Outcomes of robot-assisted partial nephrectomy for completely endophytic renal tumors: A multicenter analysis.

INTRODUCTION: Multicenter retrospective analysis of robotic partial nephrectomy for completely endophytic renal tumors (i.e. 3 points for the 'E' domain of the R.E.N.A.L. nephrometry score) was performed. MATERIALS AND METHODS: Patients' demographics, tumor characteristics, perioperative, functional, pathological and oncological data were analyzed and compared with those of patients with exophytic and mesophytic masses (i.e. 1 and 2 points for the 'E' domain, respectively). Multivariable logistic regression analysis was used to assess variables for trifecta achievement (negative margin, no postoperative complications, and 90% estimated glomerular filtration rate [eGFR] recovery). RESULTS: Overall, 147 patients were included in the study group. Patients with a completely endophytic mass had bigger tumors (mean 4.2 vs. 4.1 vs. 3.2 cm; p < 0.001) on preoperative imaging and higher overall R.E.N.A.L. score. There was no difference in mean operative time. Estimated blood loss was higher in the endophytic group (mean 177.75 vs. 185.5 vs. 130 ml; p = 0.001). Warm ischemia time was shorter for the exophytic group (median 16 vs. 21 vs. 22 min; p < 0.001). Postoperative complications were more frequent in patients with endophytic tumor (24.8% vs. 19.5% vs. 14.8%; p < 0.001). Six (4.5%) patients had positive surgical margins, there was no difference between groups. Trifecta was achieved in 44 patients in endophytic group (45.4 vs. 68.8 and 50.9%, p < 0.001). Multivariable analysis for trifecta revealed that clinical tumor size (odds ratio: 0.667, 95% confidence interval: 0.56-0.79, p < 0.001) was only significant predictor for trifecta achievement. CONCLUSIONS: Our findings confirm that RAPN in case of completely endophytic renal masses can be performed with acceptable outcomes in centers with significant robotic expertise.

Clips Can be Safely Used for Vascular Control of the Renal Vessels During Laparoscopic Donor Nephrectomy.

OBJECTIVE: To review our experience using clips to control the renal vessels during laparoscopic donor nephrectomy (LDN) and determine the safety of this practice. METHODS: We performed a retrospective review of patients who underwent LDN at our centre January 1, 2007-September 17, 2019. The primary outcome was the rate of complication associated with vascular control of the renal vessels, which included (1) conversion to open to manage bleeding, (2) additional procedures for bleeding, and (3) major bleeding requiring blood transfusion. Secondary outcomes included the rate of renal artery/vein clip dislodgement or crossing, change in hemoglobin, warm ischemia time and the incidence of intra-operative complications and postoperative in-hospital complications. RESULTS: We included 503 patients who underwent LDN, of which 497 were left sided. The main renal artery was controlled with 3 titanium clips in 489 (97%) cases. The main renal vein was controlled with 2 polymer-locking clips in 478 (95%) cases. For our primary outcome, there were no conversions to open to manage bleeding, no secondary procedures due to bleeding and no major bleeding requiring blood transfusion. Additionally, there were no donor deaths. Regarding our secondary outcomes, there were 5 intraoperative events related to the titanium clips being placed on the renal artery and 1 intraoperative event related to the polymer-locking clips on the renal vein, none of which resulted in any morbidity. CONCLUSION: Using 3 titanium clips on the renal artery and 2 polymer-locking clips on the renal vein during left LDN is safe and provides excellent vascular control.

Measuring volumetric segmentation changes in the ipsilateral and contralateral kidney postpartial nephrectomy.

