Tear nanoDSF Denaturation Profile Is Predictive of Glaucoma.

Primary open-angle glaucoma (POAG) is a frequent blindness-causing neurodegenerative disorder characterized by optic nerve and retinal ganglion cell damage most commonly due to a chronic increase in intraocular pressure. The preservation of visual function in patients critically depends on the timeliness of detection and treatment of the disease, which is challenging due to its asymptomatic course at early stages and lack of objective diagnostic approaches. Recent studies revealed that the pathophysiology of glaucoma includes complex metabolomic and proteomic alterations in the eye liquids, including tear fluid (TF). Although TF can be collected by a non-invasive procedure and may serve as a source of the appropriate biomarkers, its multi-omics analysis is technically sophisticated and unsuitable for clinical practice. In this study, we tested a novel concept of glaucoma diagnostics based on the rapid high-performance analysis of the TF proteome by differential scanning fluorimetry (nanoDSF). An examination of the thermal denaturation of TF proteins in a cohort of 311 ophthalmic patients revealed typical profiles, with two peaks exhibiting characteristic shifts in POAG. Clustering of the profiles according to peaks maxima allowed us to identify glaucoma in 70% of cases, while the employment of artificial intelligence (machine learning) algorithms reduced the amount of false-positive diagnoses to 13.5%. The POAG-associated alterations in the core TF proteins included an increase in the concentration of serum albumin, accompanied by a decrease in lysozyme C, lipocalin-1, and lactotransferrin contents. Unexpectedly, these changes were not the only factor affecting the observed denaturation profile shifts, which considerably depended on the presence of low-molecular-weight ligands of tear proteins, such as fatty acids and iron. Overall, we recognized the TF denaturation profile as a novel biomarker of glaucoma, which integrates proteomic, lipidomic, and metallomic alterations in tears, and monitoring of which could be adapted for rapid non-invasive screening of the disease in a clinical setting.

Plasma nanoDSF Denaturation Profile at Baseline Is Predictive of Glioblastoma EGFR Status.

Glioblastoma (GBM) is the most frequent and aggressive primary brain tumor in adults. Recently, we demonstrated that plasma denaturation profiles of glioblastoma patients obtained using Differential Scanning Fluorimetry can be automatically distinguished from healthy controls with the help of Artificial Intelligence (AI). Here, we used a set of machine-learning algorithms to automatically classify plasma denaturation profiles of glioblastoma patients according to their EGFR status. We found that Adaboost AI is able to discriminate EGFR alterations in GBM with an 81.5% accuracy. Our study shows that the use of these plasma denaturation profiles could answer the unmet neuro-oncology need for diagnostic predictive biomarker in combination with brain MRI and clinical data, in order to allow for a rapid orientation of patients for a definitive pathological diagnosis and then treatment. We complete this study by showing that discriminating another mutation, MGMT, seems harder, and that post-surgery monitoring using our approach is not conclusive in the 48 h that follow the surgery.

An AI-Powered Blood Test to Detect Cancer Using NanoDSF.

Glioblastoma is the most frequent and aggressive primary brain tumor. Its diagnosis is based on resection or biopsy that could be especially difficult and dangerous in the case of deep location or patient comorbidities. Monitoring disease evolution and progression also requires repeated biopsies that are often not feasible. Therefore, there is an urgent need to develop biomarkers to diagnose and follow glioblastoma evolution in a minimally invasive way. In the present study, we described a novel cancer detection method based on plasma denaturation profiles obtained by a non-conventional use of differential scanning fluorimetry. Using blood samples from 84 glioma patients and 63 healthy controls, we showed that their denaturation profiles can be automatically distinguished with the help of machine learning algorithms with 92% accuracy. Proposed high throughput workflow can be applied to any type of cancer and could become a powerful pan-cancer diagnostic and monitoring tool requiring only a simple blood test.

