Fabio Crocerossa1, Umberto Carbonara2, Francesco Cantiello3, Michele Marchioni4, Pasquale Ditonno5, Maria C Mir6, Francesco Porpiglia7, Ithaar Derweesh8, Lance J Hampton9, Rocco Damiano3, Riccardo Autorino10. 1. Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA; Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy. 2. Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA; Department of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy. 3. Department of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy. 4. Urology Unit, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, SS Annunziata Hospital, Chieti, Italy; Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University of Chieti, Chieti, Italy. 5. Department of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy; Unit of Urology, National Cancer Institute IRCCS Giovanni Paolo II, Bari, Italy. 6. Department of Urology, Fundacion Instituto Valenciano Oncologia, Valencia, Spain. 7. Division of Urology, San Luigi Hospital University of Turin, Orbassano, Italy. 8. Department of Urology, UCSD, San Diego, CA, USA. 9. Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA. 10. Division of Urology, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA. Electronic address: ricautor@gmail.com.
Abstract
CONTEXT: Radical nephrectomy (RN) is the gold standard treatment for large and locally advanced renal tumors. Although robot-assisted radical nephrectomy (RRN) is being increasingly adopted, it remains unclear whether it offers benefits over standard laparoscopic radical nephrectomy (LRN) or open radical nephrectomy (ORN). OBJECTIVE: To compare the outcomes of robotic surgery to those of laparoscopic and open surgery in patients undergoing RN for renal cell carcinoma (RCC). EVIDENCE ACQUISITION: A systematic search was performed across MEDLINE, EMBASE, and Web of Science for retrospective and prospective studies comparing RRN to LRN or ORN. A meta-analysis evaluated perioperative safety, effectiveness, survival, and cost-effectiveness outcomes. The weighted mean difference (WMD) and odds ratio (OR) were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale. Sensitivity analyses were performed to assess the robustness of the estimates. EVIDENCE SYNTHESIS: Twelve studies involving 64 221 patients were identified and included in the analysis. Compared to LRN, RRN was associated with statistically significant longer operative time (WMD 37.44 min; p = 0.03), shorter length of stay (WMD -0.84 days; p = 0.02) and higher total costs (WMD US$4700; p < 0.001). Compared to ORN, RRN was associated with shorter length of stay (WMD -3.06 days; p = 0.002), fewer overall complications (OR 0.56; p < 0.001), lower estimated blood loss (WMD -702 ml; p = 0.01), and higher total hospital costs (WMD US$4520; p = 0.004). There was high heterogeneity across all analyses. CONCLUSIONS: In patients undergoing RN for RCC, RRN seems to offer some key advantages compared to ORN, including shorter hospitalization and fewer complications. Compared to LRN, RRN provides similar surgical outcomes but at higher total costs. These findings should be interpreted within the limitations of this type of analysis, given high heterogeneity between studies and poor robustness for most outcomes. Randomized clinical studies with long-term follow-up are needed to obtain more definitive results. PATIENT SUMMARY: In patients with renal cell carcinoma, robot-assisted radical nephrectomy shows perioperative advantages compared to open radical nephrectomy, but not compared to laparoscopic radical nephrectomy.
CONTEXT: Radical nephrectomy (RN) is the gold standard treatment for large and locally advanced renal tumors. Although robot-assisted radical nephrectomy (RRN) is being increasingly adopted, it remains unclear whether it offers benefits over standard laparoscopic radical nephrectomy (LRN) or open radical nephrectomy (ORN). OBJECTIVE: To compare the outcomes of robotic surgery to those of laparoscopic and open surgery in patients undergoing RN for renal cell carcinoma (RCC). EVIDENCE ACQUISITION: A systematic search was performed across MEDLINE, EMBASE, and Web of Science for retrospective and prospective studies comparing RRN to LRN or ORN. A meta-analysis evaluated perioperative safety, effectiveness, survival, and cost-effectiveness outcomes. The weighted mean difference (WMD) and odds ratio (OR) were used to compare continuous and dichotomous variables, respectively. Quality was assessed using the Newcastle-Ottawa scale. Sensitivity analyses were performed to assess the robustness of the estimates. EVIDENCE SYNTHESIS: Twelve studies involving 64 221 patients were identified and included in the analysis. Compared to LRN, RRN was associated with statistically significant longer operative time (WMD 37.44 min; p = 0.03), shorter length of stay (WMD -0.84 days; p = 0.02) and higher total costs (WMD US$4700; p < 0.001). Compared to ORN, RRN was associated with shorter length of stay (WMD -3.06 days; p = 0.002), fewer overall complications (OR 0.56; p < 0.001), lower estimated blood loss (WMD -702 ml; p = 0.01), and higher total hospital costs (WMD US$4520; p = 0.004). There was high heterogeneity across all analyses. CONCLUSIONS: In patients undergoing RN for RCC, RRN seems to offer some key advantages compared to ORN, including shorter hospitalization and fewer complications. Compared to LRN, RRN provides similar surgical outcomes but at higher total costs. These findings should be interpreted within the limitations of this type of analysis, given high heterogeneity between studies and poor robustness for most outcomes. Randomized clinical studies with long-term follow-up are needed to obtain more definitive results. PATIENT SUMMARY: In patients with renal cell carcinoma, robot-assisted radical nephrectomy shows perioperative advantages compared to open radical nephrectomy, but not compared to laparoscopic radical nephrectomy.
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