OBJECTIVE: To analyze the volumetric changes of the ipsilateral and contralateral kidneys and their effect on functional outcome post partial nephrectomy using segmentation analysis. PATIENTS AND METHODS: We have analyzed the data of 119 patients from a single surgeon series of partial nephrectomy patients. Median follow-up was 11.40 months. Patients with bilateral tumors, and solitary kidney were excluded from analysis. Volumetric measurements were performed using a semiautomated tissue segmentation tool. A simple linear regression model to assess the predictors for parenchymal volume loss (PVL). A multivariable linear regression model was used to evaluate the association between PVL and warm ischemia time (WIT), controlling for other factors. RESULTS: Mean WIT was 12.09 ± 4.40 minutes and the mean percentage decrease in the volume of the operated kidney was 16.99 ± 13.49%. WIT (ß = 1.24, P < 0.001) and tumor complexity (simple vs. intermediate, ß = 0.06, P = 0.984; simple vs. high, ß = 11.62,P = 0.007) were associated with PVL. A 1 minute increase in WIT was associated with an increase in the percentage volume loss in the operated kidney by 1.38% (ß = 1.20, P < 0.001). Patients with high tumor complexity (ß = 11.17, P = 0.009) had a significantly higher percentage volume loss compared to patients with simple tumor complexity. Ipsilateral PVL (ß = -0.35, P = 0.015) and male gender (ß = -9.89, P = 0.021) were associated with change in eGFR. After adjusting for confounders, % volume loss (ß = -0.32, P < 0.001) remained a significant predictor for contralateral hypertrophy. CONCLUSION: Tumor complexity results in higher WIT and increased PVL as measured by volumetric segmentation. PVL is a key factor associated with functional outcome, and is directly linked to WIT. Increased PVL is also associated with decreased contralateral hypertrophy. Prospective studies with larger samples sizes will be required to validate our findings.

Prediction of pentafecta achievement following laparoscopic partial nephrectomy: Implications for robot-assisted surgery candidates.

BACKGROUND: In clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making. METHODS: Patients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN. RESULTS: RAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P < 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased. CONCLUSION: When pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.

Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help?

OBJECTIVES: To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. PATIENTS AND METHODS: Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. RESULTS: Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. CONCLUSION: In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15 min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.

Introducing Robot-Assisted Laparoscopic Donor Nephrectomy after Experience in Hand-Assisted Retroperitoneoscopic Approach.

BACKGROUND: Robot-assisted laparoscopic donor nephrectomy (RALDN) can help to improve donor safety by enabling enhanced precision, flexibility, control, and vision. We are presenting our initial series during the introduction of RALDN by comparing our adopted surgical technique, hand-assisted retroperitoneoscopic donor nephrectomy (HARPDN), performed at the same time interval. METHODS: We performed 12 RALDN and 27 HARPDN with Pfannenstiel incision between March 2018 and July 2018. We evaluated the demographics, operation duration, warm/cold ischemia time, estimated blood loss, length of hospital stay, postoperative complications, and donor and recipient serum creatinine levels retrospectively. RESULTS: Demographics including sex, mean of age, and body mass index of the 2 groups were similar. Five cases were right sided nephrectomy in the HARPDN group. We performed only left sided donor nephrectomy in the RALDN group. The duration of operation and warm ischemia time was significantly longer in the robot-assisted group (P < .001). Postoperative major complications were not detected in any of the donors. The function of the transplanted kidneys in both groups was good on the fifth day and 1 month postoperatively. CONCLUSION: We introduced the robot-assisted approach for donor candidates who are not suitable candidates for HARPDN in our center. The operation time and warm ischemia time was longer in the RALDN group, but it did not have any impact on outcome. The robot-assisted donor nephrectomy technique can be introduced safely in centers experienced in the hand-assisted approach.

Comparison of perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy: Comparative outcomes of cT1a versus cT1b renal tumors.