Biopsy Grade Group as a reliable prognostic factor for BCR in Afro-Caribbean men with intermediate- and high-risk prostate cancer.

PURPOSE: The Grade Group (GG) classification is recommended by guidelines as a reliable prognostic factor of prostate cancer. However, most studies have been performed on the Caucasian population. Our objective was to validate GG classification as a safe way to classify intermediate- and high-risk patients with African ancestry. PATIENTS AND METHODS: This was a retrospective study in an Afro-Caribbean population. A total of 1236 patients were included between 2000 and 2015. Patients were stratified according to (GG). Survival analysis was performed using the Kaplan-Meier method, univariate and multivariate analyses using the Cox model. RESULTS: There was no significant difference at 5 and 10-year BCR-free survival between the intermediate- and high-risk groups, based on the D'Amico classification. There was a highly significant difference in BCR-free survival at 5 (p < 0.0001) and 10 years (p < 0.0001) for patients of GG 1 and 2 vs 3, 4, and 5, respectively. There was no significant difference in 5-year BCR-free survival of patients of GG grades 1 and 2, whether lymph-node dissection was performed or not. There was a significant difference between GG 2 and 3 patients in 5 (p = 0.008) and 10-year BCR-free survival (p = 0.01). High PSA (p < 0.0001), pathological GG ≥ 3 (p < 0.0001), pathological stage pT3 (p < 0.0001) and positive margins (p < 0.0001) were factors for BCR in multivariate analysis. CONCLUSION: The GG 2015 classification appears to be a better prognostic factor than D'Amico classification for intermediate- and high-risk Afro-Caribbean patients.

Active Surveillance for Favorable Risk Prostate Cancer in African Caribbean Men: Results of a Prospective Study.

PURPOSE: Active surveillance is a treatment option for favorable risk prostate cancer. However, data are missing on populations of African descent. We evaluated the safety and benefit of active surveillance in an African Caribbean cohort with favorable risk prostate cancer. MATERIALS AND METHODS: Between 2005 and 2016, a single center, prospective cohort study was performed in Guadeloupe, French West Indies, including patients on active surveillance who had low risk prostate cancer (prostate specific antigen 10 ng/ml or less and Gleason score 6 or less) or favorable intermediate risk prostate cancer (prostate specific antigen 10 to 20 ng/ml, Gleason score 3 + 4 or less and life expectancy less than 10 years). Treatment was recommended in case of grade progression, increased tumor volume, prostate cancer doubling time less than 36 months or patient wish. Overall survival, disease specific survival and duration of active surveillance were calculated with the Kaplan-Meier method. Multivariate analysis was performed using the Cox proportional hazards model to identify predictors of active surveillance termination. RESULTS: A total of 234 patients with a median age of 64 years were enrolled in study. Median followup was 4 years (IQR 2.3-5.5). Overall survival at 30 months, 5 years and 10 years was 99.5%, 98.5% and 90.7%, respectively. Disease specific survival at 30 months, and 5 and 10 years was 100%. At 30 months, 5 years and 10 years 72.7%, 52.6% and 40.4% of patients, respectively, remained untreated and on active surveillance. Age (HR 0.96 per additional year, 95% CI 0.93-0.99) and prostate specific antigen density (HR 1.52 per additional 0.1 ng/ml, 95% CI 1.20-1.89) were found to be independent predictors of active surveillance termination. CONCLUSIONS: Active surveillance is safe and beneficial for highly selected African Caribbean patients. It seems to be feasible for patients at low risk and intermediate favorable risk. Prostate specific antigen density could help better select these patients.

Perineal robot-assisted laparoscopic radical prostatectomy: feasibility study in the cadaver model.

