Li Marzi10, Nicola Longo11, Vincenzo Mirone11, Emanuele Montanari12, Francesco Porpiglia9, Riccardo Schiavina7, Luigi Schips13, Claudio Simeone3, Salvatore Siracusano4, Carlo Terrone14, Carlo Trombetta15, Alessandro Volpe16, Francesco Montorsi1, Vincenzo Ficarra17, Marco Carini2, Andrea Minervini18. 1. Unit of Urology, Division of Experimental Oncology, URI-Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy. 2. Department of Urology, University of Florence, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy. 3. Department of Urology, Ospedali Civili Hospital, University of Brescia, Brescia, Italy. 4. Department of Urology, Azienda Ospedaliera Universitaria Integrata (A.O.U.I.), Verona, Italy. 5. Division of Urology, Department of Surgical Sciences, San Giovanni Battista Hospital, University of Turin, Turin, Italy. 6. Department of Urology, University Hospital of Tor Vergata, Rome, Italy. 7. Department of Urology, University of Bologna, Bologna, Italy; Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy. 8. Department of Urology, Papa Giovanni XXIII Hospital, Bergamo, Italy. 9. Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, School of Medicine, Orbassano, Turin, Italy. 10. Department of Urology, University of Florence, Unit of Urological Minimally Invasive Robotic Surgery and Renal Transplantation, Careggi Hospital, Florence, Italy. 11. Department of Urology, University Federico II, Naples, Italy. 12. Department of Urology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy. 13. Department of Urology, SS Hospital. Annunziata, Chieti, Italy. 14. Department of Urology, University of Genova, Genova, Italy. 15. U.C.O. Clinica Urologica, Università degli Studi di Trieste, Trieste, Italy. 16. Department of Urology, Maggiore della Carità Hospital, Novara, Italy. 17. Department of Human and Paediatric Pathology, Gaetano Barresi, Urologic Section, University of Messina, Messina, Italy. 18. Department of Urology, University of Florence, Unit of Oncologic Minimally-Invasive Urology and Andrology, Careggi Hospital, Florence, Italy. Electronic address: andreamine@libero.it.
Abstract
BACKGROUND: Partial nephrectomy (PN) has a non-negligible perioperative morbidity. Comparative evidence of the available surgical techniques is limited. OBJECTIVE: To compare the perioperative outcomes of open, laparoscopic, and robotic PN. METHODS: Data of 2331 patients treated with PN for cT1 renal tumors were extracted from the RECORd2 database, a prospective multicenter project. Multivariable regression models assessed the relationship between surgical technique and surgical margins, warm ischemia time, postoperative complications, and acute kidney injury (AKI). The probability of achieving a modified trifecta (negative margins, warm ischemia time <25min, and no Clavien-Dindo ≥2 complications) was examined for each surgical approach. RESULTS: Minimally invasive techniques had lower rate of Clavien-Dindo ≥2 complications than that of open surgery (odds ratio [OR] for robotic surgery: 0.27; 95% confidence interval [95% CI]: 0.15-0.47, p< 0.0001; OR for laparoscopy: 0.52; 95% CI: 0.34-0.78; p= 0.002). The probability of receiving ischemia was highest for robotic PN (p< 0.001). Among on-clamp PN, laparoscopy had longer ischemia than open (estimate: 1.09; 95% CI: -0.00 to 2.18; p= 0.050) and robotic (estimate: 1.36; 95% CI: 0.31-2.40; p= 0.011) surgery. When compared with open PN, the risk of AKI was roughly halved for patients treated by robotic and laparoscopic surgery (both p< 0.0001). Positive margins rate did not differ between the groups (all p≥ 0.1). The likelihood to achieve a modified trifecta was not affected by surgical technique in the overall population (all p≥ 0.075). In Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score < 10 lesions, robotic surgery had higher probability of achieving a modified trifecta than open PN (OR: 1.66; 95% CI: 1.09-2.53; p= 0.018) and laparoscopy (OR: 1.34; 95% CI: 0.94-1.90; p= 0.11). CONCLUSIONS: In PADUA<10 renal tumors, robotic PN allows for higher rates of trifecta than open and laparoscopic surgeries. The impact of surgical technique on perioperative outcomes of PN might be limited in more complex lesions. PATIENT SUMMARY: We evaluated the association between surgical technique and perioperative outcomes of partial nephrectomy. In less complex (Preoperative Aspects and Dimensions Used for an Anatomical [PADUA] score < 10) lesions, robotic PN allows for higher rates of trifecta when compared with other surgical techniques.
BACKGROUND: Partial nephrectomy (PN) has a non-negligible perioperative morbidity. Comparative evidence of the available surgical techniques is limited. OBJECTIVE: To compare the perioperative outcomes of open, laparoscopic, and robotic PN. METHODS: Data of 2331 patients treated with PN for cT1 renal tumors were extracted from the RECORd2 database, a prospective multicenter project. Multivariable regression models assessed the relationship between surgical technique and surgical margins, warm ischemia time, postoperative complications, and acute kidney injury (AKI). The probability of achieving a modified trifecta (negative margins, warm ischemia time <25min, and no Clavien-Dindo ≥2 complications) was examined for each surgical approach. RESULTS: Minimally invasive techniques had lower rate of Clavien-Dindo ≥2 complications than that of open surgery (odds ratio [OR] for robotic surgery: 0.27; 95% confidence interval [95% CI]: 0.15-0.47, p< 0.0001; OR for laparoscopy: 0.52; 95% CI: 0.34-0.78; p= 0.002). The probability of receiving ischemia was highest for robotic PN (p< 0.001). Among on-clamp PN, laparoscopy had longer ischemia than open (estimate: 1.09; 95% CI: -0.00 to 2.18; p= 0.050) and robotic (estimate: 1.36; 95% CI: 0.31-2.40; p= 0.011) surgery. When compared with open PN, the risk of AKI was roughly halved for patients treated by robotic and laparoscopic surgery (both p< 0.0001). Positive margins rate did not differ between the groups (all p≥ 0.1). The likelihood to achieve a modified trifecta was not affected by surgical technique in the overall population (all p≥ 0.075). In Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score < 10 lesions, robotic surgery had higher probability of achieving a modified trifecta than open PN (OR: 1.66; 95% CI: 1.09-2.53; p= 0.018) and laparoscopy (OR: 1.34; 95% CI: 0.94-1.90; p= 0.11). CONCLUSIONS: In PADUA<10 renal tumors, robotic PN allows for higher rates of trifecta than open and laparoscopic surgeries. The impact of surgical technique on perioperative outcomes of PN might be limited in more complex lesions. PATIENT SUMMARY: We evaluated the association between surgical technique and perioperative outcomes of partial nephrectomy. In less complex (Preoperative Aspects and Dimensions Used for an Anatomical [PADUA] score < 10) lesions, robotic PN allows for higher rates of trifecta when compared with other surgical techniques.