OBJECTIVES: To assess the perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy for cT1b renal tumors compared with cT1a. METHODS: From February 2015 to May 2018, 100 robot-assisted partial nephrectomy patients who underwent robot-assisted partial nephrectomy without renorrhaphy for renal tumors were included. We retrospectively reviewed the medical records, and compared the perioperative outcomes of 66 and 34 patients for cT1a and cT1b tumors, respectively. Inner suture was carried out in the opened collecting system or renal sinus, whereas parenchymal renorrhaphy was not. For hemostasis, the soft-coagulation system was used, and absorbable hemostats were placed on the resection bed. RESULTS: The median tumor size and RENAL nephrometry score were significantly different between the two groups (cT1a vs cT1b: 23.5 vs 45 mm, P < 0.001, 6 vs 8, P < 0.001). The median operating time and warm ischemic time were significantly longer in the cT1b group than in the cT1a group (154 vs 184 min, P < 0.001; 14 vs 21 min, P < 0.001). The median blood loss was not significantly different (2.5 vs 50 mL, P = 0.109). The positive surgical margin rate was 4.5% versus 11.7% (P = 0.22). Postoperative complications classified as Clavien-Dindo grade III or higher were port-site herniation (one patient), acute cholecystitis (one patient) and pseudoaneurysm (one patient) in the cT1b group. Urinary leakage was not observed in the two groups. CONCLUSIONS: Robot-assisted partial nephrectomy without renorrhaphy using the soft-coagulation system and absorbable hemostats appears to be feasible for renal or cT1b tumors. However, longer warm ischemic time and a high rate of complications can be expected compared with cT1a tumors.

The Self-Retaining Barbed Suture for Parenchymal Repair in Laparoscopic Partial Nephrectomy: A Systematic Review and Meta-Analysis.

Objectives. The warm ischemia time (WIT) is key to successful laparoscopic partial nephrectomy (LPN). The aim of this study was to perform a meta-analysis comparing the self-retaining barbed suture (SRBS) with a non-SRBS for parenchymal repair during LPN. Methods. A systematic search of PubMed, Scopus, and the Cochrane Library was performed up to March 2018. Inclusion criteria for this study were randomized controlled trials (RCTs) and observational comparative studies assessing the SRBS and non-SRBS for parenchymal repair during LPN. Outcomes of interest included WIT, complications, overall operative time, estimated blood loss, length of hospital stay, and change of renal function. Results. One RCT and 7 retrospective studies were identified, which included a total of 461 cases. Compared with the non-SRBS, use of the SRBS for parenchymal repair during LPN was associated with shorter WIT (P < .00001), shorter overall operative time (P < .00001), lower estimated blood loss (P = .02), and better renal function preservation (P = .001). There was no significant difference between the SRBS and non-SRBS with regard to complications (P = .08) and length of hospital stay (P = .25). Conclusions. The SRBS for parenchymal repair during LPN can significantly shorten the WIT and overall operative time, decrease blood loss, and preserve renal function.

The methods and techniques of identifying renal pedicle vessels during retroperitoneal laparoscopic radical and partial nephrectomy.

BACKGROUND: Retroperitoneal laparoscopic radical and partial nephrectomy (RLRN and RLPN) have become the preferred modes of management for renal malignancy. One of the most critical steps in the RLRN and RLPN process is to seek and control the renal pedicle. The current study focuses on introducing methods and techniques that can help quickly and accurately identify the renal pedicle vessels during RLRN and RLPN. METHODS: RLRNs and RLPNs were performed for 292 cases in our hospital from November 2014 to January 2017. Different measures were adopted to seek and manage bilateral renal pedicle vessels. All operation procedures were performed by the following three steps: dissection, opening, and clamping. For the left lateral, after the perirenal fat in the dorsal and lateral side was fully dissected, the kidney was pushed toward the ventral side. The renal artery was visible when opening the dense bulging connective tissue, which was located in the middle of the dorsal interior of the kidney. Then, the renal artery was clamped with a Hem-o-lok or the Bulldog clamp. For the right kidney pedicles, the inferior vena cava was first identified and then dissipated upward. When the inferior vena cava was not visible, it was often the location of the right renal artery. The treatment for the artery was the same as for the left renal artery. Relevant clinical characteristics of patients, such as operative time, intraoperative blood loss, and duration of postoperative drainage, were analyzed retrospectively. The three-step method of identifying renal pedicle vessels during retroperitoneal laparoscopic radical and partial nephrectomy was evaluated. RESULTS: All operations were successfully accomplished with satisfying results, during which the artery could be controlled quickly, and no cases were converted to open surgery due to severe bleeding of renal pedicle vessels. There were no complications involving renal vessels during the entire study. The mean operative times were (81.9 ± 19.71) min and (88.2 ± 21.28) min for RLRN and RLPN, with an average intraoperative blood loss of (91.7 ± 47.10) ml and (62.4 ± 47.45) ml, respectively. The warm ischemia time for RLPN was (19.3 ± 5.6) min. The postoperative drainage-tube was removed within (4.5 ± 1.29) d (RLRN) and (4.6 ± 1.98) d (RLPN); the mean postoperative hospital stay times were (7.0 ± 2.4) d and (5.9 ± 1.98) d, respectively. CONCLUSION: The three-step method of identifying renal pedicle vessels during RLRN and RLPN is direct and feasible, and it may help simplify the operating procedure and improve the safety of the surgery. It may be of great practical application value in the clinical field.