PURPOSE: To evaluate the feasibility of perineal robot-assisted laparoscopic radical prostatectomy (P-RALP) in the cadaver model. METHODS: The prostate was assessed by ultrasonography and cystoscopy in the lithotomy position. After incision and subcutaneous dissection, a single-port device was placed and the robot was docked. The rectourethralis muscle was divided and the levator ani fibers were split. The Denonvilliers fascia was incised and the posterior prostate and seminal vesicles were dissected. The apex was dissected and the urethra was transected. The anterior and lateral planes were dissected and the prostate pedicles were clipped. The prostate was freed from the bladder neck and the vesicourethral anastomosis was performed. The robot was undocked and the wound was sutured in layers. Cystoscopy confirmed integrity of the anastomosis. The specimen was sent for histopathology examination. RESULTS: Nerve-sparing P-RALP was successfully completed in three cadavers. Median time for setting was 23 minutes. Time for posterior dissection was 15 minutes. Dissection of the apex and section of the urethra took 9 minutes. Time for anterolateral dissection was 14 minutes. Time for bladder neck dissection was 7 minutes. Vesicourethral anastomosis took 8 minutes. Total operative time was 89 minutes. The prostate capsule was grossly intact and histopathology examination was negative for prostatic tissue in all distal urethral sections and in two of three bladder neck sections. CONCLUSIONS: P-RALP is feasible in the cadaver. Future studies should evaluate the feasibility of lymph node dissection through the same incision, clinical feasibility, and prospective comparisons with standard techniques.

Active surveillance for low-risk prostate cancer in African American men: a multi-institutional experience.

OBJECTIVE: To compare the outcomes of active surveillance (AS) series between African American men (AAM) and non-AAM diagnosed with low-risk prostate cancer at 3 medical centers. METHODS: Between 2005 and 2012, 214 men accepted AS on the basis of favorable clinical features and parameters after initial and repeat biopsy. Failure was defined as increase in Gleason score >6, total positive cores >33%, maximum cancer volume in any core >50%, or a prostate-specific antigen >10 ng/mL. Disease progression and overall AS failure were compared between the 2 groups. RESULTS: Of 214 men, 75 were excluded, leaving 67 AAM and 72 non-AAM on AS. Median age at diagnosis was 64 and 67 years for AAM and non-AAM, respectively, and median follow-up was 34 and 46 months, respectively. During this time, 44 AAM (66%) remained on AS, and 23 (34%) underwent treatment, of whom 6 (26%) were treated by patient choice and 17 (74%) because of disease progression. In the non-AAM group, 59 (82%) men remained on AS, and 13 (18%) underwent treatment, 8 (62%) were treated by patient choice and 5 (38%) because of disease progression. The 3-year freedom from overall treatment was 74% and did not differ by race (P = .06). The 3-year freedom from disease progression was 85%, where AAM were at significantly higher risk of disease progression (hazard ratio = 3.8; 95% confidence interval: 1.4-10.4; P = .01). CONCLUSION: Our study suggests a higher disease progression rate in AAM who choose AS for low-risk prostate cancer compared with non-AAM, signifying a potential need for closer follow-up and more stringent enrollment criteria in AAM.

Robot-assisted partial nephrectomy (RAPN) for completely endophytic renal masses: a single institution experience.

