Outcomes of Robotic Nephrectomy Including Highest-complexity Cases: Largest Series to Date and Literature Review

doi:10.1016/j.urology.2014.11.063

Urology

Volume 85, Issue 6, June 2015, Pages 1352-1359

https://doi.org/10.1016/j.urology.2014.11.063 Get rights and content

Objective

To review the outcomes of robot-assisted laparoscopic nephrectomy (RALN) after 101 consecutive cases, the largest reported series to date. The benefit of adding robotic technology to laparoscopic nephrectomy is unclear and controversial. We used robotics for nephrectomy routinely, including for simpler cases rather than laparoscopy, as well as for the most complex nephrectomies rather than open surgery.

Methods

We reviewed a prospective database of 101 consecutive nephrectomy procedures by a single surgeon (R.A.). All were initiated as RALN regardless of complexity. Patient characteristics and outcomes were reviewed, including tumor complexity, conversion rate, transfusions, length of stay, and complications.

Results

Mean age was 60 years (19-86 years), and mean body mass index was 31 kg/m² (16-54 kg/m²). Ninety patients had tumors with mean size of 8.2 cm (2.2-25.8 cm). Eighty were malignant, including 31 pT3a tumors (39%), with 9 renal vein thrombi. Eight malignancies had caval tumor thrombi (10%). Local invasion required 1 bowel resection, 1 partial hepatectomy, and 1 distal pancreatectomy, all performed robotically with no conversions to open surgery. Ipsilateral retroperitoneal lymphadenectomy was performed in 40 patients removing 13.7 nodes (4-36). Mean operative time and blood loss were 172 minutes (57-411 minutes) and 67 mL (10-400 mL) with only 1 transfusion (1%). Mean length of stay was 1.1 days (0-7 days), with 94% discharged by postoperative day 1. Clavien grade III-IV complications occurred in 5% without deaths.

Conclusion

Robotic nephrectomy allows for consistent outcomes regardless of procedure complexity. Completion of procedures without need for open conversion was possible even in the most complex procedures, including those with vascular and contiguous organ invasion.

Section snippets

Methods

A prospective database of 101 consecutive nephrectomies by a single surgeon (R.A.) between 2008 and October 2012 was reviewed with institutional review board approval. All patients underwent RALN regardless of complexity, although the patients were consented for possible open conversion if necessary. This experience began after performing several hundred robotic procedures, after which the surgeon began performing only RALN rather than ORN or LN regardless of complexity. All consecutive RALNs

Results

Mean patient age was 60 years (19-86 years) as per Supplementary Table 1. Mean patient body mass index (BMI) was 31 kg/m² (16-54 kg/m²), including 38 patients of BMI 30-39 kg/m² and 14 patients of BMI >40 kg/m². RALN was performed for tumors in 90 patients with the remaining performed for benign conditions such as recurrent pyelonephritis and/or chronic obstruction with an absence of function or atrophy (including 1 dialysis patient who underwent bilateral RALN).

Mean tumor size was 8.2 cm, with

Comment

LN has emerged as an alternative to ORN for RCC not amenable to nephron sparing. LN is increasingly replacing ORN, as shown by Poon et al,¹² in that ORN decreased from 54% of all nephrectomies in 2003 to 29% in 2010. In addition to comparable cancer control when applied judiciously, LN has demonstrated improved cosmesis and reduced morbidity.3, 4

Nevertheless, ORN continues to be performed in large numbers. This may be because laparoscopy might not be applicable to all nephrectomies even in

Conclusion

RALN is an effective method for nephrectomy and produced consistent outcomes in experienced hands regardless of procedure complexity. Avoidance of open conversion was possible even in the most complex procedures, including in morbidly obese patients, those with vascular and contiguous organ invasion, and those requiring full lymphadenectomy.