DDD score for renal tumor: An intuitive and comprehensive anatomical scoring system to access the outcomes of retroperitoneal laparoscopic partial nephrectomy.

OBJECTIVE: To present a DDD scoring system in assessing the complexity and outcomes of retroperitoneoscopic nephron-sparing surgery for kidney tumor. METHODS: We retrospectively evaluated 232 patients who underwent retroperitoneoscopic nephron-sparing surgery between January 2013 and September 2017 for a renal tumor. Both the DDD score and RENAL score were used to classify the tumors. The DDD score consisted of the maximal tumor diameter inside the kidney, the maximal tumor depth into the medulla or collecting system and the minimal distance from the tumor to the main renal vessels. RESULTS: The DDD scoring systems were significantly associated with warm ischemia time (P = 0.007) and estimated blood loss (P = 0.017). There was an insignificant positive correlation between the DDD score and the operative time (P = 0.051). Meanwhile, the RENAL score had a significant correlation with the decreasing value of the estimated glomerular filtration rate. Patients with high or moderate DDD scores had a 13.6-fold or 8.4-fold risk of overall complications than those with low DDD scores, respectively (all P < 0.05). As for RENAL score, patients with moderate scores had a 2.9-fold risk of overall complications compared with patients in the low scores group (P = 0.004). In the receiver operating characteristic curve analysis, the DDD score had the greatest area under the curve for overall complications (area under the curve 0.625, P = 0.009), which was more than the RENAL score (area under the curve 0.620, P = 0.013). CONCLUSIONS: The DDD score is an intuitive renal tumor scoring system that is more effective than the RENAL score in complexity assessment, and marginally better in prediction of the risk of overall complications of retroperitoneal laparoscopic nephron-sparing surgery.

Transumbilical laparoendoscopic single-site donor nephrectomy: evolving trends.

BACKGROUND: We report our experience with laparoendoscopic single-site donor nephrectomy (LESS DN). METHODS: Retrospective comparative study of data from 200 Consecutive left LESS DN (group A) compared to 205 consecutive conventional laparoscopic donor nephrectomy (LDN) (group B). Standard laparoscopic instruments were used in all patients. Right nephrectomies were excluded. RESULTS: From 05/2015 to 12/2017, 200 LESS DN (group A) and from 10/2011 till 04/2015, 205 LDN (group B) were performed. In group A and B, respectively, the mean operative time was 175.9 ± 24.9 versus 199.88 ± 37.06 min (p = 0.0001), the mean warm ischemia time was 5.2 ± 1.02 versus 3.64 ± 1.38 min (p = 0.0001), the mean BMI was 24.8 ± 4.5 versus 25.2 ± 4.7 kg/m2, complex vascular anatomy was found in 60 (30%) and 68 (33.2%), average length of incision was 5.2 versus 7.7 cm (p = 0.001), scar satisfaction rate 8 versus 6 (p = 0.004), mean morphine equivalents 81.0 versus 70.5 mg; (p = 0.03), average timing for return to work was 42 versus 50 days; (p = 0.001). There was no conversion to open surgery in both groups. One case converted to hand-assisted laparoscopic nephrectomy in group A. Pure LESS-DN was successfully completed in 169 patients (84.5%). In group A, due to technical difficulties, additional 1 or 2, 5-mm port(s) was added in 21 and 10 cases, respectively. Two negative explorations were performed in the first post-operative week for picture of small bowel obstruction. We had port site hernia in one donor, superficial wound infection in three donors and blood transfusion was required in two donors in group A. CONCLUSIONS: Our experience with LESS-DN is encouraging. LESSDN can be integrated as a standard approach for renal donation without additional donor risk. Moreover, LESS DN gives more flexibility by possibility to add one or more 5-mm ports in case of technical difficulties.