OBJECTIVE: To analyse the outcomes of robot-assisted partial nephrectomy (RAPN) for completely endophytic renal tumours. PATIENTS AND METHODS: Medical records of patients who had undergone RAPN for a completely endophytic (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) enhancing renal mass at our Centre from 2006 to 2012 were retrieved from our prospectively maintained RAPN database and used for this analysis. Demographics, surgical and early postoperative outcomes were compared with those of patients with exophytic masses (i.e. 1 point for the 'E' domain) and those of patients with mesophytic masses (i.e. 2 points for the 'E' domain). RESULTS: In all, 65 patients (mean age 56 years; mean body mass index 29.4 kg/m(2) ; mean Charlson comorbidity index 3.2) were included in the study group, accounting for 16.7% of RAPN cases over the study period. The main surgical outcomes were: mean operative time 175 min, mean estimated blood loss 225 mL, and mean warm ischaemia time 21.7 min. Pathology showed a malignant histology in 48 cases (74%), mostly clear cell renal cell carcinoma. Two positive margins (3%) were found. Patients with a completely endophytic mass had smaller tumours on preoperative imaging (mean 2.6 vs 3.3 for mesophytic vs 3.7 cm for exophytic; P < 0.001), and higher overall R.E.N.A.L. score (mean 8.7 vs 7.6 vs 6.4; P < 0.001). There was a lower rate of unclamped cases in the endophytic group (3.1% vs 4.8% vs 18%; P < 0.001). There were no differences in intraoperative complications, length of hospital stay, positive margin rate, postoperative change in estimated glomerular filtration rate, given a similar length of follow-up (mean 12.6 vs 15.7 vs 14.5 months; P = 0.3). CONCLUSION: RAPN for completely intraparenchymal renal tumours can be safely and effectively performed in centres with significant robotic expertise, with surgical outcomes resembling those obtained in the general RAPN population.

Three-year oncologic and renal functional outcomes after robot-assisted partial nephrectomy.

BACKGROUND: With the wider adoption of minimally invasive partial nephrectomy (PN), intermediate- and long-term outcomes data are needed to make firm conclusions about oncologic and functional efficacy, especially for robot-assisted PN (RPN). OBJECTIVE: To report intermediate-term oncologic and renal functional outcomes of RPN. DESIGN, SETTING, AND PARTICIPANTS: We performed a chart review of patients who had undergone RPN since June 2006; patients with a minimum of 2 yr of follow-up were included in this study. Length of follow-up was calculated from the date of surgery to the date of last clinical follow-up. Patients who were either lost to follow-up or who had follow-up outside of our center were sent surveys. INTERVENTION: Transperitoneal RPN with or without hilar clamping. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The demographic, preoperative, and postoperative data were statistically analyzed. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), and cancer-free survival (CFS). Upstaging of chronic kidney disease (CKD) was calculated, as well. Univariate and multivariate analyses were performed to show predicting factors for the latest estimated glomerular filtration rate (eGFR). RESULTS AND LIMITATIONS: Of 427 patients, 134 had a minimum follow-up of 2 yr, and 70 had a minimum of 3-6 yr of follow-up. The mean age was 59.1±12.5 yr, body mass index (BMI) was 29.8±6.2 kg/m(2), and Charlson comorbidity index (CCI) score was 4.2±1.6. The mean tumor size on computed tomography (CT) scan was 3.0±1.6 cm, RENAL score was 7.2±1.8, estimated blood loss (EBL) was 270.7±291.9 ml, operative time was 189.1±54.8 min, and warm ischemia time (WIT) was 17.9±10.3 min. A total of two intraoperative complications (1.5%) and five high-grade Clavien complications (3.7%) occurred. Patients stayed on average for 3.7±1.7 d in the hospital, and the average follow-up was 3.0±0.9 yr. OS was 97.01% at 3 yr and 90.20% at 5 yr; CFS was 98.92% at 3 yr and 98.92% at 5 yr; and CSS was 99.04%, as projected by the Kaplan-Meier method. The mean preoperative GFR was 88.2±0.8 ml/min per 1.73 m(2); the latest postoperative GFR was 80±24 ml/min per 1.73 m(2), with a 8±17.4% change. There was a 20.2% upstaging of CKD postoperatively, but no patients started dialysis. CONCLUSIONS: This study reaffirms that RPN is effective in renal function preservation and oncologic control at an intermediate follow-up interval.

Robot-assisted partial nephrectomy for hilar tumors: perioperative outcomes.

