Open to Debate

The Motion: Robotic Partial Nephrectomy is Better than Open Partial Nephrectomy

Partial nephrectomy is performed with the aim to preserve renal function. But the occurrence of postoperative acute kidney injury (AKI) can interfere with this goal. Our primary aim was to evaluate associations between pre-specified modifiable factors and estimated glomerular filtration rate after partial nephrectomy. Our secondary aims were to evaluate associations between pre-specified modifiable factors and both serum creatinine concentration and type of nephrectomy.

The records of 1955 patients who underwent partial nephrectomy were collected. Postoperative estimated glomerular filtration rate (eGFR) was used as the primary outcome measure. Twenty modifiable risk factors were studied. A repeated-measures linear model with autoregressive within-subject correlation structure was used. The interaction between all the factors and type of nephrectomy was also studied.

A total of 1187 (61%) patients had no kidney injury, 647 (33%) had stage I, 80 (4%) had stage II, and 41 (2%) had stage III injury. The mean eGFR increased an estimated 0.83 (99.76% CI 0.79–0.88) ml min⁻¹ 1.73 m⁻² for a unit increase in baseline eGFR. Mean eGFR was 2.65 (99.76% CI: 0.13, 5.18) ml min⁻¹ 1.73 m⁻² lower in patients with hypertension. Mean eGFR decreased 0.42 (99.76% CI: 0.22, 0.62) ml min⁻¹ 1.73 m⁻² for a 10-minute longer in duration of procedure and decreased 2.09 (99.76% CI: 1.39, 2.80) ml min⁻¹ 1.73 m⁻² for a 10-minute longer in ischemia time. It was 3.53 (99.76% CI: 0.83, 6.23) ml min⁻¹ 1.73 m⁻² lower for patients who received warm ischemia as compared to cold ischemia.

Potentially modifiable factors associated with AKI in the postoperative period were identified as baseline renal function, preoperative hypertension, longer duration of surgical time and ischaemia time, and warm ischaemia.

Robot-assisted partial nephrectomy (RPN) in the setting of chronic kidney disease (CKD) presents additional challenges for the preservation of renal function.

To evaluate functional outcomes of RPN in patients with CKD relative to patients undergoing RPN without baseline CKD.

A total of 1197 consecutive patients who underwent RPN at five academic institutions between 2007 and 2012 were identified for this descriptive study. A total of 172 patients who underwent RPN with preexisting CKD (estimated glomerular filtration rate [eGFR] of 15–60 ml/min per 1.73 m²) were identified. Perioperative results of 121 patients were compared against propensity score–matched controls without CKD (eGFR ≥60 ml/min per 1.73 m²).

RPN in patients with or without baseline CKD.

Descriptive statistics and propensity score–matched operative and functional outcomes.

After propensity score matching, patients with baseline CKD had a lower percentage eGFR decrease at first follow-up (−5.1 vs −10.9), which remained significant at a mean follow-up of 12.6 mo (−2.8 vs −9.1, p < 0.05), and they had less CKD upstaging (11.8% vs 33.1%). CKD patients were less likely to be discharged in the first two postoperative days (39.7% vs 56.2%, p = 0.006) and had a higher rate of surgical complications (21.5% vs 10.7%, p = 0.007). The retrospective analysis was the main limitation of this study.

RPN in patients with baseline CKD is associated with a smaller decrease in renal function compared with patients without baseline CKD, but a higher risk of surgical complications and a longer hospital stay.

Robotic technology has enabled urologists to perform a variety of laparoscopic surgeries. Robotic surgery offers enhanced optical magnification and visualization with precise surgical movements. We report the first case series of robot-assisted laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous testicular cancer in three consecutive patients. All procedures were performed using a modified template nerve-sparing approach. The mean patient age was 31 yr. Estimated blood loss was 150–200 ml; operative time was 150–240 min. Length of stay was 2 d, and there were no perioperative complications. This early series in carefully selected and well-informed patients represented a limited experience. These results may not be applicable to all surgeons. Further long-term follow-up with a larger number of patients are warranted to validate these preliminary findings.