Predictors of renal function after open and robot-assisted partial nephrectomy: A propensity score-matched study.

OBJECTIVE: To investigate parameters predicting short- and long-term renal function after open partial nephrectomy and robot-assisted partial nephrectomy. METHODS: Medical records of 896 patients who underwent open partial nephrectomy or robot-assisted partial nephrectomy from 2004 to 2017 at a single large-volume institution were retrospectively reviewed. Propensity score matching of open partial nephrectomy and robot-assisted partial nephrectomy group was carried out with a ratio of 1:1. Postoperative outcomes were compared, and multivariate logistic regression was carried out to identify the parameters influencing acute kidney injury and chronic kidney disease progression. RESULTS: No significant differences in preoperative characteristics were observed between the two study groups after matching. Robot-assisted partial nephrectomy was significantly associated with a longer warm ischemic time (P < 0.001) yet, estimated blood loss, positive surgical margin, rates of major postoperative complications and chronic kidney disease progression were significantly lower in the robot-assisted partial nephrectomy group (P < 0.001, 0.033, <0.001, <0.001, and 0.005, respectively). Multivariate analysis showed robot-assisted partial nephrectomy was more favorable than open partial nephrectomy in terms of preserving renal function. Patients with a higher baseline estimated glomerular filtration rate were significantly associated with a greater risk of acute kidney injury (odds ratio 1.036; 95% confidence interval 1.021-1.052; P < 0.001), but a decreased risk of chronic kidney disease progression (odds ratio 0.975; 95% confidence interval 0.955-0.994; P = 0.011). Other independent predictors of chronic kidney disease progression were warm ischemic time (P = 0.025), age (P = 0.035), body mass index (P = 0.041) and diabetes mellitus (P = 0.035). CONCLUSIONS: Baseline estimated glomerular filtration rate, warm ischemic time and surgery type are independent predictors of both acute kidney injury and chronic kidney disease progression. Robot-assisted partial nephrectomy is more favorable than open partial nephrectomy for reducing estimated blood loss, positive surgical margin, major postoperative complications and renal function preservation.

Navigation of Intelligent/Interactive Qualitative and Quantitative Analysis Three-Dimensional Reconstruction Technique in Laparoscopic or Robotic Assisted Partial Nephrectomy for Renal Hilar Tumors.

Purpose: To evaluate the feasibility and effectiveness of the navigation of intelligent/interactive qualitative and quantitative analysis (IQQA) three-dimensional (3D) reconstruction technique in laparoscopic or robotic assisted partial nephrectomy (LPN or RAPN) for renal hilar tumors. Patients and Methods: The study retrospectively reviewed 26 patients with hilar tumors from February 2016 to February 2018. IQQA 3D reconstruction technique was applied for the purpose of navigation and resection of the tumors. Relevant clinical parameters and surgical outcomes were recorded. Results: All 26 LPN or RAPN were effectively completed without conversion to a hand-assisted or an open approach. Under the navigation of IQQA, all tumors were found precisely at the first time during surgeries. The mean operative time was 142 minutes (142 ± 35), with a mean warm ischemia time of 24.3 minutes (24.3 ± 9.5). The estimated blood loss was 156 mL (156 ± 112). No intraoperative complications occurred. Two patients suffered from postoperative complications. All patients had negative margins on the final pathological examination. At a mean follow-up period of 3 months, the mean glomerular filtration rate is 22.5 mL/min (22.5 ± 7.1) without tumor recurrence. Conclusions: With peculiar features, such as accurate location, complete resection, and fewer perioperative complications, the navigation of IQQA 3D reconstruction technique in partial nephrectomy represents a safe and effective procedure for hilar tumors.

Endoscopic Robot-assisted Simple Enucleation Versus Laparoscopic Simple Enucleation With Single-layer Renorrhaphy in Localized Renal Tumors: A Propensity Score-matched Analysis From a High-volume Centre.