OBJECTIVE: To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) for hilar vs nonhilar tumors. MATERIALS AND METHODS: The study retrospectively reviewed 364 patients with available computed tomography scans undergoing RAPN. Demographic data and perioperative outcomes results were compared between the hilar (group 1, n = 70) and nonhilar tumors (group 2, n = 294). Multivariate analysis was used to identify predictors of warm ischemia time (WIT), estimated blood loss (EBL), major perioperative complications, and postoperative renal function. RESULTS: There were no differences with respect to demographic variables. Hilar tumors had higher RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) scores (P <.001) and were larger (3.9 vs 2.6 cm, P <.001). Surgeries for hilar tumors were associated with greater operative time (210 vs 180 minutes, P <.001), longer WIT (27 vs 17 minutes, P <.001), and increased EBL (250 vs 200 mL, P = .04). No differences were noted in transfusion rate, length of stay, complications (overall and major) and positive margins. Postoperative estimated glomerular filtration rate showed no significant difference between hilar vs nonhilar patients on postoperative day 3 (70.12 vs 74.71 mL/min/1.73 m(2), P = .31) or at last follow-up (72.62 vs 75.78 mL/min/1.73 m(2), P = .40), respectively. Multivariate analysis found hilar location was independently associated with increased WIT without significant changes in EBL, major complications, or postoperative renal function. CONCLUSION: RAPN represents a safe and effective procedure for hilar tumors. Hilar location for patients undergoing RAPN in a high-volume institution seems not be associated with an increased risk of transfusions, major complications, or decline of early postoperative renal function.

Repeat robot-assisted partial nephrectomy (RAPN): feasibility and early outcomes.

OBJECTIVE: To demonstrate the feasibility, and to report our single-centre perioperative outcomes of repeat robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: From June 2006 to June 2012, 490 patients underwent RAPN for a renal mass at our centre. Of these patients, nine who had undergone previous ipsilateral nephron-sparing surgery (NSS) were included in the analysis. Patient charts were reviewed to obtain demographic data, preoperative surgical history, operative details, and postoperative outcomes and follow-up data. RESULTS: In all, 12 tumours were removed in nine patients (median age 69 years; six female). A third of the operations were performed on patients with a solitary kidney. The median (range) R.E.N.A.L. nephrometry score for the resected masses was 7 (4-8). The warm ischaemia time was 17.5 min and in three of the nine patients an unclamped procedure was performed. No intraoperative complications were registered, whereas only two minor complications occurred postoperatively. There were no renal unit losses. All surgical margins were negative. There was no significant difference between mean preoperative and latest postoperative mean estimated glomerular filtration rates (70.5 vs 63.5 mL/min/1.73 m(2) , P > 0.05). At a mean (sd) follow-up of 8.3 (13) months, eight of the nine patients with a pathology diagnosis of malignant neoplasm were alive and free from disease at the latest follow-up. CONCLUSION: Although technically more demanding, repeat RAPN can be safely and effectively performed in patients presenting with local recurrence after primary NSS for kidney cancer.

Robotic retroperitoneal transvaginal natural orifice translumenal endoscopic surgery (NOTES) nephrectomy: feasibility study in a cadaver model.

OBJECTIVE: To evaluate the feasibility of pure robotic natural orifice translumenal endoscopic surgery (R-NOTES) nephrectomy. METHODS: Two R-NOTES nephrectomy approaches were attempted in 3 female cadavers. A single-port device was inserted through an incision in the posterior vaginal fornix. In the first approach, the peritoneal cavity was accessed in the lithotomy position. In the second approach, the retroperitoneum of 2 cadavers was accessed in the prone jackknife position. The ureter was identified and followed cranially. The hilum was stapled and the kidney was dissected. The specimen was extracted into a bag. The incision was closed with an open approach. RESULTS: The first approach was not possible because of collision of the robotic arms against the legs and limited bowel retraction. After modifying the approach, a right transvaginal R-NOTES retroperitoneal nephrectomy was successfully completed, without adding extra ports. Time for setup was 128 minutes. Time to identify the ureter was 53 minutes. Dissection and control of the renal pedicle was completed in 21 minutes. Time to complete the dissection and extraction of the kidney was 36 minutes. Time to complete the procedure was 238 minutes. There were no injuries to retroperitoneal organs or vessels. In the third cadaver, there was rectal injury during the access. We were unable to complete the procedure because of the cadaver height. CONCLUSION: Transvaginal R-NOTES nephrectomy is technically challenging but feasible in select female cadavers. Retroperitoneal approach in the prone jackknife position was instrumental in facilitating robotic access to the kidney through the vagina. Improvements in the technique and instrumentation are necessary to make this approach safe and reproducible.