References (29)

C.P. Filson et al.
Surgeon characteristics and long-term trends in the adoption of laparoscopic radical nephrectomy
J Urol
(2011)
M.D. Shuford et al.
Complications of contemporary radical nephrectomy: comparison of open vs. laparoscopic approach
Urol Oncol
(2004)
Z.N. Gordon et al.
Completely intracorporeal robotic renal autotransplantation
J Urol
(2014)
R. Abaza
Initial series of robotic radical nephrectomy with vena caval tumor thrombectomy
Eur Urol
(2011)
S.A. Poon et al.
Trends in partial and radical nephrectomy: an analysis of case logs from certifying urologists
J Urol
(2013)
M. Yezhelyev et al.
Combined nephrectomy and major hepatectomy: indications, outcomes, and recommendations
J Am Coll Surg
(2009)
D.Y. Yang et al.
Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?
J Urol
(2014)
A. Berger et al.
Laparoscopic radical nephrectomy for renal cell carcinoma: oncological outcomes at 10 years or more
J Urol
(2009)
A.P. Steinberg et al.
Laparoscopic radical nephrectomy for large (greater than 7 cm, T2) renal tumors
J Urol
(2004)
J.R. Colombo et al.
Seven years after laparoscopic radical nephrectomy: oncologic and renal functional outcomes
Urology
(2008)

D.W. Klingler et al.

Feasibility of robotic radical nephrectomy—initial results of single-institution pilot study

Urology

(2005)

I.S. Gill et al.

Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States

Cancer

(2001)

S.H. Jeon et al.

Comparison of laparoscopic versus open radical nephrectomy for large renal tumors: a retrospective analysis of multi-center results

BJU Int

(2011)

K.R. Ghani et al.

Progression from laparoscopic to robotic renal surgery: the next frontier

BJU Int

(2010)

Cited by (31)