OBJECTIVE: To compare perioperative results and early oncological outcomes of endoscopic robot-assisted simple enucleation (ERASE) and laparoscopic simple enucleation (LSE) by using a propensity score-matched analysis. METHODS: We evaluated 383 patients who underwent transperitoneal ERASE or LSE for renal tumors from November 2012 to October 2016. Propensity score matching was performed on age, gender, body mass index, Eastern Cooperative Oncology Group score, tumor side and size, preoperative estimated GFR and PADUA score. RESULTS: In total, 278 and 105 patients underwent ERASE and LSE, respectively. The PADUA score was ≥10 for 61 (21.9%) and 13 (12.4%), respectively (P = .034). After matching, mean operative time and warm ischemic time were significantly lower with ERASE than LSE (171.9 vs 188.2 minutes; P = 0.016 and 20.9 vs 24.2 minutes; P = .001). The estimated mean blood loss was similar (167.7 vs 183.3 mL; P = .315). The conversion rate to open surgery or radical nephrectomy was similar with ERASE and LSE (1.0% vs 5.0%, P = .214) and the rate of intraoperative complications was lower (2.0% vs 8.9%, P = .030). The overall incidence of positive surgical margins was similar (P = .614). The median follow-up was less for ERASE than LSE patients (22 vs 38 months). Recurrence did not differ between the 2 groups: 2 ERASE cases (2.0%) versus 4 LSE cases (4.0%) (P = .679). CONCLUSION: ERASE is a safe and acceptable alternative to LSE. ERASE appears to confer shorter operative time, shorter warm ischemic time and lower rate of intraoperative complication.

Trifecta Outcomes in Renal Hilar Tumors: A Comparison Between Robotic and Open Partial Nephrectomy.

OBJECTIVES: To report a comparative analysis of outcomes in patients who underwent excisions of renal hilar tumors using both open and robotic approaches. MATERIALS AND METHODS: We retrospectively reviewed robotic and open patients who underwent partial nephrectomy of renal hilar tumors between 2011 and 2016. "Trifecta" was defined as negative surgical margins, no complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics. RESULTS: One hundred robotic and 64 open patients had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups (p < 0.05). On adjusted analyses, robotic partial nephrectomy (RPN) achieved equivalent rates of trifecta to open surgery (21.1% vs 13.9%, respectively, p = 0.387). There were no differences between robotic and open cohorts for negative margin rates (72.8% vs 90.4%, p = 0.124), absence of complications (68.6% vs 75.2%, p = 0.587), or GFR ≥90% (39.4% vs 21.6%, p = 0.111). The robotic cohort had a shorter mean length of stay (3.8 vs 5.0 days, p = 0.012), and no difference in estimated blood loss (253.3 vs 357.1, p = 0.091) or operating time (199.8 vs 200.4, p = 0.961). CONCLUSIONS: In our analysis both open and RPN for hilar tumors were equally likely to achieve a low "trifecta" outcome with a shorter mean length of stay in the robotic cohort.

Reevaluating Warm Ischemia Time as a Predictor of Renal Function Outcomes After Robotic Partial Nephrectomy.

OBJECTIVE: To explore whether variation of warm ischemia time (WIT) is associated with functional and perioperative outcomes following robotic partial nephrectomy (RPN). MATERIALS AND METHODS: Six hundred sixty eight patients, each with 2 kidneys, undergoing RPNs for a cT1 tumor were identified from a U.S. multi-institutional database. The associations between WIT, normal excisional volume loss (EVL), and surgical and renal function outcomes, including acute kidney injury at discharge and percent change in eGFR at up to 24 months post-RPN, were evaluated using Spearman's rank correlation test as well as multivariable models controlling for tumor, surgeon, and patient characteristics. RESULTS: WIT was weakly correlated with EVL (r = 0.32, P < .001), blood loss (r = 0.34, P < .001), and length of stay (r = 0.35, P < .001). WIT was found to be significantly associated with acute kidney injury at discharge (odds ratio = 6.23; confidence interval 1.52, 30.39). Extended WIT was not found to be significantly associated with renal function decline at 1 year post RPN (P > .05). CONCLUSION: Extended WIT is associated with worse perioperative outcomes. While controlling for tumor size and EVL, effects on short-term renal function were still seen after as short as 20 minutes. Efforts to limit warm ischemia time should continue to be implemented during RPN to maximize postoperative renal function.