Robot-assisted transrectal hybrid natural orifice translumenal endoscopic surgery nephrectomy and adrenalectomy: initial investigation in a cadaver model.

OBJECTIVE: To assess the feasibility of robotic transrectal hybrid natural orifice translumenal endoscopic surgery (NOTES) nephrectomy and adrenalectomy. MATERIALS AND METHODS: A male cadaver was used for the present investigation and placed in lithotomy position. An 8- and 12-mm port was inserted through the same periumbilical skin incision. An incision was then created in the rectum 1 cm above the pectinate line, and a submucosal tunnel was developed, through which a robotic 8-mm port was inserted under vision. The cadaver was then placed in the right side up, flank position. The laparoscope and the right robot instrument were introduced through the umbilicus while the left robot instrument was introduced through the rectal port aiding the peri-umbilical ports in kidney and adrenal dissection. After completion of the nephrectomy, the kidney was placed in a specimen bag and extracted intact through the rectum. Closure of the rectal incision was accomplished extracorporeally using 2 suture layers. RESULTS: Robotic transrectal hybrid NOTES nephrectomy and adrenalectomy were completed successfully. The total operative time was 145 minutes, of which the access and robotic docking required 20 minutes. Kidney dissection and hilar control was achieved within 60 minutes. Right adrenalectomy, specimen extraction, and rectal closure was completed in 15, 30, and 20 minutes, respectively. CONCLUSION: We report the first investigation of a robot-assisted transrectal hybrid NOTES nephrectomy and adrenalectomy in a cadaver model to assess the range of motion and articulation of the robotic platform. Additional investigations in live animal model are needed to evaluate the safety of the transrectal approach.

Robot-assisted ureteroneocystostomy: technique and comparative outcomes.

BACKGROUND AND PURPOSE: Ureteroneocystostomy can be used for the treatment of patients with a wide variety of ureteral pathology. Over the last decade, robot-assisted surgery has become more commonly used as a minimally invasive approach for reconstructive upper urinary tract procedures. The aim of this study is to present our experience with robot-assisted ureteroneocystosctomy (RUNC) with a comparison with that of open ureteroneocystostomy (OUNC). PATIENTS AND METHODS: Medical records of 25 patients who underwent RUNC and 41 patients who underwent OUNC or at our institution between 2000 and 2010 were retrospectively analyzed. Perioperative and postoperative data including demographics, surgical outcomes, and clinical and radiographic findings at postoperative follow-up were considered in the comparative analysis. Descriptive statistics were used to present the data. The significance of the difference between variables was evaluated using the Wilcoxon rank sum test for continuous and Fisher exact test for categorical variables. RESULTS: No significant differences were detected in terms of baseline patient characteristics between the two groups. The OUNC procedures were performed with a shorter median operative time (200 vs 279 min., P=0.0008), whereas RUNC patients had a shorter hospital stay (median 3 vs 5 days, P=0.0004), less narcotic pain requirement (morphine equivalent, mg 104.6 vs 290, P=0.0001), and less estimated blood loss (100 vs 150 mL, P=<0.0002). There as no significant difference in the rate of reoperation between groups: RUNC 2/25 (7.6 %) vs OUNC 4/41 (9.7%) P=0.8. Limitations include the retrospective nature of the study and the difference in indications for surgery. CONCLUSION: RUNC provides excellent outcomes with shorter hospital stay, less narcotic pain requirement, and decreased blood loss when compared with the open procedure. Advantages of the robotic platform for dissection and suturing can be useful for complex minimally invasive urologic reconstructive procedures.