Does size matter? Comparing robotic versus open radical nephrectomy for very large renal masses
2022, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
Since the advent of robotic-assisted surgery, advances in technique have continued to expand the boundaries of what types of surgeries can be performed safely with this technology, especially in urologic surgery. Robotic-assisted RN (RRN) has shown to be safe and effective for the treatment of large and complex renal tumors in a few series [3,4]. However, there is a paucity of data directly comparing RRN to open RN (ORN) for very large renal masses.
We evaluated perioperative and mortality outcomes of robotic-assisted radical nephrectomy (RRN) vs. open radical nephrectomy (ORN) for very large renal cell carcinomas (RCC).
Adult patients with non-metastatic RCC >10 cm in size (pT2b) were identified from the National Cancer Database (2010–2017). Mixed-effects multivariable logistic regression adjusting for patient, tumor, and facility characteristics were used to evaluate rates of positive margin, prolonged length of stay (LOS) (>75th percentile), 30-day readmission, and 30-day and 90-day mortality for RRN vs. ORN. Overall survival (OS) was evaluated using the Kaplan-Meier method and adjusted Cox proportional hazard modeling.
Of the 2,977 patients who underwent radical nephrectomy, 492 (16.5%) underwent RRN. Factors associated with RRN included male gender, metro or urban locations, academic facilities, Charlson-Deyo score >2, private or Medicaid insurance, and surgery in a later year (all P < 0.05). Tumors ≥15.1cm in size were associated with a higher rate of conversion to open surgery (P < 0.001). ORN was associated with increased median postoperative LOS (4d [interquartile range; IQR 3–6] vs. 3d, [IQR 2–4]; P < 0.01). RRN demonstrated no significant difference in the risk of positive margin, 30-day readmission, 30-day mortality, or 90-day mortality. RRN was associated with a decreased risk of prolonged LOS (OR 0.38; 95%CI [0.28–0.53]). There was no difference in long-term OS observed in patients treated with ORN vs. RRN.
Very large, non-metastatic RCC can be safely and effectively treated with RRN. Rates of conversion to open were higher for tumors ≥15.1 cm. RRN has comparable long-term OS and improved LOS compared to ORN.
Robot-assisted Radical Nephrectomy: A Systematic Review and Meta-analysis of Comparative Studies
2021, European Urology
Citation Excerpt :
Moreover, the benefits arising from the minimally invasive nature shared between RRN and LRN (shorter hospital stays, quicker recovery) might be nullified by potential disadvantages (lack of tactile feedback, longer set-up times, higher overall costs) [6–8]. Some distinct features of robot-assisted surgery may be beneficial in tackling demanding procedures such as the management of large tumors, aberrant anatomy, or higher tumor stages involving contiguous organ invasion that are generally handled with ORN [9]. Locally advanced nonmetastatic RCC with venous tumor thrombosis is usually treated with RN and thrombectomy.
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).
To compare the outcomes of robotic surgery to those of laparoscopic and open surgery in patients undergoing RN for renal cell carcinoma (RCC).
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.
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.
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.
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.
Impact of the COVID-19 Crisis on Same-day Discharge After Robotic Urologic Surgery
2021, Urology
To assess the impact of the COVID-19 pandemic on the rate of same-day discharge (SDD) after robotic surgery
We reviewed our robotic surgeries during COVID-19 restrictions on surgery in Ohio between March 17 and June 5, 2020 and compared them with robotic procedures before COVID-19 and after restrictions were lifted. We followed our formerly described protocol in use since 2016 offering the option of SDD to all robotic urologic surgery patients, regardless of procedure type or patient-specific factors.
During COVID-19 restrictions (COV), 89 robotic surgeries were performed and compared with 1667 of the same procedures performed previously (pre-COV) and 42 during the following month (post-COV). Among COV patients 98% (87/89 patients) opted for same-day discharge after surgery versus 52% in the historical pre-COV group (P < .00001). Post-COV, the higher rate of SDD was maintained at 98% (41/42 patients). There were no differences in 30-day complications or readmissions between SDD and overnight patients with only 2 COV (2%) and no post-COV 30-day readmissions.
SDD after robotic surgery was safely applied during the COVID-19 crisis without increasing complications or readmissions. SDD may allow continuation of robotic surgery despite limited hospital beds and when minimizing hospital stay is important to protect postoperative patients from infection. Our experience suggests that patient attitude is a major factor in SDD after robotic surgery since the proportion of patients opting for SDD was much higher during COV and continued post-COV. Consideration of SDD long-term may be warranted for cost savings even in the absence of a crisis.
French ccAFU guidelines - update 2020–2022: management of kidney cancer
2020, Progres en Urologie
Objective. – To update the French guidelines on kidney cancer.
Methods. – A systematic review of the literature between 2015 and 2020 was performed. The most relevant articles regarding the diagnosis, the classification, surgical treatment, medical treatment and follow-up of kidney cancer were retrieved and included in the new guidelines. The guidelines were updated with corresponding levels of evidence.
Results. – Thoraco-abdominal CT scan with injection is the best radiological exam for the diagnosis of kidney cancer. MRI and contrast ultra-sound can be useful in some cases. Percutaneous biopsy is recommended when histological results will affect clinical decision. Renal tumours must be classified according to pTNM 2017 classification and ISUP grade. Metastatic kidney cancers must be classified according to IMDC criteria. Partial nephrectomy is the recommended treatment for T1a tumours and can be done through an open, laparoscopic or robotic access. T1b tumours can be treated by partial or total nephrectomy according to tumour complexity. Radical nephrectomy is the recommended treatment of advanced localized tumours. There is no recommended adjuvant treatment. In metastatic patients: cyto-reductive nephrectomy can be offered in case of good prognosis; medical treatment must be counseled first in case of intermediate or bad prognosis. Surgical or local treatment of metastases should be considered in case of solitary lesion or oligo-metastases. First line recommended drugs in metastatic patients include the associations axitinib/pembrolizumab and nivolumab/ipilimumab. Cystic tumours must be classified according to Bosniak Classification. Surgical excision should be offered to patients with Bosniak III and IV lesions. It is recommended to follow patients clinically and with imaging according to tumour aggressiveness.