Two-Dimensional Versus Three-Dimensional Laparoscopic Systems in Urology: A Systematic Review and Meta-Analysis.

BACKGROUND: Laparoscopy is widely used in the urological field. This systematic review and a meta-analysis were conducted to assess the clinical and surgical efficacy of the three-dimensional (3D) laparoscopic system in comparison with two-dimensional (2D) laparoscopy for treatment of different urological conditions. METHODS: Following guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic literature search in Web of Science, PubMed, Cochrane Library, and EMBase was carried out to identify relevant studies published up to May 2018. Articles published in the English language of both randomized and observational studies comparing 3D and 2D laparoscopic systems in urological surgeries were included. Level of evidence and quality assessments of all included studies were conducted. Interested data were extracted for comparison and meta-analysis. RESULTS: Our literature search generated 17 studies comparing 3D and 2D laparoscopic systems in different urological surgeries. Of these, 13 studies containing 548 and 449 patients operated on with 2D and 3D laparoscopic systems, respectively, were included for meta-analysis. These 13 studies were divided into three groups according to surgical type. Group 1: Partial nephrectomy (PN); operative time (p = 0.19), estimated blood loss (EBL) (p = 0.51), dissecting time (p = 0.58), and suturing time (p = 0.28) were not statistically significant between 2D and 3D laparoscopic systems. However, warm ischemia time during PN was significantly shorter during 3D laparoscopy (p < 0.00001). Group 2: Pyeloplasty; this procedure showed no significant difference between the two systems. Group 3: Radical prostatectomy (RP); shorter operative time (p < 0.0001) and lower EBL (p = 0.001) were associated with the 3D laparoscopic system. CONCLUSION: Three-dimensional laparoscopy mainly improves the depth of perception, leading to better visibility, which is important for some complex urological surgeries such as PN, pyeloplasty, and RP. Based on our findings, 3D laparoscopy seems to provide better clinical and surgical outcomes in some urological procedures compared with conventional 2D laparoscopy.

Retroperitoneal vs Transperitoneal Robot-assisted Partial Nephrectomy: Comparison in a Multi-institutional Setting.

OBJECTIVES: To evaluate retroperitoneal robot-assisted partial nephrectomy (RAPN) against transperitoneal approach in a multi-institutional prospective database, after accounting for potential selection bias that may affect this comparison. PATIENTS AND METHODS: Post-hoc analysis of the prospective arm of the Vattikuti Collective Quality Initiative database from 2014 to 2018. Six hundred and ninety consecutive patients underwent RAPN by 22 surgeons at 14 centers in 9 countries. Patients who had surgery at centers not performing retroperitoneal approach (n = 197) were excluded. Inverse probability of treatment weighting was done to account for potential selection bias by adjusting for age, gender, body mass index, comorbidities, side of surgery, location/size/complexity of tumor, renal function, American Society of Anesthesiologists score, and year of surgery. Operative and perioperative outcomes were compared between weighted transperitoneal and retroperitoneal cohorts. RESULTS: Ninety-nine patients underwent retroperitoneal RAPN; 394 underwent transperitoneal RAPN. Hospital stay in days-median 3.0 (Interquartile range [IQR] 2.0-4.0) transperitoneal vs 1.0 (1.0-3.0) retroperitoneal; P < .001, and blood loss in mL-125 (50-250) transperitoneal vs 100 (50-150) retroperitoneal; P = .007-were lower in the retroperitoneal group. There were no differences in operative time (P = .6), warm ischemia time (P = .6), intraoperative complications (P = .99), conversion to radical nephrectomy (P = .6), postoperative major complications (P = .6), positive surgical margins (P = .95), or drop in estimated glomerular filtration rate (P = .7). CONCLUSION: In a multi-institutional setting, both retroperitoneal and transperitoneal approach to RAPN have comparable operative and perioperative outcomes, except for shorter hospital stay with the retroperitoneal approach.