Cryoablation versus minimally invasive partial nephrectomy for small renal masses in the solitary kidney: impact of approach on functional outcomes.

PURPOSE: We evaluated the change in renal function after renal cryoablation and partial nephrectomy based on tumor complexity according to the R.E.N.A.L. nephrometry score. MATERIALS AND METHODS: We retrospectively reviewed the data of patients who had a renal tumor in a solitary kidney, and underwent renal cryoablation and partial nephrectomy between December 2000 and January 2012. Renal tumor complexity was categorized into 3 groups by R.E.N.A.L. nephrometry score as low (4 to 6), intermediate (7 to 9) and high (10 to 12). All baseline demographic data, perioperative parameters and followup data including renal function were collected. Comparisons were made among similar tumor complexities. RESULTS: In the renal cryoablation and partial nephrectomy groups 29 patients (43 tumors) and 33 patients were identified, respectively. In all renal tumor complexities, renal cryoablation provided a better perioperative outcome in terms of median operative time, estimated blood loss, transfusion, hospital stay and complications. The median change in serum creatinine and estimated glomerular filtration rate was slightly greater in the partial nephrectomy group. However, the differences were not statistically significant for any of the tumor complexities. Three patients (10%) in the renal cryoablation group and 2 (6%) in the partial nephrectomy group required long-term dialysis. CONCLUSIONS: In patients with solitary kidneys, renal cryoablation is associated with superior perioperative outcomes compared to partial nephrectomy. Specifically, partial nephrectomy is not associated with greater loss of renal function than renal cryoablation regardless of the extent of tumor complexity.

Comparative outcomes and assessment of trifecta in 500 robotic and laparoscopic partial nephrectomy cases: a single surgeon experience.

PURPOSE: We report a comparative analysis of a large series of laparoscopic and robotic partial nephrectomies performed by a high volume single surgeon at a tertiary care institution. MATERIALS AND METHODS: We retrospectively reviewed the medical charts of 500 patients treated with minimally invasive partial nephrectomy by a single surgeon between March 2002 and February 2012. Demographic and perioperative data were collected and statistically analyzed. R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in mm, anterior/posterior and location relative to polar lines) nephrometry score was used to score tumors. Those scored as moderate and high complexity were designated as complex. Trifecta was defined as a combination of warm ischemia time less than 25 minutes, negative surgical margins and no perioperative complications. RESULTS: Two groups were identified, including 261 patients with robotic and 231 with laparoscopic partial nephrectomy. Demographics were similar in the groups. The robotic group was significantly more morbid (Charlson comorbidity index 3.75 vs 1.26), included more complex tumors (R.E.N.A.L. score 5.98 vs 7.2), and had lower operative (169.9 vs 191.7 minutes) and warm ischemia (17.9 vs 25.2 minutes) time, intraoperative (2.6% vs 5.6%, each p <0.001) and postoperative (24.53% vs 32.03%, p = 0.004) complications, and positive margin rate (2.9% vs 5.6%, p <0.001). Thus, a higher overall trifecta rate was observed for robotic partial nephrectomy (58.7% vs 31.6%, p <0.001). The laparoscopic group had longer followup (3.43 vs 1.51 years, p <0.001) and no significant difference in postoperative changes in renal function. Main study limitations were the retrospective nature, arbitrary definition of trifecta and shorter followup in the RPN group. CONCLUSIONS: Our large comparative analysis shows that robotic partial nephrectomy offers a wider range of indications, better operative outcomes and lower perioperative morbidity than laparoscopic partial nephrectomy. Overall, the quest for trifecta seems to be better accomplished by robotic partial nephrectomy, which is likely to become the new standard for minimally invasive partial nephrectomy.

Robotic partial nephrectomy: imperative vs elective indications.