Conclusion. – These updated recommendations should assist French speaking urologists for their management of kidney cancers.
Objectif. – Mettre à jour les recommandations sur la prise en charge des cancers du rein.
Méthodes. – Une revue systématique de la littérature a été faite sur la période allant de 2015 à 2020. Les articles jugés les plus pertinents concernant le diagnostic, la classification, le traitement chirurgical, le traitement médical et le suivi du cancer du rein ont été sélectionnés et incorporés aux recommandations. Les recommandations ont ainsi été actualisées en spécifiant le niveau de preuve (fort ou faible).
Résultats. – L’examen de référence pour faire le diagnostic et le bilan d’extension des cancers du rein est le scanner thoraco-abdominal injecté. L’imagerie par résonance magnétique (IRM) et l’échographie de contraste sont indiquées dans certains cas particuliers. La biopsie percutanée est recommandée dans les situations où ses résultats influenceront la décision thérapeutique. Les tumeurs du rein doivent être classées selon la classification pTNM 2017 et le grade nucléolaire de l’ISUP. Les cancers du rein métastatiques doivent être classés selon les critères de l’IMDC. La néphrectomie partielle est le traitement de référence des tumeurs T1a et peut être faite par voie ouverte, laparoscopique ou robotique. Les thérapies ablatives et la surveillance active sont des options chez les patients âgés avec des comorbidités. Les tumeurs T1b doivent être traitées par néphrectomie partielle ou totale en fonction de la complexité tumorale. La néphrectomie totale est le traitement de première intention des cancers localement avancés localisés. Aucun traitement adjuvant n’est recommandé. Chez les patients métastatiques : la néphrectomie cytoréductrice peut être proposée et recommandée en cas de bon pronostic ; le traitement médical doit être proposé en première intention en cas de pronostic mauvais ou intermédiaire. Le traitement chirurgical ou local des métastases peut être proposé en cas de lésion unique ou d’oligo-métastases. Les molécules recommandées en première ligne chez les patients métastatiques sont les associations axitinib/pembrolizumab et nivolumab/ ipilimumab. Les tumeurs kystiques doivent être classées selon la classification de Bosniak. L’exérèse chirurgicale doit être proposée en priorité aux lésions Bosniak III et IV. Il est recommandé de suivre les patients en adaptant les modalités à l’agressivité tumorale.
Conclusion. – Ces recommandations actualisées sont un référentiel qui permettra aux praticiens français et francophones d’encadrer au mieux leur prise en charge des cancers du rein.
Minimally Invasive Surgery for Patients with Locally Advanced and/or Metastatic Renal Cell Carcinoma
2020, Urologic Clinics of North America
Citation Excerpt :
Currently, several studies support the notion that minimally invasive RN can be safely performed even in more complex and clinically advanced cases. Depending on the study, the rates of Clavien grade IIIa or higher complications range from 3% to 10% for MIS, generally less than what is reported for ORN12,19–22 (8%–25%). There are only a few studies comparing robotic RN (RRN) with LRN.
Comparative Efficacy of Laparoscopic Versus Robotic Adrenalectomy for Adrenal Malignancy
2019, Urology
To evaluate whether the technical advantages of robotic-assisted surgery over standard laparoscopy, which are well established for complex renal surgery, lead to variable surgical outcomes between laparoscopic adrenalectomy (LA) and robotic adrenalectomy (RA).
Using the National Cancer Database, we identified patients who underwent LA or RA for nonmetastatic primary adrenal malignancy from 2010 to 2013. Primary outcomes were need for open conversion, surgical margin status, and performance of regional lymphadenectomy. Secondary outcomes were length of stay, readmission, and perioperative mortality. Baseline characteristics and outcomes were compared between approaches using the chi-square, Fisher's exact, and Mann-Whitney U tests.
Two hundred thirty-eight (82%) LA and 51 (18%) RA cases were identified. The LA and RA groups did not show any significant differences in terms of patient age, gender, race, Charlson score, tumor laterality, size (median 4.2-9.0 cm), histology, grade, hospital type, and case volume. The rate of open conversion was 5.9% for RA versus 17.2% for LA (P = .04). There were no significant differences in rates of positive margins, lymphadenectomy, inpatient stay, readmission, or mortality.
RA significantly decreases need for open conversion compared to LA. Although RA improves technical feasibility, the oncological adequacy of minimally invasive resection remains uncertain.

View all citing articles on Scopus

: Financial Disclosure: Ronney Abaza provides consulting and educational programs such as visiting surgeon programs for Intuitive Surgical but is not paid for these personally. Remuneration is made to education funds formerly at the Ohio State University Foundation and now with his current employer OhioHealth, and this money is used for educational programs for residents, fellows, visiting surgeons. He also has category (c) disclosures with Intuitive Surgical and SurgiQuest. The remaining authors declare that they have no relevant financial interests.

View full text

Laparoscopy and RoboticsOutcomes of Robotic Nephrectomy Including Highest-complexity Cases: Largest Series to Date and Literature Review

Objective

Methods

Results

Conclusion

Section snippets

Methods

Results

Comment

Conclusion

J Urol

Urol Oncol

J Urol

Eur Urol

J Urol

J Am Coll Surg

J Urol

J Urol

J Urol

Urology

Urology

Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States

Cancer

Comparison of laparoscopic versus open radical nephrectomy for large renal tumors: a retrospective analysis of multi-center results

BJU Int

Progression from laparoscopic to robotic renal surgery: the next frontier

BJU Int

Laparoscopy and Robotics
Outcomes of Robotic Nephrectomy Including Highest-complexity Cases: Largest Series to Date and Literature Review