Retroperitoneal Robotic Partial Nephrectomy: Systematic Review and Cumulative Analysis of Comparative Outcomes.

OBJECTIVES: To compare the outcomes of retroperitoneal vs transperitoneal approach for robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: A systematic review of the literature was performed through January 2018 using PubMed, Scopus, and Ovid databases. Article selection proceeded according to the search strategy based on PRISMA criteria. Only studies comparing retroperitoneal to transperitoneal approach for RAPN were deemed eligible for inclusion. RESULTS: Seven retrospective case-control studies were identified and included in the analysis, with a total number of 1379 patients (866 for transperitoneal group; 513 for retroperitoneal group). In the retroperitoneal group, tumors were slightly larger [weighted mean difference (WMD): 0.29 cm; 95% confidence interval (CI): 0.04-0.54; p = 0.02], and more frequently located posterior/lateral (odds ratio: 0.61; 95% CI: 0.41-0.90; p = 0.01). In two of the studies only posterior tumors had been included. Both operating time (WMD 20.17 min; 95% CI 6.46-33.88; p = 0.004) and estimated blood loss (WMD 54.57 mL; 95% CI 6.73-102.4; p = 0.03) were significantly lower in the retroperitoneal group. In addition, length of stay was significantly shorter in the retroperitoneal group (WMD 0.46 days; CI 95% 0.15-0.76; p = 0.003). No differences were found regarding overall (p = 0.67) and major (p = 0.82) postoperative complications, warm ischemia time (p = 0.96), and positive surgical margins (p = 0.95). CONCLUSIONS: Retroperitoneal RAPN can offer in select patients similar outcomes to those of the most common transperitoneal RAPN. Furthermore, it may be particularly advantageous for posterior upper pole and perihilar tumors and associated with reduction in operative time and hospital stay. Robotic surgeons should be ideally familiar with both approaches to adapt their surgical strategy to confront renal neoplasms from a position of technical advantage and ultimately optimize outcomes.

Pure Laparoscopic Living Donor Left Lateral Sectionectomy in Pediatric Transplantation: A Propensity Score Analysis on 220 Consecutive Patients.

Left lateral sectionectomy for donor hepatectomy is a well-established alternative to deceased donor pediatric liver transplantation. However, very little is available on the laparoscopic approach (laparoscopic left lateral sectionectomy [L-LLS]). With the aim to assess safety, reproducibility under proctorship, and outcomes following living donor liver transplantation in children, a comparative single-center series using propensity score matching (PSM) to evaluate open left lateral sectionectomy (O-LLS) versus L-LLS was carried out in a relatively short time period in a high-volume pediatric transplant center. A retrospective, observational, single-center, PSM study was conducted on 220 consecutive living donor hepatectomies from January 2011 to April 2017. The variables considered for PSM were as follows: year of operation, recipient age, indication for transplant, recipient weight, donor sex, donor age, and donor body mass index. After matching, 72 O-LLSs were fit to be compared with 72 L-LLSs. Operative time and warm ischemia time were significantly longer in L-LLSs, whereas blood loss and overall donor complication rates were significantly lower. Postoperative day 1 and 4 pain scores were significantly less in the L-LLS group (P = 0.015 and 0.003, respectively). The length of hospital stay was significantly shorter in L-LLS (4.6 versus 4.1 days; P = 0.014). Overall donor biliary complications were 9 (12.5%) and 1 (1.4%) for O-LLS and L-LLS (P = 0.022), respectively. Vascular complications occurred in 3 (4.2%) children without graft loss in the laparoscopic group. The 1-, 3-, and 5-year overall patient survival rates were 98.5%, 90.9%, and 90.9% in the O-LLS group and in the L-LLS group 94.3%, 92.7%, and 86.8% (P = 0.28). In conclusion, L-LLS for donor hepatectomy is a safe and reproducible technique yielding better donor perioperative outcomes with respect to the conventional approach with similar recipient outcomes.