OBJECTIVE: To assess the impact of imperative or elective indications on the perioperative outcomes of patients undergoing robotic partial nephrectomy. MATERIALS AND METHODS: Between January 2008 and August 2011, 381 consecutive robotic partial nephrectomies were retrospectively included. Two groups of patients were identified: those who underwent the procedure for an imperative indication (n = 98) and those who underwent the procedure for an elective indication (n = 283). Perioperative and renal function outcomes were compared between the 2 groups. Multivariate analysis was performed to determine whether imperative indications were predictors of complications, chronic kidney disease stage upstaging, postoperative estimated glomerular filtration rate, and percentage of estimated glomerular filtration rate decrease. RESULTS: There were no differences between the 2 groups with respect to RENAL score and tumor size. Patients in the imperative group were more likely to have a higher Charlson Comorbidity Index score (6 vs 4, P < .001), higher chronic kidney disease stage (P < .001), and lower estimated glomerular filtration rate (61.9 vs 88.6 mL/min/1.73 m(2), P < .001). Perioperative outcomes were similar with respect to warm ischemia time, estimated blood loss, operative time, transfusion rate, positive surgical margin rate, and length of stay. Imperative indications were associated with higher major complication rate (7.22% vs 2.47%, P = .032), but not with overall (31.6% vs 26%, P = .62) and intraoperative complications (6.1% vs 3.2%, P = .22). In multivariate analysis, imperative indication was an independent predictor of postoperative estimated glomerular filtration rate but was not a predictor of percentage of estimated glomerular filtration rate decrease and chronic kidney disease upstaging. CONCLUSION: Patients undergoing robotic partial nephrectomy for an imperative indication have similar functional outcomes than those with an elective indication. However, they are at higher risk of major complications.

Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis.

CONTEXT: Centres worldwide have been performing partial nephrectomies laparoscopically for greater than a decade. With the increasing use of robotics, many centres have reported their early experiences using it for nephron-sparing surgery. OBJECTIVE: To review published literature comparing robotic partial nephrectomy (RPN) with laparoscopic partial nephrectomy (LPN). EVIDENCE ACQUISITION: An online systematic review of the literature according to Cochrane guidelines was conducted from 2000 to 2012 including studies comparing RPN and LPN. All studies comparing RPN with LPN were included. The outcome measures were the patient demographics, tumour size, operating time, warm ischaemic time, blood loss, transfusion rates, length of hospital stay, conversion rates, and complications. A meta-analysis of the results was conducted. For continuous data, a Mantel-Haenszel chi-square test was used; for dichotomous data, an inverse variance was used. Each was expressed as a risk ratio with a 95% confidence interval p<0.05 considered significant. EVIDENCE SYNTHESIS: A total of 717 patients were included, 313 patients in the robotic group and 404 patients in the laparoscopic group (seven studies). There was no significant difference between the two groups in any of the demographic parameters except for age (age: p=0.006; sex: p=0.54; laterality: p=0.05; tumour size: p=0.62, tumour location: p=57; or confirmed malignant final pathology: p=0.79). There was no difference between the two groups regarding operative times (p=0.58), estimated blood loss (p=0.76), or conversion rates (p=0.84). The RPN group had significantly less warm ischaemic time than the LPN group (p=0.0008). There was no difference regarding postoperative length of hospital stay (p=0.37), complications (p=0.86), or positive margins (p=0.93). CONCLUSIONS: In early experience, RPN appears to be a feasible and safe alternative to its laparoscopic counterpart with decreased warm ischaemia times noted.

Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes.

BACKGROUND: Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors. OBJECTIVE: To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥ 7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. INTERVENTION: LPN or RPN. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis. RESULTS AND LIMITATIONS: There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m(2) compared with 30.7 kg/m(2), p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m(2), p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p<0.001) and a higher decrease in percentage of eGFR (-16.0% compared with -12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study. CONCLUSIONS: RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings.